Imagine This

Imagine this.  You’re the parent or teacher of a child with social, emotional, and behavioral challenges.  You know the child’s behavior falls outside the norm (maybe it's even scary or dangerous) and that he’s not getting the help he needs.  But you don’t quite understand what’s going on with the child or how you can help.  You do know that the child is having a detrimental effect on your household, your marriage, your classroom, his peers, and/or his siblings. You’re desperate for information that will help you understand, that will help you help.  If you’re a parent, you decide to make an appointment with your family physician or counselor.  If you’re a teacher, you refer the child into your school’s assessment process.  After what can be a very long wait, you finally get the information you were waiting for:  “He has oppositional defiant disorder.”

Many who are reading this edition of The Real World aren’t having any trouble imagining this scenario.  You’ve been there, done that (though the diagnosis may not have been oppositional defiant disorder).  On first hearing the child’s diagnosis, you may remember thinking, “Good!  I knew there was something going on here.  Now he’ll get the help he needs.”  But sooner or later you came to realize that the diagnosis really didn’t provide you with very much information at all.  What the diagnosis told you is that someone else also thinks the child’s difficulties are beyond the norm.  But you didn’t need a diagnosis to tell you that.  There’s an excellent chance you already knew.

I’ve often said that parents of kids with behavioral challenges go through two developmental stages (it seems teachers may pass through these stages as well).  Phase One:  believing that a psychiatric diagnosis is going to give you the information you need to understand and help your child or student.  Phase Two:  coming to the recognition that a diagnosis didn’t give you the information you needed to understand and help your child or student.  Neither oppositional defiant disorder nor the vast majority of other psychiatric diagnoses that are commonly hung on children tell you what you really need to know.  Most diagnoses just tell you what deviant behaviors a kid is exhibiting. 

The circular thinking inherent in this process isn’t always so obvious, so here goes:

Parent or Teacher:  Doctor, why is he throwing tantrums, defying adult rules and requests, and refusing to do what he's told?
Doctor:  Because he has oppositional defiant disorder.
Parent or Teacher:  How do you know he has oppositional defiant disorder?
Doctor:  Because he’s throwing tantrums, defying adult rules and requests, and refusing to do as he’s told.

Yet, these days, in the real world, the instant it becomes clear that a child has social, emotional, or behavioral challenges, the quest for the diagnostic holy grail commences.  In many school systems, a diagnosis is what a kid needs to access services it’s already clear he needs.  In many places, diagnoses influence funding decisions.  A diagnosis is what a kid needs for his mental health provider to be reimbursed by an insurance carrier.  A diagnosis is what a kid needs for his parent(s) to know that there is a support group comprised of parents whose children exhibit similar behaviors. 

But the down-side of diagnoses outweighs the up.  Diagnoses pathologize kids.  Diagnoses make it explicit that “the problem” resides within the kid.  Diagnoses make it clear that it’s the kid who needs fixing, thereby providing justification for many ineffective interventions directed solely at the kid.  Diagnoses scare off potential helpers (“He has bipolar disorder!  I don’t know anything about bipolar disorder!  That’s for someone else to deal with!”).  Diagnoses deprive kids of the help they clearly need (“I’m sorry, Mr. and Mrs. Taylor, but your daughter doesn’t meet full diagnostic criteria for Asperger’s disorder, so she doesn’t qualify for our program.”)  And, worst of all, diagnoses are distracting.  They cause potential helpers to focus more on what a child is doing rather than on why and when he’s doing it…and on what the potential helpers can be doing to help.

Why is a child exhibiting challenging behavior?  The Collaborative & Proactive Solutions approach provides the following answer:  Because he or she is lacking the skills not to exhibit challenging behavior.  

When does the child exhibit challenging behavior?  The CPS model has an answer to that, too:  He exhibits challenging behavior when the demands being placed upon him exceed the skills he has to respond adaptively.  Would the child prefer to respond adaptively?  Of course!  Is the child choosing to respond maladaptively?  Now why would he choose to do that? If he had the skills to respond adaptively, he would.

And what do challenging kids do when they’re having difficulty responding adaptively to the demands being placed upon them?  They exhibit the behaviors that are the basis for the diagnosis they will receive.

Now imagine this.  Imagine that we all came to our senses and decided that categories weren’t so important or meaningful after all.  Imagine that we all realized that challenging behaviors occur on a spectrum, something I refer to as the Spectrum of Looking Bad.  At the “easy” end of the spectrum we’d include behaviors like whining, sulking, pouting, and crying.  Moving in the “less easy” direction we’d find behaviors like screaming, threatening, growling, swearing, spitting, biting, kicking, hitting, head-banging, lying, and stealing.  Moving still further in the “less easy” direction would be behaviors that are harmful (sometimes fatal) to oneself or others.  But we’d recognize that all of those behaviors – irrespective of which ones a kid may be exhibiting – occur when the demands being placed on a kid exceed that kid’s capacity to respond adaptively.  (Just to normalize this, we all look bad when the demands being placed upon us exceed our capacity to respond adaptively.  Why do most of us look bad less often than challenging kids?  Because we have skills they're lacking.)

Imagine further:  instead of putting massive amounts of time and energy into trying to determine the “right” diagnosis, we’d instead focus our efforts on identifying the lagging skills of each challenging child and the specific conditions (unsolved problems) in which those lagging skills were being demanded…in other words, the conditions in which the child was “looking bad.”  We’d use the Assessment of Lagging Skills and Unsolved Problems (CLICK HERE) to make sure we have the right lenses on, to organize our efforts to help, and to determine what problems need to be solved.  We’d rely a lot less on punishment and a lot more on problem-solving.  And we’d solve those problems collaboratively (rather than unilaterally).  Over time, we’d have a lot of solved problems – and a lot less challenging behavior -- to show for our efforts.

In many places – families, schools, inpatient psychiatry units, therapeutic group homes, and residential and juvenile detention facilities – this is no pipe dream.  It’s the reality.  Just not enough places…yet.

By the way, there's a very good article describing the issues associated with diagnoses and the forthcoming DSM-V in Wired Magazine.  CLICK HERE if you'd like to read it. 

* * * * * * *

I’ve received numerous emails from people asking me to weigh in on the tragedy that occurred in Tucson, Arizona.  I’ve been closely following Gabby Giffords’ amazing day-to-day progress and have dared to imagine her leading a happy, productive life when she leaves the hospital.  I’ve been watching how our leaders have responded to the tragedy, some admirably, some less so, and wondering if their newfound civility will last beyond the end of January.

And, yes, I’ve been following what there is to read about Jared Lee Loughner.  Though hard information has been lacking – we really don’t know what he was thinking -- it certainly seems reasonably clear that he wasn’t in his right mind when he began shooting.  He joins others who have committed similar horrific acts in recent memory:  John Hinckley, Mark David Chapman, and those (their names are usually less familiar) who’ve walked into their workplaces or university campuses or schools and killed co-workers or fellow students and faculty.   

Speculation has begun about what Jared’s psychiatric diagnosis might be, and apparently there’s an emerging consensus that he must be suffering from a “severe mental illness,” such as schizophrenia or bipolar disorder (CLICK HERE).  But, as Sal Gentile astutely points out in an article for PBS (CLICK HERE), that really doesn’t tell us anything.  It certainly doesn’t tell us why Jared did what he did (most individuals carrying those diagnoses don’t commit violent acts and are at only slightly increased risk for doing so).  While his behavior over the past two years was considered odd, scary, and dangerous, he apparently didn’t meet “criteria” for being “arrestable” or “hospitalizeable,” which is why he was able to purchase a gun and do what he did.  One thing is crystal clear: suspending (actually expelling) Jared from his community college was utterly ineffective at ensuring that his difficulties were well-understood and well-addressed (CLICK HERE) the same way that the very same intervention is equally ineffective when it's applied (millions of times each year) to kids in our public elementary and secondary schools in North America.

It’s always easy after a tragedy to talk about what could have been done to prevent the tragedy in the first place.  I’m not going to do that.  As things presently exist, I think such horrific events are sadly inevitable. But shouldn't we be giving more thought to whether we can more effectively help those in our society -- kids and adults -- who are lacking skills, have problems they're having difficulty solving, and are having difficulty making it in the mainstream as a result?  Failure to do so means we're accepting the status quo...that every month or so, something like what happened in Tucson will happen again.  (By the way, in many neighborhoods, shootings occur far more often than monthly.)  It's a tough problem (CLICK HERE).  I wonder if our leaders are up to the task.

Along those lines, I’m also wondering about whether our leaders are aware that while we elect them to represent our views, those views only take on relevance in the context of trying to solve problems.  Whether or not Sarah Palin’s "cross-hairs" graphic or the vitriol that public figures referred to after the shootings had anything to do with what happened in Tucson, the tone set by that graphic and that vitriol is not conducive to the collaborative resolution of tough problems we need from our representatives.

Ross W. Greene
January 18, 2011