When professionals speak of children, they usually speak in terms of categories and generalizations. This is understandable. Since there are millions of children in this country, it is very difficult to have meaningful discussions about children with problems if those discussions are restricted to talking about only individual children. Therefore, in any discussion of children, the usual procedure is to speak of average developmental stages, or the ADHD child, or the out-of-control child, or the child with a learning disability, etc. Essentially, childcare professionals have boiled the full reality of children down to an easier to understand mental map that is supposed to facilitate clear communication of the reality of individual children. Parents and educators have of course also started using the terminology of mental health.
The most prominent map we have is the DSM-IV, (Diagnostic and Statistical Manual of Mental Disorders) a collection of diagnoses with their presenting characteristics, produced by the American Psychiatric Association, which is often referred to by schools and programs working with children with behavioral/ emotional problems. It is virtually the bible for therapists and other childcare workers. The purpose of the DSM-IV is to facilitate communication among professionals, and with any other adult, regarding any pathology that might be detected. For example, when a psychological evaluation concludes a child is Bi-polar, the childcare professional, or the parent or any other adult who then works with the child, can read the description of Bi-polar in the DSM-IV. From that one word diagnosis, the adult will have an indication of the full range of behaviors that might be expected, which will give important clues as to what kind of interventions are necessary. This approach is trying to take advantage of the consensus of research and experience with each disorder, without having to duplicate that body of knowledge in each evaluation report.
Unfortunately, the frequent unspoken assumption is that this map accurately reflects the reality of children. All too often forgotten is the fact that this map is only a simplification. In other words, the map is not the territory (or child). Overlooking this fact can lead to incomplete, inaccurate or misleading conclusions. This problem is addressed in part by the popular establishment of dual-diagnosis centers. A Dual-diagnosis center recognizes, for example, a child diagnosed with substance abuse and Bi-polar needs radically different interventions than a child with substance abuse and learning disabilities.
So far, so good. However, the reality goes further then what the map can possibly address. Two children with identical diagnoses might need radically different interventions depending on what is found in their social history and an examination of their immediate environment. In other words, a proper intervention can only be done if a parent or childcare worker uses the map as only part of the picture, and supplements it with a complete social history and a look at the immediate environment of the child. Sometimes the behavior of a child can be better explained by his/her environment or upbringing than just viewing it as a pathology. A childcare worker who accepts the unexamined assumption that the map is the territory will probably miss other factors that might be even more important in the reality of any individual child, which will lead to what is commonly referred to as Misdiagnosis.
Two other problems suggest the DSM-IV map, or any other map of children’s problems, should be used cautiously and only as a working hypothesis map, rather than as a complete reflection of the reality of a child. I was privileged to attend a presentation at the Youth Care program in Salt Lake City recently, by Ellen Behrens PhD, who is doing consultant work for the Aspen Education Group. One point she emphasized was that all the research indicated the major common denominator of successful therapy was the ability of the therapist to develop a good relationship with the child. She presented positive relationships with the child as the vital foundation of any successful intervention. It is more important than any therapeutic model, technique, training or experience brought to any intervention with the child. The adult who limits their perspective by simply accepting the map as the territory can easily overlook the importance of developing a relationship with any specific child.
She mentioned another concept that caught my attention, the concept of Fidelity. Essentially, Fidelity looks at how accurately research findings, with all its parameters and cautions, are reflected in day-to-day practice. Basically, as I understand it, poor fidelity would be where a therapist generalizes research findings way beyond what the researchers had actually concluded, while good fidelity would suggest the practitioner understands the limitations of the research and acts accordingly.
Probably the best example of the lack of Fidelity in treatment is the increasing numbers of children diagnosed and treated for ADD (Attention Deficit Disorder) and ADHD (Attention Deficit Disorder with Hyperactivity). Very often in my practice working with parents and their children with problems, the children are diagnosed with ADD and/or ADHD and are being treated with Ritalin, or another drug. Sometimes there is an adequate evaluation, but all too often, the initial cause is simply a situation where a teacher complains about problems in the classroom, and the Physician bows to the perceived teacher and parent pressure by prescribing Ritalin with maybe only a cursory examination. This is absolutely contrary to the recommendation of the DMS-IV, and the recommendation of all experts in the disorder. Unfortunately, this is the foundation of how the diagnosis are sometimes developed, which happens far more often than professionals would like to admit. In this kind of situation, they seem to assume that a simplified map is all they need to evaluate the child.
The above example goes even further to show the problem of how seeing the map as the territory can lead to real problems. In the above example, not only are the professionals using an abbreviated version of an already simplified map, but all too often, there is not an adequate evaluation, social history, consideration of the child’s total environment, consideration of how to foster positive relationships, or any look at what the research really indicates. They are just treating masses of children quickly by utilizing a popular routine solution. In these situations, the total reality of the individual child is not given any serious consideration.
Many of the criticisms leveled against mental health practitioners, and the whole profession of practicing psychology, can be traced to the existence of practitioners that seem to only look at the map, and appear to ignore the other important perspectives mentioned above. Criticisms of parents often can also be traced back to them only seeing the map as the territory. Many responsible professionals and mental health organizations are working hard to remind practitioners and other adults working with children to avoid oversimplifying, and to see each child as a whole person. A good place for any person working with children to start would be with the idea that the map is not the territory. There is more to a child than that contained in the DSM-IV.