To Diagnose or Not to Diagnose in Children’s Mental Health?  That is the Question

A young girl on a bike

Photo: Martin Yaffe

When considering the issue of to diagnose or not for children with mental health issues, we must consider the potential advantages and potential harms associated with diagnosis. While much has been written about the potential harms of diagnoses in adults, i.e. the stigmatizing effect, much less has been written about the effects on children, although I believe the harms are even greater. I did find this article in Psychology Today that is worth reading.

Here are a few points to consider…

1. I have been working at a children’s mental health in Toronto for over 30 years. During the first 10 years I recall a very large banner across one entire wall, which read “CHILDREN ARE LIKE CEMENT. EVERYTHING THAT LANDS ON THEM MAKES AN IMPRESSION” I read that banner every day. It was hard to miss. It made me think of the power of words, which children  are all too familiar with;  hurtful words being at the root of bullying. Even the children’s antidote– “Sticks and Stones will Break my Bones, but Words will never harm me,” always struck me as a classic defense mechanism and an example of true irony. It is a verbal denial of the truth– using the power of words to defend against the power of words.

Think about the fragility of children’s self-esteem and self-image. Professionals and parents interact with children in their “formative” years. During this time many children deal with many negative messages that they must defend against– taunts from other children, relationship failures, academic failures, family break-ups, adults who are themselves stressed and sometimes take out their frustrations on the children, etc. There are many places where negative messages about the self can come from. Do professionals really need to add more to the list in order to do their jobs, and give those words the added power of authority in the process?

In “Raising Your Spirited Child,” Mary Sheedy Kurcinka, talks about how labels set expectations and once expectations are in place there is a phenomenon of self-fulfilling prophecy. Advertisers spend millions of dollars coming up with just the right labels because they are so powerful. They tell us what’s inside the can and convince us to want and trust it. She also mentions the Pygmalion Effect, well documented in the literature—that children learn who they are from others in their lives. The labels we give kids, whether they fall in the category of casual name-calling, like “the wild-one” or “lazy”, or the professional sounding ones like “oppositional defiant disordered,” or “ADHD”, have profound effects on other people’s expectations of them and the children’s expectations of themselves. Mary Kurcinka writes: “If we are going to build a healthy relationship with our kids, we must lay the labels out on the table, dissect them, and then redesign those that make us and our kids feel lousy, the ones that cloud our vision and hide the potential within.”

2. There is also the issue of reliability of our diagnoses. Are they really based on genuine causes like medical diagnoses are intended to be, or are they more subjective and thus prone to more unreliability and error? Many of our professional diagnoses, even ADHD, which is more of a neurological disorder, are often made on the basis of subjective questionnaires, like the Conners’. (Interesting that even Keith Conners’ is aghast about how the diagnosis of ADHD is skyrocketing. Check out his comments in the New York Times article by Allan Schwartz on the Selling of Attention Deficit Disorder just a few weeks ago.

Think about the lack of precision to questionnaire data, how a parent’s own psychological make-up can affect how they view a child, and hence how they might respond to a questionnaire. There are many factors which might be contributory. To name a few– whether this is their first child, or third, whether they’ve had girls and now a boy, whether the boy reminds them of their failed marriage partner, are they depressed and therefore unable to handle normal childlike activity, are their expectations unrealistic, are they a step-parent, are they displacing or projecting some of  their own issues onto the child, etc. Overall, to what extent is the questionnaire a measure of the adult’s personality profile, rather than the child’s? We cannot really know the answer to that question, without doing a thorough evaluation of the adult, which is beyond our scope in children’s mental health, but it is certainly something to keep in mind, before jumping to conclusions about children, based on questionnaire data  alone.

This is one reason why I have tried to include as much data about the child’s actual functioning in the ADHD assessment, which includes measures of working memory ( The research supports the connection between poor working memory and ADHD), as well as the child’s performance on the Conners’ Continuous Performance Test. Parents seem to understand the results of the test, and when, for example, I can show them that the child did extremely well on the test, they are less likely to think the child has a neurological disorder. If, however, the child does poorly, the parent(s) seem to get it and is more accepting of the diagnosis. They are less likely to accept a diagnosis based on questionnaire data alone. They seem to intuitively understand the weakness of the data themselves.  One of the reasons, I believe, that the diagnosis of ADHD has been skyrocketing, is that most diagnoses are based on questionnaire data alone, which can be quite unreliable.

3. The unreliability of mental health diagnoses is a problem, in itself. The more professionals the family sees who give formal diagnoses, the greater the chances are that the diagnoses will differ. The family then becomes confused and are more likely to throw their hands up, putting the problem back on us, saying “If  the professionals can’t agree on what the problem is, how do you expect us, the parents, to know what to do?” It is the responsibility of the professional community to at least try not to confuse people.

4. Getting back to the stigmatization of diagnoses. I recall a conversation I had with Dr. Irvin Yalom, Psychiatrist and Prof Emeritus at Stanford. Having read a lot of his writings and holdinghim in high esteem, I attended a workshop he gave at the Evolution of Psychotherapy Conference in California about 15 years ago. He was lecturing about the dangers of diagnosis for adults, saying that once you give someone the diagnosis of, let’s say “schizophrenia” or “borderline personality disorder,” it’s hard to see that person as fully dimensional, fully human. You begin to view them as their diagnosis– “a schizophrenic,” or “a borderline personality.” I was beginning to panic at the time because I was about to teach the course at York in Abnormal Personality Disorder, but I was fortunate to have a conversation with him, expressing my concerns. His answer was priceless. He said, “It’s like learning the play the piano. When you practice, you play scales over and over, but when you play, you forget about the scales and you just play.” It at least gave me a framework to understand the usefulness of learning the language and to get behind teaching the course.

5. We have no choice but to make diagnoses in the area of learning disabilities, because without them children would not receive the individual help they need. It’s a question of allocation of resources to those children who need the most help. In these cases I believe the benefit  of making a formal diagnosis far outweighs the harms.  But there are still harms, and it is the responsibility of the professional involved to make a concerted effort to counteract the potential  harms associated with the diagnoses of the learning disorders. We need to help children and their parents truly understand that this diagnosis does not mean they cannot learn or that they are not as smart as others. Believing this would contribute greatly to the harm of the diagnosis.

I recall a landmark study done by Bryan and Bryan, 1975, where they gave two groups of children the same test. One group had been diagnosed with LD and the other had no diagnosis. The test was too difficult for all of them and they all did poorly on it. The interesting results came when the children were asked why they did poorly. The children who had no diagnosis blamed external factors– it was too hard, they hadn’t been taught the information, etc. All of the children who had a diagnosis blamed their learning disability for their poor performance. This speaks to the power of the diagnosis and to the importance of to what we attribute our successes and failures. Our attributions eventually lead to our self-image.

There is also the classic Rosenhan study (1973) where normal (professional actors) people entered a mental hospital under false pretenses. They gained admission and were given DSM diagnoses. Once inside they stopped acting and tried their best just to be themselves and be normal. Every action they engaged in, however, was viewed within the lens of their diagnosis. If they complained about anything at all they were viewed as “oppositional.” The bottom line, once you have a diagnosis it’s almost impossible to shed.

6. Does having a diagnosis in hand make it easier or harder to parent a child? For example, the diagnosis of Oppositional Defiant Disorder (ODD)is based almost exclusively on questionnaire data. All it really does is identify that there is a relationship problem and a lot of anger is being expressed, probably from both sides, but the diagnosis is given only for the child. Once the diagnosis is made, it may give the false sense that the problem exists in the child alone– “a bad seed,” “just like my ex-husband.” Once this is confirmed by a professional diagnosis, it may make it more difficult for the parent to see the child in a positive light.  From a narrative perspective, the narrative has been set and may be difficult to alter. In my opinion, it only solidifies rather than introduces the possibility of change to the relationship and how the child is viewed.  Ultimately, in my opinion,  this is neither  helpful to the parent nor  to the child. One must ask the question—for whom is a mental health diagnosis made? Perhaps it serves the professional more than the client(s).

7. Does making a diagnosis make it easier to treat the child; does the diagnosis really inform the treatment?  Medical diagnoses, such as diabetes or heart disease clearly inform treatment. But in the area of mental health, we can offer the same treatment based on a description of the problem itself. Would it make any difference to treatment whether we diagnosed a child with Oppositional Defiant Disorder (ODD)or not? We would still treat the anger and the possible relationship problems. Other questions worth thinking about– Are there some diagnoses that really do change the treatment? If we diagnose an attachment disorder, does that make a difference? What do we do differently? How about Post Traumatic Stress Disorder -PTSD? If we make a diagnosis and then we don’t provide the treatment that will specifically treat that disorder, how much have we helped or hindered the individual’s situation?

There is much to ponder and discuss. I look forward to to the conversation.