Diagnosis of Mental Health in Young Children: DIAGNOSTIC FORMULATION
Marie Kanne Poulsen, Ph.D.
Behavioral problems can be viewed from both dimensional and categorical perspectives (Rutter & Tuma, 1988; Zeanah, 2000). From a dimensional point of view, most common emotional and behavioral disturbances throughout childhood may be conceptualized on a continuum ranging from normality to disorder. It frequently is difficult to differentiate degrees of worrisome behavior. The symptom may be a sign of transitory stress, a sign of adaptation, or a signal that some underlying developmental process such as relationships is not being suitably negotiated (Greenspan & Wieder, 2001).
The question clinically is how to determine whether child behavior is within normal expectations, is at risk for disturbance, or indicates the actual presence of a categorical disorder. The role of the diagnostic process is to differentiate between the broad variations found in typical behavior and the presence of disturbed behavior. In the final analysis, the actual diagnosis depends on careful and thorough assessment and integration of all the available data. Beyond the differential categorical diagnosis, there is a need to explain the extent, scope, and nature of an infant’s or young child’s difficulties. The value of diagnostic formulation is that it helps the clinician understand the child in the context of family and community (Department of Health and Human Services, 1999). The role of diagnostic formulation is to review and integrate findings, identify predisposing and precipitating factors, establish a multiaxial differential diagnosis, and provide current knowledge of the prognosis and consequence of symptoms (“Practice Parameters,” 1997).
Diagnostic formulation synthesizes biological, psychosocial, and cultural influences that influence the child’s way of adapting to the world. The diagnostic process thus expands the formal categorical diagnosis. In collaboration with the family, child temperament, developmental competency, neurobehavioral regulatory mechanisms, and health issues are explored, along with the quality of dyadic relationships and family psychosocial strengths and stressors. Behavior that is considered normal is that which conforms to prevailing cultural and societal expectations. Acceptable child behavioral responses in any given situation are based on the expectation of the majority of the group at that given point in time. Behavioral expectations are a function of the prevalent societal norms within the family’s cultural group.
Families in the United States have pluralistic cultural beliefs and values that influence diverse caregiving practices, different family styles of communication, and various expectations of behavior. Mental Health: A Report of the Surgeon General (Department of Health and Human Services, 1999) noted that the same behavior in one setting or culture might be acceptable and even “normative,” whereas it may be seen as pathological in another. For example, in a study of parental expectations in Anglo and Filipino families, there was a twenty-month difference in weaning expectations, a twenty-five-month difference in independent sleeping, and a thirteen-month difference in expectations of a child playing alone (Carlson & Harwood, 2000).
Interpretation of child behavior and the development of differential diagnoses and treatment plans must be attuned to the unique worldviews of the families served (American Psychological Association, 2003). The Diagnostic and Statistical Manual of Mental Disorders: DSM IV (American Psychiatric Association, 1995) notes that if the referred behavioral pattern is a culturally sanctioned response to a particular event, it cannot be considered as a mental health disorder. Diagnostic considerations must incorporate an understanding of family ethnic, linguistic, racial, religious, and cultural background and how such factors influence diverse parenting styles, child-rearing practices, behavioral expectations, and child and family service and support needs.