Dr. Barkley meinte:
„Now keep in mind that Symptoms and Impairments are two different things:
And I hear people use the terms interchangeably, they are not: it just creates confusion-
And so for those of us who have developed rating-scales of Impairment, it is very important to distinguish these terms from each other.
So before we get started, I just want to spend one minute on this distinction: Symptoms
] are the cognitive and behavioural expressions of a disorder- they are the things you are doing,
that we use to identify you as having this disorder. Impairments
[Beeinträchtigungen/Funktionseinschränkungen in best. Lebensbereichen
] are the consequences of what you are doing
- you act and the environment kicks back. The environmental response to you is an impairment.
So you can be inattentive at school- that is a symptom. But if you are not finishing your papers and you are getting lower grades and you are held back in
school and then you do not finish High School- that is the environment kicking back. It is the adverse consequences that flow from behaving with these symptoms: So please make those distinctions! Because I hear people talking about all the time:“Oh, he is impaired in executive functioning.”
No- he is deficient in executive functioning, those are symptoms of his disorder.
But what we saw this morning [Anmerk.: Vortrag über die Folgen von unbehandeltem ADHS]
is the environment kicking back:
the consequences that accrue over your lifetime.
If you wish, the paper trail of your impairments: through the archives, your school records, your driving records,
your criminal records, your substance abuse records,your mental health records, government assistance records…
We could go on and on: but you are leaving this trail of consequences as you go through life acting with these symptoms…
That is the distinction! By the way, they are correlated only .5 to .6 with each other on average -sometimes higher, sometimes lower.
There is a very important message in that correlation: While symptoms do predict impairment, they are not the same! Impairments can persist even after symptoms have been managed, Impairments can be reduced without ever addressing symptoms
. Impairments are situation-specific.
So for example: if I am in a wheelchair and I am physically disabled,
I may be able to get into this hotel using a ramp at the front of the building.
That has reduced my impairment in this hotel: I can enter and leave as readily as you can. But I still have my disability, my disorder… So notice, by altering the physical environment around a disorder, one can in fact diminish and decrease
the extent of impairment from the disorder.
So I caution you: because we are all big on using treatments and medications, behaviour management and cognitive therapy to focus on symptoms
- but we do not pay enough attention to the impairments! Sometimes they are still there, other times they resolve with symptomatic treatment.
So as we move into treatment here, I do not want to keep saying it on each domain: do not just treat the symptoms- look at the impairments and make sure
that is coming down as well.
It usually is, but they are not assured, they are not guaranteed.
So, many companies with pharmaceutical products are now going back and specifically documenting the reduction in consequences
- the reduction in harm and impairment associated with a reduction in symptoms.
Whereas previously we assumed: if we change one, we change the other! So there is no need to look…
And now we now, there is a great need to look! At the end of the day, what we need to do with our patients is to reduce their impairments! Symptomatic reduction is a means to do that- it is not the end in itself. Reducing a Conners-Scale [bekannte Symptom-Checkliste] to zero is not why somebody came to you!
They came to you because of school failure, relationship problems, driving difficulties,
substance use problems… Those are the things we need to look at to be sure, that when we are altering these symptoms, we are altering those outcomes.
Usually we do, but not always… You must assess both- not just use a rating scale of symptoms and assume, because it is changing, the life of your patient is changing.
Maybe it is- maybe it’s not… Make sure that it is!