Helping all children become happy learners

The Spectrum of Diagnoses

Introduction

Many of the common diagnoses for developmental behavioural, social and learning conditions overlap each other in terms of the traits and needs they present with. Though each will have precise criteria laid down in diagnostic manuals for their assessment, they nevertheless may explain symptoms that are also covered by a different condition. An individual rarely presents as a 'text book' example of any one diagnosis. Instead it is more likely that they present with a range of traits from more than one possible condition. Diagnosis is therefore about which symptoms present the most difficulties for the child and what condition best explains this. 

The diagram shows ten common diagnoses. An individual may present only with traits from one condition. However, it is more likely that they will have traits that cross a number of possible diagnoses. Diagnosis is therefore about making judgements about which condition or conditions best describes their needs.



The Spectrum of Diagnoses Diagram

Diagnosis Confusion

Because traits overlap two children with different diagnoses may at times present with the same sorts of difficulties or needs. For example: 

Consider two four and half year old children. Child A has a diagnosis of autism (ASD) but also presents with undiagnosed traits of ADHD. Child B has a diagnosis of ADHD but can appear to have traits of ASD. In this example, both children present with the same behaviour of frequently following their own agenda. There are many potential reasons why children might follow their own agenda and not those of adults. For child A and B, though their behaviour may appear similar it is highly likely that it is determined by different factors. This could be poor understanding of social hierarchy and rules for child A and poor attention and impulsivity for child B. However, just to ensure a little bit of confusion here, child A by following their own agenda might appear to have poor attention and by going off and doing what they want appear impulsive. Equally child B might present with immature social understanding of rules and adult status. 

These similarities in behaviour and potential underlying causes can make determining the exact diagnosis a challenge for professionals.

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Behavioural Diagnoses

If we ignore the diagnoses of dyscalculia and dyslexia, which involve standardised cognitive and memory performance assessments, the other eight conditions above are behavioural diagnoses. This means that their assessment, regardless of the diagnostic tools used, are about observed behaviour. This might involve a little observation by the diagnosing professional; often in a clinic setting but sometimes in another setting such as school or the home. However, generally, a higher proportion of observation will be that reported by parents and school or nursery (kindergarten) staff and through their completion of written questionnaires. These written assessments are then analysed against the diagnostic manual citeria to make an objective judgement about whether a child has a condition or not. This all sounds thorough and robust until we remember that observing and defining behaviour is largely subjective. Two different observers might notice different behaviours or even perceive the same behaviour as being different. The most commonly used assessment questionnaires often try to compensate for this through repeating similar behaviours with different descriptions. However, it is fair to say that assessment is not precise or exact and that diagnosis is therefore based on probability rather than certainty.

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Professional Bias

Every human is subject to their own personal biases. Some of these are sub-conscious and affect our perceptions and judgements. For example, when people buy a new car they often tend to notice more of the same make and model on the road than they did before. The same happens with professionals making judgements about behaviour. A whole teacher training day on autism and quickly staff are viewing behaviour through an 'autistic lens' and reporting more children with possible ASD traits. The same school later does training on ADHD and now they are more 'tuned' to this condition and report children with possible ADHD. Now it is a positive step for schools to do such training and to have increased awareness in recognising the signs of these conditions. However, as we have discussed above, many children will present with needs that overlap different conditions and there is a risk that our bias towards one particular condition may influence the way we describe their behaviour. This in turn can influence the judgements made by the diagnosing professional. 

It also worth mentioning that parents may also be affected by bias. Many will do their own research into a particular condition for a while before completing assessments and reporting behaviour. 

Finally, there are the doctors and psychologists etc; who will also not be immune from being biased towards one or more condtions. Thus, professionals who specialise in autism may perceive more autistic traits in children whilst another professional specialising in ADHD might see more traits of attention deficit and hyperactivity.

Conclusions

The purpose of this article is not to cast doubt on the validity of any particular diagnosis. Rather it is about clarifying that each individual is just that, an individual who is unique. Diagnoses are extremely useful. They provide labels that communicate quickly a certain set of ideas about the strengths and difficulties of someone and their possible needs. But they can risk over simplifying the situation. Two individuals with, for example, autism are not necessarily alike. In fact they may present with completely different strengths and weaknesses. Equally an individual may be best served by multiple diagnoses whilst another has none though they both have similar traits. So what I am suggesting is that it is all a bit messy. That any diagnostic label is at best an incomplete description and at worst an inaccurate one. Thus, we should both embrace and challenge diagnostic labels. Using them to guide our understanding of the individual but being ready to accept their limitations and the possible value of looking elsewhere for descriptions borrowed from other diagnoses. Finally, as our understanding of and acceptance of human neurodiversity grows, we may find both more accurate and more inclusive ways of describing each unique individual. But for the moment diagnoses remain useful but imperfect tools.

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