DSM-IV Training Guide For Diagnosis Of Childhood Disorders

Judith L. Rapoport, Deborah R. Ismond

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317823841
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

First published in 1996. Revised to reflect changes made in DSM-IV as they pertain to childhood psychiatric disorders, this updated DSM-IV Training Guide for Diagnosis of Childhood Disorders provides specific instructions for optimally using the DSM-IV. This meticulously researched companion guide will provide welcome clarification and definition of the terms and concepts included in the DSM-IV criteria for disorders pertaining specifically to children and adolescents. The volume encompasses both psychopathology specific to infancy, childhood, and adolescence and other psychiatric disorders, such as Anxiety, Obsessive-Compulsive Disorder, Depression, and Schizophrenia, that are more common as adult disorders by may appear in childhood. While the diagnostic criteria for these are largely the same for children and adults, there are differences that emerge when making differential diagnosis of these disorders for children, as illuminated in the Training Guide. This companion guide focuses on the manifestation of various disorders, differentiation among syndromes, and qualify of characteristics. Numerous and vivid case vignettes clearly illustrate clinical symptoms and demonstrate the application of diagnostic guidelines. The book highlights the multiaxial approach of DSM as a means of assessing the child from a variety of perspectives including exogenous factors influencing development, sources of a particular disorder, and the child's innate limitations and capabilities. Diagnostic criteria and main features of specific disorders are highlighted in numerous tables and figures interspersed throughout the volume. Most importantly, the Guide highlights the gray areas of diagnosis with the hope that increased clinical awareness and record keeping will lead to more accurate classification - and ultimately superior treatment - in the future. The DSM-IV Training Guide for Diagnosis of Childhood Disorders will serve clinicians well in the sometimes difficult and subjective quest for the appropriate diagnosis, treatment, and management of children and adolescents with psychiatric disorders. It will also serve to promote the kind of dialogue and research that will lead to even greater diagnostic consensus among practitioners and encourage a more reliable and valid diagnostic practice in the future.

Part I
An Overview of Psychiatric Diagnosis in Infants, Children, and Adolescents

Part I provides an overview of diagnosis in children and adolescents. Chapter 1 discusses the history of childhood disorders and the evolving field of child psychiatry. Chapter 2 provides definitions and addresses multiple diagnoses and diagnostic validity and reliability. Chapter 3 considers specific issues relevant to diagnosis in childhood, such as age, assessment and evaluation, reactive nature, intellectual functioning, and access to services.

Chapter 1
Historical Perspective on Diagnosis of Childhood Disorders

Child psychiatry is a very recent addition to the scientific study and treatment of mental disorders. Around the turn of the century, Binet introduced the first psychometric measure for children, but the scale was not used in the United States until after 1910. This occurrence was closely followed by the application of psychoanalytic theory, which strongly influenced child psychiatry in that it viewed childhood experience as a determinant of adult psychopathology. The emphasis placed on the meaning of childhood events and their influence on later psychiatric disturbance evoked interest in obtaining information directly from children.

Leo Kanner’s textbook, Child Psychiatry (1935), was a milestone for American child psychiatry, marking its birth as a specialty in this country. Kanner’s expositions served as a model of descriptive clarity and engendered an increased awareness of and interest in the types of children depicted. His description of infantile autism is a well-known example. Kanner’s text still provides one of the clearest examples for diagnosis in child psychiatry; in fact, in several instances, the DSM categories have little to add.

During the past 50 years there has been an explosion of information describing human behavior at all ages, documenting developmental changes, and explaining mechanisms and processes of change. Although child psychologists have formulated assessment techniques and have designed tests in a variety of cognitive and behavioral areas, the impact on research techniques has remained minima] except in the area of psychometric testing.

Perhaps the two most important influences on modern diagnosis and measurement in child psychiatry have been the areas of psychopharmacology in this country and psychiatric epidemiology in Great Britain. The contribution of the Isle of Wight study (Rutter, Tizard, & Whitmore, 1970) cannot be overstated. Among other findings are the relative frequency of behavioral disturbance in childhood, the powerful nonspecific association between neurological impairments and behavioral disorders, and the association of Learning Disorders with Conduct Disorder. More recently, in the United States, the Epidemiological Catchment Area (ECA) studies of adults (Robbins, Helzer, Crougham, & Ratcliffe, 1981) have prompted interest in earlier diagnoses because of reports of childhood or adolescent onset for many disorders, particularly Anxiety Disorders. These findings remain a major influence on current research in the field.

During the 1950s psychopharmacology brought about dramatic changes in both patient care and the direction of research and assessment in general psychiatry in the United States and in Europe. The advent of new medications created renewed interest in describing changes in symptomatology directly attributable to treatment efficacy. This resulted in the development of rating scales and the use of double-blind techniques and it increased the amount of attention placed on diagnosis in the prediction of outcome.

Pediatric psychopharmacology took considerably longer to get started, despite early reports of the efficacy of stimulants for treatment of behavioral disorders in children (Bradley, 1937) and general interest in child development in the 1930s and 1940s. The use of rating scales to record initial symptom levels and subsequent changes has had a potent effect on present-day clinical descriptions and ratings. It is not surprising that major influential textbooks on pediatric psychopharmacology (Weiner, 1977, in press; Werry, 1978) emphasized the importance of measurement and diagnosis. The goal of physiological dissection of syndromes on the basis of drug response (though not particularly realized in child psychiatry [Rapoport, 1985] but an excellent heuristic principle) has led to careful delineation of syndromes among children participating in drug-research trials.

Although in its early stages psychopharmacological research sparked acute interest in childhood diagnosis, an intrinsically practical question emerged: Would the same medication work for similar or different indications? Thus, distinctions noted between autism and schizophrenia, or between Attention-Deficit/Hyperactivity Disorder and Conduct Disorder, assisted in decisions about treatment and in the prediction of outcome. It is no accident that almost half of the DSM committee on disorders of childhood and adolescence was made up of researchers who were working in pediatric psychopharmacology.

It is ironic that stimulant medications, which have a diagnostically nonspecific effect (Rapoport, 1985), comprise the only group of compounds that have influenced the most accurate clinical description in modern child psychiatry research. The very speed and reliability of the effects of such medications, however, have inspired numerous junior clinicians and researchers to document the influence of these drugs in a simple, objective fashion. Research has shown that virtually all children will become less restless and more attentive when given a stimulant drug (Elia, Borcherding, Rapoport, & Keysor, 1991; Rapoport et al., 1980), and that clinical efficacy depends on the individual balance between the almost universal focus of attention and more idiosyncratic side effects (Elia et al., 1991). The optimism engendered by such demonstrated changes has had a profound effect. Other diagnostic studies on Mania (Bowring & Kovacs, 1992) and Obsessive-Compulsive Disorder (Flament et al., 1985) were similarly prompted by psychopharmacological optimism.

Development of assessment tools was a natural adjunct directly related to this increase in clinical documentation. Much effort has gone into validating rating scales and questionnaires and in exploring interview parameters that might predict or reflect stimulant drug effects (see Appendix II; Rapoport & Conners, 1985). Perhaps simple, practical measurements of parameters such as motor activity have helped renew interest and faith in descriptive measures.

Diagnosis is vital for child psychiatry. The development and progress of this subspecialty have made the timing of DSM-III, DSM-III-R, and now DSM-IV propitious for general clinical as well as research use. The impact of DSM-III on child psychiatry was remarkable. Although intended for use in the United States, publication of DSM-III and DSM-III-R aroused intense international interest, and literally hundreds of articles in the United States and abroad have addressed the accuracy and meaningfulness of the DSM system in child psychiatry, as well as its differences from ICD-9. It is likely this trend will continue for both the DSM-IV and ICD-10.

As part of the revision process for DSM-IV, 2 out of 12 field trials provided intensive investigation of the childhood-onset syndromes Disruptive Behavior Disorders and Pervasive Developmental Disorders. Because of this extensive work, these two diagnostic groups reflected the most substantive changes in DSM-IV.

The most important impact of the DSM system on child psychiatry is harder to objectify—that is, improved communication within the clinical community and across research centers. Over the past decade, and particularly since DSM-III-R was published, child psychiatrists have increasingly appreciated the need for reliability and validity within a diagnostic system.

To further ongoing research on diagnosis of childhood disorders, a number of national and international efforts have taken place in recent years. The National Institute of Mental Health (NIMH) has sponsored several workshops addressing classification issues for Disruptive Behavior Disorders and Pervasive Developmental Disorders, as well as a series of international workshops to focus on discrepancies between and problems within ICD-10 and DSM-IV.

Although pediatric psychopharmacology and epidemiology provided much of the impetus for improved diagnosis (Kashani, Orvaschel, Burk, & Reid, 1985; Rapoport, 1987a; Rapoport & Conners, 1985), an impressive number of studies on diagnosis per se have taken place outside of these particular areas of investigation (e.g., Lahey, Applegate, Barkley, et al., 1994; Lahey, Applegate, McBurnett, et al., 1994; Prendergast et al., 1988; Volkmar et al., 1994). DSM-IV is the next step in this process of clarification and refinement.

Chapter 2
Definition of Disorder

Classification is essential for scientific progress in any discipline. This is difficult enough in general psychiatry, but in child psychiatry the diagnostic process is particularly challenging. To begin with, there is less information about natural history, familial patterns, and developmental aspects of most of the childhood behavioral disorders. Because of this, most diagnostic categories have been generated on the basis of what clinicians agree they recognize from clinical descriptions as fitting what they see in their own practice. In addition, the particular group of children seen and the type of clinic to which they go may vary widely among clinicians, thus introducing a referral bias, which will influence clinicians’ knowledge of disorders because their perception is influenced by their experience. Adequate epidemiological data to support the phenomenon of clinic-based diagnosis are often not available.

Wide variation also exists in the degree to which child clinicians have been trained to be descriptive. Inferential recounting of a patient’s difficulties is based on the quality of the clinician’s interaction with the child and his or her family or his or her extrapolations from fantasy. Although the field of child psychiatry has advanced considerably in recent years, general psychiatry is still further advanced than child psychiatry in terms of descriptive methods and in having available more standardized interview techniques and widely used rating scales (such as the Hamilton Scale for Depression). Several such tools are now being used more widely in child psychiatry, but they are still in the early stages of development and their effectiveness will depend on clear, descriptive communication and the ability to use multiple informants (see Appendix II: Rapoport & Conners, 1985).

Ideological debates about “caseness” versus “continuum” arise whenever the question of diagnosis is raised. This book is intended as a companion to DSM-IV, and so the disorders are discussed as if they were discrete entities. As Eisenberg has eloquently argued (1986), disease definitions may, in part, be social constructs. More important within biomedicine, however, is the process by which so-called discrete entities, such as anemia, are inevitably broken down into even smaller meaningful subgroups as medical research advances.

Importance of Multiple Diagnoses

DSM-IV continues to use most of the diagnostic groupings contained in DSM-II1-R. (See Table 4.1, Chapter 4, which compares DSM-II1-R and DSM-IV childhood disorders.) Multiple diagnoses are encouraged, except when a specific differentia] diagnosis is required, as is the case between Schizophrenia and Mood Disorders. A special consideration with respect to child diagnosis must be stressed at this point.

In light of the relative lack of validating information regarding diagnostic categories for children, why add to the confusion by using multiple diagnoses for the same child? An important benefit is that the process has already provided information on which to base DSM-IV decisions about multiplicity of groups. The overlap that existed between categories such as Attention-Deficit/Hyperactivity Disorder and Conduct Disorders has been weeded out. Oppositional Defiant Disorder is often diagnosed together with Attention-Deficit/Hyperactivity Disorder. Although overlap between these two categories has been reduced in DSM-IV, DSM-V is almost certain to make further changes. For example, outcome studies of Oppositional Defiant Disorder, as it is now defined, may conclude that it is a mild form of Conduct Disorder; thus, delineating structures will be scrutinized and modified further to avoid duplication.

The multiaxial feature of the DSM system is deemphasized in DSM-IV; for now only Personality Disorders and Mental Retardation are coded on Axis II. Debate also remains about the extent to which multiple diagnoses should be used. Implicit in the DSM system is the notion that multiple diagnoses will lead to better categorization. The ICD-10 is in fundamental disagreement with this position (see Appendix I). Opponents of the DSM point of view think that multiple diagnoses beg the question; that crucial clinical decisions about salient features of a case may be avoided, albeit inadvertently. They also question whether or not overlap will be accurately and consistently recorded, especially since studies show that multiple diagnoses are not consistently applied across centers (Prendergast et al., 1988). Despite the differences of opinion, we feel that multiple categories are of express importance for the DSM system because a single, highly specific diagnosis does not capture the case. The surge of research on comorbidity is also supportive of the DSM approach (Bernstein, 1991; Biederman et al., 1992).

Although the DSM urges multiple diagnoses and will influence clinicians to make more than one, critics are also concerned that important differential diagnoses will not be made because of such multiple recordings. This is unlikely. Mutually exclusive differential diagnoses are specified in the criteria for many Axis I disorders. For example, hyperactivity as a symptom may occur in both Attention-Deficit/Hyperactivity Disorder and Schizophrenia. When specific symptoms can be accounted for by more than one disorder, the nature of the total symptom picture will determine the diagnosis (e.g., Attention-Deficit/Hyperactivity Disorder or Schizophrenia). In other cases, it will be evident that some diagnoses, at least descriptively, are mild forms of another. One would not make the diagnosis of both Conduct Disorder and Oppositional Defiant Disorder, for example.

Some diagnostic combinations will remain murky. In practice it will be difficult to diagnose both Moderate Mental Retardation and Learning Disorders or Communication Disorders, although neither category is excluded as a differential diagnosis in DSM-IV so long as the specific deficit is out of proportion to the severity of Mental Retardation. Similarly, when the child’s IQ is less than 50, in our opinion, it is difficult to support an independent diagnosis of Pervasive Developmental Disorder. Asperger’s Disorder and Schizoid Personality Disorder are another quagmire.

Diagnostic confusion also occurs when children show signs of more than one disorder—for example, the mixture of anxiety/depression symptoms with Conduct Disorder or hyperactivity— and thus gives rise to diagnostic debate. By urging multiple coding, DSM-ÍV differs from ICD-10, which would choose the salient disorder or else specifically code “Mixed Disturbance of Emotions and Conduct (312.3).” Previous studies showed that multiaxial coding eliminated some of the confusion created by frequently associated disorders (Prendergast et al., 1988; Russell, Cantwell, Mattison, & Will, 1979; Rutter, Shaffer, & Shepherd, 1975; Stephens, Bartley, Rapoport, & Berg, 1980). Now that almost everything is coded on Axis I,...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Listing of Tables
• Preface
• Introduction
• Part I An Overview of Psychiatric Diagnosis in Infants, Children, and Adolescents
• Part II Basic Concepts for Use of DSM-IV for Diagnosis of Childhood Disorders
• Part III Major Classifications and Differential Diagnoses
• Appendices
• References
• Name Index
• Subject Index