When a parent brings their child in for evaluation, I naturally assume first that there is something out of the ordinary. At the very least, there is something out of the ordinary from the parent's perspective. The parent is worried about their child and wants to either make sure there is nothing wrong, or if there is, then it is identified so they can take whatever steps would likely be helpful. For this reason, it can be very frustrating for a parent when the child is evaluated and does not qualify for a diagnosis. It would seem strange that a parent would want their child to be diagnosed with a disability or disorder. Indeed, I do not think the parent wants their child to be diagnosed, but the parent wants some kind of answer or explanation for their child's behavior (and what to do about it). It may be that the parent merely wants reassurance that the behavior is actually "normal", or wants a strategy to use with the behavior of concern. In this post, I want to discuss "subclinical diagnosis", which is what happens when a child's behavior is unusual, but not unusual enough for a diagnosis.
To receive a clinical diagnosis, a child must meet certain conditions. These conditions are laid out in the Diagnostic and Statistical Manual of Mental Disorders (currently Fifth Edition), also called the DSM-5. However, a clinician does not rely exclusively on the DSM-5 for determining if a child has a disability. A skilled clinician has many resources used for understanding development and disorders (such as professional journal articles, books, and workshops), and ultimately the clinician must use "clinical judgment" when determining if a child presents with enough symptoms and enough severity to qualify for a diagnosis. The DSM-5 allows for "clinical judgment", and the clinician should meet with the child's parent to discuss the evaluation results and how to understand the results.
Discussing the results of an evaluation can take a lot of time, but the clinician has a responsibility to help the parent understand what the results mean and how the parent can use that information. If a child meets the conditions for a clinical diagnosis, then the clinician will explain this and what it means (along with recommendations of what to do about it). Alternatively, a child may not meet the conditions for a clinical diagnosis, in which case no diagnosis is given because the number or severity of symptoms is too low. In some cases, a child may not meet enough of the conditions for a clinical diagnosis, but does exhibit a number of significant symptoms, which require an explanation and may need accommodations. This may lead to a "subclinical diagnosis." A subclinical diagnosis may eventually lead to a clinical diagnosis if the symptoms continue or worsen in the future. Symptoms of a subclinical diagnosis may also be distressing for the parent, child, or teachers. The clinician should take time to discuss symptoms of a subclinical disorder with the parents and provide recommendations for how to address these, even though the child does not currently meet all of the requirements for a clinical diagnosis.
If a child does not meet the conditions for a clinical diagnosis, then it may be more difficult for a parent to get services for the child. Typically, a clinical diagnosis is one required part of getting school-based services (special education services) under IDEA (the Individuals with Disabilities Education Act). A child with a subclinical diagnosis may, at the school's discretion, receive additional assistance such as a Behavior Improvement Plan. Therefore, it is recommended for parents to discuss their concerns with the school and maintain a cooperative relationship with the school.
Lastly, if a parent is concerned that the evaluation may not be adequate or valid, then they should always be willing to seek a second opinion from another qualified professional. Evaluations provide a limited period of insight into a child and their behavior. The child may simply not show their usual symptoms during that time, which can lead to no diagnosis.
For more information on diagnosis and evaluations, see the following:
