Why do we give such credence to metaphorical diseases like ADD, ODD and Asperger's?

Great Debates
161

I’m not picking on you, I just think that this is a good example of what I’m talking about.

Someone, somewhere decided at some point that 20/20 vision is ‘normal’ and that if someone’s vision is worse than that, it gets corrected with lenses.

What tickles my brain about the whole thing is, why stop at 20/20? Why decide that’s ‘normal’ and ‘unimpaired’ if it’s possible to ‘correct’ everyone’s vision so that they could see even better than 20/20? The eye chart’s got a 20/16 line on it, right? Maybe 20/20 is impaired vision?

It’s like that with the ADD thing. If we can give people a pill, and make them perform better at some task, then how do we know who’s really impaired and who’s getting a ‘more than human’ boost? Even if I’m not impaired, there’s really no law against performance enhancing in software writing, so would it be OK for me to get a doctor to prescribe me some Ritalin because it makes me work to a higher level than I do now? Use it in the way that an athlete would use some performance enhancing drug?

162

To come back to the issue of “over-diagnosis” of ADHD, the issue is quite important. It is obviously in the best interests of children that our diagnostic tools are as accurate as possible, and that clinicians adhere to the most accurate protocols for diagnosis as possible. However, the question of whether a diagnosis is over-diagnosed presumes that we can identify the actual level of ADHD and the rate at which clinicians are reporting its identification. The first element is impossible to determine, and the second is not easy because there is no single database of all clinical services provided nationally, regionally or even locally.

Perhaps the easiest way to get an estimate of the rate at which clinicians are diagnosing ADHD is to look at Medicaid treatment data sets. Unfortunately, I could not find any published studies that provided prevalence rates based on clinical diagnosis. I did a quick perusal of the results of entering into Google the terms “ADHD prevalence Medicaid.” I found the following bits of information:

In Louisiana, the prevalence of service use for ADHD was 5.7%.

http://rxweb.ulm.edu/pharmacy/CE/ADHD%20article%20and%20quiz.pdf

In the Mid Atlantic States, the prevalence of service use for ADHD was 3.3 - 3.6%.

http://apha.confex.com/apha/130am/techprogram/paper_47666.htm

In the APS Health System, a multistate commercial health plan, the rates were 12.8% among MA population and 6.9% among commercial service users.

http://www.apshealthcare.com/providers/bhp/2003_annual_eval_adhd.pdf

The following caveats should be applied:

  1. These results were from a relatively brief Google search and perusal of the contents. It is possible that I have misread the information I have presented, and the numbers above could be misrepresentative of the prevalence in other regions or among other groups. Certainly the search I did would be called anything but exhaustive.

  2. Medicaid service users generally show higher rates of disorder than other populations, largely for economic reasons, meaning that these rates would likely be higher than the rate of diagnosis among the population at large.

  3. These rates are for service use for ADHD, which presumes a diagnosis of ADHD, but it could be possible that that was not always the case. I would imagine that this risk is rather small, however.

  4. These prevalence rates are rates of ADHD service use compared to a population of service users. This would inflate the rate relative to the larger population, which would include people not among MA or medical care plan service users.

Barbaresi and colleagues (2002) in Archives of Pediatrics and Adolescent Medicine, reported on a study of a Minnesota birth cohort (from 1976-1982) through 19 years of age. In the review of school records for these 5,718 children, 7.4% of children had a clinical diagnosis noted in their file.

Keeping in mind that prevalence rates generally based on some standardized interview technique (structured clinical interview or questionnaire) are conservatively around 5% to 7%, these numbers would not support the assertion that significant over-diagnosis is occurring.

163

Like you said, finding numbers on diagnoses is damn difficult, and they tend to be all over the board. Depending on your criteria, estimates range from 1% to close to 20%. Professionals who believe that it is over-diagnosed seem to be fairly easy to find, though. If you read the transcript from the Presidential task force that I cited above, they enter on the discussion pretty much on the assumption that kids are being over-diagnosed and spend a fair amount of discussion about a) why this might be and b) whether there is a discriminatory aspect of it; that is, whether minority children are being over-represented.

Another thing that makes it tough is wading through discussion of actual diagnoses and the labels and groupings applied to kids in the education system that aren’t actual diagnoses but impact the kids in a lot of ways as if they were.

In other words, not only does it appear that we don’t know, it’s damn hard to find data to even make good guesses on. For me, the key issue is at what point on the continuum would it make sense to draw a line between “different” and “disordered”. If there is a right place to draw this line, I tend to believe that the more conservative European standard is more reasonable, winding up with an estimation of about 1%–and I do think that this may also be high.

The President’s Commission talked a good bit about two suspected motivations to diagnose: 1) Teachers anxious to get difficult students out of their classes and 2) the extra funds available to schools based on the quantity of special needs kids.

Several people also gave testimony about the situations that I mentioned earlier, where diagnoses are made by people who are not qualified to make the diagnosis or at the recommendation of these people.

I think it is far too easy to check off the “symptom” criteria and give differential criteria (life impairment, etc.) short shrift. And, as I’ve mentioned, I think there are a lot of children who are being left behind, not because of their shortcomings, but because of the shortcomings of their teachers. In other words, they have life impairment that isn’t a necessary result of their ADHD “traits”.

If we can get to a point where teaching is based more on science and less on whacky theories, I’ll start to feel a lot more comfortable with claims by educators about the “limitations” of a particular child.

There is some pretty interesting discussion about issues of teaching in the Commission transcript (although tending more toward surface-scratching than detailed discussion), particularly in the second half of the document.

-VM

164

Just for the sake of precision, it is difficult to access data on actual clinician-based diagnoses, but not so difficult to find data from studies using structured clinical issues or checklists, which is included in many published studies.

Yes, and generally speaking, it’s good that professionals are worried about over-diagnosis. My question is what is the evidence suggesting that over-diagnosis is actually occurring, and if so by how much? If we can’t be sure it is happening, we should be much less cavalier about pronouncing it so.

I guess what I am concerning myself with here is the diagnosis of ADHD, given the topic of the thread. I would agree that schools group and label kids for different purposes. But teachers and schools still cannot assign diagnoses.

It sounds like we agree that we cannot conclude that over-diagnosis is occurring.

By European standard, I assume you mean the ICD-10, which by the way consists of essentially the same set of criteria that you were harshly calling into question earlier in this thread. http://www.adhd.org.nz/ICD101.html. The difference is that in the ICD-10, you cannot have ADHD unless you have criteria of hyperactivity, impulsivity AND inattention, and you also cannot have ADHD if you also have depression or anxiety. Thus, the young man I mentioned previously, who suffered only from inattention, would not meet criteria for ADHD using the ICD-10. Furthermore, the ICD-10 distinguishes diagnoses of ADHD (technically “Hyperkinetic Disorder) and a diagnosis of Hyperkinetic Conduct Disorder, whereas we would have ADHD and Conduct Disorder separately using DSM-IV.

Likewise, some of the people in this thread who described having ADHD and depression would not have ADHD but only depression. You may like it for the lower prevalence rate that it yields, but this does not make it accurate or more useful than the DSM-IV. Just for accuracy, the Swanson article the CDC cites to come up with the 1% rate actually describes a 1-2% rate, and shows ICD-10 epidemiological data ranging from 1-4%, with only one study finding a rate of 1%. It appears to me in reading the paper that they are talking about ADHD (HKD) and excluding Hyperkinetic Conduct Disorder. This means that the European system you are referring to yields rates of 1 to 4% of pure ADHD –Combined Type without comorbid anxiety, depression or Conduct Disorder. I would wager that the epidemiological rates of DSM-IV ADHD with all those restrictions would end up about the same.

We are still left with nothing to tell us how severe any problem of over-diagnosis might be. I also don’t know how often teachers are proffering diagnoses, but I can only reiterate that they are not suited to do so, and should not be given credence if they do. However, they may tell you that your child is markedly louder, is up and out of his chair frequently, and shouts out answers impulsively, and they probably have better opportunity to observe these behaviors than anyone else.

165

Which wouldn’t address the issue of overdiagnosis at all, for someone of your views or of someone of mine.

I think we can be pretty sure it’s happening, if not by how much. At the end of the Presidential Commission meeting, they opened the floor for comment. One of the people who commented is a legislator from Connecticut, who is also an RN, who pushed passage of a bill forbidding schools advising parents to get their kids medicated. She became concerned working in the ER and noticing how many of the kids coming in were on stimulants.

There is also testimony by one parent who was told by a school official that their child would have to be put on medication or would not be allowed in school. Also, one of the school system representatives acknowledged during question-answer time that unqualified school counselors are recommending parents medicate their kids. You can also find testimony describing the process where parents are told their kids need medication, go to a family doctor and, after a 15 minute conversation, walk out with a script.

Most of the witnesses at this meeting were selected based on their expertise with special needs kids and/or special education, and pretty much everyone of them acknowledges that there is a problem. Nonetheless, your posts seem to indicate that you think this is all just something I am making up.

In practice, there seem to be a number of cases where they pretty much are. I can’t imagine that a doctor can follow the guidelines for diagnosis in 15 minutes. But he could listen to the parent report what the school said, ask a couple questions, and jump to a conclusion.

I’m pretty comfortable concluding that it is occurring, but I clearly can’t tell you how much. Since you insist on knowing how much it is occurring before concluding that it is, then I doubt we will find any way to agree. I DO ask you to keep in mind that I have no say-so of any kind over what kinds of studies are conducted or published in this area. And I hope we can agree that they seem to be needed.

I did not call the criteria into question in the way that you are implying. I pointed out that they are subjective and that it is very easy to describe any child as meeting them at different times, which, to me, makes it unsurprising that those who have not been trained in the evaluation of the criteria would be likely to overdiagnose. I also pointed out that there seem to be a fair number of diagnoses being made by people who are not trained in applying these criteria.

Since I believe it likely that we are drawing the line between “different” and “dysfunction” in a way that is too inclusive, it should not be surprising that I prefer for the criteria to be used in a more restrictive way.

I think that’s a pretty safe wager. I saw a reference to one study where they asked European practitioners to use the DSM criteria, and their diagnoses began closely matching the American prevalence rates. I think that there is enough evidence to show that the criteria can be applied in a consistent way. However, there seems to be good reason to believe that they are not being applied in this way in a lot of practice. And, of course, there remains the question of what this means about the kids in question. I don’t question that properly trained clinicians can consistently separate these kids from the population. I question the assumptions about the degree to which they are “broken”.

However, that is my opinion, and I have reasons for holding it, just as you have reasons for holding yours. Clearly, there isn’t enough data either way for one of us to convince the other (or if there is, we haven’t found it). The fact remains that one of the critical differenial criteria is the evidence of impairment in important areas of life. And I continue to maintain that better, more scientific approaches to teaching and training will lead to far fewer kids being held back by their “condition” in a way that impairs their functioning.

I don’t think we have ever had any disagreement on this point.
And, once again, it’s bedtime and I haven’t got the next installment of what I wanted to present ready for you guys…

I am making progress; you just can’t see it yet.

-VM

166

In which case, the problem is not schools making recommendations but incompetent doctors. Rather than banning teachers from making recommendations to parents (especially considering that their input can be beneficial), why not revoke medical licenses due to violations of existing regulations? A doctor who prescribes ritalin in fifteen minutes based soley on the word of the parents, should not be practicing medicine. OTOH, a teacher who wonders if a student has ADD and tells parents that they should see a doctor about it, is doing their job.

167

These are anecdotes. Lots of people will tell you that the Social Security System is in crisis, for example, but that does not make it true.

No, I don’t think you are making it up. I think you are repeating a claim. I’m saying that there isn’t any evidence for this claim. I’m saying that it isn’t outside the realm of possibility, but I would like to see the evidence first. I have presented you with some data that suggests it isn’t (i.e. prevalence rates in several samples of MA data, a study utilizing data from school records). You shouldn’t go disregarding some experts and believing the opinions of others just because you agree with them.

My point is to illustrate that the claim of over-diagnosis is based on no evidence, since any evidence would give us an idea of how frequently it is occurring. Further, it is important that we try to get a handle on whether this is simply a matter of fine tuning some protocols, or if there is a massive epidemic requiring drastic measures.

168

Hello, all.

I have managed to produce a good bit more information for you. However, I have achieved this by studiously ignoring all the threads on this board for several days. I haven’t looked at anything in any threads since my last post. With only a certain amount of time to “play” here, I get too wrapped up in the minutiae of the various debates on don’t make any progress on what I set out to do. The fact that work is pretty hectic right now isn’t helping. I am now going to post the completion of my “argument”. It is quite lengthy. However, I still think there is some benefit here for those who are struggling to do what’s best for their children. I am breaking it up some to make it easier to read–or skip through for those that don’t have the patience for my tendency toward verbosity.

I offer it in the spirit of sharing with those who might be helped by it. Not to tell people what to do, or how to raise their kids. And not to criticize parents of ADHD kids. With only a few exceptions, my experience of these parents has been that they are pretty damn heroic. When a child is not progressing as he should, parents are left with tough decisions and, often, limited information with which to make them. I am offering an introduction to Direct Instruction, for your consideration as a resource that is available to you. As a part of this, I am offering some of the “theory” behind it, so that you can better evaluate its usefulness. I also am bringing up some tangential information, but I have tried to keep it to a minimum for those of you who prefer to “get to the point”.

I started off with a synopsis of ADHD as a clinical diagnosis. I am picking back up with a brief discussion about medicating the condition, focusing again on summarizing what we know, with only a little about what I personally think. I will finish with discussion of Direct Instruction. Medication is one potential “weapon in your arsenal”. Direct instruction, like behavior modification techniques, is another.

Note: It’ll probably be near the end of the week before I can check in again. I have to make a short business trip to Mexico.
MEDICATING ADHD

Okay, so I’ve seen some pretty, um, interesting websites and read a fair amount of debate on ADHD. In terms of seeing an overview of what’s known and what’s thought about ADHD, I recommend the transcript from the Presidential commission. The “final report” they produced is not quite as interesting, and in distilling the info they gathered, they have a tendency to gloss over important points and “vague things up” a bit. I’ve been trying to find some harder numbers on ADHD diagnoses and kids on meds. All I could find were isolated examples; several sources cite a study that determined that 10% of the white male kids in Va Beach were on stimulants. I have found references to a NIMH study that concluded that, overall, ADHD is not particularly over-diagnosed or overprescribed–even though they found high numbers in places and low numbers in others. This is based on the US estimate of 5%-10% of kids being ADHD. In other words, you need to have a pretty high number of diagnoses for it to exceed a “target” of 5% or 10%.

As a part of this, there are still people debating whether ADHD is “real”, and various conspiracy theories as to why it was invented. However, this debate seems to be dying down. For those who bother to look at the numbers and understand what is being reported, there is no doubt that the ADHD diagnosis is valid. That is, it really does describe a group of kids and the criteria can be applied consistently by those with the proper training. I am still of the opinion that there is a lot of “difference” being labeled as “disorder”. Here are some links where you can follow the debate; some are research-oriented and some are more political:

The ADHD Debate at “Safer Child, Inc.” - I’ve never heard of this organization, but they seem to do a pretty even-handed job of reporting on the debate.

“Unquiet Minds” at aaddsg.org - The site is aimed at adult ADHD sufferers. This article has some interesting comments from adults about how their ADHD symptoms help or harm them in the work world. There is also some background on ADHD and the debates surrounding it.

“Neal Boortz and ADD” at freerepublic.com - If you’re interested in hearing from people who don’t believe in ADHD as a political position, you’ll get a kick out of this. It also includes an interesting collection of conspiracy theories and emotional back-and-forth. It’s kind of interesting to see the progression from top to bottom of this page.

Treating ADHD With Medication - I’m not sure what iqhealth.com is, but this is an information page that summarizes the JAMA and NIMH reports that say that everything is just fine.

Here are some facts that do not seem to be in dispute:
[ul]
[li]Stimulants like Ritalin make ADHD people more like non-ADHD people. At one time, it was thought that, if a person responded to Ritalin, then this confirmed the diagnosis. However, it has since been learned that many people who do not meet the diagnosis criteria still experience improved concentration and “focus” on these stimulants.[/li][li]Different people find different stimulants to be more effective.[/li][li]For some people, drug treatment loses effectiveness over time.[/li][li]Many people experience a worsening of symptoms (that is, worse than pre-medication) when they stop the medication.[/li][li]Stimulants do not in any way “cure” ADHD. To the extent that this is a disorder, the medication treats symptoms. Similarly, Tylenol may help alleviate flu symptoms, but will have no impact on the time taken to recover.[/li][li]The symptoms of ADHD usually diminish as the person reaches adulthood. In particular, if hyperactivity is present, it seems to largely go away, while the person may still complain of difficulty with concentration and focus.[/li][li]The effects of these medications are pretty broad. Numerous parents have reported that their child is a “different person” when taking Ritalin.[/li][li]The abilities that that are lacking in ADHD people (so-called “executive” functions) are low, to a lesser degree, in all children. These abilities develop throughout childhood and adolescence.[/li][/ul]

To me, the point that these executive functions are still developing into early adulthood is worth considering. It seems logical that this development is either the result of learning or of ongoing brain development. If it were my kids, I would worry that, by supplementing these functions, the needed development might be hampered (or learning might not occur). The analogy in my mind would be something like, say, if you were to carry a child around all the time, they would not learn to walk (or develop the necessary balance and/or leg strength). As far as I have been able to tell, there is no evidence for or against this. That is, it is nothing more than a concern of mine.

Also, I found some of the comments in the “Unquiet Minds” item interesting: There were several adults mentioning how their different way of working came in handy for their particular jobs. Numerous sources have pointed out that, while ADHD people have difficulty focusing on difficult or boring tasks, they can concentrate extremely intensely–and for amazingly long periods–when the task is interesting to them. When I see that, I think about Einstein teaching himself advanced math and physics in his spare time. When I talk about what we might be losing by medicating ADHD kids, it is this sort of thing that I am talking about. That said, if you told me that one person could create a wondrous boon for society, but he would have to suffer most of his life in order to achieve it, I would probably say that society can wait.

My last collection of advice wrt ADHD and medication:
[ul]
[li]There are quite a few different problems that a child can have that can mimic ADHD. A crucial part of any ADHD diagnosis is the systematic elimination of other possible causes of the behaviors in question. Any diagnosis that does not include serious time and effort investigating other potential causes should not be trusted. In particular, any diagnosis based on a brief doctor visit should not be trusted. Ideally, the diagnosis should be made by someone with specific training and experience with ADHD.[/li][li]If the problems can be addressed without medication, this is preferable.[/li][li]While I believe that most, if not all, of these kids could do perfectly well using behavior modification techniques and better training, I also believe that life is too short for families to be living through years of misery because they are not able to achieve adequate results without medication. Until we fix our education system, there is really only so much that most parents even have the opportunity to do.[/li][li]Which, as far as this particular topic goes, takes me back to about where I started: I think that parents should try to avoid medicating their kids if they can. However, if the problems are not improving, they will only be made worse if the child is not able to progress at school. While I have some concerns about the long-term effects of stimulants on kids, these concerns are much less strong than the obvious harm that results from failure to succeed in school. In other words, while the meds may do some harm, they are far preferable to sacrificing a child’s education, which will most definitely do significant harm. If the child’s education and/or emotional development are at risk, then the risk of the medication seems to be the safer course. And parents that have made this choice shouldn’t be beating themselves up about it.[/li][li]With or without medication, ADHD kids need consistent, effective discipline. And they need to learn just as much as other kids do. Regardless of the decision to medicate, I would recommend that parents of ADHD children learn all they can about effective behavior management–and there are many resources available in this area–AND about teaching/training, which seems to be getting short shrift in the self-help section.[/li][/ul]

Several pages earlier in the thread, a poster talked about the difficulty of getting a nephew dressed to go out. For the most part, this was discussed as a discipline/motivation issue. The underlying assumption in that approach is that the child knows exactly what to do and how to do it, he just isn’t doing it. While this assumption may be correct, it is important to keep in mind that we know that ADHD kids often learn differently than other kids. When dealing with any child, it is important to always be mindful of what he knows/understands when assigning tasks. With ADHD kids, this is particularly crucial.

-VM

169

THE CYCLE

Breaking the “cycle of failure” is the primary goal of Direct Instruction. The first few years of school are vital for children because they are focused on reading and basic math. Obviously, a child that has not mastered reading will be at a disadvantage in every subject, unable to understand his textbooks. DI is focused largely on reading because it is so crucial to further progress. Starting even in the early grades, our schools work within a paradigm of presenting information and grading children on how well they learn it. A child “passes” when he demonstrates a certain level of learning. DI proponents believe that skills like reading are too important to allow a child to “pass” without having mastered it. That said, DI is not focused on holding kids back; it is focused on teaching in such a way that children gain a level of skill at the task that may be described as “mastery”.

Based on their research, DI founders describe a cycle of failure that begins with a child being taught in a way that does not work for him or is confusing to him–or that he is not ready for because of missing skills. As repeated attempts are made, the child and the teacher become increasingly frustrated. The child is not able to do what is being asked. From the child’s standpoint, the teacher may as well be demanding that he flap his arms and fly up to the ceiling. Repeated attempts frustrate the child, and he becomes less willing to cooperate in the “lessons” because they seem pointless. The teacher believes that the child is able to do what is being asked and becomes increasing frustrated at the child’s “refusal” to cooperate or pay attention–and cannot hide this from the child. The child’s self-esteem begins to suffer and he begins to associate teaching sessions with bad feelings. He becomes increasingly resistant to the periodic attempts, often involving rising levels of reward and punishment, to force him to do something that he cannot. The focus of the teacher moves from teaching to behavior management.

Particularly with young children and tasks that were mastered years ago by the teacher, there is a tendency to assume that the task is simple, that the child will succeed at it if he will “just try”. When the child balks, it is seen as a motivation issue or a discipline issue. Other potential causes for the balk are overlooked: The child doesn’t understand the instructions, the child has not mastered a prerequisite skill, the material is being presented in a confusing way, etc. It is critical to make sure that the child is, in fact, able to do what is being asked, particularly when dealing with children who are different from normal–because of environmental factors, developmental problems, or “conditions” like ADHD–and may not have mastered knowledge or skills that they are expected to have.

Breaking (or preventing) the cycle requires a clear understanding of the prerequisite tasks and methodically ensuring that important tasks are mastered before moving on to the next one. I mentioned previously that I worked for a time with a group of disadvantaged kids. Most of them were in the 3 to 4 year-old range and were from awful family situations. They were already pretty well-known for being unmanageable and were being separated from the “normal” kids for much of their day. During my first couple of days, I observed numerous instances of failure to follow–or even acknowledge–instructions. They played differently from the other kids and they interacted differently with the adults. I saw a lot of apparent “deliberate defiance” and “not listening”. However, I also noticed patterns in the kinds of instructions that they would not follow or had trouble following correctly. With limited evaluation tools available to me, I started playing “games” with the kids. During their free time, I would see one sitting and playing alone, and I would sit down with the child and start playing. Interestingly, the other kids would usually come join the game, which was similar to a grammatical Simon Sez:

“Touch your nose.”
“Touch your ear.”
“Raise your hand.”

I was very careful not to give any non-verbal cues, like looking at the children’s hands, to go with the instructions. Since the tasks were simple, and presented in an unexpected way, the kids tended to think it was hilarious. As they settled into it, I began experimenting with more complex instructions. The goal was to find out how developed their language skills were.

“Raise your left hand. Raise your right hand.” Most did not know “left” and “right”.
“Stand up and raise your hand. Sit down and touch your nose.” Compound simultaneous instructions. For the most part, they were able to do two at once.
“Touch your nose, then raise your hand.” Several were not able understand that there were two instructions and would tend to just follow the second one. This, in and of itself, explained the continuous difficulties they were having when told things like, “Put away your toy and then sit down in your seat.”
“If I am touching my nose, then raise your hand.” There was a little girl in the group who was thought to be seriously disordered. She had a tendency to speak in gibberish, basically a bunch of syllables with a few words scattered in between. Interestingly, she was the only one of these kids that was consistently able to evaluate If-then constructions and perform the right action.
“If I am not touching my nose, then raise your hand.” The various ways that adults create negations using “not” can create quite a bit of difficulty.

For the most part, my suspicions were shown to be correct: A lot of the cases of “defiance” that I was seeing were, in fact, cases of the child not understanding the instructions being given. I also discovered that one of the children was almost deaf. It turned out that he had problems with ear infections and the doctor had recommended putting tubes in his ears, but his mother was deathly afraid of “surgery”. One of the small victories we achieved while I was there was convincing her to allow him to have the tubes. Needless to say, his progress at school accelerated impressively once he was able to hear what was being said to him.

At its core, Direct Instruction is nothing more than systematically teaching skills, evaluating continuously to ensure that mastery is achieved, and insisting on mastery before moving to the next skill.
TEACHING AND LEARNING

Direct Instruction is not built around some ground-breaking new theory or teaching “recipe”. It is built around making the best use possible of what we know about cognition and learning, and careful presentation of new knowledge and tasks. For humans, learning is closely tied to repetition. We master tasks by practicing them. We maintain skills by using them. DI teaching sessions are focused on providing lots of opportunities for children to practice being right and are very participatory. To that extent, watching someone teach a class using DI can be like watching a game show or some sort of audience participation event. You’ll hear the teacher say a lot of things structured like this: “Two plus two is four. What is two plus two?” The kids rarely “wander” because they are continually participating. Lessons consist of “teaching” the task, and then practicing the task. By continually requiring the children to practice, the teacher is also able to continually evaluate how well the material is being learned. Teachers are focused on encouraging repetitions of right answers and discouraging/preventing wrong answers.

Often, particularly with kids that are different from normal, the hardest part can be getting that first succesfull attempt. When possible, one of the most powerful teaching tools is modeling. Demonstrate the “correct” behavior to the child. When we were working with the autistic child, it took days to get him to say anything at all in response to “Tell me what you want.” So we modeled it, over and over, taking turns giving instructions to each other. After an hour or so of saying, “I want a cracker” and then being given one, I usually left the sessions quite full. The first time he said, “I want a cracker” was like an epihany. For weeks, we continued to have to model the behavior at the start of every session, but it was never again as hard as that first utterance. In Direct Instruction, each “session” is considered to be a limited number of opportunities to practice success, and the goal is to take advantage of as many as possible, without wasting time or chances.

So, there is a focus on doing the right things. Equally important, there is a focus on NOT doing the wrong things. When teaching a child, it is crucial to remember that every behavior on the part of the teacher is potentially teaching the child. Statements like “Why can’t you pay attention?” can quickly teach a child that he is unable to pay attention. Continually instructing a child to do things that he cannot do teach him that he is incompetent. Exasperated sighs, eye rolls, eyebrow-lowering teach the child that interacting with him is unpleasant and that he is a disappointment. Saying things like, “If you do that one more time, I will send you to your room” and then not doing it teach him that you are untrustworthy. Enforcing rules one day and not enforcing them the next teaches him that you are unpredictable. A child that is having difficulty understanding verbal instructions may be acutely attuned to non-verbal cues.

Particularly with complex tasks, it is important to break the task down carefully and present it in a way that does not cause unnecessary confusion. While many kids may be able to “work past” confusing lessions or instructions, some will be completely bewildered. Even before going to school of any kind, many children learn their “ABC’s”. They learn to be able to say–or at least sing–the names of the letters and to recognize them on sight. They are taught that there is a connection between the name of a letter and the sound it represents in a word. Unfortunately, our most hard-working letters, the vowels, do not adhere reliably to the sound of their names. In fact they don’t adhere reliably to any sound at all. There is the letter ‘A’ which has a long A sound (I don’t have any way of putting a line over it, so just imagine a capital ‘A’ as a small ‘a’ with a line over it) as in the word ‘lake’ but then has a short sound in ‘hat’ (I’m not even mentioning the “ah” version). This lack of consistency is difficult for many children to become accustomed to and can be particularly confounding with kids that have a lower aptitude for this sort of learning. For this reason, DI teachers do not teach the names of the letters. Instead, they teach sounds. The kids learn that the symbol ‘a’ “sounds like” a as in hat and that the symbol ‘a’ with a line over it sounds like A as in lake. DI teachers use flash cards that include symbols for the various sounds and the kids practice associating the correct sound with the correct symbol. Presenting the letters in this way solves the problem of confusion about what a letter “really is”. Later, once recognizing letters and blending them to make words is mastered, they are taught rules for determining which “version” of a letter is present in a word (like noticing a “silent ‘e’”). A DI instructor is careful to present every task in a way that it can be mastered in a step-wise fashion and that the individual steps can be learned without confusion.

So, in short, DI is, in many ways, a studied way of thinking about teaching. It is a deliberate approach to providing kids with skills that they need:
[ol]
[li]Break complicated tasks into smaller, teachable tasks.[/li][li]Model tasks or demonstrate correct answers in a way that encourages the child to reproduce them appropriately.[/li][li]Require the child to practice to ensure that mastery is achieved.[/li][li]Evaluate performance rigorously to ensure that progress is measured and level of mastery is known.[/li][li]When the child balks, investigate carefuly to determine the cause of the balk. In particular, make sure that the balk is not the result of a prerequisite skill that has been assumed to be mastered when it is not. The focus is on what must be taught to get past the balk and not on what traits of the child might create a tendency toward balking.[/li][/ol]

Going back to the example of the ADHD child that wouldn’t or couldn’t get dressed to go out, a DI proponent would, in the case of noncompliance, first set out to determine how well the child understood and had mastered the task. The child would be instructed to perform each step in sequence (take off your shirt) and observed closely to see if there is a step that causes the child to balk. The steps would then be grouped (put on your socks and shoes), and the groups would become increasingly complex until they were all grouped into “Get dressed”. There would be a lot of practice. Instead of instructing the child to get dressed and checking back a few minutes later, a DI-oriented teacher might go into the room, get completely undressed and then re-dress with the child, modeling each task and discussing it with the child. If the child has difficulty buttoning his shirt, he might be encouraged to completely unbutton and re-button it several times. All of these steps would not be presented as a chore but as an interesting activity to participate in.

-VM

170

THE PRACTICE OF TEACHING

The naming of “Direct Instruction” is a deliberate reminder to practitioners to take a practical, methodical approach to teaching that is task-oriented and requires a continuous dialogue between the teacher and the child. It is also a jab at much of the practice going on in education today. If these techniques are “direct”, then the implication is that the other techniques are “indirect”. Sticking with language instruction, I’ll make a simple example of teaching the A sound using a flash card. The card is shown to the child, and the child is asked to make the sound associated with the symbol.

Teacher: What does this letter sound like?
Child: blink
Teacher: A. This letter sounds like A. What does it sound like?
Child: a.
Teacher: No. A. This letter sounds like A. What does it sound like?
Child: A.
Teacher: Correct. Shows new card What does this letter sound like?
Child: A.
Teacher: No. This letter sounds like a. What does it sound like?
Child: a.
Teacher: Correct. Switches to first card What does this letter sound like?
Child: A.
Teacher: Correct. Wow, you are really good at this.

Letters would be added one at a time over multiple sessions. Letters that yield more incorrect answers are noted and drilled more heavily until they are mastered. Periodically, even letters that have been mastered are brought back again to make sure that they are not forgotten. I have described one teacher and one child, but the more common scenario is one teacher with a group of children and all the children answering as a chorus, with the teacher singling out kids as necessary to verify that they are answering correctly. It is this continuous chorus of kids answering the teacher throughout the lesson that makes a Direct Instruction session stand out the first time you witness one. I also remember thinking that it looked like it might be exhausting for the teacher. It definitely takes focus and energy.

Notice that the child is not allowed to sit and wonder what the answer is. If he does not answer in a time that shows that he “knows” the answer, the teacher provides it and gives him another chance. The important thing is that he still gets practice at saying the right answer. It is this practice that will ultimately ensure that he knows the correct response, not time spent searching his memory for possible answers. Also, wrong answers are not discussed or “thought about”. They are corrected quickly and, um, directly. The teacher does not repeat the incorrect answer; instead, the teacher immediately “replaces” the incorrect answer with the correct one.

Here are some examples of the mistakes that teachers and parents often make that lead to an “indirect” way of teaching:

Testing For Psychic Powers

Teacher: What does this letter sound like?
Child: blink
[Time passes…]
Teacher: Billy, tell me what this letter sounds like.
Child: shrug
Teacher: Well, what do you think? Think about this letter and where you might have seen it before. What do you think it sounds like? Surely you can make a guess?
Child: O?
Teacher: No, but that’s close. Think about another sound that’s like O but different…

Notes: If nothing else, a great deal of time is wasted here that could have gone to productive practice. Even worse, the child has practiced a wrong answer. Combined with all the time and concentration spent producing it, he is likely to have a fairly stong association of O with this symbol, and it will take even more work to replace this with the correct answer. In fact, the next time he sees the letter, he is likely to remember it as a “hard” letter and have that much less confidence in his ability to produce the correct sound. At the same time, the child feels less “smart” because he was not able to psychically determine the sound of the letter. The teaching time has, so far, been dominated by time spent sitting and feeling uncomfortable.
Reinforcing Incorrect Responses

Teacher: What does this letter sound like?
Child: O.
Teacher: I don’t think that’s right. O is for words like ‘hope’ and ‘coat’. This is not O. Do you want to try again?

Notes: Not only has the child practiced a wrong answer, the teacher has mentioned the incorrect answer several times while still holding up the A card. In effect, the teacher is strengthening the association of the A symbol with the O sound.
Criticising Needlessly

Teacher: What does this letter sound like?
Child: shrug
Teacher: Come on, Billy, I know you know this on. We worked on this yesterday. Don’t you remember yesterday? If you ever want to read, you’re going to have to learn these letters.

Notes: This is not much different than saying, “You aren’t very good at this, are you?” Might as well tell the child that reading is hard and he’ll never be very good at it.
Playing Psychotherapist

Teacher: Why don’t you listen to me when I’m talking to you? Why can’t you pay attention? Why can’t you follow instructions?

Notes: One thing that pretty much all kids are not known for is introspection. Not only is this harmful to their self-esteem, it is also a ridiculous waste of time. If these things are really issues, then these are questions that the teacher should be asking him/herself.
Distracting With Vague Tasks

Teacher: What does this letter sound like?
Child: glances out window, shrugs
Teacher: Billy I want you to pay close attention to the card I’m showing you. Look very closely at this letter. Notice the way it is shaped. See how there are two lines here, and another line between them? You’ve seen this letter before. Now, think about it carefully and tell me what sound it makes?

Notes: While knowing how a letter is constructed is important in writing, it is not important in reading. Again, valuable practice time is being wasted and the child is being instructed to do things like “pay attention” and “think carefully” that are too nonspecific to be very useful. In particular, “paying attention” is difficult to succeed at because you can “pay attention” for five minutes, glance away for two seconds, and be evaluated as having not “paid attention”. If the child is not looking at what he needs to see, instructions should refer to that specifically: “Look at this card in my hand.”
Playing College Professor

Teacher: This letter sounds like a. We use it to make words like ‘hat’ and ‘bat’. Notice how the words sound alike? And this letter sounds like i. We use it for words like ‘sit’ and ‘hit’. Let’s look at some more words that use these letters…

Notes: In this case, the practice gets skipped altogether. The child is expected to have perfect recall and to figure out how to blend letters into words immediately on his own. In a variation on this, the practice portion of each task is relegated to homework. To my way of thinking, the teacher has given him/herself a promotion to a position where “boring” tasks can be delegated to others. In other words, the teacher has decided that the actual teaching is someone else’s responsibility (or the child’s). My elder daughter is in first grade. Her teacher sends homework assignments to my wife that involve practicing drawing letters over and over again–even though my wife has no training in the teaching of letter-drawing. Fortunately, my wife does not work and has plenty of time to muddle through these practice sessions with Daughter1. However, I am not optimistic about the level of mastery that will be reached by other kids in the class with different home situations. Lately, they’ve been having to write words and sentences. At one point, my wife said to me, “She keeps mixing up her b’s and d’s. Do you think she’s dyslexic?” I said, “No, I think she needs more practice drawing these letters.” So, my wife instituted a system where, if Daughter1 writes a ‘b’ instead of a ‘d’, she stops and has to draw a ‘b’ ten times. Last I checked, she hasn’t had to practice a ‘b’ or a ‘d’ in months.
Trying To Turn A Kid Into A Machine

Notice that, in the very first example I gave, the teacher makes a point of communicating that the child is doing well. The child’s abilities are complimented and the monotony is broken up. If you watch a DI instructor, you’ll notice that they keep their faces animated and keep a “game” atmosphere. When the children are being drilled with b’s and d’s, it can seem like the teacher is being tricky, and the teacher will play this up for humor. The more it feels like a game, the more the children attend to it and the longer it takes for the task to become boring. Children will also tend to notice what other kids are saying, which will help the teacher know when one of the kids is giving a wrong answer. The desire to compete will cause the kids to try to answer ever more quickly and correctly. Many educators begin to get uncomfortable when a teaching session looks like too much fun, even though the should be striving for more of it. All through the animal kingdom, it is easy to see how the young practice skills they will need as adults through various kinds of play.
Taking It Too Far

Teaching in this way is very effective and the children tend to master material very quickly. Forcing them to continue to practice something well after they have committed it to memory will turn from fun into boring repetition. DI teachers are careful to keep sessions at a reasonable length (30 min to 1 hour) and to move on when the kids are getting the answers right and becoming fidgety. They are also careful to ensure that there is a place that is associated with teaching. The children play in a different place from where they are taught. In addition, if a child becomes disruptive or uncooperative, they are moved to a different place. It is important that the only activity associated with the learning “place” is positive participation in the learning activity.
Thinking of Children As Adults

This is pretty much the opposite of the previous one. Watching a session of this sort, adults can become bored very quickly. Those of us that know what an ‘a’ sounds like have a hard time focusing too closely on practicing it. However, for the kids, this is not old hat, and so the practice is not as boring as it might seem to adults. In fact, practicing something new can be quite entertaining and satisfying. Anyone who has whiled away several hours pitching playing cards into a garbage can has experienced this.
NO CHILD LEFT BEHIND

My first experience of Direct Instruction was in a daycare center. Some of the kids were there because they needed special help, but most of them were there because their parents happened to work at the University and the daycare center was convenient for them. The kids spent much of the day just being kids, but they would have a few classroom sessions scattered throughout the day. I remember visiting a session that was packed with 3 and 4 year-olds. The first thing that struck me was how involved with the lesson the kids were. A student teacher was standing at the blackboard and leading the practice. About 20 kids were gathered around in chairs, answering questions like a tiny, high-pitched chorus. Most of the time, they were smiling. When I walked in, they glanced at me briefly and then immediately turned back to the more interesting stuff going on up front. The second thing that struck me was what they were learning. They were doing addition and subtraction. Later, I watched 4 year-olds practicing substituting a short ‘a’ with a long ‘a’ when they saw a silent ‘e’. Every child in the room–not just the gifted ones–was already reading at a second or third grade level. I was astonished.

Since that time, I have often thought about the expectations we place on kids when they start school. We use teaching techniques that require a lot of them. We teach them the letter A that sounds like a, but sometimes sounds like A or ah. We teach them the letter ‘e’ and then correct them for pronouncing it at the end of a word. Compared to the careful presentation of Direct Instruction, current teaching techniques seem to be almost designed to confuse the children. It becomes a techniques of weeding out children that can’t figure certain things out on their own. We humans have a way of stumbling around and screwing things up in numerous ways before we figure out the “right” way of doing things. It doesn’t really bother me that it has taken so many years of human development to learn what we know about teaching and learning. What really bothers me is that, after having learned so much, we aren’t applying what we have learned in most of our schools.

Educators have responded to idea of Direct Instruction with defensiveness and outrage. They have described the teaching techniques as cruel and theorized various ways that they might stifle creativity. The reflexive resistance to such a deliberate, planned approach to teaching is mystifying to me. In the same way, I am mystified by concerns that standardized tests will encourage teachers to “teach to the test”. Isn’t that what you want? You design a test that evaluates whether children have mastered what they need, and then you teach them in such a way that they can pass it. I can’t think of a more scientific approach to the process. The teachers’ union in this country is a powerful lobby, and educating children is clearly not a high priority for them. They fight efforts to ensure that teachers are qualified, to evaluate teacher performance, or to create standards for teaching excellence. These are the people that I am angry about. I have seen, in so many cases, how quick they are to inform parents of this or that deficiency in a Child: “Well, your child is falling behind in reading, and we think it is because he has x condition.”

Yeah? Well, maybe he does. Then again, maybe you aren’t teaching him correctly. It bothers me that parents are encouraged to modify their kids to make them better suit the way teachers want to teach, while teachers seem so unwilling to modify their teaching to better suit the way pretty much all children learn. In reading about the President’s commission on special education, I was morbidly fascinated by the amount of time that was spent discussing the kids–what color they were, what disabilities they had, how much money their parents had, how they behaved–and how little time was spent discussing the teachers and how the teaching is being carried out. If we ever truly want to insist that no child be left behind, I think that we must insist at the same time that our publicly funded teachers use teaching techniques that a grounded in the best that cognitive science has to offer. Speaking solely for myself, I’ll give a lot more credence to claims by schools about a child’s deficiencies when I see evidence that they have first addressed the deficiencies of the teachers.

Anyway, I hope this provides a bit of a “look” at what Direct Instruction is all about. The DI folks are focused on where they think they can do the most good, which is why they focus so much on reading and writing. However, the fundamentals of teaching and learning are equally as true for learning other important skills, including those that we don’t always purposely teach, like social skills. For parents with kids who are “different from normal”, like ADHD kids, I encourage you to find out more about DI and how it can be used to ensure that your kids learn the things they need to know.

As a first step, when the child fails to do what is expected, before addressing it as a disciplinary issue, I recommend careful evaluation to try and determine if the child knows what is expected and how to achieve it. Test the child’s understanding of the instructions. Have the child practice tasks that cause problems. It is amazing what can be achieved when you switch from a disciplinary or deficiency-focused approach to a teaching approach. First you make absolutely sure that the child is able to perform the task, THEN you focus on how to “make” him do it.

-VM

171

Much of it utterly irrelevant to this thread,

You still haven’t shown any reason why DI shoudl be considered useful for ADHD.

Except that you still haven’t shown why DI should be considered any more useful in the treatment of ADHD than insulin or peptobismol.

With all the studies of ritalin etc out there, you found no evidence to back up this hypothesis? From this, I can only come to the preliminary conclusion that you are once again talking out of your ass.

Except that without meds I could not, and still can’t, do things like read Tolkien. Or a large number of other things I enjoy a great deal. I want a cite of those sources. The claim that people with ADHD can focus if the task is interesting to them is bullshit. Sometimes we can. Sometimes we can’t. To reduce it to ‘This is boring so my ADHD kicks in’ is unbelievably stupid.

[QUOTE]

[li]Which, as far as this particular topic goes, takes me back to about where I started: I think that parents should try to avoid medicating their kids if they can. However, if the problems are not improving, they will only be made worse if the child is not able to progress at school. While I have some concerns about the long-term effects of stimulants on kids, these concerns are much less strong than the obvious harm that results from failure to succeed in school. In other words, while the meds may do some harm, they are far preferable to sacrificing a child’s education, which will most definitely do significant harm. If the child’s education and/or emotional development are at risk, then the risk of the medication seems to be the safer course. And parents that have made this choice shouldn’t be beating themselves up about it.[/li][/QUOTE]

Either provide evidence that the medications are doing harm or admit this claim is totally unfounded in reality

That assumption was entirely true in my case when I had the same problem.

172

I have edited the following quote down to information relevant to this thread

I am not now, and never was, claiming that DI was something you made up or hallucinated. However, like string theory or the proper conjugation of German verbs, it has nothing to do with this thread. You still haven’t demonstrate why DI would be helpful to ADD kids other than claiming with almost religious zeal ‘DI is the solution to all problems’

173

That and citing Free fucking Republic!!! I mean, yeesh, why not just use Art Bell as a citation!

174

Alright, here’s what you don’t know you don’t know. The American Psychiatric Association publishes the Diagnostic and Statistical Manual which is the handbook for psychiatrists, clinical psychologists, and the like. When the manual was updated in the 1970’s (DSM-III, published 1980) the American Psychiatric Association attempted to define “mental disorder” as being rooted in physiology. Thus, psychiatric conditions would qualify as diseases in the traditional sense, connoting that some body part has physically malfunctioned. The American PSYCHOLOGICAL Association threatened legal action if this definition was replaced with one that provides no focus on any specific etiology.

The reason for this is that without the endorsement of the American PSYCHIATRIC Association, a group of MD’s, many of the conditions that psychologists (PhD’s) research and treat would no longer be credible in the eyes of insurance companies or organizations that grand research dollars such as the National Institute of Health of the National Institute of Mental Health. Twenty-five years ago psychology really needed the endorsement of the Psychiatric community.

Conditions such as Oppositional Defiant Disorder are referred to as mental diseases because there exists a clear definition of the symptoms, as well as a “fix” to ameliorate the symptoms. Sometimes it works pretty well and sometimes it doesn’t.

The bottom line here is that there are people who present very predictable clusters of behavioral quirks, which are really better labeled as “syndromes.” ADHD, ODD, eating disorders, anxiety disorders are examples, and all are very real and if left unchecked, can have horrible effects. Some of these symptom clusters have a more clear cut basis in physiology and traditional medicine (schizophrenia, for instance) than others, but whatever the basis for a psychological disorder, it should be professionally treated if possible.

175

Not sure how many have seen or heard this?

full article at

http://www.newscientist.com/article.ns?id=dn6886