Subclinical Diagnosis

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:

• Diagnosis
• Understanding Diagnostic Results

Psychobabble and Jargon (quick reference)

There is a lot of lingo and jargon in psychology and education. Sometimes I relax into my jargon when talking with parents and eventually notice the look of confusion on their faces. It can take effort to be aware of what we're saying and make sure we use terms that make sense. Unfortunately, when parents go to a meeting at the school they often hear lots of jargon and get confused. School personnel may not realize that they're using a bunch of jargon (after all, they use it everyday when talking to each other) or that the terms are unfamiliar to parents. I saw a very helpful post on another blog recently, where the author collected a bunch of terms used in schools and special education and provided nice explanations for them. I'm posting a link to that here and highly recommend reading through it to learn a bit about terms used in schools and special education.

Education Lingo Every Parent Should Know

What's the Big Deal with a Diagnostic Label?

Diagnostic labels can bring relief, sadness, confusion, or anger. Often they produce all of these emotions at the same time. When I meet with parents to talk about the results of an evaluation, I wish I had an hour to go over the main results, a couple of hours for them to leave and think about it, and then another hour to talk about their questions and what to do next. I usually end up spending an hour or two with them talking about the results and coming up with some kind of immediate plan. Then we make another appointment after they've had time to think about everything and come up with new questions.

Labels can be scary because we don't want our kid to have "that label", for other people to say things or judge them, and sometimes because we don't want to accept that label. A lot of work goes into reducing the "stigma" (the negative thoughts associated with a label), but that work is never-ending because a label means "something unusual" has happened. We may also think that if there is a label, then it will never get better. While it may be true that there are some challenges that will always be there, it is wrong to think things will never get better.

On the other hand, labels can be useful. One of the main purposes of a label is so that we can work toward making things better. With a label a child may get access to services he previously couldn't. We may understand a bit more about why the child does the things he does, or maybe why he doesn't do some things he should. As a result, we might become more patient with our child once we know "what's going on." We can also start using lots of research to find better ways of helping the child.

Labels often seem to create more questions than they answer, but we can start asking better questions. We're no longer trying to find our way through a large, open field. We have clearly marked paths, and can start exploring them. Finding the approach that is best for your child may begin with an evaluation and a label, but it continues with problem-solving and working together.


I have two documents that discuss evaluations and labels in more detail:

Diagnosis - more information about the process of making a diagnosis

Understanding Diagnostic Results - written with one of my colleagues, this one is about questions that often come up after the diagnosis