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Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder?

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by Fan_of_Meehl, Jul 29, 2015.

  1. Fan_of_Meehl

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    Interesting article with implications for the many adult ADHD cases cropping up everywhere (usually with a prescription for Adderall in tow). If the results can be replicated, may be seen as a real call for folks to be more careful in their history taking, assumptions, and critical thinking as they make psychiatric diagnoses.

    http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2015.14101266
     
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  3. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    I can only see the abstract at the moment. Did they also assess for mood and anxiety disorders? We often get referrals for "Adult ADHD" and it usually turns out to be one of several other things such as high levels of anxiety or depression, LOTS of substance use, or they are confused why they are failing college classes when they averaged C's and D's in high school.
     
  4. Fan_of_Meehl

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    Good questions. Located a .pdf:
     

    Attached Files:

  5. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    Unclear, it's definitely part of a huge longitudinal study, but they don't clearly state what exactly was screened for in the adult sample at the time, and how they ensured symptoms weren't double counted. Also, the adult ADHD group was about 30 out of a thousand, and twice as many of those than the Childhood ADHD were on medications for "other" psychiatric disorders. I guess I'm just skeptical that there is an "adult onset ADHD" when many symptoms seem to be much better accounted for by other psychiatric diagnoses.
     
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  6. Therapist4Chnge

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    I'm very skeptical. If the person doesn't have a clear pattern from childhood (has pediatric notes, report cards w teacher comments, etc), it is almost always one or more psychiatric Dx's. I see quite a bit of executive dysfunction cases that mimic ADHD, though they are typically head injury related and much less commonly FTD.
     
  7. Ollie123

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    Far from my area of expertise, but how we define psychopathology is definitely an area of interest.

    I think its important to distinguish between "adult ADHD" and "adult-ONSET adhd" here as the latter implies the problems did not begin until adulthood. I won't be so bold as to say this never happens, but I suspect it is extremely rare. On the other hand, I hold no doubts some symptoms of childhood ADHD can persist into adulthood. Why and when that happens is still an open question. I do think the vast majority of "Adult ADHD" you see is normative variation in attentional capacity that has been misdiagnosed. In some cases, even among people with better-than-average attention who are simply more concerned about normal fluctuations in attention.

    That said, the requirement for a history never sat entirely well with me. I think its understandable at present, but we need to come up with a better solution long-term. Particularly inattentive type may not produce many outward signs. As we all know, there are a tremendous number of components of cognition and poor attention can be compensated for in a great many ways. There should be some way to capture this, since in an otherwise bright individual it may not be til adulthood that the system is stressed to the point where inattention becomes a significant problem. We can take a history, but "I've always had troubles paying attention" doesn't seem like a very reliable/valid indicator of what we want to get at....as others have said, the presence of other psychopathology is often a huge confound. Even sub-syndromal levels could impact these sorts of responses.
     
  8. PSYDR

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    I'll just go ahead and trust the longitudinal imaging studies from people like Shaw, Castelleano, and that clown college they call Harvard that indicate that ADHD is either a delay or an incomplete cortical thickening that coincides with genetic polymorphisms, behavioral difficulties, and neuropsychological deficits over a study that indicates that attention somehow just craps out in adulthood with no known etiology. That's just me though.
     
  9. AcronymAllergy

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    Agree that I'm highly skeptical. My take is that at least with how we currently conceptualize ADHD, if it shows up in adulthood (i.e., truly adult-onset), it's not ADHD, it's something else.

    Whether that represents a unique and as yet unidentified neurodegenerative-type condition, the early stages of a known neurodegenerative condition, or influences from other factors (e.g., medical problems, toxin exposure, substance abuse, etc.) remains to be seen, but it's not ADHD.

    RE: neuropsych and ADHD, I do wonder if perhaps some of the reason for the lack of more consistent findings has to do with the "diagnostic polymorphism" of the condition and/or incorrect diagnosis in research studies. It could of course also reflect the fact that we don't have many tests appropriate for identifying the cognitive difficulties.
     
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  10. Therapist4Chnge

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    One of the issues I've run into with "Adult ADHD", which again I don't believe actually exists when psych and other factors are controlled for, is that the person is still struggling at work and would benefit from one or more interventions. I will take some "Adult ADHD" referrals with the caveat that I'm not there to confirm ADHD nor check a box so a PCP can feel comfortable rx'ing a stimulant, but instead I'm there to evaluate and make recommendations (as appropriate) in regard to functioning at work, etc. The tricky part is that stimulants are found to be effective in the vast majority of people w. ADHD and also those without it. I usually recommend non-pharmacological interventions first and only in clear cases where the assessment data and corroborating data are supportive of actual ADHD recommend stimulants are a first line option.
     
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  11. Par4thecourse

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    Whether or not sufficient time is available to do a thorough work-up, a detailed look at the adult's entire life is critical. School performance, social involvement, in addition to work history and eliminating every other possible medical issue that could look like or mask ADHD, needs to be examined.

    I've never heard of Adult-onset ADHD. And I don't know how the inattentive type compensates adequately, sufficiently, so that he or she wouldn't suffer serious ramifications over time. I know how I compensated that made it possible to get by socially as a kid. Nodding my head at a change in the conversational tone, a certain inflection, looking concerned if the person seemed sad, smiling at what I thought was lighthearted banter, while having absolutely no idea what was discussed. That worked until I was required to act upon what had been said and I couldn't ask anyone for help. "Stupid" and "Big Dummy" inevitably followed. I would be devastated, not having a clue what had just happened. My use of compensating was such an integral part of me that I didn't know that's what I was doing.

    For anyone seriously interested in helping those with this disorder, I plead with you to learn everything you can about the condition and the people who have it. We are still on the outside looking in. Autism and dyslexia are like the big kids on the block, rightfully so. ADHDers can't get no respect, as it were, you know? We've been failures all our lives and now, even with ADHD becoming a widely recognized problem, we still feel like 3rd rate hurting pups. I'm here to tell you that this disorder is devastating. If those who come to you for help haven't been traumatized, their ADHD symptoms may be moderate or misconstrued. Not to minimize either, but ADHD, the injurious type, requiring medical intervention, should be overwhelming. Perhaps the reason some doctors see minimal benefits resulting from the application of medication is that their symptoms are fairly manageable.

    I couldn't put one sentence together on this website without meds or 40 cups of coffee. I couldn't read a paragraph here, or anywhere else, for that matter, either. I can't follow a conversation. I blurt stuff out, anticipating what you are going to say, but I'm usually way off base. On other less frequent occasions, when something fascinates me, I can block out everything else and go nuts with intensity. Football has that kind of impact on me.

    You can make a tremendous difference in our lives. You could give others a chance to live. You could save children from countless hours wasted in the prison of a classroom where we do time and struggle to learn anything.
     
  12. psych844

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    This is in a nutshell my frustration with the field.

    Lack of work history is looked at "issues with work"..when it can simply be laziness/motivation, little options because of lack of skills, having to do a tough job (so alternative seems better..disability/diagnosis), bad bosses/not getting a long with coworkers.
    Not being able to pay attention = ADHD..not just a lack of interest/motivation, etc etc
     
  13. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    1. Why is this posted in this thread?
    2 I dont follow you.
    3. I dont understand how that is related to the field in any way.
     
  14. psych844

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    I'm not surprised.
     
  15. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    I just meant it seems like a semantic argument or quibble on your part.

    All those things you mentioned obviously result in "issues with work." That phrase/wording doesn't imply the cause. What exactly u is your problem with it? And what point are you trying to make?
     
  16. psych844

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    I think it's pretty simple what I'm saying. Adult ADHD is all that other stuff I said (essentially "life"..we all have ****ty bosses, we all have motivation/interest issues, some people don't have skills so they have to concentrate at a job they hate...so for a lot of these people it's just not a real condition.) It's a boss going over to and saying to a guy "why the heck are you on your FB all the time"? "Bud, I need you to focus instead of having a cigarette every 5 mins" ..and then they come into the psychologists office and try to pull a fast one....."I can't focus..I have issues at work..I think I have ADHD". So what I'm just saying is..it's other stuff, not a real mental illness, and the ****ty thing is we have no way of knowing if someone has a real condition or if it is for gain.
     
  17. Justanothergrad

    Justanothergrad Counseling Psychologist
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    Oh good. This again.


    I agree entirely. I've seen folks present for attention issues and then it turns out, meth is bad or I don't have actual study skills.

    In the study they used diagnostic interviews to identify the groups and a few measures to compare, although some of those didnt make their case very well (e.g., WAIS scores were closer to the 'normal' group than to the childhood ADHD group for most domains and many other scores fell somewhere between the two groups). At best, it looks like this describes ADHD is a dimensional issue rather than a categorical one. Of course, that wouldn't really surprise me either.. but this isn't my main area by any stretch. It would have been more interesting to examine performance on various attention tasks (WMS, CPT, ANT, whatever) then conduct discriminant function analysis to see how those folks were grouped. I suspect that would not have been as "neat". That would have been more convincing.
     
    #16 Justanothergrad, Apr 23, 2016
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  18. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    There is no "adult onset" AD/HD if thats what you are getting at, I agree. The lit simply does not support it, and currently understood model of its etiology simply do not support it. (See PsyDrs post in this thread).

    But not everyone with ADHD dies in their teens either, right? So, we can expect some evidence of the disorders manifestation and impairment in adulthood as well. Assessment of AD/HD is difficult in adults. Comirbidities roblem, and Occam's razor usually indicates...something else.

    You may want to read Barkley to get up speed on neuro evidence of the entity that we call AD/HD. The entity that results in the behavioral symptoms is real, whatever name you want to call it.

    You might also want to read the lit on symptom validity testing.
     
    #17 erg923, Apr 23, 2016
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  19. Therapist4Chnge

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    It usually *is* a psychiatric dx (or at least psychiatric symptoms). The second assertion is just flat out wrong. There are a number of ways to tease out feigning and non-credible reporting.
     
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  20. psych844

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    No, there really isn't. There might be in some contexts...but if you're smart about it, it's easy enough to get through the process. I've seen countless people do it.
     
  21. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    You should read more.

    And use/infer from personal experiences less. Isn't that what you generally complain about anyway-Psychologists using impressions abd experience over science and research?
     
    #20 erg923, Apr 23, 2016
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  22. psych844

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    Read what?

    How can there be research on feigning/lying in contexts where there was no instruments even used to make a diagnosis? (Ie Anxiety diagnosis)

    I realize that in contexts where there is gain, instruments are used to pick up on lying.
     
  23. Justanothergrad

    Justanothergrad Counseling Psychologist
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    1. context predicts the type, quality, and number of feigning instruments used

    2. gain is required for malingering

    3. there are plenty of ways, and they are effective.
     
  24. Therapist4Chnge

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    Seriously? You think your personal experience and/or a few ppl you know is sufficient evidence to support your view?

    *face palm*

    It's frankly insulting to those of us who actually went through training, put in the hours, and actually do this in the real world.
     
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  25. PSYDR

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    Presumably them squiggles what make words. Like in the lie-berry.
     
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  26. Par4thecourse

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    There must be a history of impairment or difficulty beyond the ordinary struggles most everyone has and they must be present in at least 2 major life functions like work and in one's education, in any adult seeking a diagnosis. Sub-test scatter on the Woodcock Johnson for example is indicative of attentional issues. It isn't proof but a common pattern found in ADHD folks. *There's the Connors tests, too. That history is either supported through independent verification or it isn't. That's why teachers, guidance counselors, coaches etc. should fill out comprehensive checklists in addition to spouses, co-workers, supervisors, work history. If you have ADHD, it will show up in your life in a powerfully destructive fashion, or what symptoms you are experiencing are not ADHD by definition.

    *"The Conners 3 is a well-designed instrument with excellent technical properties that promises to be instrumental in the evaluation, diagnosis, and treatment response of children with ADHD and co-morbid disorders.”

    BTW, I have no ties to Connors

     
    #25 Par4thecourse, Apr 24, 2016
    Last edited: Apr 24, 2016
  27. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    For goodness sakes, son. In the military, I think they say: "use you head. That that bump 3 feet above your ass. "
     
  28. psych844

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    You want me to read research that doesn't exist? Please re-read what I said.
     
  29. psych844

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    It's not my "view". Clinical judgement has been shown to be as often right as wrong..so in the contexts where someone is basing a diagnosis purely on interview/their judgement..yes I think they are getting it wrong about half the time..and yes I've seen it happen quite a few times.
     
  30. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    Except that it does. And you should read it. You are big boy. Use pubmed and play around with keywords.

    And did you get throughout the SVT/PVT lit yet?

    Would you like to solicit the local licensing board for you license at this time?
     
    #29 erg923, Apr 24, 2016
    Last edited: Apr 24, 2016
  31. Justanothergrad

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    You have zero knowledge of treatment, diagnosis, or the training in the field as you have repeatedly proved. Please stop assuming that you have learned more in your junior year in college than we have in our doctoral programs. It's insulting. It may be surprisingly for you to learn but we have a stronger base of knowledge of the literature than you do. Your personal experience and limited exposure to the literature is not nearly as representative or vast as you imagine it to be.
     
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  32. psych844

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    Well if saying that makes you feel better about your training, that's great.
     
  33. Justanothergrad

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    How many psych courses have you taken again?

    You may want to read about the Dunning-Kruger Effect. It applies here.
     
    #32 Justanothergrad, Apr 24, 2016
    Last edited: Apr 24, 2016
  34. smalltownpsych

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    You are making a valid point that diagnosis is difficult in our field and especially with something like attentional problems, but that does not mean that the patient doesn't have problems that could benefit from treatment. Part of our job is to help educate the person about the possible causes and options for treatment. Ultimately they have to be their own expert when it comes to making a final determination about what is going on inside their own head and the choices they want to make in their life. That's why the pure medical model doesn't work well in our field.
     
  35. psych844

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    Doesn't apply to me at all. In fact, I tend to underestimate how well I do at things. But overall, I'm very very accurate in terms of how well I think I did and how well I actually did.
     
  36. Justanothergrad

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    The irony- you are so accurate in your perceptions that you don't listen to experts in the field you want to go into.

    How many undergrad classes was that again? Give me a breakdown.
     
  37. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    I don't know what this is about, because you are presumably here because you want to be a psychologist? It's a little too early to become self-hating.

    Anyway, your poo-pooing of certain methods within psychiatry/clinical psychology is not only naive, but also bolsters the notion that more (as in the additional of psychological test data) is better/preferable in terms of clinical assessment in all cases. The more data points, the better, right? Well, not so fast. Incremental validity is at play, as is cost, time (both yours and the patients), diminishing returns, and spurious correlates.

    Although reasonable psychologists can disagree, there is a case to be made that neuropsychological testing provides no incremental value in the assessment of suspected AD/HD, at least if rule-outs that would necessitate testing (Learning disorders, TBI effects, other neuro insults) are not at play. Now, it is true that people with ADHD are a bit more likely to have certain cognitive profiles than are people without ADHD. For example, people with ADHD, on average, tend to score slightly lower on tests of working memory, processing speed, and verbal fluency than on tests of visual–spatial reasoning, fluid reasoning, and crystallized intelligence. However, most people with ADHD do not have this particular profile and most people with this profile do not have ADHD. In the end, a diagnosis of ADHD cannot be ruled in by any particular cognitive profile, nor can any particular cognitive profile rule it out. I do still advocate the use of standardized measures (with norms) in the assessment of suspected AD/HD (not extensive IQ testing or cognitive assessment), as well as symptom validity too, however. However, the key to this disorder, as with so many others (schizoaffective disorder, personality disorders, etc) is the HISTORY. The clinical interviews importance should not underestimated.

    If your response to all this is something along the lines of: "Yea, well what do you but what they tell you?" I would simply direct you to my response the last time you griped about this.

     
    #36 erg923, Apr 24, 2016
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  38. psych844

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    What's the point? I'm only about 5 courses away from graduating with Honours Psychology degree..so basically, everything you would expect.
     
  39. Justanothergrad

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    Five courses away? So what, you've taken 5 or so? I've taken that many assessment courses in grad school.

    Why do you think five courses gives you as much knowledge as you think it does when EVERY SINGLE PERSON here tells you that you don't know what you think you do? Embrace your ignorance. We all do. It's healthy and a natural part of learning.
     
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  40. Therapist4Chnge

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    Obviously his ~5 undergrad classes and personal exploration of our profession prepared him to set us straight in our ignorance of the field. Given his level of confidence we should just ignore our fancy degrees, tens of thousands of hours of experience, and numerous contributions to the literature and accept it's all been for naught.

    I for one am happy to now have all of this free time in which to toss darts at a dart board and guess at what afflicts each patient that walks through my door.
     
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  41. psych844

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    What?

    Can you not read? I'm a few credits away from completing an undergrad in Psychology. Meaning, I've taken close to 40 Psychology courses. (I've taken it all..Stats, Research Methods, Social Psych, Forensic Psych, Behavioral Neuroscience, Learning Disorders, etc)
     
  42. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    And the implication of this is.....? You almost have bachelors degree in psychology?

    Which then means you have no applied specialty training in this field. So, why are you being so resistant to feedback?
     
  43. psych844

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    No clue what relevance it has. I'm just answering a question that was posed.

    I think justanothergrad is interested in deflecting from the the actual conversation because he doesn't have any facts to refute anything I'm saying.
     
  44. Par4thecourse

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    The ability to focus attention lies on a continuum. No one pays attention perfectly all the time and most people have the ability to focus at least occasionally.

    Problems with paying attention become a medical concern when the inability to sustain attention is profound and occurs frequently even when it is critical to the individual's overall health and well-being to do so. All other potential causes for such disturbances must be ruled out before a proper diagnosis of ADHD can be made.
     
  45. psych844

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    I'm def being a bit combative, no doubt, but I'm not resistant to feedback at all. I appreciate when I get direct answers to claims I'm making..people like Ollie, MamaPhd, and you, have for most part kept to answering my claims/criticisms head on. The responses have been reasonable and fair. Other people are deflecting, creating straw men, and not addressing the arguments I'm making, and that is frustrating (Justanothergrad being culprit #1)
     
  46. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    But you dont ask questions, for the most part. You make inaccurate claims and statements due to lack of knowledge and training, and then expect refutation. This approach would not go over with colleagues or professors of supervisors. You may have to learn this through their feedback instead of ours though. But this is not a conversation if feel like I should need to have with someone at the graduate level. Its not going to be pleasant one for you.
     
    #45 erg923, Apr 24, 2016
    Last edited: Apr 24, 2016
  47. Justanothergrad

    Justanothergrad Counseling Psychologist
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    And then assume that they should be treated with equal weight or responded to as if we need to disprove it.
     
  48. Par4thecourse

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    What is particularly upsetting about having this disorder is what I sense is the all too common assumption that authority figures (teachers, in my case) make about the ADHD child. We are deliberately misbehaving, in their minds. We are willful, bad, disruptive children because we want to be. We are calloused, troubled, obstinate and hard-hearted punks looking for opportunities to be disruptive. In my case at least, the exact opposite was true. Interestingly, it was their misperceptions and their mistreatment that actually turned me into a hateful monster. And I did become a vicious human being. That is one reason it is important to me to shed light on this disorder. By itself it is a difficult thing to deal with; add to it the moral judgements, the condemnation, the humiliation that are heaped on the child as he struggles to get by and it becomes overwhelming and deeply painful.
     
  49. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    Ah, an undergrad degree and minimal life experience. The perfect mix to create fauxperts in the field.
     
  50. psych844

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    I have made some inaccurate claims..ie it's easy to become competent as a Clinical Psych. I didn't mean the process to become one is easy. It is not only a long road but it takes dedication, hard work, professionalism, and mental toughness. The fact that people's lives are in your hands lends credence to your argument that Phd level training should be the norm. It's a good one.

    I do have some criticisms, however. And those criticisms are borne out of my own, and my families/friends, experiences with the mental health system. No, I'm not claiming to be an expert on diagnosis and treatment, but from how I've seen anxiety disorders diagnosed..it's a bit of a joke to me. Some of my friends were diagnosed with social anxiety and panic disorder..in one or two sessions.. 50 minute interviews. In at least couple of these cases the people admitted they lied or exaggerated their symptoms so they could eventually get disability. It was part of a larger plan to go in see a Psychologist to just get "help", and then use those visits later when another clinician was evaluating them for disability. New Clinicians look at the file "oh look..there is a history!!". So my frustration here is just objective My only argument is that when mental health professionals deal with particular populations, (problems) the assessment/diagnosis is essentially about trusting the clients story, background, and symptoms. Why? 1. No instrument are used to gauge severity, and of course there is no objective test to prove their illness (ie frmi) 2. Collateral info is from people who are not unbiased and who are not mental health professionals.

    So if someone can prove to me how diagnosing anxiety is not essentially taking a detailed history, having collateral info, ruling out some things, and then essentially "mixing all that info together in your head" to come to a diagnosis..feel free..but that is how it is.

    If you are being honest with yourself at all, you realize that a lot of the info that is used to suggest a diagnose can have multiple explanations:
    Ie. Does no work history actually prove or suggest person is unable to work? No..it might be laziness, lack of interest/motivation, lack of skills to do work they would want to do. Is a client going to admit that? No.
    Ie Does a history of having mental health treatment prove you legitimately have a condition? No.
     
  51. psych844

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    I've probably had more life experience than all of you combined on this forum.

    But when you don't have a point, deflect!
     

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