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The New Therapist
with Anthony D. Smith, LMHC

Improving Diagnostic Accuracy: Have Skepticism, Part 2

It might seem convenient, as discussed in part 1, for a patient to come to us pre-diagnosed. This doesn’t give a clinician license, however, to blindly accept the inherited diagnosis.Thinking of your encounter as a second opinion can lead to a world of improvement for the patient. Consider Jacques (identifying information and other details disguised):

12-year-old Jacques was involved with the court due to threats towards a teacher. It was documented in the referral for evaluation that, for about a year, he had been experiencing increasing trouble focusing, struggled with irritability, was often restless, impulsive and easily distracted. Sometimes Jacques appeared to be daydreaming.  During that time, Jacques began treatment for ADHD and was on his second therapist in 8 months. The court requested a diagnostic evaluation to better understand the youth and to see if he was receiving proper care.  After interviewing the family, I began contacting collateral resources for data. This incuded Jacques’ then-therapist, Anna, a long-standing member of a particular therapy practice. I asked what diagnosis and symptoms they were working on. “ADHD,” said Anna. “I’ve seen that in other documents and the family reports it, too,” I replied, furthering, “What evidence of the condition have you observed? What specifically are you addressing in the sessions?” Anna explained, “That’s the diagnosis he arrived with.” I pressed, “I know it’s in his history, but do you think it’s accurate?” “That’s the diagnosis he came to us with” Anna repeated, adding, “I’m working on helping him focus.” I asked if there was any discussion about family dynamics, knowing there was a separation happening. “Yeah, the stress has definitely made his ADHD worse,” she finished.

I often joke that my job is to disprove that all court-involved youth have ADHD. It seems the bulk of the population we evaluate have the diagnosis in their charts. Not unusually, ADHD turns out to be inaccurate. Sometimes there is indeed ADHD, along with additional, co-occurring conditions, the symptoms of which were historically assumed to be accounted for by ADHD.  Numerous other conditions can masquerade as ADHD. These include trauma, dissociative disorders, generalized anxiety, and depression, each requiring a different and/or additional treatment approach. ADHD is a “popular” diagnosis and even a cursory look at literature reveals concerns of over-diagnosis (Bruchmuller et. al, 2012; Schwarz, 2017). Unfortunately, if it is an inattentive, restless boy, the knee-jerk response tends to be ADHD, and it sticks.

What’s going on?

Something didn’t add up, though, for Jacques. He had no early developmental history typical to ADHD, such as the surfacing of inattentiveness and hyperactivity by kindergarten or thereabouts. He had no history of mental health concerns until middle school and it would be extremely unusual for someone to develop ADHD then. Jacques also didn’t have a history of problems in school up until 6th grade.

What was going on, was that when Jacques was 10, his parents began having problems, which they thought they kept quiet. By the time Jacques was 11, in 6th grade, his parents were living in separate parts of the house and often fighting after he went to bed. Now, when Jacques was age 12, his father was preparing to move out. It’s no coincidence Jacques’ difficulties skyrocketed at this time. Indeed, when I asked Jacques how the family situation had been on him, he admitted he was very angry at both parents and worried about what life was going to be like. Picking at his cuticles and bouncing his leg, Jacques’ anxiety was palpable as he explained how his parents hated each other. His ultimate fear was that his mother was going to keep him from seeing his father.

Keeping it real

Some minor detective work went a long way. While he indeed was inattentive, irritable and restless, Jacques’ symptoms developed as his parents’ relationship deteriorated in front of him. A more accurate diagnosis would be Adjustment Disorder With Mixed Disturbance of Emotions and Conduct. No matter how hard a therapist might try to get Jacques to calm down and focus with interventions for ADHD, nothing was going to change until he processed the separation and, ideally, family therapy also took place.

When inheriting a client with a previous diagnosis, even if it is from someone whose opinion you trust, it can’t hurt to review the diagnosis/diagnoses and see for yourself. For new clinicians, it is good practice to learn to raise an eyebrow at any of the following and be extra careful in your diagnostic investigation:

  • The patient has a long history of the same diagnosis, yet despite being invested in their psychotherapy, they have shown little to no improvement.
  • It’s a popular/knee-jerk diagnosis such as ADHD, Bipolar disorder or Autism (especially in the absence of specialized evaluations for Autism spectrum conditions).
  • The patient diagnosed themselves.
  • The diagnosis is from a non-mental health specialist, such as their primary care provider.

The above do not mean your patient could not very well experience the diagnosis being reviewed, but they do leave more room for error. Considering that upwards of 40% of people in mental health care are misdiagnosed (Buffington, 2015), erring on the side of caution is never a bad thing.

References:

Bruchmüller, K., Margraf, J., & Schneider, S. (2012). Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis. Journal of Consulting and Clinical Psychology, 80(1), 128–138. https://doi.org/10.1037/a0026582

Buffington, P. (2015, July) Psychopharmacology: What Every Mental Health Professional Need to Know About Psychotropic Medications. PESI (organizer). Continuing education seminar conducted from Lynnewood, Washington.

Schwarz, A. (2017). ADHD nation: children, doctors, big pharma and the making of an American epidemic. Scribner.

Improving Diagnostic Accuracy: Have Skepticism, Part 2


Anthony Smith, LMHC

Anthony Smith is a licensed mental health counselor in Massachusetts with 20 years of experience. He has worked in facilities and in private practice performing therapy and diagnostic evaluations across a wide array of populations both demographically and clinically. This includes 17 years in the forensic arena, where he currently provides assessments for the juvenile courts. Aside from interest in the intersection of psychology and law, Anthony is particularly in interested differential diagnosis and supervision of new practitioners. He regularly teaches abnormal psychology and creates courses on the lived experience of people with mental illness, along with supervising graduate student counselling practicums at a local university. When not providing clinical services, teaching or blogging, Anthony can be found hiking and fly-fishing around the Northeast and American West.

 


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APA Reference
Smith, A. (2020). Improving Diagnostic Accuracy: Have Skepticism, Part 2. Psych Central. Retrieved on October 29, 2020, from https://pro.psychcentral.com/new-therapist/2020/06/improving-diagnostic-accuracy-have-skepticism-part-2/