Diagnosis in child mental health

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

2. Criticisms of current diagnostic systems

As mentioned above, the DSM has been subject to much criticism. These criticisms run the gamut from concerns about particular controversial mental health conditions (e.g. gender dysphoria, autism spectrum disorder) (e.g. Lev, 2013; Volkmar & Reichow, 2013) to wholesale rejection of the philosophical and/or scientific basis of such frameworks (e.g. Gambrill, 2014; Timimi, 2014). Two caveats should be noted before exploring these criticisms. First, while critiques of the DSM and ICD are important, especially given their worldwide influence, it is also important to acknowledge that many of the accusations levelled at these diagnostic systems are not necessarily all about the systems themselves. They are also about the ways in which these systems are used in society, particularly in societies such as Australia and the US, which privilege biomedical understandings of mental health. Diagnostic systems cannot always be held responsible for all the ways in which they are used or misused.

Second, there is a tendency for critics of current diagnostic systems to overgeneralise (Bell, 2017). Documents such as the DSM-5 and ICD-10 are very diverse, meaning that there are generally many exceptions to any blanket statements about the entire works. For example, the argument that the DSM pathologises normal human experiences may be credible when considering generalised anxiety disorder, but it is difficult to see how it applies to Tourette's disorder. As Bell (2017, paragraph 42) suggested, "diagnosis can really only be coherently criticised on a case-by-case basis or where you have demonstrated that a particular group of diagnoses share particular characteristics". With these provisos in mind, the following criticisms of the DSM and similar diagnostic systems are some of the most commonly cited.

Pathologising normal human experience

Perhaps the most widespread criticism of the DSM is that it has led to the "medicalization of normal life" (Frances, 2013, p. iii), expanding the concept of mental disorder to include difficult but expectable human experiences such as sadness, grief, shyness, anxiety, disappointment, inattentiveness, irritability, anger and stress (e.g. Frances, 2013; Greenberg, 2013; Paris, 2015).

Criticisms of this sort usually come in one of two variants (Maj, 2015). First, some argue that specific diagnoses such as ADHD and disruptive mood dysregulation disorder do not qualify as legitimate mental health conditions. Second, some suggest that the thresholds for diagnosis of legitimate conditions, such as major depressive disorder and generalised anxiety disorder, are too low.

Unfortunately, the question of over-pathologisation is very difficult to settle because there is no clear definition as to exactly what a mental disorder is. The current boundaries between normal human problem and mental health condition are decided not by clear-cut laboratory tests, but rather by a mixture of professional opinion, empirical evidence and risk-benefit analysis (Frances & Widiger, 2012; Maj, 2015). It is undoubtedly difficult to create diagnostic criteria that adequately recognise human distress and impairment without encroaching on experiences that are generally considered a part of "normal life". Nonetheless, labelling healthy people as mentally disordered has many negative results, including stigma, unnecessary treatment, overuse of potentially harmful psychotropic medications, the misallocation of medical resources, and personal and familial distress (Batstra & Frances, 2012).

Decontextualising mental health difficulties

Another common criticism of the DSM is that it obscures the contexts in which mental health conditions occur. Some authors focus this criticism on social determinants - including poverty, marginalisation and discrimination - which have been consistently identified as among the strongest predictors of many mental health conditions (Allen, Balfour, Bell, & Marmot, 2014). Others suggest that the DSM inadequately accounts for individuals' historical and current relational context, which may include trauma, attachment difficulties, and child abuse and neglect (Dignam, Parry, & Berk, 2010; Parry & Levin, 2012; Watt, 2017).

As proponents of the biopsychosocial model have stressed for over three decades, children's health and development occurs within multiple contexts, including the family, school, local neighbourhood and community environments, and each of these environments is in turn influenced by broader social, economic, political and cultural factors. Children's development can also be profoundly influenced by adverse experiences such as abuse and neglect, with some suggesting that many mental health symptoms should be seen as adaptations to trauma rather than as pathologies (Watt, 2017). The disorders in the DSM, however, are generally identified by focusing on individuals' recent symptoms.

Although the DSM has long claimed to be "atheoretical", numerous authors (e.g. Castiglioni & Laudisa, 2015; Timimi, 2014) have argued that its symptoms-based "checklist" approach actually relies on a strongly individualistic worldview, one which precludes understandings that account for historical and environmental influences. Such individualism neatly dovetails with the biomedical model of mental health, which sees mental health conditions as biologically based brain diseases, and which consequently emphasises pharmaceutical treatments over more holistic interventions (Castiglioni & Laudisa, 2015; Deacon, 2013).

Lack of scientific validity

It is common for critics to argue that while the DSM demonstrates adequate reliability (i.e., it helps ensure that professionals use the same terms in the same ways), it lacks validity, which, in the broadest sense, means that the disorders described do not accurately capture the nature of people's mental distress and impairment.

Some critics have focused on the processes by which the DSM framework is constructed, arguing that the diagnostic categories should be decided by scientific evidence rather than committees of experts, or that committee members' links to the pharmaceutical industry create egregious conflicts of interest (e.g. Greenberg, 2013). Others have criticised the lack of conceptual clarity and scientific objectivity in the DSM, suggesting, for example, that the absence of biological corroboration for the vast majority of disorders undermines the validity of the entire framework (e.g. Deacon, 2013).

A number of alternatives to symptoms-based diagnostic frameworks have been proposed, the most popular being the Research Domain Criteria (RDoc) project (Insel, Cuthbert, Garvey, & Heinssen, 2010), which aims at grounding diagnostic criteria in neuroscience and behavioural science. However, none of these alternatives have gained widespread acceptance from the mental health field. Even though some of the architects of recent iterations of the DSM have agreed that the current system is far from perfect, they have suggested that it is still necessary until a widely accepted alternative can take its place (Frances & Widiger, 2012).

Cultural insensitivity

Although the DSM goes some way in accounting for cultural variation in how mental health difficulties are experienced, labelled and explained, some authors have argued that it is complicit in the process of cultural colonisation. That is, it imposes one understanding of distress and impairment on cultures and groups of people who have their own legitimate alternative understandings (Barker, 2003; Timimi, 2014).

The authors of the DSM-5 recognise that the document is a cultural artefact of the US, stating that, "The current formulation acknowledges that all forms of distress are locally shaped, including the DSM-5 disorders" (American Psychiatric Association, 2013, p. 758). Yet because of the DSM's vast influence on healthcare systems, government departments and universities worldwide, its categories of health and sickness are often presented as the only valid perspective (Barker, 2003; Timimi, 2014).

Alternative viewpoints, such as traditional Aboriginal and Torres Strait Islander understandings of wellbeing - where health is seen as an outcome of the harmonious interrelation of mental, physical, cultural, spiritual and environmental factors (Poroch et al., 2009) - are sidelined. As Watters (2010, p. 2) explained, this "globalization of the American psyche" does not simply affect how pre-existing symptoms are interpreted, but can influence the very ways in which people experience mental health difficulties:

Over the past thirty years, we Americans have been industriously exporting our ideas about mental illness. Our definitions and treatments have become the international standards. Although this has often been done with the best of intentions, we've failed to foresee the full impact of these efforts. It turns out how people in a culture think about mental illnesses - how they categorize and prioritize the symptoms, attempt to heal them, and set expectations for their course and outcome - influences the diseases themselves. In teaching the rest of the world to think like us, we have been, for better or worse, homogenizing the way the world goes mad.

While the criticism that the DSM is colonising is important to consider, it is, at least in part, an outcome of the framework's vast influence, as opposed to inherent features of the framework itself.

Critical reflections

  • What are your reactions to reading the above criticisms of diagnostic frameworks? Do these criticisms challenge your views? Do they support views you already hold?
  • Are any of these criticisms especially relevant to the children and families you work with?
  • Have there been times when your work with children has been negatively affected as a consequence of their diagnosis? How did you attempt to overcome this?