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STEPHEN SCHLEIN

When the diagnosis is part of the problem

IN RECENT MONTHS, two alarming events involving children occurred in the Boston area. One was the fatal stabbing in January of a student at Lincoln-Sudbury High School, allegedly by a fellow student. The other was the death of a 4-year-old girl in Hull from a drug overdose. How does one make sense of these tragedies?

I am a clinical psychologist with no personal knowledge of these particular situations. But I am aware of changes in the field of mental health that could have contributed to these catastrophes.

How could a child be diagnosed with a bipolar disorder at the age of 2? When an adolescent who has been diagnosed with Asperger's syndrome is charged with murder, as in the Lincoln-Sudbury case, what is the relevance of that diagnosis -- since the condition has nothing to do with violence?

Our society wants a quick fix for everything. Children and adults are diagnosed with mental disorders based on their behavior in a fast-paced world, and not on their personal internal world. One much-discussed scenario occurs when a child acts up in school, and the teacher or other school personnel suggests that the child has attention-deficit disorder and needs medicine. The ADD diagnosis is so prevalent today that it's losing its reliability as a useful diagnosis.

This sloppy labeling is arrived at from observing someone's behavior. Yet, this process avoids any in-depth critical assessment and establishes a superficial picture of the person, ignoring the fact that every individual is a complex social being.

The same is true of the current "epidemic" of bipolar disorder. This diagnosis seems to have become another all-purpose diagnostic label, just like ADD. How could one possibly diagnose a toddler with a bipolar disorder, when there's so much going on in the life of a 2-year-old child related to normal problems of human development and ordinary concerns of daily living?

We are too quick to slap a diagnosis on someone before we have any real personal in-depth understanding.

It is outrageous when an adolescent is diagnosed as bipolar. One doesn't need to be a developmental psychologist to realize that the stage of adolescence is potentially the most tumultuous in the human life cycle. Yes, teenagers will be moody and emotional. Yes, adolescents can become seriously out of control, psychotic, and even suicidal. Utilizing a psychosocial road map, a solid psychodiagnostic evaluation can look beneath the surface and analyze the complexity of internal and external pressures, ranging from academic and social to family, physical, and sexual concerns.

But all of these pressures are part of normal human development, and often have little or nothing to do with a biochemical or organic psychiatric disorder.

After being criticized over the case in Hull, the state Department of Social Services announced recently that it is bringing on more medical experts, including child psychiatrists and other personnel. As they evaluate future cases, these experts need to look beyond simple psychological labels.

The psychodiagnostic work performed by mental health providers in our society is deteriorating. In the past, diagnostic testing performed by psychologists emphasized "projective testing," which was designed to look inside a person to evaluate their feelings and emotions, personality development, and life circumstances.

These days, most psychodiagnostic work-ups provide a useful evaluation of the neuro-cognitive functioning of the individual, but ignore personal inner dynamics. This is a shame. A personality assessment should provide an in-depth perspective, using an analysis of self-esteem, the quality of interpersonal relationships, the impact of anxiety, and the strength of "ego functions," such as reality testing, judgment, and thought processes.

The field of mental health has regressed in a most dramatic fashion. We now have a whole culture obsessed with diagnostic labels. The focus is on taking the right medicine, as opposed to a consideration of basic issues of psychology and human development.

We seem to have forgotten that we are dealing with complex human beings, not just biological organisms.

Stephen Schlein is a clinical psychologist and psychoanalyst in Lexington.

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