Beyond Diagnosis

byMoshe Shtuhl, Ph.D.

When parents seek psychological or developmental help for their children, the professionals involved usually evaluate the child with the goal of coming up with the right diagnosis for the child. While accurate diagnosis is a very important first step, in itself, it is not enough to provide the important pieces of the puzzle needed to allow us to best help the child and the family.

When a family starts receiving therapeutic services at Family Compass the first few sessions are devoted to the therapist getting to know the family and evaluating the child, including considering a diagnosis. Diagnosis is essential because it gives us an idea about the nature of the child’s challenges and a general direction as to how to help the child. For example, following a comprehensive neuropsychological evaluation at Family Compass a child who was highly motivated but still struggling at school was found to present with significant difficulty with the ability to sustain attention, to “hold” information in mind, as well as a tendency to work inefficiently and therefore at an unusually slow pace. The overall diagnostic picture was consistent with a diagnosis of an attention disorder. Another child who was also struggling at school was found not to have any learning or attention challenges but to experience emotions very intensely. When frustrated he had little ability to control his temper. Often when he needed to be patient or persevere with studying, he over reacted with anger and defiance which led to punishment and negative cycles of interaction with teachers, which in turn made learning more difficult.

While both of these children were referred to Family Compass for the same reason, namely struggling with learning, the underlying reasons for their challenges were very different.

Generally speaking, these different reasons for their challenges are what we aim to capture in a diagnosis. For one child, an attention disorder and the second child, difficulty regulating his emotions. Based on these diagnoses, the course of action recommended to the parents of these two children were very different; one child received supports and interventions that aimed to facilitate better attention and related abilities, the other child received therapy and recommendations to parents to help their child become better able to cope with his emotional intensity, develop emotional thinking and the ability to develop habits to support him to be calmer. As these two examples show, an accurate diagnosis is indeed an essential outcome of the process of an evaluation. Without it, efforts to help a child can be misdirected and unhelpful.

However, while essential, parents need and should require more than a diagnosis before considering a treatment plan to address their child’s challenges. This is because diagnosis alone does not provide all the information needed in order to tailor an intervention to the specific needs of a child. Here are several related reasons that address this insufficiency:

Diagnostic Categories are very broad: They are so broad that at times it is hard to recognize that two children with such differing expression and severity of challenges could possibly have the same diagnosis. Therefore, children that have the same diagnosis might need very different intervention plans to help them overcome their difficulties. This is true of all diagnoses but it is especially true of some, such as the diagnosis of autism. The so called “autism spectrum” is so wide that saying that a child presents with symptoms of autism gives us very little idea about the individual child’s specific needs.

Diagnostic Categories are only descriptions: The medical model instructs us that a diagnosis captures the essence of a person’s difficulties. If a doctor determines that you suffer from Bacterial Pneumonia, for example, this means that you have a bacterial infection in your lungs and this is usually treated with a course of antibiotics. Though not widely known, the diagnosis of behavioral and developmental challenges does not have this level of accuracy or specificity. Instead, behavioral and developmental diagnoses only convey a description of symptoms that often occur together, but do not necessarily convey the root cause of a problem.

This is true about almost all behavioral diagnoses but especially in regard to some, such as the diagnosis of Oppositional Defiant Disorder. This diagnosis generally conveys that the child presents with behavioral challenges, but says very little, if anything about the root cause of the challenges. Still, these diagnostic categories are helpful because they serve as a short cut to describe various symptoms that go together and that often lead us to a general idea about how to help. But, unlike medical diagnoses, mental health diagnoses do not relate to specific challenges with specific origins, either in the environment or genetics. This failure to convey a specific root cause is a second, related reason, for parents to aim to get information beyond a diagnosis.

Diagnosis only describes the problem, not the child: To know how to help the child, you need to know the child; each child’s temperament, interests, motivations and most importantly strengths are essential in determining the best ways to help each child. Therapy research has consistently shown that children get better not only when therapy addresses weaknesses or problems, but rather when we work with their strengths. When therapists convey to parents only deficits and problems, they are doing a dis-service to the family and child by discouraging and disregarding the great leverages of working and emphasizing every child’s gifts.

Every family is different: Last but not least, whatever the suggested plan, it needs to fit your family situation. There are various ways to help children, but a family’s well-being is always essential. A family with a child that exhibits learning disabilities but also struggles with a health crisis of one of the parents clearly needs a different plan then if health problems were not present. Best parenting solutions for a working parent might not be best for a stay-home parent and vice versa. When helping a child it is important to remember that the child develops within a family and that solutions must also address and fit the family as a whole.

In a nutshell, we should never aim to treat a diagnosis but rather strive to understand and help a unique child, with her various specific characteristics, challenges and gifts. Each individual child must be supported and helped to thrive within her particular family and school, and a diagnosis is a good first step, but never enough.