Diagnosis in child mental health

Exploring the benefits, risks and alternatives
CFCA Paper No. 48 – July 2018

1. Strengths of current diagnostic systems

For much of the 20th century, mental health practice did not place much focus on particular diagnostic categories (Mayes & Horwitz, 2005). Early psychiatric frameworks (e.g. DSM-I and DSM-II) conceived of mental health symptoms as reflections of intrapsychic conflicts or difficult life circumstances that existed on a continuum with normality. However, with the publication of the DSM-III in 1980 the nature of mental health classification was revolutionised, as Mayes and Horwitz (2005) explain:

In a remarkably short time, psychiatry shed one intellectual paradigm and adopted an entirely new system of classification. The DSM-III imported a diagnostic model from medicine where diagnosis is "the keystone of medical practice and clinical research" (Goodwin & Guze, 1996). Psychiatry reorganized itself from a discipline where diagnosis played a marginal role to one where it became the basis of the specialty. The DSM-III emphasized categories of illness rather than blurry boundaries between normal and abnormal behavior, dichotomies rather than dimensions, and overt symptoms rather than underlying etiological mechanisms.

The DSM's symptom-based model of categorisation allowed the mental health professions to develop highly standardised ways of measuring mental health difficulties (Kawa & Giordano, 2012). This standardisation, which was and continues to be enormously productive, is the root of most of the strengths of the DSM and similar frameworks. Some of the commonly cited strengths of these frameworks are:

A common language for service providers

Diagnostic frameworks give psychiatrists, psychologists, social workers and other health and welfare practitioners a common language to define and understand mental health difficulties (Frances & Widiger, 2012). When professionals use the same terms in the same ways, diagnosis and treatment can become more predictable and standardised.

Before DSM-III, it was more likely that two mental health professionals would provide different diagnoses for the same patient (Mayes & Horwitz, 2005). One of the keys to the success of the new classification system was its increased inter-rater reliability, which is a measure of how often two or more people arrive at the same diagnosis given the same presenting patient (Batstra & Frances, 2012).

A reliable framework for researchers

Standardised diagnostic frameworks have been powerful enablers of mental health research (Mayes & Horwitz, 2005). Large-scale clinical research relies on reliable diagnostic categories, which allow the research to be replicated by multiple researchers. The lack of reliable diagnostic categories in early psychiatric frameworks made such research virtually impossible. The publication of DSM-III and its successors precipitated a massive proliferation of clinical research (Mayes & Horwitz, 2005). Indeed, "evidence-based practice" in mental health is underpinned by the diagnostic categories provided by standardised diagnostic frameworks.

A coding system for statistics and administration

Government regulators and insurance companies around the world have enthusiastically embraced DSM and ICD frameworks because of the increased clarity they provide (Mayes & Horwitz, 2005). For example, DSM-5 criteria are used to determine diagnoses for some conditions, including for children, that are likely to meet the disability requirements for eligibility to the National Disability Insurance Scheme (NDIS) (National Disability Insurance Agency, n.d.).

Increased clarity in legal proceedings

Although the American Psychiatric Association (2013, p. 25) cautions that "the use of the DSM-5 should be informed by an awareness of the risks and limitations in its use in forensic settings", the DSM is relied upon in many areas of the Australian legal system, both civil and criminal. Legal proceedings often require that experts conduct evaluations and provide judgement on the mental health of the parties involved, and the DSM, as imperfect as it is for legal purposes, provides "the best tool for experts to achieve a reliable and accurate judgment on the presence or absence of specific mental disorders" (Frances & Halon, 2013, p. 343).

Critical reflections

  • What would your practice with children and families be like without the common language provided by frameworks such as the DSM?
  • Does the standardised nature of mental health diagnosis benefit your work with children and families? Does it hinder your work in any way?
  • Can you think of any other benefits to using standardised diagnostic frameworks?