Diagnosis in child mental health
The identification and diagnosis of child mental health conditions attracts controversy. Uproars about the over-diagnosis of attention deficit/hyperactivity disorder (ADHD) have been a media staple in recent years, with claims that Australia has become a "medication nation" (Schwarz, 2016) nurturing "a generation of Ritalin kids" (Fife-Yeomans, 2009, paragraph 1). The federally funded "Healthy Kids Check", aimed at screening 3-5 year olds for signs of psychosocial and development problems, was defunded after three years, but not before generating considerable debate within both popular and academic forums (e.g. Newman, 2012; Prior, 2012). And the early intervention strategies of the nationwide Early Psychosis Prevention and Intervention Centres (EPPIC) have attracted ongoing criticism, with, for example, prominent United States (US) psychiatrist Allen Frances (2011, paragraph 4) declaring them "a vast and untried public health experiment that will almost surely cause more harm to children than it prevents".
No recent document in the field of mental health has generated more debate than the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013; hereafter "DSM" is used to refer to the diagnostic manual in general, as opposed to any particular edition). In Australia, as in the US, the DSM is the primary system for identifying mental health conditions in both children and adults.
The DSM provides labels for clusters of behavioural health symptoms (i.e., it is descriptive), and in the large majority of cases does not attempt to describe the aetiology of the symptom-based disorders it identifies (i.e., it is not explanatory). It is a highly influential document, not only shaping research, policy and treatment, but drawing the official boundaries between "normal" and "abnormal", healthy and sick. As Mayes and Horwitz (2005, p. 265) observed, "few professional documents compare to the DSM in terms of affecting the welfare of so many people".
Perhaps because of its pervasive influence, the DSM has been subject to intense scrutiny. For example, it has been criticised for medicalising the normal rhythms of life, decontextualising mental health difficulties, and being influenced by the profit-motives of pharmaceutical companies. These and other criticisms are outlined in the sections below. It should be noted here, however, that many of the criticisms of the DSM are as much about its misuse as they are about the framework itself. For example, while the DSM presents itself as a descriptive document, it is often inappropriately used as an explanatory framework, in which case the social and developmental contexts of mental health conditions can easily be obscured.
When those being diagnosed are children, new layers of complexity are introduced.
Children are profoundly dependent and sensitive to their contexts. Despite the widespread propagation of biological explanations of mental health, the strongest predictors of child mental health difficulties are family and environmental factors (J. Bayer et al., 2011; Patalay & Fitzsimons, 2016). For example, adverse childhood experiences, including exposure to family violence and maltreatment, are strongly associated with mental health difficulties in both childhood and later life (Kerker et al., 2015).
Normal child developmental trajectories also vary widely, meaning that it can be difficult to make accurate diagnoses for younger children (Prior, 2012; Szaniecki & Barnes, 2016). Where children are concerned, the lines separating normal development and mental health difficulty can be particularly troublesome to draw. And even if these lines are drawn accurately, appropriate supports are often unavailable (Prior, 2012).
Despite these complexities, Australia has witnessed a steady rise in the number of children diagnosed with mental health conditions, which is concordant with worldwide prevalence trends (Merten, Cwik, Margraf, & Schneider, 2017). Research has also documented a recent increase in the use of psychotropic medications to treat child mental health difficulties (Zito et al., 2003). Such trends have concerned many mental health professionals, who have argued that the field of child mental health is marred by "epidemics" of overdiagnosis and over-treatment (e.g. Basu & Parry, 2013; Batstra & Frances, 2012). However, overdiagnosis and over-treatment are a problem of developed countries, with chronic under-recognition of child mental health difficulties a more likely scenario in the developing world (Barbour et al., 2013).
While many service providers have well-established views on diagnosis, they may not have the capacity to explore the debates, complexities and nuances of diagnosis in child mental health. They may not be aware, for example, that the disorders in the DSM and similar frameworks are arrived at through the consensus of committees of mental health experts, are sometimes based on scant empirical evidence, and tend to be more influenced by historical and practical considerations than any clear rationale (Frances & Widiger, 2012).
That diagnostic categories are decided by committees and influenced by practical considerations does not automatically make them invalid. Indeed, the boundaries of diagnostic categories are rarely drawn by scientific evidence alone; many physical medical conditions also have their diagnostic parameters decided and revised by committees of experts. Nonetheless, it does suggest that the diagnostic categories used in the Australian mental health care system are not set in stone. Rather, they are ways of understanding human challenges that convey both benefits and risks, and for which there can be legitimate alternative understandings. The more insight that service providers have into the nature of the diagnostic frameworks that shape their practice, the more likely it is that they will make appropriate decisions when children in their care are experiencing mental health difficulties.
Language is important
The language used in the context of mental health experiences and systems is important. Some terms are obviously stigmatising or outdated (e.g. "schizo", "nuts"). Others can seem benign, but actually reflect unproven or misleading views. There are many different opinions about the respectful use of language in the context of mental health, and it is incumbent upon each service provider to identify language that reflects their own views, is consonant with the principles of their workplace, and respects the dignity of the service users with whom they work. The following notes on language use in this paper reflect the informed preferences of the author:
- The terms "mental health condition", "mental health difficulties" and "distress and impairment" are used throughout this paper. These terms acknowledge the difficult experiences of those diagnosed with mental health conditions, while avoiding some of the limitations identified throughout this paper, such as over-medicalisation.
- Because this paper advocates for the use of the biopsychosocial model in paediatric mental health, the term "mental illness" is not used. This term can be seen to suggest that conditions such as major depressive disorder, ADHD and oppositional defiant disorder are biologically based brain diseases.
- The word "disorder" is used in places throughout this paper, but only in the context of referring to the DSM (which classifies "mental disorders") or specific diagnostic categories (e.g. "conduct disorder"). A limitation of this word is that it can negate the understanding that some mental health symptoms are reasonable reactions to, or even adaptive solutions for, trauma or difficult circumstances (Watt, 2017). For example, in the disordered context of a family home where there is violence and abuse, it may be adaptive for a child to develop the symptoms of anxiety. To label the child's anxious response as "disordered" subtly locates the issue in them, rather than in their family environment.
About this paper
This paper is designed to encourage practitioners to critically reflect on the role diagnostic systems play in their work with children and families.
Sections 1 and 2 explore the most widely cited strengths and criticisms of current diagnostic systems. Section 3 explores the evidence behind claims of widespread overdiagnosis of certain child mental health conditions. In section 4, children's and parents' views of diagnosis are explored. Finally, in section 5, a number of alternatives or adjuncts to current diagnostic systems are outlined and then illustrated in an extended case study.
At the end of each section is a series of "critical reflections", designed to encourage practitioners to connect what they have read back to their own professional experiences. While this paper is intended primarily for service providers in the child and family welfare sectors who work with children from birth to 12 years of age, it is also likely to be relevant to a wide range of health and welfare practitioners. Many of the readers of this paper will work in non-clinical environments and will not themselves be responsible for diagnosing children. Nonetheless, diagnostic labels will still influence their work in myriad ways, affecting how they interpret children's distress and impairment, the expectations they have of families, and the interventions they provide.
Diagnostic systems: DSM, ICD and DC:0-5
The DSM features heavily in this paper, at times acting as a proxy for similar diagnostic systems. The reasons for this are twofold. First, as the DSM has been subject to much more critical analysis than any other diagnostic system, most of the literature relevant to this paper was focused on the DSM. Second, as already mentioned, the DSM is the most widely used diagnostic system in Australia.
The International Classification of Diseases (ICD) is the main alternative, though it is similar to the DSM in many respects, tending "to follow palely in the footsteps of its big American brother" (Tyrer, 2014, p. 283). The major difference between the DSM and ICD is that while the former provides operational diagnostic criteria for its disorders, the latter relies on narrative descriptions of disorders. Efforts are currently being made to "harmonise" the two diagnostic systems, so they share the same "metastructure", as well as the same terms to denote their major diagnostic categories (Maj, 2011).
The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, ZERO TO THREE, (DC:0-5 2016) is an alternative for diagnosing infants and young children that places more focus on incorporating contextual factors into the diagnostic process, though it is small and lesser known than the DSM or ICD.
This paper is firmly rooted in the view that child mental health difficulties are best understood within the biopsychosocial model, which focuses on the ways in which biological propensities interact with psychological and social factors to lead to specific behavioural and emotional outcomes (Engel, 1977).
While the biopsychosocial model is widely invoked in Australian health services, it is common for the "bio" aspects of the model (e.g. genetic predispositions, psychotropic medications) to receive more attention than the "psycho" (e.g. coping skills, personality) and the "social" (e.g. socioeconomic status, social support) (Gambrill, 2014). Conditions such as major depressive disorder, ADHD and oppositional defiant disorder are often presented as biologically based brain diseases - a position that has little empirical support despite vast amounts of funding being allocated to uncovering the biological bases of mental health conditions (Deacon, 2013). For example, none of the psychiatric disorders identified in the DSM-5 have been shown to have a simple biological cause, and few have reliable biomarkers (i.e., they cannot be diagnosed using medical procedures, such as blood tests or fMRI scans) (Deacon, 2013; Frances & Widiger, 2012). Similarly, there exists no credible evidence that mental health conditions are caused by "chemical imbalances" in the brain, nor that psychotropic medications work by correcting such imbalances (Deacon, 2013). As the editor of the most widely read trade publication in the field of psychiatry, the Psychiatric Times, observed, "in truth, the 'chemical imbalance' notion was always a kind of urban legend - never a theory seriously propounded by well-informed psychiatrists" (Pies, 2011, paragraph 1).
- What are your views about diagnosing children with mental health conditions? How do these views influence the way you work with children and families?
- How have your views about diagnosis been changed or reinforced by professional training and experience, personal experience, and/or the media?
- How has your understanding of diagnostic systems influenced your practice? Are there understandings that you would like to develop in order to enhance your practice?
1 The United Kingdom and many other European countries favour the tenth edition of the International Classi cation of Diseases (ICD-10; World Health Organization, 1992), which for the purposes of this paper is similar to the DSM.