Wednesday, February 4, 2015


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


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  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


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

Tuesday, March 4, 2014

ADHD World

ADHD World


For many years there have been tantalizing studies purporting to show that neurofeedback (NFB) improves symptoms of ADHD, with lasting effects after treatment is finished. NFB has focused on minimizing slow EEG waves (theta) and increasing fast waves (Beta).

Unfortunately all of the studies have suffered from methodological limitations of one sort or another, with the most common fault being that the control groups are non-blinded, so the clinical observations by parents or others can be biased by knowledge of which treatment the child received. It has been very difficult to provide a sham treatment that is not obviously apparent to observers or EEG managers who measure the outcome.

A recent study by Steiner and colleagues provides an excellent example. Their study was unique in that it took place in the school system, where the patients or controls received three times weekly training. The ADHD experimental group received the NFB training, while the control group received a computer-based attention training program. Both groups were examined by direct obseervations in the classroom as well as by the Conners Rating Scales by parents. The results, even 6 months later. showed superiority of response on the rating scales for the NFB treatment.

But note that the direct classroom measures showed no difference. The controls were obviously different in appearance to the raters as well as known by the EEG managers.Fortunately, these kinds of limitations have been apparent to others, and recently a new study was funded by NIMH that has introduced sophisticated controls in the form of a "sham" treatment where even the EEG technicians cannot be aware of which group is getting the real treatment. Dr Gene Arnold and a team of exerienced NFB trainers will carry out the study with consutation from outside statistical experts. This new study should once and for all show whether NFB  has SPECFC lasting effects for ADHD chidren.