Sunday, February 14, 2016

NASP EXPERIENCE

I didn't plan to watch the Republican debate last night. But Time Warner Cable screwed up again and failed to record what turned out to be a thrilling basketball game, which Duke won at the buzzer by Grayson Allen's tip-in. I was mightily miffed and needed some light entertainment.  It was as expected,  a raucous slur-fest in which each debater reviled the others, a comedic display bordering on childish ranting.
But enough of my misspent evening. I have a load of impressions longing to be released about my whirlwind week in New Orleans.
Travel to and from the Big Easy via Charlotte was, like all travel these days, partly a struggle to manage maneuvering of wheel chair, walker, luggage, and airplane sardine-like seating. My intrepid wife did her usual heroic juggling of documents, carry-on of medical baggage, and equipment managing, all the while fighting a cold (as an employee of Durham public schools she is always fighting a cold).
My wife was thrilled to catch the Mardi Gras parades up close, while I was content to catch an occasional glance from our 9th floor room. The excesses of Fat Tuesday, with the drunken audiences crowded into a dangerous mix of pickpockets and wildly exuberant onlookers held little interest, except for her safety. But she managed well by engaging helpful Stewart, a bell hop whom she charmed into showing her the safer spots to view the mayhem.
On the following days she was occupied with workshops to bolster her required CEUs for her job as School Psychologist. I spent a lot of free time people-watching in the large lobby, always jammed with conventioneers and their laptops, seeking respite from their workshops before once more leaping into the fray (not actually crying "Once more for King Harry and our English dead.")
One example out of that mix was one day when I finally found an empty table for three, all else being filled up. So I sat for quite some time, until I got bored and listened to Dietrich-Fischer Dieskau lieder on my cell phone. Finishing that after an hour or so, I suddenly had a couple who asked if they could be seated at the two empty chairs at my table. Of course!
For some time they conversed as if I wasn't there, and I had no choice but to hear their conversation.  The older man was the former supervisor of the younger woman when she was a graduate student. They met for the first time in many years. He was asking her about her work now. She was telling him how easy it was to use the computerized automated report tool for the BASC ( popular Behavior assessment scale for children). He was very animated, saying, "A monkey could do that! The only thing you should focus on is being a change agent; doing something positive to enhance their lives,"and so forth.
I stood up ready to leave, extended my hand and introduced myself. "OMG! She says," and then asks if she could have a picture with me, I was flattered as always to be recognized as the old guy widely known in her field, and presumed to have passed away years ago. I told the supervisor I agreed wholeheartedly with his sentiments about the BASC. I wished them well and remarked that it was good they could still talk to each other after all the years. Laughter.
My encounters with school psychologists continued the next day when I was scheduled to sit at my publisher MHS's booth for a Q & A session by passers by.  Most of the people who stopped seemed to be young females just starting out as school psychologists.
I usually asked about their work and heard their mixture of pleasure at the variety of roles they filled, as well as the drudgery they experienced  a lot of the time, filling out reports, attending unproductive meetings, and sadness at the overwhelming disabilities among their clients and families.
I was usually positive, telling them they had a unique chance to observe the amazing variety of psychopathology that passes by them every day in their job. They had a chance to accumulate valuable insight based on their intuitive capacity to synthesize their impressions over time. I allowed that one of my great regrets was not recording those impressions in a daily journal, something whose significance I I only discovered recently in my own life.
The response to that mini-seminar was rewarding. They suddenly recognized how valuable their brain was, beyond the numbing drudgery required by the great bureaucracy they are part of. Collecting their impressions over time could elevate their profession to a higher level, seeing patterns beyond the artificial tools psychologists often become wedded to and which actually can obscure the unique qualities they see from direct impressions.
Perhaps I will give that sermon at the next NASP convention!

Wednesday, February 4, 2015

HIGH TECHNOLOGY AND MENTAL ILLNESS: A MATCH MADE IN HEAVEN, OR HELL?

When I first trained as a clinical psychologist in the Department of Social Relations at Harvard, it seemed peculiar at first that the program required Anthropology, Sociology, Social Psychology, Behavior Theory, as well as the expected specific practicum and clinical training. The idea seemed to be that clinical work cannot be separated from broad experience with everything human.

Clinical assessment itself had the usual lectures and practicum experience on symptom-based psychopathology, but also emphasized Robert White's and Henry Murray's approach of detailed life stories. Every life is a story that has to be understood from its beginning, adhering to Aristotle's advice that, "If you would understand any single thing you must observe it from the beginning." Mental life and its accompanying behavior and environments are complex and ever-changing; something only hinted at in a single hour of gathering the story. Good preparation is like good novels, something to be read with care.

Poetry also often informs us of mental life not otherwise easily understood. How better to understand grief than Shellley's Music When Soft Voices Die, or stream of consciousness and T.S. Eliot's Lovesong of J. Alfred Prufrock? In those moments in the office when patiently listening to the story of a family or patient, everything you know or believe informs how the story is eventually put together. An awesome responsibility. Great scholarship and classical learning does not completely prevent atrocious ideas as well as some profound ideas taking over the mind, like Dawkins' concept of mental viruses (as the history of psychoanalysis abundantly shows). But our culture has always valued learning as the foundation of healthy human life.

Back at Hopkins the early 60's the clinical process seemed straightforward: gather as much information in the time allowed, using tools of the trade such as interview, psychological testing, brief consultation, behavioral strategies such as Jacobsonian Progressive Relaxation, new ideas (at the time) such as Wolpe's hierarchical fear exposure, family social work, and so on. Randomized clinical trials formed the basis of the new developments in psychopharmacology. Psychiatrists, psychologists, and social workers shared the load as a team. Some of what we learned has been proven invaluable to the lives of patients, though some of what we learned has also been committed to the dustbin of history as evidence became available.

Much has changed since that time. We had no computers, cell phones, diagnostic structured interviews, rating scales or APPs. My first study involved a checklist of referral problems gleaned from the table of contents of a Handbook of Child Psychiatry. By changing the checklist into a scale and factor analyzing the results, I created a useful scale for gathering information and tracking treatment effects. But I never envisioned that the scales would be applied without the requisite training at the professional level, as a helpful tool, not an end in itself in writing the story. Recently we read of teachers who exaggerate the symptoms of troublesome children to insure that they receive drug therapy, thus increasing the financial benefits of a reward-based special education system.

Now something has happened that we never envisioned. Rating scales and clinical applications like Cognitive Behavior Therapy,  Self Examination of symptoms,  of mood, behavior states, thoughts and related activities, drug side effects, dietary choices, and more are being recorded on APPs for cell phones. These programs act like self-managing therapy or recording devices, that can also include physiological parameters like heart rate, blood volume, or even EEG. The patient has, in a sense, become their own doctor. The APP acts like an extension of the doctor's knowledge, but knowledge applied and evaluated by the patient.

But one question is troubling: Do they work? Could they be harmful as well as helpful? We have always assumed that various forms of mental illness are by definition subject to processes that involve more than ordinary problems of living. True, this assumption may be incorrect and also needs examination by empirical data. Can the explosion of reliance on new technology turn out to be harmful to the individual, or at the least an expensive waste of time? Could they further the over diagnosis and over treatment already a disaster in much of the mental health arena? It may seem lame to say, "Go ahead, let's try it until further research answers our concerns," but perhaps we should also become more Scottish at heart and say, Caveat Emptor!

Readers of this blog are already conversant with the new technology. I am curious how you all respond to the question above.

Thursday, January 1, 2015

Impairment and Development of Rating Scales for ADHD

For the past several years we have been updating the Conners Rating Scales in order to accomplish several goals:


  • Establish new norms based upon a large census-based sample in North America, using the latest statistical analytic methods
  • With the 3rd Revision of the ADHD Scale (C-3), add items to improve test-taking validity
  • Provide separate norms for DSM and empirically based factor ADHD items
  • Add a new scale to cover broader aspects of childhood psychopathology (Comprehensive Behavior Rating Scale  or CBRS)
  • Provide more useful detailed report features with automated scoring
Data from the large standardization project can reveal important information about the diagnosis of ADHD. For example, the significance of the Impairment data comparing the general population with diagnosed ADHD is the fact that they show an excess of diagnoses were made without reference to impairment. A substantial portion of responses to the question of degree of impairment among children with a diagnosis of ADHD in the sample is "Never," this despite the fact that approved DSM standards were supposedly used. 

Diagnosing from symptoms without evidence of impairment is simply shoddy practice! 




Thursday, May 1, 2014

DSM-5 OPENS THE DOOR FOR INCREASE IN OVER-DIAGNOSIS OF ADHD

A recent report on field trials of DSM-5, reports that the results "support" the validity of the new official APA manual compared to the earlier DSM-IV manual, because DSM-5 identified more ADHD children. (see alert.psychiatricnews.org.)  Approximately  10.84% in DSM-5 vs 7.38% in the earlier version were identified using a structured parent interview. The main source of the difference appears to be the change in the required age of onset of ADHD from age 7 to age 12.

The leader of the study, Kathleen Merikangas is a well-known epidemiologist at NIMH, but remarkably she chose to see the higher recognition rate as a plus, whereas early criticism of this change had universally feared that it would open the gates to more false diagnoses of ADHD.

Although this trial was for children age 12 to 15, one can well imagine the profound impact the greater recognition will mean for adult ADHD as well. Now the requirement that diagnosis find significant pathology at age 7 or younger no longer applies. Children 12 years or older with conduct disorders or oppositional defiant disorder will now find an easier path to an ADHD diagnosis.

The fear that such early information for age 7 or younger would be difficult to obtain is greatly exaggerated; we seldom had trouble obtaining such information from the patient or from relatives or significant others. Parents are often still available for older patients, and the profound effects upon the early years of the patient are seldom forgotten by the patient themselves.

The greatest beneficiaries of the DSM-5 changes in age of onset criterion for diagnosis of ADHD will be pharmaceutical sales of stimulant drugs.

Sunday, March 23, 2014

ADHD CLINICAL PRACTICE OVERVIEW: BEST ARTICLE

One of the best aricles about ADHD, its appearance to the practicing clinician, the evidence supporting its treatment, and formal guidelines for management, recently appeared.

In a succinct and clear exposition, pediatricians Heidi Feldman at Stanford and Michael Reiff at the University of Minnesota lay out the typical appearance of ADHD in children and adolescents, the specific treatments known to work best, and the essential recommendations for management based upon good scientific studies.

This nine page document is well worth reading, as opposed to much of the lengthy tomes of nonsense available on the internet and blogosphere. The entire article is a thoughtful response to the following question:

"A 9-year-old boy who received a diagnosis of attention deficit-hyperactivity disorder (ADHD) at 7 years of age is brought to your office by his parents for a follow-up visit.  He had behavioral problems since preschool, including excessive fidgeting and difficulty following directions and taking turns with peers. Parent and teacher ratings of behavior confirmed elevated levels of inattention, hyperactivity and impulsivity that were associated with poor grades, disruptions of classroom activities, and poor peer relationships. He was treated with sustained release methlylphenidate. Although teacher and parent rating scales after treatment showed reduced symptoms, he still makes careless mistakes and has poor grades and no friends. What would you advise?"

The article appears in The New England Journal of Medicine, 2014;370:838.46. An audio version is available at NEJM.org.