Tuesday, November 2, 2010

Everyone Claims To Be An Expert On ADHD: Recognizing Bias

This week's guest blogger is Michael J. Labellarte Sr., MD.

Bias can be an obstacle to getting appropriate help for a child with ADHD. My session at CHADD’s conference will focus on how to recognize and minimize bias among the various professionals and family members involved in the child’s life.

Psychiatrists often discuss bias in terms of research and statistics, in the attempt to protect the scientific integrity of research data from factors that can erode the accuracy of research findings. Psychiatrists rarely discuss bias in terms of factors that can erode accuracy of diagnosis.

With a disorder as controversial as ADHD, a discussion of bias as it pertains to professional educators and treatment personnel is a can of worms. However, a discussion of clinical bias regarding ADHD will help parents navigate a complicated system where everyone claims to be an expert, from grandparents to international scholars. The goal here is illuminate how a variety of individuals tend to think, feel, behave, and make decisions, the better to predict and avoid common mistakes.

As soon as parents, pundits, and ADHD “experts” try to judge someone else’s thoughts, beliefs, and behaviors, they risk the introduction of observer bias. The most important observer bias is called fundamental attribution error which helps drive the controversy around ADHD. Fundamental attribution error describes this observer attitude: that another person’s behavior reflects their character or personality and not their circumstances; whereas the observer’s behavior depends on circumstances and not character or personality.

This kind of bias is lethal to accurate diagnosis and management of ADHD (or any other psychiatric disorder) whether it comes from parents, educators, psychiatrists, or whomever. Bias opens the door to easy distortions (such as oversimplification or overgeneralization) and more destructive factors such as insufficient data, insufficient comprehension, misinterpretations, misattributions, desperation, misinformation, deception, and mistrust between professionals and patients and families.

My conference session will detail steps parents can take to minimize bias in all its various forms as an obstacle to getting appropriate help for their child, including:

1. Assemble an experienced team for short-term consultation and longer-term management.
2. Get the “lay of the land” by identifying all of the various professional and familial “stakeholders” involved in the child’s life.
3. Gather information systematically, through a variety of sources.
4. Focus the information in the medical model style: A consultation begins with a presenting problem, it does not begin with a conclusion to rule in or rule out a diagnosis.
5. Observe for evidence of professional bias, including shortcuts, forced conclusions, and clichés.
6. Demand enough feedback for informed consent before making a decision about treating or not treating ADHD, if it is present. True expertise will manifest during the informed consent process, which usually includes the rationale for diagnosis, a plan for further assessment, treatment options that include medical, psychological, and school-based interventions, the risks and benefits of treatment or withholding treatment, and the expected course of ADHD if treated or if not treated in your child.

I hope you will join me for this important discussion at the CHADD conference in Atlanta from November 11 through November 13.

Michael J. Labellarte Sr., MD, is a board-certified child and adolescent psychiatrist who treats children and families at his CPE Clinic, LLC, in Towson, Columbia, and Severna Park, Maryland, as well as Vero Beach, Florida. He is an assistant professor of psychiatry at the Johns Hopkins University School of Medicine, the University of Maryland School of Medicine, and the University of Florida College of Medicine.


Eva O'Malley said...

Hi Dr Labellarte,
I recently attended a local presentation by a chiropractor, who sold his craft in a derogatory and narrow-focused approach. This included bashing much valid and robust research for pieced together outdated and inflammatory slides, depicting parents who medicate their children for ADHD as being to lazy and society's downfall to ascribing every quirk a "syndrome"
What is the best way to enlighten the doctor that lying is fraud. He "adjusts" children, stating their neurology is "blocked" and if you ask me that's not only very dangerous it's just creepy.

Marie Paxson said...

Thank you, Dr. Labellarte, for this blog entry. I'm so glad that you are bringing this topic to light. As an "end-user" of mental health services, I can't tell you how many times I was on the receiving end of bias and/or lack of knowledge about ADHD during professional visits. This was demoralizing, time-wasting, and costly.

A member of my CHADD chapter went to her physician to start the process of managing her undiagnosed and untreated ADHD. The doctor told her that people who claimed they had ADHD were only looking for performance-enhancing drugs. Unbelievable - in this day and age! When doctors don't have complete knowledge and background in physical health conditions, they don't hesitate to refer patients to specialists. But when someone comes in for help with ADHD, this is the kind of attitude they encounter....

I look forward to learning more about how to recognize bias and how those with the responsibility of diagnosis and treatment are (hopefully) working to minimize its effect.

faustest said...

Bias really is a difficult topic because of the "hammer effect" -- you know, when you are a hammer, everything looks like a nail.

Years ago, when I had my son evaluated, I was told by the psychiatrist that not only did he have ADHD and Tourette (triggered by the ADHD meds)-- which we already knew -- but that the concussion he had at age 2 had damaged his brain, that he would never accomplish much, and that my job was just to be his "cheering section" because he would probably never be able to live an independent life. This son went on to score a perfect 800 on his math SAT, is now about 35, with two college degrees (chemistry and engineering), has held a good job for many years as an engineer, is married and a wonderful father to his small child. Thank the Lord I never believed that psychiatrist, and I just wish I remembered who he was so I could thumb my nose at him.

Sometimes, as parents, we need to know that doctors can be wrong too. When what they say seems to make no sense, look elsewhere until you find something that DOES make sense.

In my son's case,the only thing wrong with his brain was that it could not tolerate the petrochemical additives so common in food today. Of course we had no idea, but decided to try it anyhow after they took him off all the meds and gave up ... We took the chemicals out of his diet and he got better ... no ADHD, no TS, no more asthma ... no more special school, no more neurologist appointments .... boy was that ever worth the effort!! Effort? Actually, it was no big deal once I learned what brands of stuff to buy.

Anonymous said...

Hi Dr Labellarte
My name is Beth Campos, and I am a speechpathologyst from Brasil, and I've been working with children with ADHD for a long time.I only receive news about the conference today , and I would like to receive early news about the next conference, because I would like to go in teh next one.
Thank you a lot. best wishes.

Unknown said...

Michael seems to be a hard worker and feel he stands as an example for many!

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Anonymous said...

I am new to learning about ADHD as my son, aged 15, was recently diagnosed in December 2010. As many of you might relate to, this is one step along an arduous journey of sifting through many questions. Without the characteristic of hyperactivity and exceptional athletic skills at home, ADHD never entered our minds. After years and years of lukewarm literacy intervention at school someone finally suggested that his cum file was characteristic of ADD. I was the one still who had to figure out how to pursue this determination. We are fortunate in having a pediatrician qualified for such a diagnosis.

Ironically, I am a seventeen year educator who is also an EdD candidate. With only three months in to learning about ADHD, I can already see how easily barriers arise to the diagnosis, treatment, and interventions.

Subjectivity, policy, and definitions work together in making determinations that touch upon Labellarte's Step 5. "Observe for evidence of professional bias, including shortcuts, forced conclusions, and clichés." This is a lot for the average person to work through. It's a lot for me to sift through in spite of being an insider to the educational system. I am still sifting.

CHADD has made great strides in building advocacy for a condition that has only been recognized a little more than 20 years.