In which I disagree with a colleague

As I've mentioned in some post or another in the past, I generally enjoy Skeptical OB, particularly when she is railing against idiotic anti-medical mumbo-jumbo. However, I take exception to something she said in a recent post. In the course of offering sage advice about parents needing to accept their children for who they are, not who parents wish them to be, she says this:
How much more difficult then, to manage this task when your child is disabled in some way. Hence, there is an overwhelming desire to deny the truth of a diagnosis, or, more commonly, to refuse even to have the child evaluated for a diagnosis. Of course, no one expresses their denial in this way. Instead, they claim that they don't want the child to be "labeled." Or, even more fashionably, people assert that learning and psychiatric disabilities are "over diagnosed" among children.


What does the diagnosis of a learning or psychiatric disability entail? Those who fear "labeling" imply or assume that the diagnosis of the disability is arbitrary; the psychologist or learning specialist meets the child and on the basis of impressions drawn from that meeting, and impressions drawn from speaking with parents and teachers, arrives at a diagnosis. The reality is that the diagnosis is usually reached by neuro-psychological testing.

Neuro-psych testing is complex and comprehensive. There are a seemingly endless array of tests to diagnose every disability and every possible variation of a disability. A diagnosis is not an "impression," it is a 15-20 page report detailing the tests and results, explaining the child's observed difficulties by reference to the results, and detailing an intervention plan that will be geared toward the way the individual child learns.

The second assumption is that children being "over-diagnosed" with learning and psychiatric disabilities. In other words, children are routinely receiving diagnoses that are not true. Curiously, this assumption is only made in regard to children. No one claims that adults who receive a diagnosis are being "over-diagnosed." This is supposedly a phenomenon that is restricted to children, yet no one offers an explanation as to why "over-diagnosis" is restricted to children.
I'm sorry to say this, but much of what Dr. Tuteur says here is simply wrong, or at least inconsistent with my experience.

Let us assume that the diagnosis we're thinking of when we talk about children being "over-diagnosed" is ADHD. I see a lot of kids because of parent/teacher concern about this diagnosis. (A lot.) And the diagnosis of ADHD is not made through a complicated process of neuro-psychiatric testing. Rather, forms are completed by teachers and parents wherein they record their observations (or, if you prefer, their "impressions") of the child in various settings using a scale. The responses are then tabulated, with certain scores indicating ADHD. It is a very imprecise method of diagnosing the disorder, and one that is incredibly susceptible to bias by frustrated teachers and parents.

Conversely, the people who conduct neuro-psychiatric testing in our area are very clear that they are not in the business of sussing out the source of behavioral problems, and tend to get testy if they think a referral was not indicated. Neuro-psych testing is meant to determine if a specific neurological problem is having psychiatric manifestations. Since ADHD is not related to a known neurological deficit, neuro-pysch testing is not an appropriate means of diagnosis.

Another diagnosis that has enjoyed a recent vogue is bipolar disorder, which is armchair psychiatry's new black. Again, I can't speak with authority about how this disorder is diagnosed by most providers, but I have sat horrified in a seminar at a respected professional conference while colleagues discuss giving the diagnosis to patients in order to justify the use of powerful psychiatric medications that would otherwise not be indicated for treating their more challenging adolescent patients. In other words, by assigning the diagnosis with loose or arbitrary standards, one could use bigger guns when trying to medicate away the troubled behaviors at hand. And I am more than happy to say that many adults are over-diagnosed with psychiatric disorders, not just kids.

I think Dr. T's overall message to parents is sound. Raise the kids you have, rather than pretending they are as perfect or exceptional as you wish. But she evinces too much confidence in how psychiatric diagnoses are made. It is, sadly, far more arbitrary and subjective than she seems to think it is.


  1. Hey Dan!

    While by no means am I the person to hold forth on this issue, I did recently learn via experience that there is a difference between a so-called "therapeutic medication evaluation" and a "full psychological evaluation." While I don't know what the latter entails, I do know that with the former, and by the use of the forms Dan describes here and with a relatively brief meeting to see how the child "presents," it is possible to give a diagnosis of ADHD for the purpose of prescribing stimulant medication like Ritalin, etc. Depending on state/county differences, this can be done by a pediatrician or psychiatrist.

    In addition, when children are enrolled in some specialized therapeutic programs, they may be given a sort of "non-transferrable" diagnosis, say something like ODD, which will guide their treatment plan, though it is not an evaluation that would stick as a label or be implicated in later therapeutic or medication decisions.

    Note the neutral tone, here. I don't know enough to walk in this minefield, though over drinks I'd be happy to offer up my experiences and intuitions.

    P.S. Paris = Inf. Tasks

  2. Thanks for commenting, Paris. (By the bye, love the Infinite Tasks blog.)

    My point, which perhaps was unclear, is simply that the diagnosis of ADHD is often impressionistic, contra Dr. T's post. I don't think this is necessarily either inaccurate or inappropriate, but it isn't the iron-clad diagnostic battery that she seems to imply.