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It is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.

Maslow’s law of the instrument

Misdiagnosis and overdiagnosis using DSM and special education labels tends to bias understanding of behavioral and emotional concerns. Assignment of a diagnostic label plays a major role in decisions to intervene and may profoundly shape a person's future. People tend to associate strong images with specific labels and act upon these images. Sometimes the images are useful generalizations; sometimes they are harmful stereotypes.

Back in 1975, Nicholas Hobbs warned:

Categories and labels are powerful instruments for social regulation and control, and they are often employed for obscure, covert, or hurtful purposes: to degrade people, to deny them access to opportunity, to exclude "undesirables" whose presence in some way offends, disturbs familiar custom, or demands extraordinary effort. . . .Society defines what is exceptional or deviant, and appropriate treatments are designed quite as much to protect society as they are to help the child. . . . "To take care of them" can and should be read with two meanings: to give children help and to exclude them from the community.

Given the potential for harm caused by misdiagnosis and overdiagnosis, those who study diagnostic classification are especially concerned about the role labeling plays in segregating individuals with physical, cognitive, social, and emotional differences—including a disproportionate number from minority groups.

Labeling is inevitable, but labels need to be applied from a broad perspective of the causes human behavior and with a full tool chest of descriptors that range from normal behavior and emotions through intense disordered states. This is essential to countering the tendency to pathologize and sensationalize the ways in which youngsters respond to and cope with many of the demands of growing up. Before thinking about a mental disorder, good practice calls for differentiating the commonplace from the rare. (If you hear hoof beats, is it more likely to be a horse than a zebra?)

A good example of describing a full range of differences is found in

The Classification of Child and Adolescent Mental Diagnoses in Primary Care published by the American Academy of Pediatrics. http://www.contentedits.com/img.asp?id=16977

Before highlighting problem functioning, this classification manual stresses developmental variations within the range of expected behaviors for different age groups

For instance, with respect to sadness, the manual indicates that “transient depressive responses or mood changes to stress are normal in otherwise healthy populations.”

In Middle Childhood: The child feels transient loss of self-esteem after experiencing failure and feels sadness with losses as in early childhood.

In Adolescence: The adolescent's developmental presentations are similar to those of middle childhood but may also include fleeting thoughts of death. Bereavement includes loss of a boyfriend or girlfriend, friend, or best friend. ...

The manual describes sadness as a problem (not a disorder) when there are “behaviors serious enough to disrupt functioning with peers, at school, at home, but not severe enough to meet criteria as a disorder.” These include “some symptoms of major depressive disorders in mild form (e.g., depressed/irritable mood, diminished interest or pleasure, ,weight loss/gain, or failure to make expected weight gains, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue or energy loss, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think/concentrate). However, the behaviors are not sufficiently intense to qualify for a depressive disorder. These symptoms should be more than transient and have a mild impact on the child's functioning. Bereavement that continues beyond 2 months may also be a problem.”

In Middle Childhood: The child may experience some sadness that results in brief suicidal ideation with no clear plan of suicide, some apathy, boredom, low self-esteem, and unexplained physical symptoms such as headaches and abdominal pain....

In Adolescence: Some disinterest in school work, decrease in motivation, and day-dreaming in class may begin to lead to deterioration of school work. Hesitancy in attending school, apathy, and boredom may occur....”

As the above brief example suggests, having language to describe the range of emotions that includes normal responses can help prevent misdiagnosis and overdiagnosis and counter tendencies to misprescribe interventions.

For a related discussion of concerns, see:

>Countering the Over-pathologizing of Students' Feelings & Behavior:
A Growing Concern Related to MH in Schools
https://smhp.psych.ucla.edu/pdfdocs/practicenotes/pathology.pdf

Please share your thoughts on all this.

Send your responses to Ltaylor@ucla.edu
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