Children In Care Go Down A Rabbit Hole When It Comes to Diagnosis and Treatment

Their world becomes Alice In Wonderland like. A recently published study by McGuire et al (2022) gave one of two alternative vignettes to 270 mental health professionals. The only difference in the narratives was that in one the child was described as being in care and in the other as living with their mother. For the sample in which the child was described as living with their mother, the rate of diagnosis of PTSD was more than double (31.0% vs 14.5%). According to NICE, children with PTSD should follow a particular treatment pathway, trauma focussed CBT. Thus for every child in care placed on the  correct NICE pathway, another would be misdirected. Matters were even worse than this, as only one half of those who diagnosed PTSD recommended a NICE approved treatment (trauma Focussed CBT or EMDR).

Overall the most popular diagnosis was developmental trauma (57.3%)  followed by attachment problems (22.1%) and PTSD (14.5%). But these clinicians seemed unphased, that there is no evidence-based protocol for either developmental trauma or attachment problems. The use of such diagnostic labels is an exercise in unbridled clinical judgement that serves the interests of neither the children in care  nor the troubled child not in care.

Unfortunately the use of idiosyncratic rules of thumb (heuristics) is commonplace, 9 out of 10 of those diagnosed with ADHD are boys, but boys are only 3 times as likely to have ADHD as girls, Bruchmuller et al (2012) the representativeness heuristic operates, in that boys are seen as prototypical. Heuristics short circuit decision making, sacrificing accuracy for speed. But they are not the exclusive preserve of clinicians working with children, their usage is ubiquitous  amongst mental health professionals. It is an article of faith amongst aspiring mental health clinicians that the ‘medical model’ must be derided at every turn, diagnosis is anathema to be replaced by the autocracy of the clinicians judgement. But it is unfettered clinical judgement, imagine what would happen if Judges engaged in this with regards to sentencing! Diagnosis is built on explicit criteria and another clinician can challenge whether there is sufficient evidence that those criteria are/were met. We can even distil more reliable diagnostic criteria. There is no appeal against the autocracy of unbridled clinical judgement, it is an exercise in power without responsibility. We are back to the era that pre-dated the randomised controlled trials of psychological interventions in the 1970’s. It was like being at the Mad Hatter’s Tea Party, I remember having the timidity to ask on a social work course ‘does this social casework, work?’ and arriving late for a T Group, to be told this was a manifestation of ‘resistance’, my remonstration that I had missed the bus counted for nought.  The social casework totally failed, with failures to protect children abounding and idiosyncratic decision making, supplemented with box ticking.


Dr Mike Scott