Solving ‘Under’ and ‘Over’ Diagnosis in Drugged Children

Solving ‘Under’ and ‘Over’ Diagnosis in Drugged ChildrenThe number of children/adolescents diagnosed with neurodevelopmental and neuropsychiatric disorders has risen dramatically since the mid-1990s. This has been in tandem with the increased use of psychotropic medications, often multiple agents (“drug cocktails”) as the mainstay of intervention.

Research supports both the “underdiagnosis” and “overdiagnosis” of mental health disorders in children/adolescents, with the exception of the good evidence-based support for medication management in cases of primary attention deficit disorder, which are not associated with significant co-morbidity.

One thing is certain – most children/adolescents with one or more mental health diagnoses who are treated, frequently for extended periods with various “drug cocktails,” are not receiving intensive diagnostic evaluations.

More specifically, “drive-by” assessments in primary care and mental health settings have become an acceptable standard of care while comprehensive psychological/neuropsychological testing and psychoeducational evaluation are clearly the exception.

There are several reasons for the significant underutilization of detailed psycho-diagnostic testing. First, many parents and other consumers of mental health care as well as health care professionals and specialists, regrettably including far too many child psychiatrists, have limited knowledge regarding psychometric assessment.

A second factor is the steadily worsening “pass the buck” phenomena in special education and behavioral health care. Public schools are overwhelmed with the number of students referred for evaluation and most special education departments do not have the staffing or expertise to perform proper assessments in many cases.

Additionally, syndromes such as ADD, which are arguably better conceptualized as psychoeducational conditions than medical illnesses, continue to fall under the purview of medical professionals for diagnosis and treatment, which limits the assessment role played by school departments.

Third, managed care plans remain reluctant to approve authorization for testing conducted by community-based psychologists employed in clinics, hospitals and private practice. Authorization for evaluation of neurodevelopmental conditions – learning disorders and ADD are routinely denied.

When authorizations are approved, the time and payment allotted for the evaluation are typically so limited that psychologists are often given the draconian choice of providing an inadequate and ethically dubious assessment or declining to take the case. Pediatricians, other primary care physicians and medical specialists – notably psychiatrists and neurologists – involved in the assessment and treatment of childhood mental health disorders, have done little to advocate for more adequate authorizations from insurance companies for psychodiagnostic testing.

A collaborative cost-sharing model involving parents, special education departments and community-based clinicians can lead to the timely completion of comprehensive clinical evaluations.

Special education departments could agree to provide assessment within traditional areas of expertise – intelligence and academic skills evaluation, parent and teacher rating scale assessment, socio-emotional testing, speech/language, occupational therapy and physical therapy evaluations.

Community-based psychologists would complete any needed additional evaluation. This could involve administration of neuropsychological tests and, as needed, more in-depth socio-emotional assessment and an evaluation of family functioning.

Fees for record reviews and attendance at psychoeducational planning meetings would be paid to the psychologist by the school department, the family or cost-shared between the two parties.

This model is most clearly indicated for children/adolescents with complicated clinical histories and behavioral symptoms associated with impaired school achievement/functioning. Many of these cases fall within the pervasive developmental disorder, post-traumatic stress disorder, major affective/mood and/or psychotic spectrums.

For a subset of these children, there may be additional questions about risk of self-harm and/or harm to others. These types of cases pose significant challenges for parents and school staff in terms of the completion of an affordable in-depth assessment.

Special education departments, parents and community-based psychologists are strongly encouraged to forge stronger alliances around the issue of how to make top-notch clinical assessments readily available and affordable for children and their families. The medical community is encouraged to step up advocacy and to become more familiar with use of psychometric assessment.

By Jerrold M. Pollak, PhD

Excerpt from Psychotherapy Practice Tips, Part 2

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