Diagnosis
LATHA HACKETT
CAROLINE BOND
1 2 TH J U N E 2 0 1 4
Learning Outcomes
 1b.3 understand the need to provide service users (or people acting on their
behalf) with the information necessary to enable them to make informed
decisions
 2a.4 be able to develop psychological formulations using the outcomes of
assessment drawing on theory, research and explanatory models
 3a.1 understand the structure and function of the human body, relevant to their
practice, together with a knowledge of health, disease, disorder and dysfunction
 3a.1 understand psychological theories of, and research evidence in, child and
adolescent development relevant to educational psychology
Activity
In pairs discuss:
1. Your experience so far of working with diagnostic
labels
2. Thinking about a case you have been involved with:
- who made the diagnosis?
- How were you made aware of the diagnosis?
- Did it involve contact with other professionals? If so,
how did this informed your work?
- How did the diagnosis informed your assessment
and intervention?
What is diagnosis?
 the identification of the nature of an illness or other
problem by examination of the symptoms.
 the distinctive characterization in precise terms of a
genus, species, or phenomenon.
Diagnostic Systems
 International Classification of Mental and
Behavioural disorders. Version 10- ICD 10. World
Health organisation.
- Children/Young people – Multi-axial
Classification.
 Diagnostic and Statistical Manual of Mental
Disorders – fifth Editions. American Psychiatric
association. – DSM5.
 Clinical Formulation.
What is classification
 It is like a language.
 Aids communication.
 Aids in thinking about a complex problem.
Good Scientific Classification
 Clarity.
 Comprehensiveness.
 Acceptability to users.
 It should change when understanding changes.
 Each class is a concept not a thing.
Why do we need diagnostic systems?
 Improve reliability of diagnostic judgements.
 Guidelines for diagnosis – enhances the
agreement among clinicians and investigators.
 Proper use need specialised clinical training
(knowledge and clinical skills).
 Reflect a consensus of current formulations of
evolving knowledge in our field.
 Does not encompass all the conditions.
Purpose
 Provide clear descriptions of diagnostic categories
to enable clinicians to diagnose, communicate,
study and treat.
 In mental health – face a remarkable collection of
phenomena.
 So we will need different classification for different
purpose.
 Early ones – Psychoanalytic theory – reliability
was low among clinicians.
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Purpose
 Provide clear descriptions of diagnostic categories
to enable clinicians to diagnose, communicate,
study and treat.
 In mental health – face a remarkable collection of
phenomena.
 So we will need different classification for different
purpose.
 Early ones – Psychoanalytic theory – reliability
was low among clinicians.
.
Research Purposes
 Good diagnostic Schemes.
 Groups of children have to be homogenous.
 Replicable.
 Hypothesis testable – ODD under the age of 8 and
WS parent training.
 Obsessions and stereotypies – treatment for one
tried on the other.
 ADHD and Mania – study of neurotransmitters.
Clinical Purposes
 Practitioners need to know – application of research
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to clinical practice.
Communication between clinicians.
Statistical record keeping.
Audit of response to interventions.
Communication between users and carers.
Abuses.
 When they are considered as things rather than a
concept.
 E.g. teacher – not really ADHD but all due to social
reasons.
 Child with disproportionate difficulty in learning to
read does not come up to MLD so no statement.
Principles of a Multi-axial framework
 Diagnosis – needs several elements
 Mental disorder, Mental retardation, presence or
absence of a brain disorder
 In most cases it is multiple reasons that a child has
difficulties.
Remember
Conditions such as
 Pathological Gambling.
 Paedophilia
 Does not imply they meet legal or other non-
medical conditions that constitutes a mental
disease, Mental disorder or Mental Disability.
 (individual responsibility/disability
determination/competency)
Remember
 Coding for diagnosis – refers only to the persons current
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situations.
NOT to the person himself/herself.
Carry no implications about permanency & irreversibility –
so not appropriate for labelling of individuals.
Coding should not be basis for recommendations for
institutional placement etc.
Psychiatric diagnosis are descriptions and not
explanatory. ADHD – a description of symptoms and not
why the child behaves the way he does.
Remember
 Categories do not provide aetiological basis for the
disorder exception PTSD. But they are defined as a
gp of symptoms only used if they meet the criteria.
 Reactive attachment disorders of Childhood &
Disinhibited attachment disorder of Childhood –
they need to have the behaviours to make this
diagnosis.
Remember
Depressive illness in children – adult depression differs in
heritability, presentation and response to medication.
Tricyclic antidepressant are ineffective in children
No age bar for diagnosis.
Child being brought to see you – so he must be disordered the child’s behaviour may be adaptive to nurture.
ADHD – pattern of beh changes with age – adolescents less
over activity and more disorganisation
Not all children with Autism are the same – descriptions such
as autistic and brain damaged are not useful.
ICD 10 – Multi-axial classification
 6 axis – Multi-axial classification.
 First 4 axis – ICD 10 categories
 Axis 1 -Clinical Psychiatric Syndromes
 Axis 2 – Specific Disorders of Psychological
development.
 Axis 3 – Intellectual level.
 Axis 4 Medical conditions.
ICD 10 – Multi-axial classification
 Axis 5- Associated abnormal psychosocial situations.
 Axis 6 – Global association of Psychosocial disability.
Multi-axial classification in child psychiatry
 Avoid false dichotomies from having to decide
between two diagnosis. Autism & Mental
retardation.
 Has to be a coding on each category – this is more
complete and less ambiguous e.g. Autism and no
mental retardation. Axis 1 and axis 3.
 Avoids artefactual unreliable results – a child with
psychosocial difficulties and other difficulties will
have codes on all categories.
Clinical Diagnosis and Formulation.
 Convenient and economical communication.
 Statistical recording and Audit.
 Diagnosis does not automatically generate a plan
of management – eg Autism with challenging
behaviour and Autism without.
 IQ, Peer relationships etc
 Diagnosis is only one part that guide decision
making
Co-occurrence of different symptom patterns
 Co-morbidity – 2 or more separate and independent
disorders are present in the same person
 Tourette’s disorder and ADHD is common
 ASD and ADHD common
 ASD with anxiety disorder common
Example Autism ICD-10 and DSM5
ICD-10 (WHO, 1992) categories
 F84 Pervasive Developmental disorders (Childhood
Autism, Rett’s Syndrome, Other childhood disintegrative
disorder, Asperger’s Syndrome, Atypical Autism, PDDNOS)
F84.0 Childhood Autism
- a pervasive developmental disorder defined by the
presence of abnormal/and or impaired development that
is manifest before the age of 3 years
- Characterised by abnormal functioning in a)social
interaction, b) communication and restrictive c)
repetitive behaviour
- Boys: girls 3:1 or 4:1
Example Autism ICD-10 and DSM5
 F 84.1 Atypical Autism
- Differs from autism in terms of age of onset or failure to
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fulfil all 3 criteria or insufficient demonstrable
abnormalities in 1 or 2 of the 3 areas (social interaction,
communication and restrictive, repetitive behaviour)
F84.5 Asperger’s Syndrome
Qualitative abnormalities of reciprocal social interaction
and restricted and repetitive activities/interests
No language or cognitive delay
Clumsiness common
Boys:Girls 8:1
Example Autism ICD-10 and DSM5
 DSM5 (APA, 2013) categories
 Neurodevelopmental disorders (intellectual disability,
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communication disorders (incls. pragmatic), Autism
Spectrum Disorder, ADHD, specific learning disorder, motor
disorders)
Autism Spectrum Disorder
A. Persistent deficits in social communication and social
interaction across multiple contexts
B. Restricted, repetitive patterns of behavior, interests, or
activities
Severity categories and co-occurrence descriptions e.g.
with/without language impairment or intellectual impairment
http://www.md-fm.com/Vreport-vid-61-comefromback.html
Evaluation of DSM5
 Social communication disorder not discreet and
could create a new category for those who don’t quite
meet autism criteria (Tager-Flusberg, 2013)
 Intellectual disability diagnosis an improvement as
focuses on adaptive functioning not just IQ
(Kaufmann, 2013)
 A more dimensional approach to ASD which signals
a range of needs that service providers will need to
address including severity (Baron Cohen, 2013). This
more multi-dimensional approach is also likely to
improve research and identification for girls
Clinical Diagnosis and Formulation
 Like a Map for navigation – to be aware of what
you may encounter.
 Without it – you could get into difficulties.
 Danger is relying on development of treatment
protocols – may inhibit the process of tailoring
services to individual needs.
 Product of assessment – full clinical formulation.
This encompass more than a diagnostic label.
Agreement
Ratings by experienced clinicians – moderate
concordance
Training can improve diagnosis
Increased rules in ICD 10 has increased inter rater
reliability
Unrealiability in diagnosis – is not ambiguous
classification – clinicians trying to fit their
hypothesis with diagnosis - anchoring
Mental Health Services,
Referral and Joint Working
Tier model of treatment
 Tier 1 –services which deal with MH problems, but
have different primary focus e.g. SS, GPs, schools,
probation
 Tiers 2 & 3 – services whose primary aim is dealing
with MH problems in a locality (CAMHS)
 Tier 4 –specialist regional MH services
Levels of need for treatment
0.075 % children will need Tier 4
1.85% Tier 3
4
7% Tier 2
Tier 3
15% Tier 1
7% Tier 2
15% Tier 1
75%
Thinking about involving CAMHS
 Mental health interventions cannot treat problems of
social adversity
 Like other medical services, attendance at CAMHS is
voluntary
 Same standards of consent apply as for medical
treatment generally
 Medical standards of confidentiality
Problems to discuss with CAMHS
 Presenting features outside normal range for child’s
age, intellectual ability, or culture
 Severe enough to interfere with everyday life
 Sudden apparent change in behaviour, emotions
thoughts that is persistent (2 wks)
 Problems persisting despite tier 1 interventions
Referral letter
 Essential – Description of Problem, who wants to
change, how the decision to involve CAMHS was
made, background information needed to
understand the problem.
 Optional – Background info- family composition
& structure, developmental history, school
performance, medical history, medication and past
history of CAMHS involvement.
Referral Pathway.
 Direct referrals – General Practitioners, Community
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Paediatricians, Hospital Paediatricians, School nurses.
Other referrals from education psychologists, School
Attendance Improvement Service - Referrer has discussed
with the GP/ School doctors/Com Paed. Copied to the GP,
Health Visitors, School Nurses, Surestart Children’s
Centres and daycare providers.
HV, SN – referral discussed with the GP or Com Paed,
referral copied to the GP.
Children Families and Social Care – Multi-agency &
Liaison meetings
Mental Health in Schools
CAMHS Professionals
 Child and Adolescent Psychiatrists
 Child and Adolescent Clinical Psychologists.
 Nurse Practitioners and CPN’s Community
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Psychiatric Nurses
Child & Adolescent Mental Health Practitioners
Child Psychotherapists
Family Therapists
Specialist Speech and Language Therapists
Specialist Social Work Practitioners
CAMHS in Manchester – Tier 2 3 & 4
CAMHS directorate - Tier 2 & 3
North – Psychology, Psychiatry – Booth Hall CH.
Central – Psychology & Psychiatry – Winnicott Centre.
South – Psychology & Psychiatry – Carol Kendrick unit.
16-17 Community Mental Health Team -Emerge
Specialist teams – Children’s and Parents Service - CAPS (0-5 Years),
CAPS TIP – Training in Partnership (5-8 yrs)
 CT-LAC – Consultation & Therapeutic Services for Looked After
Children, Manchester Link etc.
Tier 4
 Galaxy house (RMCH), McGuiness Unit , Hope & Horizon unit
(Pennine care) All services are made up of a small number of
clinicians.
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Multi-agency working in CAMHS
 Consultation and liaison with other agencies (school nurses,
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health visitors)
Integrated service delivery in:
SCAIT – Social Communication Assessment & Intervention
Team (Education Psychology, Diversity & Inclusion,
Community Paediatrics in Team)
CTLAC
CAPS/CAPSTIP (Parenting Groups with other agency
professionals)
Mental Health in Schools (S M/cr pilot includes CAMHS
worker in school team)
Referral Times
 Routine referral – Seen within 11 weeks (psychiatry)
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or 13 weeks (psychology).
Urgent referral – Prioritised.
Emergency – seen within 24 hours or next working
day.
9-5 weekday on call service.
Out of hours on call service.
CAMHS
Assessments & Interventions
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Varies in complexity and lengthy
Assessments include liaison with other agencies ( e.g.
schools, social services, community health services)
Partnership with child/family (consent for contact,
unless CP concern, letters copied)
Partnership CAMHS/ other agencies
Assessment
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The first interview with patient and their family
The first interview may take up to l½ hours.
Who should be there?
Parent or child or young person seen first?
Presenting difficulties, the severity and impact on the
family or wider society e.g. school.
Factors that triggered, exacerbated or maintained the
presenting problems.
The strengths of the family and child and whether they are
motivated to working on the issues.
The expectations and ideas that the family have about being
seen by CAMHS.
Further assessments
may take place in school, clinic, home or nursery
Assessment heading
 Current difficulties
 History of current difficulties
 Past health – mental and physical health problems
 Developmental history starting from Pregnancy
 Family history of mental and physical health
problems
Interview with the child
 Depends on age and cognitive ability
 Setting up the session – crayons, age appropriate
toys
 Adolescent – more an interview as in an adult
 Observation of play, interaction, language, motor
difficulty etc
Mental State Examination
 Appearance and behaviour: dress, physical appearance, motor activity, co-
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ordination, involuntary movements.
Language: expression, comprehension, speech – spontaneous, quantity, rate,
rhythm, and complexity.
Mood: subjective, objective, symptoms/signs of depression, suicidal feelings,
anxiety, panic, anger, aggression, and irritability.
Abnormal beliefs, experiences, thought content, hallucinations, delusions,
worries, fears, preoccupations, obsessions, fantasies or wishes.
Social response to interviewer: humour, rapport, eye contact, empathy,
and co-operation, shy, confident.
Cognition: attention span/distractibility, draw a person (note grip,
handedness), write name, give days of week, months of year, counting, simple
arithmetic, orientation, memory, general knowledge, reading skills/level of
attainment.
Example - assessment
of
ASD
46
National Autism Plan for Children
Guidelines
 Multi-agency -Psychiatry, Clinical Psychology,
Speech Therapy, Community Paediatrics,
Educational Psychology, Specialist Teachers
 Set time scales
 Multi-modal – developmental history, school obs,
direct assessment
 Assessment and intervention provided
Example ASD assessment
47
 Information from Parents – Detailed developmental history, behaviour
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– covering all aspects of social communication, imagination, flexible
thinking, onset, co-morbid features, pregnancy, birth, medical , family,
psychiatric history etc etc
Autism Diagnostic Interview (ADI) & Diagnostic Interview Schedule for
Social and Communicative Disorders (DISCO)
Vineland Adaptive behaviour Scale – a semi-structured interview with
parents – measures functional ability – three domains communication,
daily living and socialization
Information from other professionals – interviews, reports and
questionnaires
Investigation – medical if appropriate, usually if there is dysmorphic or
other features – suspicion of syndromes etc & Medical Genetics
assessment.
Formulation
 Once all the information has been collected, it is possible to
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produce a formulation.
This is a brief description of the child’s presenting
problems, any precipitating, predisposing or maintaining
factors. It helps to consider the factors under Biological,
Psychological & Social categories.
PREDISPOSING
PRECIPITATING
MAINTAINING
PROTECTIVE
Types of treatments offered
after initial assessment
 Supportive counselling.
 Individual therapy e.g. psychotherapy, play
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therapy.
Cognitive behavioural therapy.
Solution focused brief therapy.
Parent training.
Family Therapy.
Systemic work.
Group therapy.
Medication.
Example ASD intervention
Central Manchester treatment as usual:
 Information for parents/carers re process of diagnosis
and who will be involved
 Attendance at parent’s post diagnostic group
 Joint meeting with parents and school or education
provider
 Additional interventions provided by specific members
of team e.g. social skills groups, Hanen programme
(SLT), school training and IEP planning (EP),
behaviour management at home, Cygnet (CP, MHPs)
Any other questions regarding diagnosis
or ASD?