Measuring the Nature of Parenting Practices in Studies

A "scientific" journal article entitled, “Which dimension of parenting predicts the change of callous unemotional traits in children with disruptive behavior disorder?” By Muratori and others in the August 2016 issue of Comprehensive Psychiatry attempted to determine whether parenting practices influenced the development of so called callous and unemotional (CU) character traits in children. Alternatively, are those traits – which are common in children with disruptive behavior –more genetic in origin? 

In the study, no significant relationship was found between "negative" parenting and CU traits; these two variables were also unrelated when "positive" parenting was considered in the same model. However, using a slightly different model, higher levels of positive parenting predicted lower levels of CU traits.

Although I would like to believe and tend to agree that “positivity” in parent-child relationships helps decrease acting out behavior in children, a huge problem with this type of study is how the hell can you precisely measure the nature of the relationship between parents and children? The biggest problems with that include the fact that these relationships are not constants but vary across time and situational contexts. Parents might be good disciplinarians when it comes to providing children with adequate curfews, for example, but terrible at allowing them to stay up all hours of the night. Furthermore, the disciplinary practices certainly change over time as the children get older.

Second, how does a study even attempt to measure the tone of parenting practices? This study used a measure called The Alabama Parenting Questionnaire (APQ) [40] – mother report. This parent report measure has five subscales: parental involvement, positive parenting, poor monitoring/supervision, inconsistent discipline, and corporal punishment. Items are rated on a 5-point Likert scale, ranging from 1 (never) to 5 (always).

They used the mother’s own report of her own disciplinary practices! If a mother were abusive or inconsistent, how likely do these authors think she would admit to it, even if she were very self-aware, which obviously many people are not. There is no way to be sure, of course, but the odds are very good that the amount of “negative” parenting is  higher than their study results would indicate, while the amount of “positive” parenting could be overestimated. 

And which particular types of those parental behaviors listed in the instrument were the most relevant to the question at hand? There is no way to know!

When it comes to assessing the effects of family interactions, details make a huge difference. And as I have maintained over and over again, in order to get these details, you would need a camera on both the parents and the children 24 hours a day over a significant time period. This type of study using absolutely no direct observation of what is purportedly being measured is a complete waste of time.

Counting Symptoms that Don’t Count, Part II: Compared to What?

In my blogpost of July 24, 2010, Counting Symptoms That Don’t Count, I wrote.

“So what does a doctor who spends so little time with a patient do to save time? I mean besides completely ignoring the patient's relationships, history of trauma, humanity, etc…Well, one thing they can do is ask only about symptoms, and blindly accept the patient's yes or no answer without even checking to see if the patient understands the difference between a transient mood state and a psychiatric symptom. Better yet, before the doctor even sees the patient, he or she can have the patient fill out a symptom checklist, and base his diagnosis entirely on that. (Of course, his secretary could make a diagnosis doing that, so the patient really wouldn't even have to talk to the doctor at all).”

The inappropriate use of self report tests designed to screen patients as actual diagnostic instruments has become even more of an issue than ever. As you may recall from earlier posts, such instruments are purposely designed to cast a wide net so as not to miss someone in need of treatment, and as such, they snare many patients who do not, in fact, need treatment. 

As managed care is tightening its ever present grip, full psychiatric diagnostic interviews are being marginalized. This is especially true in the so call “collaborative care” models, in which psychiatrists merely advise primary care physicians without necessarily seeing the patient themselves. 

Fellow blogger George Dawson, M.D. beautifully describes the problems with the use of a depression screening instrument in wide use called the PHQ-9:  “…let's talk about what is really happening here.  This is all about a patient coming in and being given a PHQ-9 depression screening inventory…  It generally takes most patients anywhere from 1 - 3 minutes to check off the boxes.  Conceivably that could lead to a diagnosis of depression in a few more minutes in the primary care clinic.  At that point the patient enters the antidepressant algorithm and they are they are officially being treated [they may be given an antidepressant on the basis of the pHQ-9 results alone - DA]. The care manager reports the PHQ-9 scores of those who do not improve to the "supervising" psychiatrist and gets a recommendation to modify treatment."

No determination of whether the symptoms are clinically significant. No determination of whether the symptoms reported are merely relatively normal reactions to adverse environmental events. No nothing.

To appreciate why symptom checklists are so problematic, I need to discuss something called a Likert Scale. A Likert Scale asks the patient to “rate” a symptom by level of severity, frequency, importance, or how strongly the test taker agrees with a statement. There is usually a 4 to 7 point scale with a  number attached.  Examples:

Not at all - 0

Several days - 1

More than half the days - 2

Nearly every day -3

(the PHQ-9 Likert Scale)

Very Frequently = 5

Frequently = 4

Occasionally =3

Rarely = 2

Never  =1

Not difficult at all = 0

Somewhat difficult = 1

Very difficult = 2

Extremely difficult =3

Very Important = 5

Important = 4

Moderately Important =3

Of Little Importance =2

Unimportant =1

Notice that the questions are asking the test taker to make a judgment about a symptom, but do not really define each level. It is therefore up to the test taker to decide whether the symptom occurs “often” or is “difficult” compared to some standard. But compared to what? Most people will use their own experience as reference points, and apply the terms according to this subjective standard.

So how is this a problem? Well, for depression inventories, most people have never seen someone with a severe melancholic depression who is thinking, moving and talking at a snail’s pace and who is totally and constantly overwhelmed with his or her depression all day every day for weeks at a time.  

Having never seen this, the average person does not know how bad depressive symptoms can be – unlike an experienced psychiatrist who has seen the whole gamut of depressed feelings. They therefore will not compare themselves to that, which is actually the relevant comparison!

So each test taker is, in effect, creating his or her own scale. What seems like "often" to them might not seem like very often at all to someone else. This makes the results next to meaningless for making a real diagnosis.

For those interested in statistics, the issue was neatly summed up by John Knight, a commenter on a Psychology Today Blog Post that criticized another post I had written.  He wrote:

“Firstly, there is nothing more subjective than self-reporting. How on earth can we treat what a client reports as objective data? Can any patient really detach themselves and report their... 'status' objectively, and interpret their symptoms and place scores on a Likert-type scale in the same manner as everyone else? What about the issue of the relationship to the practitioner? Can a patient be trusted to report objectively without trying to spare the practitioner's feelings? Or the opposite - what if they are annoyed and want to give negative feedback to someone they don't like?

Secondly, these Likert-type scales are often being processed as interval-level data rather than ordinal data. For the statistically uninitiated, ordinal data generally consists of "an arbitrary numerical scale where the exact numerical quantity of a particular value has no significance beyond its ability to establish a ranking over a set of data points" (thank you Wikipedia), whereas interval data will be something like degrees, metres, kilometres, and so on.

A Likert-type scale is ordinal data, but weak arguments and statistical trickery are being employed to treat it as interval data, which is easier to process and looks more scientifically impressive.

To lay off the accountant language for a moment, many CBT practitioners are treating patient self-reports with the same kind of measurable, real-world objectivity that one would treat degrees celsius, metres, kilometres, and so on. That is quite simply disgusting, and should trouble the conscience of any scientist willing to employ the method.”

Another problem is that instruments like the PHQ-9 ask questions about how many days a week a person experiences a symptom, but do not ask how long the symptoms last on a given day when present, let alone about the circumstances in which a symptom makes an appearance.

Let’s look at the questions, and I’d like the reader to envision two scenarios. The first is the melancholic depressive described above. The other is a man who gets involved and preoccupied with his duties at work and feels fine there, but every night after he gets home he becomes embroiled in a continuing conflict with his wife, who is threatening divorce, and only then starts to become extremely upset. 

I think the reader will see how it is quite possible that both of these very different individuals might answer the PHQ-9 questions in almost the exact same way, and come out with identical scores. The first would benefit from an antidepressant. The other would not, and probably needs marriage counseling instead.

PHQ-9 Patient Depression Questionnaire

Over the last 2 weeks, how often have you been bothered by any of the following problems.

Not at all - 0

Several days - 1

More than half the days - 2

Nearly every day -3

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself—or that you are a failure or

have let yourself or your family down

7. Trouble concentrating on things, such as reading the

newspaper or watching television

8. Moving or speaking so slowly that other people could

have noticed. Or the opposite - being so figety or

restless that you have been moving around a lot more

than usual

9. Thoughts that you would be better off dead, or of

hurting yourself

add columns

TOTAL:

10. If you checked off any problems, how difficult have these problems made it for you to do your work take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Copyright © 1999 Pfizer Inc.

Oh gee, look at who came up with this scale. A drug company. How convenient!!

The Big Lie and Pharmaceutical Marketing

Joseph Goebbels

The “big lie” is a propaganda technique in which a falsehood is repeated so often and in so many different ways that people come to believe that it is true.  The term is generally credited to master Nazi propagandist Joseph Goebbels.  According to Wikipedia, he wrote the following paragraph in an article dated 12 January 1941, 16 years after Hitler's first use of the phrase "big lie," titled "Aus Churchills Lügenfabrik" and translated "From Churchill’s Lie Factory." It was published in Die Zeit ohne Beispiel.

The essential English leadership secret does not depend on particular intelligence. Rather, it depends on a remarkably stupid thick-headedness. The English follow the principle that when one lies, one should lie big, and stick to it. They keep up their lies, even at the risk of looking ridiculous.

The technique has become commonplace in all sorts of marketing and is particularly rampant in Pharmaceutical Company marketing.  It is part and parcel of the process of turning facts that have never been established into established facts, as I wrote about in my post of January 31, 2012.

I of course need to make the following disclaimer for any reader who is logic-challenged:  Just because someone uses a propaganda technique invented by the Nazis does not make them a Nazi. I am not calling anyone in the pharmaceutical industry a Nazi, so don’t write me a letter.

I have already done several posts on how drug companies have turned irritability, temper tantrums, affective reactivity and other very normal behaviors and emotions in children into symptoms of mania (or ADHD, or both).  In this post I will add one more, to show how often this nonsense is repeated over and over again in poorly designed and misleading journal articles, complete with plausible deniability, and then reported uncritically in the medical press.

One way to propagate a lie about the effectiveness of pharmaceuticals is through the publication of studies in which subjects fill out self-report tests or are subjected to symptom rating scales based on their immediate presentation at the time they are seen. The results of symptom ratings scales are tabulated uncritically and produced in a journal article-  as if the results of the tests prove something.  I discussed some of the issues involved in symptom rating scales in my previous posts, Counting Symptoms That Don't Count, and A Stupid Study and an Even Stupider Headline.

A journal article called Age Group Differences in Bipolar Mania by Safer, Zito, and Safer was published online in the journal Comprehensive Psychiatry on June 12, 2012.  As reflected in the title of the journal article, the psychiatric press dutifully but incorrectly wrote that the conclusion of the article was that symptoms of bipolar are different in children and adolescents with mania than they are in adults.   

The study seemed to say that aggression, irritability and motor activity were more prominent symptoms in pre-teens than teens.  Adolescents had more aggression and irritability than adults, while adults showed more grandiosity and hypersexuality.  Proof positive that the symptoms said to be more common in teens and pre-teens were actually symptoms of bipolar disorder?  

If you only read the news reports or superficially glossed over the abstract of the actual article, you might think so.

Yet in actuality this was yet another repetition of the same old big lie technique.  Looking at the abstract of the article more closely, the conclusion was a little different: that the results of a symptom rating instrument, the Young Rating Mania Scale (YMRS), showed this, not a complete and comprehensive diagnostic evaluation of the subjects in question: "In age-grouped YMRS item assessments of bipolar mania, anger dyscontrol was most prominent for youth, whereas disordered thought content was paramount for adults." 


Notice how the authors cannot be accused of lying, since this is in fact what their study actually showed.  The "take home message," however, is that this means that these symptoms are in fact valid symptoms of bipolar disorder in kids.


So let's take a closer look at the study and the YMRS.  The study was based on a review of the literature describing several other studies, and the other studies that were chosen for review were "... studies reporting age group differences in total YMRS scores that included individual baseline item scores."  So this study reviewed other studies that used what I will soon show is a highly suspect test. 

Symptom rating instruments like the YMRS are meant for two purposes: 


1. To be screen out patients who for sure do NOT have the diagnosis and make sure that anyone who might have the diagnosis is included for evaluation. In other words, the tests are designed to have a lot of false positives, that is, people who score positively on the test but do not in fact, have the disorder.


The authors of this review clearly know that the YMRS is a screening instrument:  "These outpatient studies required a minimum YMRS total baseline score of 20 for inclusion and achieved total baseline YMRS scores of 28 to 33 indicating at least moderate manic symptoms [20,22,23,25]. In these clinical trials sponsored by industry, trained raters did the YMRS item scoring at baseline. The subjects who met full research criteria for mania were subsequently randomized into placebo and medication treatment groups."


2.  To measure changes in symptoms over time in patients who have already been diagnosed correctly by other means. The other means that are used usually consist of research diagnostic clinical interviews, but we have no way of knowing how well the clinical interviews were done - particularly whether the duration and pervasiveness criteria of the symptoms were applied correctly, since this is frequently not done by drug company shills. 


But even using a symptom rating scale to measure changes in symptoms is frought with difficulty, particularly in the case of the YMRS, which completely ignores the issue of symptom pervasiveness and duration.


The problem with tests that ask patients to rate their own symptoms was described succinctly by one patient, who purportedly said about a psychiatrist who used a self report question as the entire basis for prescribing drugs, "The question is always the same. He asks me, ‘On a scale of 1 to 10, rate your mood.’ I answer, but you know, in 6 hours I might have a different answer.”   


Many of these rating scales uses what is called a Likert Scale.  Likert Scales generally ask a patient or a researcher to rate the severity of a given symptom on a 4 to 7 point scale.  A big issue with Likert Scales in self-report instruments is that when they ask whether a symptom is mild or severe is that they do not indicate the answer to the question, compared to what?  Compared to a patient with a clinical disorder, or compared to the symptoms as they have been experienced by the patients themselves?  When someone is very sad but has never been clinically depressed, he might rate the sadness as severe.  Having perhaps never seen another person with a severe clinical depression, he has no external reference point that would distinguish a normal mood from a highly abnormal mood.


Now for the YMRS. The YMRS asks a clinician to rate the patient's symptom based on what the patient looks like or says at the time of the interview. Let's look at item number 5 on the YMRS scale, irritibility.  The interviewer is asked to rate it on a 5 point scale based on observations during administration of the test.  0 = absent, 1 = subjectively increased, 2 = irritable at times dring the interview, or recent episodes of anger or annoyance on the ward, 3 = frequently irritable during the interview: short, curt throughout, and 4 = hostile, uncooperative, interview impossible.


Notice that there is no requirement than an effort be made to find out why the patient presents with irritability during the interview.  It just assumes that it is due to the underlying mania.  But how long has it been going on?  Just today?  How do we know the patient is not acting irritable because he had been having a really bad day, or because the interviewer was perceived as condescending? We don't.  


Or take item #6, rate and amount of speech.  Manic patients have what we called pressured speech - they talk and talk and no one can get a word in edgewise.  This is present regardless of external circumstances.  If a patient exhibits very fast speech in the YMRS interview, on the other hand, the symptom could conceivably be present because the patient is in a big hurry to leave on that particular day, but characterologically likes to make sure the doctor gets a very precise answer with all its myriad details to any question.  


Without this additional information, the answers to the questions are meaningless!  In children, aggression and irritability have hundreds of potential causes besides their supposedly being symptoms of bipolar disorder.


But the mantra that they are indeed symptoms of bipolar disorder in children is once again subtly repeated.  Over and over and over again: the big lie technique in operation.

How Do You Know if You Should Try Treating Your Depression With Medication?

I have frequently blogged in this venue about the efficacy of antidepressants in “depression.”  I have pointed out that “depression” has a wide variety of different meanings, and that there are also several different syndromes of depressive disorders in the diagnostic manual, the DSM.  While there is considerable overlap in the symptoms of the various syndromes, some are far more likely to respond, and respond dramatically, to antidepressant medication than others.

I have also ranted against physicians who use “symptom checklists” or other self-report “tests” to make a diagnosis of depression, rather than use an extensive clinical interview.  The tests often say very little about whether a symptom a patient complains of is clinically significant for a certain diagnostic syndrome or not.  Aside from not looking at the psychosocial context in which the symptom occurs, the tests usually say very little about three important qualities of clinically significant symptoms – their pervasiveness, persistence, and whether or not they are pathological.  They also do not clearly show whether the symptoms all cluster together at the same times.

As I have pointed out several times, in order to make sure the patient is giving the doc an accurate and complete picture of their mood state, a good doctor must often ask one or even several follow up questions whenever a patient says “yes” or “no” in answer to a question about the presence of a symptom.

But how about a potential patient?  How does a non-professional know whether or not to even consult a physician about their mood state?  Why not just ignore it and see if it goes away?  Alternately, why not just go to a psychotherapist and handle it with psychotherapy alone?

That’s a very important question.  A similar question has recently been widely featured in the media in response to a proposed change in the DSM.  How does a patient or a doctor know when normal grief after the death of a loved one morphs into a clinical depression that would respond to medication?  The argument has mostly been about how long a doctor should wait after such a death before making a diagnosis of clinical depression, (major depressive disorder). 

While it is good that a doctor should not be overly hasty about making a diagnosis in this situation, in some genetically-prone individual, a stress of that severity can indeed trigger a major depressive disorder in a relatively short period of time.  Should that patient have to wait to be relieved of his or her suffering?  Certainly, any proposed “waiting period” specified in the DSM would have to be somewhat arbitrary.

To help patients figure out who to consult and when to consult a physician, a new self-report instrument is available that is significantly superior to the usual ones.  It is called the Post-Bereavement Phenomenology Inventory. It is meant to distinguish normal grief from major depression, but potentially it could also be used to distinguish major depression (likely to respond to meds) from another depressive syndrome, dysthymia (much less likely to respond to meds).

It was meant for physicians and not for patients to review for themselves, but even though it is better than most self-report instruments, IMO it should still not be used in place of a complete and wide-ranging clinical interview.  Context, prior history of major depressive disorders, family history of depression, and a whole host of factors need to also be considered.

But as a screening tool for patients, I think it might be helpful.  It uses a strategy called prototype matching.  This strategy focuses on the difference between depressive syndromes rather than the similarities.  The questions contain different descriptions of how each depressive symptom would present itself in classic cases of the two syndromes, and asks the patient, “[Which of the two descriptions] better describes how you have been feeling, thinking, or behaving for the past one to two months?”

Here it is.  I hope this will help potential patients decide whom to consult.  The first descriptions in each question are of the symptom presentation seen in major depression, while the second are of depressive symptoms that are less likely to respond to medication.  Of course, this is hardly foolproof, but generally the more you answer the questions one way or the other, the more likely you are to be experiencing one syndrome or the other. 


If someone's depression seems to conform mostly to the first prototype rather than the second, there are certain things that people often say to them that are both inappropriate and counterproductive.  An excellent list of such things can be found at http://www.medicalbillingandcoding.org/blog/11-things-you-should-never-say-to-someone-with-depression/

1.       I am filled with despair nearly all the time, and I almost always feel hopeless about the future.

versus

      I feel sadness a lot of the time, but I believe that eventually, things will get better.

2.      My sadness or depressed mood is near­ly constant, and it isn't improved by any positive events, activities, or people.

versus

       My sadness or depressed mood usually comes in "waves" or "pangs;' and there are events, activities, or people who help me feel better.

3.      When I am reminded of my loss (of a loved one, friend, job, etc), I feel nothing but pain, bitterness, or bad memories.

versus

    

       When I am reminded of my loss (of a loved one, friend, job, etc), I often feel intense grief or have painful memories, but sometimes I have good thoughts and pleasant memories. 

4.      I will probably never get back to feeling like my "old self" again.

versus

       Things are really tough now, but I'm hopeful that with time I will feel more like my "old self.”

5.      I feel like a worthless person who has done mostly bad things in life, and has let my friends, family, and loved ones down.

versus

       I feel like I'm basically a good person and that, in general, I have done my best for my friends, family, and loved ones.

6.      All I can think about lately is me and how miserable I feel; I hardly think about friends, family, or loved ones, ex­cept to blame myself for some failing.

  versus

       Even though I'm less social and out­going since my loss, I still think a lot about friends, family, and loved ones, often with good feelings about them.

7.      When friends or family call or visit and try to cheer me up, I don't feel anything or I may feel even worse.

   versus

       When friends or family call or visit and try to cheer me up, I usually "perk up" for a while and enjoy the social contact.

8.     I often have persistent thoughts or im­pulses about ending my life, and I often think I'd be better off dead.

     versus

     I sometimes feel like a part of me has been lost and I wish I could be reunited with the person or part of my life I am missing, but I still think life is worth living.

9.      Almost nothing that I used to like do­ing (reading, listening to music, sports, hobbies, etc) is of any comfort or con­solation to me anymore.

     versus

   The things that I have always liked do­ing (reading, listening to music, sports, hobbies,etc)  give me some comfort and consolation, at least temporarily.

10.  I feel "slowed down" inside, like my body and mind are stuck or frozen, and like time itself is standing still.

   versus

       My concentration isn't as good as usu­al, but my body and mind aren't slowed down, and time passes in the usual way.