in the first and second groups, respectively. These specifiers provide a more precise description of children’s behavior than the diagnostic label alone.
Table 1.1
Review
DSM-5 uses a categorical approach to classification because it requires children to meet specific criteria to be diagnosed with a disorder. Youths who do not meet all criteria are not diagnosed with the disorder.
DSM-5 also uses a prototypical approach to classification for many disorders. Children can show a subset of possible signs and symptoms that reflect a typical child with the disorder.
DSM-5 uses a dimensional approach to classification for several disorders. Clinicians can indicate the severity of children’s disability or distress on a continuum ranging from mild to severe.
What Are the Advantages and Disadvantages of Diagnosing Children?
Possible Benefits
Diagnosis has a number of benefits. Perhaps the most obvious benefit to diagnostic classification is parsimony. Imagine that you are a psychologist who has just assessed a 3-year-old child with suspected developmental delays. You discover that the child shows severe and pervasive problems with social communication and repetitive behavior. Instead of describing each of these symptoms, you can simply use the appropriate diagnostic label: autism spectrum disorder.
A second advantage to diagnosis is that it can aid in professional communication. Another mental health professional who sees your diagnosis knows that your client exhibits the signs and symptoms of autism described in DSM-5. The second professional does not need to conduct her own assessment of the child to arrive at an independent diagnosis to know something about the child’s functioning.
A third advantage is that a diagnosis can aid in prediction. If you know that your client has autism, you can use the existing research literature to determine the child’s prognosis or likely outcome. For example, most children with autism show chronic impairment in social and communicative functioning; however, prognosis is best among children with higher cognitive abilities and better developed language skills. The research literature also indicates that children who participate in treatment before age 4 often have the best developmental outcomes. You might share this information with the child’s parents so they can make more informed decisions regarding the child’s education and treatment (Pijl, Buitelaar, de Korte, Rommelse, & Oosterling, 2019).
A fourth and closely related benefit of diagnostic classification is that it can help to plan treatment. If you know that your client has autism, you can also use the existing research literature to plan an intervention. For example, a number of studies have indicated that early, intensive behavioral interventions can be effective in improving the social and communication skills of young children with autism. Other forms of treatment, such as art and music therapy, have far less empirical support (Volkmar, Reichow, Westphal, & Mandell, 2015).
Fifth, diagnostic classification can help individuals obtain social or educational services. For example, the Individuals With Disabilities Education Improvement Act of 2004 (IDEIA) is a federal law that entitles children with autism to special education because of their developmental disability. Special education might involve enrollment in a special needs preschool, early intensive behavioral training paid by the school district, provision of a classroom aide or tutor, academic accommodations, occupational skills training, and other services.
Sixth, diagnostic classification can be helpful to caregivers. Although no parent is happy when his or her child is diagnosed, many parents feel relieved when their child’s disorder is finally identified. After hearing that her 3-year-old child had autism, one parent said, “Well, I finally know what’s wrong. I always suspected it and now I know. I suppose we can finally move forward.” Diagnostic labels can also facilitate communication between caregivers of children with similar disorders in order to share information and gain social support.
Finally, diagnostic classification can facilitate scientific discovery. Researchers who conduct studies on the causes and treatment of autism can compare the results of their investigations with the findings of others. Indeed, many studies are conducted by teams of researchers across multiple locations. As long as researchers use the same diagnostic criteria and procedures to classify children, results can be combined to generate a more thorough understanding of the disorder.
Potential Drawbacks
The DSM-5 classification system also has some inherent disadvantages and risks (Hyman, 2011; Rutter, 2011). One drawback of the DSM-5 approach is that it often gains parsimony at the expense of detailed information. Although a diagnostic label can convey considerable information to others, it cannot possibly provide the same amount of information as a thorough description of the individual. As we have seen, children assigned the same diagnosis can display different patterns of behavior and levels of impairment. We must not overlook the unique strengths and weaknesses of each child.
A second criticism of the DSM-5 diagnostic system is that it does not adequately reflect the individual’s environmental context. Mental health professionals seek to understand children’s problems in the context of their developmental level and surroundings. Many problematic behaviors exhibited by children and adolescents can be seen as attempts to adapt to stressful environments at specific points in time. For example, some physically abused children attempt to cope with their maltreatment by becoming defensive and mistrusting others. Although these coping strategies can psychologically protect them when they were experiencing abuse, they may interfere with the development of interpersonal relationships later in life (Cicchetti & Doyle, 2016).
A third drawback of the DSM-5 lies in its focus on individuals. DSM-5 conceptualizes psychopathology as something that exists within the person. However, childhood disorders are often relational in nature. For example, youths with oppositional defiant disorder show patterns of noncompliant and defiant behavior toward others, especially adults in positions of authority. Considerable research indicates that the quality of parent–child interactions plays an important role in the development of oppositional defiant disorder. Furthermore, treatment for this disorder relies heavily on parental involvement. However, in the DSM-5 system, oppositional defiant disorder is diagnosed in the child. The DSM-5 approach to diagnosis can overlook the role caregivers, other family members, and peers play in the development and maintenance of children’s problems.
A fourth limitation of the DSM-5 system is that distinctions between normality and abnormality are sometimes arbitrary. In the categorical approach used by DSM-5, individuals either have a disorder or they do not. For example, to be diagnosed with ADHD, a child needs to show at least six symptoms of inattention or hyperactivity–impulsivity. If the child displays only five of the required six symptoms, he would not qualify for the ADHD diagnosis. Although this lack of diagnosis might seem like a good thing, it could mean that he does not receive the treatment or support services that he needs.
A final criticism of the DSM-5 is that sometimes boundaries between diagnostic categories are unclear. Categorical classification systems, like DSM-5, work best when all members of a diagnostic group are homogeneous, when there are clear boundaries between two different diagnoses, and when diagnostic categories are mutually exclusive. Unfortunately, these conditions are not always met. When two disorders include the same signs or symptoms, children can be diagnosed with both disorders, causing an artificial co-occurrence of the two conditions. For example, bipolar disorder is a serious emotional disorder seen in approximately 1% to 2% of youth. Some studies indicate that as many as 80% of youths with bipolar disorder also meet diagnostic criteria for ADHD. In most cases, children with bipolar disorder clearly show symptoms of ADHD, even when they are not having mood problems. In some instances, however, the high co-occurrence of bipolar disorder and ADHD is caused by the same signs and symptoms included in the diagnostic criteria for both disorders: