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Summer 2001

Summer 2001

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Medical Matters:

PST, RAD, OCD, ADHD?An Alphabet of Childhood Psychiatric Diagnoses!

Practical Considerations for Families

Many children and families involved with the worlds of foster care and adoption are regularly assaulted with an alphabet soup of diagnoses, ranging from ADHD (Attention Deficit Hyper-activity Disorder) and ODD (Opposition Defiant Disorder) to RAD (Reactive Attachment Disorder) and PTSD(Post-Traumatic Stress Disorder).Unlike many ?diagnoses' in fields of medicine such as pediatrics and neurology, these are all clinical diagnoses, meaning that these diagnoses are derived solely from observations and reports of behaviors; rather than a blood, urine or radiologic test.Parents may wonder what these diagnoses actually mean? Do they identify the source of any given child's concern?Do they suggest a ?most appropriate' treatment? Or do they predict a child's future?

Realizing that the ultimate goal of all of us (parents and professionals alike) is to identify and then provide appropriate treatment options for children and their families, in my opinion, the only way to get to a correct treatment is to start with a correct diagnosis. Sometimes the diagnosis is well described by an alphabet soup (RAD, PTSD, ODD, ADHD, etc), but in my experience; those letters only shed light on one facet of any given child. In addition, children with any one of these diagnoses may present very differently from another child with the exact same diagnosis or diagnoses.

I have recently been asked several questions about the common symptoms of RAD and PTSD: Are they really the same disorder just showing up in different ways?Why is one considered a ?developmental disorder' (RAD) and another an ?anxiety disorder' (PTSD) in the DSM? Could RAD in childhood turn into PTSD in adulthood? Using the diagnoses of RAD and PTSD as case examples, it is informative to understand how we came to be using the Diagnostic and Statistics Manual, now in it's fourth edition (DSM-IV) to describe children who may manifest a variety of behavioral, emotional or cognitive difficulties.It is critical to consider the evolution of these specific diagnoses that might help explain why many so-called professionals (self included!) might be coming up with a variety of names for similar presentations; or completely be missing the boat on some aspects of diagnosis. I've been aware of and working with the various versions of DSM criteria for more than a decade.But one certain thing is that what is gospel according to the DSM-IV is most likely to be quite different by publication of the new edition. Sadly, medicine, especially the mental health field, isn't black/white, but mostly gray.

As with any mental health diagnosis, the definitions used in the DSM classifications are created by a panel of ?experts? who put their heads together in an attempt to gather consensus on a diagnosis. This is done primarily to provide a common ground for diagnosis, not to clarify the cause or to identify treatment. While still much better than the chaos related to diagnosis prior to the first edition of the DSM, there's still room for improvement. What is actually meaningful? What are the treatment implications resulting from these diagnoses? Without a useful diagnosis, therapy is hit or miss at best, and studying the usefulness of therapy for uncertain diagnoses is nearly impossible.This partially explains why there are not a lot of great studies suggesting which therapies really work for which diagnoses, and why there's much overlap in therapeutic approach.

As with any clinical diagnosis, similar symptoms can result from many causes.RAD and PTSD are attempts to describe the features of a child (or adult) as they relate to the world, but these symptoms could be secondary to many different causes.It is also important to know that the DSM committees historically have not had much input from the pediatric community (i.e. child-focused people), so very few of the diagnoses actually deal with children. The notable exceptions are those that are almost exclusively diagnosed during pediatric years (i.e. PDD categories including Autism, Child Disintegrative Disorder and Rett's Syndrome).

RAD as described in the DSM-IV theoretically represents a constellation of features that represent the most extreme example of the failure of a young child to develop a positive primary attachment early in life.Attachment itself was a theoretical framework (Bowlby, & others) that tried to explain how children learn to rely on caretakers as a solid base from which to explore the world. The theory was then put into practice by observing children with a variety of attachment behaviors (thought to relate to emotional attachment) and how they responded to caretakers initially and to adults as they get older.Without a strong base, cognitive and emotional development is hindered and manifest in certain behaviors. Crucial to the long term is that later relationships are not as rich as one might otherwise expect; and many of the negative symptoms associated with RAD are present (including significant anxiety, anti-social behavior, developmental/ learning/attentional concerns).

How do these diagnoses impact on treatment decisions? Regardless of diagnosis, the treatments for both PTSD and RAD are ideally experiential (plus behavioral modification, psychopharmacology and eventually cognitive therapies, in some cases).Most importantly, any treatment needs to be individualized for the unique child and family expected to benefit from it.

In my opinion, it's also critically important to realize that many of the features attributed to PTSD and RAD may be the effects of serious brain injury, malnutrition, exposure to substances, chronic neglect/ abuse, or neuro-endocrine or neurormetabolic effects?all secondary to one's environment.Yet many children do incredibly well despite the odds stacked against them.

Ultimately, we may get better at diagnosing what the true underlying difficulty(ies) may be for any given child. But until then, we're left with ?best approximations' as described by groups of people with grey hair. Sorry, but medicine, especially psychiatry, is still not an exact science!

Lisa Albers, M.D., M.P.H., of the Developmental Medicine Center and Adoption Program, specializes in developmental/behavioral pediatrics; psychology; infectious diseases; and endocrinology. She uses a multidisciplinary team approach for families with concerns for their children through international and domestic adoptions.Dr. Albers may be reached at (617) 355-5209 or albers_l@hub.tch.harvard.edu.

Feature Articles in the
Summer 2001 issue:
Volume 1 Number 2

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Departments

Editor’s View
by Dick Fischer

Coming Through the Wry
by Ratna Pappert

Letters to the Editor
In The News

Agency Speak
by Debbie Riley, M.S.

Ask Ashley Anything
by Ashley Rhodes-Courter

Washington Watch
by Maureen Hogan

Advocating for KidsZ
by Barbara Tremitiere, Ph.D.

Spiritually Connected
by Kim Combes

Early Intervention
by Deb Schell-Frank

Medical Matters
by Lisa Albers, M.D., M.P.H.

Research Review
by Peter Gibbs

Resource Review
by Debbie Smith, M.S.W., L.C.S.W.

Point / Counterpoint

Orphans of the Living
by Maureen Hogan

On Moderate Ground
by Robert G. Lewis

What IS Family Preservation?
NCCPR Excerpt

The Ten Commandments of the ASFA
by Maureen Hogan

Book Review
by Ellen Rardin

Feature Stories

Kids in Care - These Kids Want YOU!
Photo Essay

150 Ways to Show Kids You Care
Author Unknown

Why Would Anyone Want to Adopt a Teenager?
by Chester Jackson

Rising Above “The System”
by Tamara Dawn Widner

I Think I’ve Got It!
by Elly Cirino

Sidebar

by Carlos Cirino

Fostering Clear-heartedness - Through Transistions to Traditions
by Rebecca Weller

What Parents Want Professionals to Know
by Linda A. Grillo

LifeBooks and Lip Smacking Stories
By Beth O’Malley

New Foster Care Breakthrough Series

Just Let Me Brag Already!
by Audrey Esposito

Foster Parenting with “Attitude!”
by Janell White

When Opportunity Knocks
by Danielle Nabinger

Foster Kids May Fare Worse After Returning Home
by Suzanne Rostler

Faces of the Alphabet
by Deb Wasserbach

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