talkativeness, and impulsive behavior. Some children with bipolar disorder may be incorrectly diagnosed with ADHD also because of this overlap in signs and symptoms (Youngstrom, Arnold, & Frazier, 2010).
Research Domain Criteria
The National Institute of Mental Health (NIMH) is attempting to move beyond the current DSM-5 system of classifying mental disorders based on descriptions of signs and symptoms (Insel & Lieberman, 2013). NIMH has launched the Research Domain Criteria (RDoC) initiative to identify the genetic and biological causes of each disorder. The RDoC are based on the assumption that mental disorders are “biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior” (Insel & Lieberman, 2013). The goal of this initiative is to use genetic and biomedical research to identify the underlying causes of these disorders in order to provide more effective treatments. Specifically, research targets several levels of analysis: genes, molecules, cells, neural circuits, physiology, and behavior.
Critics of DSM-5 argue that instead of being a “bible” of mental disorders, it functions more like a dictionary—providing mere definitions in terms of observable signs and self-reported symptoms. Instead, advocates of the RDoC initiative argue that a new system is needed that addresses the underlying genetic and neurological causes for each disorder (Reed, Robles, & Dominguez-Martinez, 2018).
The DSM-5 and RDoC initiative reflect different approaches to conceptualizing mental disorders (Lilienfeld & Treadway, 2016). Time will tell if classification based on underlying genetic risk and neural circuitry increases diagnostic validity and leads to more effective treatment than one based on description. In the meantime, psychologists should not forget the rich information that is gained from approaching childhood disorders from both biological and psychosocial perspectives in the context of youths’ development and surroundings. Recent advances in mental health research indicate that psychological, familial, and sociocultural influences are at least as important in explaining the cause and maintenance of childhood disorders as the genetic and biological factors emphasized by these other diagnostic systems (Cicchetti, 2016a, 2016b). Furthermore, most evidence-based treatments for these disorders operate at these “higher” levels by improving the psychological, familial, and sociocultural functioning of children and families (Christophersen & Vanscoyoc, 2013). We must not neglect these psychosocial interventions for helping at-risk youths while simultaneously looking to the future.
Review
A DSM-5 diagnosis is parsimonious, it allows professionals to communicate clearly with each other, and it can be helpful in predicting outcomes and planning treatment. A diagnosis can also help children gain access to educational or psychological services, help caregivers understand their child’s behavior, and facilitate research.
A DSM-5 diagnosis may not provide a detailed description of the child’s strengths and functioning, may not reflect the child’s developmental or environmental context, and may focus too much on the child rather than on important people in his or her life.
Whereas a DSM-5 diagnosis is based largely on the signs and symptoms of each disorder, the proposed RDoC initiative classifies children based on underlying biological causes.
How Do Social–Cultural Factors Affect Our Understanding of Mental Health?
Culture, Race, and Ethnicity
As we have seen, children’s mental health problems must be understood in the context of their family’s cultural background and experiences. Culture refers to the values, knowledge, and practices that people derive from their membership in social groups. It reflects their history, developmental experiences, and current social contexts that shape their perspective. Aspects of one’s culture include their geographic origin, migration status, language, religion, disability status, sexual orientation, and identity. Culture is highly influenced by people’s social network—that is, their family, friends, and members of their community (Comas-Diaz & Brown, 2018).
Race is a culturally constructed category that can be used to divide people into groups based on superficial physical traits. Although race has no agreed-upon biological definition, race is used by the US Census Bureau for demographic purposes and racial identification can influence people’s values, beliefs, and actions. In the United States, race categories include White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander. People can also identify as multiracial (English et al., 2020).
Ethnicity is a culturally constructed identity that is used to define groups of people and communities. A child’s ethnicity can be rooted in a common history, geographic location, language, religion, or shared experience that distinguishes one group from others. For example, an adolescent might identify as Latino because he was born in Latin America. He might be White, Black, indigenous American, Mestizo, or multiracial. Another adolescent might identify as Hispanic because she speaks Spanish. She might have been born in Barcelona, Buenos Aires, or Baltimore. A third adolescent might identify as a Honduran American immigrant. Although he was born in Latin America and speaks Spanish, his experiences immigrating to the United States with his family are most important to his identity and worldview (Comas-Diaz & Brown, 2018).
Mental health professionals must carefully differentiate symptoms of a mental disorder from behaviors and psychological states that are sanctioned in a given society or culture. For example, a 3-year-old named Joseph insists on sleeping with his parents at night. Although Joseph’s refusal to go to bed by himself may indicate a sleep disorder, it might also reflect his family’s social–cultural beliefs and values. For example, in many non-Western societies, requiring young children to sleep alone is considered cruel and detrimental to their social and emotional development. If Joseph’s sleeping is culturally appropriate, it does not concern his parents, and it does not limit his family’s activities, it would not be classified as a mental health problem (Mindell, Sadeh, Kwon, & Goh, 2013).
Case Study: The Importance of Culture, Race, and Ethnicity
Between Two Worlds
Julia was a 16-year-old Asian American girl who was referred to our clinic by her oncologist after she was diagnosed with a rare form of cancer. Julia refused to participate in radiation therapy or to take medication for her illness. Her physician suspected that Julia was paranoid because she flew into a rage when he tried to examine her in his office.
Julia reluctantly agreed to meet with a therapist in our clinic who was aware of Julia’s social–cultural background. Julia was the American-born daughter of Hmong immigrants from Laos in Southeast Asia. Julia’s parents sought asylum in the United States because of the Laotian civil war and genocide of the Hmong people. Julia’s parents did not speak English and had limited contact with individuals outside the Hmong community. Julia attended a public high school and had good English language skills but was mistrustful of American culture and Western medicine.
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Julia admitted that she was scared about her cancer diagnosis and wanted to receive treatment. However, she also wanted to respect her parents and to honor her family’s traditional values and way of life. Her therapist suggested that a Hmong faith healer talk with her physician to identify which aspects of medical treatment might be acceptable to Julia and her family. Over time, Julia was able to successfully participate in Western medical treatment by having community elders attend all of the radiation therapy sessions, purify the medications prescribed by the oncologist, and perform other remedies important to Julia and her family.
Differentiating abnormal symptoms from culturally sanctioned behavior is especially challenging when clinicians are asked to assess youths from other cultures (Causadias, Vitriol, & Atkin, 2019). Consider Julia, an Asian American adolescent from a diverse background.