Le cas particulier de certaines professions de la santé et des relations humaines

Plus de la moitié des professions réglementées en vertu du Code des professions sont liées au domaine de la santé. Pour la plupart, leur champ d’exercice professionnel a été décrit en 1973 et n’avait pas été substantiellement revu depuis^[*].

Dans le cadre du Plan d’action ministériel en vue de la mise à jour du système professionnel, des modifications substantielles au Code des professions et à certaines lois particulières ont été apportées en juin 2002 par l’Assemblée nationale du Québec, avec l’adoption du Projet de loi n^o 90. Puis, en juin 2009, dans la poursuite de la mise à jour amorcée avec le plan d’action ministériel, le Projet de loi n^o 21 est sanctionné. Ces dispositions, dont certaines sont entrées en vigueur en juin 2010, visent le domaine de la santé mentale et les relations humaines.

L’objectif gouvernemental est de moderniser l’organisation professionnelle de la santé dans le secteur public, en vue d’une meilleure organisation des services et d’un accès plus rapide aux soins de santé, dans une perspective de protection du public. Ces modifications survenues en 2002 et 2009 concernent les dix-huit professions de la santé suivantes :

Audiologiste Conseiller et conseillère d’orientation Diététiste Ergothérapeute Infirmière et infirmier Infirmière et infirmier auxiliaire Inhalothérapeute Médecin

Orthophoniste Pharmacien Physiothérapeute Psychoéducateur et psychoéducatrice Psychologue Technologiste médical Technologue en imagerie médicale et en radio-oncologie Thérapeute conjugal et familial Thérapeute en réadaptation physique Travailleur social

Champ de pratique

Ces professions bénéficient d’une description renouvelée de leur cadre d’intervention. Un champ de pratique énonce maintenant les principales activités de la profession ainsi que sa finalité.

Au-delà de leurs distinctions, les professions visées partagent certains éléments de leur champ de pratique. En effet, ces professions ont dorénavant pour mission commune d’informer et de promouvoir la santé, de prévenir la maladie, les accidents et les problèmes sociaux auprès des individus, des familles et des collectivités.

Activités réservées

Les activités réservées transforment l’assiette d’exclusivité préalablement établie pour quatre professions à exercice exclusif, soit la profession d’infirmière, de médecin, de pharmacien et de technologue en imagerie médicale et en radio-oncologie.

Les quatorze autres professions, qui sont à titre réservé, se voient attribuer une assiette d’exclusivité également sous la forme d’activités réservées. Précisons que certaines activités réservées sont partagées par plusieurs professions.

Entrée en vigueur

Le 30 janvier 2003 sont entrées en vigueur les dispositions relatives aux professions d’infirmière et d’infirmier, d’infirmière et d’infirmier auxiliaire, d’inhalothérapeute, de médecin, de pharmacien, de technologue en imagerie médicale et en radio-oncologie et de technologiste médical.

Le 1^er juin 2003 sont entrées en vigueur les dispositions concernant les diététistes, les ergothérapeutes, les orthophonistes et audiologistes, les physiothérapeutes et les thérapeutes en réadaptation physique.

Le 23 juin 2010 sont entrées en vigueur certaines dispositions du Projet de loi n^o 21 concernant les conseillers et conseillères d’orientation, les psychoéducateurs et psychoéducatrices, les psychologues, les thérapeutes conjugaux et familiaux et les travailleurs sociaux.

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SOURCE & RÉFÉRENCES

Conseil Interprofessionnel du Québec

Cognitive-behavioral therapy for ADHD people

Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactivity Disorder (ADHD) is getting a lot of attention in children, but it’s widely recognized in adults too: about 4.4 percent of adults in the United States have ADHD. Many of those adults are on medication, but may continue to have symptoms of inattention and impulsiveness that impair their lives. The prognosis for these patients is influenced by the severity of symptoms, comorbidity, I.Q., family situation such as parental pathology, family adversity, socioeconomic status, and treatment.

More than 70 percent of the individuals who have ADHD in childhood continue to have it in adolescence. Up to 50 percent will continue to have it in adulthood. Although it’s been estimated that 6 percent of the adult population has ADHD, the majority of those adults remain undiagnosed, and only one in four of them seek treatment. Yet, without help, adults with ADHD are highly vulnerable to depression, anxiety, and substance abuse. They often experience career difficulties, legal and financial problems, and troubled personal relationships.

COMORBIDITY

A group of researchers, led by Isaac Szpindel, M.D., sought to assess comorbidity types and frequencies and age and gender characteristics in a large sample of children and adolescents ages 3 to 18 years with attention-deficit/hyperacitivity disorder (ADHD) found that among children and adolescents with ADHD, more than 80 percent had a diagnosis of at least one other psychiatric disorder, most commonly oppositional defiant disorder and conduct disorder, according to new research being presented at the American Psychiatric Association’s Annual Meeting (May 25, 2010). ADHD is highly comorbid and exhibits specific age and gender characteristics that evolve with age, the researchers concluded. Understanding of these features can aid in the formulation of differential diagnoses and in the choice of medication in children/adolescents with ADHD.

ADHD is highly comorbid and exhibits specific age and gender characteristics that evolve with age, the researchers concluded. Understanding of these features can aid in the formulation of differential diagnoses and in the choice of medication in children/adolescents with ADHD.

LONG-TERM USE OF METHYLPHENIDATE (PSYCHOSTIMULANTS)

Attention Deficit Disorder is commonly treated with stimulant medications such as Ritalin (methylphenidate), thus psychostimulants are far and away the most popular treatment in young children. ADHD is a serious disorder that has long-term negative consequences on a person’s life. In general, treatment with methylphenidate (psychostimulants) provides some long-term benefit, but it’s not perfect, and most children with ADHD continue to struggle into their teen years, compared with their peers without ADHD.

However, this medication has short-term effects and numerous undesirable side effects. The psychostimulants ordinarily do not cover the entire day, leaving parents at a loss for how to help children manage their symptoms in the evening or on weekends, and may be less efficacious for domain of function, such as peer or family interactions, that involve complex multi-determined interpersonal components. Thus psychosocial treatments also have a large role to play in the treatment of ADD/ADHD.

Treatment, particularly stimulant medication, can be helpful in the short term for patients with ADHD, but the long-term impact of treatment is deemed unclear. The effects of long-term methylphenidate treatment (psychostimulants treatment) on the developing brains of children with ADHD is the subject of study and debate¹,². There is a lack of evidence of the effectiveness in the long term of beneficial effects of methylphenidate with regard to learning and academic performance. The long-term effects on mental health disorders in later life of chronic use of methylphenidate is unknown. There is limited data that suggests there are benefits to long-term treatment in correctly diagnosed children with ADHD, with overall modest risks³. The long term effectiveness of methylphenidate has not been scientifically demonstrated. Tolerance and behavioural sensitisation may occur with long-term use of methylphenidate⁴. There are no well defined withdrawal schedules for discontinuing long-term use of stimulants⁵. The withdrawal or rebound symptoms of methylphenidate can include psychosis, depression, irritability and a temporary worsening of the original ADHD symptoms.

The side effects of Ritalin are very frightening. The Physicians Desk Reference lists the possible side effects of taking Ritalin: anorexia, nausea, dizziness, heart palpitations, headache, dyskinesia, drowsiness, blood pressure and pulse changes, tachycardia(racing heart), angina, abdominal pain, restlessness, insomnia, loss of appetite and arrythmia. Hallucinations and toxic psychosis may also occur in patients taking Ritalin. Treatment of ADHD by way of Methylphenidate has led to legal actions including malpractice suits regarding informed consent, inadequate information on side effects, misdiagnosis, and coercive use of medications by school systems. Teachers, parents and doctors continue to advocate Ritalin, and Although Ritalin is not the answer for every child, most physicians use it as their first form of treatment. Pharmopsychology is the most widely used technique to treat ADHD (Rief, 1998).

Some researchs hints that hidden risks might accompany long-term use of the medicines that treat attention-deficit hyperactivity disorder, and a smattering of recent studies, most of them involving animals, hint that stimulants could alter the structure and function of the brain in ways that may depress mood, boost anxiety and, in sharp contrast to their short-term effects, lead to cognitive deficits, thus inappropriate treatment is particularly worrisome because of the unknown impacts of long-term stimulant usage, on children’s health, who are either having, or either not having, ADHD⁶. Also, research with rats finds that Ritalin at low doses encourages neurons to fire together, but at high doses it’s just another stimulant⁷.

PSYCHOSOCIAL TREATMENT

A study led by Steven Safren at Massachusetts General Hospital Behavioural Medicine works toward an evidence-based approach to treating adults with the condition. The main therapy tested in this study was a form of cognitive behavioural therapy, which helps people form healthy habits and thought patterns. This therapy targeted three skill sets: problem-solving, reducing distractibility, and dealing with negative thinking and stress associated with the disorder. Participants who went through cognitive behavioural therapy had significantly better outcomes. Safren and colleagues had already published a therapist manual and client workbook detailing their cognitive behavioural therapy method, both called “Mastering Your Adult ADHD,” in 2005.

Skills typically taught during cognitive-behavioral therapy include education about symptoms and medications, emotional regulation, self-esteem building, problem-solving skills, mindfulness and strategies for improving motivation, concentration, listening, impulsivity, organization and time management. It is important to note that pharmacological interventions alone may be insufficient, and thus combining cognitive behavioural therapy is recommended. Family therapy and support groups may also prove a useful adjunct in adult ADHD management.

Dr. Lenard A. Adler noted that adult ADHD affects 4.4% of the US population. “Not only is it common, but most of [those affected] are unrecognized and untreated. We know that anywhere between 10% and 25% of adults with ADHD are actually diagnosed and treated at this time.”⁸ “If we can improve our diagnostic assessments, the chance that we’re going to be able to bring more people into being diagnosed and treated for a very common and impairing condition should improve,” said Dr. Adler. But when you improve their executive function, it just lets them perform better. Executive Functionning problems are “the most consistent and discriminating predictors” of adult ADHD.

Although medication is the current treatment of choice, many adults with ADHD cannot or will not take medication. In addition, most patients taking medication, although considered responders (defined as patients who experience a ≥30% reduction in ADHD symptoms), continue to experience clinically significant symptoms, highlighting the need for “alternative and next step strategies.

“[ADHD] is a very impairing and distressing disorder, and while medications help, they don’t teach people skills to cope with their problems. This treatment is a relatively easy, short-term, skills-based treatment that teaches patients self-management skills to further reduce their symptoms”. ADHD patients who continue to have symptoms despite medication use should be considered potential candidates for Cognitive behavioral therapy. A previous pilot study of CBT by Dr. Safren and colleagues in this patient population showed those taking medication who received CBT had greater symptom reduction compared with those taking medication alone (Behav Res Ther. 2005;43:831-842).

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SOURCES & RÉFERENCES

1 2003. “ADHD & Women’s health – Attention Deficit/Hyperactivity Disorder”. Available at: http://findarticles.com/p/articles/mi_m0NKT/is_1_25/ai_99698688/pg_4/. [Accessed December 30, 2010].

2Edmund J. S. Sonuga-Barke, Margaret Thompson, Howard Abikoff, Rachel Klein, Laurie Miller Brotman. “Nonpharmacological Interventions for Preschoolers With ADHD: The Case for Specialized Parent Training” (PDF). Infants & Young Children 19 (2): 142–153. While most recent studies suggest that methylphenidate is relatively well-tolerated by young children, some suggest that side-effects might be more marked in preschoolers than in school-aged children (Firestone, Musten, Pisterman, Mercer, & Bennett, 1998). Furthermore, some researchers have argued that there is the potential for negative long-term effects on the developing brains of young children chronically medicated (Moll, Rothenberger, Ruther, & Huther, 2002).”. http://depts.washington.edu/isei/iyc/sonuga_19.2.pdf. Retrieved 2010-12-29.

3Kociancic T, Reed MD, Findling RL (March 2004). “Evaluation of risks associated with short- and long-term psychostimulant therapy for treatment of ADHD in children”. Expert Opin Drug Saf 3 (2): 93–100.

4Patrick KS, Straughn AB, Perkins JS, González MA (January 2009). “Evolution of stimulants to treat ADHD: transdermal methylphenidate”. Human Psychopharmacology 24 (1): 1–17.

5Ashton, H., Gallagher, P. & Moore, B., 2006. The adult psychiatrist’s dilemma: psychostimulant use in attention deficit/hyperactivity disorder. Journal of Psychopharmacology, 20(5), pp.602 -610.

6Higgins Edmund S. (July 2009) “Do ADHD Drugs Take a Toll on the Brain?” Scientific American, http://www.scientificamerican.com/article.cfm?id=do-adhd-drugs-take-a-toll, [Accessed December 30, 2010].

7(July 2008), “Ritalin Dose Changes Effect”, Scientific American http://www.scientificamerican.com/podcast/episode.cfm?id=081535BC-EB62-D649-01B40A271E2C0EDE, [Accessed December 30, 2010].

8Brauser, Deborah. (2010) “Executive Functioning Problems Consistent Predictors of Adult ADHD”, Medscape Medical News, November 2010, http://www.medscape.com/viewarticle/732402, [Accessed Fabuary 26, 2011].

Exploring models of disabilities!

Attention deficit hyperactivity disorder (ADHD) is typically a life-long condition that results in functional limitations. Function limitations may be mild or they can be quite severe, depending on the severity and management of ADHD symptoms and comorbidities. Workplace settings present a wide variety of diverse occupational research challenges. Because the impact of the condition will vary from setting to setting, obtaining a consistent and reliable picture of adaptive or maladaptive functional performance directly attributable to ADHD is difficult.

While there seems to be evidence of many success stories of adults with ADHD who are self-employed and have found a controllable “niche” that they flourish in, most of those seeking entry or upward mobility in the workplace have to live and play by the rules of a world that has little understanding or sensitivity of the emotional impacts of having this hidden disability and the costs to the individual trying to “keep it together”.

The intent of this paper is twofold. First, it seeks to familiarize the reader with the concepts of impairment, disability, handicap, functional limitations, functional capacities, and functional assessment. Second, provide a quick review of disability models (or disablement models), and third, to discuss the concept of Functional Limitation (FL) in relation with ADHD, and with disabilities models.

MODELS OF DISABILITY

Disablement Model is a conceptual explanation of the process and underlying mechanisms by which disease, injury or birth defect impacts a person’s ability to function (perform their expected role in society). Different contributions could be divided into three groups of models : models in which disability is an attribute of the person, models in which disability is related to the environment, and models in which disability is linked to the person-environment relationship.

Models of disablement are helpful in understanding the process of how a person loses abilities, and are important in the selection of interventions to address those losses. Models of disablement are tools for defining impairment and, ultimately, for providing a basis upon which government and society can devise strategies for meeting the needs of disabled people. Models of disablement define disability, determine casual and responsibility attributions, influence professional practice, drive payment systems, and guide legislation (Dembo, 1982; Hahn, 1993; Nagi, 1969; Zola, 1989). Models of disability are the underlying structure for large, complex diagnostic/defining systems. Models of disablement refers to systems of definitions and theories about human disability that are used to provide a framework for discussion or to explain disabilities in relation to clinical diagnosis, rehabilitation medicine, employment issues, public policy-making, and similar concerns.

Surprisingly, the power of models of disablement is rarely acknowledged or addressed; nor, are these models questioned or challenged (Gill, Kewman, & Brannon, 2003; Harper, 1991; Pledger, 2003). Indeed, most practitioners are only marginally aware that there are other models and that patients/clients/consumers may, and often do, subscribe to a different model. A therapeutic alliance, therefore, is difficult to establish if the professional and client define the disability differently and, as a result, envision different treatments and services. Most practitioners function in the way in which they have been educated and trained (Bauman & Drake, 1997; Bluestone, Stokes, & Kuba, 1996; Gill et al., 2003; Hogben & Waterman, 1997; Kemp & Mallinkrodt, 1996; Parsons, Hernandez, & Jorgensen, 1998).

The literature is replete with attempts to apply a wide variety of sociological and psycho-sociological theories to disablement phenomena. Disablement has been explained in terms of deviance theories, labeling and functionalist theories, symbolic interactionalism, somatopsychological and attitude theories, marxist and
other materialistic theories, and more recently feminist theories, postmodern interpretations and many others.

GROUPS OF DISABLEMENT MODEL :

• The Charity Model of Disability : The charity model looks at disability as a personal tragedy ;
• The Moral/Religious Model of Disability : The religious model views disability as a punishment inflicted upon an individual or family by an external, usually supernatural, force. Sometimes the presence of “evil spirits” is used to explain differences in behavior, especially in conditions such as schizophrenia. Acts of exorcism or sacrifice may be performed to expel or placate the negative influence, or recourse made to persecution or even death of the individual who is “different”. In some cases, the disability stigmatizes a whole family, lowering their status or even leading to total social exclusion. Or it can be interpreted as an individual’s inability to conform within a family structure. Conversely, it can be seen as necessary affliction to be suffered before some future spiritual reward. ;
• The Medical Model of Disability (also known as the biomedical model, and as the functional-limitation model): The medical model of disability has a long history, is the most well-known to the general public, and carries with it the power and prestige of the well-established medical profession. This model, rooted in the scientific method and the benefactor of a long tradition, has had dominance in shaping the understanding of disability.The medical model for many years has been the dominant approach to disability. The medical model of disablementhas an emphasis on pathology-based causes of impairments that can lead to a disability. This model reflects a treatment approach to the disability with the aim of ameliorating the pathology or impairment in order to cure or lessen the disability. Clinically, the medical model guides the selection of interventions toward the aim of lessening or curing the pathology or impairment and its resulting functional limitation.The medical model assumes that the first step solution is to find a cure or – to use WHOterminology – make disabled people more “normal”. This invariably fails because disabled people are not necessarily sick or cannot be improved by remedial treatment. The only remaining solution is to accept the “abnormality” and provide the necessary care to support the “incurable” impaired person. Policy makers are limited to a range of options based upon a program of rehabilitation, vocational training for employment, income maintenance programs and the provision of aids and equipment.The medical model holds that disability results from an individual person’s physical or mental limitations, and is largely unconnected to the social or geographical environments. It is sometimes referred to as the Biological-Inferiority or Functional-Limitation Model. This model locates the “problem” of disability in the deviant body of the individual, rather than in society itself or in the way the deviant mind or body is perceived. When people such as policy makers and managers think about disability in this individual way they tend to concentrate their efforts on ‘compensating’ people with impairments for what is ‘wrong’ with their bodies by targeting ‘special’ welfare benefits at them and providing segregated ‘special’ services for them and so on. The medical model of disability also affects the way disabled people think about themselves. Many disabled people internalize the negative message that all disabled people’s problems stem from not having ‘normal’ bodies. Disabled people too can be led to believe that their impairments automatically prevent them from participating in social activities.
• The functional-limitation model (medical model) has dominated the formulation of disability policy for years. Although we should not reject out-of-hand its therapeutic aspects which may cure or alleviate the physical and mental condition of many disabled people, it does not offer a realistic perspective from the viewpoint of disabled people themselves. To begin with, most would reject the concept of being “abnormal”. Also, the model imposes a paternalistic approach to problem solving which, although well intentioned, concentrates on “care” and ultimately provides justification for institutionalization and segregation. This restricts disabled people’s opportunities to make choices, control their lives and develop their potential.
• The biomedical modelhas had dominance in shaping the public’s understanding of disability because of the following factors: a) the long history of the Biomedical model, b) its reliance on the prestigious and authoritative academic disciplines of medicine and science, c) its strong explanatory power, and 4) the public’s intuitive understanding of medical diagnoses. Moreover, many disability scholars feel that the dominance of the Biomedical Model will continue, and increase, as the profession of medicine evolves into more specializations. This model has fragmented the disability community into diagnostic categories and thus robbed them of their collective history and memory. The rather dated criticisms of the biomedical Model of Disability, including the pathologization, categorization, objectification, and privatization of disability.Due to this “individualization,” “privatization,” and “medicalization” of disability, the Biomedical Model has remained silent on issues of social justice. Until recently, the biomedical model itself has been silent on issues of social justice. While no one believes that medical professionals deliberately created injustice and discrimination, nonetheless, the result has been injustice. Scholars feel that disability has been “misrepresented” as only a health concern and because of this discrimination and prejudice based on disability result, but also frequently remain unrecognized. Further, to the general public, this discrimination and prejudice does not appear to be prejudice and discrimination because it is the medical professions who have been given the mandate to respond to all the needs of people with disabilities.Defining disability as solely a medical concern that requires high levels of expertise, training, and technology also lends scientific credibility to the idea that all of the difficulties experienced by people with disabilities are the result of their physical abnormalities or physical inferiority. Higgins (1992) summarized this when he remarked that we make people with disabilities foreigners in their own country. The well-defined normative basis of disability of the biomedical model also relieves society of any need to provide accommodation. The entire focus is on changing the individual (rehabilitation) rather than changing the environment (accommodation). In the biomedical model, disability is thought to be dysfunction, abnormality, pathology, disease, or defect. Simply stated, it is better not to have a disability. Disability is deviance, not a valued difference. Disability is defined as an observable deviation from biomedical norms of structure or function that directly results from a disease, trauma or other health condition (Boorse, 1975, 1977). Goffman (1961, 1963) describe the process of stigmatizing and the creation of “deviance”. Therefore, individuals with a disability understand that they belong to a devalued group, regardless of their individual attributes, achievements, or resources. Often individuals with disabilities eventually accept the disabled role of inferiority and deviance. In the biomedical model, pathologizing and privatizing disability was another way in which to effectively absolve “society” from any responsibility to deal with disability issues.The biomedical model has provided the basis for much of the legislation that mandates services for people with disabilities and also guides the reimbursement and payment systems of government agencies and insurance companies (Berkowitz & Hill, 1986; Wolfensberger, 1972; Zola, 1993). Therefore, both the services and funding the individual with a disability receives are based on the biomedical model. The profession of medicine has, for centuries, been based on the two outcome paradigm of cure or death and vestiges of this paradigm are reflected in payment systems. Therefore, after medical stabilization, much of the funding is withdrawn, not taking into consideration the individual’s greatest needs (Yelin, 1992). Nonetheless, disabilities are chronic conditions which require care and not cure. Health maintenance, patient education, maintaining the highest quality of life, avoiding secondary conditions, and responding to interaction of the disability with the aging process are all medical services that are necessary for someone with a disability, but typically are not funded or underfunded. Simply because the Biomedical Model does not take the environment into consideration, payers will not see the individual benefits (or overall social benefit) of paying for services such as marital counselling or other types of counselling. Environmental and social interventions frequently are not funded. Psychiatric disabilities, which are highly dependent upon the environment of the individual, are not well-funded. Such environmental accommodations could render the individual highly functional (Wright, 1991). ;
• The Rehabilitation Model of Disability : The rehabilitation model is similar to the medical model; it regards the person with a disability as in need of services from a rehabilitation professional who can provide training, therapy, counselling or other services to make up for the deficiency caused by the disability. Persons with disabilities have been very critical of both the medical model and the rehabilitation model. While medical intervention can be required by the individual at times, it is naive and simplistic to regard the medical system as the appropriate locus for disability related policy matters. Many disabilities and chronic medical conditions will never be cured.
• The Expert/Professional Model of Disability : The expert/professional model has provided a traditional response to disability issues and can be seen as an offshoot of the Medical Model. Within its framework, professionals follow a process of identifying the impairment and its limitations (using the Medical Model), and taking the necessary action to improve the position of the disabled person. This has tended to produce a system in which an authoritarian, over-active service provider prescribes and acts for a passive client.
• The Social Model of Disability: The social model views disability as a collection of factors and conditions, many of which are created by society and act as barriers to the individual’s participation in society. The Social Model views disability as a consequence of environmental, social and attitudinal barriers that prevent people with impairments from maximum participation in society.The social modelof disability makes the important distinction between ‘impairment’ and ‘disability’. So, in a social model of disability the key definitions are: Impairment – An injury, illness, or congenital condition that causes or is likely to cause a long term effect on physical appearance and / or limitation of function within the individual that differs from the commonplace. Disability – The loss or limitation of opportunities to take part in society on an equal level with others due to social and environmental barriers.The social modelfocuses on the need for social interventions to enable all persons to participate in society regardless of their abilities. This model guides the selection of interventions toward the aim of lessening the disability, which is a result of both a physical condition as well as social and/or environmental barriers.The social modelhas been worked out by disabled people who feel that the individual model does not provide an adequate explanation for their exclusion from mainstream society – because their experiences have shown them that in reality most of their problems are not caused by their impairments, but by the way society is organized. The social activists and advocates for persons with disabilities have argued that disablement is a political issue, a matter of basic civil rights. Persons with disabilities are a social minority who have been systematically discriminated against in all areas of life (Eisenberg et al., 1982; Barnes, 1991). The limitations they face in education, employment, housing and transportation are not the products of their medical condition, but of social attitudes of neglect and stereotypical images about their capacities and needs (Gartner and Joe, 1987). Since the source of the disadvantage is a failure of the social environment, the appropriate strategies for remedying this are political: change attitudes, change policies and laws.The social modelthus takes account of disabled people as part of our economic, environmental and cultural society. The barriers that prevent any individual playing a part in society are the problem, not the individual. Barriers still exist in education, information and communication systems, working environments, health and social support services, transport, housing, public buildings and amenities.The social modelhas been developed by disabled people in response to the medical model and the impact it has had on their lives. Under the social model, disability is caused by the society in which we live and is not the ‘fault’ of an individual disabled person, or an inevitable consequence of their limitations. Disability is the product of the physical, organizational and attitudinal barriers present within society, which lead to discrimination. The removal of discrimination requires a change of approach and thinking in the way in which society is organized.Unfortunately very little empirical research has been done on the fundamental question of how intrinsic features of an individual interact with features of the social environment to produce disablement. How precisely does the social environment create disablement? Should we expect patterns of disadvantage linked to special physical or mental conditions? How do we identify which aspects of the social environment are responsible for disadvantage? Which interventions will make a difference, and can we measure the improvement? ;
•  The Sociopolitical Model of Disability : the sociopolitical model sees disability as a result of environmental and social factors: people with impairments are disabled by barriers in society, by its structures and norms. Advocates of the Sociopolitical Model believe that much of the prejudice and discrimination experienced by people with disabilities occurs not in spite of the Biomedical Model, but because of the Biomedical Model. The Sociopolitical Model asserts that the Biomedical Model, by dividing individuals into groups based on diagnostic categories or functional traits, has effectively fragmented people with disabilities into competing interest groups. The various disability groups must compete for tangible resources and services. ;
• The Biopsychosocial Model of Disability : the biopsychosocial model is being articulated that embraces aspects of social, biological and psychological factors thus recognizing the complexities of simplistic interpretation and definition ;
• The Economic Model of Disability : Under the economic Model, disability is defined by a person’s inability to participate in work. It also assesses the degree to which impairment affects an individual’s productivity and the economic consequences for the individual, employer and the state. Such consequences include loss of earnings for and payment for assistance by the individual; lower profit margins for the employer; and state welfare payments.The Economic Model is used primarily by policy makers to assess distribution of benefits to those who are unable to participate fully in work. In recent years, however, the preoccupation with productivity has conflicted with the application of the Medical Model to classify disability to counter fraudulent benefit claims, leading to confusion and a lack of co-ordination in disablement policy. ;
• The Functional Model of Disability — Interactionnal Approach : In Great Britain, sociologists sought their explanations outside of the more individualistic, American approach, adopting more overtly political theoretical accounts. The model also arose within social psychology (Meyerson, 1948, 1988) only to be labelled by some researchers the “interactive” model — a name likely derived from the internationalist school of American sociology (Lemert,1962) — and by others the “environmental” approach, to disability (Amundson, 1992; Bickenbach, 1993; Imrie, 1997) ;This relationship has been described as that of fixer (the professional) and fixee (the client), and clearly contains an inequality that limits collaboration. Although a professional may be caring, the imposition of solutions can be less than benevolent. If the decisions are made by the “expert”, the client has no choice and is unable to exercise the basic human right of freedom over his or her own actions. In the extreme, it undermines the client’s dignity by removing the ability to participate in the simplest, everyday decisions affecting his or her life.
• The Customer/Empowering Model of Disability : The customer/empowering model is the opposite of the expert/professional. Here, the professional is viewed as a service provider to the disabled client and his or her family. The client decides and selects what services they believe are appropriate whilst the service provider acts as consultant, coach and resource provider. Recent operations of this Model have placed financial resources into the control of the client, who may choose to purchase state or private care or both. ;
• The Administrative Model of Disability : The administrative model focuses upon disability as an assessment process for identifying needs. ;

THERE ARE MANY DISABLEMENT MODEL :

1. Nagi’s Disablement Model [Saad Nagi, 1965] (pathology -> impairment -> functional limitations -> disability) : Uni-dimensional (pathology-based) and unidirectional model of disability only, does not account for impairments and functional limitations not due to pathology, and does not consider societal barriers: architectural, attitudinal. Active pathology refers to any interruption or interference with normal processes, and efforts of the organism to regain normal state. Impairment is defined as any loss or abnormality of anatomic, physiologic, mental, or emotional structure or function. Functional limitation is defined as a limitation in performance at the level of the whole organism or person. Disability then applies to a limitation in performance of socially defined roles and tasks within a sociocultural and physical environment. In the 1960s and 1970s, Saad Z. Nagi developed an influential model of disability based on his research on rehabilitation outcomes (Nagi, 1964, 1965, 1976, 1987). Nagi’s concepts strongly influenced other models of disability, including those of the WHO and the NCMRR. ;
2. A second revision of Nagi’s model, Verbrugge and Jette’s Model of the Disablement Process[Verbrugge and Jette] : While integrating this model with I.C.I.D.H., they developed a new disablement model in order to describe how chronic and acute conditions affect functioning in specific body parts, mental function and daily life, and the role of personal and environmental factors in disablement (Verbrugge and Jette, 1994). Verbrugge and Jette elaborated on Nagi’s model in “an attempt to attain a full sociomedical framework of disablement, which they defined as the impact that chronic and acute conditions have on functioning of specific body systems and on people’s abilities to act in necessary, usual, expected, and personally desired ways in their society” (Jette, 2006:729). Altman (2001) notes that Verbrugge and Jette focused on task orientation, while Nagi focused more on role orientation toward limitation. As already noted, Verbrugge and Jette accepted the elements of Nagi’s model: active pathology, impairment, functional limitation, and disability. They operationalized the Nagi model by identifying various types of necessary, usual, expected, and/or personally desired roles and activities under Nagi’s concept of disability that should be tracked and measured. These included (Verbrugge and Jette, 1994). In addition Verbrugge and Jette (1994) tried to make the model more dynamic by identifying factors that affect what they called the “disablement process.” They posited three sets of variables that affected the “pathway” to disablement of a given individual. These were:Risk Factors: Risk factors are “predisposing phenomena that are present prior to the onset of the disabling event that can affect the presence or severity of the disablement process. Examples include sociodemographic background, lifestyle, and biologic factors.” ;Indra-individual Factors : Indra-individual factors “operate within a person, such as lifestyle and behavioral changes, psychosocial attributes and coping skills, and activity accommodations made by the individual following onset of a disabling condition.” ;Extra-individual Factors : Extra-individual factors are in the external “physical as well as the social context in which the disablement process occurs. Environmental factors relate to the social as well as the physical environmental factors that bear on the disablement process. These can include medical and rehabilitation services, medications and other therapeutic regimens, external supports available in the person’s social network, and the physical environment.”Verbrugge and Jette stimulated research into the impact of risk factors, intra-individual factors, and extra-individual factors on impairment, functional limitation, and disability and how they influence the disablement process ;
3. A third revision of Nagi’s model, Institute of Medicine’s (IOM’s) Enabling-Disabling Model[Brandt and Pope, 1997, IOM] (pathology -> impairment -> functional limitations -> disability) : In 1997, an IOM committee issued a report, Enabling America: Assessing the Role of Rehabilitation Science and Engineering, which responded to a congressional request for an assessment of rehabilitation research and technology development efforts. The report extended the 1991 IOM model by making “clear reference to the importance of the environment in causing, preventing, and reducing disability” (IOM, 1997:1). The IOM report added several dimensions to the Nagi model. First, it proposed three interacting risk factors—biological, environmental (social and physical), and lifestyle/behavioral—that affect each element of the disabling process: pathology, impairment, functional limitation, and disability. Second, it added impact on quality of life as a part of the disabling process (IOM, 1991:84-91). In effect, it added another component to Nagi’s model—features of the social and physical setting affecting an individual’s degree of disability that could be targeted for change. The IOM report helped bring Nagi’s conceptual model of disability to a wider audience and helped stimulate research on the environmental aspects of the disablement process.The committee explicitly adopted the elements of Nagi’s disability model (but called them “components of the disabling process” in the report)—i.e., pathology, impairment, functional limitation, and disability—with disability defined as “a limitation in performing certain roles and tasks that society expects of an individual” (Table 2-1). The IOM report focused on the “enabling process,” by which it meant efforts to reduce disability. Enabling could be accomplished by either restoring function in the individual (i.e., traditional rehabilitation) or expanding access to the environment, or both. The report also introduced the notion of secondary conditions as “any additional physical or mental health condition that occurs as a result of having a primary disabling condition” and that “quite often increase the severity of an individual’s disability and are also highly preventable” (IOM, 1997:3-5).According to the report, “the committee enhanced the 1991 IOM model to show more clearly how biological, environmental (physical and social), and lifestyle/behavioral factors are involved in reversing the disabling process, i.e., rehabilitation, or the enabling process. The enhancements include bidirectional arrows between the various states of the enabling–disabling process to indicate that the disabling process (described in the 1991 IOM model) can be reversed with proper interventions (i.e., the enabling process)” (IOM, 1997:6).The graphic representation of the new IOM model did not include a box for “disability,” in an effort “to help clarify the fact that disability is not inherent in the individual, but rather is a product of the interaction of the individual with the environment” (IOM, 1997:8). The report proceeded to recommend research and engineering needs and opportunities by domain: pathology and impairment research, functional limitation research, and disability research. Disability research would be “explicitly focused on the effects of the environment in producing or reducing disability” (IOM, 1997:12).In the report, the committee noted that the 1991 IOM model had some shortcomings. First, disability was depicted in the 1991 model as a linear process, which was fine for the 1991 report’s focus on ways to prevent disability but did not allow for reversal of disability through rehabilitation. Second, the earlier model gave a “limited characterization of the environment and the interaction of the individual with the environment.” Third, the 1991 model provided a limited “representation of societal limitations” (IOM, 1997:67).The International Classification of Impairments, Disabilities and Handicaps (ICIDH) [Philip Wood, WHO, 1980] (disease -> impairment -> disability -> handicap):
4. In 1976, the World Health Assembly of the World Health Organization (WHO) approved for publication a classificatory instrument incorporating a version of the social model. The result, eventually published in 1980, was the International Classification of Impairments, Disabilities and Handicaps(ICIDH) (World Health Organization, 1980). Here was an international classification of disablement, suitable for research and a myriad of other uses, that appeared to embody the insights of the social model.The underlying biopsychosocial model represents a synthesis of medical and social models, rather than a mere adoption of the social approach. The ICIDH made conceptual distinctions, based on Nagi, among impairment, functional limitations (which, however, WHO called “disability”), and disability (called “handicap” by WHO), which allowed recognition that disability is based not just on the attributes of the individual (the medical model) but also on the interaction between the person and society (the biopsychosocial model). The disease is defines as the intrinsic pathology or disorder. Impairment is defined as any loss or abnormality of psychological, physiological, or anatomical structure or function at organ level. Disability refers to any restriction or lack of ability to perform an activity in normal manner. Handicap then applies to disadvantage due to impairment or disability that limits or prevents fulfilment of a normal role [depends on age, sex, sociocultural factors] for the person. On the negative side, the ICIDH used the word “handicap” to label the result of the interaction between the person and the social setting. This label seemed to perpetuate the idea that the problem is more the inability of the person to fit into usual social roles rather than restrictions imposed by environmental barriers and social attitudes, which could be modified to enable an impaired person to participate in work and other normal activities. The model was also still medically based (i.e., diseases, injuries, or other disorders result in impairment, which cause functional limitations, which, in turn, reduce the person’s ability to participate in society). This did not recognize the complexity of the disablement process, especially the role of contextual factors, or the fact that the correlations between degree of impairment, extent of functional limitation, and level of disability are low.Among the many uses of the ICIDH discussed in the literature are health information surveying (Bonte, 1986), population studies (Chamie, 1995), rehabilitative outcomes measurement (De Kleijn-de Vrankrijker, 1989), research on home care for the elderly (Rusinowitz et al., 1993) and psychiatric research (Wiersma, 1986).Yet, despite its promise, almost from its first appearance critics have argued that the ICIDH and it’s model of disablement are deeply flawed (Fougeyrollas, 1995). Despite the attempt to offer a non medical model of disablement, the promise was never fully, or clearly, realized. The root problem was a subtle ambiguity of language that undermined the intended model. Try as the drafters might to insist that disabilities exist because of social expectations of normal performance and that handicaps are socially constructed disadvantages, they persisted in using language that suggest a very different picture : Disadvantage accrues as a result of [the individual] being unable to conform to the norms of his universe. Handicap is thus a social phenomenon, representing the social and environmental consequences for the individual stemming from the presence of impairments and disabilities. (World Health Organization, 1980, p. 29). Although presumably not intended, this passage suggests that people are disadvantaged because of their disabilities alone, and that handicaps are caused by impairments and disabilities. As a result, the user of the ICIDH cannot record, let alone measure, the effect that an unaccommodating environment has on people’s lives. The user can record changes in a person’s level of ability, but would have no way of knowing whether that was the result of changes to the person (rehabilitation), or changes to the social and physical environment (accommodation). As far as the ICIDH is concerned, the social and physical world is immutable and benign. The underlying model does not clearly acknowledge that the presence of social barriers and the absence of social facilitators play any sort of role in the creations of the disadvantages that a person with a disability experiences.In 1993, the World Health Organization began the process of revising the ICIDH. Released in 2000, the ICIDH-2 embodies what is now termed the “biopsychosocial” model, a synthesis of the medical and social approaches to disablement. ;
5. National Center for Medical Rehabilitation Research (NCMRR) of Bethesda [1993] : The stated mission of the NCMRR, a center within the National Institutes of Health, is to enhance the quality of life of people with disabilities through the development of scientific knowledge. NCMRR developed a model that describes disability and was based both on Nagi’s model and on the I.C.I.D.H. in an attempt to overcome the limits of both, more precisely, the fact of assuming a linear causal relationship among the various consequences of pathologies, and failing to analyze the role of environmental factors in the dynamics of the relationships among the various levels (NCMRR 1993); NCMRR (1993) built on the Nagi model by including the impairment, functional limitation, and disability domains corresponding to the organ, person, and societal levels, but NCMRR added another level or “dimension,” called “societal limitation”. Societal limitations are barriers to full participation in society that result from attitudes, architectural barriers, and social policies. The NCMRR model pulled external barriers out of the environmental domain for special emphasis, highlighting the fact that these barriers could be reduced or eliminated by public policy.
6. International Network on Disability Creation Process (INDCP) [Patrick Fougeyrola, INDCP, 1991-96-99] : An explicative model of the causes and consequences of disease, trauma and other disruptions to a person’s integrity and development;
7. International Classification of Functioning, Disability and Health (ICF) [WHO, 2001] : The World Health Organization (WHO) authorized the International Classification of Functioning, Disability and Health (ICF) in 2001. The ICF defined disability as a complex interaction between body structures and functions, health issues, and environmental and personal factors which affect the participation of people in activities. The ICF model broadens the health care provider’s focus from the pathological process to the level of health and participation of the person. To the contrary, when viewing a person through a medical model of disablement, disability is viewed as a consequence of dysfunctional health, not a component of health. The ICF provides a tool that measures a person’s functioning and participation within society, regardless of his disability. The ICF provides for a more interacting picture of the person and the contributing factors that influence his daily functioning and participation. It serves to overcome many of the limitations of previous disablement models by examining not only the health condition (wellness, disorder, or disease) but also contextual factors (personal and environmental factors), body structure and function, activities, and participation.

THE CONCEPT OF FONCTIONAL LIMITATION

The concept of functional limitations (FL) has occupied a cardinal role in the field of rehabilitation for many years. Despite the centrality of this concept to the daily work of rehabilitation professionals, it has not been without its share of problems. For example, the very notion of a classification of functional limitations has spawned many, and often, rather diverse efforts by researchers and clinicians (e.g., Crewe & Athelstan, 1981; Marsh, Konar, Langton & LaRue, 1980; Sarno, Sarno & Levita, 1973; Wright, 1980). Furthermore, the ever-evolving conceptualization of the terms of impairment, disability and handicap, and their relationship to functional limitations and functional capacities (i.e., residual functions maintained following a disease or injury) has also thwarted efforts at defining, clarifying and categorizing functional limitations (Granger & Gresham, 1984; Halpern & Fuhrer, 1984; Nagi, 1969, 1976; World Health Organization, 1980). Finally, the various systems developed over the past four decades to assess human functions show a remarkable degree of diversity, and range from those directed at measuring only physical functions to those addressing a wide array of life spheres (i.e., physical, psychological, social, educational, vocational and environmental areas) (Agerholm, 1975; Brown, Gordon & Diller, 1983; Granger & Gresham, 1984; Halpern & Fuhrer, 1984).

The concept “Functional limitation” (FL) may derive from the NAGI, NCMRR, ICIDH, disability models.

According to the ICIDH of the World Health Organization (WHO), a functional limitation is any health problem that prevents a person from completing a range of tasks, whether simple or complex.

SOME DEFINITIONS RELATED TO DISABILITY

Impairment is defined as “any loss or abnormality of psychological, physiological, or anatomical structure or function” (World Health Organization, 1980, p. 47). Impairment reflects disturbances at the body’s organ level (e.g., leg, back, brain). Measures of impairment typically include those concerned with specific restrictions of some physical, mental or emotional capacity (Halpern & Fuhrer, 1984).

Disability is defined as “any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being” (WHO, 1980, p. 143). Disability reflects disturbances at the person level. In other words, it relates to deficiencies in normally expected function, performance, or behaviour (e.g., inability to walk, inability to sit for an extended period of time, limited self-awareness, limited ability for acquisition of knowledge). Measures of disability customarily include those addressing restrictions of skills a person manifests when interacting with the environment (e.g., Activities of Daily Living Scales) (Halpern & Fuhrer, 1984).

Learning disability (sometimes called a learning disorder[1] or learning difficulty), is defined as a classification including several disorders in which a person has difficulty learning in a typical manner, usually caused by an unknown factor(s). The unknown factor is the disorder that affects the brain’s ability to receive and process information. This disorder can make it problematic for a person to learn as quickly or in the same way as someone who isn’t affected by a learning disability. Learning disability is not indicative of intelligence level. Rather, people with a learning disability have trouble performing specific types of skills or completing tasks if left to figure things out by themselves or if taught in conventional ways.

A Functional Limitation (FL) is “a consequence of a health problem and represents an inability to meet a standard of an anatomical, physiological, psychological, or mental nature (impairment). This can lead to reduction in behavioural skills or performance of tasks (disability) or deficits in fulfilment of social role (handicap)” (Granger, 1984, p. 16). As such, FL represents a substandard organismic performance (Nagi, 1976), particularly in performing life activities, using skills and fulfilling social roles. FL, then, is the result of an interaction between an impairment and the environment (Granger, 1984; Indices, 1979).

A Functional Capacity (FC) is the “degree of ability to perform a specific role or task which is expected of an individual within a social environment” (Indices, 1979, p. 7). Hence, FC represents the residual physical, cognitive or behavioural capabilities of an individual in his or her task performance and environment negotiation.

Functional Assessment (FA) is “the measurement of purposeful behaviour in interaction with the environment, which is interpreted according to the assessment’s intended uses” (Halpern & Fuhrer, 1984, p. 3). The three primary categories of behaviour include (a) physical, cognitive or emotional capacity; (b) performance of useful skills or tasks; and (c) performance of social roles. Environments in which behaviour is performed include the home, community and workplace (Halpern & Fuhrer, 1984). Thus, while FL and FC address the object or outcome of assessment, FA refers to the actual process of the assessment.

Whereas impairment and disability are terms that pertain to organic and behavioural dysfunctions, respectively, FL and FC imply two additional components, namely, analysis of diagnostic (for impairment) and performance (for disability) indicators, and assessment of abilities and activities (see, for example, Granger, 1984; Halpern & Fuhrer, 1984). Put differently, impairment and disability are general terms that are more concerned with diagnosis and classification of organic conditions and their assumed skill performance. FL and FC, alternatively, are applied terms where specific degrees of limitation or residual capacity are addressed and assessed as they relate to particular life contexts.

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NOTES

For the purpose of determining eligibility for accommodation, the symptoms and functional limitations must meet the Americans with Disabilities Act (ADA) definition of a disability.

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REFERENCES

LIVNEH, HANOCH., MALE, ROBERT., 1993. “Functional limitations: a review of their characteristics and vocational impact”, Journal of Rehabilitation, http://findarticles.com/p/articles/mi_m0825/is_n4_v59/ai_16514154/?tag=content;col1.SMART, JULIE F., 2009. “The power of models of disability”, Journal of Rehabilitation, http://findarticles.com/p/articles/mi_m0825/is_2_75/ai_n31947281/?tag=content;col1.

FOUGEYROLLAS, PATRICK., 2006. “Convergences and differences between ICF and DCP : The issue of environmental factors’influence in the construction of human functioning and disability”, INDCP-CIRRIS-IRDPQ-Laval University-Quebec Canada.

SNYDER, ALISON R, JOHN T PARSONS, TAMARA C VALOVICH MCLEOD, R CURTIS BAY, LORI A MICHENER, AND ERIC L SAUERS., 2008. “Using Disablement Models and Clinical Outcomes Assessment to Enable Evidence-Based Athletic Training Practice, Part I: Disablement Models”, Journal of Athletic Training 43, no. 4: 428-436, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2474823/.

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SOURCES

Stobo, John D., McGeary, Michael., Barnes, David K. IMPROVING THE SOCIAL SECURITY DISABILITY DECISION PROCESS – Committee on Improving the Disability Decision Process: SSA’s Listing of Impairments and Agency Access to Medical Expertise, Institute of medicine of the national academies, The national academies press, Washington D.C.

…

Du ritalin pour le système de l’éducation?

« La prévention permet d’échapper à une destinée négative et aide à acquérir des compétences et des connaissances qui donnent accès à destinée en général plus enviable. » (Veinot, décembre 1999, p. 1) [TRADUCTION LIBRE]

Au Québec et, plus généralement, les sociétés occidentales ont fait de la médecine un modèle qui envahit progressivement tous les domaines, au point que peu de questions lui échappent aujourd’hui : on traite les enfants hyperactifs et délinquants par la médecine; on traite les dysfonctionnements de la famille ou de l’entreprise par la médecine; on traite les difficultés d’insertion sociale par la médecine, etc. À cet égard, une société qui renvoie tous ses problèmes à la médecine n’est-elle pas une société malade?

Depuis plusieurs années maintenant, l’on observe une augmentation de la consommation de comprimés, dont, entre autres, les antidépresseurs et le méthylphénidate. Ainsi, la firme de recherche IMS Brogan rapporte en décembre 2010 que les Québécois sont plus que jamais les champions du Ritalin au Canada. En 2010, les Québécois ont consommé près de 32 millions de comprimés de cette famille de médicaments (méthylphénidate), ce qui constitue un nouveau record. Le nombre de prescriptions pour obtenir ces comprimés, qui sont remis surtout aux enfants agités à l’école chez qui on diagnostique un trouble du déficit de l’attention avec ou sans hyperactivité (TDAH), est également en hausse ^1,2,3.

La consommation de ces médicaments est beaucoup plus importante au Québec qu’ailleurs au Canada. Alors qu’elle compte pour moins du quart de la population, la province accapare désormais 35,3 % de l’ensemble des comprimés et 44 % des ordonnances distribuées au pays^1.

Pour traiter les symptômes du TDAH, le médicament le plus souvent prescrit est la Ritalin (méthylphénidate), un psychostimulant. Le Ritalin est utilisé dans des proportions élevées au sein de certaines communautés, et nous devons en savoir plus sur ces communautés, et nous avons besoin de savoir si cela convient ou non.

Devrions-nous voir là l’un des symptômes du modèle québécois, celui de se rendre au modèle médical en ce qui concerne la gestion du TDAH, a gestion de troubles de l’apprentissage, la gestion des troubles psychologiques, voir même les troubles de comportements, et celui de faire usage de la médicalisation, de la psychologisation?

L’école est-elle devenue un environnement psychopathologique en lui-même? Tente-t-on de considérer des symptômes de surfaces comme des causes, sans vraiment prendre en considération les racines profondes du problème? Au lieu de se concentrer sur la coercition ayant pour objectif la régulation du comportement des enfants, l’on cèle la dégradation des conditions éducationnelles et de l’environnement socioéconomique et familial. En fait, les enfants sont-ils plus malades que l’on pense? Les conditions environnementales sont-elles si dénaturées, si corrompues, si troublées, que le modèle favorisant le développement sain et normal du cerveau n’est plus présent? La manière dont on élève et éduque les enfants les prive-t-ils des pratiques qui les amènent au bien-être? En considération du phénomène croissant de « bullying » (agression), et de l’accroissement de psychopathologies chez les enfants, peut-on assumer qu’il y a une dégradation des conditions environnementales des enfants, brimant ainsi le développement normal et sein de ces derniers?

Là où l’on devrait trouver une multiplicité de méthodes éducatives et pédagogiques, l’on trouve le nivellement par le bas et l’homogénéisation par la méthode. Là on l’on devrait considérer l’enfant comme un sujet qui se construit, l’on considère l’enfant comme un « objet ». Or un objet épistémique ne se développe qu’en conséquence d’une action alors qu’un sujet se construit, essentiellement dans l’interaction sociale (Lenoir, Larose, & Hébert, 2000).

La réponse « Ritalin » est-elle une réponse d’un système éducatif devenu propice au décrochage scolaire cachant une déresponsabilisation et une abdication fondées, entre autres, sur le déni de la dégradation scolastique? La réponse « Ritalin » est-elle une réponse d’un système frustrer de ne pas voir les enfants s’adapter à une machine à broyer la différence?

DU DIAGNOSTIC

Notons que le diagnostique du TDAH est consigner dans la bible des psychiatres, le Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, American Psychiatric Association, 2000; et prochainement le DSM-V). La perspective psychodynamique se fonde, entre autres, sur l’observation du comportement pour établir un diagnostic. Le diagnostic est parfois une zone floue. Il est commun pour ceux qui font le diagnostic du TDAH d’utiliser des listes de vérification de comportement lorsque l’on étudie la possibilité de TDAH. Et c’est là que le problème se pose et génère certaines dérives.

De plus, pour la plupart des personnes atteintes du TDAH, des comorbidités peuvent se développer et accompagner le TDAH, et ce, tout au long de la vie. Ainsi, les comportements anxieux peuvent se superposer aux comportements du TDAH, voire même s’entre exacerber. Également, certaines psychopathologies peuvent générer des comportements que l’on retrouve dans la nomenclature du comportement du TDAH. Ainsi, la difficulté à moduler les émotions peut également être caractéristique de certaines psychopathologies, et de la nomenclature diagnostique du TDAH. L’intervention psychologique et psychosociale s’avère donc appropriée, opportune, et nécessaire. C’est pourquoi j’estime qu’établir un diagnostic que sur l’observation du comportement s’avère parcellaire, biaisé, et inopportun. On doit alors également établir une évaluation neuropsychologique en bonne et due forme pour étayer le diagnostic du TDAH. L’intervention multidisciplinaire et multimodale vise essentiellement à minimiser les erreurs de diagnostic du TDAH.

Non seulement il existe un phénomène de « sur-diagnostic » (faux positif), mais également de « sous-diagnostic » (faux négatifs).

LE MODÈLE MÉDICAL

Le modèle médical (et pharmacothérapeutique) relève de l’approche traditionnelle du diagnostic et du traitement de la maladie telle qu’elle est pratiquée par des médecins dans le monde occidental depuis l’époque de Koch et Pasteur. Le modèle médical est fondé sur la notion de maladie. Le médecin se concentre sur le dysfonctionnement anatomique, physiologique et biochimique du patient, et ce, en utilisant une approche de résolution de problèmes. Les antécédents médicaux, les examens physiques, et les tests diagnostiques servent de base à l’identification et au traitement d’une maladie spécifique. Le modèle des soins infirmiers diffère du modèle médical parce que le patient est perçu globalement (holistiquement) comme une personne en relation avec l’environnement, les soins infirmiers sont alors formulés sur la base d’une évaluation holistique de toutes les dimensions de la personne (physique, émotionnel, mental, et spirituel) qui suppose de multiples causes aux problèmes rencontrés par le patient. Les soins infirmiers se concentrent ensuite sur toutes les dimensions, pas seulement physiques. Ce serait désenchantement concernant le modèle médical qui a été le principal déclencheur du développement des théories des soins infirmiers.

« Le modèle médical qui a, pendant toute une période, contribué au développement d’une pédagogie progressiste est devenu aujourd’hui un obstacle à celle-ci. » Le modèle médical paralyse la réflexion sur d’autres modes d’intervention qui, eux, prendraient en compte, tout à la fois, la dimension holistique de la personne, la dimension collective, l’environnement, la recherche des causes profondes et le travail sur le long terme tout au long de la vie.

Les orthopédagogues se situeraient entre un modèle médical et un modèle pédagogique enseignant, mais pour les élèves en difficulté le modèle médical inadapté, en fait l’institution scolaire rechercherait des pédagogues médiateurs. Au Canada, le psychologue scolaire est un psychologue au sens corporatif du terme. Il détient une formation disciplinaire complète de psychologue et intervient en tant que professionnel dans un champ distinct de celui de l’éducateur ou de l’enseignant. En Amérique du Nord, la psychologie scolaire n’existe qu’en fonction d’une définition contextuelle excessivement restreinte, l’adaptation des conduites sociales et à moindre titre, des conditions favorisant l’adaptation scolaire de l’enfant, à l’intérieur du contexte scolaire lui-même. L’intervention en psychologie scolaire est donc généralement plus une intervention curative ou thérapeutique que préventive. C’est un peu comme si l’homme se coupait inexorablement de lui-même, toujours plus distant. C’est un peu comme si l’on considérait l’enfant extirper de ses racines socioéconomiques et familiales, comme si l’on compartimentait une partie de l’enfant pour l’usage du système de l’éducation.

Malgré ses limites, le modèle biopsychosocial serait le modèle médical le plus abouti dont nous disposons à ce jour. Il reste pourtant mal compris et mal utilisé. Sur le plan théorique, cet ensemble d’hypothèses explicatives de la santé considère facteurs biologiques, psychologiques et sociaux sur un pied d’égalité, dans un système de causalités complexes, multiples et circulaires. Il s’agit d’une représentation de l’être humain dans laquelle les facteurs biologiques, psychologiques et sociaux sont considérés comme participant simultanément au maintien de la santé ou au développement de la maladie. Une pratique clinique inspirée du modèle biopsychosocial intègre en permanence les perspectives biologique, psychologique et sociale et nécessite une participation active du patient, dont le corollaire est une importance accrue des aspects éducationnels. La relation thérapeutique est donc profondément modifiée. Une meilleure diffusion du modèle biopsychosocial nécessite un ajustement de l’enseignement, de la recherche et du financement de l’acte intellectuel. Notons simplement que le modèle biopsychosocial remplace des systèmes de causalités simples et linéaires par des causalités multiples et circulaires, parfois difficiles à identifier et à contrôler. Ceci implique pour le clinicien (et le malade) une navigation souvent inconfortable entre complexité et incertitude.

Le modèle écosystémique présente un regroupement des modèles théoriques systémique et écologique. Si l’approche écosystémique sert de cadre de référence conceptuel à une bonne partie du discours portant sur l’intervention éducative auprès de l’enfant, son application est souvent parcellaire, voire même réductrice, et peu d’études envisagent l’analyse des relations de l’enfant avec son environnement de façon holiste. Plusieurs modèles écosystémiques ont été élaborés, mais celui de modèle de Bronfenbrenner (1979) est, à l’origine, centrée sur la relation entre l’enfant (ou l’individu en développement) et des environnements distincts, mais dont la complémentarité est assurée par la médiation du sujet. Il s’agit d’un modèle, non pas du développement de l’individu, mais plutôt des contextes dans lesquels ce développement se produit et où il effectue des transactions et des transitions.Cela étant, les environnements ou les contextes peuvent être considérés de façon plus ou moins cloisonnée, comme il est possible de les voir en tant que zone de contextualisation d’une même réalité. L’approche systémique offre un cadre d’analyse qui détourne l’attention de l’individu et de ses caractéristiques (donc du modèle médical, voire même biopsychosociale) pour la porter vers les interactions. Elle permet une analyse plus globale où l’individu et son environnement physique sont vus comme un tout en interaction. Le système étant une entité, un changement dans une partie du système affecte le système comme « tout » et chacune de ses parties. Le modèle écologique oriente l’analyse des besoins du sujet vers son environnement l’individu devient indissociable de ses milieux de vie; ses apprentissages sont liés à son environnement et il agit sur cet environnement.

La perspective écosystémique et biopsychosociale favorise une intervention en amont, précoce, préventive, globale et holistique. Au-delà de la médicalisation du modèle médical, la perspective écosystémique et biopsychosociale préconise d’étudier les phénomènes sociaux et les individus en tant que systèmes en interaction avec d’autres systèmes, donc de les étudier dans leur globalité et non pas considérés isolément. L’encadrement doit viser l’appropriation de connaissances et de compétences (« empowerment ») afin d’acquérir les capacités à prendre en charge leur projet éducatif ainsi que leur autodétermination (« enabling ») et autonomies.

LE TROUBLE DU COMPORTEMENT

« [...] des enseignants mettent de la pression sur les parents pour que leurs enfants prennent des médicaments lorsque ceux-ci commencent à présenter un « trouble de comportement »^1,2,3. « C’est sûr qu’on diagnostique de plus en plus le TDAH. C’est une problématique de plus en plus connue et reconnue par les enseignants. [...] certains enfants pourraient très bien fonctionner sans être médicamentés. »^1,2,3. « Est-ce que tous les enfants qui ont les symptômes d’un TDAH devraient consommer du Ritalin? Pas nécessairement. Parfois, on pourrait mettre en place des choses à l’école, pour éviter de se rendre à la médication. »

En fait, tant que l’enfant ne perturbe pas le cadre ni ne présente de difficultés apparentes, il n’est pas catégorisé, étiquetté, stigmatisé, comme ayant un « trouble de comportement ». Or, le TDAH affecte le comportement du sujet atteint. Mais qu’ente-t-on par trouble du comportement?

Une étude d’un économiste de l’Université de l’État du Michigan, Todd Elder, conclut que jusqu’à un million de petits Américains pourraient être traités avec des comprimés sans justification. Dans un échantillon de 12 000 enfants, il a constaté que les plus jeunes d’un groupe de maternelle ont 60 % plus de « chances » d’être diagnostiqué TDAH que leurs pairs aîné. Tout au long du cheminement scolaire, le constat serait similaire, monsieur Elder note que les plus jeunes consomment deux fois plus souvent des médicaments de la famille du Ritalin. Ainsi, on assimilerait les symptômes d’immaturité émotionnelle et intellectuelle aux symptômes du TDAH. Il y aurait une grande différence entre la maturité d’un enfant de 5 ans et celle d’un enfant de 6 ans^4,5,6.

Le psychologue et professeur en adaptation scolaire à l’Université Laval, Égide Royer, explique : « Il y a une surmédicalisation des problèmes d’apprentissage. » Les garçons, plus turbulents, en feraient particulièrement les frais. « On réagit de manière médicale à un problème qui est probablement mental. [...] On semble confondre maturation normale de l’enfant avec problème de comportement. » L’on mésestimerait la réaction normale face à des problèmes psychologiques et psychosociaux, tel que les difficultés avec leurs parents et de leurs parents, une situation de crise, au stress, voire même le manque de sommeil, qui serait trop souvent assimilé au TDAH.

Le professeur Gérald Boutin, de l’UQAM, croit que les enseignants qui insistent auprès de parents pour que leurs enfants soient médicamentés ne le font « pas de gaieté de coeur. » « Quand ils arrivent là, c’est que les autres moyens auxquels ils auraient pu avoir accès ne sont pas disponibles » plaide l’expert^1,2,3. « On en met beaucoup sur le dos des enseignants, mais c’est vraiment par désarroi qu’ils se tournent vers cette option », estime M. Boutin, qui pointe du doigt le manque de ressources dans les écoles pour expliquer le phénomène^1,2,3.

Mais est-ce le rôle des Professeurs de produire un diagnostic de « trouble de comportement » et de favoriser la consommation de méthylphénidate? Les professeurs sont-ils formés pour non seulement produire une évaluation des capacités cognitives d’un élève, mais également de produire un diagnostic psychologique, neuropsychologique, voire même psychiatrique? Notons qu’un enfant peut mal vivre une condition non diagnostiquée d’un ou plusieurs troubles d’apprentissages.

La marge entre un comportement lié à un problème d’attitude, et un comportement lié à un TDAH et à un trouble d’apprentissage peut être mince, voire même floue. Mais est-ce un trouble du comportement parce que l’enfant de cadre pas dans les attentes du professeur? Le trouble du comportement est-il établi en fonction de critères plus ou moins subjectifs, en fonction des comportements attendus par le professeur? Les déficits dans les habiletés sociales en sont même venus à être considérés comme étant des troubles spécifiques d’apprentissage au point où il devenait difficile de distinguer entre trouble d’apprentissage et trouble de comportement.

Les enseignants jouent un rôle déterminant dans le diagnostic et la perception que les professeurs ont d’un comportement joue un rôle important dans de nombreux diagnostics de TDAH. Les symptômes d’un enfant qui bouge souvent, se laisse distraire facilement, a du mal à rester assis, à attendre son tour dans un groupe, ou à terminer une tâche, parle trop ou interrompt, peut-être assimilé à un trouble de comportement. Or, ces symptômes n’impliquent pas nécessairement un TDAH, car il existe des conditions psychopathologiques qui ressemble du TDAH. L’établissement du diagnostic du TDAH nécessite également un diagnostic différentiel, ce dernier permettant d’exclure toute condition qui pourrait être assimilée à tort à un TDAH.

L’adaptation sociale des enfants est un sujet auquel on s’est beaucoup intéressé au cours des dernières années.

Les habiletés sociales sont habituellement définies comme des comportements appris qui sont socialement acceptables et qui permettent à un jeune d’initier et de maintenir des relations positives avec ses pairs et les adultes (Walker, Colvin et Ramsey, 1995).

Un nombre considérable d’études ont démontré l’existence de liens étroits entre la compétence sociale (définie de manière générale) chez les enfants et un développement sain et une bonne capacité d’adaptation ultérieure. (p. ex., Crick et Dodge, 1994; Parker et Asher, 1987; Rubin et Krasnor, 1986). Il se dégage un consensus voulant que la compétence sociale désigne l’efficacité des interactions avec autrui, tant du point de vue de soi-même que des autres (Rose-Krasnor, 1997; Segrin, 2000). On a constaté que les enfants qui ont de la difficulté à fonctionner en société affichent davantage de comportements inadaptés (p. ex., agression, dépression), sont plus souvent rejetés par leurs pairs et sont de façon générale moins bien adaptée socialement plus tard (Crick, 1996; Eberly et Montemayor, 1998; Rys et Bear, 1997). Le développement et l’emploi de compétences prosociales représentent l’un des principaux aspects de la compétence sociale. Les constatations issues des études menées dans le domaine de la compétence sociale ont permis aux chercheurs de mieux comprendre les types de cognitions et de mécanismes sociaux qui mènent à un comportement socialement acceptable ou non acceptable selon autrui. Les théories de la compétence sociale les plus connues sont en général axées sur une division fonctionnelle de la compétence sociale et sont concentrées sur les comportements adaptatifs, les aptitudes sociales, l’absence de comportements inadaptés et les cognitions sociales en fonction de l’âge.

Le modèle écologique et transactionnel du développement humain, lequel considère l’individu comme un mécanisme à autoredressement s’adaptant de façon active et constante à son environnement est de plus en plus accepté dans le domaine de la psychologie du développement et d’autres domaines connexes. Les interactions entre l’individu et son environnement sont en outre considérées à la fois bidirectionnelles et synergiques (Bronfenbrenner, 1979; Sameroff et Chandler, 1975; Sameroff et Fiese, 1990).

Pour pouvoir utiliser un modèle écologique pour étudier la compétence sociale, il nous faut tenir compte de l’écosystème complet dans lequel se fait le développement. L’approche de l’écosystème met l’accent sur les contextes dans lesquels se déroule le développement et sur les interrelations entre les différents contextes contribuant au développement de l’enfant (Bronfenbrenner 1979, 1989). Le modèle écologique et transactionnel de Bronfenbrenner nous sert de guide pour tenter de comprendre l’interaction de facteurs multiples et l’incidence de ces derniers sur le développement de l’enfant.

AGIR EN AMONT : LE DÉVELOPPEMENT DU CERVEAU

L’emphase démesurée, voire disproportionnée, portée par les professeurs sur la notion de « trouble de comportement » des enfants ayant un TDAH et des troubles d’apprentissages peut celer un aspect fondamental du trouble : le développement dysfonctionnel de certaines régions du cerveau et des fonctions cognitives (la mémoire, l’attention, le langage, le raisonnement, le visuospatial, les gnosies, les praxies, les fonctions exécutives [la flexibilité mentale, l'inhibition, la catégorisation, l'abstraction, l'anticipation, la planification, l'organisation, le raisonnement, la résolution de problèmes, la concentration, la régulation des émotions]). Les fonctions exécutives constituent l’ensemble des fonctions de contrôle de la cognition et du comportement. On définit les fonctions exécutives comme l’ensemble des processus permettant à un individu de réguler de façon intentionnelle sa pensée et ses actions afin d’atteindre des buts. La régulation qu’elles permettent est généralement appelée contrôle exécutif ou contrôle cognitif. Les fonctions exécutives entretiennent des liens étroits avec la réussite scolaire, et on retrouve des déficits exécutifs dans divers troubles du développement, tels que l’autisme et TDAH ou encore le syndrome de Tourette.

Ainsi, il ne suffit plus d’abreuver les enfants de connaissances et d’informations, puis d’en évaluer le taux de rétention, mais bien d’assurer le développement du cerveau dans un contexte scolaire, d’où l’importance de renforcer les fonctions cognitives et exécutives.

L’examen neuropsychologique précise les fonctions exécutives déficitaires. Cependant, il est nécessaire de tester les autres fonctions cognitives.

Tout comme l’intervention scolaire, « processing interventions » est plus efficace en bas âge. « Processing interventions », particulièrement celles de nature « remedial », est nécessaire avant même la maturation de certaines régions spécifiques du cerveau là ou les processus d’intérêt sont localisés. La clef pour une éducation et un entraînement réussi du cerveau relève de l’enrichissement et de « retraining » à des stages de développement précis (Feifer & DeFina, 2000). Les changements sont plus difficiles à acquérir une fois que la structure neuronale est établie et que la myélinisation soit complétée. La fenêtre d’opportunité concernant les processus de base se trouve dès la prime enfance et pendant les premières années de l’école élémentaire; cependant, les processus cognitifs de haut niveau, particulièrement la planification, le raisonnement, le traitement exécutif, continuent leurs développements jusqu’à l’adolescence.

LE RITALIN : UNE RÉPONSE PARCELLAIRE, VOIRE MÊME RÉDUCTRICE

Le Ritalin, la réponse au manque de ressources !

J’estime que le Ritalin n’est pas un médicament, mais bien une pharmacopée visant seulement à réduire les symptômes du trouble. Un peu comme les médicaments pour le rhume, ou les allergies saisonnières. Le « Ritalin », et autres pharmacopées destinées au traitement du TDAH, ne guérissent pas le trouble. C’est pourquoi je déconseille vivement d’obliger un enfant à être condamné à prendre une médication pour le reste de ces jours.

D’abord, parce que cette médication à un effet sur le cerveau, et que ce dernier est en pleine croissance chez l’enfant et l’adolescent, et que rien ne démontre que la pharmacopée répare les altérations et/ou atteintes au cerveau. Autrement dit, on a démontré que chez les personnes atteintes du TDAH, il y a des régions de cerveau plus petites, ou plus grosses, que chez la moyenne des gens dit « normal ». D’ailleurs peu d’étude étudie les effets à long terme de la prise de méthylphénydate. En fait, la médication n’est qu’une béquille. Il y a certes une certaine réduction des symptômes, mais rien ne semble indiquer, ni à priori, ni a posteriori, de l’aspect curatif ou compensatoire de la médication sur les causes fondamentales du TDAH. Ensuite, parce que la médication ne permet pas de développer les stratégies d’adaptation, d’accommodation, métacognitive et cognitive, ni même d’avoir un effet thérapeutique sur les comorbidités reliées au TDAH. J’admets qu’il soit possible d’utiliser la médication, temporairement pour les cas d’une certaine sévérité, afin de permettre l’établissement et la stabilisation des premiers apprentissages, quels qu’ils soient, qui permettra à l’enfant une pratique optimale des stratégies.

EN CONCLUSION

Santé Canada (1999) considère que les capacités et les facultés d’adaptation de la personne constituent un déterminant clé de la santé.

Le développement d’interventions novatrices et efficaces s’avère donc essentiel. Seule une intervention comportant, entre autres, une éducation (ou rééducation pour les adultes tardivement diagnostiquées), constituée de la pratique d’un ensemble de stratégies de remédiation cognitives⁷ et métacognitives^8,9, permettra à l’adulte en devenir de développer son cerveau, et de produire un effet curatif, ou compensatoire. La remédiation cognitive, qui consiste à stimuler les processus cognitifs déficitaires à l’aide d’exercices spécifiques, constitue une de ces nouvelles approches, tout comme la remédiation métacognitive qui consiste pour sa part à développer la capacité de l’individu à réfléchir sur ses propres processus cognitifs. J’ai donc une grande confiance au phénomène dit de la plasticité du cerveau, puisque ce dernier est une entité en plastique pouvant subir des changements dynamiques tout au long de sa durée de vie à la suite d’une éducation spécifique.

L’intervention doit également se porter dans tous les milieux de vie, et dans toutes les sphères de la vie de l’enfant/l’adolescent/l’adulte, et sur le développement de stratégies d’adaptation et d’accommodations et de l’établissement d’un encadrement répondant aux besoins spécifiques de la personne, surtout les enfants, ayant un TDAH.

L’accompagnement, l’encadrement dans un contexte d’intervention multimodale et multidisciplinaire nécessitent l’établissement d’équipe multidisciplinaire, voire même transdisciplinaire, surtout chez les enfants.

Les enfants doivent apprendre à vivre avec la TDAH, comprendre leurs différences. Ils doivent être capables de prendre du recul et de contextualiser leurs vécus avec le trouble. L’intervention psychologique s’avère donc appropriée, opportune, et nécessaire.

Est-ce donc un signe de notre époque de voir la surmédicalisation des troubles psychologiques, la médicalisation du social? Les troubles du comportement sont-ils lier à un environnement inopportun et inappropriés pour les enfants? Cherche-t-on à « régulariser », à niveler, les enfants, afin de les adapter à la « machine » du système d’éducation et à la « machine » de la syndicalisation? Est-ce que l’économie de marché et la marchandisation de l’individu détruisent le tissu et les liens sociaux?

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BIBLIOGRAPHIE

BERQUIN, A. (2010). « Le modèle biopsychosocial : beaucoup plus qu’un supplément d’empathie », Revue Médicale Suisse, Med Suisse 2010;6:1511-1513, http://rms.medhyg.ch/numero-258-page-1511.htm [Accessed December 30, 2010].

MORRIS, Richard J., and MATHER, Nancy. (2007). « Evidence-based interventions for students with learning and behavioral challenges ». Routledge, November 19 2007, ISBN: 9780415964555.

PARRILA, Rauno K., MA, Xin., FLEMING, Darcy., RINALDI, Christina. (2002). « Développement des compétences prosociales ». [s.l.] : [s.n.], [s.d.]., http://www.rhdcc.gc.ca/fra/sm/ps/dsc/fpcr/publications/recherche/2002-001274/page01.shtml [Accessed January 10, 2011], Octobre 2002, ISBN : 0-662-89318-2. 

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AUTRES SOURCES

1MÉNARD, SÉBASTIEN. (2010) « 32 millions de pilules : Le Québec, champion du Ritalin », le Journal de Montréal, 29 décembre 2010, http://lejournaldemontreal.canoe.ca/journaldemontreal/actualites/sante/archives/2010/12/20101228-035500.html, [Accessed December 30, 2010].

2« Niveaux records : Le Québec, champion du Ritalin », 28 décembre 2010, Canoe.ca, http://tvanouvelles.ca/lcn/infos/national/archives/2010/12/20101228-072836.html, [Accessed December 30, 2010].

3MÉNARD, SÉBASTIEN., (2010) « Quebecers pop Ritalin in record amounts », Toronto Sun, QMI Agency, December 28 2010, http://www.torontosun.com/news/canada/2010/12/28/16689801.html, [Accessed December 30, 2010].

4RICARD-CHÂTELAIN, BAPTISTE., (2010) « Du Ritalin souvent prescrit aux benjamins hyperactifs d’une même classe », Cyberpresse, 19 août 2010, http://www.cyberpresse.ca/le-soleil/actualites/education/201008/18/01-4307747-du-ritalin-souvent-prescrit-aux-benjamins-hyperactifs-dune-meme-classe.php, [Accessed December 31, 2010].

5« Déficit de l’attention: un million d’Américains diagnostiqués à tort », Agence France-Presse, Washington, 18 août 2010.

6« Nearly 1 million children potentially misdiagnosed with ADHD », Michigan State University, 17 August 2010, Disponible sur : < http://news.msu.edu/story/8160 >, [Accessed December 30, 2010].

7Stevenson C. S., Whitmont S., Bornholt L., Livesey D., Stevenson R. J. « A cognitive remediation programme for adults with Attention Deficit Hyperactivity Disorder ». Aust N Z J Psychiatry. October 2002, Vol. 36, n°5, p. 610-616.

8SOLANTO M. V., MARKS D. J., MITCHELL K. J., WASSERSTEIN J., KOFMAN M. D. « Development of a New Psychosocial Treatment for Adult ADHD ». Journal of Attention Disorders [En ligne]. 1 May 2008, Vol. 11, n°6, p. 728 -736. Disponible sur : < http://dx.doi.org/10.1177/1087054707305100 >.

9SOLANTO M. V., MARKS D. J., WASSERSTEIN J., MITCHELL K., ABIKOFF H., ALVIR J. M. J., KOFMAN M. D. « Efficacy of Meta-Cognitive Therapy for Adult ADHD ». Am J Psychiatry [En ligne]. 1 August 2010, Vol. 167, n°8, p. 958-968. Disponible sur : < http://dx.doi.org/10.1176/appi.ajp.2009.09081123 >.

Social psychology, a few definitions!

The social learning theory emphasizes the importance of observing and modeling the behaviors, attitudes, and emotional reactions of others. Thus it focuses on learning by observation and modeling. The theory originally evolved from behaviorism but now includes many of the ideas that cognitivists also hold; as a result it is some times called social cognitive learning.

Social learning theory talks about how both environmental and cognitive factors interact to influence human learning and behavior. It focuses on the learning that occurs within a social context. It considers that people learn from one another, including such concepts as observational learning, imitation, and modeling (Abbott, 2007).

Social cognition is an aspect of social psychology concerned with exploring the way in which people interact with each other and their environment. When people are interacting with each other, they are constantly in the process of storing new information while recalling existing information which may be helpful to the interaction. It is important to be aware that much of social cognition takes place on a subconscious level. Social cognition is the encoding, storage, retrieval, and processing, in the brain, of information relating to conspecifics, or members of the same species. Social cognition is the study of how people process social information, especially its encoding, storage, retrieval, and application to social situations. Social cognition has its roots in social psychology which attempts “to understand and explain how the thoughts, feelings, and behavior of individuals are influenced by the actual, imagined, or implied presence of others” (Allport, 1985, p. 3). It studies the individual within a social or cultural context and focuses on how people perceive and interpret information they generate themselves (intrapersonal) and from others (interpersonal) (Sternberg, 1994).

Social schema theory builds on and uses terminology from schema theory in cognitive psychology which describes how ideas, or “concepts” from the world around us are represented in the brain, and how they are categorized. According to this view, when we see or think of a concept, a mental representation or schema is “activated”, bringing to mind other information which is linked to the original concept by association. This activation often happens unconsciously. As a result of activating such schemas, judgements are formed which go beyond the information actually available, since many of the associations the schema evokes extend outside the given information. This may influence thinking and social behavior regardless of whether these judgements are accurate or not.

The social environment of an individual, also called social context or milieu, is the culture that he or she was educated and/or lives in, and the people and institutions with whom the person interacts.

Social competence is the condition of possessing the social, emotional, and cognitive, intellectual skills and behaviours needed to succeed as a member of society, thus needed for successful social adaptation.

A social skill is any skill facilitating interaction and communication with others. Social rules and relations are created, communicated, and changed in verbal and nonverbal ways. The process of learning such skills is called socialization.

Pro-social skills help people get along with others and navigate difficult social situations in positive ways and for better social interactions, self-control, and problem solving. The ability to behave in prosocial ways is also referred to as social intelligence. In the book “Social and Emotional Development” [Redleaf Press, 2008], authors Riley, San Juan, Klinkner and Ramminger describe prosocial behavior as “voluntary behavior intended to benefit another person”. “Pro-social” is the opposite of anti-social. Anti-social actions result in others feeling distant while prosocial actions are relationship skills that invite others to feel positive and seek interaction. Pro-social skill set comprises : 1) Social Interaction Skills, 2) Self Control/Anger Management Skills, 3) Problem Solving/Conflict Resolution Skills.

The term emotional intelligence refers to the child’s ability to understand others’ emotions, perceive subtle social cues, “read” complex social situations, and demonstrate insight about others’ motivations and goals.

Socialization is a process of learning norms, rules, regulations, values and attitudes of society. It is a lifelong process which starts from childhood till to the death of a person. Socialization is a vital process of learning through which the society exists. Each and every society socializes its members according to its own values. A man learns ways of attitudes, behaviors, languages, and cultures of a society through the process of socialization.

The debate of “nature” (heredity) and “nurture” (the social environment) is being made since decades. However, Without the concept of language a member cannot create relationships with others. Language is a source to create relationships and to take part into the social interaction.

Agents of socialization are the people and groups which influence our emotions, attitudes and behavior etc. Family, religion, day care, school, peer groups and workplace are the agents of socialization that prepare us to take our place in society. Socialization is a lifelong process in which an individual learns the essentials of society. The norms, mores, values, attitudes, thoughts and folkways are being transmitted from one generation to another with the help of socialization.

Overdiagnosis, overtreatment and overshadowing

ADHD, A GROWING CONCERN

Attention deficit hyperactivity disorder (ADHD) is one of the most common reasons children are referred to mental health professionals (Brown, 2000). Stangely, Early intervention approaches have rarely been implemented for the prevention of ADHD. And since ADHD is conceptualized as a lifespan disorder, one realizes that stimulants do not cure the disease but only treat the symptoms, leading to long-term use of the drugs.

When people use the term overdiagnosis, they typically refer to children who are diagnosed with ADHD but should not be, i.e. the false positives. However, overdiagnosis is only one side of the coin of poor diagnoses. There will also be children who warrant the diagnosis but go unidentified or undiagnosed, i.e. the false negatives.

FALSE POSITIVE : OVERDIAGNOSIS & OVERTREATMENT & OVERSHADOW

The overdiagnosis is the diagnosis of a condition or disease more often than it is actually present.

A recent spike in diagnoses of ADHD and other mental disorders has fueled an unprecedented reliance on pharmaceutical medications to treat children, with long-term effects that remain unknown. The rate of new ADHD diagnoses in the Western world is reaching epidemic levels.

During the 90s, a rapid increase of stimulant use was noticed in several western countries. In the US, the prevalence of stimulant use increased from three to seven fold among children under 18 years of age between 1987 and 1996¹. Another US study by Castle et al., estimated that the prevalence of ADHD medication among children aged 0–19 increased from 2.8% in 2000 to 4.4% in 2005. They also concluded that the prevalence in adults doubled from 0.4% to 0.8% in between 2000 and 2005. Treatment rates grew more rapidly for adults than for children and more rapidly for women than for men². The prescription of stimulant medication, which is very frequently used to treat ADHD, has significantly increased over the past decade (Ghodse, 1999; Olfson, Marcus, Weissman, & Jensen, 2002). A recent U.S. Centers for Disease Control and Prevention report estimating that one in 10 American children – a total of 5.4 million – has been handed that label (dec. 2010).

Quebec kids popped 32 million Ritalin pills in 2010 according to numbers compiled by health care research firm IMS Brogan ^3,4,5. That’s a 10% jump from last year and part of an ongoing trend in the province. In fact, Quebec accounts for 35% of the Ritalin pills distributed in Canada and for 44% of all prescriptions written for the drug.

The Ritalin familly drugs have now become noticed by students, professionals, athletes and teenagers. They are looked at by these people as “smart drugs”, cognitive enhancers, performance enhancers.

Does this involved what I’ve come to think of as the ADHD Industrial Complex, made up not only of the powerful pharmaceutical industry, but an emerging, lucrative and mostly unregulated industry of non-drug alternatives.

FALSE POSITIVE : MISDIAGNOSIS

A misdiagnosis is an incorrect diagnosis.

With the increased use of medication and broader definitions for diagnoses like Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactivity Disorder (ADHD), kids and adults who were previously just ‘acting up’ now have a label and what we call a ‘black hole diagnosis’. Often, “The bad-behaviour label is just used by people who don’t have a clue.” It is not uncommon to hear of the misdiagnosis of ADHD, wherein a child’s behaviors are attributed to ADHD when in actuality they are caused by or related to some other condition or trait (e.g., Perry, 1998).

Many times parents and teachers do not feel like dealing with a child that is out of control. Diagnosis and treatment is a quick fix to change any negative behavior. A positive diagnosis is seen as an aid to general parenting. It solves the problem of an unruly child. The problem is that treatment usually takes one form and that is to medicate them. It is much easier when a problem child just stops being a problem. This solves the problem for parents that do not have the time to parent and teachers that feel they do not have the time to teach. What it does not do is address the underlying problem that the child has. It is a form of medicalisation.

In a recent U.S. Study, almost one million children in the United States are potentially misdiagnosed with Attention Deficit-Hyperactivity Disorder (ADHD) because they were the youngest and least mature in their kindergarten classes. “The youngest kindergartners were 60 per cent more likely to be diagnosed with ADHD than the oldest children in the same grade. Similarly, when that group of classmates reached the fifth and eighth grades, the youngest were more than twice as likely to be prescribed stimulants. But these ‘symptoms’ may merely reflect emotional or intellectual immaturity among the youngest students”⁶. A child that is easily distracted, fidgety and interruptive in school might not have a clinical case of attention-deficit hyperactivity disorder (ADHD), but might rather just be ‘acting’ his or her age. Younger children may be mistakenly diagnosed as having ADHD, when in fact they are simply less mature : similar students have significantly different diagnosis rates depending on when their birthday falls in relation to the school year. Some 4.5 million U.S. children under the age of 18 have been diagnosed with ADHD. And approximately 2.5 million children take stimulant medication to counteract the symptoms of the disorder. Some 20 percent of those kids might have been misdiagnosed due to their relatively young age in the classroom⁷.

FALSE NEGATIVE : UNDERDIAGNOSIS & UNDERTREATMENT

The underdiagnosis is a failure to recognize or correctly diagnose a disease or condition especially in a significant proportion of patients.

ADHD is under-identified and under-treated as an underlying factor for prolonged poor health in the adult population (Biederman, Faraone, Monuteaux, Bober, & Cadogen, 2004). Wender, Wolf, and Wasserstein (2001) have concluded that ADHD is probably the most undiagnosed psychiatric disorder in adults. Furthermore, a new study, published in Archives of Pediatrics & Adolescent Medicine, found that 8.7 percent of children in the United States between the ages of 8 and 15 years, or approximately 2.4 million children, meet validated ADHD diagnostic criteria. However, more than half have not been diagnosed and about two-thirds are not receiving consistent treatment with ADHD medications⁸.

One study shows that psychiatrists are less confident about making the diagnosis of ADHD in patients with learning disability, especially adults. Hence the diagnosis may go undetected with a resultant lack of appropriate treatment which may furthercompound existing impairments⁹.

CONCLUSION

The important thing is making sure these kids get really good treatment, not just medication.

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SOURCES & RÉFÉRENCES

1 ZITO, J.M. et al. (2003). Psychotropic practice patterns for youth: a 10-year perspective. Archives of Pediatrics & Adolescent Medicine, 157(1), pp.17-25.2CASTLE, L. et al., 2007. Trends in medication treatment for ADHD. Journal of Attention Disorders, 10(4), pp.335-342.3MÉNARD, SÉBASTIEN. (2010). “32 millions de pilules : Le Québec, champion du Ritalin”, le Journal de Montréal, 29 décembre 2010, http://lejournaldemontreal.canoe.ca/journaldemontreal/actualites/sante/archives/2010/12/20101228-035500.html, , [Accessed December 30, 2010].

4 “Niveaux records : Le Québec, champion du Ritalin”, 28 décembre 2010, Canoe.ca, http://tvanouvelles.ca/lcn/infos/national/archives/2010/12/20101228-072836.html, [Accessed December 30, 2010].

5 MÉNARD, SÉBASTIEN., (2010). “Quebecers pop Ritalin in record amounts”, Toronto Sun, QMI Agency, http://www.torontosun.com/news/canada/2010/12/28/16689801.html, [Accessed December 30, 2010].

6 “Nearly 1 million children potentially misdiagnosed with ADHD”, Michigan State University, Aug. 17, 2010, http://news.msu.edu/story/8160, [Accessed December 30, 2010].

7 HARMON, Katherine., (2010). “Are some ADHD-labeled kids just young for their grade?”, Scientific American, Aug 17, 2010, http://www.scientificamerican.com/blog/post.cfm?id=many-adhd-diagnoses-might-be-blamed-2010-08-17, [Accessed December 30, 2010].

8 “Study Shows ADHD Underdiagnosed and Undertreated”, Cincinnati Children’s Hospital Medical Center, January 2008, http://www.cincinnatichildrens.org/health/subscribe/ped-insights/01-08/adhd-study.htm, [Accessed December 30, 2010].

9 S. Buckley, P. Dodd, A. Burke, S. Guerin, J. McEvoy, and J. Hillery, “Diagnosis and management of attention-deficit hyperactivity disorder in children and adults with and without learning disability,” Psychiatric Bulletin, vol. 30, no. 7, pp. 251-253, Jul. 2006.