By Prof Katrina Williams
What’s become of sensitive, worried, highly strung and shy children? Where are the attention-seeking, energetic and clever children, those with hobbies, or the ones who were good at maths, but not at art? All of these terms were once commonly used. Some children were even well-behaved and others naughty. But somehow, over the last couple of decades, these children have been replaced by children who are anxious, depressed, socially avoidant, autistic, obsessional, those who have ADHD or are ‘gifted and talented’.
Let’s talk about ‘John’. He’s a bright six-year-old, but doesn’t pay attention in class. He fidgets a lot, gets out of his chair and moves around the room, sometimes seems to be in his own world and doesn’t join in with the other children at lunch time. John might have ADHD, autism spectrum disorder and be “gifted and talented”, or he might be bored with class activities and shy. But the way we talk about John is critical, because it directly influences what happens next.
If we’re worried that John is bored, we ask him questions. If we think he could be shy we support him to join in with other children. We can also think about John’s other characteristics, because he might also be fair, modest or curious. But if we think John has ADHD or another diagnosis we refer him for assessment and health professional advice.
Since the 1980s, the Diagnostic and Statistical Manual of Mental Disorders (DSM) and other similar classification systems have become widely used in healthcare. These systems were first designed to help clinicians diagnose mental health disorders in adults when biological or well developed clinical tests did not exist. Over time diagnoses have changed, many have broadened, and sections on neurodevelopmental disorders have been added, and diagnoses have increasingly been applied to children and young people. These diagnostic labels are needed to provide a common language for difficulties that create risks and impact a child’s well-being and ability to participate in their community.
At the same time there has been new thinking about ways to prevent problems, giving rise to the idea that perhaps by detecting subtle perturbations of behaviour, like those we see in disorders, assistance might be offered and a disorder prevented from developing. Services have changed, and for children to receive early intervention or extra support at school we must increasingly apply labels that attract specific funding.
John illustrates why we should worry about the dominance of DSM and similar classifications in the way we talk about children. If John is described as having ADHD his behaviour has been abnormalised, and this may not be accurate or helpful. The way we talk could change the way we think about him and his potential, and in turn change the way we interact with him and his family. It could change the opportunities we give him. If John was assessed by a doctor and labelled ADHD and “gifted and talented”, his view of himself is likely to change too. The potential positive and negative impacts of these alterations in perceptions of others and self are not known.
We all have traits that influence the way we behave and these traits often stay with us. However, the behaviours related to them can be modelled with experience and can vary at different times and in different situations. John is unlikely to ever be the most outgoing person in a group and his intelligence is likely to persist, with both needing to be modelled to suit his roles as an adult.
If we use the full repertoire of language that is available to us, including strengths, to describe behaviours in children and young people we give ourselves space to think about whether a behaviour is transient or creating persistent difficulties, and also to think about possible causes and ways to assist, if assistance is needed.
Let’s not lose sight of children with problems of neurodevelopment or emotional adjustment who require additional supports, but let’s not use the same terms to talk about all other children too.
Prof Katrina Williams is Director of Developmental Medicine at The Royal Children’s Hospital, Melbourne