© Priory Lodge Education Ltd., 1997
First Published January 1997 Version 1.0.
A Personal Response to Ian Ford's Paper
Joe Dawson. BSc(Hons), M.A., M.Ed., (LEA Educational
Psychologist)
100661.2311@compuserve.com
Ian Ford's paper contains much with which the majority of Educational Psychologists would find they were in agreement. In particular his belief that the treatment (and indeed diagnosis) of ADHD must take into account "multimodal models" which take into account not only the biochemical and behavioural but also the environment and the effects of coaching (teaching) is a view with which many EPs would agree.The educational aspect of ADD or hyperactivity is one that is (justifiably) becoming increasingly important. "Hyperactivity is not at present recognized as a specific category of special educational need. There has been a wealth of psychological and psychiatric research into the condition...By contrast there has been little in the way of educational research." (Taylor, 1994, p 130). The effects of the dearth of educational research into ADD and attendant attentional (and relational problems) has left the diagnosis and treatment a very one sided( clinically sided) affair. It is true to argue that in the two years since Taylor wrote that piece there has been movement towards incorporating a more educational stance and understanding of ADD. There are aspects of his paper with which I would wish to take issue. The educational (as opposed to the clinical) psychologist is likely to come across many of the same difficulties children display as are our clinical colleagues (as children often do not compartmentalize their difficulties). This is not to attempt to deny that there are categories of difficulty (and child perhaps) that are distinct to the two types of psychologist. Although it is not very clear, it appears that Ford is implicitly suggesting that the diagnosis rate for ADHD would rise if (like dyslexia) its diagnosis were taken out of the hands of clinical psychologists and child psychiatrists. This argument is highly debatable. Many educational psychologists are extremely reluctant to "diagnose" difficulties and give a behaviour type a label if there is not conclusive proof and global acceptance of the terminology to be used. This is not to be viewed as a lack of professional assertiveness nor should it be seen as a political stance. The reluctance (in my view) springs from a background of growing independence and assertiveness in the Educational Psychology profession where the profession is more prepared to argue a position in opposition to popular opinion where the profession does not see a convincing case being made. It should also be seen against a background of increasing litigation against Educational Psychologists where professional opinions are increasingly being challenged in the courts and at Special Educational Needs Tribunals. Being certain of one's facts is therefore essential. This is an area that, as yet, appears not to be influencing much assessment in the clinical field. While it would be wrong to draw from this the conclusion that EPs are assessing with one eye on possible litigation it is true that the threat of litigation (which has been made considerably easier for parents under successive Education Acts) is a factor to be taken into consideration when attempting to assess controversial and unceratin concepts.
Ford's analysis of the development of provision for children with Emotional and Behavioural Difficulties (EBD) is flawed. The proposition that, "brighter children with behavioural problems were classified as having "Emotional and Behavioural Difficulties (EBD)" flies in the face of the facts and suggests that those assessing EBD (i.e. educational psychologists) made their assessments based solely on the IQ score of a child and ignored any other assessment (such as observation, interview, personal construct psychology, counselling approaches, other agency assessment and so on). This is not so. If his assertion were true today's EBD special schools would be full of "bright" children/students with behavioural difficulties. This is not the case.
Attention Deficit Disorder is increasingly among the group of difficulties that Educational Psychologists are coming across in their daily round. The great increase in the number of exclusions from school is the visible and very public side to the increasing number of children in schools who are demonstrating challenging behaviour. Many EPs (if the author's experience is typical - and there is no reason to suppose it isn't) have referred to them children whose teacher or carers ask, "Is it ADD ?" Such a relatively straightforward question cannot be given a straightforward answer. There are no generally accepted, objectively testable and observable diagnostic criteria. Taylor (op. cit.) talks of the "over-extended category of "ADHD"".As the British Psychological Society's recent publication on the topic described ADD, it is an "evolving concept" (BPS, 1996). There is confusion over the exact terminology of the condition. ADD or ADHD (Attention Deficit Hyperactivity Disorder) or more favoured in the UK (until recently) "Hyperkinetic Syndrome". The shorthand ADD will be used here. There are possibly differences between the definitions of ADD and AD/HD. This is a debate which is still going on. There is also a debate going on (albeit more quietly) about the definition of ADD. Indeed Taylor (op cit) argues that the theories concerning ADD are just that - theories with little empirical evidence to support them:
""Attention Deficit Disorder" and the power of the phrase is so great that it has discouraged critical thought about whether there is indeed a deficit" (p 137)
"Children with the disorder (ADD/ADHD) form a heterogeneous group, but are generally characterized by high levels of impulsivity, activity, inattention and an inability to regulate their behaviour according to situational demands. Impulsivity, or lack of self control, may be the most problematic and core symptom of ADD" (Schweitzer and Suler-Azaroff, 1995, p671).
This triad of difficulties appear to be a common theme in the papers concerning the disorder (BPS, op cit.). Many children in school at some time will display these difficulties of impulsivity, overactivity and inattention. What appears to be of significance is the prevalence and intensity of these behaviours and indeed the behavioural manifestation of impulsivity. As will be seen motivational, emotional and situational factors are vitally important in this condition. Indeed Ford points out the importance of these factors.
EPs will get referred to them children who because of their behaviour are not, "accessing the curriculum on offer to them in their schools" (DES, 1993). Children fulfilling this criteria may have a "Special Need" and therefore be eligible for consideration of a Statement of Special Educational Need. These children are the disruptive, challenging individuals whose academic attainment suffer due to their behaviour.
"The child who repeatedly disrupts your class and who seldom completes assignments may not be deliberately troublesome, but could be showing signs of Attention Deficit Disorder" (U.S. Dept of Education, 1996).
These children may indeed be displaying signs of ADD but they may not be - they may be being deliberately troublesome. Indeed they may be children who have ADD but on occasions deliberately display challenging behaviour - it may be learned behaviour that is being displayed. The point to be made here is that if the only significant diagnostic feature is troublesome behaviour then it is unsurprising that there is great debate about ADD's successful diagnosis.If the troublesome behaviour is strongly associated with inattention then other forms of behavioural psychopathology must be investigated before the jump is made to ADD.
Ford is correct in his assertion that there is "core" of young people with emotional and behavioural difficulties who cannot be contained in "mainstream" or "special" schooling and who indeed get into trouble with the police. These are the youngsters whom the education system are desperately attempting to support by coming up with creative and novel solutions to their need for "an education".The reasons for these youngsters difficulties in "fitting" in with the standard education system on offer (and indeed its difficulty in fitting in with them) are myriad and deserve thorough and full investigation.
Ford goes on to suggest that the definition of these youngsters' difficulties depends on the theoretical framework that the therapist or worker comes from and their beliefs are founded in. This is undeniably true. Ford goes on to argue that there is the belief that ,"the "vast majority" of EBD cases are caused by socio-educational problems." The implication again being that there are far more cases of ADD undiagnosed and therefore being mistakenly put down to these "socio-educational" reasons instead of the "real cause". This is an old debate. Indeed one discussed by Winnicott (1957). Teaching, Winnicott argues, needs more diagnosis (admittedly this is a simplification of the argument but and accurate reflection of it). The teaching of children as one homogeneous group is unlikely to produce the most effective results as there is a great variety of children with a great variety of difficulties, learning styles and emotional difficulties in their responses to school. The understanding, assessment and "diagnosis" of these is the job of the Educational Psychologist. One major reason for including at a very important level the expertise of the Educational Psychologist in the understanding and "diagnosis" of ADD. The sociological aspects of education must be taken into account. Indeed, as Ford himself admits, in the treatment of ADD the environment must be taken into consideration. So: logically, it must be considered in its diagnosis. It may be that there are children whose difficulties are incorrectly being attributed to socio-educational causes and the underlying biochemical or neurological cause is being missed. This being the case there is a great need for a more accurate diagnostic tool for such youngsters. An inaccurate diagnostic tool and drug treatment does them an equal (if not worse) injustice. Taylor (op. cit.) argues that both biological and psychosocial factors are involved in hyperactivity (in its severest manifestations) and, "minor degrees of "ADHD" are likely to have an even stronger mix of psycho cial factors in the causes." (p 141)
There have been attempts to give a tighter and more precise definition to the disorder (the DSM and ICD attempts). The most recent DSM (DSM IV) criteria are tighter and more precise than those given previously. However it is easy to see an area for disagreement and latitude in diagnosis. There is great disagreement among professionals regarding the diagnosis of ADD (and the various behaviours needed to be displayed for a diagnosis to be made). For example impulsivity is one aspect of ADD diagnosis. There is much disagreement concerning the measurement and definition of impulsivity:
"these disagreements arise, at least in part, because, phenotypic impulsivity can have several forms (e.g. cognitive, emotional or motoric) and there may be several physiological pathways leading to what on the surface appears to be the same behaviour." (Kindolon, Mezzacappa and Earls, 1995).
Indeed Kindolon et al (op cit) postulate the need to examine the area of impulsivity further - particularly the area of , " cognitive inhibitory control versus a motivational component of impulsivity relating to insensitivity to punishments" (p659). Inhibition and motivational factors are becoming increasingly important in the area of ADD diagnosis:
" Children in certain circumstances wait if they wish to do so. This points yet again to the importance of motivational factors in determining the children's inhibitory and attentional performance" (BPS, 1996, p22).
It can be seen then that various aspects of the observable behaviour necessary for a diagnosis of ADD are under debate. There is no clearly definable, objective set of criteria available for ADD diagnosis. It is imperative that those who are heavily involved in behavioural assessment and analysis (such as educational psychologists) are heavily involved in the debate regarding the furtherance of the ADD diagnostic criteria.
"Given the strong concurrence and co-morbidity of ADHD to other childhood disorders at least screening for a full range of childhood disorders must be considered part of the diagnostic process for ADHD" (Goldstein, 1994 p 111).
Ford argues that although the diagnostic criteria for AD/HD are, " inadequate, inconsistent and confusing" they are as good as the notes from a Child Guidance Clinic which refer to, for example, "sibling rivalry". The important point to be made here is that the understanding of a behavioural and emotional problem in terms of its behavioural and emotional antecedents is entirely logical and defensible. The approach can give rise to the problem solution crudely put, the way in to a problem can show the way out. However what Ford appears to be arguing, that the diagnostic criteria for ADD does not have to be precise and "tight" because the diagnostic criteria used in other settings for other difficulties , in his opinion, are equally "woolly" is no argument. To suggest one set of diagnostic criteria is acceptable because it is as "poor" as another is no justification of that set of diagnostic criteria. Educational psychologists often can be the first professional to be asked for an assessment of a child's attentional/behavioural difficulties. A clear set of diagnostic criteria would be welcomed and is needed. The area of subjectivity in assessment cannot be removed entirely but should be reduced to a minimum. The concept of ADD is evolving and needs continually working on.
It is unsurprising that the Educational Psychologist will often be the first professional to see a child with suspected ADD.
"The classroom offers one of the best settings in which to identify inattentive, off-task, impulsive and overactive behaviours, indeed the behaviours associated with the diagnosis of ADHD (DuPaul and Rapport, 1993).
In the DSM IV criteria for ADHD there are six direct references to behaviour in school. The "defining features of the condition is behaviour which appears inattentive, impulsive and overactive ...... and is a significant hindrance to their social and educational progress." (BPS op cit) A child's lack of attention, their impulsiveness and overactivity are often best seen in the confines of the formal academic setting of the classroom where these skills are most tested. Indeed as a the US Education Department document (1996) states,
"Many children with ADD are not identified until they enter school." (US Dept of Education, op cit.)
Goldstein (op cit) goes on to argue that,
"Given the strong comorbidity of learning disability and poor scholastic attainment over time to ADHD .. a thorough quantitative and qualitative academic assessment is recommended for all children evaluated for or receiving a diagnosis of ADHD." (p 123).
To a degree the job of the Educational Psychologist in general is to observe (or otherwise measure) a child's performance (in a wide variety of areas) and judge whether it is within "normal" bounds. If the judgment made is that the child's behaviour is beyond the norm then the role of the EP is one of coming up with ideas and approaches which allow the child the greatest possible chance of having a similar educational experience (and chance of success - however that is measured) as those whose performance is within normal limits. This role is extremely difficult particularly in the area of ADD. All children at times are inattentive (or appear to be) all children have limited concentration spans and find inhibiting certain aspects of their behaviour difficult. The child with ADD displays these traits but at a frequency and intensity which takes them beyond the norm. The author is of the opinion that the role the Educational Psychologist can play in the assessment and diagnosis of ADD is central. Very few professionals (especially those with the expertise of the educational psychologist in the observation and assessment of behaviour) have the opportunity to observe a child in the home and in the school and take evidence concerning the child's behaviour from school teachers , parents and carers. The importance of looking at the child's behaviour in school cannot be overemphasized. A multi-professional approach is to be favoured in the diagnosis of ADD due to the ability of such an approach to examine and analyze behaviour in different contexts and with different expertise. This is a point Ford makes well.
Children do perform and act differently in different contexts and as many of these contexts should be taken into consideration as possible.
"Children with attentional problems are notoriously inconsistent n their behaviour over time or across situations." (Stein et al, 1995).
This quote highlights another difficulty and that is the analysis of behaviour over time. The diagnosis of ADD must be seen as an evolution rather than a litmus test type of diagnosis. Behaviour should be seen and observed, not only over an number of different contexts (eg home and school) but over time too. Only then can a full and useful picture of the child's behaviour be drawn.
It is undoubtedly true that the diagnostic criteria for ADD is evolving. Stein et al (op cit) describe the levels of "adaptive functioning" in groups of diagnosed ADD/ADHD children and those children with Pervasive Developmental Disorder/Mental retardation. They suggest,
"Perhaps deficits in adaptive behaviour should be added to the list of problems often associated with ADD/ADHD and assessment of adaptive functioning should be included in the diagnostic evaluation of individuals with ADD/ADHD." (Stein et. al. op. cit., p668).
This paper has looked at the role and function of the Educational Psychologist in the diagnosis of ADD. The role of the EP in the treatment of ADD must also be central.
"A possible reason for the poor long term prognosis of ADHD may be the failure of current treatment approaches to address adaptive skills deficits. potential treatment approaches that could be provided alone or in conjunction with medication and other psychosocial treatments of ADD/ADHD include : direct teaching of adaptive behaviour skills to children and adolescents, instructing parents and teachers in ways to facilitate the development of adaptive skills". (Stein et al , op cit, p669).
It is clear that there is a way to go in the development of a set of diagnostic criteria for ADD (AD/HD ). From the standpoint of an Educational Psychologist the role and contribution the Educational psychology profession can play cannot be overstated. Ford's article expresses a view which has much to recommend it but it contains some views which I would contend blur his vision regarding some of the causes and possible approaches to the diagnosis and treatment of the behavioural and emotional difficulties children display with ADD. Ford's paper must be seen as a positive attempt to add to the debate and further the evolution of the concept of ADD.
References
British Psychological Society (1996) Attention Deficit Hyperactivity Disorder (ADHD): A Psychological Response to an Evolving Concept. BPS. Leicester
Department For Education (1993) The Code of Practice. HMSO. London
DuPaul,G.J. and Rapport,M.D. (1993) Does mythelphenidate normalize the classroom performance of children with attention deficit disorder? Journal of the American Academy of Child and Adolescent Psychiatry, 32, 190-198
Goldstein,S. (1994) "Understanding and assessing ADHD and related educational and emotional disorders." Therapeutic Care and Education. Vol.3, No.2. Summer 1994. 111-129
Kindolon,D.,Mezzacappa,E. and Earls,F. (1995) Psychometric properties of impulsivity measures: temporal stability, validity and factor structure. Journal of Child Psychology and Psychiatry. Vol36. No.4 654-661
Richards,I. (1994) "ADHD, ADD and Dyslexia. Therapeutic Care and Education. Vol.3, No.2. Summer 1994. 145-159
Schweitzer,J.B and Sulzer-Azaroff,B. (1995) Self-control in boys with Attention Deficit Hyperactivity Disorder : effects of added stimulation and time. Journal of Child Psychology and Psychiatry. Vol. 36, No 4. 671-686
Stein,M.A., Szumowski,E, Blondis,T.A. and Roizen N.J. (1995) Adaptive skills dysfunction in Add and ADHD children. Journal of Child Psychology and Psychiatry. Vol.36, No.4. 663-670
Taylor,E.(1994) Hyperactivity as a special educational need. Therapeutic Care and Education. Vol.3, No.2. Summer, 1994 130-144
United States Department of Education (1996). Attention Deficit Disorder: What teachers should know. U.S. Department of Education. Washington
Winnicott,D.W. (1957) The Child, The Family and the Outside World. Penguin. Harmondsworth.