Hello all! It’s Dr Justin here again. And I just have to speak up…. let’s talk about diagnosis, neuroaffirming language and clinical rigour!
When seeking a psychological assessment or treatment for neurodivergence, such as autism or ADHD, it is reasonable to expect your experience, views and wishes will be respected. This is as it should be. However, your psychologist’s (or psychiatrist, or paediatrician for that matter) role is not simply to affirm casual diagnoses but to apply scientific and statistical rigor in determining whether a particular diagnosis is appropriate. This is not about doubting your experiences or invalidating your struggles, but about ensuring that the diagnosis, and therefore the treatment and support you receive, is accurate and evidence-based.
To use an analogy, suppose I am driving my car, and quite suddenly I hear a very loud knocking beneath me. Seconds later there’s a terrific bang and the car stops. Later, when I speak to my mechanic, they will (if he or she are any good) assume that I know more about what happened than they. So when I report that I heard a loud knocking noise, and then a loud bang that scared the crap out of me I expect to be believed and treated with sympathy. Moreover, that information will likely prove helpful (if not essential) to their work in determining what went wrong. So, I know more about my experience than they do, but that doesn’t mean I know anything about diagnosing and remediating my problem; hence I hired the professional who does. I might suggest that I’ve read a lot about limited slip differentials and suggest they start there, and they might even smile and nod (thinking ‘Well, it doesn’t really work like that’). After all, I am not a mechanic, but I know my experiences.
The Ethical Obligation of Scientific Inquiry in practise.
Psychologists are bound by ethical and professional standards that require them to base their assessments, treatment and diagnoses on sound scientific evidence. This means that they must approach every assessment with professional skepticism; an attitude of open-minded inquiry combined with a commitment to rigorous evaluation.
While counselling skills, compassion and positive regard are essential in assessment and therapy, good assessment and treatment must be guided by additional, equally important principles. Here are some really important technical and ethical principles in psychological diagnosis that aren’t talked about anywhere near as often as they should be.
First up, Evidence-Based Practice. Psychological assessment and diagnosis must be grounded in the best available research, combined with clinical expertise and an understanding of each client’s unique presentation. This includes but isn’t limited to obtaining evidence from several sources; questionnaires, interviews, documentary review, psychological tests and observation/interview. One source is never sufficient.
Psychologists are committed to the Scientist-Practitioner Model. This means psychologists are trained not only as clinicians but also as scientists, meaning they are ethically required to apply critical if not syllogistic reasoning, which they use to formulate hypotheses about the nature and cause of your difficulties, and then test their hypotheses by gathering, analysing and applying empirical evidence. In fact, when psychologists register, they give their word to do exactly that.
Differential Diagnosis. Many conditions share overlapping symptoms. A psychologist must carefully consider all possible explanations for a client’s experiences to arrive at the most accurate diagnosis. For example, there are a great many difficulties and disorders that look very much like Autism and/or ADHD, but are not, and the application of ASD and ADHD remedies to those disorders will not only be ineffective, but they may also be downright harmful.
Why Casual-Diagnosis Cannot Replace Rigorous Psychometric Assessment
Let’s start this section with what I mean by ‘casual diagnosis’. In the first category, anyone who diagnoses themselves. Yes, that applies to psychologists, psychiatrists or anyone with training in neurodevelopmental disorders. If they diagnose themselves they have a fool for a clinician and need to get a better one. Period.
The second category includes clinicians who make any such diagnosis from a single source of information, or by only taking account of present symptoms. Clinicians making such casual diagnoses need to reflect on their practice, and/or seek further training. That’s a hill I’m happy to die on.
While reading, discussion and your experience can be valuable tools in understanding oneself, they do not replace structured clinical assessment, using data from multiple sources and life periods. So self-diagnosis by those without training in developmental psychology, diagnostic and psychometric principles are the third and by far the most common category. Remember most of what you read about ASD or (especially) ADHD on the internet is designed to make a profit, not improve community mental health.
Self-diagnosis is tempting and to some extent, we are naturally inclined towards it. The human mind naturally seeks patterns, and books or online information about neurodivergence often presents broad symptom descriptions that can feel personally relevant (even when the descriptions are accurate, most on the internet are not). This effect even has a name – the Forer effect. Without rigorous assessment, there is a risk of misattributing difficulties to ASD or ADHD when they are instead related to other conditions, such as trauma, anxiety, or extreme personality traits.
A psychologist worth their brass plaque is ethically obliged to explore all possibilities before confirming a diagnosis and will take this seriously. This may mean the language used in the assessment process does not align with fashionable neurodivergent-affirmative language that assumes a pre-existing diagnosis. And nor should it. While this might sometimes feel invalidating, it is not intended to dismiss your experiences. Rather, it reflects the need for scientific rigor in assessment, which ultimately benefits you and the community by ensuring the most appropriate treatment and support.
The Importance of Correct Diagnosis
An accurate diagnosis leads to targeted and effective treatment. If a person is mistakenly diagnosed with a neurodevelopmental condition when their difficulties stem from another cause, they may not receive the right interventions, support, or accommodations. Conversely, if a genuine neurodivergence is overlooked, the individual may struggle unnecessarily without access to the appropriate resources. A child who doesn’t really have a neurodevelopmental disorder might benefit from a diagnosis because they get an educational assistant at school, but not so much when years later, they are fully functioning but not allowed to join the police force or become an airline pilot.
You’re probably not ‘normal’, but you’re probably not the only divergent in the village.
The infiltration of USA style, polarised political tribalism into psychological assessment and practise is an increasing problem. So much so, many of my colleagues have (among themselves) expressed a fear of speaking up about it for fear of being labelled as ‘anti-neurodivergent’, ‘anti-this’ or ‘anti-that’ when all they really want to do is balanced and effective assessment (the courageous Claire Rowe of Sydney Australia a notable exception here). I have lost count of the number of excellent psychologists who, on expressing concerns about the current state of diagnosis and politicisation of psychological practise end their comment with ‘If anyone heard me say THAT, I’d be cancelled in a minute’. They’re not joking. Pervasive neurodevelopmental diagnoses as a quasi-political movement is poor psychology; it is bad for assessment, bad for community mental health and bad for children.
This is a serious issue. Serious enough for me to risk being ‘cancelled’ over, because if I have to dilute professional scepticism and empirical rigour in assessment to avoid being labelled as some kind of class traitor, I frankly would rather do something else for a living (I make pretty good cappuccinos, and bake a rocking sourdough). Of course, all the above also comes with significant and sustained pressure to bend assessments to get over the line in terms of criteria and severity as a means to secure NDIS or other school-based funding, and this pressure can be quite unpleasant. I have met numerous young people who are probably neurodiverse and have been diagnosed. They are largely functional, bright and doing well at school with minimal support but according to their ‘diagnosis severity level’ shouldn’t be able to feed themselves unsupervised. In several such cases I was informed the diagnostic severity level was openly and cynically inflated to secure funding. Clinicians who do this may be well intentioned, but this harms people with more severe presentations who need access to limited funding. Soon, the more ‘severe’ categories will cease to be taken seriously, harming those who need the help most. To put it baldly, the practise of inflating severity or endorsing diagnoses in the absence of (or often contrary to) evidence to secure funding support amounts to fraud, is corrupt and should be reported wherever it occurs.
This is of course part of a wider issue. Psychological terms are, more and more in recent years, used inappropriately to divide, demean or signal membership of groups vis-à-vis the ‘others’. Narcissists versus nice people (we’re all a little narcissistic), any use of the word anxiety used to mistakenly denote a disorder. But here’s the truth. The only place the world is divided into ‘neurotypicals’ and ‘neurodivergent’ is on Tik Tok and in the DSM 5 (TR). This isn’t necessarily as bad as it sounds, provided we understand that the line between people diagnosed with a neurodevelopmental disorder or not is arbitrary; it is not real. The diagnostic criteria in the DSM V (TR) use to determine who ‘has’ a neurodevelopmental disorder versus those who do not is a useful fiction, like money or the LBW rule in cricket. That is, we agree on it as a way of managing the distribution of finite resources, and those who need accommodations to get along. But the dichotomy is not real, in real life it’s a spectrum and we’re all on it to some extent. One can be really different, have trouble fitting in but not quite meet sufficient diagnostic criteria.
Professional Skepticism is Not Personal Doubt
It is important to understand that professional skepticism is not personal disbelief. Your psychologist is not questioning your experiences – please forgive me if omit the redundant word ‘lived’ and avoid that sickly tautology so fashionable these days – they’re ensuring their interpretation of those experiences is grounded in robust, scientific assessment. Their primary goal is to provide you with the most accurate and helpful understanding of your symptoms, which will ultimately guide the best possible interventions and support.
By approaching assessment with an open mind, one that allows for all possibilities, including confirmation, refinement, or reconsideration of a casual-diagnosis you are participating in a process that prioritises your well-being and ensures that you receive the most effective care possible.
