The uses and abuses of diagnosis
27 December 2013
Well-established evidence from social science shows that maltreatment at a young age can have major long-term effects on development. But what goes on in the brain of a child who is abused or neglected? What does neuroscience add?
A few years ago, Graham Allen MP used Ct scans to powerful political effect. His report on Early Intervention illustrates the negative impact of neglect on the brain: the child’s brain is significantly smaller than average and has abnormalities suggesting abnormal development. As he points out: ‘building more advanced cognitive, social, and emotional skills on a weak initial foundation of brain architecture is far more difficult and less effective than getting things right from the beginning.’
Using evidence from natural sciences to back up what we already know carries status—but Eileen Munro, Professor of Social Policy at LSE, remains sceptical. Although evidence is becoming increasingly visible, we have only a very embryonic understanding of how it can and should inform practice. Most people are surprised there’s a physical correlate of well-known psychological features and can be overly impressed by it as a result. It seems to disproportionately influence politicians in particular.
Professor Munro is concerned this brings with it a degree of fatalism: brain damage is usually irreversible, so there’s a danger of justifying coercive preventative measures (perhaps intervening in families that look vulnerable on paper) and underfunding later therapeutic services by placing too much emphasis on this kind of evidence. Essentially, it risks over-locating the problem in the child whilst undervaluing social and environmental factors. So despite its appearance of dealing with hard data, it can be very distorting.
What do practitioners say about it? Emily Simonoff, Professor of Child & Adolescent Psychiatry, argues that cognitive neuroscience currently plays a minimal role in diagnosis, which is still chiefly based on observation. Mental health disorders are usually multifactorial in their origin, involving a combination of biology/genetics, family experiences, and the wider social environment. They occur in about 10% of children, but only 25% of these actually receive support. And with cuts to a third of services in recent years, fewer children are being seen, with this year marking the first crisis in patient beds for children and adolescents in over a decade.
Diagnosis can provide a passport to effective treatment, allowing crucial access to other services, education and support. However, understandably there’s concern around the labelling and stigmatisation of ‘normal variation’ as a disorder. Furthermore, inaccurate diagnosis can lead to the wrong intervention and therfore delay treatment, whilst misunderstanding of the causes can wrongly apportion blame to parents or others.
Here, neuroscience could help to personalise our approach to diagnosis. But we’re still a long way off being able to apply it at an individual level. In the meantime, we need to integrate this new type of evidence with existing ways of thinking. Scientists should correct misinterpretations and play a greater role in educating and informing the public, and politicians need to re-phrase mental health disorders to use neuroscience more appropriately.
- These opinions and debates were informed by an event on The Ethics of the Cognitive Sciences: Children’s pathologies—how do we think about children’s mental health?, hosted by LSE.