Daily Archives: August 21, 2010

Attention Deficit Hyperactivity Disorder (ADHD)


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Attention-deficit/hyperactivity disorder (ADHD) is characterized by chronic, pervasive, and developmentally inappropriate patters of inattention, impulsivity, and/or hyperactivity.  (Netherton, Holmes, & Walker, 1999, p. 98)

I wasn’t surprised at all that ADHD was mockingly referred to as “the latest fad in psychiatry” or “the disorder of the 90s.”  I graduated from high school in 1995, and I remember hearing about it as early as 8th grade.  It was probably the first “formal” pathology I was ever exposed to, and the first disorder I was able to have a conversation about with my school peers.  Obviously this was driven by the media to some degree, but at some point it became part of our collective conscious as high school students.  Even as kids, we could drop ADHD in a conversation and everyone would have some general idea what you were talking about.  I was barely 14 the first time I saw someone trade Ritalin for enough cash to get a soda and a candy bar.

We all grew up with people that “didn’t listen to instructions” or “became bored easily.”  We’ve all ran into the kid who “makes indiscreet remarks without regard for social consequences,” I like to call them the class-clowns.  What confuses me, is that the ambiguous nature of the criteria for diagnosis could probably apply to most kids in one way, shape, or another.

This is the first DSM-IV-TR I have experienced that requires sub-typing.  I was previously unaware of ADHD Combined Type, ADHD Predominantly Inattentive Type, ADHD Predominantly Hyperactive-Impulsive Type, ADHD in Partial Remission, or ADHD NOS.  (Netherton et al., 1999, p. 101)  The separation of the diagnostic criteria in the DSM-IV-TR and the ICD-10 seems to make logical sense to me.

I, too, was under the impression that most people outgrow their ADHD problems as they reach adolescence.  (Netherton et al., 1999, p. 103)  I still know a few adults that would describe themselves as ADHD, despite the fact that research suggests that the vast majority of people learn to compensate for these problems and therefore make a satisfactory adult adjustment.  Perhaps the few self-described adults I know are more the exception than the rule.  It leaves me to wonder about prevalence, and how many “normal” adults I know that were previously diagnosed with ADHD.

ADHD is best diagnosed outside the clinical environment since symptoms are much more likely to occur in situations that are highly repetitive, boring, or familiar.  (Netherton et al., 1999, p. 104)  Because of the nature of the pathology, we are increasingly dependent on the accounts that are reproduced by parents, teachers, and other engaged caretakers.  I totally agree with Netherton and associates that it can provide “a basis for determining how likely it is that parents and other caretakers will implement recommended treatment strategies on behalf of their child or adolescent,” (Netherton et al., 1999, p. 106) but I question the consistency of the reporting as a measure of diagnosis.  While I can’t totally discount second hand accounts, I would be inclined to go observe personally so that I can draw my own conclusions.  Is it considered acceptable for a clinician to go observe a kid in the classroom?

I have never heard of “drug-free holidays,” nor have I know my associates who were diagnosed with ADHD to discontinue the use of pharmacotherapy on the weekends… but I would be inclined to recommend it just we can get a measure of exactly what effects the medication is having.  I think the concept is especially useful where combined interventions have been implemented.

Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

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MTV’s I have Autism


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MTV dares to impress with “I Have Autism.”  The presentation details the lives of three very inspiring young men who all have differing presentations of what has been described as “pervasive developmental disorders” or “autistic spectrum disorders.”  (Netherton, Holmes, & Walker, 1999, p. 77)  As a group, their autism appears to separate them as different from their peers, mostly because the disorder makes it really difficult for them to connect with the world around them.  All of them share a desire to be like “typical teenagers.”

Jeremy, 17, was diagnosed at the age of 3 with severe autism.  He has never been able to speak nor has he had friends like normal teenagers.  This non-verbal form of autism allows him to make sounds, but he is unable to form sentences.  He also struggles to control his facial expressions and his body movements.  Overall, Jeremy’s biggest challenges are communication and socialization.

At the age of 15, he began to use a letter board to communication, and over time, they came to find that he was essentially a normal 15 year old kid inside.  When he could finally communicate, he told his parents that he wanted to make friends his own age.  They decided to try something different at the age of 17, namely, employing technology called a LiteWriter.  The LiteWriter represents his last opportunity to communicate with his peers and classmates before he graduates from high school.  The LiteWriter has a voice that reads out what’s typed.  As a result of his advances, made possible by the LiteWriter technology, Jeremy invites a number of his peers over to his home for his 18th birthday party.  He totally didn’t know what to expect at his party, as he had only seen teenage parties on television.  Although Jeremy still has some significant challenges to overcome, I think has made great strides toward achieving autonomy as it relates to communication and socialization.

Jonathon, 19, is an Artistic Savant.  His case presents us with many “typical” Autistic traits coupled with extraordinary artistic talent.  10% of Autistic people have some form of special skill, and it is evident throughout the presentation that he is very passionate about his art.  His language is somewhat impaired, making conversation very difficult.  He has a very hard time with abstract thought, and has a great deal of trouble articulating the specific feelings that his is having.  He is very sensitive to sound, and often wears headphones to block out extraneous noise that overwhelms him.  Jon says Autism means “Brain is not working.”  Lately, he has been experiencing sudden and uncontrollable outbursts that are having a negative impact on his ability to express himself through his art.  Beyond his art, it is affecting his overall quality of life.  He seems to be progressively degenerating, having the outburst with increased intensity and frequency.  His medical team has not yet determined the source of the outbursts, but his father is working on proactively working on helping him control his emotions.  His lacks of ability to control these emotional outbursts are his biggest challenges, and the issue remains unresolved at the end of the segment despite extensive testing.

Elijah, 16, has Asperger’s Syndrome.  The primary difference between Asperger’s and autism is the level of functioning.  Asperger’s is described as a “high functioning form” of autism.  Elijah does not see Asperger’s as a disability, and rightfully so… he’s a really smart kid.  Most people who have Asperger’s have average or above average intelligence, but like Elijah, many have trouble with social interaction and communication.  As a child he repeated phrases, and was very difficult for outsiders to understand.  He wants to be a comedian, but he is worried that if he tells people he is autistic, they might not like him.  He is writing his own original comedy material and attempting to develop his comedy talent.  Because Elijah is worried people will think he’s weird, he has a great deal of stress regarding the disclosure of his condition.  As a result, I think Elijah’s biggest challenge is self-esteem, or self confidence.  His success in the Las Vegas comedy festival really helped him take positive steps toward being comfortable with his condition.  I was very surprised (and impressed) that Elijah was able to overcome his fear of people judging him.  The end of the segment suggested that he intended to start every show with a joke about Autism, and as a result, I would consider his biggest challenged resolved!

As a future counselor, I found this particular video to be really inspiring from a number of different perspectives.  First, the presentation gives us a basic understanding of how different each individual case can be.  I have formed the opinion that regardless of how many PDD cases I encounter, I really need to wipe my slate clean and access each case objectively.

Through the first segment, I would have expected Jeremy to have to most difficulty overcoming his condition.  In the end, I think he was the one of the three that managed to cover the most distance and make the greatest strides to achieve his goals.  This really challenged my lower expectations for Jeremy, given his lower level functioning.  I really appreciated the integration of technology into his development.  I found Jeremy’s story to be the most inspiring because they really challenged him to confront his fears… and ultimately he overcame his trepidation.  I was really impressed, and very inspired by his story.

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Roles of the Counselor with Learning Disabled Clients and Families


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Is there a counseling or therapeutic role in the context of these disorders, or is the role of the counselor primarily a social/educational one?  It’s a complex question regarding a complex disorder; there are no simple solutions.  Within the context of learning disabilities (LD) and mental retardation, there are a number of different roles we, as human services or mental health professionals, can fill in the multidisciplinary model of treatment for clients with LD.   Our expertise is needed not only by the clients themselves, but also by the families who endeavor to provide support for special needs individuals.  Finally, we should not discount our role in supporting other professionals, as we can have an impact, even if indirect, by allowing them to continue to function effectively in those sometimes challenging roles.

Direct treatments of clients with LD are most often focused on adaptation skills “since problems in adaptation are more likely to improve with remedial efforts than is the cognitive IQ, which tends to remain a more stable attribute.”  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 42)  Traditional interventions for children with learning and coordination disorders include: (1) general educational management of learning-disabled children eligible for special education services in the public schools; (2) specific methods of instruction; (3) cognitive-behavioral techniques to teach efficient problem strategies and to improve attitudinal/motivational problems, and (4) mental health approaches with children who have co-occurring social-emotional disorders.  (Netherton, Holmes, & Walker, 1999, p. 40)

A contemporary program that extends the boundaries of more traditional interventions is the “treatment mall.”  The programming (in the treatment mall model) is the result of a collaborative process involving the patient, his or her treatment team, a program design team (which has participant representation), and group facilitators from the many disciplines that practice in the treatment mall.  The emphasis of psychosocial rehabilitation programming is improving functional level, increasing capacity for recovery, and instilling hope.  Psychosocial rehabilitation treatment malls use a multidisciplinary team approach.  Nurses, psychologists, rehabilitation therapists, social workers, nutritionists, physical therapists, physicians, community college educators, and community support providers work together to teach patients with serious mental illness or mental retardation and developmental disabilities the skills and adaptive behaviors needed to live successfully in a community setting following discharge from the hospital.  (Ballard, 2008, expression Program Description)  The sidebar of the Ballard article specifically recognizes psychology staff as contributing to courses designed for short stay participants, including courses titled Legal Issues/Focus, Understanding Your Illness, Competency Restoration, Building Your Brainpower, and Building the Life You Want.  (Ballard, 2008, expression Sidebar)

Our contributions to the learning disabled community as mental health professionals are not confined to treatment malls.  High levels of frustration, with associated performance anxiety and depression, are not uncommon in LD children.  (Netherton, Holmes, & Walker, 1999, p. 45)  Accurate diagnosis provides a clear direction for interventions.  (Costello & Bouras, 2006, expression abstract)  Although substantially increased in recent years, research evidence about the prevalence of mental health problems in individuals with intellectual disabilities and the risk factors for developing specific psychiatric disorders is limited and often conflicting.  Most estimates of the prevalence of psychiatric illness in people with intellectual disabilities range from 10-39%.  (Costello & Bouras, 2006, expression Prevalence)  This suggests that our role isn’t simply confined to teaching problem solving techniques and life skills, but more importantly, addressing the underlying psychological issues that impact the learning disabled community as a whole.  Large numbers of individuals with intellectual disabilities living in the community exhibit psychiatric or behavioral problems arising from mental health problems.  Together the joint contributions of mental illness and intellectual disabilities indicate a group of individuals whose needs are considerable, and whose quality of life will be seriously impaired if the illness is not effectively identified and treated.  (Costello & Bouras, 2006, expression Implications)

So, to answer the question… Is there a counseling or therapeutic role in the context of these disorders, or is the role of the counselor primarily a social/educational one?  Yes, all of the above.  As we continue to define our roles, inevitably we will continue to develop new models of treatment and rehabilitation for our LD clients.  I contend that mental health professionals play a critical role at every point of entry, and should continue to play a significant role into the foreseeable future.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Ballard, F. A. (2008, Feb). Benefits of psychosocial rehabilitation programming in a treatment mall. Journal of Psychosocial Nursing & Mental Health Services, 46(2), 26-33. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1422243211&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Costello, H., & Bouras, N. (2006). Assessment of mental health problems in people with intellectual disabilities. The Israel Journal of Psychiatry and Related Sciences, 43(4), 241-252. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1254155791&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Definition of Intellectual Disability


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What two (2) major elements are necessary for a diagnosis of mental retardation?

Intellectual disability is a disability characterized by significant limitations both in (1) intellectual functioning and in (2) adaptive behavior, which covers many everyday social and practical skills.  (American Association on Intellectual and Developmental Disabilities [AAIDD], 2010 , para. 1)

What are the limitations of this definition?

The first and most objective limitation is the age of onset.  This disability originates before the age of 18.   (AAIDD, 2010 , para. 1)

A second quasi-objective limitation to a diagnosis of mental retardation is intelligence quotient (IQ).  One criterion to measure intellectual functioning is an IQ test.  Generally, an IQ test score of around 70 or as high as 75 indicates a limitation in intellectual functioning.  (AAIDD, 2010 , para. 3)

A third, more subjective measure, is the degree to which a disability limits adaptive behavior.  Standardized tests can be used to gain objectivity in the areas of conceptual, social, and practical skills.

Fourth and finally, the AAIDD takes qualitative differences in environmental, cultural, socioeconomic, and other normative factors (language) into consideration.  They acknowledge that limitations often coexist with strengths, and that outcomes can be positive with sustained personalized supports.

How does this definition compare to the DSM-IV TR?

The DSM-IV-TR criterion(s) for a mental retardation diagnosis are as follows… (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 41)

A)    Significantly sub-average general intellectual functioning accompanied by;

B)    Significant limitations in adaptive functioning in at least two of the following skill areas:

  1. Communication
  2. Self-Care
  3. Home Living
  4. Social/Interpersonal Skills
  5. Use of Community Resources
  6. Self-Direction
  7. Functional Academic Skills
  8. Work
  9. Leisure
  10. Heath
  11. Safety

C)    The onset must occur before age 18.

The DSM authors make more formal recommendations on which IQ tests should be used to measure IQ and acknowledge differences of measurement between them.  They share commonality with the AAIDD definition in the regard to the arbitrary IQ cutoff (approximately 70-75 or below).  The DSM also shares concern with AAIDD in that they “take into account factors that may limit test performance (e.g., the individual’s socio-cultural background, native language, and associated communicative, motor, and sensory handicaps). (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 42)  Like the AAIDD, the DSM posits a dimensional assessment of strengths and weaknesses when the nature of the disability skews IQ scores.

Although I think the variance in severity is implied by the AAIDD, the DSM authors codified the broad differences between individuals with mental retardation.  On the whole, my impression is that the AAIDD definition was written and based on the DSM-IV-TR.


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References

American Association on Intellectual and Developmental Disabilities. (2010 ). Definition of intellectual disability. Retrieved March 26, 2010, from http://www.aamr.org/content_100.cfm?navID=21

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Reflections on Pervasive Developmental Disorders (PDD)


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Pervasive Development Disorders (PDD) cover a large group of disorders including Autism, Rett’s disorder, Asperger’s disorder, childhood disintegrative disorder, and PDD NOS (often atypical autism).

Of particular interest to me, was that the parents of autistic children tend to show a consistently higher educational level.  (Netherton, Holmes, & Walker, 1999, p. 77)  What a peculiar statistic?  This, and other hereditary based anomalies, has given us a huge insight into the etiology of the spectrum of autistic disorders.

I was familiar with the “refrigerator mother” concept before reading the chapter, I think primarily because I too have seen Rain Man.  I did not know, however, that the implication had been discredited and discarded.  (Netherton et al., 1999, p. 79)

I have had the pleasure of knowing one young man with autism quite well; his story is remarkable.  I first came into contact with Joe because my mother was working as his in home health aide.  As our families came to know each other, he would often come over and play.  I remember well the day that his parents (Ray and Janet) came over disgusted about how they “had said Joe would never be able to work or live independently.”  (Shute, 2009, para. 2)  He has grown into a business owner, a sole proprietor, of a Kettle Korn business in Kansas that anticipates grossing six figures by 2012. (Shute, 2009, para. 1)  I have really proud to have known him and contributed to his development as a peer and a playmate.  I would encourage the reader to visit the website to learn more http://www.poppinjoes.com/home

I also took the time to watch the 1993 PBS Frontine documentary titled “Prisoners of Silence.”  The documentary outlines the differing views and associated research surrounding a phenomenon that has been coined “facilitated communication” or FC.  (Netherton et al., 1999, p. 85)  It would suffice to say that my jaw dropped about 30 minutes into the video when they discovered that there was “no conclusive evidence that facilitated messages can be reliably attributed to people with disabilities.”  (Netherton et al., 1999, p. 86)  I think I too wanted to believe that a breakthrough had been made, and I can’t imagine what a crushing blow it was to the families and facilitators that had the core of their believe system regarding FC shaken.  (Palfreman, 1993)  Please refer to the references section, and I have added a link to the video on Google Videos.

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References

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Palfreman, J.  . (Producer). (1993, October 19). Prisoners of silence [Television broadcast]. : Public Broadcasting Service. Retrieved from http://video.google.com/videoplay?docid=3439467496200920717#

Shute, N. (2009). How 1 autistic young man runs a business. Retrieved from http://www.usnews.com/health/family-health/brain-and-behavior/articles/2009/04/02/how-1-autistic-young-man-runs-a-business.html

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