Why we need to be aware of diagnostic overshadowing - Dandelion Training & Development

Whilst traditionally a term used in more medical environments, over recent years the recognition of diagnostic overshadowing has increased.

Diagnostic Overshadowing occurs where a child (or adult) symptoms are attributed to their previous diagnosis rather than exploring their cause, meaning or what they relate to. Diagnostic Overshadowing was first coined in 1982, by psychologist Steven Reiss. He discussed that those with psychiatric needs often had their symptoms minimalised or dismissed as being part of their disability, which prevented thorough assessment and their needs being appropriately met.

Diagnostic overshadowing occurs when a child or adolescent (or adult) receives a diagnosis for one condition, and the practitioner or other professionals will attribute all their symptoms to this single condition and may not question that there may be a comorbidity, or additional diagnosis which was required.

Hallyburton (2022) discusses ‘Diagnostic overshadowing, the misattribution of symptoms of one illness to an already diagnosed comorbidity, leads to compromised patient care and likely contributes to increased mortality experienced by individuals with mental illness.’

Unless you are a doctor, psychologist or psychiatrist, we have no role in diagnosing a child. However, you may, at times, meet a child or young person whose parents, or they themselves, raise a concern that they feel there is something ‘wrong’ or ‘different’ about them. Where an existing condition has already been diagnosed, commonly, we can find that all symptoms are attributed to this, rather than exploring more thoroughly which can cause limitations and mean that children’s needs are not sufficiently met. Conversely, this also means that in some cases, we may see an escalation of needs. For instance, a child whose anxiety is all attributed to their ASD diagnosis may become a school refuser as the anxiety is not appropriately supported.

So, what can it look like?

These are only examples, to allow readers to reflect on what diagnostic overshadowing may look like in their setting:

A child has a diagnosis of anxiety, and their difficulty to concentrate, engage or complete work is attributed to this and therefore their symptoms of Attention Deficit Disorder are not identified.

A child who engages in self-harming behaviours such as head banging or hitting themselves is labelled as having behaviour needs when their emotional literacy levels mean that they cannot express their feelings so demonstrate their distress through behaviour.

A child who has previously had a diagnosis of anorexia, who struggles to regulate their emotional responses, continues to find it difficult to eat a wide range of foods and has difficulty with peer relationships has their challenges attributed to their bodyweight instead of exploring their need for an Autism Spectrum Disorder diagnosis.

A child who has difficulty regulating their food intake is labelled as obese, and parents are advised that they should do more physical activity and prepare healthier snacks. Blood tests are not performed so the underlying thyroid condition is not picked up.

A child who finds it difficult to manage auditory sensory input is diagnosed with sensory processing disorder, ignoring the acute pain that they feel at hearing loud noises which is related to Hyperacusis.

Professional Curiosity

Whilst only a small section of examples, all these scenarios highlight the importance of professional curiosity. If something does not fit, then we need to exercise more curiosity and ask more questions, looking for wider input to help us appropriately identify children’s needs so that strategies, support and interventions allow them to thrive.

Reference:

Hallyburton A. Diagnostic overshadowing: An evolutionary concept analysis on the misattribution of physical symptoms to pre-existing psychological illnesses. Int J Ment Health Nurs. 2022 Dec;31(6):1360-1372. doi: 10.1111/inm.13034. Epub 2022 Jun 19. PMID: 35718951; PMCID: PMC9796883.

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