Least Restrictive Diagnosing
by Jonathan M. Gransee, Psy.D. Licensed Psychologist
The rise in the rate of diagnosing children with mental health issues seems to be one of the more significant challenges facing the field of child and adolescent psychology today. One could also argue that this is, to some extent, true of adult psychology, as there has been a notable increase in the rate at which Bipolar Disorder is being diagnosed in adults, and other diagnoses that were in the past restricted only to children (Attention-Deficit/Hyperactivity Disorder), are now being assigned to adults, in some instances. This paper, however, has as it’s focus the diagnosing of children and adolescents.
Examining the annals of diagnostic history, it is clear that there has been a general trend towards increasing the percentage of children diagnosed with some mental health disorder or another. For years, the predominant diagnosis had been Attention-Deficit/Hyperactivity Disorder (Or Attention-Deficit Disorder, an earlier version of this diagnosis). Typically, treatment of this disorder has involved the use of stimulant medications, which have been thought to be relatively innocent in terms of causing any long-term physical effects on the prescribee. Yes, there have been concerns about lack of weight gain/lack of typical growth, and concerns about increased aggressiveness, as well as concerns about the occasional hallucinating child. Further, there have been the concerns about the possible increase in the rate of mood disorders in children who have been given long-term stimulant treatment. However, ADHD symptoms seem to subside as the child ages, and oftentimes, medications are discontinued in adolescence or early adulthood, as the child matures and there does not appear to be a need for continued medication. So, while the concerned practitioner could point to the possible deleterious effects of long-term medication therapy, at least they could console themselves with the notion that the child would, at some point, come off the medications.
Enter Childhood Bipolar Disorder. This disorder, when appropriately diagnosed, presumably is a long-term, probably lifelong disorder. And, medications reign supreme as the treatment of choice for this disorder, and it is unusual to see a Bipolar Child (or adult, for that matter), go without any type of medication. As well, since Bipolar Disorder is presumed to be a lifelong disorder, it is presumed that medications will be needed for life. Further, because adult Bipolar Disorder individuals can go weeks, months, or even years between episodes, but then decompensate to a point that is debilitating, the common approach is to advise the client to continue medications indefinitely. In other words, a diagnosis of Bipolar Disorder can very well relegate the person to a lifetime of medication management. And, since a child who is diagnosed with Bipolar Disorder may well carry that diagnosis into adulthood, unchallenged by diagnosticians who do not want to show disrespect to their colleagues by discontinuing a previous diagnosis, a child diagnosed with Bipolar Disorder will probably still have that diagnosis as an adult. Thus, when we diagnose a child with Bipolar Disorder, we are creating a crop of future adults with this disorder, and potentially relegating them to a lifetime of medication management.
With that thought in mind, it makes sense (at least to this writer), to be careful. What does this mean, exactly? Does that mean that we do not give the diagnosis to children? Or does it mean that we need to be very strict in our screening for this disorder, in children, to insure that we are correct? In this writer’s opinion, both are appropriate. Research regarding Childhood Bipolar Disorder is far from conclusive, in terms of recommending an eager approach to diagnosing this disorder in children. Some research suggests that there may indeed be childhood pre-symptoms to adult Bipolar Disorder, and there have been a number of research articles suggesting diagnostic criteria for Childhood Bipolar Disorder. However, there is other research to suggest that diagnosing Bipolar Disorder in Children is not necessarily appropriate, as many children diagnosed with this disorder at a young age end up not meeting the criteria for Bipolar Disorder as they age. One could argue that this is due to successful treatment, but this does not seem to be the case, and regardless, would suggest that another, less stigmatizing/less long-term diagnosis would be appropriate, and that Childhood Bipolar Disorder should only be assigned in cases in which there is not a successful resolution to early intervention.
This brings us to the point of this article: The concept of Least Restrictive Diagnosing. Most of us, and in particular those of us who work for school systems, are aware of the concept of the Least Restrictive Environment. The idea is that the child should be placed in a classroom that is as high-functioning as possible, and that the child should receive therapeutic interventions that allow for the closest approximation to a regular education. The idea is not to restrict the child’s ‘normal’ development by overdoing it, in terms of determining the child is unable to participate in a regular learning environment, which might cause irreparable harm, in terms of limiting his/her exposure to typical academic challenges, and his/her exposure to typical social challenges.
So how does that equate, in terms of diagnosing a child with a mental health disorder. Well, first of all, there needs to be some acknowledgment that diagnoses are restrictive. In what way are they restrictive? They are restrictive in that they change others’ conceptualization of the child, which in turn may change their responses to the child, etc. For instance, a child who receives a label of Asperger’s Disorder may be treated differently by their parents, in terms of social expectations, than a child who receives a label of Anxiety Disorder, NOS. As well, the child who is told they have Asperger’s Disorder, and that they are hard-wired to not be able to understand social situations, may actually try less in social situations, as a result. Diagnoses restrict! An adult who is told they have ADHD may stop trying as hard to pay attention, because they may feel that they have limited control over doing so. Diagnoses change a person’s perspective!
Copyright June 2008. These articles cannot be used in any fashion without the explicit permission of the author, except for individual use.
Disclaimer: This information is not intended to diagnose or treat any condition, and is for the sole purpose of providing alternate perspectives. If you feel that a mental health condition exists in yourself or the person you are reading this article for, you are advised to seek out psychological or psychiatric services.