We are fortunate to live in an age where medical diagnosis has advanced. Many conditions have similar symptoms but different underlying causes. A disease caused by a virus will not respond to treatment with antibiotics and so, if it is serious enough, we can run tests to find out the exact pathogen involved. Often the best we were able to do prior to the advent of modern medicine was alleviate the symptoms.
An understanding of underlying causes also helps prevention. Once you know that diseases may be caused by microorganisms, you can put in place aseptic practices that help prevent their spread.
Imagine if we didn’t have these understandings. Imagine if diseases were categorised as things like, ‘stomach ache condition’ or ‘sneezing syndrome’. Imagine a world where a visit to the doctor would elicit only circular logic:
- You have ‘stomach ache condition’ or ‘SAC’
- We know this because you have a stomach ache
- Your stomach ache is caused by the fact that you have SAC
This wouldn’t be particularly helpful. At most it might give legitimacy to the prescription of painkillers but it wouldn’t help much in dealing with the cause.
Welcome to the world of the Diagnostic and Statistical Manual of mental health (DSM), produced by the American Psychiatric Association and currently in its fifth iteration (DSM-5). DSM-5 is the gold standard used by clinicians to diagnose mental health disorders.
According to an interesting review article by Khoury, Langer and Pagnini, the first draft of the DSM, produced in 1952, contained only 108 disorders (including homosexuality which we would not now consider to be a disorder – it was dropped for DSM-II published in 1973). The number of disorders has increased in different iterations of DSM:
||Number of disorders
DSM-5 did not change the number of disorders but did substantially change the threshold for making diagnoses, leading to a potential increase of up to 28%. Anyone noting a rise in diagnosed mental health disorders over a timeline that includes different iterations of DSM therefore needs to account for these inflationary pressures. According to Khoury et. al., statistics from various studies now suggest that, ‘almost all of the population has mental disorders’. If so, what does it mean to have a mental disorder? What does it mean to be normal? What is the significance of a diagnosis?
There are growing concerns about the effects of such over-diagnosis. Attention Deficient Hyperactivity Disorder (ADHD) has raised particular concerns due to the tendency to treat it with powerful psychostimulant drugs such as Ritalin. Yet there are other worries associated with labelling students, such as stigmatisation, stereotyping and the fundamental attribution error.
Fundamental Attribution Error
The fundamental attribution error is our tendency to ascribe the behaviour of others to their personal characteristics rather than the situation they face. Imagine a man in a business suit cuts in front of you at the airport security line. It is tempting to think, ‘he must be a selfish person – I bet he thinks he’s more important than the rest of us’. However, he might be in danger of missing a plane that will take him home to see his dying mother. We can’t know. When we consider our own behaviour, we are much more likely to attribute it to circumstance.
A diagnosis of a mental health disorder is certainly something that, for many people, will explain behaviour and so it will tend to take our attention away from circumstance. There is strong evidence from the ‘behaviourist’ tradition in psychology that behaviour can and is modified by circumstance. For instance, antecedent control involves manipulating the environment to prevent troublesome behaviour. Behaviourism also stresses the effect of positive reinforcement and negative consequences on behaviour, usually stressing the use of the former.
Behaviourism is often contrasted with a cognitive approach. The former takes little interest in the internal structure of the mind whereas the latter posits mental mechanisms to explain behaviours. As a student of Cognitive Load Theory, I have a foot in the cognitive camp, yet I do not want to discard the insights from behaviourism. Once we label students, we risk putting too much emphasis on their intrinsic traits at the expense of neglecting environmental strategies that may be effective.
Oppositional Defiant Disorder
Oppositional Defiant Disorder (ODD) is one of the disorders set out in DSM-5. The main diagnostic criteria are:
A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.
- Angry/Irritable Mood
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
- Argumentative/Defiant Behavior
4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.
8. Has been spiteful or vindictive at least twice within the past 6 months.
Further guidance suggests that for individuals 5 years or older, the behaviour should occur at least once per week for at least six months. DSM-5 notes that, “individuals with this disorder typically do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances.” DSM-5 also points out that, in many cases, bad parenting means that some children have been subject to unreasonable demands.
So what is the value of a diagnosis of ODD? To what extent does it differ from normal behaviour? I am not entirely sure. According to Khoury et. al., “labels can create self-fulfilling prophecies, reducing expectations, ambitions, and changing perceptions and behaviours toward the individual carrying the label” [references omitted]. If a teacher learns that a child has been diagnosed with ODD then how will this affect the strategies the teacher employs? Will they give up when, in fact, antecedent control, positive reinforcement and consequences might help?
I can understand why people might want to explain behaviour in this way. There is a stereotype of a certain kind of teacher – I’m not sure how many are out there – who blames children for their poor behaviour and seeks only to punish or exclude. Such teachers might not take into account the difficult background of a child and may take no responsibility for trying to help them develop. However, I am not convinced that labeling children adequately addresses this problem. It provides no real explanation for the behaviour at all, just a further elaboration of what it looks like, and it potentially let’s the teacher off the hook; the problem may no longer be a ‘bad’ child but neither is it something the teacher can address.
A way forward
Khoury et. al. suggests a ‘mindful’ approach as an alternative to DSM-style labeling. Thankfully, this doesn’t involve meditation, rather it is about being more conscious of different thought processes. Rather than packaging up symptoms and labeling them as disorders, we should deal with them separately, as they arise. After all, there is a lot of overlap between the symptoms of different disorders. If we don’t – and can’t – know the fundamental cause then why not deal with them at the symptom level?
In a school context, my interpretation of this would look like a graduated or tiered approach, similar to that pursued by schools that adopt School Wide Positive Behaviour Interventions and Support (SWPBIS). At the classroom level, when teachers are teaching 30 students at a time, there is a role for whole-class teaching of the required behaviours that is supported by antecedent control, positive reinforcement and negative consequences. However, this will not work with all students. Further intervention may be required with a smaller number of individuals. Interestingly, the ‘Plan B’ idea in this recent New York Times article is an example of one such intervention. In my view, the author makes the mistake of setting this in opposition to behaviourist strategies rather than as an approach to adopt when behaviourist methods are not enough.
If the main value of a diagnosis is in providing access to resources then I think we need to redesign our systems. Instead of insisting on defined disorders at an individual level, resources could flow to institutions depending on the prevalence of different behaviours and the requirement for interventions. Although still subjective, these criteria would be more contained and defined and may disrupt the phenomenon of resources flowing to the more savvy parents.
Unfortunately, there might be students for whom no intervention has so far enabled them to function appropriately in the classroom. In this case, they may pose a risk to the safety of other children or they may prevent them from learning. Such students may need to be temporarily removed from a classroom or school or, in extreme cases, they may need specialist provision. Decisions to permanently exclude such students should never be taken lightly and should come at the end of an exhaustive process of intervention. Excluded students should also experience continued intervention with the aim of returning to a standard classroom. I don’t think such a reasonable, measured and proportionate approach should be a matter of controversy.
Invoking the law
However, some academics and other specialists and consultants are ideologically opposed to exclusion from mainstream education at any stage. As a practising teacher, this can be hard to reconcile but it is worth knowing that this attitude exists. For these protagonists, a DSM-5 diagnosis offers a further advantage. If they can convince state authorities to recognise a mental health disorder as a disability then disability discrimination legislation can be invoked, forcing unwilling schools to continue to include violent or disruptive children in the classroom.
I am not sure whether this is the motivation, but I have certainly noticed the speed with which some people resort to the law to support their views on behaviour management. When I have blogged about my concerns regarding certain kinds of differentiation, I have been informed that it is a legal requirement and some have suggested that merely questioning differentiation is an incitement to break the law. It is unfortunate if professional concerns around this issue descend into authoritarianism. There is a legitimate discussion to be had about the best ways to support troubled children throughout their education and it is justifiable to be concerned about the effects of labeling students.