MICHAEL J. LABELLARTE, SR., M.D.
Annapolis, Millersville, Towson, and Columbia, MD dr.labellarte@cpeclinic.com
cell:443-956-2463 www.cpeclinic.com

• No current conflicts of interest
• Assistant Professor, Part Time
• Johns Hopkins Medical Institutions
• University of Maryland SOM
• University of Florida COM
2

Pharmacology
Psycho-Social
School-Based

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Traditions- highlight The Perspectives
•
The Role of Bias
•
Guild/setting approaches
•
DSM-5 approach
•
NIMH approach

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Psychodynamic: Freud (1907)
•
Psychobiology: Meyer (1948)
•
DSM 1-5 (1952-- )
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Community Psychiatry
•
Bio-psycho-social: Engel (1977); Grinker
(1954?)
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The Perspectives: McHugh and Slavney, 1983.

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“... seeks to systematically apply the best work of behaviorists, psychotherapists, social scientists and other specialists long viewed as at odds with each other.”

The Perspectives
• Disease perspective
• Dimensional perspective
• Behavioral perspective
• Life Story perspective

• A disease is a mechanistic syndrome
• What a person has
• A disease requires cure or amelioration

• Parkinson’s
• Schizophrenia
• Autism spectrum disorder (ASD)?
• Bipolar Disorder
• Depression
• Obsessive compulsive disorder
• Tourette’s
• ADHD
• Etc.

• Intelligence
• Learning Disorders
• Communication issues
• Personality
• ASD?

• A dimension has relative value
• Who a person is
• Dimensional extremes require guidance

• “Difficult”?
• “Defiant”?
• Unstable?
• Extroverted?
• Too open?
• Disagreeable?
• Not concientious?

Hulk
*
70 100 130
Intelligence Quotient (IQ)
Dr. Bruce Banner
*

The Eysenck Circle (1958)
Unstable
Moody
Anxious
Rigid
Sober
Pessimistic
Reserved
Unsociable
Quiet
Introverted
Passive
Careful
Thoughtful
Peaceful
Controlled
Reliable
Even
Calm
Touchy
Restless
Aggressive
Excitable
Changeable
Impulsive
Active
Sociable
Outgoing
Talkative
Responsive
Easygoing
Lively
Carefree
Leadership
Stable
Optimistic
Extroverted

• Stable ---------- Unstable
• Extroverted ---------- Introverted
• Open to new ---------- Closed to new
• Agreeable ---------- Disagreeable
• Conscientious ---------- Not conscientious

• Motivated vs. Maladaptive behaviors
• What a person does
• Stop “bad” behavior

• Disorders of eating
• Disorders of sleep
• Disorders of sexual expression
• Substance misuse

• Oppositional
• Self-centered
• Contextual
• Often learned

• The narrative of a person’s life
• What a person (or others) understands about a person’s experiences
• Reframe negative life story concepts

• Disease
• Dimension
• Behavior
• Lif Story

• Clinical diagnosis
• Standardized testing
• Setting specific

Framing Bias:
Everyone is an Expert

Diagnosis Stakeholders
• Children and parents
• Teachers, administrators, school personnel
• Social workers and other therapists
• Psychologists and other evaluators
• Psychiatrists, pediatricians, neurologists
• Academia
• Pharmaceutica
• Insurance companies
• Pundits and politics

Pharmaceutical Controversy:
Stakeholders
• Federal Government
• Academic Community
• Treatment Community

Assessment Errors
• Cliché errors
• Desperation
• Insufficient data
• Lack of comprehension
• Misattribution errors
• Misinformation
• Oversimplification
• Relationship errors
• Reformulation to avoid labels/medications

“Expert” Errors
• Relationship errors
• Primary attribution error
• Misattribution errors
• Cliché errors
• Reformulated symptoms to avoid stimulants

Primary Attribution Error
• Your behavior is suspect, based on your flaws
• My behavior is a rational response to a situation
(including your flaws)

ADHD: Cliché Errors
• “S/He can concentrate when it’s something that s/he wants to do..”
• “S/He can sit still if s/he wants to…”
• “Too much ____ (e.g. TV, video, computer, cell phone, facebook, etc.) is all… ”
• “S/He started faking it this year, when school got hard…”

More Cliché Errors
• “In our day we didn’t have ADHD…”
• “If ADHD exists, it’s not so bad…”
• “I had ADHD and I turned out fine…”
• “ADHD is over-diagnosed…”
• “ADHD is over-treated…”

Still More Cliché Errors
• “The real problem is the drug companies…
• … the doctors…
• … the teachers…
• … the times we live in…
• … those darn kids/parents... short cuts”

ADHD: Misattribution Errors
• Bad seed
• Boys will be boys
• Poor parenting
• Normal response to stress

What is ADHD, Really?
• Attention deficit: cannot ignore competing stimuli
• Hyperactive/Impulsive: equivalent
• Disorder of executive function (EF)
• EF frames the ADHD symptoms

What is Executive Fx, Really?
• “Whatever the frontal lobes do”- Denkla
• “Conscious direction … efficient processing of info.” -Stuss and Benson
• “Maintenance of behavior on a goal ... calibration... to context” - Pennington
•
• “Self regulation across time for the attainment of one’s goal... - Barkley

Self-Regulatory Mini-Modules
(Barkley 2012)
• Inhibition
• Self-directed sensory-motor actions
• Self-directed attention
• Working memory
• Planning and problem solving
• Self-motivation
• Emotional self-regulation

•
•
Activation
• Attention
•
Effort
•
Emotion/Affect
•
•
Memory
•
Action
Brown TE, 2000, 2008

•
I (1952) : Atheoretical, standardized definitions
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II (1968): “Legitimacy”, patient education
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III (1980): More ICD, more reliability; Axis I-V
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III-R (1987): Same trends
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IV (1994)/IV-TR (2000): Same trends, behind quickly

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“Transcend limitations... beyond current ways of thinking”- but field not ready for a paradigm shift
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Empirical evidence grounds
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Continuity
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“Living, evolving document”
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Aspirations: etiological, objective, dimensional

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11 centers,Test-retest reliability or agreement:
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Cohen’s Kappa: inter-rater reliability
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DSM-5: 0.61 “very good”, cutoff-- 0.4-0.6
“good”
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0.20.4 “questionable”-- <0.2 “unacceptable”
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DSM-III: cutoff-- 0.71 “good-very good”

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NIMH distancing from DSM-5
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Strength in reliability, weakness in validity
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Will no longer fund research projects that rely exclusively on DSM criteria
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Research Domain Criteria (RDoC): NIMH

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Dx approach based on biology and symptoms
(not constrained by DSM-5)
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Biological disorders/brain circuits implicate specific domains of cognition, emotion, or behavior
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Each level of analysis... across a dimension of function
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Mapping cognitive, circuitry, and genetic aspects will yield new/better targets for treatment

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Negative Valence Systems
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Positive Valence Systems
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Cognitive Systems
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Social Processing Systems
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Arousal/Modulatory Systems

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Categorical to dimensional; early detect/prevent
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Dimensional measures included, e.g. “crosscutting symptom measure”, “WHODAS”, and
“severity scale for schizophrenia”
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Axis I-V dismantled
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NOS replaced: Other specified disorder,
Unspecified disorder
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New disorders, “renamed” disorders

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Non-axial documentation
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Important psychosocial /contextual factors (V and Z codes)
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Disability (may be replaced with the
“WHODAS”)
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GAF is eliminated (see above)

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Regrouping of disorders
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Putative underlying factors
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Underlying vulnerabilities
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Groups juxtaposed by relationship
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Within groups, ordered by age of onset

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Pediatric Modifications
Shortened duration: cyclothymia- 1 year vs. 2 year
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Alternative symptom expression: MDD- irritable mood...
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Lowered symptom threshold: GAD1 from “C” in children
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Suspended criterion: OCD- behavior not aimed at alleviating anxiety
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Special criteria: PTSD age <6- only 1 symptom required- avoidance plus negative cognition/mood

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Preschool: more hyperkinesis
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School age: inattention appears
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Adolescence: inner restlessness
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Adulthood: inattentive complaints, but impulsivity reigns

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Dx criteria
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Dx subtypes and specifiers
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Severity qualifiers are gone
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Principal Dx
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Provisional Dx “strong presumption full criteria will be met”

Co-morbid vs. Diff. Dx?
• Common disorders co-exist w ADHD
• Common disorders also masquerade as
ADHD
• Co-morbidity amplifies symptoms

SA
MDD
Anxiety
Tics
Behavior
ADHD
LD
BPAD
Personality
ASD
S/L
School Referral, “ADHD”, age 7

Psychiatric Diagnosis
• Medical model psychiatric history/MSE
• Corroborative data
• Rating Scales
• Neuropsych/Cognitive-Eductaional testing
• Ruling in/ruling out other syndromes

Rating scales are screening and measuring tools
Rating scales are not diagnostic scales

ADHD/behavior: Connors, ADHD IV, Vanderbilt,
BASC, CBCL; Executive Function: (CBS) Barkley,
Brown, (BRIEF) Gioia 2000
Pediatric Anxiety Rating Scale (PARS), RUPP 2002
Autism Spectrum Screening Questionnaire (ASSQ):
Possreud etal
Children’s Aggression Scale-Parent (CAS-P):
Halperin, 2000
Conduct Disorder Rating Scale (CDRS):
Waschbusch 2007

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Brief Psychotic Rating Scale-C (BPRS-C):
Lacher, 2001
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Children’s Depression Rating Scale (CDRS-R):
Poznanski/Mokros
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Children’s Yale-Brown Obsessive Compulsive
Scale (CYBOCS)
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Young Mania Rating Scale (YMRS): Young et al., 2000

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Personality Assessment Inventory-Adolescent
(PAI-A): ages 12-18; Morey 2007
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Colorado Children’s Temperament Inventory
(CCTI): ages 2-7; Buss and Plomin, 1984
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Junior Temperament and Character Inventory
(JTCI): ages 7-11; Luby et al., 1999 and Lyoo et al., 2004

• Novelty seeking (NS): impulsivity, extravagance, disorderliness
• Harm avoidance (HA): worry, shyness, fatigueability
• Reward dependence (RD): sentimentality, social connection, dependance
• Persistance (P): obstacle or frustration tolerance

• Emotionality
• Activity Level
• Shyness/Sociability

Formulation
• Chief complaint: “concerns” vs. “positions”
• Clinicians “attribute”
• Discern among DSM-5 nuances
• Symptom presentation varies with age
• Let the Perspectives dictate interventions