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“If All You have is a Hammer”: Some Thoughts on Diagnostic Overshadowing

Many people are uncomfortable with aspects of mental health diagnoses. The idea of neurodiversity echoes more nuanced ideas around selfhood and a search for new ways to understand individual human difference. I felt it might be helpful to reflect on the utility of current classification systems in the field of mental health, and focus specifically on autism and ADHD.

One difficulty with diagnosis is that there is risk that everything a person does is then understood through the lens of a particular diagnosis. This is known as ‘diagnostic overshadowing.’ A person with an intellectual disability (i.e., broadly speaking, a person who has an IQ < 70 who also has difficulties in day-to-day task management) might find that they are excluded from the social rituals of grief or loss, or perhaps that their behaviour is always framed as “challenging” when in fact the cause may be trauma, loss, or just the everyday struggles of living.

A hammer on a table surrounded by nails
'I suppose it is tempting, if the only too you have is a hammer, to treat everything as if it were a nail.' - Maslow

Maslow’s quote, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail,” (Maslow, 1966) is linked to this idea of diagnostic overshadowing, or the idea that we might overlook other explanations for a person’s difficulties because we are so aligned to a primary diagnosis. Thus, surface interpretations of another person’s experiences emerge, such as; “Well of course John does that…he’s autistic you know…that’s what autistic people do…”

Maslow’s words are therefore a cautionary warning for all of us. Here, I concede my own practitioner bias as I don’t feel it’s possible to be wholly neutral on this topic. As a practitioner working in the field of developmental disability, I do feel there is validity in a diagnosis of autism given that it is understood to be a neurodevelopmental condition and that it is usually helpful for a person to either know this or have others understand something of this. I see the developmental component as critical, suggesting biological validity that may not be relevant for diagnoses that may be merely descriptive of current human behaviour/state. What then ought we to do to ensure we don’t as clinicians engage in diagnostic overshadowing?

At Studio 3, we tend to be consulted around more complex and sensitive situations, in that we are usually looking at cases where simple ‘off-the-shelf’ autism interventions have been unsuccessful or perhaps reported to have caused harm. This is often so with more behavioural interventions which might have led to demand avoidance behaviours or resistance (eg. Kupferstein, 2018). What we can do is to hold diagnosis lightly, and also look for the other variables in the life of a person that might overlap with developmental conditions. Adverse past experiences or stigmatisation, for example at school, offer a rich seam of distress for young adults who have a primary autism diagnosis. Here we are regularly working not only with autism: trauma is often very much in play. And so it is necessary as a practitioner to have some understanding of how autism presents a stress vulnerability model, especially for the future relational struggles of life. I have in mind a case recently where a child’s distress had historically been framed as psychotic or just “bad” behaviour, when a systemic overview of their past linked together difficulties of attachment, neglect, and undiagnosed autism. Absence of diagnosis had led to harmful interventions and unhelpful responses by society where difference was hidden from view. In this case we worked alongside psychiatry to offer a corrective diagnosis (autism), which allowed new explanations, treatment and support pathways. And of course, the reverse might be true for some people; it seems obviously unhelpful to be wrongly diagnosed with autism if in fact your relational and emotional development was affected by adverse early life experiences or other later difficulties. These are without doubt the most complex cases my colleagues and I wrestle with.

The case of ADHD offers another emerging professional battleground I sense, where on the one hand we might understand a person to “have” ADHD and thus understand them from that perspective, or whether we can take a broader look at past struggles and current life situation and formulate a more complete sense of what might have led to the features associated with this “disorder.” At Studio 3, we talk regularly in clinical meetings about how we engage with the reality of attentional difficulties or hyperactivity on the one hand, whilst also taking account of other systemic or support variables, so that we don’t sleepwalk into medicalising all aspects of the human condition. Anxiety, trauma, depression, premature birth, and autism amongst others all present different and overlapping pathways so that it may be unwise to allow ADHD to become the new “overshadowing classification.” And thus, while Studio 3 offers diagnostic assessment for ADHD, we remain mindful of broader perspectives in the life of the person so that we can find solutions which best fit the context in which a person lives, and indeed their own strengths and weaknesses. Part of this challenge is for example to take care not to always see a child as the “identified patient,” and keep in mind that difficulties at school for example might be around perceived lack of safety in their world from their perspective. And so the question around diagnosis becomes; “Is it appropriate in this case and helpful for this client to offer a diagnosis of ADHD?”

To summarise, our approach at Studio 3 is to explore and offer diagnosis when that is felt ethically necessary or helpful as a tool which leads to clarification of a person’s difficulty or needs. We are unashamedly person-centred in our perspective. The more precise tool psychologists use alongside diagnosis is what we call formulation. A formulation might draw upon diagnosis, but seeks to arrive at a unique understanding of a person’s struggle, and thus make meaning of individual psychological or behavioural difficulty. A formulation might draw upon past losses or adverse experiences, or how change in a person’s life has caused distress they cannot cope with. An autism diagnosis, for example, might therefore lie at the heart of the formulation, but would not itself define the problem or in itself guide interventions. Similarly, nor might a formulation lead to interventions that place responsibility with the person, as often it is the support system around the person where one can realistically effect change rather than through 1:1 therapy. It is possible, for example, to work with parents or a school in response to a child with anxiety, rather than placing the onus for change on the child who may have no real insight into their distress. This of course is how we all started out in life; caregivers helped us co-regulate, and so can relational and environmental systems around us as we grow up. And so it is often the case that a person might not be equipped to cope with the tasks of 1:1 therapy, but can heal if the family, school, caregivers and/or workplace make environmental and relational adjustments so as to create conditions in which they can cope.

Most of our work at Studio 3 is about just this – supporting systems around a person to help the person themselves manage to cope. Dan Hughes (PACE; Hughes & Golding, 2012), Eli Lebowitz (SPACE; Lebowitz, Omer, Hermes & Scahill, 2014) and Professor Andrew McDonnell (Low Arousal Approach; McDonnell, 2010) offer examples of such systemic caregiver models that we can draw upon when working with families.

At Studio 3, much of our work is to support parents or caregivers to feel confident and competent to lead interventions which bring systemic safety so that a person can cope. Diagnosis often offers an important clarification that allows new thinking and ways to support a person, but is just one part of a more complex attempt to connect general theory with real people and their needs. I hope Maslow would be satisfied that his thoughts are very much alive in what we do.

Written by

Dr. John McDermott

Studio 3, Counselling Psychologist

For more information about Studio 3's diagnostic and assessment services, visit


Hughes, D., & Golding, K. S. (2012). Creating loving attachments: Parenting with PACE to nurture confidence and security in the troubled child. London: Jessica Kingsley Publishers.

Kupferstein, H. (2018). Evidence of increased PTSD symptoms in autistics exposed to applied behavior analysis. Advances in Autism, 4(1), 19-29.

Lebowitz, E. R., Omer, H., Hermes, H., & Scahill, L. (2014). Parent training for childhood anxiety disorders: the SPACE program. Cognitive and behavioral practice, 21(4), 456-469.

Maslow, A. H. (1966). The psychology of science: A reconnaissance. New York: Harper & Row.

McDonnell, A. A. (2010). Managing aggressive behaviour in care settings: Understanding and applying low arousal approaches. Oxford: Wiley-Blackwell.

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