One of my friends is Swedish. The government paid the expenses of therapy when his child was diagnosed with a disorder. I don’t remember if it was the English equivallent of ADD or ADHD.
DSeid:
Now I feel guilty.
See how easy that was?
Seriously, I was a bit afraid you might have taken that last post personally. Please believe me when I tell you that was not the spirit in which it was intended. It’s just that something you wrote triggered something in me, and it sort of “glopped out” like that.
There was a point behind it, though. Even your clinical meetings possess a psychological dynamic. In my own experience with schizophrenics I’ve often found that parents shield themselves from overwhelming guilt by relying on the psychiatric diagnosis, the assertion that schizophrenia is a “biological illness,” and medication. I strongly suspect that there are cases in which an ADHD diagnosis is employed in a similar manner.
But of course that sword cuts both ways. On the webpage of Christopher Gillberg, a famous Swedish researcher, one can read the testimonial of a woman who claims to have spent three years in family therapy at a prestigious psychotherapy institute in Stockholm. Nothing helped, she claims, and the therapists did little more than make her feel guilty for her shortcomings as a parent and blame her for her child’s problems. It nearly broke her. Finally she met Gillberg, who explained to her that her child’s condition was biological, gave him some medicine, and – vóila – he was cured. She was understandably bitter.
I will return to some of your other points as soon as I get the chance.
Hentor:
First off, wow. I’m impressed by your reply, and especially heartened by your focus on family history and dynamics as potential causal factors in a child’s behavior. I confess I had not expected you to answer “yes” to my questions regarding background and marital relations (note that DSeid replied that he tended not to “get too deep” when considering whether or not a child suffers from ADHD). I think you are wise to consider those factors in making your diagnosis, even though we may conceptualize some of them a bit differently (which doesn’t matter all that much to me, really).
I’m certainly not going to lecture you on the links between parental pathology/behavior and childhood behavioral problems, since it’s not my specialty (I work exclusively with adults) and because, as you note yourself, you have a great deal of exposure to such things yourself. I’ll assume, rather, that you know more about it than I do. I will try to get back and “fill in the dots” between Joey’s difficulties and his parent’s history/current problems as soon as I get a spare moment, and then we can talk about whether my picture has any sort of empirical (or experiential) support. I just want to answer a quick question, and make an observation. Regarding Joey’s condition as a “culturally sanctioned” response:
I was merely employing the standard DSM definition of a “disorder,” and the text is found at the bottom of page xxi in my copy.
Then I want to point out what appears to be a fundamental difference in your approach, as opposed to DSeid’s, and ask a technical question. You write:
Further down on the page, DSeid replies to TVAA by noting:
You both employ the DSM criteria but seem to have very different approaches with regard to treatment. My major concern has been more with DSeid’s approach than yours, but I’m curious to know what D thinks of your view and vice-versa.
Now, my question: you’re a clinical psychologist, and DSeid is a pediatrician. Are both of you “qualified,” in the sense of being legally recognized by the state, to diagnose a child with ADHD? I ask because I’m not familiar with the way it works in the US.
DSeid: I’m sorry, but I still don’t get it. Making subjective judgments about whether a person has something wrong with them is what permits abuses of medical power to occur.
How can we simultaneously accept the vehement claims of Hentor and Zoe that physicians aren’t appointing themselves arbiters and enforcers of societal norms when it’s clear that is more or less what you’re doing? Without empirical support for the claim that there’s something wrong with the child, what justifies your intervention besides your own beliefs and those of the majority of your profession?
Who watches the watchers? Who guards the guardians? (This is precisely the issue that Hentor fails to acknowledge: a “science” founded on the judgments of human beings isn’t a science at all. Who evaluates the standards when the laws of nature can’t?)
Accursed hamster-like creatures.
Message continues:
Again, I accept that your intentions are honorable, DSeid. But the argument that you maintain validates your actions also validates the Freudians who recommended that young girls’ clitorises be cauterized so that they could learn to have “mature” orgasms.
It’s statements like this that make it hard to participate in a discussion with you.
To say that physicians are appointing themselves arbiters and enforcers of societal norms implies intent. It also implies that you know what they’re thinking.
Now, arbitration and enforcement of societal norms may be a consequence of prescribing medication, I’m open to hearing that. But the way it’s put above sounds like an evil plot.
It sounds similar to saying that doctors who prescribe chemotherapy are appointing themselves arbiters and enforcers of baldness.
Sniping at the practice of psychiatry from someone who is admittedly unwilling to actually participate in the process of contributing to the solution; well, you shouldn’t be too surprised when it’s unwelcome and perceived as offensive.
Mr. S.,
While awaiting your responses to my other questions and comments, I’ll respond to what you have posted up so far.
If I was convinced that what I was seeing was likely caused primarily by a family dynamic rather than an inate tendency, and that remediation of that dynamic was most effective, then getting them into therrapy would be critical. In situations where the significantly greatest problem is in the home setting rather than at school, such is my approach. But to blame the family when I no evidence that such is so is akin to blaming Mom’s turning away at birth for autism. I abhor how some therapists use the famlily of origin as the scapegoat for all that ails without any real evidence that this is the case.
I am evidenciary based more than model based. Multiple studies have shown that behavoral therapy can be very useful in helping improve home behavior, but that parenting style and behavior therapy have little influence on behavior at school.
And of course evidence based reviews have come to the same conclusion.
TVAA,
I just don’t follow your thinking. There is a problem by the assessment of all concerned: parents, teachers, child alike. There is a painful situation in progress. A child who unmedicated will be a set-up to fail and more likely to end up experimenting with recreational drugs. Treated he is more likely to succeed to as far as his intelligence and motivation will take him .Why would withhold an intervention that has been shown to help resolve that situation without harmful consequences?
Please compare and contrast to my migraine example. Who am I to enforce that being headache free should be the social norm? To decide that missing school because of headaches is a bad thing? How exactly is this different?
DSeid, you omit the benefits of behavioral interventions delivered in school. Here are two examples:
Miranda A, Presentacion MJ, Soriano, M. (2002). Effectiveness of a school-based multicomponent program for the treatment of children with ADHD. journal of Learning Disabilities, 35(6), 547-563.
The objective of this study was to evaluate the efficacy of a multicomponent program for treating attention-deficit/hyperactivity disorder (ADHD) carried out by teachers in a classroom context. Dependent measures included neuropsychological tasks, behavioral rating scales for parents and teachers, direct observation of behavior in the classroom, and academic records of children with ADHD. Fifty children (aged 8 yrs 2 mo to 9 yrs 4 mo) with ADHD participated in the study. The teachers of 29 of the 50 students were trained in the use of behavior modification techniques, cognitive behavior strategies, and instructional management strategies. The other 21 students formed the control group. Parents’ and teachers’ ratings detected improvements in primary symptoms (inattention-disorganization, hyperactivity-impulsivity) and in behavioral difficulties usually associated with ADHD (e.g., antisocial behavior, psychopathological disorders, anxiety). Furthermore, the results showed increased academic scores, enhanced classroom behavioral observations, and improved teachers’ knowledge about the strategies directed toward responding to the children’s educational needs.
Fabiano GA, Pelham WE (2003). Improving the effectiveness of behavioral classroom interventions for attention-deficit/hyperactivity disorder: A case study. Journal of Emotional & Behavioral Disorders. 11(2), 124-130.
Behavioral classroom interventions are an empirically supported treatment for attention-deficit/hyperactivity disorder (ADHD). This case study reports how modifications to an existing behavior management plan improved the behavioral intervention of a third-grade African American boy (aged 8 yrs and 11 months) diagnosed with ADHD. A multiple baseline design across settings was used to demonstrate the effectiveness of the modified intervention. Behavioral observations indicated improvement in on-task behavior and reductions in disruptive behavior. The treatment was judged to be socially valid as the teachers overwhelmingly accepted it and modified the participant’s behavior to normative classroom behavior limits. This case study illustrates the importance of evaluating and modifying existing behavioral treatments for ADHD in the classroom to increase treatment effectiveness.
And, just for clarification, there is some evidence, albeit modest, of generalization of effect from home intervention to school for disruptive behavior, though this has not been demonstrated for hyperactive-impulsive behavior.
I think you undersold the effects of behavioral treatment earlier as well. I liked Karen Wells summary of the MTA study. Wells, KC (2001). Comprehensive Versus Matched Psychosocial Treatment in the MTA Study: Conceptual and Empirical Issues. Journal of Clinical Child Psychology, 30, p131.
Would you please cite where I have discussed the issue of physicians as arbiters and enforcers of societal norms? You have made an unfounded accusation about me which, in keeping with the standards of Great Debates, needs to be clarified or withdrawn.
What benefit does anyone derive from migraine headaches? Subjectively, nobody I can think of actually wants to have skull-splitting pain, nor does society gain much from it (the latter factor being secondary, since we’re putting social norms on the block now). You are the agent of your patient in enforcing the absence of headaches, and may do what is in your power to carry out that assignment.
I can’t help but share this cartoon taken from a psychology textbook:
http://www.darkprophet.net/placebo.jpg
And, electric!sheep, this differs from ADHD exactly how?
Hentor,
Sorry that I was unclear. I was really responding to the position that looking for dysfunctional family dynamics and providing therapy for it was likely to help resolve Joey’s behavior in all venues.
There is fair evidence that school based behavioral therapy is beneficial for school behaviors for as long as it is maintained. Likewise for parent training for home behaviors. The evidence for cross-over is, as you said, modest at best. There is little to no evidence for the type of intervention that Mr. S. suggests.
The best reviews of the evidence regarding diagnosis, management, and treatment of ADHD are in American Academy of Pediatric policy guidelines: .Diagnosis and Evaluation
They find good evidence for the efficacy of stimulants and fair evidence for behavior therapy’s efficacy. To quote
The school generally provides the school based intervention, often before medication is started. I generally insist on school based testing for comorbid LD and to help develop an IEP before medication is begun.
The more I think about it the more Mr. S.‘s position disturbs me. His hypothetical family that he puts forth as so dysfunctional doesn’t really seem so bad. How many real families is he talking to, that this seems so pathologic? Mom doesn’t like hugs and is anxious? Big friggin deal. Gosh, almost every family I know, patient or freind, has at least that much psychopathology. Including mine. And my parents’ stories? Oy! Many others have much much worse. Yet the kids usually turn out okay. My parents turned out mostly okay. To assume that a less than idyllic home is commonly etiologic in those who meet critera for ADHD and that therapy would fix it, is without any factual support
Do you believe the subjective “experience of ADHD” is as aversive as that of head-splitting pain? Do all people diagnosed with ADHD want to be “treated”?
Who are you or I or society to decide what subjective experience is more aversive? Fact is that for many the experience of ADHD is much more aversive than a occassional bad headache. It is with them always and interfers with function every day. And I am not treating “all people diagnosed with ADHD” only those who are asking for help. Like the migraine patients, they may not yet know what the problem is called, but they know they have pain. I label the problem and offer up treatment options. (And yes, with kids parents can function as the child’s proxy in asking for help and in making these choices.)
Hentor:
Well, I was trying to develop a scenario, so not every piece of information in it would necessarily be relevant to Joey’s condition. But I did include a number of at least potentially relevant factors. Here are some that I think are particularly important:[ul]
[li]both M. and F. come from backgrounds of relatively severe emotional impoverishment. They were themselves subjected to poor parents. They therefore lack the internal referents to good parenting they might otherwise possess. In other words, as parents, they’re “flying on instruments;” they don’t really know what a good parent would do in any given conflict with Joey, for example. Their reactions are emotionally anchored in their own histories, and thus they tend to treat Joey the way they themselves were treated, with certain modifications. In the worst case scenario, they might even experience good parenting as ego dystonic. [/li]
[li] There are “distortions” in the relationship between M. and Joey. They build on her inability to be physically available to him. I was of the impression that physical contact is very important to the emotional well-being and development of children, and that this finding was well documented in the research literature. Remember the experiment with the squirrel monkeys and the “mother figures,” one made of cloth, the other of chicken wire? Well, Joey’s mom isn’t exactly made of chicken wire, but she’s not exactly all warm and fuzzy, either.[/li]
[li] There are “distortions” in the relationship between F. and Joey. They build on F.’s overwhelming need for control. The result is that Joey has very little space for himself, and he must fight tooth and claw for it. (By the way, while I agree with DSeid’s diagnosis of M, I’m not sure I agree with his views about F. Here is a man who works long hours at a demanding, thankless job and then comes home to a woman who will scarcely touch him and a son he experiences as dangerously out of control. Were it me, I would suspect that F is basically depressed, and that his “intensity” is a defense against it.)[/li]
[li] F and M seldom do stuff together that would create anything like a sense family cohesion. They are, rather, more like two individuals (plus a child) who happen to live in the same house. They are a “family” in name only, almost. Displays of emotional warmth occur seldom, and there exists an almost tangible sense of distance among the family members.[/li]
[li] Finally, as you and DSeid have also noted, there is the standard problem of a conflict over discipline. F is strict, arguably too strict; he punishes Joey for the tiniest infraction, and seems to expect the boy to act with the restraint of an adult. M is indulgent, or, perhaps, simply lax; sometimes it seems she lacks the energy or motivation to enforce discipline. But neither give what you might call “a tempered and reasonable response” when confronted with Joey’s misbehavior.[/ul][/li]
Now I fear that I have failed to demonstrate a reliable association between the problems I’ve outlined above and the outcome of ADHD behavior in Joey. But I don’t know how I might go about doing that short of dragging you into a few sessions of family therapy with Joey and his parents and letting you decide for yourself whether or not the connections are there. Still, there are studies that link the sorts of problems I’ve outlined above to ADHD and ADHD-like behavior:
This particular study deals with way in which depression influences a mother’s perceptions of her child, but also shades over into how that perception might negatively affect her relationship with the child. The study is in no sense conclusive, but at least it demonstrates the fact that researchers do not yet automatically discount the connection between the emotional states of parents and the (mis)behavior of children:
They found that:
In my hypothetical example it is paternal anger that acts as a primary generator of ADHD-type behavior, but is that so far-fetched, really?
From this article we find other examples of the way in which “dysfunctional” family relationships impact on the subsequent behavior of children, although the findings are admittedly somewhat ambiguous:
I must admit I’m kinda surprised by this last quote, since I was mostly making up Joey and his history as I went along.
There are apparently a number of studies that find a link between parental depression and ADHD as well.
You might very well be right since I’m basing my conclusions on fairly anecdotal knowledge combined with what is probably a rather cliché version of the typical treatment regime. I was pretty impressed by your response. I’ve since spoken briefly with a colleague of mine who works with children here, and discovered my understanding of “standard clinical practice” in these cases might be rather over-simplified. (As I’ve said, I don’t work with children.)
Still, she felt that ADHD was predominantly a response to environment than an expression of genetics. And I still feel there is a fairly profound discrepancy between your approach and that of DSeid.
Of course. To begin with, there is considerable overlap between ADHD and other diagnostic categories, such as ODD. In addition, the variables of human behavior are enormous. Not every child that comes from a background similar to Joey’s is going to develop ADHD. Some will develop other problems, or perhaps not even display any overt difficulties at all. Some will suddenly run into problems as adults (and then come to me). Some may even manage to develop into relatively healthy, happy individuals.
I am trying to keep up with this discussion, but real life constraints are also keeping me very busy right now. I just want to respond to DSeid’s last point:
The problem here, perhaps not explicated clearly enough, is one of degree rather than kind. To be sure, most families include a modicum of what might be considered psychopathological, technically. God forbid that it should be otherwise. But I’m trying to argue that Joey’s family includes much more than a modicum: that it includes so much as to be a determinant factor in Joey’s behavior. In many cases, despite some deficits, families are nevertheless (on the whole) “good enough”. For Joey, however, this is not the case.
I really don’t see why we should be so disturbed by the implications of Mr. S’s position… especially since accepting the physiological disorder viewpoint implies that the vast majority of children have something physically wrong with their brains, which seems almost nonsensical.
The patient is to decide.
**
Ah, but you are calling it a disorder across the board. It’s one thing to enhance quality of life and another to claim that some pattern is below the acceptable norm. If people find the condition unaccepable in the same manner as migraine headaches, then we may indeed treat it identically. You have to consider that ADHD, unlike migraine headaches, is relative to some social reality; if kids didn’t need to concentrate on dreary subjects in an overall dreary environment, there perhaps would be no “disorder” to speak of–and that’s without considering possible non-genetic causes. Common medical disorders, on the other hand, are impediments to basic human function; whether you’re a tribesman or a businessman, heart disease, cancer, myopia, and tinnitus will have a subjectively negative effect on you. This goes back to the question I posed initially: Do all people diagnosable with ADHD want treatment? If a notable percentage does not feel they need treatment, then it could very well be said that there is no disorder; their “ADHD” is part of acceptable variation. Of course, as more people enter a social reality which requires great self-control and concentration, the number of apparently disorderly cases increases. At that point, we still need to ask whether we’re in fact dealing with a progressive social disease or a medical one.
Let me outline this up more simply: All disease is relative to functions that need to be performed. This is pretty obvious. Classical medical conditions relate to basic aspects of human functioning, and thus nearly all instances of diagnosable medical conditions are both outwardly problematic and subjectively undesirable. Psychological conditions, on the other hand, are typically of social significance; they may impede a person’s ability to function within a system of human artifice. For instance, depression is an important human feeling for one, and vital for creativity, while it is a painful illness for another. I venture that ADHD is not a problem for children who can work on immediately engaging subjects, especially with regular reinforcement from their peers, but it becomes debilitating when deep concentration is required voluntarily, despite its short-term uselessness.
The upshot is that psychiatry is free from prejudice if effectively all diagnosable individuals would like treatment, regardless of what social configuation they may belong to. Perhaps ADHD is a disorder of this type, but to the best of my knowledge, it is not–though I readily admit that it lies closer to the medical ideal than others.
Mr. S.,
Put on your cold diapassionate scientist’s hat for a few moments.
What do you know?
You know that there is an association of parental depression and negative interactions between parent and child in families that have a child with ADHD. Do not confuse association for causation.
What are the possible explanations?
-
Parental depression (in particular maternal depression) causes ADHD symptoms, either directly or indirectly through altered family dynamics.
-
The genes that cause ADHD also play a role in fostering a predisposition to depression and other affective disorders. There fore we would expect to see a greater incidence of ADHD and of affective disorders in family members of index patients.
-
Some combination of the above.
The first hypothesis would make some intuitive sense, especially to someone with a psychoanalytical bent. But there is no current evidence to support that point of view, and more pertinent to the developmenrt of treatment plans, no evidence that addressing those psychoanalytic issues has any efficacy. This does not rule out the possibility that it may be of primary etiology in some or that psychoanalytic style of therapy may be of help in some, but the “strength of evidence” is poor.
Meanwhile the second has a solid evidenciary basis. We have very good evidence that there is a strong genetic component to ADHD. I can provide the references if you really want them.
The third also makes intuitive sense and is illustrated by one of your own sources: “controlling parenting strategies appear to be elicited by active, inattentive, poorly regulated child behavior of children with ADHD (Barkley & Cunningham, 1979; Barkley, Karlsson, Pollard, & Murphy, 1985)” (emphasis added). Thus your own source would suggest that the child’s ADHD elicits a secondary controlling parenting style.* It makes intuitive sense that such could make a situation worse and result in a dysfunctional family dynamic. The only evidence for this is that the most effective approach for families that have a child with ADHD and significant problems in the home setting is one that includes both medication and behavioral therapy aimed at parenting style. This is fair evidence at best.
*Your source also supports my response that I’d be more suspicious of your scenerio a causative for ODD, if you recall.
Electric!sheep,
Exactly. The patient is to decide. Or when dealing with children the parents do. Unless you’d suggest a different standard for treatment of migraines or cancer in kids than for ADHD, parents are entrusted with making medical decisions on behalf of their children. You really need to read the guidelines BTW. No one would call these behaviors a disorder across the board, only when they are handicapping in multiple venues. Not just home or school alone. And no one is forcing meds onto the family. I offer it as part of a possible treatment plan.
Mr. S.: As a review, the purpose of your hypothetical, as I understood it, was to suggest that during a typical evaluation, information would be missed that might explain ADHD behaviors in such a way that the diagnosis of ADHD in the child would be inappropriate. Regardless of whether the diagnosis is intended to reflect an endogenous condition, your hypothetical example supports your point only to the degree that it confirms that relevant information about the etiology of the disorder would likely be missed. I contend that the majority of the information that was “missed” in our responses to your hypothetical are not demonstrably relevant to the diagnosis. To my mind, it is akin to my saying, “M’s grandfather killed a man with an axe. F was found wearing his mother’s panties on two occasions during his adolescence. M and F celebrate Christmas by wrapping presents and putting them under a decorated pine tree in the living room.”
I must admit that, in part, I thought your intent was to convey the idea that great amounts of information would be missed that would be relevant, and to that end you puffed up your scenario with ultimately irrelevant information.
· Point 1: “Emotional impoverishment” of parents, poor models of parenting. These could be related, but only to the extent that the parents actually engage in poor parenting. This is the relevant part, as parents with poor models of parenting may also engage in good parenting.
· Point 2: **Inability of Joey’s mom to be physically available to him.**Is there evidence that this quality of parenting is a risk factor for ADHD?
· Point 3: Joey’s dad’s overwhelming need for control.
I’m very sorry, but I have to say that the latter is just plain bunk, in my opinion. If one is not even displaying symptoms of depression, how can you call it such? As to the former portion of this point, I reiterate that the relevance to your ultimate point is limited by how this behavior contributes to ADHD. I know that it is said that ADHD children typically show somewhat greater compliance to and behavioral regulation in the presence of fathers than mothers, but I don’t know any literature that
suggests that controlling father behavior is a risk factor for ADHD.
· Point 4: **No family cohesion, no emotional warmth.**Once again, this is relevant to your hypothetical only to the extent that it would itself specifically predict ADHD behaviors.
· Point 5: **But neither give what you might call “a tempered and reasonable response” when confronted with Joey’s misbehavior.**This is an aspect of parenting behavior that could conceivably be causal in regards to child behavior. But remember that misbehavior is a broader construct than hyperactive-impulsive behavior. And I am not convinced that a) this type of parenting would be sufficient to reliably give rise to diagnostic-level hyperactive impulsive behavior, and b) that it would be specific to hyperactive-impulsive behavior.
And I cannot say that there has never been or would be an instance of diagnostic level ADHD behavior that was in fact caused by the scenario you have laid out. However, I hope that you are not arguing that the possibility of there being one such case invalidates the typical practice of treating ADHD. For that, you have to demonstrate the likelihood that this happens often enough to illustrate a significant problem. This is why I need to see evidence of this scenario being a typical risk factor for ADHD behavior.
I have not argued that there is not a higher rate of psychopathology in parents of children with ADHD. Nor have I argued that parental behavior does not influence child behavior. I hope that you’ll find that I have said exactly the opposite of these things. In fact I have said that I very much need to know what parents are doing as parents. Much of your cited material is relevant to these two points that I have never contested. (In fact, my own research has found linkages between parenting behaviors and conduct problems. Poor parent-child communication is a risk factor for psychopathy in young adulthood. Supervision is inversely related to conduct problems and to adult criminality.)
Studies of a higher rate of maternal depression suggest that this may be a risk factor for ADHD, or that a common genetic liability exists for psychopathology in some mothers and children. Maternal depression was not in your scenario. Maternal anxiety was. Further, the prediction from maternal depression to family discord and behavioral problems in children with ADHD does not prove that maternal depression caused the ADHD.
The prediction from maternal depression to aggression is irrelevant to the question of whether “ADHD-mimicking” behaviors are likely from the scenario you posited.
With all due respect, paternal anger was not part of your original scenario, as maternal depression was not either. But aren’t these findings also explained by mother’s being pissed off about chronic behavioral difficulties in children?
But doesn’t it say that the direction of effect is from ADHD behaviors to parenting behaviors? How would this provide support for your scenario? And ODD is not ADHD – again, misbehaviors are different from hyperactive and impulsive behaviors.
Not to be pedantic, but let’s be careful with our terminology. ODD and ADHD are frequently comorbid, but the evidence supports the assertion that they are distinct conditions (e.g. Loeber et al., 2001).
But there needs to be a greater degree of specificity between this set of predictors and a typical outcome of hyperactive-impulsive behavior for this to be a useful scenario. Again, that presumes that your intention was to show that standard practice would miss relevant risk factors for hyperactive-impulsive behavior. I reiterate that if this happens once, it does not cast doubt on the thousands upon thousands of instances that it does not. And the specificity of a predictive link from overall level of family dysfunction to child ADHD behavior is not there. As your evidence indicated, the direction is such for child disruptive behaviors, but is actually in the opposite direction for child ADHD behaviors.
You may find Cunningham & Boyle particularly helpful. They examined parent adjustment, family dysfunction, parenting and parent-child relationships in association with emerging ADHD or ODD symptomatology in preschoolers. They found that these factors were associated with ODD but not ADHD. They also found that difficulties at preschool were much more determined by ADHD than by ODD, which was more associated with parenting and family factors. This paper will also provide you with other citations supporting these relationships.
Cunningham CE, Boyle MH (2002). Preschoolers at risk for attention-deficit hyperactivity disorder and oppositional defiant disorder: Family, parenting, and behavioral correlates. Journal of Abnormal Child Psychology, 30, 555-569.
Hent:
Yes, that’s correct. I was thinking that the typical way of making such a diagnosis would be based on the presupposition that ADHD is primarily genetic; that ADHD can be identified in terms of a kind of “checklist” of the child’s behavior, without reference to parental practices; and that the course of treatment would be a prescription of Ritalin, first, maybe coupled with some behavior modification therapy. I submit that this presupposition is very close to DSeid’s approach, as he has outlined it in this thread.
As I’ve stated a couple of times, I find your approach, which takes into account the history of the child’s problems and the relationship between parents and child, much closer to my own view of things. However, since you requested that I “close the circle” for you, I gave it a shot.
Hmmm… I thought I had already agreed with this – or rather, I thought I had made it clear that if you take into account the interpersonal dynamics of the parent-child relationship, you are taking into account information that I consider to be relevant to the diagnosis. Still, you or I asked a semi-rhetorical question a page or so back, to wit: if therapeutic interventions without medication result in an improvement, or even near disappearance, of Joey’s symptoms, does that mean that Joey, himself, suffered from “ADHD?” If Joey’s parents learn a bucket of new parenting techniques, and Joey begins as a result to function more appropriately, how can we then say that Joey suffered from the “disorder,” when his improvement was primarily the result of a change in his parents? I mean, wouldn’t it be more appropriate to claim that it was the parents who suffered from the “disorder?”
You’ve asked me for evidence that my characterization of “standard clinical practice” is correct. I’ve admitted that most of my knowledge regarding this is anecdotal. But now I’d like to ask you for evidence that your approach is standard. I do know people, both here and in the States, who received none of the interventions you’ve recommended: rather, they got a prescription for one stimulant or another, and no recommendations for changing their parenting strategies whatsoever. I do not know any child who has been diagnosed or treated in the manner you recommend. I freely admit that since my knowledge of this field is limited, so I could be wrong about it.
Of the 5 points I listed, you acknowledge that points 1 and 5 were relevant. Regarding point 3, F’s overt attempts to control Joey, I specifically quoted from a study, above, that coupled that sort of behavior with ADHD. To repeat:
There is a chicken and egg question here of course, that both you and DSeid have brought up; it is entirely possible that the “controlling” behavior is a reaction to the child’s disorder. However, in my hypothetical case, I tried to make it clear that this behavior was more the parents’ fault than Joey’s. If such behavior can result in ODD, then I don’t see why it can’t result in ADHD. Perhaps, in Joey’s case, there’s some overlap. What do I know? It’s a hypothetical situation.
Regarding this:
It’s extremely common in my practice. I would guess that as many as 25% of my patients deny an underlying sense of depression and isolation with a manic exterior; they usually start therapy when the exterior collapses and the depression becomes manifest.
This leaves points 2 and 4. You are correct to surmise that I don’t have any evidence that these factors lead to ADHD-like behavior. You will forgive me, perhaps, but I’ve spent all afternoon slogging through the literature and, as I wrote earlier, I’m not a specialist in this field. I will therefore submit them merely as factors that compound Joey’s already fairly bad situation.
Well, it was my original point, submitted for discussion, but as I’ve pointed out, I might be relying on an incorrect view of typical practice. If you can demonstrate that the course of action you delineated on page 4 concerning how you would go about treating Joey is typical, then I’ll concede that point.
No, you get me wrong here; I did not mean that it is typical. What I meant was that there can be occasions in which these factors influence a child’s behavior, but are not taken into consideration because of the DSM system. It’s just a hypothetical example of how that could be the case, meant only as an illustration. I’m not interested in throwing out the DSM-IV; I just wanted to demonstrate that sometimes, the system has weaknesses. Both you and DSeid have conceded as much previously, or at least so I thought. And as I’ve pointed out, I couldn’t imagine what we would replace the DSM with. That doesn’t mean the system is perfect, and I was trying to provide a concrete example of how such imperfections might, on occasion, manifest themselves. Naturally, as an expert on ADHD, you can trash my example with your eyes closed, but perhaps you could even come up with a better one as well.
Indeed I did. But you asked me to “close the circle” for you, so I tried.
Sorry. I thought it was kind of obvious that F’s controlling behavior towards Joey was basically aggressive in nature. Should have been clearer on that point.
Yeah, I did. It was precisely that paper I quote from earlier.
They did indeed state that they found family dysfunction more highly correlated to ODD; but the intro stated that ADHD and family dysfunction were also correlated. I think.
It’s late here and I have to go to bed now.
Again, the very idea of a disorder tends to transcend the sum of individual decisions about normality. As such, your practice judges even those who do not see themselves as ill. In other cases, however, this idea codifies sentiments independent of culture, and universal to all afflicted persons, as is arguably the case with heart disease, cancer, etc.
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Unfortunately, yes–it is impossible to separate judgments about children from the prevailing sentiment of a time. The question for you to consider is this: At what point does parental modification of behavior via chemicals switch from helpful to abusive? In many situations, a completely docile child is good (no one enjoys possessive, screaming kids), but would that be a perversion of nature? Ultimately, is it even possible to distinguish between the elimination of suffering and the prescription of happiness?
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You misinterpreted what I had written. See top.