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Thursday, June 13th, 2013
Shaming kids in public has become a parenting trend. You’ve seen the stories. Kids forced by their parents to stand in public holding some kind of sign indicating a wrongdoing. It could be that they stole. It could be that they were disrespectful. But the bottom line is that some parents believe that these kind of humiliating moments – or instances of tough love – may have enough impact to change their kid’s behavior for the better.
So … is this a good or bad idea? While I contend that it’s a bad idea, let’s walk through some of the more subtle points.
We typically hear of stories in which parents are extremely frustrated with their kids. Some are afraid that their kids will get into deep trouble. They feel like they have run out of options and don’t know what else to do. So I understand that they are ready to do something. I’ve seen them in many of my own research studies and have also seen them in juvenile court and understand that they want a solution.
But I suggest that a public shaming is not the corrective measure they are looking for. Will it shock a kid in the short term? Maybe. Will it fundamentally change all of the factors that led to the persistent troubling behavior in the first place? Probably not. And that’s the point.
In practice, and in research, you will find kids with all kinds of problems. Acting out, stealing, lying, cheating. Using drugs and drinking. Being disrespectful. It really begins to hit when they hit the early teens. In order to take on these kinds of behaviors, it’s necessary to work with parents and their kids – using methods that have been proven to work across decades of research – to improve three core parenting skills:
Monitoring: Really knowing who your kid hangs out with and what they do – so you can prohibit or change their patterns of behavior when you see warning signs of trouble. This leads us to ….
Limit Setting: Making sure your kid understands the boundaries you set and learning effective methods for applying them with consistency. This only happens by improving ….
Communication: How many arguments would you imagine a parent has had with a child before resorting to shaming kids in public? Would you anticipate that their dynamics revolve around yelling and screaming at each other? Many times it will. Parents and kids need to learn techniques for improving their level of communication with each other. And parents need to develop communication skills that help them shape their kid’s behavior by being authoritative and not authoritarian.
None of these skills come easily or quickly. They take dedicated effort on the part of parents, kids, and their practitioner. But putting in this kind of effort over time can change behavior – over the long term and not just temporarily.
Frustrated parents and kids who are acting out are realities. It’s agreed that parents in these situations need some type of recourse to right the ship. It can be suggested that public shaming teaches kids about power structures and coercive behavior and teaches much less about learning rules and morality and empathy. What’s really required is that parents and kids have an opportunity to work together to improve their relationship so that parents can be more effective on a daily basis and not feel the need to resort to drastic measures that may not have long-term benefits.
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Friday, May 31st, 2013
The big theme this month was DSM-5. It’s here, we’re reacting – and parents will be dealing with the implications of this diagnostic system for quite some time.
So …. here’s a recap of what was covered this month:
General Issues: Changes Made, Controversies Raised, And What To Expect
An Overview For Parents
The “Saving Normal” Debate
Specific Disorders: What You Need To Know
Autism Spectrum Disorder
Disruptive Mood Dysregulation Disorder
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Wednesday, May 29th, 2013
The biggest controversies that arise in diagnostic systems – like DSM-5 – come about when a previous diagnosis category is eliminated (as is the case with Asperger’s Disorder) or a new one is introduced. Such is the case with the new disorder Disruptive Mood Dysregulation Disorder (DMDD). Part of the rationale for including it was to prevent inappropriate use of a diagnosis of pediatric bipolar disorder. But that’s not a strong enough rationale to introduce a whole new diagnosis. So … should it be in the DSM-5?
The answer is no. Here’s why.
The idea of the DSM is to represent not just current clinical thinking but sufficient evidence to support a diagnostic category. This process is already murky because DSM-5 operates by defining a disorder as a collection of symptoms. While this is necessary when known causes – and gold standard methods for identifying a disorder – are not available, we typically rely on a number of carefully designed studies that support diagnostic criteria. Simply put, that is what is lacking right now with respect to DMDD.
We are just starting see research studies that evaluate the utility of the diagnosis of DMDD. At best, they highlight the complexities involved in sorting through whether or not DMDD offers unique insight into the developmental profile of a specific subset of children who could profit from intervention.
And that’s the point. This research is important and will continue. But until it yields more clear guidelines – which will take some time – it’s just not time to include it in DSM-5. There is concern that kids with extreme temperamental traits – like those who are prone to tantrums – will get inappropriately labeled. It may be that many kids who will get the DMDD diagnosis can be better captured by other disorders with similar symptom profiles (like oppositional defiant disorder). Until we have better trials to evaluate these issues DMDD should not be in the manual. That’s how clinical science is supposed to work.
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Friday, May 24th, 2013
The new diagnostic criteria for ADHD in DSM-5 flag issues that deserve attention if you are a parent. These include:
1) Age doesn’t matter as much. In prior versions of the DSM, ADHD was represented as a disorder which starts in childhood – an onset prior to age 7 had to be established to make a diagnosis. This has changed – the age of onset has been extended to before 12 years of age. So parents should be aware that ADHD symptoms may now be detected later in childhood. And parents too may be more likely to be diagnosed themselves, as the new criteria make it easier to recognize ADHD in adults.
2) Age does matter though. While it is legitimate to say that children, teens, and adults all can show symptoms of ADHD, applying the criteria to the different age groups requires much clinical skill. Keep in mind that the proper use of DSM-5 requires this. For example, a clinician must apply the same criteria to a 5-year-old, a 10-year-old, and a 15-year old. The symptoms of ADHD reflect behaviors that can be shown by any child – it’s typically the frequency of these behaviors (they occur much more often as compared to what’s expected developmentally), the pervasiveness of the behaviors (you see them at home and in school), and the consequences of the behaviors (e.g., a kid is having difficulties keeping up with school work, is getting in trouble in school). A clinician needs to have a reference point for each age in their head in order to properly apply the DSM-5 criteria. This means that they should have very solid training in developmental science as part of their overall expertise. This is particularly true given the controversies about diagnosing and treating ADHD in preschoolers.
3) Be careful who applies the criteria. The DSM series (we are now on the 5th edition) is a guidebook for clinicians. It represents current thinking on the most telling signs of a disorder. It does not say anything about how the information should be collected to come to a clinical decision. So, you need to beware of anyone who doesn’t do a full, comprehensive evaluation that includes observations of the child, interviews with the child, much discussion with parents, acquiring lots of information from parents via questionnaires, collecting information from teachers and school personnel, and ideally a range of tests (including neuropsychological exams) that can consider alternative issues (like underlying learning disorders). This kind of evaluation is required to prevent overdiagnosis of ADHD, which may be rampant these days.
4) DSM-5 does not dictate what treatment will work best. DSM-5 is designed to facilitate the diagnostic process. It does not dictate the treatment strategy. A diagnosis of ADHD does not mean that a child necessarily needs Ritalin or other similar medications to control the symptoms. That’s a whole different discussion with a clinician who is trained to consider a range of treatment strategies. It is always wise to consider first behavioral treatments for ADHD and determine, after a sufficient amount of time, how much improvement can be gained by them before thinking about medication. Do not believe a practitioner who only endorses medication after a diagnosis is made.
The bottom line is the the DSM-5 is not intended to be used in a simplistic way to quickly diagnose ADHD and immediately promote medication. It is a tool that helps clinicians come to a determination of where a child is at developmentally with respect to ADHD. This is a complex process that requires lots of clinical insight. Having DSM-5 in hand doesn’t change that.
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Tuesday, May 21st, 2013
As a parent, you may be wondering why such a fuss is being made about the release of the DSM-5 (the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association). Here is a brief overview of why it may be (0r become) relevant to you – and why it’s important to learn about the issues that are being debated.
Many Kids Will Experience A Mental Disorder
The primary reason parents need to know about DSM-5 is that many psychiatric disorders that originate in childhood are not uncommon. Consider some rough numbers:
- Around 1 in 50 kids are being diagnosed with Autism Spectrum Disorder
- Around 1 in 10 kids are being diagnosed with Attention Deficit Hyperactivity Disorder
- Around 1 in 10 kids are being diagnosed with Conduct Disorder
- Around 1 in 10 kids are being diagnosed with an Anxiety Disorder
- Around 1 in 10 kids are being diagnosed with a Mood Disorder
- Around 1 in 2 teens have reported meeting diagnostic criteria for at least 1 disorder in their lifetime
Having a good look at these numbers means that lots of parents will be faced at some point in time with the possibility of having their child evaluated for a disorder – and will need to consider treatment options. That’s where the DSM-5 comes in.
DSM-5 Is The Primary Guide For Clinical Diagnosis
The DSM-5 is the handbook used by a broad range of health care professionals who evaluate individuals (youth and adults) for potential psychiatric disorders. It’s an authoritative guide that reflects a consensus statement on the best way to categorize disorders along with the specific symptoms and rules to be used to make a diagnosis. The intention is to make it reflect current clinical thinking that is supported by research. It is not perfect, it reflects a particular point of view by those charged with generating the guidelines, and there is much debate (and criticism) of the diagnostic approach taken by the DSM-5.
All that said, the fact remains that the DSM-5 will be used if you bring your child to a health care professional for evaluation. The clinician will consider lots of information during this process – the DSM-5 does not dictate what information they use and how they get it. It’s intended to serve as a guide to the endpoint of making (or not making) a diagnosis. And it serves as the template for a health care provider to request reimbursement from insurance companies to support treatment.
Why All The Controversy Now?
The DSM-5 is a revision of the prior version which was released in 2000. As such, it includes a number of changes – some of which are minor, some of which are major. Beyond the more general discussions about what’s “normal” and what isn’t, the key things that parents need to know are the practical implications of the changes. As a parent, you should be aware of the changes to disorders that are especially relevant for youth. Here’s a brief overview:
Autism Spectrum Disorder: Major changes have occurred. In the prior version, a spectrum of disorders were available to clinicians, reflecting important variations in symptom profile. Four disorders were listed: Autistic Disorder, Asperger’s Disorder, Childhood Disintegration Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. The key change is that there is now just one diagnosis made of Autism Spectrum Disorder (ASD) – and the other diagnostic categories will no longer be used. Proponents of this change suggest that it is more accurate by defining the core features of ASD that were common to all of the disorders in the spectrum and allowing for differences in severity level under one diagnostic umbrella. Critics suggest that a number of youth who require diagnosis and treatment will not be diagnosed – and that the reliance on severity levels may make it harder for kids with more mild symptoms to receive treatments they need. There’s no answer to these issues yet – they will unfold over time as data are collected. But if your child is evaluated for ASD, it’s in your best interests to be up on the debates and have informed discussions with your clinician in order to make sure you are advocating for the best care for your child.
Attention Deficit Hyperactivity Disorder (ADHD): Minor changes have occurred. In the past, there had to be evidence that a child showed symptoms of ADHD before age 7. That has been extended to age 12 in the DSM-5. There is also more attention to making diagnoses in adults more manageable. All of these changes mean that if you have an older child who has never been diagnosed with ADHD, they might now be evaluated differently. It’s also important to know what isn’t in the DSM-5 – a lower limit on age. That is, there are no guidelines in terms of how young a child may be when making a diagnosis. This is relevant as there have been (controversial) suggestions that kids as young as 4 years of age could be diagnosed (and many in fact have). Know that DSM-5 does not offer guidance here and you will need to make up your own mind if this makes sense for your child – hopefully with the appropriate guidance of a well-trained clinician. Overall, the worry here is that kids of all ages may be overdiagnosed.
Conduct Disorder (CD): Minor changes have occurred. Conduct disorder represents a persistent pattern of rule breaking behavior and behavior that violates the rights of others. It can be diagnosed in young children as well as teens. The primary change has been to incorporate symptoms indicating a callous and unemotional interpersonal style. The thinking here is kids with this profile may be especially prone to experience problems in the future – and require more intensive management and treatment. Be aware that these symptoms will receive more attention now in the diagnostic process.
Disruptive Mood Dysregulation Disorder (DMDD): This diagnosis reflects a major change – it is a new diagnostic category. The idea was to provide a diagnostic option for kids who show persistent irritability and extreme emotional and behavioral outbursts. The rationale for developing the DMDD criteria was to make sure kids who show these symptoms do not get mislabeled as having pediatric bipolar disorder – but still may qualify for treatment. The controversy is that many feel that there is not sufficient evidence to support this new diagnosis – and in the worst case scenario kids who do not have psychiatric problems will be diagnosed with a disorder and get treatment that they don’t need.
Over the next few days, I will publish blog posts that consider each of these four disorders in greater detail, and provide some guidance for parents to help sort through these complex issues. There are no straightforward answers to be found – rather parents need to know about DSM-5 so they can be prepared to navigate the best decisions for their child.
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