Diagnostic Overshadowing
Definition:
A clinical bias in which a patient’s presenting symptoms are misattributed to a previously identified condition, disability, or characteristic rather than recognized as indicators of a separate, co-occurring condition. In internationally mobile contexts, diagnostic overshadowing operates in two directions: neurodevelopmental presentations may be attributed to the child’s migration or relocation experience rather than assessed for underlying conditions; and in children with known neurodevelopmental diagnoses, new symptoms may be attributed to the known diagnosis rather than investigated for co-occurring conditions or mental health challenges arising from relocation stress.
Comparable terms:
Diagnostic masking (see separate entry — related; masking refers to misattribution of neurodevelopmental signs to cultural context; overshadowing refers to misattribution of new symptoms to an existing diagnosis) · Clinical bias (broader — any systematic error in clinical judgment) · Diagnostic fixation (clinical — the cognitive tendency to stop seeking alternative explanations once a diagnosis is established) · Attribution error (psychology — the broader cognitive mechanism underpinning overshadowing)
Sources:
Diagnostic overshadowing was first coined by Reiss, Levitan, and Szyszko in the early 1980s to describe the tendency to assess individuals with intellectual disability less accurately, with subsequent research consistently demonstrating that a known diagnosis negatively impacted clinicians’ ability to make accurate judgments about co-occurring conditions. Kanne, S. (2018). Diagnostic overshadowing. In F. Volkmar (Ed.), Encyclopedia of Autism Spectrum Disorders. Springer.
In studies of autism in ethnic minority and immigrant-background populations, diagnostic overshadowing has been documented as a mechanism through which behavioral and emotional presentations are foregrounded, obscuring underlying neurodevelopmental conditions and contributing to delayed or missed autism diagnosis in non-White youth. Ruffin, N.M. & Sanusi, P. (2025). Race/ethnicity, intellectual disability, and diagnostic characteristics among school-aged youth with autism. Autism Research.
See also:
Diagnostic Masking (Neurodiversity & Medical Complexity Abroad); Cultural Humility (Cultural Adaptation); DSM (Wellbeing & Mental Health). Diagnostic overshadowing is most effectively countered by the clinical practice of cultural humility — the explicit acknowledgment that one’s assessment framework may carry cultural assumptions that distort perception of the presenting child. Practitioners assessing internationally mobile children with known neurodevelopmental diagnoses should maintain active inquiry about new symptoms rather than defaulting to attributing change to the known profile or to the relocation context. The DSM entry provides the diagnostic framework within which overshadowing most commonly occurs; cultural humility provides the attitudinal corrective.
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