Give My Child a Label: Strategies of Epistemic Corroboration in Case-Building within Child Mental Health Assessments

Child mental health services are in rising demand, but increasingly overstretched and difficult for families to access. This article examines rhetorical techniques used by parents seeking a mental health diagnosis for their child. Using recordings of consultations from a child mental health clinic (UK) with 28 families, analysis focuses on the use of ‘epistemic corroboration’, a strategy by which third-party candidate diagnoses are reported to support the parents’ case. That is, parents draw upon the expertise of non-present professional persons to strengthen their proposed diagnostic claims. Conversation analysis shows how this epistemic corroboration is reported by parents and received by mental health practitioners. Conclusions illustrate that mental health diagnosis for children is actively pursued by parents as they navigate labelling. This has implications for understanding the dilemmas created for families of possible medicalisation of their child to achieve the levels of support being sought.


Introduction
Recent years have seen a significant increase in social recognition of, and a corresponding rise in concerns over, child mental health.Indeed, the COVID-19 pandemic and associated lockdowns led to a considerable increase in demand for mental health services for children and young people, especially in groups already disadvantaged and marginalised, with demand far outstripping supply across the world (Fegert et al., 2020).The responsibility for meeting this demand, and in determining whether a child reaches a threshold for clinical diagnosis and consequent supports and treatment falls to mental health practitioners.These practitioners use clinical classification systems to account for a child's functioning to decide whether children or young people are sufficiently ill to access support services and treatments (American Psychiatric Association (APA), 2013).In determining which children qualify for services, these classification systems, like the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) rely on the medicalisation of children's social and behavioural development (Strong, 2014), positioning them as sitting across the boundary of what is 'normal' in society and requiring medical intervention.
It is important to recognise that mental health systems classifying the mental health of children and young people are historically and culturally specific and are intrinsically tied to medical power in terms of deciding what constitutes the typically developing child (Burman, 2008).Some have therefore argued that the medicalisation of society is a form of social control, and its surveillance pushes adherence to social norms (Nettleton, 2020).Any appreciation of 'pathology' is grounded in a constructed understanding of 'normality' (Canguilhem, 1989), and in this way the 'atypical' child is created rather than revealed by professional practices founded in that child surveillance under the guise of developmental milestones (Burman, 2008).Despite this contextual understanding of how labels function socially, notions of labelling children's emotions and behaviour have become embedded in lay understanding of typicality and parents seek out explanations when concerned and if they require support from services.This is largely due to the complex mediating factor of the parental relationship and parental understandings of normalcy (Cunningham, 1994).Such constructions of normalcy are thus connected to parental self-presentation as competent (Lauritzen, 1997).Indeed, research has illustrated that parents may seek to make sense of their uncertainty by pursuing a label while simultaneously acknowledging the constraining nature that such diagnostic language brings (McLaughlin and Goodley, 2008).
In managing their uncertainty and raising concerns about their child, parents must navigate a complex landscape of help-seeking.In seeking a possible diagnosis for their child, they must first register their concerns, and the initial step is a mental health assessment.In the UK, these initial mental health assessments are mostly conducted through Child and Adolescent Mental Health Services (CAMHS) attached to the National Health Service (NHS) following a referral from the General Practitioner (GP) (Karim, 2015).However, in the current context of NHS funding restrictions and competing demands, CAMHS tend to be over-subscribed, under pressure and difficult to access, and this initial step can be challenging for families.For example, research estimated an average of just over three years from the initial registration of family concerns to eventual diagnosis (Crane et al., 2016;Shanley et al., 2008).Consequently, families have much at stake in convincing practitioners of the validity of their case during the assessment.
In bringing a child to a mental health clinic, parental accounts of the child are a fragile endeavour as they risk positioning their child as 'unfixable' (Lester et al., 2015), or being positioned as themselves to blame for any difficulties (Blum, 2007;O'Reilly and Lester, 2016;Patrika and Tseliou, 2016).Thus, any appeal to practitioners to classify a child is a careful practical accomplishment relying on multi-party verbal interaction, namely the negotiation between mental health practitioners, adult family members and the child or young person.It is through language and social interaction that the child's pathology is constructed and realised for all practical purposes in the social world (Avdi et al., 2000, Brownlow andLamont-Mills, 2015;O'Reilly and Lester, 2017;Strong, 2012).The rhetorical business of persuading a professional to take their concerns seriously is a challenge, and reveals not only a power differential, but an associated epistemic inequality between parents and mental health practitioners in relation to rights to mental health assessment and diagnosis.In particular, the practitioner conducting the assessment may refer to reports and documentation from other professionals not necessarily available to parents, such as the GP referral or reports from school pastoral services (although parents can request to see these).
With this prioritisation of expert opinion to inform assessment and diagnosis, parents may feel they are not on an equal footing when presenting their own perspectives.Furthermore, in the assessments, parental accounts are accompanied by the child's version of what they consider to be the difficulties experienced, and potentially other family members too.These accounts may not always be entirely congruent, as the child may actively disagree or offer an alternative reading of an event or issue, or parents may be contradicted by the other present parties (e.g. a grandparent).Likewise, the parents themselves may offer slightly different or even contradictory accounts of events in building their case.
In this article, we analyse one strategy used by parents in this kind of asymmetrical institutional context (see Drew and Heritage, 1992).In our data, we observed that parents orient to a need to introduce into their accounts other, more socially validated sources of information from other, non-present parties in ways that show that the version of the child they are presenting is not theirs alone.These third-party accounts are presented in a way to bolster parents' own accounts of their child's problems.We refer to this as epistemic corroboration.
Within the initial assessment, different epistemic sources can be brought into play to underpin claims made about the child's proposed problems.Among the co-present participants of the family members and practitioners, they bring different kinds of knowledge to the table.The family members (mother, father, grandparent, sibling) bring experiential knowledge about their family life, while practitioners doing the assessment bring 'expert' knowledge from their professional training.But also other, non-present third parties can be animated, their opinions being referred to by the co-present interlocutors: primarily by family members.
Analysis identified that parents engage in rhetorical work that functions to persuade mental health practitioners of the validity of their claims.They accomplish this by utilising the views of non-present professional third parties who are reported to corroborate their construction of the nature of the problem.This epistemic corroboration by non-present third parties was sometimes presented first and followed with descriptive evidence.Alternatively, behavioural evidence was presented first and followed by epistemic corroboration: Third-party proposed candidate diagnosis -the parents propose a candidate diagnosis by reporting the views of a non-present third party in a recognised profession like GP or teacher.Typically, this third-party report is offered by parents first as a possible decision of the assessment.The parent then offers descriptions of the child's behaviour that align with that reported candidate diagnosis.
Third-party reported corroboration -the parent cites the views of a non-present professional third party as a supportive opinion that corroborates their own view of the nature of the child's symptoms and behaviours being indicative of a mental health diagnosis.

Method
Based on a data corpus of initial assessment meetings recorded as part of the routine work of a child and adolescent mental health clinic in a large UK city, we use the methods of conversation analysis (Hutchby and Wooffitt, 2008) to examine the techniques by which family members seek to introduce externally sourced information into their narratives of concern over the child's behaviour or development.
Our analysis focuses on the pre-diagnostic screening process conducted as core institutional business in a CAMHS setting.Before a diagnosis can be ascertained and a label ascribed, practitioners trained in such matters must first agree that a 'problem' exists, which becomes the foundation for determining the nature of the help or treatment offered.Thus, the initial assessment is designed to provide an initial formulation of the possible presenting problem (Parkin et al., 2003), and identify any risks that may require attention (Mash and Hunsley, 2005).

Data
Data were collected in partnership with a CAMHS clinic.Our focus was on the initial assessment meetings in the general outpatient setting; that is, the strand of the service designed to identify and stream patients to more specialist pathways of treatment (or discharge).Sampling was purposeful, and data were video recorded to capture all elements of the interactions.For safeguarding purposes, urgent and acute appointments were excluded.
Each assessment lasted for approximately 90 minutes and 28 families were included.All families had been referred from their GP and had been waiting approximately six to eight months for their appointment.The referred children attended with one or both parents (in 27 cases the mother attended, with 20 cases the mother attending without the father, and in eight cases the father attended, with one case being the father only and the other seven attending with the mother).Some appointments also included siblings or other family members and sometimes other professionals.The demographic profile of the children was 64% boys (N = 18) and 36% girls (N = 10) aged from six to 17 years.Assessments typically included two professionals.The data included all team members, ranging from child and adolescent psychiatrists of different levels of seniority, clinical psychologists, assistant psychologists, occupational therapists, psychotherapists and community psychiatric nurses (CPNs) (i.e.nurses specialising in mental health).

Ethics
Ethical approval for the project was provided by the National Research Ethics Service.In practice, all parties (including all children) gave consent or assent prior to the assessment.They also gave consent or assent at the end of the assessment so that they could make an informed decision once clear about what had been recorded.All parties were given information about the study in advance and appropriate safeguarding was in place.Pseudonyms were used throughout transcription and no identifying features appear in this article.

Analytic Method
Applied conversation analysis (CA) is an approach to talk-in-interaction that primarily attends to social interaction in institutional settings (Lester and O'Reilly, 2019).In general, CA's aim is to investigate the sequential organisation of talk as a way of accessing participants' understandings of, and collaborative means of organising, natural forms of social interaction.A distinctive methodological feature is that CA gathers its data of naturally occurring interactions as they unfold in real time using video-or audio-recording technology.Recordings are transcribed in close detail to allow for fine-grained analysis of the design, exchange and coordination of talk-embodied actions within social interaction (talk-in-interaction).CA's utilisation of naturally occurring data to capture what happens in real-world practice can be especially helpful for examining healthcare interactions (Kiyimba et al., 2019).Capturing real-world data as evidence can be beneficial to patient care, especially as patients and clinicians become acclimatised to the presence of recording devices (see Parry et al., 2016).
Our use of CA here does not seek to make any claims about the a priori goals of parents engaged in help-seeking, rather, we inductively illuminate the social actions engaged in by parents through their talk.In using this inductive approach, data were explored by the research team members to identify phenomena, with an attitude of unmotivated looking (Sacks, 1992).Once a recurring phenomenon was identified, the data corpus was searched for every extract that included this phenomenon.A closer analytic review of these extracts then identified more specific social actions that were found to cluster around certain themes.While there were several different ways in which parents built a case that their child required a mental health label, the ones that involved drawing upon the expertise of non-present third parties were selected as a point of focus.Our interest in these particular social actions was the asymmetry between the family members and the mental health practitioners and their relative epistemic differences.Extracts were chosen from a range of different families to illustrate the scope of the phenomenon across the data corpus.

Findings
Frequently, in a medical setting, in presenting the nature of a problem, members are engaged in a process of justifying the need for medical intervention (Heritage and Robinson, 2006b).In CAMHS, specifically, problem presentation occurs within an environment where there could be potential other readings of the child's difficulty, such as insufficiencies in parenting or inappropriate parental over-concern (see O'Reilly and Kiyimba, 2021;Trigueros et al., 2022).Analysis revealed that parents engaged in rhetorical work to persuade practitioners that the child's problems were grounded in medical reasons.They accomplished this by utilising the views of nonpresent professional third parties who were reported to corroborate the nature of the problem, that is, epistemic corroboration.We start by exploring cases whereby there is a third-party proposed candidate diagnosis and move to discussing third-party reported corroboration.

Third-Party Proposed Candidate Diagnosis
In extract (1), the child is being assessed on a return visit to CAMHS, having previously been seen by a mental health practitioner (referred to as 'Terry') for an intervention to address symptoms of obsessive-compulsive disorder (OCD).The CPN opens with a formulation of the child's description of events demonstrating that her understanding is that things have 'got worse' and checks with mother and child that this summary is accurate, providing a platform for them to expand on the difficulties faced.

Extract (1): Family 21 (Child = 17 years)
The CPN formulates the reason for the return visit as being a worsening of symptoms over the 'last year'.The formulation and subsequent confirmation-seeking question (lines 1-2, 6) are directed towards the child, as is common in this setting when discussing reasons for attendance (Stafford et al., 2016).The child's brief responses seem to  indicate a disagreement (lines 5, 7), which could initiate further investigation by the CPN.However, the mother interjects to provide more detailed turns, despite her initial assertion that she does not 'wanna start interfering' (lines 3-4).This is consistent with evidence from other clinical settings where professionals tend to select children as problem presenters, but it tends to be parents that undertake this action, speaking 'for' the child while also orienting to their child's rights to speak for themselves (Hutchby and Wooffitt, 2008;Stivers, 2001).The mother's turn (spanning lines 8-19) contains several actions that contest her child's apparent disagreement with the CPN's formulation that things have 'got worse' over the past year.In other words, she seeks to maintain the worsening of symptoms as a reason for the return visit; however, in several ways, she seeks to upgrade the status of those symptoms and, by extension, the severity of the diagnosis.It is noted, however, that in proffering an alternative diagnosis, as a lay person the mother uses hedging devices including 'more issues' (line 10), 'other things' (line 12) and 'such as like' (line 14).These hedging devices serve the mother in positioning herself as having fewer epistemic rights to lay unequivocal claims to diagnostic labels, rather she is offering them to the medical professional for ratification.
She first complains that the work done by Terry 'didn't do ANYthin' at all to help him' (line 8).This complaint uses an extreme case formulation (Pomerantz, 1986), 'didn't do ANYthin' at all', to add extra emphasis to the mother's opinion, highlighting its noteworthiness as an evaluation of the clinic's professional decision making.Later, she works to present the case that the current mental health practitioner is required to revisit the diagnosis and potentially accept that the previously assigned label was incorrect, or at least incomplete.By ascribing a new candidate diagnosis of 'autism' to an absent medical professional, the family doctor, the mother legitimises her use of medical-diagnostic terminology (Heritage and Robinson, 2006b).In addition, the use of the adverb 'actually', often used to emphasise the legitimacy of a claim ('the doctor actually thinks there's more issues', line 9-10), serves to bolster her position that the current diagnostic label of OCD and associated treatment is inappropriate (Clift, 2001).Thus, using 'actually', Terry's first name versus the title 'doctor', and the positioned failure of treatment for OCD, all function cumulatively to discredit the OCD diagnosis, and rhetorically preference the non-present doctor's account that it may be 'autism'.
Notably, during the mother's account, the co-present psychiatrist and CPN restrict themselves to the production of minimal responses: a continuer (Schegloff, 1982) in line 13 and an acknowledgement token 'Okay' in line 20.Through these actions they enable the epistemic corroboration furnished by the GP and offered forth by the mother at least to be heard: to be given space within the ongoing diagnostic process.
In other examples, the co-present practitioners can play a more active role in eliciting a family member's epistemic corroboration for a candidate diagnosis proposed by the third party.The next extract provides an example of this.As the extract begins, the psychiatrist is seeking to clarify the developmental milestones from the child's early life.

Extract (2): Family 17 (child = 16 years)
Additional to ascertaining normative biological developmental milestones, the psychiatrist also demonstrates an interest in investigating the child's educational and social history.Having begun by asking for confirmation that the child went to preschool nursery, the psychiatrist seeks the mother's assessment of that experience (line 3).Instead of presenting her own assessment, the mother articulates the view of the pre-school nursery.By reporting this, without offering any disagreement, she implicitly indicates her agreement with this assessment.The use of the pronoun 'they' in referring to the nursery as an organisation with multiple staff, rather than specifying a specific individual, accomplishes a claim to an institutional perspective.In line 6, rather than an acknowledgement token or continuer, the psychiatrist actively solicits further information about what the nursery workers may have said in their evaluations of the child's behaviour.This provides the mother the opportunity, in response, to run through a series of possible diagnoses put forward by the nursery: dyspraxia, 'obvious. . .underlying thingys', learning difficulties, culminating in a statement that the child was assigned to a SENCO (Special Educational Needs Coordinator) from the relatively young age of four.The specification of a professional role in this instance demonstrates the necessity of additional professional support to manage the child's difficulties.
Thus, although the mother does not, as happened in extract (1), propose a specific candidate diagnosis, she utilises the third-party nursery workers' proposals about the range of possible diagnoses for her child to bolster her case that a referral for CAMHS treatment should be an outcome of this assessment meeting.In this instance, moreover, she is assisted in that corroboration project by the co-present psychiatrist's questions.
In extract (3), we see a similar third-party offering as family members seek to bring into play the opinions of a different kind of non-medical third party, the headmaster at the child's  Heritage and Robinson (2006b: 84) demonstrated that in accounting for visits to medical professionals, patients often report that others have 'urged or supported their decision to make the visit'.In this case the mother and grandmother work together to indicate that the headteacher was instrumental in the visit to CAMHS, as he 'pushed' for the child to be assessed by a specialist mental health clinic.But whereas a GP, for example, can be assigned to a membership category with entitlement to expert medical knowledge on health conditions, including mental health, here the headteacher would not normatively be accorded the same level of epistemic rights to comment on such conditions.Nonetheless, while potentially epistemically 'lay' in terms of mental health, he does have epistemic rights as an educationalist and holds a senior position, and thus would hold some knowledge of child mental health by virtue of his educational experience and training.This is oriented to by the mother and grandmother who build the case that this headteacher has undertaken additional 'research', which increases his epistemic authority on such matters.Based on this research the headteacher is reported to discount the possibility of personality disorder as a diagnosis for the child, and instead proposed 'detachment disorder'.Notably, a discussion of the possibility of personality disorder as a candidate diagnosis for the child proposed by the mother came earlier in the session and was discounted by the psychiatrist.In this extract the grandmother reported that this possible explanation was also discounted by the headteacher (line 13).The mother had proposed personality disorder as a possible outcome of the assessment, based on the knowledge that the child's biological mother had this diagnosis.
In line 17, with a marked lack of hesitation or mitigation, the psychiatrist issues a straightforward rebuttal of the proposed diagnosis, by denying its legitimacy: 'there's no such thing as detachment disorder'.She goes on to further dispute the likelihood of the child's problems being an example of another, more psychiatrically legitimate condition, 'attachment disorder'.In so doing, the psychiatrist calls into question the epistemic rights of the headteacher to make a specialist mental health judgement ('he's misunderstood that', line 18), rather than a potential mispronunciation or misreporting of what the headteacher said by the parties in the room.
However, despite the psychiatrist's attempt to dismiss the third-party proposed candidate diagnosis, the grandmother adopts a different tack to corroborate her claims by reporting a range of behaviours that are inconsistent with the psychiatrist's evaluation.In this instance, she evidences her claim by reporting the child's inability to engage in typical relationships with peers in the school environment.This again introduces the headteacher as a member with legitimate epistemic rights to make a candidate diagnosis due to his first-hand experiential knowledge of witnessing the child's behaviour in relation to her school peers.In effect, the family members seek to circumvent the psychiatrist's blunt, and epistemically authoritative disagreement with the candidate diagnosis by a layering of epistemic weight, adding rhetorical components together to strengthen the case being built.Thus, despite the mother and grandmother's efforts to propose a range of candidate diagnoses, the psychiatrist refutes each of these possibilities in what Smith (1978) refers to as a process of 'cutting out' differential diagnoses.

Third-Party Reported Corroboration
In the previous section, third parties' candidate diagnoses (autism, dyspraxia, learning difficulties, 'detachment disorder') were offered by parents and corroborated with behavioural descriptions that were congruent with that label.In the following set of examples, the parent(s) describe the behaviour of their child in ways that imply a potential mental health difficulty.They follow this description by citing a non-present third-party professional view as a way of corroborating their claims.
In the following example, the parents report the child's behaviour in the school context, citing emotional challenges that have led to her exclusion from mainstream education and placement in a specialist school.However, the specialist school are currently in the process of trying to refer the child back into mainstream education, but the child and her parents feel that her mental health needs preclude this from being an option.They therefore are seeking a medical diagnosis to utilise as leverage with the educational system to meet the needs of their child.
Extract (4): Family 19 (child = 14 years) The father begins to present a case that the child's 'anger' problems require a specialist school that can cope with this extreme behaviour.However, the psychiatrist begins to reformulate this in more positive terms and argues that the child has potential to achieve academic successes (line 7).In line 8 without discounting the child's potential, the mother begins in overlap to re-focus the discussion onto the child's problems.She raises concern about her daughter's anxiety without using a specific candidate diagnosis and by hedging 'and other issues' (line 19) to display the possibility for a range of mental health diagnoses.She does this in the context of epistemic corroboration, introducing the views of her own CPN.As in extract (3), there is a layering of epistemic valence as the mother's account proceeds.First, the CPN, as a registered mental health practitioner, is positioned as having put forward, to the mother, a candidate diagnosis: that the child's mental health problems are 'mirror images' of the mother's own condition.The legitimacy of this proposal is given additional weight, at least implicitly, by the fact that the mother has evidently been through a diagnosis that is enough to warrant her own CPN visiting her at home 'every three weeks' (line 12).It is during these visits that the non-present third-party mental health professional is positioned as having 'actually brought that up' (line 11).
In positioning the concern as being initiated by the CPN, this functions as a form of stake inoculation (Potter, 1996).In other words, positioning the concern as that of the CPN deflects any potential accusation of the child's difficulty being either related to limitations in parental discipline or a product of an over fussy mother.The fact that the expert other has appropriate epistemic rights and first-hand witnessing of the child thus obligates the mother to action that concern.
As aforementioned, the first part of the mother's case about the need for mental health services occurs as an interruption of the psychiatrist's positive appraisal of the child that the child can 'achieve' and has 'potential'.Her case-building challenges a reading of the child that is incongruent with the version the mother is attempting to present.In that context, the psychiatrist's response towards the end of the extract (lines 28-29) is interesting, in that it overtly returns the topic of their discussion to the question of the child's potential in school, including her possible return to mainstream school in due course.Whether this represents an implicit rejection of the case presented by the mother is not clear: both mother and psychiatrist refer to the child getting 'help' (lines 24, 28).However, in sequential terms, it seems to position the mother's attempted epistemic corroboration account as an interjacently positioned action (Hutchby and O'Reilly, 2010) disrupting the psychiatrist's positive appraisal of the child.
In the following two extracts, we again show that rather than sourcing a candidate diagnosis initially from a third party, the parents more overtly begin with their own assessment of the child's difficulties, then cite more epistemically valid third-party views in support of that.
Extract (5): Family 18 (child = 13 years) Mother: even when Nathan (.) and I apologise if I'm being 2 negative ↓to (.) towards ya (0.3) even when Nathan: 3 (0.8) good (1.6) <he's ↓hard to manage> 4 Therap: UM 5→ Mother: and this is not (.) just my own per↓cep[tion 6 Therap: [um: 7 (0.4) 8→ Mother: erm this is (.) from a ↓person that deals with 9→ children's difficult be[hav]iour every day in her= 10 Therap: [mm ] 11 Mother: =profession (0.6) um: she actually had ↓Nathan for 12 about ten days (0.5) an:d she said that (.) [lit]erally= 13 Therap: [↑mm] 14 Mother: =had to be on 'im (.) <ALL THE [TI]ME> 15 Therap: [mm] 16 (0.3) 17 Mother: and (0.9) some of the ↓things: coz he couldn't annoy This extract begins with the mother outlining that the child's behaviour is difficult to manage, even on a good day.Here, the mother's assertion of the child's doctorable reason for attending the initial assessment is supported in the next turn by her report that this reading of the child's behaviour is not merely her own lay opinion but is corroborated by an expert non-present other: 'this is not just my own perception' (line 5).Although the exact profession of the third party goes unspecified and is also a family member, it is her professional status working with SEN (Special Educational Needs) children that is made relevant in the current conversation, a profession that involves frequent exposure to children's difficult behaviour: she is described as 'a person that deals with children's difficult behaviour every day in her profession ' 8-11).This is aligned with her family status as this professional person had the child stay with her and her husband for 'ten days' (line 12), a period sufficient to formulate an understanding of his behaviour.Regarding epistemic layering, then, the mother presents the non-present expert third party as having epistemic rights to knowledge about children's mental health needs by virtue of her profession, but also because of the longevity of her experience.As in previous examples, the use of epistemic corroboration is given additional, rhetorical weight using extreme case formulations: 'literally had to be on 'im (.) <ALL THE TIME>' (line 12-14); 'to get him out the ↓house for school it's literally °she has to be° behind 'im constantly' (line 23-24).
In our final extract, we find an inversion of sorts, in that the mother's proposed diagnosis is so specific it is, in fact, the psychiatrist who seeks out epistemic corroboration for the mother's claims.Here the mother presents the issue that a former ADHD diagnosis is questioned by the family and by the paediatrician (Dr Salomon) and alternatively 'autism' framed as Asperger's is proposed.
Extract (6): Family 16 (child = 8 years) The mother's initial account is not only first-hand, but highly specific, using terms such as 'obsessiveness', 'very Aspergersy' and 'hyperactivity'.She proffers an account in which the child had difficulties when younger, which ultimately became a 'diagnosis' of 'hyperactivity' (lines 7-8).Here, then, the mother is not only using terminology usually restricted to the higher epistemic status of the professional but proposes that her child already has a diagnosis of a disorder of some sort.This poses a challenge to the co-present practitioners.Whether or not they agree with the proposed assessment of the child's difficulties, the mother is attempting to occupy epistemic ground normatively reserved for the professional.In response, the psychiatrist introduces distance between himself and the mother's proposal, first stating that the mother has 'mentioned that a couple of times' referring to the characteristics associated with Asperger's (like obsessiveness), and then asking whether it is something the mother is 'considering' (lines 9-11).In such a way, the psychiatrist makes it clear that he is not the source of the proposed diagnosis, in the process implying there is no guarantee that such a diagnosis will be the outcome of the present meeting.The interactional accomplishment is a process of 'cutting out' (see Smith, 1978) potential diagnoses, and ruling in other possible differential diagnoses.The mother's next turns insist on the validity of the proposed diagnosis (lines 12, 14), which consequently prompts the psychiatrist to seek a form of epistemic corroboration, invoking a non-present third-party professional: 'have you talked to Doctor Saloman about it?'(lines 15-16).
The mother's response (lines 17-22), while beginning with an emphatic 'NO::', shifts tack almost immediately to acknowledge that, in fact, 'Well yeah I have spoken to her' and that Doctor Saloman herself had indicated that the mother should attend the CAMHS assessment meeting 'with an open ↓mind' (line 20).In other words, she concedes that Doctor Saloman may have doubts about the hyperactivity/obsessiveness/'Aspergersy' diagnosis that the mother is forwarding.
Finally, while the mother asserts that Doctor Saloman is 'in agreement' with her (line 25), the psychiatrist orients to the fellow professional status, and hence higher epistemic authority of the absent paediatrician, seeking to check whether any such diagnosis has been made (line 26).Again, the mother must ultimately admit that there has been no professional diagnosis of her child's condition from the doctor, while continuing to push back against the validity of hyperactivity as the only explanation.Nevertheless, the subsequent second mention of approaching the CAMHS assessment meeting with an 'open mind' (line 31) has its own rhetorical function, serving to demonstrate parental reasonableness and willingness to consider other possibilities, which acts as a kind of stake inoculation against the potential of her being seen as rigidly invested in a specific outcome.

Discussion
In an environment of stretched resources where access to mental health services is limited globally and, in the UK (Knapp and Wong, 2020), help-seeking behaviours can be challenging, and families have much at stake in illustrating to those with medical power that their child needs support.In this article, we have shown that when provided the opportunity to engage with mental health practitioners for an initial child mental health assessment, parents work hard discursively to establish a need for a mental health diagnosis, which is the gateway for treatment and other resources.The accomplishment of a label not only has explanatory power to account for children's behaviour, but also functions to gain help in educational and other settings.Through analysis we illustrated that the parental agenda tended to lean towards this explanatory power by seeking a medical label for their child through a diagnosis of a mental health condition.However, broadly speaking, the agenda of the practitioner is different.While they have the power to assign such a label, they are also gatekeepers of the medical resources and have a professional responsibility to assign labels appropriately, in the best interest of the child, and where medically warranted.Evidently, therefore, parents must manage their stake in the outcome of the assessment to convince the expert in front of them that a label is appropriate.
In managing their stake and interest in the outcomes of the assessment, our analysis showed that where parents proposed candidate diagnoses, they did so by drawing up the expertise and knowledge of others.A rhetorical framework used by parents that functioned to emphasise the validity of their viewpoint was that of epistemic corroboration, which tended to be used in two ways.First, we described third-party proposed candidate diagnosis whereby a parent proposed a potential diagnostic label articulated from a non-present professional third party.Second, we described third-party reported corroboration, whereby the parent cited a non-present professional third party's suggested diagnosis as supportive of their own assessment of the child's difficulties.In these ways, parents draw upon the voices of expert others to legitimise their own epistemic claims about their child's mental health difficulties.
Arguably, if parents simply wanted to make sense of what was going on with their child, a thoughtful formulation would suffice.However, it seems that parents were actively pushing for a diagnostic label in the initial mental health assessments that we analysed.Whether or not they believed that the wider social structures contributed to their child's mental health difficulties, and whether they conceive of some possible alternative way to access necessary resources, is not evident in their discourses.In the specifics of the assessments a diagnostic label appeared to be the preferred outcome and one they actively pursued through epistemic corroboration.While the literature strongly indicates that mental health diagnoses can be stigmatising (Timimi, 2014), we did not observe any parental discursive references to stigmatisation in their use of medicalised terminology and the epistemic value of other's reports.
Ultimately, the ways in which parents oriented to the value of a medicalised diagnosis is recognisable in their epistemic appeal.Parental epistemic valence for medical diagnostic categories is relatively low in comparison with the epistemic valence held by mental health practitioners.Because there is an epistemic asymmetry between parents and mental health practitioners, this equates to a power differential in decision making for the allocation or not of diagnostic labels and any associated resources that this may lead to.This reflects the powerful role that mental health practitioners have in determining what constitutes normality and by contrast what constitutes pathology (Burman, 2008).Indeed, diagnosis itself carries a powerful role as this provides a 'cultural expression' of what is accepted as normal by society (Jutel, 2009).To offset this asymmetry parents are observed to borrow the expert knowledge of other professionals to add to their own lay knowledge of their child's difficulties.The sum of their own parental knowledge and the borrowed expertise in their corroborative narratives functions to offset the asymmetry and tip the balance of power slightly in their favour.
Many medical mental health practitioners maintain the use of mental health classification systems and value diagnosis as a tool to differentiate mental health conditions to determine treatment pathways.In this way assessment and diagnosis are interactional sites where power is displayed in relation to how mental health resources are allocated (Jutel, 2009), based on the very notion of what counts as sickness (Nettleton, 2020).In this way, parents become consumers of medicalised ways of explaining their child's behaviour (Strong, 2014).There are however some practitioners in the field of psychiatry and psychology who challenge this prevailing view and promote a more critical or sociological way of thinking about labels (e.g.Timimi, 2014).A key argument in this movement is that western individualised models of psychiatric diagnosis focus on internal mental states without adequately recognising the impact of social challenges such as children's home environment, socio-economic deprivation, racial discrimination, gender discrimination, socio-political structures and other wider systemic influences.Thus, sociological framings seek to disrupt social norms to account for difference (Coleman-Fountain, 2016).
What we have illustrated through our discussion is the value of a social-interactional understanding of diagnosis and related mental health practice (see Heritage and Maynard, 2006a).Our findings have important implications for practitioners working in the field.Mental health practitioners can benefit from understanding the discursive ways in which certain kinds of knowledge become privileged over other kinds of knowledge and should be encouraged to regularly reflect on the power they hold.From a medical perspective, it is helpful when working with families to recognise and acknowledge the value of experiential accounts and actively find ways to credit those.But it is equally evident from our data that families recognise the epistemic privilege associated with medicine and medical terminology, and thus they attempt to articulate their everyday challenges using language that is congruent with medicalisation.
In conclusion, one of the advantages of using naturally occurring data of actual mental health assessments is that it is possible to identify the social actions that occur within and constitute a diagnostic negotiation.Conversation analysis provides a powerful analytic tool to examine language as a vehicle for the management of power dynamics between lay persons and medical professionals.But even within those asymmetrical dynamics, and even though diagnostic labels can be stigmatising, the fact that these are the gateway to services means that parents, ultimately, are prepared to fight to acquire one.
Victoria Lee is a former PhD student at the University of Leicester and recently graduated.Victoria conducted her research through the Greenwood Institute of Child Health, where she focused her research exploring the sociology of diagnosis and mechanisms by which parents seek diagnoses to explain their children's behaviour and feelings.Victoria used conversation analysis to examine child mental health assessments and explored the phases of the appointment, the way in which help is sought and the ways in which decisions are made.
Ian Hutchby is Honorary Professor in the Department of Sociology, University of York, and a visiting researcher in the Greenwood Institute for Child Health, University of Leicester.Ian was Head of the Department of Sociology at Leicester (2011Leicester ( -2014) ) and is a fellow of the Higher Education Academy.Ian conducts research in conversation analysis, focusing on child counselling and family psychotherapy, media talk and political communication, conflict talk, communication and technology.

Date submitted May 2022
Date accepted November 2022 1 At the age of fo:ur school.This discussion follows from an extensive reporting of the child's behaviour and the concerns that the [adoptive] mother and grandmother have about the child.The orientation to the headmaster's perspective is therefore drawn upon to build on that earlier account.This extract shows, first, how such a layperson (albeit an educationalist) can be accorded additional epistemic valence by family members through having 'researched' the issues in question.Second, however, we see that such third-party views are not always accepted by the co-present practitioner.Indeed, in this case, they are summarily dismissed (line 17).