ARO-HEALING

CHILDHOOD PSYCHOPATHOLOGY

 THE NATURE OF PSYCHOPATHOLOGY

 METHODS OF EVALUATION AND INTERVENTION

PROLOGUE

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.

 Cultural Norms

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.

Developmental Norms

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

Measures

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.

 Summary

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.

Epilogue

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.

ACHENBACH, T. M. "The Classification of Children's Psychiatric Symptoms: A Factor­ Analytic Study." Psychological Monograps, 1966, 80:(Whole No. 615), 1-37.

ACHENBACH, T. M. Developmental Psychopathology. New York: Ronald Press, 1974. ACHENBACH, T. M. and M. LEWIS. "A Proposed Model for Clinical Research and Its Application to Encopresis and Enuresis." Journal of the American Academy of Child Psychiatry, 1971, 10, 535-554.

AL-ISSA, 1. "Problems in the Cross-Cultural Study of Schizophrenia." Journal of Psy­chology, 1969, 71, 143-151.

BAZZOUI, W. and 1. AL-IsSA. "Psychiatry in Iraq." British Journal of Psychiatry, 1966, 112, 827-832.

BECK, A. T. "Reliability of Psychiatric Diagnoses. 1. A Critique of Systematic Studies."

American Journal ot Psychiatry, 1962, 119, 210-216.

BEMPORAD, J" PFEIFFER, C., and W. BLOOM. "Twelve Months Experiences with the GAP Classification of Childhood Disorders." American Journal ot Psychiatry, 1970, 127, 658-664.

BOWER, E. M. The Early Identification ot Emotionally Handicapped Children in School (2nd ed.). Springfield, Illinois: Thomas, 1969.

COPELAND, J. "Aspects of Mental Illness in West African Students." Social Psychiatry, 1968, 3, 7-13.

Crisis in Child Mental Health: Challenge tor the 1970's. Report of the Joint Com­mission on Mental Health of Children. New York: Harper and Row, 1970.

DEl\1YER, M. K., CHURCHILL, D. W., PONTIUS, W., and K. M. GILKEY. "A Comparison of Five Diagnostic Systems for Childhood Schizophrenia and Infantile Autism." Journal of Autism and Childhood Schizophrenia, 1971, 1, 175-189.

Diagnostic and Statistical lHanual. American Psychiatric Association. Washington, D.C.: Special Printing, 1965.

DSM-III: Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) . The Task Force on Nomenclature and Statistics of the American Psychiatric Association. New York: The American Psychiatric Association, 4!l5!77 (draft).

The Nature of Psychopathology

DOHRENWEND, B. P. and B. S. DOHRENWEND. "Social and Cultural Influences on Psy­chopathology. Annual Review of Psychology, 1974, 25, 417-452.

DRAGUNS, J. G. and L. PHILLIPS. Psychiatric Classification and Diagnosis: An Overview and Critique. Morristown, New Jersey: General Learning Press, 1971.

FREEMAN, M. "A Reliability Study of Psychiatric Diagnosis in Childhood and Ado­lescence." journal of Child Psychology and Psychiatry and Allied DisciPlines, 1971, 12: (1), 43-54.

FREUD, A. Normality and Pathology in Childhood. New York: International Universities Press, 1965.

GARMEZY, N. "The experimental study of children vulnerable to psychopathology."

In A. Davids (Ed.), Child Personality and Psychopathology: Current Trends, Vol. 2. New York: Wiley, 1975.

GILBERT, G. M. "A Survey of Referral Problems in. Metropolitan Child Guidance Centers. journal of Clinical Psychology, 1957, 13, 37-42.

Group for the Advancement of Psychiatry, Committee on Child Psychiatry: The Diag­nostic Process in Child Psychiatry.GAP report No. 38, August, 1957.

Group for the Advancement of Psychiatry, Committee on Child Psychiatry: Psycho­pathological Disorders in Childhood: Theoretical Considerations and a Pro­posed Classification. GAP report No. 62, June 1966.

HUNT, W. A., WITSON,C. L., and E. B. HUNT. In P. H. Hoch and]. Zubin (Eds.), Current Problems in Psychiatric Diagnosis. New York: Gruen and Stratton, 1953.

JOHNSON, S., WAHL, G., MARTIN, W., and S. JOHANSSON. "How Deviant Is the Normal Child? A Behavioral, Analysis of the Preschool Child and His Family." In R. Rubin, J. Brady and J. Henderson (Eds.), Advances in Behavior Therapy:

Proceedings of the Association for Advancement of Behavior Therapy, 1969-73, Vol. 4. New York: Academic Press, 1973.

KLEINMUNTZ, B. Essentials of Abnormal Psychology. New York: Harper and Row, 1974, p. 389.

KRAMER, M. A. "A Discussion of the Concepts of Incidence and Prevalence as Related to Epidemiologic Studies of Mental Disorder.American journal of Public Health, 1957, 47, 826-840.

KREITMAN, N., SAINSBURY, P., MORRISEY, J., TOWERS, .J" and]. SCRIVENER. "The Re­liability of Psychiatric Assessment: An Analysis." journal of Mental Science, 1961, 197, 887-908.

LORR, M., KLETT, C. ]., and D. M. McNAIR. Syndromes of Psychosis. New York: Mac­Millan, 1963.

MALZBERG, B. "Mental Disorders in the United States." In A. Deutsch and H. Fish­man (Eds.), Encyclopedia of Mental Health(6 vols.). New York: Franklin Watts, 1963.

MEEHL, P. E. "Some Ruminations on the Validation of Clinical Procedures." Cana­dian journal of Psychology, 1959, 13, 102-128.

MEYER, A. The Commonsense Psychiatry of Doctor AdolPh Meyer (A. Lief, Ed.).

New York: McGraw-Hill, 1948.

MORSE, W. C., CUTLER, R. L., and A. H. FINK. Public School Classes for the Emotion­ally Handicapped: A Research Analysis. Washington, D.C.: Council for Ex­ceptional Children, 1964.

MUNClE, W. Psychobiology and Psychiatry (2nd ed.). St. Louis: Mosby, 1948.

NASH, J. Developmental Psychology: A Psychobiological Approach. Englewood Cliffs, New Jersey: Prentice-Hall, 1970, p. 306.

::-:;,-e of Psychopathology

?A5A:\IANICK, B., DINITZ, S., and M. LEFTON. Psychiatric Orientation and Its Relation to Diagnosis and Treatment in a Mental Hospital.American journal of Psy­chiatry, 1959, 116, 127-132.

REDICK, R. Utilization of Psychiatric Facilities by Persons Under Eighteen Years of age. United States, 1971. Statistical Note 90. Department of Health, Education, and Welfare, 1973.

RI:\lLAND, B. "The Differentiation of Childhood Psychoses: An Analysis of Checklists for 2,218 Psychotic Children." journal of Autism and Childhood SchizoPhrenia, 1971, 2, 161-174.

RUTTER, M., LEBOVICI, S., EISENBERG, L., SNEVNEVSKIJ, A. V., SADOUN, R., BROOKE, E., and T. Y. LIN. "A Triaxial Classification of Mental Disorders in Childhood." journal of Child Psychology and Psychiatry, 1969, 10, 41-61.

SABOT, L. M., PECK> R., and J. RASKIN. "The Waiting Room Society." Archives of General Psychiatry, 1969, 21, 25-32.

SANDIFER, M. G., Jr., PETTUS, C., and D. QUADE. "A Study of Psychiatric Diagnosis." journal of Nervous and Mental Disease,1964, 139, 350-356.

SCHMIDT, H. W. and C. P. FONDA. "The Reliability of Psychiatric Diagnosis." journal of Abnormal and Social Psychology, 1956, 52, 262-267.

SHAKOW, D. "The Role of Classification in the Development of the Science of Psycho­pathology with Particular Reference to Research. In M. M. Katz, J. O. Cole, and W. E. Barton (Eds.), The Role and Methodology of Classification in Psychiatry and Psychopathology. Public Health Service Publication No. 1584. U.S. Depart­ment of Health, Education, and Welfare, Public Health Service, 1968, pp. 116­143.

TAUBE, C. A., and N. G. MEYER. Children and State Mental HosPitals. DHEW Statis­tical Note 115. Publication No. (ADM) 75-158. Rockville, Maryland: U.S. Department of Health, Education, and Welfare, 1975.

WARD, C. H., BECK, A. T., MENDELSON, M., MOCK, J. E., and J. K. ERBAUGH. "The Psychiatric Nomenclature: Reasons for Diagnostic Disagreement." Archives of General Psychiatry, 1962, 7, 198-205.

'VERRY, J. S. and H. C. QUAY. "The Prevalence of Behavior Symptoms in Younger Elementary School Children. American journal of Orthopsychiatry, 1971, 41, 136-143.

ZIGLER, E. and L. PHILLIPS. "Social Competence and Outcome in Psychiatric Disorder." journal of Abnormal and Social Psychology, 1961, 63, 264-271.

ZUBIN, J. "Classification of the Behavior Disorders." Annual Review of Psychology, 1967,18, 373-406.

TABLE 2-1 Summary of DSM-1I1 Categories

Diagnostic and Statistical Manual of Mental Disorders

Diagnostic Categories

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

Psychosexual Dysfunctions

M. Disorders Usually Arising in Childhood or Adolescence (see Table 2-2)

Mental Retardation

Pervasive Developmental Disorders Attention Deficit Disorder

Specific Developmental Disorders Stereotyped Movement Disorders

Speech Disorders Not Elsewhere Classified Conduct Disorders

Eating Disorders

Anxiety 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

Administrative Categories

 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.

F. Enuresis

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

G. Encopresis

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.

B. Bulimia

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.

C. Pica

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

Healthy Responses

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.

Healthy responses:

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.

Developmental Deviations:

1.                     Deviations in maturational patterns

2.                     Deviations in specific dimensions of development

3.                     Motor

4.                     Sensory

5.                     Speech

6.                     Cognitive functions

7.                     Social development

8.                     Psychosexual

9.                     Affective

10.                  Integrative

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.

Psychoneurotic Disorders:

1.                  Anxiety type

2.                  Phobic type

3.                  Conversion type

4.                  Dissociative type

5.                  Obsessive-compulsive type

6.                  Depressive type

7.                  Other psychoneurotic disorder

Personality Disorders

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.

Personality Disorders

1.                   Compulsive personality

2.                   Hysterical

3.                   Anxious

4.                   Overly dependent

5.                   Oppositional

6.                   Overly inhibited

7.                   Overly independent

8.                   Isolated

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.

Psychotic Disorders:

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.

Psychophysiologic Disorders:

1.                    Skin

2.                    Musculoskeletal

3.                    Respiratory

4.                   Cardiovascular

5.                   Hemic and lymphatic

6.                   Gastrointestinal

7.                   Genitourinary

8.                   Endocrine

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.

Brain Syndromes:

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.