Circles Inside Squares: A Graphic Organizer to Focus Diagnostic Formulations

When parents bring their child or adolescent for consultation with a mental health professional, they are usually frustrated, worried, and confused. They may have a litany of complaints about symptoms and problematic behaviors exhibited by their son or daughter, and the entire family is likely to feel bewildered, caught up in intense, conflicting emotions. One of the most important services a clinician can offer in this situation is to provide a clear formulation of the presenting problems so that all involved can grasp underlying problems in the context of stresses and strengths of the child and family. I have developed a simple graphic that seems useful as a tool to organize my diagnostic formulations. This graphic consists of two separate squares within which are overlapping circles of a Venn diagram. It can be used to present a clinician’s view of the patient’s present life situation and to focus conversation between patient, family members, and clinician about how best to understand, prioritize, and respond to the current dilemmas of the patient and family. Near the end of an initial consultation, I draw a moderately large square on a paper to represent the patient as a person. Within this square, I note several important strengths of the patient—e.g., ‘‘very bright,’’ ‘‘good at fixing things,’’ ‘‘hard worker,’’ ‘‘loyal to family,’’ ‘‘great soccer player,’’ ‘‘excellent guitar player.’’ I feel that it is important to begin with recognition of the patient’s strengths to counteract the tendency of patient and family during an initial consultation to focus solely on the patient’s weaknesses and failures. I want to make explicit my recognition of the patient as not simply a bundle of problems, but as a person who has strengths as well as impairments. During a consultation that has focused on a child’s serious difficulties in schoolwork and family life, it seems important to recognize that this child also is the best pitcher on his little league team, well-liked by several close friends, or kind to her little sister. After mentioning and writing important strengths in the ‘‘patient square,’’ I draw several overlapping circles within that square to represent each appropriate diagnosis, perhaps one circle for attention-deficit/hyperactivity disorder (ADHD) overlapped with others for reading disorder and disorder of written expression, as well as another for anxiety. (See the Venn diagram in Figure 1 for an illustration.) The overlap indicates the extent to which impairments of one disorder are similar to or interacting with impairments of other disorders. Most patients have one or more comorbid disorders in addition to their primary diagnosis; this model provides a way to highlight one problem while also recognizing other impairments that complicate the situation. I use the largest circle to represent the diagnosis that describes the problems that are most important at the present time; additional diagnoses are represented in sizes proportional to their apparent importance. Sometimes in the initial session, I am uncertain about how to conceptualize and label a specific problem. An example might be a child who clearly has ADHD, but also has chronic and fairly severe difficulties in getting along with peers, lacks empathy, often annoys classmates with inappropriate comments, and tends to avoid contact with others of the same age outside school. In the first consultation, I may be uncertain as to whether the child suffers from Asperger’s disorder or social anxiety in combination with ADHD. At that point, I might draw a circle and label it ‘‘social problems with other kids’’ and add a couple of question marks to indicate that we do not yet have a clear understanding of those specific difficulties. Accepted July 28, 2005. Dr. Brown is with the Department of Psychiatry, Yale University School of Medicine, New Haven, CT. Correspondence to Dr. Thomas E. Brown, 1188 Whitney Avenue, Hamden, CT 06517; e-mail: tebrownyu@aol.com. 0890-8567/05/4412–1309 2005 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000183463.64648.a5