Second of 3 part series

Why have the diagnosis and range of childhood psychiatric disorders changed so very much over the last several decades?

Answer:

My medical Ask a Specialist in late 2005 discussed why making psychiatric diagnosis, particularly in children, requires considerable expertise. Over the last decades the definition of and number of formal diagnoses available has expanded. There has also been much effort put into defining these diagnoses in a way that delineate one from another.

The American Psychiatric Institute first published the Diagnostic and Statistical Manual of Mental Disorders in 1952. Successive volumes, the most recent of which was published in 2000, DSM-IV-TR, have added to the number of included diagnoses and the symptoms that should be exhibited in individuals with the diagnosis. The recent manuals define psychiatric illness more from a medical rather than a psychoanalytic perspective. There began to be a clear distinction between normal and abnormal rather than a continuum of neurosis to psychosis. This coincided with the trend toward viewing psychiatric illnesses as neurological in etiology.

http://www.bipolarworld.net/Bipolar%20Disorder/History/hist4.htm

The total number of defined diagnosis in adults and children grew from 60 in 1952 to 200 in 1982. The number of diagnoses appropriate for children has similarly expanded. These include such diagnoses as Autism, Attention Deficit Hyperactivity Disorder, Learning Disabilities and Tic Disorders.

Coincident with the increase in numbers of diagnosis which typically occur in children, there has been a movement to identify adult diagnoses that might have onset in childhood. Different psychiatric groups have embarked on defining and studying disorders previously not commonly diagnosed in children, such as Bipolar disorder. At the present time, there is not a specific category for Bipolar Disorder or Schizophrenia occurring in childhood but The Academy of Child and Adolescent psychiatry has been attempting to define the components of such diagnoses. There has also been a move to standardize treatment of such disorders when they occur in childhood but these standards are not yet universally recognized.

In addition to these diagnoses not being universally defined, there is overlap in symptoms between diagnoses. For example, anxiety can be associated with significant inattentiveness and a high activity level. Learning and communication disabilities can cause a child to be inattentive and fidgety because they do not understand what is being asked or the task is too difficult for them. Inattention and high activity levels are key components in the diagnosis of Attention Deficit Disorder (ADHD). If one does not look at a child carefully enough or talk with teachers and parents and get a good history of the behaviors, one could easily diagnose ADHD in a child who instead had communicative or learning handicaps. This does happen with some frequency. The problem with a misdiagnosis is that stimulants can worsen anxiety and will not treat learning disabilities. This situation is further complicated by the fact that children with ADHD can also have learning disabilities or be anxious.

Another example is that a child who is mentally retarded with a cognitive age of three and a chronological age of 9 is usually less attentive than one would expect chronologically and closer in attending abilities to his cognitive level of 3 years. Often these diagnoses come down to a judgment call and one clinician might say a child has ADHD while another disagrees. At such times, it is helpful to get additional information such as talking with the child’s teacher or observing behavior in the classroom and comparing the child’s attention with that of similar peers.

The difficulty of defining and diagnosing different childhood psychiatric disorder has led to the development of behavioral checklists. Some of these are lists of questions about behavior that a parent or teacher or the child himself can answer on scale graded for severity, for example, 1 to 4 with 4 being worst severity. The sum of the severities are added up and compared with the total symptom scores of children of the same age. Many of these have questionnaires ask about symptoms of different diagnoses in random order. For instance one might ask if the child “worries a lot” or about fidgeting. The symptoms of the various disorders would be grouped in the scoring and then totals for the different groups totaled. For example the “worries a lot” would go with anxiety but the “fidgeting” would go into the total for anxiety as well as ADHD. This would produce scores for the different diagnoses and can give comparative information from teacher and parent.

The clinician can use the standardized results of these check lists combined with observations and history to justify a specific diagnosis. This saves clinician time and contributes to the accuracy of the diagnosis. More elaborate computerized checklists and standardized interviews (oral questions standardized and answers quantified) have been developed to diagnose and differentiate psychiatric diagnosis in both adults and children.

As the level of sophistication in making childhood psychiatric diagnose grows, so does the desire to classify and treat severe behavioral disorders of childhood that have not been previously grouped or labeled. More recently, as previously mentioned, there has been an effort to define Bipolar Disorder that has onset in childhood. There has been an attempt to standardize this diagnosis but at the current time, many disparate children are getting the diagnosis and being treated for the diagnosis rather than the presenting behavioral symptoms.

The growth in discussion and educational materials on the internet has generated a huge quantity of information and disinformation about psychiatric diagnoses in general but particularly those in childhood. Parents are anxious to get their children diagnosed and treated and very eager to share information with other parents. This is generally very helpful and to be encouraged but it can also muddy the waters and perpetuate disinformation.

In summary, making diagnoses of childhood psychiatric disorders requires a great deal of knowledge and skill and then gathering of much information and comparing it with those symptoms characteristic of the disorder. This part of the problem is overwhelming and intensifies the difficulty of treatment. Psychiatric research is hard to do in general but particularly in children. The third and final part of this series will address treatment of childhood psychiatric disorders and present an overview of the difficulties of performing and evaluating psychiatric research, particularly in children.