A tri-axial classification of mental disorders in childhood. An international study

Child and adolescent mental health multiaxial classification: A useful biopsychosocial framework for paediatrics?

In child and adolescent psychiatry, the multiaxial classification approach has been developed over some decades and remains very relevant as it encapsulates the biopsychosocial approach, an approach which is also central to paediatric practice. There is considerable overlap between developmental-behavioural paediatrics and child and adolescent mental health, including presenting clinical problems, diagnoses, multidisciplinary and holistic approach to assessment and management, and similar use of pharmacological agents and psychosocial interventions. Multiaxial classification can be of use to paediatricians in a variety of ways, both in clinical practice and for teaching purposes. It can improve communication between the two disciplines and promotes a more holistic diagnostic representation in a structured and consistent format. Presented here are a number of practical ways in which the multiaxial biopsychosocial framework can be used, including case description, formulation, timeline and interventions, training and teaching.

The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond

In this paper we review the impact of DSM-III and its successors on the field of autism-both in terms of clinical work and research. We summarize the events leading up to the inclusion of autism as a "new" official diagnostic category in DSM-III, the subsequent revisions of the DSM, and the impact of the official recognition of autism on research. We discuss the uses of categorical vs. dimensional approaches and the continuing tensions around broad vs. narrow views of autism. We also note some areas of current controversy and directions for the future.

Multiaxial classification in child and adolescent mental health - a reaffirmation of benefit and practical applications

OBJECTIVE

Classification systems and their practical implications have become increasingly important in child and adolescent psychiatry. This paper presents the evolution and practical applications of a multiaxial classification system for children and adolescents presenting to mental health services. Included are some worked examples demonstrating both the complexity of many presentations and how broadening the use of the multiaxial system can help in identifying appropriate interventions.

CONCLUSIONS

Classification systems in child and adolescent psychiatry have largely remained uniaxial in nature. A multiaxial system encapsulates the broader biopsychosocial aspects of the presenting child or adolescent, and orders complex data in a concise manner. This approach can be used to concisely communicate with other treating clinicians, and assist with case reviews, formulation and teaching.

Psychiatrie et épidémiologie

L’épidémiologie psychiatrique s’est beaucoup développée depuis trente ans. Après avoir rappelé les définitions et méthodes fondamentales en épidémiologie, nous décrivons des progrès accomplis en épidémiologie psychiatrique. Parmi eux, la définition des cas, les techniques d’identification des cas, et la recherche de facteurs de risque sont présentés ici. Pour les illustrer, certaines connaissances actuelles sur les facteurs de risque dans la schizophrénie et la dépression sont brièvement décrits. Ensuite, les travaux en psychiatrie de l’enfant sont brièvement présentés en insistant sur quelques difficultés spécifiques à la recherche en pédopsychiatrie. Finalement, après avoir fait le point de la situation française, quelques opinions communes qui freinent l’essor de la recherche épidémiologique sont passées en revue. Les conclusions soulignent la possibilité et la nécessité de développer cette approche multi-disciplinaire en psychiatrie.

Family process and youth internalizing problems: A triadic model of etiology and intervention

Despite major advances in the development of interventions for youth anxiety and depression, approximately 30% of youths with anxiety do not respond to cognitive behavioral treatment, and youth depression treatments yield modest symptom decreases overall. Identifying networks of modifiable risk and maintenance factors that contribute to both youth anxiety and depression (i.e., internalizing problems) may enhance and broaden treatment benefits by informing the development of mechanism-targeted interventions. A particularly powerful network is the rich array of family processes linked to internalizing problems (e.g., parenting styles, parental mental health problems, and sibling relationships). Here, we propose a new theoretical model, the triadic modelof family process, to organize theory and evidence around modifiable, transdiagnostic family factors that may contribute to youth internalizing problems. We describe the model's implications for intervention, and we propose strategies for testing the model in future research. The model provides a framework for studying associations among family processes, their relation to youth internalizing problems, and family-based strategies for strengthening prevention and treatment.

The multiaxial assessment and the DSM-III: a conceptual analysis

With the release of the DSM-III, multiaxial assessment, which was a new concept, was introduced to daily clinical practice. This article will review the history and the development of the concept of multiaxial assessment and will focus on the its relationship to the DSM-III. In conclusion I will discuss different critiques of the concept.

Adult diagnostic and functional outcomes of DSM-5 disruptive mood dysregulation disorder

OBJECTIVE

Disruptive mood dysregulation disorder (DMDD) is a new disorder for DSM-5 that is uncommon and frequently co-occurs with other psychiatric disorders. Here, the authors test whether meeting diagnostic criteria for this disorder in childhood predicts adult diagnostic and functional outcomes.

METHOD

In a prospective, population-based study, individuals were assessed with structured interviews up to six times in childhood and adolescence (ages 10 to 16 years; 5,336 observations of 1,420 youths) for symptoms of DMDD and three times in young adulthood (ages 19, 21, and 24-26 years; 3,215 observations of 1,273 young adults) for psychiatric and functional outcomes (health, risky/illegal behavior, financial/educational functioning, and social functioning).

RESULTS

Young adults with a history of childhood DMDD had elevated rates of anxiety and depression and were more likely to meet criteria for more than one adult disorder relative to comparison subjects with no history of childhood psychiatric disorders (noncases) or individuals meeting criteria for psychiatric disorders other than DMDD in childhood or adolescence (psychiatric comparison subjects). Participants with a history of DMDD were more likely to have adverse health outcomes, be impoverished, have reported police contact, and have low educational attainment as adults compared with either psychiatric or noncase comparison subjects.

CONCLUSIONS

The long-term prognosis of children with DMDD is one of pervasive impaired functioning that in many cases is worse than that of other childhood psychiatric disorders.

Sons and daughters beyond your control: episodes in the prehistory of the attention deficit/hyperactivity syndrome

Hyperactive and inattentive children have been discussed in both the pedagogic and medical literature since the nineteenth century, and many controversies associated with attention deficit and hyperactivity disorder (ADHD) have been repeatedly analyzed in different contexts. The 'prehistory' of the ADHD concept-that is, up to the definition of ADHD in DSM-III and of the corresponding 'hyperkinetic disorder' in ICD-9-is outlined, with an emphasis on the literature not previously discussed in English language reviews of the subject.

Childhood disintegrative disorder: distinction from autistic disorder and predictors of outcome

Childhood disintegrative disorder, a rare, relentlessly progressive neurologic disorder, first described by Heller in 1908, remains a condition of great interest. It has long been debated whether it is a discrete disorder or simply a late-onset variant of childhood autism. We have studied 6 cases of childhood disintegrative disorder, collected over 8 years, and followed for 2.5 to 22 years (mean 8.6 years). Childhood disintegrative disorder begins later in life than autism, and following a period of entirely normal development; the regression is more global and more severe than in autism; seizures are more frequent than in autism, yet demonstrable organicity in childhood disintegrative disorder is decidedly rare. Lastly, the prognosis is usually much worse than in autism, but in those cases with neither seizures nor epileptiform activity on electroencephalography (EEG), the outcome may be more favorable. Childhood disintegrative disorder should be viewed as a condition distinct from childhood autism.

Psychosocial stressors and the prognosis of major depression: a test of Axis IV

BACKGROUND

Axis IV is for reporting 'psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental disorders'. No studies have examined the prognostic value of Axis IV in DSM-IV.

METHOD

We analyzed data from 2497 participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) with major depressive episode (MDE). We hypothesized that psychosocial stressors predict a poor prognosis of MDE. Secondarily, we hypothesized that psychosocial stressors predict a poor prognosis of anxiety and substance use disorders. Stressors were defined according to DSM-IV's taxonomy, and empirically using latent class analysis (LCA).

RESULTS

Primary support group problems, occupational problems and childhood adversity increased the risks of depressive episodes and suicidal ideation by 20-30%. Associations of the empirically derived classes of stressors with depression were larger in magnitude. Economic stressors conferred a 1.5-fold increase in risk for a depressive episode [95% confidence interval (CI) 1.2-1.9]; financial and interpersonal instability conferred a 1.3-fold increased risk of recurrent depression (95% CI 1.1-1.6). These two classes of stressors also predicted the recurrence of anxiety and substance use disorders. Stressors were not related to suicidal ideation independent from depression severity.

CONCLUSIONS

Psychosocial and environmental problems are associated with the prognosis of MDE and other Axis I disorders. Although DSM-IV's taxonomy of stressors stands to be improved, these results provide empirical support for the prognostic value of Axis IV. Future work is needed to determine the reliability of Axis IV assessments in clinical practice, and the usefulness of this information to improving the clinical course of mental disorders.

Classification issues and challenges in child and adolescent psychopathology

The major advances that have taken place over the last half century are reviewed with a focus on those that are particularly important with respect to classification issues in the field of child and adolescent psychopathology. Attention is paid to the conceptual issues in DSM and ICD development and differences between the two classifications. Specific recommendations for changes in ICD-11 are presented and an online supplement provides specific details with respect to diagnostic categories that are in need of further testing.

Research review: Child psychiatric diagnosis and classification: concepts, findings, challenges and potential

The conceptual issues are briefly noted with respect to the distinctions between classification and diagnosis; the question of whether mental disorders can be considered to be 'diseases'; and whether descriptive psychiatry is outmoded. The criteria for diagnosis are reviewed, with the conclusion that, at present, there are far too many diagnoses, and a ridiculously high rate of supposed comorbidity. It is concluded that a separate grouping of disorders with an onset specific to childhood should be deleted, the various specific disorders being placed in appropriate places, and the addition for all diagnoses of the ways in which manifestations vary by age. A new group should be formed of disorders that are known to occur but for which further testing for validity is needed. The overall number of diagnoses should be drastically reduced. Categorical and dimensional approaches to diagnosis should be combined. The requirement of impairment should be removed from all diagnoses. Research and clinical classifications should be kept separate. Finally, there is a need to develop a primary care classification for causes of referral to both medical and non-medical primary care.

Developing ADHD

Over the past 50 years the concept of attention deficit/hyperactivity disorder (ADHD) has developed from the notion of a specific form of brain dysfunction to that of a heterogeneous set of related behaviours. The great advances in genetics, neuroimaging and neuropsychiatry have made it one of the best understood forms of complex mental disturbance--but much remains to be done to translate understanding into practice. More effective treatment may come from identifying and treating more specific components of disorder and by a focus on identifying the factors determining course in the longer term so that they, as well as the core features of disorder, can become targets for intervention.

Behaviorally-based disorders: the historical social construction of youths' most prevalent psychiatric diagnoses

Psychiatry in the USA controls the definitions of mental health disorders and diagnosis through required practice utilization of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and fiscal reimbursement using it. The present sociohistorical research paper presents and critically examines the Manual's systemic and diagnostic development of today's most prevalent youth mental health diagnoses (conduct and oppositional defiant disorders). Through a social construction theoretical paradigm, this research identified diagnostic classification systems, nosology changes, critical time periods, conducive social and cultural conditions, and key individuals involved in the development of these youth behaviorally-based disorders within two distinct historical time frames: 1880 to 1968 and 1969 to 2000. It also identified patterns of nosology system and diagnostic category changes based upon very limited empiricism, inordinately influenced by a limited number of individuals, and understood through a socially constructed framework.

Psychosocial situations, quality of depression and schizophrenia in adolescents

The relationships between acute life events and type of depression were evaluated among inpatient adolescents with schizophrenia. Forty-two adolescent inpatients were assessed, 25 with schizophrenia and 17 with personality disorder. Acute life events and other psychosocial situations were identified with the ICD-10 Axis V semistructured interviews. The Depression Equivalent Questionnaire for Adolescents (DEQ-A) and the Positive and Negative Symptom Scale (PANSS) were used to measure quality and severity of depression. In the patients with schizophrenia, psychosocial situations were related to the anaclitic type of depression, whereas in the subjects with personality disorder, they were highly correlated with introjective depression. In the schizophrenic group, the psychosocial situations related to depression were of a more intrapersonal nature and, in the personality-disordered group, they were more interpersonal. Environmental factors play an important role in the course of schizophrenia in adolescents and should remain a focus of study. Object relations theory may be of heuristic value in the investigation of these factors.

Bedingen abnorme psychosoziale Umstände längere Verweildauern in einer kinder- und jugendpsychiatrischen Klinik?

Zusammenfassung. Es wird untersucht, ob das Vorliegen abnormer psychosozialer Belastungen (Achse V der ICD-10) die Dauer der stationären Behandlung von Kindern und Jugendlichen mit einer psychiatrischen Störung verlängert. Deswegen wurden die Daten stationär zwischen Juli 1990 und Dezember 1999 behandelter Patienten mit den Diagnosen einer Hyperkinetischen Störung (F 90.x), einer Störung des Sozialverhaltens (F91.x), Störung des Sozialverhaltens und der Emotionen (F92.x) sowie Anorexia nervosa (F50.0) untersucht. Es zeigte sich, dass Patienten mit einer kombinierten Störung des Sozialverhaltens und der Emotionen häufiger Belastungen auf der fünften Achse aufwiesen, während dies bei anorektischen Patientinnen seltener der Fall war. Bezogen auf die jeweilige psychiatrische Hauptdiagnose ergaben sich auch unterschiedliche Häufigkeiten der Art der psychosozialen Umstände. Es ergab sich für hyperaktive und anorektische Patienten ein signifikanter Zusammenhang zwischen Anzahl der Achse V-Diagnosen und Verweildauer: Pro zusätzlicher Achse V-Diagnose stieg die stationäre Behandlungsdauer bei anorektischen Patientinnen im Mittel um 20,5 Tage, für die hyperkinetischen Patienten um 4,3 Tage.

Quality of life: a dimension in multiaxial classification

The study provides an overview of the historical aspects of multiaxial classification. Particular reference is paid to the multiaxial formats of ICD-10, DSM-IV and the WPA International Guidelines for Diagnostic Assessment (IGDA). The IGDA proposes a tetraaxial format with quality of life as one axis as well as an axis on symptomatology, an axis on adaptive functioning and an axis on environmental/psychosocial conditions. The axis on quality of life is added in recognition of the increasing importance placed upon the patient's perception of his/her capacity of self fulfillment and the attention paid to quality of life as a major descriptor of health status as well as an outcome measure of clinical care.

Childhood disintegrative disorder: should it be considered a distinct diagnosis?

First termed Dementia Infantilis by Theodore Heller in 1908, Childhood Disintegrative Disorder (CDD) has had a history longer than that of Autistic Disorder. Presently, CDD is classified as a Pervasive Developmental Disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. The characteristics most often cited as distinguishing CDD from Autistic Disorder, another one of the Pervasive Developmental Disorders, is the age of onset and evidence of normal development prior to the presence of symptomatology. Otherwise, the behavioral symptoms of CDD and Autistic Disorder are strikingly similar. The purpose of this article is to provide a historical background on CDD, examine the evolution of diagnostic criteria, review the existing literature pertaining to the disorder, and, finally, to draw conclusions regarding the validity of CDD as a distinct diagnosis with reference to current and alternative classification approaches.

Childhood disintegrative disorder

Childhood disintegrative disorder (CDD) is a clinical syndrome characterized by disintegration of mental functions and regression of acquired language and intellectual functions after a period of normal development typically of 3 to 4 years. Although recognized for many years, research on this condition is less advanced than that in autism. Epidemiological data are limited but the condition is much less common than autism. The relationship of this condition to autism remains the topic of debate. Neuropathological and other medical conditions are sometimes associated with the disorder but contrary to earlier belief this is not typical. Collaborative research would facilitate our understanding of this condition.

The nature of psychiatric classification: issues beyond ICD-10 and DSM-IV

OBJECTIVE

The aim of this paper is to provide an overview of the methodological underpinnings of current classification systems in psychiatry, their impact on clinical and social practices, and likely scenarios for future development, as an introduction to a series of related articles in this issue.

METHOD

The method involved a selective literature review.

RESULTS

The role and significance of psychiatric classifications is placed in a broader social and cultural context; the 'goodness of fit' between ICD-10 and DSM-IV on one hand, and clinical reality on the other hand, is examined; the nature of psychiatric classification, compared to biological classifications, is discussed; and questions related to the impact of advances in neuroscience and genetics on psychiatric classification are raised for further discussion.

CONCLUSIONS

The introduction of explicit diagnostic criteria and rule-based classification, a major step for psychiatry, took place concurrently with the ascent to dominance of a biomedical paradigm and the synergistic effects of social and economic forces. This creates certain risks of conceptual closure of clinical psychiatry if phenomenology, intersubjectivity and the inherent historicism of key concepts about mental illness are ignored in practice, education and research.

Two males with childhood disintegrative disorder: a prospective 14-year outcome study

A prospective 14-year outcome study of two children meeting DSM-IV criteria for childhood disintegrative disorder is presented. Their ages at first evaluation were 4 years 7 months and 6 years 3 months. Both are now adults and continue to have a severe pervasive developmental disorder, mental retardation, seizure disorder, and are non-verbal. Both require residential care.

How specific are "specific developmental disorders"? The relevance of the concept of specific developmental disorders for the classification of childhood developmental disorders

The concept of "specific developmental disorder" (SDD) refers to delays in developmental domains such as language and speech development, motor coordination or the development of scholastic skills, in the absence of sensory deficits, subnormal intelligence or poor educational conditions. The key element in this concept is the notion of a discrepancy between observed and expected level of development. In DSM-III-R and ICD-10, SDD serves as a conceptual umbrella, suggesting that the subsumed disorders are of the same type. In DSM-IV, the SDD umbrella is not used explicitly, but the notion of a discrepancy is present in the categories of Learning Disorders, Motor Skill Disorder and Communication Disorders, suggesting a close relationship between these disorders. One of the advantages of the use of SDD as a unifying concept is that it contributes to the standardisation of the description of the various disorders. However, based on reviews of research regarding the reliability and validity of the SDD categories, we argue that the application of a unifying SDD concept has been premature. For each of the categories for disorders in scholastic skills, language, speech and motor coordination, the notion of a discrepancy between observed and expected level of development should be elaborated and tested more thoroughly, before SDD can be used as a unifying concept in classification.

Abnormal psychosocial situations and eating disorders in adolescence

OBJECTIVE

To assess the relationship between abnormal psychosocial situations and eating disorders in adolescents.

METHOD

Twenty girls with eating disorders, 20 girls with major psychiatric conditions, and 20 healthy controls took part in the study. They were interviewed using a semistructured interview designed by the World Health Organization to diagnose the psychosocial situations included in the International Classification of Disease Axis 5 classification for child and adolescent psychiatry. All subjects were also given the Eating Attitudes Test.

RESULTS

Many life events and psychosocial adversities differentiated significantly between the patients and controls. Inappropriate parental pressure was specific only for the subjects with eating disorders compared with the other psychiatric patients. In addition, Eating Attitudes Test scores correlated significantly with hostility toward child, sibling disability, parental overprotection, inappropriate parental pressures, and negative changes in family relationships.

CONCLUSION

These results support the growing literature on the interrelationship between disordered family relationships and eating disorders. They point the way for developing treatment programs dealing with these issues.

Classification of child and adolescent psychopathology

This review will consider some of the major issues in the classification of child and adolescent psychopathology. The central issue will be the value of classification systems in child and adolescent psychopathology research. Some comment will also be made on the value of the existing classifications in clinical practice.

Abnormal psychosocial situations. Preliminary results of a WHO and a German multicenter study

The World Health Organization (WHO) provided instructions for field trials with the completely revised psychosocial axis of the MAS (Multiaxial classification scheme in child and adolescent psychiatry). A description is given of the purpose, the stages and the procedures of the field trials, the participating centres and the samples. The results of the studies concerning applicability and reliability are given and discussed, as well as those of a quasi validity study, in a comparison of anxiety disorders and disruptive behaviour disorders. In general the applicability is very satisfactory, especially when the diagnostic guidelines are followed strictly. The preliminary results of the reliability studies are rather inconsistent. The difference in training apparently played a very important role. The quasi validity study yielded indications that there are not only differences in quantity but in particular in quality of the psychosocial situations, as outlined in the categories of the axis, of different psychiatric disorders.

Childhood disintegrative disorder: issues for DSM-IV

Childhood disintegrative disorder, also known as Heller syndrome or as disintegrative psychosis, is a relatively uncommon condition which has variably been included in official diagnostic systems. Available evidence regarding the validity of this diagnostic concept, particularly with regard to autism, supports inclusion of the category in DSM-IV. Proposed criteria and narrative description for the disorder are presented.

Classification of pervasive developmental disorders: some concepts and practical considerations

Classifications have to meet a variety of purposes. Clinical and research needs are different and there is much to be said for separate clinical and research schemes. Care is needed to ensure that classifications provide an appropriate medium for teaching about diagnosis and do not cause difficulties when used as a "passport" to resources. Principles of classification are considered in relation to the need to take course, as well as symptomatology, into account, and with respect to the neuropsychiatric interface. The value of a multiaxial approach is noted. The pros and cons of autism and pervasive developmental disorders (PDD) as an overall descriptive term, of lumping or splitting, and of different choices with respect to PDD subcategories are discussed.

The role of the child psychiatric ward in health care: experiences with different types of admissions over a period of twenty-one years

The concept of the child psychiatric unit is considered. The character, capacities and activities of one unit are described and some features of the admissions over its first 21 years are discussed in relation to the findings of other studies. Among the factors considered are the patients' presenting diagnoses, their sex, their physical health and their length of stay in the Unit. Some possible future directions for the Unit are discussed, and the pattern of work over the two decades covered by the study is related to current and future requirements. It is suggested that for several categories of disorder, a child psychiatric unit offers unique advantages in both assessment and treatment.

Classification of abnormal psychosocial situations: preliminary report of a revision of a WHO scheme

A WHO working group undertook a radical revision of the psychosocial axis for the classification of abnormal psychosocial situations. The rationale for the revision and the approach taken is described, together with the overall structure of the coding scheme and the subcodings within each category.

School phobia: patterns of family functioning

Seventy-six families of children with school phobia were evaluated with the Family Assessment Measure. Mothers and fathers, as separate groups, rated clinically significant dysfunction in the parent-child relationship in the areas of role performance and values and norms. There were no significant differences between intact and single-parent families on ratings of family dysfunction. There was significantly less family dysfunction as rated by mothers and by children if the child had a diagnosis of pure anxiety disorder compared to families of school phobic children in other diagnostic categories.

The reliability of child psychiatric diagnosis. A comparison among Danish child psychiatrists of traditional diagnoses and a multiaxial diagnostic system

The study was conducted to compare an experimental multiaxial diagnostic system (MAS) with traditional multicategorical diagnoses in child psychiatric work. Sixteen written case histories were circulated to 21 child psychiatrists, who made diagnoses independently of one another, using two different diagnostic systems. Diagnostic reliability was measured as percentage of interrater agreement. The highest diagnostic reliability was obtained in psychotic disorders, the lowest in personality disorders. The MAS implied improved diagnostic reliability of mental retardation, somatic disorders and developmental disorders. Adjustment reaction (reactio maladaptiva) was the diagnosis most commonly used, but with varying reliability in both systems. The reliability of the socio-economic and psychosocial axes were generally high.

Childhood Onset Pervasive Developmental Disorder

Two male children meeting criteria for Childhood Onset Pervasive Developmental Disorder (COPDD) are described. The current DSM-III category of COPDD may have value in separating these children from others with PDD. The authors suggest that these two children, and other children described in the literature as having dementia infantalis and/or disintegrative psychosis, have a distintegrative disorder resulting in muteness, profound mental retardation and severe autistic symptomatology. The term "pervasive disintegrative disorder" may be appropriate for such children and specific diagnostic criteria are suggested. The disorder appears to be extremely rare, with a prevalence estimate of 0.11 per 10,000.

Assessing dementia. Part I: Difficulties, definitions and differential diagnosis

Despite the pressures of an increasingly ageing population and an ever increasing scientific knowledge, the clinical characteristics of dementia remain poorly defined. This relative lack of clarity in clinical understanding has led to diverse diagnostic problems, including those of mistaken diagnosis as well as over- and under-diagnosis in different settings. This paper focuses on the syndromal and aetiological diagnosis of dementia by outlining current clinical definitions, considering differential diagnosis in detail and reviewing characteristics of common dementing disorders. The past emphasis on a search for treatable causes, the reliance on laboratory investigations and the concept of subcortical dementia are all questioned. Aspects of evaluation that are stressed include the value of brief objective cognitive testing, a knowledge of normal age-related cognitive changes, flexible criteria for Alzheimer's disease and a comprehensive individualised evaluation of the person. Broader assessment issues will be dealt with in a second paper.

Disintegrative psychosis of childhood: teenage follow-up

Nine patients with disintegrative psychosis of childhood were reviewed after follow-up periods of 11 to 16 years. Eight of the nine had a uniform picture of early normal development for two years or more, followed by subacute regression over a period of a few months, to become functionally severely retarded with autistic behavioural features and overactivity. Neurological investigations were consistently negative. The clinical course has remained largely static for these patients, but two have developed epilepsy. They are likely to remain severely handicapped, but not to deteriorate. It is possible that this remarkably homogeneous clinical picture is the result of unidentified encephalopathic processes occurring during early childhood.

Screening for behaviour problems in nurseries: the reliability and validity of the Preschool Behaviour Checklist

The development of the Preschool Behaviour Checklist, for screening emotional and behavioural problems in preschool children in group settings, is described. Inter-rater reliability and internal consistency was established, and its validity was shown using a variety of methods. These include observations of the children, interviews with staff, comparison between clinic and nonclinic populations, factor and cluster analysis and comparison with another screening questionnaire. Uses of the PBCL for training and inservice work are outlined. The limitations of screening as a method of identifying children with behaviour problems are discussed.

Extralinguistic speech characteristics of children with conduct and anxiety disorders

Nine children with conduct and nine with anxiety disorder participated in the study. The subjects were requested to respond to verbal tasks (counting, picture description, story telling). Disturbance of conduct was associated with short initial hesitation before speaking. It is suggested that the initial hesitation variables are measures of reflection and cognitive planning. Anxiety across subjects was associated with increased breath rate and lower output of speech per breath. It is suggested speech breath variables are reliable measures of anxiety. Implication for the diagnosis and management of child psychiatric disorders are discussed.

The reliability of dangerousness assessments. A decision making exercise

One hundred and ninety three raters drawn from six countries and representing different professional groups considered 16 case histories. Raters were asked to indicate what degree of 'dangerousness' they attributed to each individual and what they considered to be the optimal management. The level of agreement between raters concerning the assessment of dangerousness was generally low, the level of 60 per cent being reached for only 4 cases out of 16. Psychiatrists did not reach a higher level of agreement on the ratings of dangerousness than non-psychiatrists. Psychiatrists had a tendency to rate individuals as more dangerous than did non-psychiatrists. The results of this exercise do not support the use of 'dangerousness' as a scientifically or operationally valid concept.