THE NATURE OF PSYCHOPATHOLOGY
METHODS OF EVALUATION AND INTERVENTION
Martin, a nine year old caucasian boy, was referred for psychological evaluation because of his poor performance in school, surly and hostile behavior in school and at home, several recent thefts, frequent lying, bed wetting for the last three years, and his inability to get along with peers, parents, siblings, or teachers. The youngest of three boys, his brothers were three and six years older than he. Mother had separated and divorced when Martin was about six years old, and a year later she married a man who was ten years her senior and who had not been married before. Martin's stepfather was an electrician who worked long hours to provide a good income for his family. He had high expectations for his stepsons and was extremely critical of them when they failed to measure up to his standards. Mother, too, was demanding. In addition, she was high strung, easily upset, a meticulous housekeeper, and a woman who had doubts about her' ability to cope with her sons, her husband, and her home responsibilities.
Martin's brothers seemed to get along well at home and were excellent students in school. They excelled in athletics and were a great source of pride to their parents. Martin began first grade doing well but, when his mother and father divorced, his school performance fell off and he began wetting his bed at night. Martin's mother and his brothers were very critical of him, tending to pick on Martin and use him as a scapegoat for their own pent up frustration and anger. Martin's academic difficulties continued, and he had to repeat the second grade. His stepfather soon added another critical voice, and Martin reacted by striking back with anger. He fought with his brothers, talked back to his mother, and fabricated stories to avoid doing what his parents asked of him. At school, he began to bully and fight younger boys and take some of their belongings and hide them. Teachers noted that he seemed to enjoy tormenting other children, but they could not find any effective way to stop his aggression. Shortly before he was referred for evaluation, Martin stole a neighbor's bicycle and some money from his mother's purse. He rode around until long past dinner time when he was expected home. He returned the bike to the neighbor's garage, and then entered the back door of his house, only to be greeted by a set of worried but very angry parents. The next day, his parents decided that Martin needed professional help.
What prompted Martin's parents to seek the assistance of a psychologist? Was it primarily their concern about his theft of the bike and money, or was it a reaction to a combination of Martin's prior behaviors and his most recent actions as worrisome indications of a serious problem? Whichever reason prompted them, their choice rested on some vague and implicit notion about what constitutes abnormal behavior. Although there is no single definition that we would agree upon at this point, or, for that matter, that would completely satisfy most professional workers, we need to define the domain of abnormal behavior in order to have a common basis for further study. In addition, we need to grapple with the issues and problems surrounding the classification of children's disorders to better understand what groupings have been proposed, how the various categories are used, and how reliable they are. Finally, as important background information, we need to consider the scope of the problem, the procedures used to measure the frequency of abnormal conditions, and the sources of error associated with these measures.
What Is Psychopathological Behavior?
Martin's case illustrates that psychopathological may be easier to recognize than to define, because psychopathology involves a number of important dimensions that are given differential weight in arriving at a decision. His mother and stepfather had the opportunity to evaluate Martin's behavior continually in light of his previous personality, its appropriateness to his life circumstances, and its effect on him. and others. They may have seen his academic decline and bedwetting at age six as a temporary but understandable response to the stress of his parents' separation and divorce. But the persistence of these behaviors along with the appearance of hostile and then antisocial acts suggested that his condition had not only worsened, but that it was also seriously affecting the lives of others. Martin's mother and stepfather recognized his psychopathology, but they based their recognition on multiple and vague criteria that were not generally applicable. Therefore, we must delineate a set of criteria for psychopathological behavior that is generalizable beyond the single case and is comprehensive and explicit.
Abnormal behavior may be thought of as deviant in the sense that it deviates statistically from the normal, the usual, the most common or typical reaction found in the majority of the population. But this criterion is limited since it implies that normality would include behaviors that are most common, and exclude those that deviate from the norm but that society may regard as superior, such as the behavior of the extremely bright child or the gifted athlete. Moreover, this standard would require that we consider within the bounds of normality the common practice of drinking and drug abuse found among high schoolers, even though society views these behaviors as deviant and undesirable. The fact that research indicates that few children go through life completely free of behavioral and adjustment difficulties implies by statistical standards that such behaviors as temper tantrums, fears, overactivity, bedwetting, lying, and stealing are normal (Werry and Quay, 1971; Johnson, Wahl, Martin, and Johansson, 1973). Yet factors other than mere occurrence, such as persistence, age of onset, or the appearance of a combination of some of these behaviors (as evidenced by Martin) may override statistical considerations in differentiating normal from abnormal.
In addition to these limitations, the statistical criterion as it now stands is too broad and vague in that it defines normal behavior in terms of what the majority does but not in terms relative to a more specific or meaningful frame of reference. However, the next two sections will deal with statistical criteria that take note of cultural values and changes in behavior that occur with development.
From the beginning of civilization, people have always noted certain behaviors that were sufficiently distinctive to be labeled abnormal. Some of these behaviors appear to be universal, since they can be found in similar forms all over the world. In fact, studies have shown that such psychopathological behaviors as hallucinations, delusions, phobias, and sexual deviations are evident across different cultures (Copeland, 1968; Al-Issa, 1969; Dohrenwend and Dohrenwend, 1974). At the same time, differences among cultures have also been reported in both the incidence of abnormal behaviors and in the specific ways they are expressed. Although suicide and alcoholism are well known universal phenomena, suicide is rare among Muslims and compulsive drinking is unusual among Jews and Chinese-Americans (Bazzoui and Al-Issa, 1966; Kleinmuntz, 1974). The specific content of a disordered behavior, such as a delusion, also is influenced by cultural factors. A delusion of persecution in Africa may take the form of a fixed belief that some large, wild, and dangerous animal is out there for the sole purpose of stalking and destroying the deluded person. In this country, the delusional content might focus on the belief that the person is under the electronic surveillance of foreign agents who plan to seize and murder him. Therefore, a distinction must be made between the basic characteristics of abnormal behavior that are constant in all cultures, and those features that vary because of cultural differences. In general, behaviors that reduce, interfere with, or disrupt the individual's personal and social adjustment are considered abnormal in all societies. However, the specific form these disruptive behaviors take, the explanation given for them, and their frequency of occurrence vary from culture to culture. The processes and functions underlying human behavior (normal and abnormal) are the same in all societies, while the specific behavioral expressions are influenced largely by one's culture. Obviously, then, what is regarded as abnormal by one culture may very well be normal in another.
The first of our criterion of psychopathological behavior, the cultural norm, recognizes that every culture establishes approved standards and expectations for the behavior of its members. Cultural norms change from time to time, but usually there is a "lag" between the introduction of the change and its widespread acceptance by the culture. Typically, cultural norms are more specific and restrictive in their prohibitions in contrast to the greater flexibility allowed for their sanctions. Moreover, there is usually more latitude and leeway given to children in terms of what they may and may not do. For example, our culture prohibits certain aggressive acts for adults, such as physical assault and stealing, while similar aggressive responses are subtly permitted for children in that they may fight, attack each other, and take things that don't belong to them without great penalty. In addition, cultural norms provide standards of behavior that are situationally defined. For the adolescent, nudity is permissible in the privacy of his or her home or even in the less than private locker room at the school gym, but it is certainly prohibited when shopping or going to class. In this way, society identifies certain behavior patterns and situations as acceptable.
Knowledge of the developmental process is essential in making decisions about whether a child's behavior is normal or abnormal, although statistical averages (as we have already noted) have their limitations for defining abnormality. We know that most children are toilet trained before the age of three. By this standard, Martin's bedwetting deviates significantly from developmental norms, since he has been enuretic £or the last three years. Of course, if Martin were younger (let us say four years old), then the deviation would be less extreme and more difficult to categorize as abnormal. In general, the greater the deviation from developmental norms, the higher the agreement will be with regard to the abnormality of the behavior.
But not all developmental deviations reflect abnormality in the sense of impaired or insufficient progress. Some children walk unaided at an earlier age than the norm, or have vocabularies and linguistic skills that far exceed the average. Most, but not all, instances of rapid or early development are looked upon as positive indications of exceptional abilities. It is at the slow end of the continuum where developmental deviations have their major significance as a negative criterion of abnormality.
Frequency, Intensity, and Duration
For discussion purposes, let us consider the question: Is the behavior of pulling hair from one's head abnormal? While many might respond affirmatively, others might ask for additional information before answering. If pulling hair occurred only once, or at the most twice, the answer might change to a firm "no." If, however, pulling hair was a frequent event, the answer would be "yes." Therefore, frequency is an important dimension in defining abnormal behaviors. In this regard, we should note that the absence or rarity of a response may be just as significant as high frequency. Martin's infrequent expression of warm and positive feelings is as indicative of abnormality as is his excessive lying or his frequent bedwetting.
Another characteristic useful in determining whether a behavior is abnormal is intensity or degree. If pulling hair merely involved the removal of a single strand of hair rather than large clumps, the behavior would be within normal limits. However, when behaviors are evident in extremes of intensity or degree, they generally fall outside of the bounds of normality and inside the range of abnormality.
Similarly, we need to include the dimension of duration to aid in distinguishing normal from abnormal behavior. Martin's lying and stealing take on greater significance if they are manifest over a long rather than a brief time span. The greater the persistence of deviant behaviors, the more likely they are to be considered as falling within the domain of abnormality.
Intellectual and Cognitive Functioning as a Criterion
In the management of everyday affairs, we expect that normal people will function well within their intellectual capabilities, even though most people do not operate at maximum efficiency most of the time. A healthy fourteen year old of superior intelligence who couldn't remember his name, address, or whereabouts would strike most of us as odd and abnormal.
Cognitive malfunctioning is apparent when a disparity exists between ability and actual performance in such areas as attention, comprehension, judgment, learning, memory, thinking, and perception. The larger the difference between a person's capabilities and actual performance, the greater is the likelihood of abnormal behavior. Children of average or higher intelligence who are extremely distractible, unable to carry out simple instructions, or unable to learn the difference between friend and foe, and those who cannot recall important, recent, or past events illustrate cognitive impairment indicative of abnormal behavior.
For the most part, normal thought processes tend to be logical, coherent, organized, and appropriate to the situation. Gross disruption and impairment of these patterns and peculiar content, known as a thought disorder, usually are good indicators of abnormal behavior. Wouldn't you think there was something radically wrong with an eleven-year-old boy who responded characteristically to simple questions such as "How are you today?" with "My God! The world is coming to an end. The weasel stole all of the bees ... no more honey ... no more money. The heck with you, you S.O.B. What do you have against fried flies?"
A particularly important instance of cognitive dysfunction is in the child's perception of reality. During normal development we learn to move about unimpaired in our environment by interpreting external cues. We learn that distant objects look smaller than nearer ones and to correct our perception when these cues are incorrect, such as when viewing things that are submerged in water. With practice and success experiences, our confidence in these perceptions of physical objects and space increases. From time to time we check our impressions with those of others, especially when in doubt. Misperceptions or hallucinations occur when a person sees, hears, or smells something that is not present in the external world of reality. Hallucinatory experiences may involve any of the senses, although visual and auditory misperceptions are the most frequently noted. Beliefs that are based on false premises are known as delusions, which are faulty perceptions or incorrect appraisals of reality or the actual behavior of others.
The ramblings of a five-year-old child about his or her imaginary playmate may be normal, but similar behavior in a teenager would be properly labeled as abnormal. The belief that the moon dangerously pollutes the atmosphere because it is made of blue cheese is distinctly abnormal in a college graduate, although it may be within normal limits for a gullible retardate who was spoofed by an older sibling. Thus, in order to be useful as a criterion of abnormal behavior, cognitive dysfunction must be considered in light of intellectual potential, developmental norms, frequency, duration, and degree of impairment.
Emotional Expression and Control as a Criterion
Some of the most vivid illustrations of abnormal behavior come from the emotional area of human functioning. Scenes of wild, explosive, and unpredictable emotional expressions are often used to describe the behavior of those considered abnormal. Extremes or sudden fluctuations of moods, infantile, inappropriate, or lack of emotional expression, and irrational but persistent fears are some of the emotional signs of personal instability. "A proper emotional development prepares the individual to appreciate the pleasurable aspects of emotion and to cope adaptively with the unpleasant. The well-rounded personality is not flat or wholly intellectual but expressive and emotionally responsive in a disciplined manner" (Nash, 1970, p. 306).
During the course of development, children learn to alter the way they express emotions. Infants show fear by crying, while teenagers may respond by avoiding or withdrawing from the feared stimuli. Children also learn to size up the situation in terms of what emotion is appropriate and what manner is acceptable for its expression. With maturity, people are expected to increase the degree of control they exercise over their feelings. Thus, over time youngsters may show required changes in the expression of anger from frantic temper tantrums to direct physical attack to verbal expression of anger, and so forth.
Deviations in emotional expression and control are varied and numerous. Emotional behavior can be inappropriate to the situation as in the show of elation over the news of the death of a loved one, or insufficient or exaggerated as reflected in either indifference or a prolonged grief reaction to a broken engagement. There may be either too little or too much control exercised over emotional responsivity as seen in impulsive acting-out behavior or in emotional constriction and inhibition. In addition, emotional regression or the use of emotional expressions evident in an earlier period of development may indicate abnormal behavior. Temper tantrums in a twelve year old who had since learned to express anger verbally is a sign of emotional regression and emotional immaturity. Here again, the greater the deviation from normal developmental patterns, the greater is the likelihood that the behavior would be regarded as abnormal.
Sometimes personal discomfort is considered a useful criterion of abnormal behavior, because it is often (but not necessarily always) a byproduct of such a state. Worry, anxiety, fears, and despondent feelings often become pervasive and all-consuming to the point where some, if not many, areas of functioning are affected adversely. When personal discomfort in any form is enduring and sufficiently troublesome to interfere with normal functioning, it can be considered abnormal. However, we must keep in mind that not all abnormal emotional behaviors are painful or uncomfortable. Seriously regressed psychotics may show silly emotional responses and a readiness to inflict pain on others or themselves without any apparent sign of personal distress. Those in prolonged states of euphoria (even if inappropriate) appear to be ecstatically happy. Sexual deviants and drug users apparently derive a great deal of pleasure from their abnormal behaviors.
Coping in Interpersonal Relations as a Criterion
It is well recognized that humans are not solitary creatures but social animals who require relationships with others for their well being. To function adequately in society, a person must acquire the capacity to interact with others on friendly and cooperative terms and maintain relationships of mutual respect, agreement, and responsibility. Because this is such an important area of human function, deviations from the expected patterns, especially those in which the rights of others are offended or violated, are considered abnormal. Typically, disruptions in a person's ability to cope with interpersonal relationships are associated with or lead to impaired functioning in many areas. Difficulties in interpersonal relations, such as social withdrawal and isolation, suspiciousness, fear, hatred of others, and uncooperativeness are behaviors that make almost any facet of life difficult to manage.
But not all deviant interpersonal relations justifiably fall within the domain of abnormal behavior. Rudeness, insensitivity, deceit, and infidelity are among the behaviors that are socially deviant, but not in and of themselves abnormal. Similarly, criminal acts of murder, rape, and theft, while deviant, cannot be classed as abnormal without further qualifications.
What then are the necessary additional considerations? If the behavior is committed by a person who is rational and otherwise shows no signs of cognitive impairment, then we think of the act, albeit vulgar, immoral, or criminal, as outside the domain of abnormality. If, however, the behavior is performed by a person whose judgment, thinking, memory, or perception is disturbed, then we consider the behavior abnormal. Emotional dysfunction is another factor that helps differentiate abnormal social behaviors from other kinds of deviant interactions. When emotional instability is present along with deviant interpersonal behavior, the social interaction is more likely to be abnormal than criminal. Therefore, in order to use interpersonal deviancy as a criterion of abnormal behavior, it is necessary to apply it in conjunction with the other criteria of cognitive and emotional dysfunction.
In summary, there is no single criterion for defining abnormal behaviors. However, for our purposes, we defineabnormal behaviors as those that persistently deviate from cultural and developmental norms in either extremes of frequency and intensity, and that are evidenced by impairment in one or more of the following areas of human functioning: intellectual and cognitive, emotional expression and control, and interpersonal relationships.
How Is Psychopathology Classified?
In the field of behavior disorders, a classification system arranges those individuals exhibiting abnormal behavior into diagnostic groupings according to certain common characteristics. From the very beginning, classification has been influenced greatly by a disease view of psychopathological behavior. This influence dates back to the contributions of Hippocrates, although the major impetus came in the nineteenth century when Emil Kraepelin undertook the careful compilation of clinical records and histories of hospitalized patients. Based on these data, he constructed a classification system that was essentially a descriptive one, in which all of his observations and clinical findings were used as diagnostic criteria. The data included symptoms and clusters of symptoms, etiology when known, physiological changes, and observations about the course and outcome.
In addition to Kraepelin, several others have contributed to present-day classification of abnormal behavior. Eugen Bleuler (1857--1939), who worked extensively with the disorder known as dementia praecox, or schizophrenia, brought about significant changes both in the name and the concept of that disorder. Bleuler's lucid description of schizophrenia and its subcategories not only replaced the Kraepelinian view of the disorder but also significantly modified its classification up to the present. Adolph Meyer (1866-1950) argued against the Kraepelinian bias that focused on the study of symptomatology, and especially against the inclination to view symptoms as signs of specific brain lesions. He took a broader approach claiming that abnormal behaviors were faulty life adaptations produced by many factors such as psychological, social, physiological,and constitutional, and not exclusively brain pathology. He introduced the concept of reaction types as a substitute for the narrowly conceived disease entities, and he emphasized the total individual as a psychobiological organism constantly called upon to adapt to a social environment (Meyer, 1948; Muncie, 1948).
Because no single system of classifying abnormal behavior had been adopted as the official standard in the field, diversity tended to prevail. Clinicians either modified existing systems or constructed their own to meet their special needs and those of the clinical facilities in which they worked. The result was "a polyglot of diagnostic labels and systems, effectively blocking communication and the collection of medical statistics "Diagnostic and Statistical Manual, 1965, p. V), This state of confusion triggered off several attempts to establish a standard nomenclature that would be nationally accepted and used.
Adult Classification Systems (DSM-I, DSM-II, DSM-III)
In 1927, the New York Academy of Medicine moved to establish a standard nomenclature of disease that would be nationally accepted. The first edition entitled Standard Classified Nomenclature of Disease was published in 1933 and was followed by two revisions, the last of which appeared in 1942. During World "Val' II, however, psychiatrists found this system to be inadequate, since it dealt effectively with only ten percent of the total cases seen. Following the war, the American Psychiatric Association undertook a revision of the Standard system. Based on material received from the Army and Veterans Administration, ideas from psychiatric training programs, suggestions from their own members, and data from the literature, they drafted a proposed revision. They revised it again and finally published it in 1951 as the Diagnostic and Statistical Manual (DSM-I). Curiously enough, the manual virtually ignored childhood disorders per se except for the inclusion of a few conditions that it listed with adult syndromes, in a manner somewhat reminiscent of the way children were viewed before childhood was discovered. In 1968, a second revision was published, known as DSM-II, which consisted of ten major categories. For the first time one of these categories was devoted exclusively to children ("Behavior Disorders of Childhood and Adolescence") and included the following subcategories:
Behavior disorders, hyperkinetic reaction, withdrawing reaction, overanxious reaction, runaway reaction, unsocialized aggressive reaction, group delinquent reaction, and other reaction. In addition, another major category, transient situational disturbances, dealt with special symptoms most commonly found in children. These additions, albeit far from adequate, represented a substantial shift in the recognition given to child psychopathology by the American Psychiatric Association.
DSM-III is the latest and most radical revision not only in its attempt to be both specific and inclusive but also in its rather extensive provisions for childhood disorders [DSM-III: Diagnostic and Statistical Manual of Mental Disorder(3rd ed.), 4-15-77 draft]. This classification system consists of seventeen major categories summarized in Table 2-1. It also provides operational criteria that specify the clinical phenomena needed to justify the diagnosis, and a multiaxial framework that gives the diagnostician additional categories on which to code the patient. There are five axes: two dealing with other categories of mental disorders; one for designating nonmental medical disorders; one for rating the severity of psychosocial stressors; and one characterizing the highest level of adaptive functioning the patient achieved within the last year.
The major category devoted to child psychopathology is more extensive and inclusive than what appeared in the previous two editions. It is designated as "Disorders Usually Arising in Childhood or Adolescence". Psychosexual disorders, particularly gender disturbances that occur during childhood and adolescence are not included in this section, although they are covered in the adult part. Surprisingly, this major category sets no age limit separating childhood from adolescence, and, in fact, includes subcategories that may be appropriate for the college years (Identity and Emancipation Disorder) or for older adults if the present condition dates back to early childhood (Attention Deficit Disorder). Childhood disorders resembling those seen in the adult but that may not lead to their adult. counterpart are given separate subcategories in this section. In addition, there are many diagnoses offered elsewhere in the manual such as phobias and adjustment disorders that can be applied to children.
The final draft of DSM-III, due to be published sometime in 1979 or 1980, is clearly more comprehensive and explicit in diagnostic criteria and categories than the previous editions. Although it is too early to judge, DSM-III gives every indication of being significantly more reliable and valid than any classification system that has yet to appear. In addition, DSM-III should reassure those concerned with the tendency of classification systems to neglect the "whole" individual. While the very nature of any sort of classification is to highlight some features and ignore others, with its multiaxial orientation, DSM-III minimizes this problem by looking at children and adults from many perspectives.
Child Classification Systems
Although the need for a uniform classification system for children and adolescence had been noted for years (Group for the Advancement of Psychiatry, 1957), it was not until 1966 that the Committee on Child Psychiatry of the Group for the Advancement of Psychiatry (GAP) completed and published their proposed system (Group for the Advancement of Psychiatry, 1966). At the time of publication, there were at least twenty three other child classification systems in use, illustrating the diversity and diagnostic confusion that has characterized the field.
The GAP system consists of ten major categories ordered (although poorly) along the dimension of prognosis, and ranging from healthy responses to the most severe disorders. Embracing the psychosomatic, developmental, and psychosocial views, the system can best be characterized as a clinical descriptive one that can be used by clinicians of varying backgrounds. The category, Healthy Responses, has never been used in any system but is included here to minimize the practice of clinicians to exaggerate minor childhood problems into pathological ones for classification purposes. For example, the new category gives the clinician the opportunity to categorize bedwetting in a two-year old as a healthy response rather than calling it abnormal. Another new category, Developmental Deviations, deals with deviations in maturational rate, or sequence, or personality development that are frequently noted in children but that are not adequately classified under other systems.
In 1969, The World Health Organization (WHO) published a multi axial classification system for childhood disorders (Rutter et al., 1969). This system includes the following four axes: (1) clinical psychiatric syndrome, (2) intellectual level (IQ), (3) associated etiological biological factors, and (4) any associated etiological psychosocial factors. Thus, a psychotic child (1) who is severely retarded (2) and who has epilepsy (3) would be coded on three of the four axes. The advantage of classifying children on various relevant dimensions offered by the WHO system is now available in the new multiaxiallook of DSM-III.
A statistical technique, known as factor analysis, has been used empirically to isolate clusters of characteristics observed in children that then become the major categories of the classification system. The effectiveness of this statistical approach rests on the nature and character of the items on which each child is rated, since the final cluster of symptoms is derived from these initial data. Consequently, factor analytic . classifications differ from one investigator : another, because the original variables under study and the items used to measure them are likely to be divergent. An example of a factor analytic classification scheme is the one proposed by Achenbach (1966), who found two general clusters which he called internalizing and externalizing or personality problems and conduct problems. In addition to the general clusters, the system also includes specific symptom clusters that are either subsumed by the general clusters or peculiar to certain developmental periods. Some of the internalizing symptoms include phobias, insomnia, stomach-aches, and seclusiveness, while externalizing symptoms include destructive, stealing, and running away. These factorial data have been replicated with new samples of children and have been used to show that externalizingboys were independently rated as more impulsive and aggrressive, while internalizing boys were considered more passive, more inclined to stay longer in psychotherapy, and to improve with treatment (Achenbach and Lewis, 1971). Several other studies using these two general clusters with children from clinics and schools indicate relationships that support the validity of these categories (Achenbach, 1974) .
The best known and most widely used psychoanalytic approach to classification is Anna Freud's "Developmental Profile" (Freud, 1965). Essentially, the profile is a diagnostic tool based on the developmental sequence proposed by psychoanalytic theory. It is used as a standard with which to compare the development of a given child. Freud rejected the heavy reliance on symptom description as the basis of diagnosing children's disorders and favored instead a more thorough assessment of the child's personality structure, functioning, and development, detailed in her developmental profile. However, she gave no objective criteria to aid the clinician in completing each part of the profile or indications of how information on the separate variables should be integrated and synthesized. Unfortunately, the profile has spawned little research and even less evaluative data, since the publications to date have, for the most part, been clinically descriptive of a single case.
Other and more specific classification schemes have been used for research purposes, especially in instances where investigators are concerned with studying one or relatively few psychopathological conditions. Usually these miniature systems specify a set of diagnostic criteria that are more behavioral and more amenable to the careful selection of clinical populations for study than is possible with the more traditional and global systems. For example, the DeMyer-Churchill system (DeMyer, Churchill, Pontius, and Gilkey, 1971) provides a set of criteria to distinguish psychotic children (see Chapter 8) into subgroups that are not included in DSM-III, GAP, or other systems previously described. Similarly, a checklist prepared by Rimland (1971) to differentiate one group of psychotic children from other groups (discussed in Chapter 8) is still popular with researchers studying childhood psychoses.
Reliability of Classification
From the time of Kraepelin to the present, the classification of abnormal behavior has had as its principal goals the understanding of etiology, the prediction of the course and outcome, and the appropriate selection of treatment for the various abnormal conditions. To a large extent, the usefulness of a classification scheme depends on the degree of consistency or agreement achieved in categorizing abnormal behavior. If little agreement is obtained, then the system has very limited pragmatic value in meeting the purpose for which it was constructed. The issue we raise is the important matter of reliability, which we shall now consider.
The Reliability of Classification
The reliability that we speak of may be one of three types:
1. Observer agreement-a measure of agreement of categorization by two or more observers.
2. Consistency agreement-a measure of agreement on categories over time, such as between the initial and final diagnosis.
3. Frequency agreement-a measure of agreement between two or more random samples of the same population with regard to the frequency of cases falling into each diagnostic category (Zubin, 1967).
Most studies of reliability have been, in fact, concerned with observer agreement, and have been based on the adult categories specified in DSM-I. We should also note that the data obtained from many of these studies, especially the earlier ones, are difficult to interpret because of their methodological shortcomings. These shortcomings involve (1) very small and unrepresentative samples of patients, (2) lack of control for rater differences in training and experience, and (3) dearth of information about patients on which ratings were based (Beck, 1962). More carefully designed studies have shown consistently that agreement is high when the classification is restricted to a few major categories that are grossly distinct from each other. However, reliability estimates sharply decline when a greater number and more specific diagnostic categories are included (Hunt, Witson, and Hunt, 1953; Schmidt and Fonda, 1956; Kreitman, Sainsbury, Morrisey, Towers, and Scrivener, 1961; Sandifer, Pettus, and Quade, 1964).
In general, consistency of diagnosis over time as a reliability measure yields even lower estimates than that obtained from studies of observer agreement (Zubin, 1967). However, this finding may be more indicative of the dramatic changes that can take place in the symptoms of a patient from one period of time to another than of poor
rater reliability. This is particularly true of those patients who, after a brief period of hospitalization, show a decrease in agitated and anxiety generated behavior because they are now in a more secure and protected environment. In addition, the increased use of drugs to treat patients and to make them more manageable has tended to bring about symptom changes over time.
Illustrative of the third measure of reliability, frequency agreement, is a study involving 538 women who were admitted to a large midwestern psychiatric hospital for the first time (Pasamanick, Dinitz, and Lefton, 1959). The patients were assigned to one of three autonomously operated wards on the basis of bed availability. There were no differences among the patients on the three wards with respect to marital status, age, education, urban-rural residence, or type of admission (voluntary or involuntary). Three different psychiatrists were placed in charge of each ward. In this way, a situation was constructed that provided each psychiatrist with equal access to patient information from other professional workers and with the "same type" of patient to diagnose. The results showed marked discrepancies among the samples with respect to the frequency that the three major diagnostic categories were used. In this connection, Zubin noted that of four studies he reviewed (including Pasamanick et al.), only one showed agreement among samples. He concluded, "In general, the results of comparative studies of random samples with regard to distribution of diagnoses do not yield a consistent picture regarding reliability" (Zubin, 1967, p. 388).
Interest in assessing the reliability of the classification of children's disorders is recent, primarily because there was no single systern that could be used uniformly until the appearance of the GAP proposal. Since its publication, the GAP scheme has been the subject of several investigations. One study found that two of the GAP categories accounted for seventy five percent of the 200 cases sampled (Personality Disorder and Psychotic Disorder). Six other categories were used sparingly (from about four to eight percent), while the two new categories (Healthy Responses and Developmental Deviation) practically were not used at all (Sabot, Peck, and Raskin, 1969). Another study attempted to determine the effectiveness of the GAP system over a twelve month period (Bemporad, Pfeiffer, and Bloom, 1970). In contrast, the new categories were found to be useful for this sample of 310 children in that they accounted for almost twenty four percent of the cases. Moreover, the distribution of the cases among the GAP categories between these two studies differed markedly in almost all instances. It is difficult to resolve the large discrepancies between these two studies, because the second study did not describe the patients Hsed with respect to socioeconomic level, race, age, educational level, and family structure. It is entirely possible that some of the differences in the findings were attributable to the substantial differences in the population sampled.
The most extensive study to date involved the diagnosis by twenty experienced child psychiatrists of forty four cases (case histories and diagnoses) submitted by member of the GAP subcommittee (Freeman, 1971). The results indicated that four categories (Reactive Disorders, Neurotic Disorders, Personality Disorders, and Psychotic Disorders) accounted for eighty three percent of the diagnoses, while the remaining categories accounted for only seventeen percent of the diagnoses. The two new categories (Healthy Responses and Developmental Deviation) were rarely used, once again raising the question of their value in a classification system. The reliability of the four frequently used categories was between sixty one and seventy two percent. There was no evidence that diagnostic agreement is higher for any specific age group. Data were also gathered to obtain a consistency over time measure of reliability by requiring the twenty clinicians to rediagnose a sample of selected cases some three months later. The clinicians placed eighty six out of a total of 120 diagnoses in the same category as before, yielding a seventy two percent agreement estimate. This figure is even more impressive in light of the fact that three cases accounted for twenty six of the thirty four disagreements recorded, and that three cases were responsible for low agreement even in the initial ratings. These findings reflect fairly high reliability for the four categories used most frequently, and a decrease in reliability when more specific subcategories are employed.
No data are available as yet with which to evaluate the reliability of the other classification systems discussed earlier.
Evaluation of Classification
Evidently the reliability of psychiatric classification is low except when diagnosis is restricted to a few broad categories. Although much of this evidence comes from studies using an out-dated system primarily intended for adults, similar inferences seem to be supported by data involving children and a classification scheme for child psychopathology (GAP). Diagnostic accuracy becomes increasingly more difficult as more categories are used and finer discriminations are required. The validity question, that is, how well diagnosis meets its goals, is extremely difficult to answer, since the goals of classification are so numerous and diverse.
In addition, DSM-II has been seriously criticized on other grounds. It has been regarded as unscientific in that it was finalized by a majority vote of selected psychiatrists rather than firmly rooted in careful empirical study. Perhaps more damaging is the confounding of etiology, symptoms, and outcome as the bases for diagnosis. Commenting on this diversity of principles, Draguns and Phillips stated, "This confusion not only makes for conceptual inelegance; it implies an ever continuing process of diagnosis terminated only at the point of patient's death. Ultimately, this orientation makes diagnosis intrinsically uncertain and unknowable" (Draguns and Phillips, 1971, p. 5). The use of behavioral description as the basic data for classification has been suggested as an alternative (Zigler and Phillips, 1961). Both etiology and prognosis would be treated as correlates of the particular class to which their relationship is known, but not as inherent attributes of the various categories. It can be argued that the present classification system is even inadequate as a descriptive scheme, because the principle of symptom appearance is not applied consistently to all categories, and the symptoms presumed to be associated with each category are not clearly specified. The system simply fails to delineate the criteria for making assignments to any given category.
Another major criticism is that classification implies separate and mutually exclusive entities. Yet there is considerable overlapping in symptomatology among the categories. For example, it has been found that the symptom of depression occurrence in sixty-five percent of patients diagnosed as manic-depressive, in fifty-eight percent of those diagnosed as psychoneurotic, and in thirty—one percent of those diagnosed as character disorders (Zigler and Phillips, 1961). Moreover, in actual practice, only one or two symptoms may be used to determine the diagnosis, although a particular entity often is characterized by many symptoms. The weight given to one or several symptoms for inclusion or exclusion in a diagnostic category is, in fact, left to the judgment of the clinician (Lorr, Klett, and McNair, 1963). It has been estimated that about five percent of the disagreement in diagnosis is attributable to the inconsistent behavior :he patient, 32.5 percent to the inconsistent behavior of the diagnostician, and 62.5 percent to the inadequacy of the classification system (Ward et al.,1962). If this appraisal is correct, then diagnostic reliability can be increased to some extent by reducing those disagreements introduced by the clinician. Improvement in the clinicians' training in the uniform use of the classification scheme as the basis for diagnostic decisions would go a long way in minimizing his source of error. However, the problems inherent in classification strongly suggest that primary attention must be directed to the development of changes in the system itself.
The issue of attaching psychiatric labels children has aroused controversy between those who see potential danger in it, and those who see its advantage in early intervention. Diagnostic labels, especially ones that reflect serious disorders, may stick to the child over the years and possibly influence later evaluations even when they are no longer appropriate. Labeling may stigmatize and set the child apart from peers, and it may encourage others to look for the child to behave in a way commensurate with. the label. Unfortunately, diagnostic categories appear real and valid to many, although we now know that they lack the precision and reliability to warrant such confidence. For these reasons and to protect children from future abuses, many clinicians are reluctant to fix a diagnostic label to children who evidence abnormal behaviors, if in the future there is a chance that others might have access to the diagnosis. On the other hand, it can be argued that diagnostic labels need not be abused or misinterpreted if the clinician exercises care in the evaluation and good judgment about who has access to it. The diagnosis should serve as the basis of a treatment plan and should be helpful in later evaluations of the child as a basis for comparison and as a measure of the child's progress.
For the present, DSM-III and to a lesser extent the GAP proposal enjoy official status and widespread use throughout the country. Within the limitations already noted, classification brings uniformity to the ordering of psychopathology and continues to serve an important communication function among professionals. While it is necessary to be aware of its shortcomings, it would be premature to ignore or completely reject the current system. Meehl supported this position when he remarked, "There is a sufficient amount of etiological and prognostic homogeneity among patients belonging to a given diagnostic group, so that the assignment of a patient to his group has probability implications which it is clinically unsound to ignore" (Meehl, 1959, p. 103). More recently, it has been argued that classification is essential for research and fundamental to the clinician in organizing the multi-faceted aspects of mental disorders (Shakow, 1968). Over the years, classification has increased our knowledge of psychopathology, and further important insights should be forthcoming with increased efforts to improve both the system and the process. We are drawn to the conclusion that the student must be familiar with the diagnostic categories presently used, because they represent handles that systematically open the storehouse of available knowledge in the field. In addition, they stress the orderly and careful accumulation of observations so necessary for making diagnostic decisions.
Scope and Measurement of Psychopathology
Statistical data about the occurrence of abnormal behavior may be arrived at in three different ways: incidence, prevalence, and expectancy. Incidence refers to the total number of new cases of a disorder that occurs within a specified population and a period of time. Prevalence is a more extensive measure in that it refers to the total number of cases (old and new) present in a given population during a specified time interval.
The major difference between incidence and prevalence measures is that the latter reflects both incidence and duration. For example, if we interpret as incidence data the often cited statistic that over one-half of all hospital beds are occupied by the mentally ill, we would conclude erroneously that there are more people who evidence abnormal behavior than is actually the case. However, if we understand this finding as prevalence data, we recognize the fact that the internment for mental disorders is much longer than the time required for other hospitalized conditions. Therefore, the statistic should not be taken to mean that one-half of all new hospital admissions each year consists of mentally ill people, but rather that mental patients occupy half of the beds available because their hospital stay is relatively long (Kramer, 1957; Malzberg, 1963).
The probability that a person will fall into a specific category of abnormal behavior sometime during his or her lifetime is an expectancy measure. Although informative, an expectancy measure is biased since it does not take into account the individual's age when the question is asked concerning the chances of becoming mentally ill. The longer one lives, the greater number of years available in which the probabilities of abnormal behavior apply. Therefore, it is more useful to ask what is one's risk of a behavior disorder if one lives to a certain age. In this way, the risk is expressed as a conditional probability, not as a joint probability of both living to such an age and becoming mentally ill. For example, the probability of living to the age of ninety and being mentally ill is less than the chances of having a behavior disorder given that one does live to the age of ninety.
Sources of Error in Measurement
Unfortunately, all of these measures are subject to several sources of error that make it difficult to estimate the extent of the problem in any definitive way. Typically, frequency figures of abnormal behavior come from public and private clinics and hospital census records. These data do not include instances of abnormal behaviors that are tolerated or go unrecognized within some subcultures of our society. For example, school phobias (fear of and refusal to go to school) are more likely to go unnoticed in a low socio-economic urban area than in an upper-middle-class urban neighborhood because truancy is implicitly sanctioned in that subculture. In addition, the measures do not reflect the number of less severe cases that are handled within the confines of the family, or those cases that are masked by physical symptoms such asthma. There is a strong tendency for some parents to postpone as long as possible the professional attention needed by their disturbed children. For that matter; some professionals tend to shy away from using "diagnostic labels connoting severe abnormal conditions to reduce the danger that the diagnosis will adversely affect how others react to the child in the future. Moreover official statistics are not adjusted in terms of the availability of services and facilities. Therefore, they do not include those cases that are unadmitted because facilities either are nonexistent or unavailable because of overcrowded conditions. A more serious source of error is the great diversity among professionals and institutions with regard to the definition and classification of abnormal behavior. Therefore, all of these measures are affected in an unsystematic way by the variability of the diagnostic labels used to categorize abnormal behaviors.
Scope of the Problem
Despite of these limitations, we do know that the United States faces a sizable and serious problem. The 1970 census indicated : "\\'e are a nation of young people with approximately fifty million of our citizens classified as minors (twenty six percent of the total population) and with one-half of this figure under the age of ten. Several separate estimates give cause for concern in that they reflect that up to ten percent of all school age children require professional attention for abnormal behaviors, and that children now constitute about thirty four percent of the total population served by outpatient mental-health centers as compared to twenty-seven percent in 1967 (Bower, 1969; Crisis in Child Mental Health: Challenge for the 1970's, 1970; Garmezy, 1975). Since 1973, the number and rate of hospital admissions (adjusted for birth rate) among children under eighteen years of age has been declining. However, it is too early to tell if this is a reliable trend or nothing more than yearly fluctuations like those noted in the previous four years (Taube and Meyer, 1975). In all probability, the decrease in hospital admissions represents a significant shift away from mental hospitals to a more extensive use of relatively new community facilities such as community mental-health centers. Of the children under eighteen years of age admitted to state and county mental hospitals in 1973, one percent was under five years of age, seven percent were between five and nine years, thirty percent were between ten and fifteen years, and sixty three percent were between fifteen and seventeen years old. However, the age at which children most frequently are referred for professional attention is between ten and fourteen years (Redick, 1973).
It has been known for a long time that boys outnumber girls in practically every diagnostic category of abnormal behavior, although as yet no satisfactory explanation for this finding is available. In some instances, the male-female ratio is as high as 5:1 (Gilbert, 1957; Morse, Cutler, and Fink, 1964; Redick, 1973). Equally puzzling is the fact that this relationship tends to hold until late adolescence. However, it dissipates in adulthood to the point where females may even exceed males in those abnormal conditions where unequal sex distributions are found. For hospitalized children, the boys exceed girls in every age group, but especially between the ages of five and nine years (Taube & Meyer, 1975).
Although the magnitude of aberrant behaviors in children is greater than we would wish, we can look to the future with optimism knowing that the field now provides formal training for its professional workers. Moreover, the encouraging advances in knowledge obtained through research make it more reasonable than ever before to expect that abnormal behaviors of children will be identified earlier, treated more effectively, and, to a greater extent, prevented.
Abnormal behavior was defines in terms of the following criteria:
1. Cultural Norm: the established standards and expectations approved by the culture for the behavior of its members.
2. Developmental Norm: The expectations based on our knowledge of the developmental process.
3. Intellectual and Cognitive Functioning: an apparent disparity between ability and actual performance in attention, comprehension, judgment, learning, memory, thinking, and perception.
4. Emotional Expression and Control: an insufficient or an exaggerated emotional reaction, inappropriate emotional expression, infantile emotional reactions, moods of despondency, extreme elation, sudden fluctuation, or too little or too much emotional control.
5. Coping in Interpersonal Relations: disruptions in or inability to cope with interpersonal relations, social withdrawal, isolation, suspiciousness, fear and hatred of others, and uncooperativeness. This criterion must be used in conjunction with the other criteria of cognitive and emotional dysfunction.
We also argued that the characteristics of frequency, intensity or degree, and duration are necessary in applying the above criteria in defining the domain of abnormal behavior.
We presented summaries of the new psychiatric classification system (DSM-III) and the GAP proposal for the classification of children's disorders. In addition, we considered the WHO multiaxial classification for childhood disorders, Achenbach's factor analytic system, Anna Freud's developmental profile, and other miniature schemes for research purposes.
We discussed measures of reliability and research findings. In general, reliability of classification is fairly high when few and broad categories are used, but it declines sharply when a greater number and more specific categories are included. We reviewed major criticisms and problems inherent in the classification system, although we concluded that classification brings order and uniformity to psychopathology and serves an important communication function among professionals.
We also considered the problems associated with estimating the frequency of occurrence of abnormal behavior, and we defined incidence, prevalence, and expectancy measures. All of these measures are affected by the variability of the diagnostic labels used to categorize abnormal behavior, by the availability of service facilities, by instances that are either tolerated or unrecognized within some subcultures of our society, and by the inclination of families to deny or ignore the problem. We presented some overall estimates of the scope of the problem.
The follow-up story on Martin is disappointing. During the three years he was seen at the Clinic, Martin had several different therapists in both individual and group psychotherapy. An abnormal EEG was uncovered, which together with his acting out behavior suggested potential benefit from chemotherapy. He was given two anticonvulsant drugs for almost a year and a half, although no behavioral improvements were noted. Soon thereafter, Martin was placed on a trial dose of an amphetamine which, according to the therapist, produced positive behavioral results. However, his mother and teachers observed no improvement in his behavior. Finally, medication and psychotherapy were discontinued because the family became pessimistic over Martin's prospect for improvement and the clinic's effectiveness in treating' him. Possibly the absence of a careful diagnostic work-up and the failure to arrive at a diagnosis for Martin were significant factors in the clinic's ineffectiveness in structuring an appropriate treatment plan for Martin and his family.
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The Nature of Psychopathology
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TABLE 2-1 Summary of DSM-1I1 Categories
Diagnostic and Statistical Manual of Mental Disorders
A. Organic Mental Disorders
B. Drug Use Disorders
C. Schizophrenic Disorders
D. Paranoid Disorders
E. Affective Disorders
F. Psychoses Not Elsewhere Classified
G. Anxiety Disorders
H. Factitious Disorders
I. Somatoform Disorders
J. Dissociative Disorders
K. Personality Disorders
L. Psychosexual Disorders
Gender Identity or Role Disorders Paraphilias
M. Disorders Usually Arising in Childhood or Adolescence (see Table 2-2)
Pervasive Developmental Disorders Attention Deficit Disorder
Specific Developmental Disorders Stereotyped Movement Disorders
Speech Disorders Not Elsewhere Classified Conduct Disorders
Disorders Characteristic of Late Adolescence Other Disorders of Childhood or Adolescence
N.Reactive Disorders Not Elsewhere Classified O. Disorders of Impulse Control Not Elsewhere Classified
O. Sleep Disorders
P. Other Disorders and Conditions
Unspecified Mental Disorder (Not Psychotic) Psychic Factors in Physical Condition
No Mental Disorder
Conditions Not Attributable to Known Mental Disorder
TABLE 2-2 Summary Description of DSM-Its Category on Childhood Disorders
Disorders Usually Arising in Childhood or Adolescence
The disorders in this section usually arise and are evident in childhood or adolescence, although no arbitrary age limit is used to define childhood or adolescence. The diagnoses in this section may apply to adults if they experienced the condition since childhood and no adult category applies. Childhood conditions resembling adult disorders that may not be continuous with these adult conditions have been given different names. A severity rating of functional impairment is made for conduct disorders. The multiaxial framework should be used whenever possible.
1. Mental Retardation
Three essential features must be present: (1) significant subaverage general intellectual functioning, (2) concurrent deficits in adaptive behavior, and (3) onset before the age of eighteen. The diagnosis is made regardless of the nature of the etiological factors, although a known biological cause should be coded on Axis III. When mental retardation develops after age eighteen, it is designated as a dementia and is coded within the organic mental disorders section. There are four subtypes of mental retardation reflecting the degree of intellectual impairment. These are labeled as mild, moderate, severe, or profound depending on an IQ criterion.
2. Pervasive Developmental Disorders
These disorders are characterized by distortions in the timing, rate, and sequence of many basic psychological functions, and they differ from specific developmental disorders in two ways: (1) the specifics show a delay in time or rate of specific discrete functions while the pervasives evidence a marked distortion of the timing, rate, and sequence of many general psychological functions that profoundly distort social and interpersonal development; and (2) the specifics appear as if they are passing through an earlier normal developmental stage, while the pervasives manifest severe qualitative abnormalities that are not normal for any stage of development. Pervasive development disorders were previously labeled atypical children, symbiotic psychotic children, and childhood schizophrenia.
A. Infantile Autism
The essential features of this syndrome include lack of responsiveness to other human beings, gross impairment in communicative skills, and bizarre responses to various aspects of the environment. All features develop within the first forty-two months of age. The operational criteria of infantile autism are as follows: (1) onset usually prior to thirty months but up to forty-two months, (2) lack of responsiveness to other human beings, (3) self-isolation, (4) gross deficits in language development, (5) if speech is present, peculiar speech patterns, and (6) peculiar interest or attachments to animate or inanimate objects.
B. Early Childhood Psychosis
Profound disturbance in emotional relationships with people and a multiplicity of bizarre characteristics developing during infancy or early childhood are the essential features. Early childhood psychosis is diagnosed by the following operational criteria: (1) gross and sustained impaired emotional relationships, (2) bizarre beliefs or preoccupations, (3) four of the eight associated features (acute and illogical anxiety, disturbed affect, resistance to environmental change, peculiar motility, speech abnormalities, language disturbances, abnormal sensory and perceptual experiences, self-mutilation), and (4) onset during infancy or early childhood.
C. Pervasive Development Disorder of Childhood, Residual State
This category is intended to meet the following operational criteria: (1) the patient's condition once was diagnosed as a pervasive developmental disorder, (2) the current clinical picture does not meet the criteria for either infantile autism or early childhood psychosis, and (3) the patient is still manifesting symptoms caused by the original disorder.
D. Unspecified Pervasive Developmental Disorders 3. Attention Deficit Disorders
This category includes two separate disorders characterized by developmentally inappropriate short attention and poor concentration.
A. Attention Deficit Disorder with Hyperactivity
The operational criteria for this disorder are as follows: (1) excessive general hyperactivity or motor restlessness for age, (2) difficulty sustaining attention, (3) impulsive behavior as evidenced in at least two of the following: sloppy work but with effort to perform, frequent calling out of turn or making inappropriate sounds in class, frequent interruption .of or intrusion into activities of other children, difficulty waiting for one's turn, poor frustration tolerance, fighting with children brought on by low frustration tolerance, and (4) duration of condition at least one year.
B. Attention Deficit Disorder Without Hyperactivity
Children with this disorder manifest, for their age, an impairment in the ability to concentrate, difficulty in completing tasks, and conspicuous lack of organization or forethought as they move from one activity to another. They exhibit difficulty sustaining attention and focusing attention but without hyperactivity. The diagnosis should not be made before the age of four. Specific developmental disorders are common and should be coded on Axis II. Impaired academic performance often is present. The operational criteria for this disorder is similar to those described in (A) except for the hyperactivity and motor component.
4. Specific Developmental Disorders (Axis II)
These disorders are coded on Axis II and are diagnosed only when there is a delay in development that is notan essential criterion for another disorder. The coding carries no etiological implications and should be made on the basis of the individual's current level of functioning without regard to its origin.
A. Specific Reading Disorder
The essential feature of this disorder is a serious impairment in the development of reading skills not explicable in terms of mental age or inadequate schooling. The impairment should be determined by a performance on a standardized reading test and it should be significantly less than predicted on the basis of the child's chronological age and a fullscale IQ obtained from an individually administered intelligence test.
B. Specific Arithmetical Disorder
The essential feature of this disorder is a serious impairment of arithmetic skills not explicable in terms of mental age or inadequate schooling. The diagnosis should be established by performance on standardized tests of arithmetic achievement significantly below that which would be expected on the basis of the child's chronological age and full-scale IQ on an individually administered intelligence test.
C. Developmental Language Disorder
Delayed language disorder is separated into two types:
1. Expressive type is characterized by an impairment in the encoding or production of language while the understanding or decoding skills remain relatively intact. The operational criteria include a defect or delay in. the production of language, and the absence of hearing impairment, general retardation, trauma, or seizures that could explain the defect.
2. Receptive type involves both the comprehension and production of language such that language acquisition is severely impaired. The deficit must be present from the first year of life and there must be an absence of general mental retardation or other more pervasive disorder that could explain the language disability in order for the diagnosis to be made.
D. Developmental Articulation Disorder
The essential feature 9f this disorder is defective articulation of the later acquired speech sounds occurring in the absence of other language impairment or physical or intellectual disorders.
E. Coordination Disorder
This involves a serious impairment absence of mental retardation or any motor coordination problems.
Primary Enuresis is characterized by persistent involuntary voiding of urine by day or night that is considered abnormal for the age of individual. The frequency should be at least one such event per month after the child has reached the age of five.
Secondary Enuresis is differentiated from primary by the second operational criteria that states that the frequency should be at least one such event per month after a period of urinary continence lasting at least one year.
in the development of motor coordination in the neurological disorder that would account for the
This disorder consists of a persistent voluntary or involuntary passage of feces of normal or near normal consistency in places deemed inappropriate for that purpose by the individual's own sociocultural setting. This should occur at a frequency of at least one such event per month for a period after the child has reached the age of five.
H. Mixed Specific Developmental Disorders
This category should be used when the patient manifests more than one specific developmental disorder, none of which is predominant.
I. Other Specific Developmental Disorders
This category is used when there is a serious impairment in a specific area of development that is not covered by the categories specified.
J. Unspecified Specific Developmental Disorders
5. Stereotyped Movement Disorders A. Motor Tic Disorder
This disorder involves purposeless, involuntary movements that are frequent, rapid, spasmodic and repetitive, and that occur in the absence of an established neurological etiology. The disorder's duration should be for at least one month, and no verbal tics are present for the diagnosis to be made.
B. Motor-Verbal Tic Disorder (Gilles de la Tourette Syndrome)
Individuals with this disorder suffer from motor and verbal tics and from sudden vocalizations. Other operational criteria include age of onset between two and fifteen years, multiple involuntary motor and verbal tics, and symptoms that wax and wane.
C. Unspecified Tic Disorder
D. Other Stereotyped Movement Disorders
This category is intended for conditions such as head banging, rocking, repetitive hand movements consisting of quick rhythmical small hand rotations, or repetitive voluntary movements involving the fingers or arms. They are distinguishable from tics in that they consist of voluntary movements and are not spasmodic. Children with these disorders are not distressed by the same symptoms as those with tics.
6. Speech Disorders Not Elsewhere Classified A. Stuttering
This disorder consists of persistent repetitions or prolongations of sounds, syllables, or words; or persistent, unusual hesitations and pauses that disrupt the rhythmic flow of speech. It occurs in the absence of mental retardation as the cause of the speech impairment.
B. Elective Mutism
This disorder is characterized by a pervasive and persistent refusal to speak in social or school situations, though the children are able and willing to speak to selected persons, usually family or peers. The diagnosis is made only when the refusal to speak is not
The Nature of Psychopathology
symptomatic of any other disorder listed and when there is evidence of normal intellectual functions.
7. Conduct Disorders
These disorders involve repetitive and persistent patterns of misconduct such as delinquency, destructiveness, or other violations of the rights of others beyond the ordinary mischief and pranks of children and adolescents.
A. Undersocialized Conduct Disorder. Aggressive Type
The operational criteria include (1) a persistent lack of concern for the feelings of others; (2) a pattern of antisocial behavior of at least four months' duration with at least one of the following: assault, defiance and defiant disobedience, destructiveness, cruelty, and vindictiveness; (3) failure to develop peer friendship patterns; and (4) behavioral difficulties at school.
B. Undersocialized Conduct Disorder. Unaggressive Type
These children (1) fail to form social bonds and develop a pattern of normal attachment to others; (2) lack bold or openly aggressive behavior, unless with those who are younger and weaker than they; (3) show five or more of the following behaviors for at least four months: stealing, lying, lack of friends, superficial friendliness for self-seeking purposes, whining and temper tantrums, repetitive running away from home overnight, repetitive staying out late at night, chronic disobedience, complaining that "nobody likes me or nobody cares about me," and poor frustration tolerance.
C. Socialized Conduct Disorder
This disorder is defined operationally by the following criteria: (1) involvement over at least a four months' period in a pattern of antisocial behavior involving either group fighting, petty thievery, minor vandalism, or other more serious delinquent or antisocial activity, such as group stealing, burglary, larceny, or assault, (2) evidence of some dependable and lasting attachments and age-appropriate relationships with some persons, whether companions, family members, or others, and (3) the presence of impairment in social relationships in the family and in school, as well as impairment in age-appropriate responsibilities at home and school.
8. Eating Disorders
A. Anorexia Nervosa
The essential features of this disorder are excessive behaviors directed toward losing weight, peculiar patterns of handling food, weight loss, intense fear of gaining weight, disturbance about body image, and in women, amenorrhea.
This disorder is characterized by an episodic pattern of binge eating (rapid consumption of a large amount of food in a discrete period of time, usually less than two hours), accompanied by an awareness of the disordered eating pattern and a fear of not being abJe to voluntarily stop eating, and depressive moods and self-deprecating thoughts. Bulimic patients must have at least three of the following symptoms: rapid consumption of food during a binge; consumption of high caloric food during a binge; inconspicuous eating during a binge; the termination of binge eating by abdominal pain, sleep, social interruption, or self-induced vomiting; repeated attempts to lose weight by severely restrictive diets or self-induced vomiting; an eating pattern of alternate binges and fasts; and use of cathartics for weight control.
This disorder involves the persistent eating of non-nutritional substances for at least one month.
D. Ruminati (Merycism)
The essential features are regurgitation of food with failure to thrive, or weight loss developing after a period of normal functioning.
9. Anxiety Disorders of Childhood or Adolescence A. Separation Anxiety Disorder
TiJe Nature of Psychopathology
Exaggerated distress of at least one month duration at separation from parents, home, or other familial surroundings that is not accounted for by any other mental disorder.
B. Shyness Disorder
This disorder involves the persistent shrinking from familiarity or contact with all strangers to the extent that it interferes with peer functioning. The child must be at least two and a half years of age and the shyness must be present for at least three months. These children usually have warm and satisfying relations with family members.
C. Overanxious Disorder
This disorder is characterized by anxiety for at least three months evidenced by persistent worrying about future events but not focused on a specific situation or object and not attributable to a recent psychosocial stressor. The anxiety is not symptomatic of another disorder and at least one of the following symptoms of anxiety also must be present: concern with competence, difficulty falling asleep, somatic complaints with no medical basis, and frequent frightening dreams.
10. Disorders Characteristic of Late Adolescence
A. Emancipation Disorder of Adolescence or Early Adult Life
The essential feature is symptomatic expression of a conflict over independence following the recent growth of independence from parental control or supervision. The condition is not secondary to any other mental disorder, and it must be manifested by two or more of the following symptoms: difficulty making independent decisions, increased dependence on parental advice, unwarranted concern about parental possessiveness, adoption of values deliberately in opposition to parents, rapid development of markedly dependent peer relationships, and homesickness.
B. Identity Disorder
Distress over an inability to reconcile aspects of the self into a relatively coherent and acceptable sense of self, not secondary to another mental disorder with onset not prior to an age of fourteen.
C. Specific Academic or Work Inhibition
The predominant clinical feature is severe distress interfering significantly with any of the following academic or work tasks and manifested by anxiety related to examinations or other tests; inability to write papers or prepare reports or to perform in studio arts activities, or by difficulty in concentration on studies or work, or avoidance of studying or work which does not seem to be under the conscious control of the individual. The previous academic or work functioning should have been at least adequate, and the individual should have intellectual and academic or work skills that are adequate, and the condition is not caused by any other mental disorder.
11. Other Disorders of Childhood or Adolescence A. Oppositional Disorder
Pervasive opposition to all authority regardless of self-interest occurring after the age of two through the age of eighteen. There is a continual argumentativeness and an unwillingness to respond to reasonable persuasion, which is not accounted for by a conduct disorder, an adjustment disorder, or a pervasive developmental disorder.
B. Academic Underachievement Disorder
Failure to achieve in most school tasks despite adequate intellectual capacity, a supportive and encouraging social environment, and apparent effort. The failure occurs in the absence of a demonstrable specific learning disability and is caused by emotional conflict not clearly associated with any other mental disorder.
Reprinted with permission of American Psychiatric Association. From Diagnostic and Statistical Manual of Medical Disorders, 3rd ed., Draft Version, Task Force on Nomenclature and Statistics, 4/5/77.
TABLE 2-3 Psychopathological Disorders in Childhood Proposed Classification
This category assesses the positive strengths of the child and tries to avoid the diagnosis of healthy states by the exclusion of pathology. The criteria for assessment are the intellectual, social, emotional, personal, adaptive, and psychosocial functioning of the child in relation to developmental and situational crises.
1. Developmental crisis
2. Situational crisis
3. Other responses
2. Reactive Disorders
This category is based on disorders in which behavior and/or symptoms are the result of situational factors. These disturbances must be of a pathological degree so as to distinguish them from the healthy responses to a situational crisis.
3. Developmental Disorders
These are disorders in personality development that may be beyond the range of normal variation in that they occur at a time, in a sequence, or in a degree not expected for a given age level or stage in development.
1. Deviations in maturational patterns
2. Deviations in specific dimensions of development
6. Cognitive functions
7. Social development
11. Other developmental deviation
4. Psychoneurotic Disorders
These disorders are based on unconscious conflicts over the handling of sexual and aggressive impulses that remain active and unresolved, though removed from awareness of the mechanism of repression. Marked personality disorganization or decompensation or the gross disturbance of reality testing is not seen. Because of their internalized character these disorders tend toward chronicity, with a self-perpetuating or repetitive nature. Subcategories are based on specific syndromes.
1. Anxiety type
2. Phobic type
3. Conversion type
4. Dissociative type
5. Obsessive-compulsive type
6. Depressive type
7. Other psychoneurotic disorder
These disorders are characterized by chronic or fixed pathological trends, representing traits that have become ingrained in the personality structure. In most but not all such disorders, these trends or traits are not perceived by the child as a source of intrapsychic distress or anxiety. In making this classification, the total personality picture must be considered and not just the presence of a single behavior or symptom.
1. Compulsive personality
4. Overly dependent
6. Overly inhibited
7. Overly independent
9. Mistrustful Tension-discharge disorders:
1. Impulse-ridden personality
2. Neurotic personality disorder Sociosyntonic personality disorders:
1. Sexual deviation
2. Other personality disorder
6. Psychotic Disorder
These disorders are characterized by marked, pervasive deviations from the behavior that is expected for the child's age. They are revealed in severe and continued impairment of emotional relationships with persons; loss of speech or failure in its development; disturbances in sensory perception; bizarre or stereotyped behavior and motility patterns; marked resistance to change in environment or routine; outbursts of intense and unpredictable panic; absence of a sense of personal identity; and blunted, uneven, or fragmented intellectual development. Major categories are based on the developmental period with subcategories in each period for the listing of a specific syndrome, if known.
1. Psychoses of infancy and early childhood
a. Early infantile autism
b. Interactional psychotic disorder
c. Other psychosis of infancy and early childhood
2. Psychoses of later childhood
a. Schizophreniform psychotic disorder b. Other psychosis of later childhood
3. Psychoses of adolescence
a. Acute confusional state
b. Schizophrenic disorder, adult type c. Other psychosis of adolescence
7. Psychophysiologic Disorders
These disorders are characterized by a significant interaction between somatic and psychological components. They may be precipitated and perpetuated by psychological or social stimuli of stressful nature. These disorders ordinarily involve those organ systems innervated by the autonomic nervous system.
5. Hemic and lymphatic
9. Of nervous system
10. Of organs of special sense
11. Other psychophysiologic disorders
8. Brain Syndromes
These disorders are characterized by impairment of orientation, judgment, discrimination, learning, memory, and other cognitive functions, as well as by frequent labile affect. They are basically caused by diffuse impairment of brain tissue function. Personality disturbances of a psychotic, neurotic, or behavioral nature also may be present.
1. Acute 2. Chronic
2.Mental Retardation 10. Other Disorders
This category is for disorders that cannot be classified by the above definitions or for disorders we will describe in the future.
Reprinted by permission from Psychological Disorders in Childhood: A proposed Classification, Group for the Advancement of Psychiatry, 419 Park Avenue South, New York, ".Y. 10016.
Taken from CHILDHOOD PSYCHOPATHOLOGY – A DEVELOPMENTAL APPROACH by IRWIN J. KNOPF, Emory University, PART 2, The Nature of Psychopathology, PAGE 26 TO 53, Copyright by Prentice-Hall. Inc., Englewood Cliffs, New York, Printed in the United States of America.
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