Misconceptions in Mental Health Diagnosis


*Printed May 5 at SCMP

Mental Health Diagnosis Is Not a Yes or No Checklist


 Since elected president, Trump’s mental health has been under a level of scrutiny unprecedented by his predecessors. What seems to legitimize this flurry of media attention is the precarious question of “Is he fit for office?” When it is within the short reach of Trump’s erratic hands—which are known to grab objects beside news headlines—to press the green-light that fires nuclear missiles, we feel both the weight and urgency of that question.

However, to frame the ramifications of someone’s mental functioning strictly in either-or terms (“Is he mentally fit to run office or not”) distracts us from considering the wider social and cultural damages Trump has stricken on the global community. As James Comey said in one of his interviews with George Stephanopoulos, the danger of Trump lies in his caustic erosion of fundamental American principles and values, and his unabashed attacks on truths and norms. What’s all the more alarming, Comey added, is that “[Trump’s antics] should wake all of us up with a start, but there’s been so much of it that we’re a little bit numb and that’s dangerous.” By widening the scope of scrutiny from the simplistic view of mentally-fit-enough-to-run-office-or-not, Comey introduces more depth to the discussion by addressing Trump’s moral-fitness and what that does to the future and the welfare of his country, and, I would argue, to our increasingly globalized community.

When it comes to understanding the mental health conditions of our children, something analogues seems to present itself when it comes to how parents approach mental health assessments in Hong Kong. When presenting their children for an assessment, parents tend to focus on what they consider the one-million dollar question: “Does my child have ADHD/autism/what-have-you, or not?” Usually, there have been concerns—some long-term, some short—that prompt an assessment request. A child’s academic performance might have been less than stellar; she might have difficulty focusing on and remembering homework assignments; and she might be uncooperative in class, isolated at school, and withdrawn at home. Or a child might have difficulty with his language development, with making and keeping friends at school, and with regulating his emotions.

Here, it will be helpful to digress a bit to provide the reader with some background information on assessments. A diagnosis is not simply a matter of matching the diagnostic criteria against a cluster of observable behaviors, ticking all the boxes that match, and adding the number of boxes to get a score. That’s part of an assessment, but definitely not all of it. Just as a running nose can indicate a flu, a cold, an allergy, or a tiny something getting stuck in your nostrils, a symptom alone doesn’t tell us much, except that it warrants further investigation. If we get a cluster of symptoms then the picture starts to become more informative. For example, if we have forgetfulness, lack of motivation, and an inability to focus, then we can start to narrow in on some likely possibilities: is it depression, anxiety, ADHD, or something else? But, as you can see, even with a cluster of symptoms we still don’t have a definitive answer. Some parents are alarmed when a child shows behaviors that fit some of the symptoms of a condition, and feel sure that their child has that said condition. That is premature. A thorough interview and observation need to be conducted by a professional as part of a comprehensive assessment process.

Nowadays, many children are presented for an ADHD and Autistic Spectrum Disorder (ASD) assessment. When the result is that the child doesn’t have “The Scary Letters,” it usually brings a lot of relief to parents. That is welcome news. However, this is also where the Trump either-or analogy sets in. When an often-dreaded diagnosis turns out to not apply to their child, parents tend to feel that all their worries disappear with the negation of a label. Without the letters that combine to form a label, parents tend to make a leap of faith to the conclusion that it means there is no problem. Their anxiety subsides, and the problem areas that first brought their child in to an assessor’s office seem less problematic, or unproblematic. Sometimes, parents chalk off those concerns as insignificant, or just a phase, or part of childhood. Somehow, one way or another, whether a diagnostic label applies seems to change the gravity of their child’s situation.

The truth is rarely that simple. And the truth is that the concerns (depending how severe and how many there are) that motivated an assessment request in the first place tend to continue to affect a child’s well-being and functioning. A child with ADHD deserves and needs help just as much as an unmotivated child who is socially isolated and withdrawn. Both of these psychological profiles, among many others, can have long-term consequences for a child if unattended to.

A problem defined is a problem half solved. The goal of an assessment is to get a good understanding of what the problem is so that we can be more effective in helping a child. We certainly don’t want to give a stimulant to a child who isn’t struggling with ADHD, just as we won’t give an antihistamine to someone with a headache. And, a lot of good can be done for a child if we find out more about, for example, what’s causing his low motivation and isolation, and find ways to help him.