Your Child’s Diagnosis-or Not

I don’t diagnose.  I mean . .  . I CAN diagnose, but I often don’t.  I am a developmental neuropsychologist and I do reassure parents that I can diagnose any possible learning disability.  But frankly, it’s not the point of my evaluation.  I don’t see my evaluations as diagnostic evaluations, but as comprehensive developmental evaluations with a good dash of neuropsychology.

What’s the difference?

Many evaluations in my field are diagnostic evaluations.  The goal of the evaluation is to converge on a diagnosis (or several) from the Diagnostic and Statistical Manual of Mental Disorders-5^th Edition (the DSM-5 for short).  This is the manual psychiatrists and psychologists use to make mental health diagnoses, including developmental and learning disabilities.  It is bible-sized, about as dense, and a little dry.

The DSM gets updated every decade or so.  Some diagnoses are removed, some are added, some are refined and made clearer (some are made muddier).  Our understanding of mental health, cognitive issues, developmental problems and learning challenges continues to evolve at a bumpy, uneven pace.   The DSM tries to keep up.

And this is one reason why I do not focus my evaluation on a DSM diagnosis.  I like the DSM. I own it.  I pull it off the shelf regularly.  I will make a formal diagnosis from the DSM-5 when it is necessary and/or when it is helpful.  (It is necessary for college and, sometimes, other school accommodations.  It is necessary for insurance submissions. It is necessary to enter certain treatment programs.)  And sometimes it is helpful. Sometimes the child is a perfect fit for the diagnosis (or diagnoses) and the treatment protocol.  Giving the diagnosis will help everyone support the child through well-studied and accepted protocols.

But frankly, there are just not that many diagnoses to choose from.  Developmental and learning disorders are categorized as Neurodevelopmental Disorders.  You get six basic choices – Intellectual Disability, Communication Disorders, Autism Spectrum Disorder, Attention Deficit/Hyperactivity Disorder, Specific Learning Disability, and Motor Disorders. There are more specific subcategories within these labels. There is also a category that is basically “Other” in case nothing else fits.

A child (or teen) can also be diagnosed with a mood disorder (depression, bipolar disorder), anxiety disorder, oppositional defiant disorder, attachment disorder or other more typically “mental health” disorder, but these are in other sections of the DSM.  I typically roam around in the Neurodevelopmental section with occasional forays to the other areas.

But, you ask, why do I resist making a diagnosis?

Here are a few of my problems with simply converging on a diagnosis:

1. There is the use of the words “Disorder” and “Disability.”  Some of the challenges I see are not a great fit for certain classrooms, but do I consider this a “disorder.”  Maybe it is just a type of normal. For example, we love (and often envy) highly energetic adults, but we are not as thrilled with highly energetic children.  However what may be a drawback now, may be an asset later.  I discuss this with parents and we make a decision to either make a diagnosis (because it does fit well enough and would be useful in some way) or describe the child’s strengths and weaknesses (or both).  The recommendations will likely be the same either way because those are based on lots of other data collected, not just the diagnosis.
2. There are only 6 general categories. Sometimes I think we are too narrowly defining our range of possibilities for the billions of people (and their styles) on this earth.  Even using more than one category may not fully describe the child I evaluated.  In addition, I really want to paint a picture of this child, not converge on diagnoses.
3. Not all of my preferred options are in there. Sensory Processing Disorder (or atypical sensory processing) being a good example. That diagnosis was proposed (strongly) for inclusion in the DSM-5, but it did not make the cut.  Sometimes, sensory issues are a leading contributor to attention problems in the child I evaluated.  So if a diagnosis is necessary, I have to make an AD/HD diagnosis (or Oppositional Defiant Disorder or Intermittent Explosive Disorder or something that fits) with an added explanation of the factors causing the problems.  Sometimes I don’t make the DSM diagnosis and focus on what I think it actually going on.  I feel like the diagnosis will actually be misleading.
4. The diagnosis might become a label. If you lead with the diagnosis – Autism, Attention Deficit Disorder, Intellectual Disability – people may only see the label, not the child.  They may form a mental bias based on the label and not expect a child to be able to learn or change because they do not see a certain skill as within the scope of that label.
5. The DSM diagnoses still do not connect brain to body very well. It tries to and does discuss various medical factors that may contribute to some diagnoses.  But sometimes there is a diagnosis, such as Oppositional Defiant Disorder, that totally fails to take into account sensory or other physiological factors that take a part in the presentation.

I have reviewed several evaluations lately that collected a lot of information and converged neatly onto a diagnosis.  The diagnosis was justified by the outward presentation of the child and the scores obtained on tests.  In fact, it was the only diagnosis in the DSM-5 that would have fit.  But the diagnosis was not helpful.  The diagnosis did not drive treatment in a way that supported the child.  It was necessary to dig under that diagnosis and find the contributing factors that led to that diagnosis.  Treating or supporting those factors were helpful to the child.

So yes, I can make a diagnosis and I will when it is needed.  But I will also continue to see evaluations as an art, as well as a science.  I want my work to be more than industry standards.  I want to paint a helpful picture.  I want to try to get to the bottom of things.