He's learning disabled. |
What's in a name? Strong images are associated with diagnostic labels, and people act upon these images. Sometimes the images are useful generalizations; sometimes they are harmful stereotypes. Sometimes they guide practitioners toward good ways to help; sometimes they contribute to "blaming the victim" -- making young people the focus of intervention rather than pursuing system deficiencies that are causing the problem in the first place. In all cases, diagnostic labels can profoundly shape a person's future.
Youngsters manifesting emotional upset, misbehavior, and learning problems commonly are assigned psychiatric labels that were created to categorize internal disorders. Thus, there is increasing use of terms such as ADHD, depression, and LD. This happens despite the fact that the problems of most youngsters are not rooted in internal pathology. Indeed, many of their troubling symptoms would not have developed if their environmental circumstances had been appropriately different.
Diagnosing Behavioral, Emotional, and Learning Problems
It is not surprising that debates about labeling young people are so heated. Differential diagnosis is difficult and fraught with complex issues (e.g., Adelman, 1995; Adelman & Taylor, 1994; Carnegie Council on Adolescent Development, 1989; Dryfoos, 1990).
The thinking of those who study behavioral, emotional, and learning problems has long been dominated by models stressing person pathology. This is evident in discussions of cause, diagnosis, and intervention strategies. Because so much discussion focuses on person pathology, diagnostic systems have not been developed in ways that adequately account for psychosocial problems. This is well-illustrated by the widely-used Diagnostic and Statistical Manual of Mental Disorders -- DSM IV (American Psychiatric Association, 1994) and by MMPI categories, as well as the dimensions formulated by Achenbach and others based on behavior rating scales.
As a result, comprehensive formal systems used to classify problems in human functioning convey the impression that all behavioral, emotional, or learning problems are instigated by internal pathology. Some efforts to temper this notion see the pathology as a vulnerability that only becomes evident under stress. However, most differential diagnoses of children's problems are made by focusing on identifying one or more disorders (e.g., oppositional defiant disorder, attention-deficit/hyperactivity disorder, or adjustment disorders), rather than first asking: Is there a disorder?
Bias toward labeling problems in terms of personal rather than social causation is bolstered by factors such as (a) attributional bias --a tendency for observers to perceive others' problems as rooted in stable personal dispositions (Miller & Porter, 1988) and (b) economic and political influences -- whereby society's current priorities and other extrinsic forces shape professional practice (Becker, 1963; Chase, 1977; Hobbs, 1975; Schact, 1985).
Overemphasis on classifying problems in terms of personal pathology skews theory, research, practice, and public policy. One example is seen in the fact that comprehensive classification systems do not exist for environmentally caused problems or for psychosocial problems (caused by the transaction of internal and environmental factors).
There is considerable irony in all this because so many practitioners who use prevailing diagnostic labels understand that most problems in human functioning result from the interplay of person and environment. To counter nature versus nurture biases in thinking about problems, it's helps to approach all diagnosis guided by a broad perspective of what determines human behavior.
To illustrate the nature of transactional thinking, let's look at learning problems In teaching a lesson, a classroom teacher will find some students learn easily, and some do not; some misbehave, some do not. Even a good student may appear distracted on a given day.
Why the differences?
A common sense answer suggests that each student brings something different to the situation and therefore experiences it differently. And that's a pretty good answer -- as far as it goes. What gets lost in this simple explanation is the essence of the reciprocal impact student and situation have on each other -- resulting in continuous change in both.
To clarify the point: For purposes of the present discussion, any student can be viewed as bringing to each situation capacities and attitudes accumulated over time, as well as current states of being and behaving. These "person" variables transact with each other and also with the environment (Adelman & Taylor, 1993).
At the same time, the situation in which students are expected to function not only consists of instructional processes and content, but also the physical and social context in which instruction takes place. Each part of the environment also transacts with the others.
Obviously, the transactions can vary considerably and can lead to a variety of outcomes. Observers noting student capacities and attitudes may describe the outcomes in terms of desired, deviant, disrupted, or delayed functioning. Any of these outcomes may primarily reflect the impact of person variables, environmental variables, or both.
Toward a Broader Framework
The need to address a wider range of variables in labeling problems is clearly seen in efforts to develop multifaceted systems. The multiaxial classification system developed by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders -- DSM IV represents the dominant approach (American Psychiatric Association, l994). This system does include a dimension acknowledging "psychosocial stressors." However, this dimension is used mostly to deal with the environment as a contributing factor, rather than as a primary cause.
The following conceptual example illustrates a broad framework that offers a useful starting place for classifying behavioral, emotional, and learning problems in ways that avoid overdiagnosing internal pathology. As outlined in the accompanying figure, such problems can be differentiated along a continuum that separates those caused by internal factors, environmental variables, or a combination of both.
Problems caused by the environment are placed at one end of the continuum and referred to as Type I problems. At the other end are problems caused primarily by pathology within the person; these are designated as Type III problems. In the middle are problems stemming from a relatively equal contribution of environmental and person sources, labelled Type II problems.
To be more specific: In this scheme, diagnostic labels meant to identify extremely dysfunctional problems caused by pathological conditions within a person are reserved for individuals who fit the Type III category. Obviously, some problems caused by pathological conditions within a person are not manifested in severe, pervasive ways, and there are persons without such pathology whose problems do become severe and pervasive. The intent is not to ignore these individuals. As a first categorization step, however, it is essential they not be confused with those seen as having Type III problems.
At the other end of the continuum are individuals with problems arising from factors outside the person (i.e., Type I problems). Many people grow up in impoverished and hostile environmental circumstances. Such conditions should be considered first in hypothesizing what initially caused the individual's behavioral, emotional, and learning problems. (After environmental causes are ruled out, hypotheses about internal pathology become more viable.)
To provide a reference point in the middle of the continuum, a Type II category is used. This group consists of persons who do not function well in situations where their individual differences and minor vulnerabilities are poorly accommodated or are responded to hostilely. The problems of an individual in this group are a relatively equal product of person characteristics and failure of the environment to accommodate that individual.
There are, of course, variations along the continuum that do not precisely fit a category. That is, at each point between the extreme ends, environment-person transactions are the cause, but the degree to which each contributes to the problem varies. Toward the environment end of the continuum, environmental factors play a bigger role (represented as E<--->p). Toward the other end, person variables account for more of the problem (thus e<--->P).
Clearly, a simple continuum cannot do justice to the complexities associated with labeling and differentiating psychopathology and psychosocial problems. Furthermore, some problems are not easily assessed or do not fall readily into a group due to data limitations and comorbidity. However, the above conceptual scheme shows the value of starting with a broad model of cause. In particular, it helps counter the tendency to jump prematurely to the conclusion that a problem is caused by deficiencies or pathology within the individual and thus can help combat the trend toward blaming the victim (Ryan, 1971). It also helps highlight the notion that improving the way the environment accommodates individual differences may be a sufficient intervention strategy.
Addressing the Full Range of Problems
When behavior, emotional, and learning problems are labelled in ways that overemphasize internal pathology, the helping strategies used primarily are some form of clinical/remedial intervention. For the most part, such interventions are developed and function in relative isolation of each other. Thus, they represent another instance of using piecemeal and fragmented strategies to address complex problems. One result is that an individual identified as having several problems may be involved in programs with several professionals working independently of each other. Similarly, a youngster identified and treated in special infant and pre-school programs who still requires special support may cease to receive appropriate help upon entering school. And so forth.
Amelioration of the full continuum of problems, illustrated above as Type I, II, and III problems, generally requires a comprehensive and integrated programmatic approach. Such an approach may require one or more mental health, physical health, and social services. That is, any one of the problems may require the efforts of several programs, concurrently and over time. This is even more likely to be the case when an individual has more than one problem. And, in any instance where more than one program is indicated, it is evident that interventions should be coordinated and, if feasible, integrated.
To illustrate the comprehensive range of programs needed to address Type I, II, and III problems, a continuum is outlined on the following page. The continuum ranges from programs for primary prevention (including the promotion of mental health) and early-age intervention -- through those for addressing problems soon after onset -- on to treatments for severe and chronic problems. With respect to comprehensiveness, the range of programs highlights that many problems must be addressed developmentally and with a range of programs -- some focused on individuals and some on environmental systems, some focused on mental health and some on physical health, education, and social services. With respect to concerns about integrating programs, the continuum underscores the need for concurrent interprogram linkages and for linkages over extended periods of time.
Concluding Comments
As community agencies and schools struggle to find ways to finance programs for troubled and troubling youth, they continue to tap into resources that require assigning youngsters labels that convey severe pathology. Reimbursement for mental health and special education interventions is tied to such diagnoses. This fact dramatically illustrates how social policy shapes decisions about who receives assistance and the ways in which problems are addressed. It also represents a major ethical dilemma for practitioners. That dilemma is not whether to use labels, but rather how to resist the pressure to inappropriately use those labels that yield reimbursement from third party payers.
A large number of young people are unhappy and emotionally upset; only a small percent are clinically depressed. A large number of youngsters behave in ways that distress others; only a small percent have ADHD or a conduct disorder. In some schools, the majority of students have garden variety learning problems; only a few have learning disabilities. Thankfully, those suffering from true internal pathology (those referred to above as Type III problems) represent a relatively small segment of the population. Society must never stop providing the best services it can for such individuals and doing so means taking great care not to misdiagnose others whose "symptoms" may be similar but are caused to a significant degree by factors other than internal pathology (those referred to above as Type I and II problems). Such misdiagnoses lead to policies and practices that exhaust available resources in serving a relatively small percent of those in need. That is a major reason why there are so few resources to address the barriers interfering with the education and healthy development of so many youngsters who are seen as troubled and troubling.
From Primary Prevention to Treatment of Serious Problems:
A Continuum of Community-School Programs to Address Barriers to
Learning and Enhance Healthy Development
Intervention Examples of Focus and Types of Intervention
Continuum (Programs and services aimed at system changes and individual needs)
Primary prevention 1. Public health protection, promotion, and maintenance to foster opportunities,
| positive development, and wellness
| • economic enhancement of those living in poverty (e.g., work/welfare programs)
| • safety (e.g., instruction, regulations, lead abatement programs)
| • physical and mental health (incl. healthy start initiatives, immunizations, dental
| care, substance abuse prevention, violence prevention, health/mental health
| education, sex education and family planning, recreation, social services to access
| basic living resources, and so forth)
|
| 2. Preschool-age support and assistance to enhance health and psychosocial
| development
| • systems' enhancement through multidisciplinary team work, consultation, and
| staff development
| • education and social support for parents of preschoolers
| • quality day care
| • quality early education
Early-after-onset • appropriate screening and amelioration of physical and mental health and
intervention psychosocial problems
|
| 3. Early-schooling targeted interventions
| • orientations, welcoming and transition support into school and community life for
| students and their families (especially immigrants)
| • support and guidance to ameliorate school adjustment problems
| • personalized instruction in the primary grades
| • additional support to address specific learning problems
| • parent involvement in problem solving
| • comprehensive and accessible psychosocial and physical and mental health
| programs (incl. a focus on community and home violence and other problems
| identified through community needs assessment)
|
| 4. Improvement and augmentation of ongoing regular support
| • enhance systems through multidisciplinary team work, consultation, and staff
| development
| • preparation and support for school and life transitions
| • teaching "basics" of support and remediation to regular teachers (incl. use of
| available resource personnel, peer and volunteer support)
| • parent involvement in problem solving
| • resource support for parents-in-need (incl. assistance in finding work, legal aid,
| ESL and citizenship classes, and so forth)
| • comprehensive and accessible psychosocial and physical and mental health
| interventions (incl. health and physical education, recreation, violence reduction
| programs, and so forth)
| • Academic guidance and assistance
| • Emergency and crisis prevention and response mechanisms
|
| 5. Other interventions prior to referral for intensive and ongoing targeted treatments
| • enhance systems through multidisciplinary team work, consultation, and staff
| development
| • short-term specialized interventions (including resource teacher instruction
| and family mobilization; programs for suicide prevention, pregnant minors,
| substance abusers, gang members, and other potential dropouts)
|
Treatment for 6. Intensive treatments
severe/chronic • referral, triage, placement guidance and assistance, case management, and
problems resource coordination
• family preservation programs and services
• special education and rehabilitation
• dropout recovery and follow-up support
• services for severe-chronic psychosocial/mental/physical health problems
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