Still Barking Up the Wrong Tree

Every 15-20 years, the people who take psychiatric diagnoses very seriously reconvene to figure out how to reconfigure the categories, presumably guided primarily by new research.  For example, the criteria (and names) for what is currently known as ADHD have been changed multiple times since I first memorized them.  And it's pretty clear that we still haven’t settled on how best to categorize kids who have explosive outbursts (a brand new diagnosis -- Disruptive Mood Regulation Disorder -- will muddle things even further).

A lot of people and institutions think those categories are very imprortant.  For example, many mental health professionals make important treatment decisions based on the child’s diagnosis.  This hasn’t been all bad:  some kids actually do end up on medicine that is helpful to them or receive treatments that are proven to be effective for specific disorders.  On the other hand, lots of kids who were ensnared in the “over-diagnosing pediatric bipolar disorder” phase that, thankfully, seems to have passed, were over- and/or inappropriately medicated and suffered significant adverse side-effects for having been on the receiving end of that diagnosis.

Many parents take the categories seriously too.  That’s because a diagnosis often validates a parent's sense that there is something different about his or her child.   What a shame parents need their child to be diagnosed with a psychiatric disorder to feel validated about that!  Of course, parents whose children may not happen to meet criteria for something – but whose children are nonetheless exhibiting significant emotional and behavioral challenges -- are at risk for missing out on the validation part.  Support groups specific to certain diagnoses have sprung up, and this hasn’t been a bad thing either.  Many parents and educators have experienced tremendous benefit from the information and support provided by these groups.

In science, the categories have been somewhat useful, as they have permitted researchers to study a variety of childhood psychiatric disorders and to come to some very general conclusions about the characteristics of, and treatments that work for, children who meet criteria for these disorders. 

And many school systems take the categories extremely seriously.  Indeed, in many such systems, decisions related to eligibility, funding, and placement are based primarily on students’ psychiatric diagnoses.  This has worked out OK for students who meet criteria for a diagnosis for which the school system has a special program, but far less well for students who didn’t quite make the cut on meeting criteria for a diagnosis or who qualified for diagnoses (e.g., oppositional defiant disorder) for which no special program might exist.

Of course, there are other shortcomings to psychiatric categories.  As I've written in a previous Real World segment, diagnoses pathologize children, thereby failing to capture the complex factors that contribute to their difficulties.  Diagnoses imply that these difficulties lie within the child…that it’s the child who needs to be “fixed”.  Diagnoses scare away potential helpers (“I can’t help him…I’ve never worked with a kid with that diagnosis before”).  And, perhaps most importantly, diagnoses are distracting…they cause us to focus on the least important component of the child’s difficulties:  the maladaptive behaviors the child exhibits when he or she is having difficulty handling life's demands in a more adaptive fashion.

Theorists and researchers in the field of developmental psychopathology have done a nice job of pointing out that the behaviors a child exhibits when he or she is having trouble behaving adaptively don’t tell us much at all about why the child is exhibiting those behaviors in the first place.  They’ve also done a nice job of telling us that a wide variety of factors can set in motion the same maladaptive behaviors (a concept known as equifinality), and that the same factors can contribute to a wide variety of challenging behaviors (a concept known as multifinality).  As such, a child’s behaviors (and the diagnoses that summarize them) frequently don’t help us understand what’s really getting in a child’s way or tell us very much at all about the kind of help a child actually needs from us adults.

Because the people who take diagnoses most seriously are at it again – the most recent attempt at re-slicing the diagnostic pie (called the DSM-5) is due out in 2013 – we’re now being reminded of the adverse ramifications of focusing on behavior instead of the more important factors defining a child’s difficulties.  We’re seeing these ramifications play out in particular right now with regard to Asperger’s disorder.  It's now clear that Asperger's disorder will no longer be part of the diagnostic nomenclature when the DSM-5 is released (CLICK HERE). Thus, many children (and adults) who have received extremely beneficial assistance on the basis of having received that diagnosis may be at risk for losing that assistance (CLICK HERE). Real lives -- perhaps lots of ‘em, though estimates vary (CLICK HERE) – may be dramatically and adversely affected by decisions about diagnostic criteria that have proven to be unreliable in the first place (that’s why they change so often).  As one might expect, this is a significant concern to those who care about and for those individuals (CLICK HERE).

What a shame so much energy has been devoted to haggling over categories of behavior, when behavior isn’t even remotely the most important information we’d need to understand and help a child with social, emotional, and behavioral challenges!  It’s pretty well known that, in the approach I originated -- until now, called Collaborative Problem Solving (though I may be prevented from continuing to call it that) -- behavioral challenges are viewed through the prism of lagging skills and unsolved problems. Helping a behaviorally challenging kid relies, first and foremost, on helping adults identify lagging skills and unsolved problems.  An instrument called the Assessment of Lagging Skills and Unsolved Problems (or ALSUP) is employed to guide the identification process.  If a kid is lacking skills, there’s work to be done.  If a kid is having difficulty in the specific situations in which those lagging skills are being demanded, then there are problems that need to be solved. These assumptions and practices are more productive and informative than counting behaviors to see if a kid meets criteria for a category.  They’re more productive and informative than relying on percentile ranks to decide whether a kid needs help.

I’m a realist: if a diagnosis is required for a child to qualify for the help he or she clearly needs, I’ll render a diagnosis.  But not happily.  A diagnosis isn’t an end point…in fact, all too often, diagnoses impede the really important work:  ensuring that the people who are trying to understand and help the child are focused on the information that’s most informative.

Lagging skills and unsolved problems are the Real Deal, and they don’t need to be lumped into categories.  They provide caregivers – parents, educators, clinicians, staff -- with the raw material for understanding children with social, emotional, and behavioral challenges.  They provide caregivers with the raw material for helping those children.  And, because they’re the Real Deal, the experts can’t change their minds about them every 15-20 years.

By the way, in the Comic Relief section of this website, you'll see a cartoon related to this topic. 

Ross Greene
May 15, 2012