again beware diagnoses

I’ve been talking recently the dangers of diagnosis, (also here, here, here, and I especially like this one), and I heard a case on public radio that illustrates this perfectly.  A preadolescent girl named Maia was struggling with some developmental problems, possibly Asberger’s, and had difficulty making friends.  She yearned for play dates but her intensity and oddness made her peers uncomfortable and they shunned her.  The story was heartbreaking particularly as Maia herself – in her childlike and slightly awkward speech – described how she spent recess at school.  Her mother then took up the story and recounted an episode in which in a fit of extreme boredom Maia knocked on a neighbor’s door near the school and asked if the boys could come out and play.  The boys were busy, she was told.  Maia sat down and began to sob, eventually wailing “no one will play with me”.

She subsequently became more difficult.  She was unresponsive, made little eye contact, frequently had tantrums.  She was even hospitalized.  There she was given the diagnosis of Conduct Disorder; other practitioners and facilities diagnosed other things.  Conduct Disorder is a serious diagnosis.  The American Academy of Child and Adolescent Psychiatry notes that “treatment of children with conduct disorder can be complex and challenging”.  Such children may grow up to be psychopathic – i.e. criminally violent, chronically unable to form relationships, dangerous, impulsive, lacking in basic connection (empathy) to other people.  In desperation, but by now with little optimism that Maia would ever be remotely happy, her parents tried a new summer camp for her.

On her first day, Maia met Charlotte, a girl free from any developmental problems or social awkwardness.  In their first meeting, in the company of Charlotte’s other friends, Maia said something that made Charlotte laugh.  Charlotte later recalled that she found Maia “perfect” in this moment.  The two went on to a wonderful summer together and then regular play dates back home.  They sat on the floor of Maia’s home with her toy horses joking and role-playing for hours, like any other children.  Meanwhile in the rest of her life Maia began responding to adults and children she’d previously ignored, tolerating activities and conversations in which she had less than perfect interest, tolerating frustration and limits, complying with rules, making eye contact, and in all other ways becoming much more like a normal child.  She still had occasional tantrums, but the change was dramatic.  One day, for example, the school bus driver left his seat to come outside and introduce himself to Maia’s mother, just to share with her the change he’d observed in Maia.

If Maia had not met Charlotte, she would have to have lucked into a good child therapist.  They do exist.  But I can tell you as a practitioner that the world – courts, schools, insurance companies of course, and sometimes even parents – are more and more interested in my providing a label for the child, and a carefully outlined treatment plan which I am supposed to know from my first or second meeting with her, one based on addressing her symptoms directly.  And of course insurance companies want her cured in about 15 sessions.  Unless I am incredibly lucky and Maia takes to me as she did to Charlotte – quite a shot in the dark – this is nigh impossible.

As we see from Maia’s symptoms, the real problem is not described by her diagnosis.  Maia was acting like a child with Conduct Disorder but what she wasn’t one.  Basing treatment on such a diagnosis would probably not work (unless she happened on a psychoanalyst who sees through the symptoms to the attachment problems beneath).  It might even make the problem worse!  Forced, pressured, cajoled, or otherwise badgered about her symptoms, Maia might become further isolated from the genuine relationships which so clearly were the cure here.

In our world sometimes when the cure doesn’t come within 10 or 15 sessions, more labels start flying – Oppositional Defiant Disorder, Asperger’s syndrome, autistic spectrum disorder, personality disorders, on and on.  This has happened with other people I’ve described in the website (Ron as a child was diagnosed with attention problems, conduct disorder, and later OCD; see also Ed, George, and there are others); these people weren’t fortunate enough to be touched early on by a Charlotte.

Such diagnostic labels and probably any resultant treatments would, I’d bet, have had little effect on Maia.  What she really needed was a special friend.

I hope this story has illustrated a point I have tried to make many times in this blog and in the website:  Diagnoses in the land of mental/emotional issues are more often than not painfully superficial.  This is especially true with children.  For the courts, I evaluate children and families involved in custody/visitation disputes.  In the process I often review prior psychiatric and psychological evaluations.  You might be astonished at the range of diagnoses that are given to a child as she goes from one difficult phase to another.  The reason the diagnoses vary so much is that they are based on the most apparent but superficial and even misleading aspects of the person – outward behavior.  Obviously behavior is important, especially when a child or adult must function in the world.  Behavior is, however, very far from the whole story and it may tell you little about what the person in question needs, and about what will help .  Take a look at the bully and especially the flincher as a very simple example of how the same issues and history can produce drastically different outward behavior and conscious attitudes, yet both these characters are the same, just under the surface; and their therapies will be quite similar as well.  No need for bully or flincher specialists; what’s needed is a person specialist.

Quick disclaimer:  Of course there are children with more complex problems than Maia – children with serious autistic spectrum disorders, or with conduct problems that are indeed precursors to adult psychopathy.  I don’t mean to oversimplify the entire realm of developmental problems by reference to this one case; they aren’t all like Maia and some need much more than the remarkably good friend Charlotte.  But again be sure you know what you’re dealing with and have considered all options.  Be wary of rushing to the diagnostic labels and specialists.  More about this here and in the other links above.

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