Mental disorders aren't necessarily valid

Great Debates
161

Glad to hear the kiddo is doing well, Mr. S.

Thank you for the additional information. You identify a problem with meta-analysis in general, one that extends beyond the policies of the FDA - a bias against publication of studies with negative results. I am frankly somewhat perturbed by the wide spread acceptance of meta-analysis as a research tool. It is better than a review, which doesn’t account for sample sizes, etc., but it is biased to finding positive results.

I will accept that the efficacy of antidepressants as a class remains unresolved. I’d be curious to see if the data on the newer SSRI’s are better. If I have the time I’ll try to do a little searching and see what I come up with. I’d also be interested if you have any reviews on studies related to the efficacy of the SSRI’s for anxiety and OCD. Here I have seen such dramatic effects first hand that I’d be very surprised if it was primarily placebo effect. But I’m not a psychiatrist, just a pediatrician with an interest in neurobiology, so I do not know the psychiatry literature all that well.

Interesting stuff. Irrelevant to the op of course, but a very interesting aside. As said before and in the Pit thread:

That mental conditions are “physiological” is a truism. Physiology is merely how the biological system works, whether it is the effect of genetic predisposition, of toxin, of infection, or behavioral experiences.

That mental conditions have, to various degrees depending on the condition under discussion and the individual case, biological inate contributors (nature) and experiential contributors (nurture) is irrefutable. That there are mechanisms by which the biologic predisposition occurs is inescapable.

“Disorder” is defined by maladaptive function within the organism’s environment. If a phenotype is associated with predictable poor outcome in the environment that the organism exists in, then that phenotype is a disorder. Whether the physiology is understood or not. Whether there are effective trreatments or not. And even if the phenotype would be adaptive in a different time and place.

The most effective way to study disorders is to pool information and experience across a community of researchers and clinicians. To do that you need to know that you are all talking about the same thing. The DSM is the best tool available to do that. It is far from perfect but it is a work in progress, not a static entity.

Treatment for different disorders is contigent upon risk/benefit analysis in individual cases. Not on whether we know all there is to know about the physiology, or whether or not we believe that a condition is all nature or all nurture. What works and at what cost/risk? You have presented some compelling arguments that the class of antidepressants as a whole may have been oversold. I remain to be informed about data specific to the more recent medications. The data for medication efficacy in other mental disorders is, in at least some cases, more solid. I am most familiar with ADD (being a pediatrician) and here medication has tested out as far superior to behavioral interventions alone, for example. I am less familiar with the data for anxiety and OCD, for example, but anecdotally have seen dramatic effects in freinds, family members, and others. This is not the same as a double blind control trial however so I could be convinced by strong data to the contrary.

Undestanding of the physiology of brain function is still embryonic. As you have a particular interest in schizophrenia, I refer you to work by Steven Grossberg for a wonderful model and also to Andreason’s work on the model of “cognitive dysmetria”. I think that these systems approaches will be most useful in the long term.

Thank you again for the informative post.

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DSeid:

Look no further. Go here, to Volume 5 of the APA’s electronic journal, Prevention and Treatment. The meta-analysis I’ve referenced deals specifically with SSRI’s:

However, as far as anxiety disorder and OCD go, I don’t have any information handy.

It might be worthwhile to consider the numbers I quoted in my previous post in context: if there was a significant difference between placebo and drug effect, how would the results differ? On a whim, I decided to see if I could locate a comparison drug. I settled on Losec, an AstraZenca product used for the treatment of heartburn. I found a couple of studies that compared the effect of Losec with other preparations and with placebo effects. Here are the results of one such study (note, the active ingredient in Losec is omeprazole):

If these results are representative of Losec-placebo studies, then we can compare them to the meta-study I’ve cited above. In contrast to the “18% drug response” found in the trials of anti-depressives, this Losec trial reports a 53% drug response (i.e., the difference between response to the drug itself [71%] and response to placebo [18%]). There was also a small difference between response to cisapride and placebo, namely 4%. This difference was regarded as statistically insignficant.

I agree with you in that I can’t quite imagine how we might replace the DSM system. But I also agree with TVAA that there are significant flaws in the DSM approach as well (in fact, I think you also mention that in a post somewhere).

There are disorders and then there are disorders. Some behaviors that might reasonably be classifieds as a “disorder” in the DSM are, when understood correctly, completely rational responses to a fucked-up environment. That was the general thrust of the anti-psychiatry movement, anyway, and in my experience there’s some truth to it.

Yes, but I wonder what the superior efficacy of medication in ADD (or ADHD) actually reflects. To take a crude example, frontal lobotomies were also superior to behavioral interventions in controlling the violent outbursts of antisocial patients. So let’s consider a hypothetical case:

Once upon a time there was a mommy, a daddy, and a little boy named Joey. Mommy and Daddy experience little Joey as being extremely active, and, upon beginning school, so does little Joey’s teacher. Joey has trouble sitting still, can’t seem to concentrate on assignments, gets easily bored, and disrupts the class. They come to you for an evaluation. What do you do?

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I have tried to follow this post, I have a vested intrest in the subject, but it is sadly over my head. My life would have been much easier if twenty years ago, they had been able to stick a gage up my ass and say you’re crazy take this.

As it is I am going this week to consult with my lawyer about my mental condition. I am afraid.

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With full knowledge of walking into a set-up, here goes:

Step one is to get more info. How old is this kid at this point? How far outside the range is his behavior? The usual inventories by parents teachers and caretakers looknig for consistent patterns. Complete history, medical, social, and otherwise to the best of my ability to obtain it looking for other confounding factors that push this out of a straight up diagnosis. Asking the school for screening of academic abilities (LD or gifted or even both).

A significant mismatch between school behaviors and home behaviors usually flags for educational issues or parental issues.

Presume it all comes straight up as consistent with ADD. Could I be missing something? Hidden abuse? Actually bipolar? Is possible. But at some point I take a working diagnosis and go with it. Review of parenting approaches sure, but medication is part of the option package and the risk/benefits of various meds are discussed and offered. If my ususal meds do little then I refer to those with more expertise because I have likely missed something along the way and/or my working diagnisis is mistaken.

As to the DSM, the point is to describe the behavior, not to attribute the cause.* A disorder can be entirely attributable to environment and be a disorder indeed and amenable to treatments either behavioral or otherwise. The DSM approach is not, IMHO, intrinsically flawed. Its current incarnation and application is very far from perfect. But it is the right way to go about doing it.

*The current DSM screws up here at points though … I think specifically of Reactive Attachment Disorder where a presumed cause is part of the diagnosis.

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** But it doesn’t follow that a problem with the functioning of the system is necessarily caused by a problem with the physiology any more than a problem with the operation of a computer is necessarily the result of faulty hardware. Faulty programming can occur with perfectly functioning hardware – if you’ll excuse the crude metaphor.

Which is one of the points I’ve been trying to get you to recognize, or at least acknowledge.

A person who’s terrified of leaving their home will probably have high levels of stress hormones, but it doesn’t follow that there’s something wrong with their adrenal glands. (There have been rare cases where “panic disorders” were linked to glandular tumors, but they’re the exception.)

** Acknowledged, but we do not know what those mechanisms are, nor do we have any reason to think that our treatments address those mechanisms.

** What do you mean, it’s “far from perfect”? What standards are you using to evaluate it?

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TVAA,

As we’ve discussed before, in the brain there is little clear distinction between the hardware and the programming other than level of analysis. (Unless you are trying to distinguish between what is open to future plasticity as programming and what has been set as hardwired.) But what I think you are getting at at is clarified by your example. What is the primary process? And this I can acknowledge. Let us extend your example with a hypothetical:

Imagine that we had a good cost-effective test to measure that documented some neurotransmitter difference in all who meet some critera of any particular mental illness. What we have even then is still a correlation, and suggestive as it might be it is not a causation. We might be able to show that the altered levels are part and parcel of the physiology of the mental illness, but that doesn’t prove that an inherent defect in that physiology is the cause of the illness in any, let alone all, cases. It could be the result of environmental factors, or the secondary result of some other more primary defect or defects.

Untangling those issues is a large focus of current research. And reasoned debate.

What don’t I like about the current DSM.? Reread a series of past posts in these threads to read my critiques. The definitions are fuzzy. They overlap at their edges between each other and between normal and I do not think that inter-user reliability of the tool has been well enough established. I am not sure that better is possible at this point in time and I am content that each incarnation has been an attempt at refinement. Especially since I have no better tool to offer up. But I am fairly sure that years from now mental illnesses will be classified differnetly as we know more. And we will use the DSM in our efforts to learn enough to replace it with something better.

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DSeid:

No no, not a set-up; just, hopefully, an illustration.

Okay.

He’s six, starting his first year in school.

On the Connors rating scale, his mother scores him five, his father six, and his teacher nine. In a CRI test, Joey ranked off the scale; he appeared to simply constantly hit the button.

Aside from normal childhood illnesses, no significant medical factors are uncovered.

Very good question, but there seems to be a consistency between school and home behaviors; in both environments he’s perceived as hyperactive, demanding, and has difficulty concentrating.

Joey comes from a middle-class white-bread family and there are no overt indications of abuse. Father is intelligent, concerned, works a white-collar job that requires him to travel a lot. Mother is at home with Joey most of the time.

Let us say that you “go with it” and prescribe Strattera, the absolute latest in ADHD medication. After two weeks, Joey appears to respond positively. In fact, let’s just say that after six months, in a follow up, both parents and teachers report a marked improvement in Joey’s behavior, and there are no noticeable side-effects.

Have you successfully treated Joey?

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Better yet:

Would you diagnose Joey as suffering from ADHD?

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Even better yet:

No matter what diagnosis you reach, is there any way to prove or disprove the validity of your conclusion?

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Strattera? Yuck. I’ve been less than impressed. I’d probably use Concerta if anything but I’d be reluctant to start meds yet.

He’s young. Just started school. The younger a child the more cautious I am before starting medication. And the harder it is to be outside of the wide range of normal. At this point we would likely be treating for the teacher’s benefit not Joey’s. At six I’d likely encourage working with the teacher on putting Joey in the front the of the class and all that, but I’d soften the ground for use of medication at a later date.

Do I call him ADHD? I’d talk about the term and talk about the concern but be reluctant to label because I am not yet sure how much this kid is going to be handicapped by his inattention, distractability, impulsivity, and/or hyperactivity. If I had made the decision to start him on meds, then I would have had to be convinced that he was outside the range and handicapped by his condition and that he met the other criteria, so I’d use the ADHD label as a working diagnosis. (If for nothing else than for coding and for the purpose of getting the school to do their end of behavioral interventions. Remember my previous comments about the pressure to pathologize.) BUT. The parents would have to suffer through my usual soapbox first. And the ADD boilerplate includes my discomfort with the label of Attention Deficit Disorder because I personally think of it as an attentional difference that has advantages as well as disadvantages. I believe that in our past this processing style was a selective advantage for some and that the parallel processing that these individuals do allows them to make connections that others fail to make, often leading to some very creative thinking. But that in today’s world it can be a disadvantage and handicapping since our current world requires a greater focus at an earlier age. When I treat I try to treat to the extent that the condition is no longer handicapping but no more. And if the meds do that, then I call it success.

As to the validity of my diagnosis … in the clinical setting I am not a scientist. I try to use terms accurately when I can but I really don’t care much in that setting about scientific validity. I care about figuring out what I should and should not do for my patients. Honestly (and I’ve said this here before) I don’t care if he “really” has ADD or not. I care if he is a functional individual and if my proposed intervention has more of a chance of doing good or harm. If he really ends up with an ODD label later on, but the medication I put him on helped him, then I’d feel no shame in having called him ADD “without validity.” In the clinical setting to me the labels are shorthand that sometimes accurately reflect the complexity of the individual and sometimes do not. Likewise I do not care if a kid is labelled as PDD or Sensory Integration Disorder, so long as the kid is getting the full evaluation for EI services and they are being administered according to the results. Call what you want so long as you get the interventions that you need.

I use science as a tool when I wear my clinician’s hat. I evaluate the literature to make reasoned predictions about what will help my patients and what might cause more harm than good. I explain the science to my patients so that they can make informed choices. But my goal at that moment in the room is not to figure out how the systems work, it is not to be a good scientist. It is to be a good clinician.

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Mr. S., I think that is an exceptionally generous restatement of the original statement in question, one that is far more likely to generate discussion rather than a “What the fuck are you talking about?” response (or, more charitably, “That is rubbish.”)

I have high regard for Kirsch and his work, and I also know that he chooses his words with great care. So, while I believe that he has highlighted the significant power of placebos (as one instance of response expectancies, by the way*), and illustrated the manner in which they may someday be found to completely explain the effect of antidepressant medications, I have to take note of summary statements of his, such as:

as well as the one I previously highlighted in bold. These indicate to me that, as the one most carefully reviewing the literature on placebos and antidepressant drugs, that the ultimate conclusion to be reached is that the original statement is rubbish. Or alternately, a hyperbolic and misleading overstatement of what is really known. Or less charitably, well, you get the gist. And I think your conclusion to your premise may, in that case, be premature. At the very least, I need to understand what Kirsch is looking at that makes him make such summary statements, and I don’t know the placebo literature nearly as well as he does such that I can draw conclusions that differ from his.

However, the real issue for me is the reshaping of an erroneous misstatement. Do you feel misstatements and hyperbole are helpful to your antipsychiatry cause? Rather than pretend that something else was said and follow up with an argument of your own re-statement, why not recognize that you are arguing a different statement? Perhaps it appears to be picking nits, but after a time, the repetition of misstatments that happen to be biased in a particular direction and presented with great bluster becomes the issue.

Regarding your proposed case study of Joey, I’ll bite as well. Given that he meets DSM criteria for ADHD, that there is no exclusionary diagnosis or evidence to suggest otherwise, I would give a diagnosis of ADHD. I would recommend behavioral interventions and provide his parents and teachers with additional material to help them learn what types of interventions have helped other children with ADHD in the past. If he persisted with problems despite the implementation of such interventions, I would recommend that he be referred for an evaluation for psychiatric medications.

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DSeid:

Before I let the other shoe drop, I want to back up and ask you one final quick question, if you have the time (and patience!). I almost missed this in your previous post – you wrote, “Review of parenting approaches sure, but…” What does that mean for you, “review of parenting practices”? What sort of review might you normally do (assuming, of course, that you didn’t sense a trap)?

By the way, I’m really more concerned here with the way in which the DSM diagnoses is used in practice, and much less concerned with the question of “scientificity.” I also have no doubt that your primary concern is your patient’s best. I’m inquiring about this in a straightforward, practical, hands-on sense. I’m not out to simply diss DSM criteria, but to explore their clinical implications, if you understand what I mean.

Let’s be clear as well that little Joey’s behavior is perceived as pretty disruptive by others in his environment, and he does meet the criteria for the disorder. That is, you’re convinced by what you know about little Joey that he is “outside the range (of normalcy) and handicapped by his condition and that he met the other criteria.”

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Hentor:

In fact, it should be highlighted that Kirsch also considers it possible that the structure of the tests underestimate the drug effect in various ways – especially if the effect of placebo + drug aren’t additive. But I still find it telling that he places so much emphasis on the fact that the statistically significant difference between drug and placebo is so small as to be “clinically dubious” (his own words), and on the ways in which the reported clinical trials might exaggerate drug effect.

I agree with you of course that caution should be exercised in drawing hasty conclusions. But on the other hand, it is interesting to note that these drugs, about which we know so little, really, are nevertheless being regularly dispensed as treatments for depression. So I wonder who might have been hasty in drawing conclusions, actually – me, or the FDA?

Yes, you’re right. But let me be clear that I don’t really have an “anti-psychiatry cause.” I understand now that the issue with TVAA has been more with his manner of presenting his case than with the case itself. I’ve therefore been more interested in cutting through the muddle and trying to focus on a reasonable version case, if you understand what I mean.

I’m just trying to keep the debate alive and move it in an interesting direction. We’ve raised some very interesting and very important issues, and it would be a shame to lose sight of them in all of this sterile flame-warring.

What sort of “behavioral interventions?”

Would you recommend medication?

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The focus here is first on consistency and on choosing battles wisely. Deciding what to draw lines in the sand over and always enforcing them, deciding what isn’t ever worth fighting about (amazing the number of battles over eating all of the Brussel sprouts), and deciding what you can negotiate over. A good resource for details is Ross Greene’s “The Explosive Child.”

The second focus is on understanding the child’s temperment other than that which makes him/her ADHD. And how to deal with those features. Turecki’s “The Emotional Problems of Normal Children” helps give some parents a vocabulary to use.

Overall, I try to find out what conflicts occur and under what circumstances and try to help figure out strategies for them.

Probably I spend less time on this than I should, and refer to other resources if I feel that parents need much more than the little cheerleading I am capable of. Most are actually already doing a very good job, I think … better than I am lots of the time.

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It is almost as if you were talking to yourselves. None of you have mentioned the one thing that consistently distinguishes placebos from anti-depressants in test after test after test. Any of you want to address that since it is very important?

BTW, I do concur that the placebo effect is rather profound in depression studies.

But the idea of becoming dependent on antidepressants when they are not making you any better is laughable. They are not physically addicting. And if you are not depressed, you don’t feel any difference in your mood at all. If you are depressed and they don’t make you any better, then they don’t become psychologically addictive. So what’s this about dependence?

I hate to be redundant, but would you please provide a cite for that accusation? Could you be more specific? (This is a recording.)

Are any of the following statements untrue?

  1. You have admitted that you are not a professional.
  2. You have admitted that you are an amateur.
  3. You have claimed that you are a cognitive psychologist.
  4. You have claimed that you don’t need credentials to be a cognitive psychologist.
  5. You have said that science is not part of psychology.
  6. You have claimed that you know more than the “experts.”
  7. You have denied saying things that you’ve actually said.
  8. You have claimed that all sciences are empirical.

It’s all there in three theads including this one. You haven’t given me any reason to lie. You damn yourself with your own words.

If you need a cite for any of these (just in case you’ve forgotten), I will be more than happy to provide them. You do know what that word means, don’t you?

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DSeid:

Okay. I take it from your response that your review consists of a little good advice and some suggestions for further reading, rather than a systematic investigation of what might be up in little Joey’s home. I submit that you’ve followed the DSM-IV recommendations quite faithfully (a little more faithfully, in fact, that many) and have responsibly treated his “disorder.” Let us say that we’ve gone six months, and that Joey has responded well to Concerta. Parents and teachers are happy that you’ve so successfully helped them with little Joey’s “ADHD.”(We’ll lay aside Hentor’s recommendation of “behavioral intervention” for the time being, until he has a chance to return to the discussion).

Now, here are some facts about Joey and his family that you don’t know:

Both Joey’s mother and father (M. and F.) come from broken homes that could easily be described as dysfunctional. In M.’s case, her parents are divorced. Her father is an alcoholic with tendencies to violence. M. is estranged from her own emotionally distant mother. F comes from a relatively impoverished background in which his parents were completely incapable of providing even a modicum of emotional comfort. He managed to fight his way out of his family by putting his nose to the grindstone and acquiring a technical degree.

M suffers from a couple of difficult-to-classify emotional difficulties. She has some vague phobias (snakes, dogs) and also some sort of mild eating disorder (not anorexia, but she nevertheless will only eat a certain small range of foods). She doesn’t travel well and is uncomfortable if she leaves her neighborhood. Because of this problem, the family seldom takes vacations together. Finally, M. doesn’t like to touch or be touched, and holds the rest of her family at a physical distance most of the time – seldom does Joey get a good night hug or kiss, for example.

F is an A-type personality, if you will excuse the psychobabble, who is extremely successful at his demanding job. However, these characteristics are slightly less advantageous in his home environment, where he is actually quite dominating and controlling, especially in his relationship to Joey. Literally from the first day he could crawl Joey was subjected to an almost non-stop, intrusive litany of “No, Joey, don’t do that; sit here; don’t sit there; don’t climb there; don’t touch that; sit still; do this; don’t do that,” etc. Every child is told by its parents on occasion to do something or to not do something, but in Joey’s case, he is told constantly to either do something or not do something by his father. In other words, quite unconsciously, F is trying to control Joey in the same way he controls himself.

F is a very active father, of course, who is constantly on the lookout for activities for the family to participate in; going to the zoo, going to the park, going swimming, etc. M, on the other hand, really doesn’t like to leave the house unless she has to. Obviously there are conflicts, and M and F have had to work hard over the years to live with each other. They seldom do things as a “family,” but rather take turns caring for Joey – which both also experience as much a burdensome chore as they do a joy.

You may have noticed that both M and F display some slightly obsessive/compulsive characteristics. Accordingly they’ve had a bit of trouble adjusting to a child who isn’t exactly “tidy.” Both parents found young Joey’s completely natural exuberance and healthy curiosity to be extremely demanding, and in private they often referred to him as “the little wild man” or “the little monster.” What an average parent might take joy in, and experience as positive (even if trying, on occasion), Joey’s parents experienced as negative and extremely trying, in an exaggerated sense.

Finally, there exists a fairly serious disciplining conflict between the parents. M says yes when F says no, often. Joey can go to M and get permission to do things even after F has told him he isn’t allowed to do them. M and F still haven’t managed to fully resolve the problem, although they talk about it regularly. In short, M and F have trouble drawing reasonable boarders and enforcing reasonable discipline for Joey, who is used to being told that he both may and may not eat some ice cream, go to the neighbor’s house, watch TV, etc., quite regularly. Consequently, Joey constantly pushes the envelop, doesn’t know when to take no for an answer, and has some difficulties in doing what he is told from the adults around him.

Do you still think Joey suffers from an ADHD disorder?

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  1. They are habit forming. 2) Their effect tends to diminish over time as the brain learns to compensate for them. Eventually, many people return to feeling just as depressed as they did before – but if they suddenly stop taking the medications, they feel much worse for the rebound. They thus conclude that they need the medications to keep from feeling really bad. Thus, people are dependent without being addicted.

** If you’re not feverish or in pain, you don’t feel any difference at all after taking an aspirin. Therefore, aspirin has no effect on normal people. :rolleyes

  1. False. I said I was not a practicing clinician in psychiatry or clinical psychology.
  2. False. I am an amateur critic of psychiatry in the sense that I do not do it to support myself. Statement is excessively vague.
  3. False. Technically, I have only claimed that I’ve been trained as a cognitive psychologist.
  4. True. No one needs credentials to be any kind of a scientist. At least one degree is required, in practice, to be a professional scientist, and usually multiple post-graduate degrees to teach in the subject or receive grants for research.
  5. False. Psychiatry and clinical psychology are not sciences. Cognitive psychology is a science. Unfortunately, the two distinct disciplines are shoehorned into one category, and there are more clinical than cognitive psychologists. This is why psychology as a whole is considered a liberal art, not a science.
  6. False. I have claimed that I know more about the history and theoretical support for psychiatric treatment methods and the professional debates about them than the majority of clinicians. DSeid is an example: he was not familiar with the controversy over the true effects of antidepressants. Which is not to criticize DSeid. Most doctors do not have the time or the inclination to personally examine the justification for every treatment and practice. I am not generally an expert in medicine (although I might be considered one in past theoretical errors in medicine, and then only relatively).
  7. Indeterminate. I have denied gross misrepresentations of things I’ve said repeatedly.
  8. True. That is in fact what I consider to be almost the defining characteristic of a science; at least, it is absolutely necessary that a field of inquiry to empirical in order to be a science.
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Mr. S.,

Trying to get at that info was part of my “step one history gathering to the best of my ability”, and the conflicts over discipline virtually a given and are the point of consistency being focus one. The mismatch between the parents’ and the child’s temperments is part of the point of focus two - being aware of the child’s tempermental features.

But of course I still think the kid has ADHD. There is solid evidence that ADHD has a strong genetic component, so I am usually more surprised to find the lack of diagnosable (if not diagnosed) conditions in the family than to find it.* The only thing that history does for me is raise my flags to worry that Joey may show up as having some more affective symptomolgy later on, because these OCD or ASD sort of parents aren’t the typical; commonly it is a parent with ADD themselves, often undiagnosed. But no, given that his behavior is percieved as worse in the school setting than at home and that both parents rated him similarly, I do not find this history to be likely etiologic or a function of distorted parental perceptions (if anything they cut him more slack than the school does), nor if I did would it change the use of the diagnosis. Although if the conflicts seemed deep enough it would make me quicker to refer them to family counselling.

*This hearkens back to your anecdodtes about family of origin psychopathology in your severely dysfunctional schizophrenics. There is good work on a broad phenotypre of schizophrrenic precursors. Some of what you see may an indirect result of problems related to that. And more so, some individuals, many even, have the ability to be exposed to significant early dysfunction and still come out okay. In others a lesser amount of dysfunction results in severe pathology. I would suspect that if you take an at risk individual and place them in a pathologic environment you would likely see the worst of the worst.

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Mr. S. asks:

Given that you have been exceptionally non-committal about the type of behavioral problems that the child is showing (as well as the context they are shown), I would have to be very general about the types of behavioral interventions. I would recommend a recent review by Russell Barkley if you are interested in general discussions of the topic. Suffice it to say that at school, these would depend on the classroom and teacher’s existing practices, and might include efforts to increase the salience of classroom rules, through posting physical reminders and verbal reminders, environmental changes, such as moving desks, changing partners and restructuring schedules, employing monitoring strategies (such as specified target behaviors during specific times of the day), selective attention and praise and reinforcement for on-task behaviors. Other academic interventions might include improving organizational skills, using tips and tricks to help remember or record necessary information, and ensure communication between school and home regarding tasks and activities to complete and the nature of behavior shown in school.

At home, parent training in child behavioral management techniques would likely be necessary. The specific focus would depend on the problems shown, but reliable intervention strategies have been developed. The delivery of these interventions also provides an opportunity to observe parenting and family behaviors that may be contributing to problematic behavior as well. They may include the development of a specific behavioral plan that employs tangible reinforcers paired with verbal and physical praise, review of methods of giving commands that are likely to improve compliance and decrease conflicts, and the appropriate use of punishments such as time out.

I would cover this as I said in my last post.

As to your exposition regarding the context in which these behaviors have developed: 1) You seem to imply that typical evaluations would not reveal such problems, or that these would not be addressed in the treatment plan. Do you have evidence that this is typically the case? 2) Do you have any evidence to suggest that these conditions typically produce behavioral responses that mimic ADHD, such that they should be exclusionary in making the diagnosis? Remember that your hypothetical included both an adequate historical review and a child who fully meets criteria for ADHD (that is, is not that he simply “has trouble sitting still, can’t seem to concentrate on assignments, gets easily bored, and disrupts the class”, but also meets sufficient diagnostic criteria to warrant being diagnosed with ADHD - including, one presumes, impairment criteria).

What evidence do you have that he should not? If he responds positively to intervention, does this mean he did not have ADHD?

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And there it is again. “A person responds to a treatment for condition X, so therefore he must have had condition X, because the treatment is specific to condition X.” Except it’s not, of course.