British Journal of Psychiatry (1992), 161, 472—480
Lecture
Child Psychiatric Disorders: Are They Classifiable? JOHN S. WEARY Classification
of child (including adolescent)
disorders
is reviewed
within six areas: requirements
for a good taxonomy, current systems of classification for children, data-capture methods, reliability and validity, the link between child and adult disorders, and directions for future developments. While substantial progress has been made, there is a continuing need for comparisons of different systems, more systematic yet practicable data capture, proper psychometric analyses of criteria and categories, intensive studies of clinical validity, closer attention to the similarity of, and links between, child and adult categories, and better definition and targeting of those disorders with a serious outcome.
To ask, as many adult psychiatrists do, whether child psychiatric disorders are classifiable, is to challenge the legitimacy of child psychiatry as a scientific discipline, since without taxonomy, there can be little science. This review will try to answer this scepticism by giving a Cook's tour of taxonomy, and thus hoping to show just how intellectually vigorous child psychiatry is, always remembering
that taxonomy is
but one small part of what child psychiatrists know and do. It should be made clear that child psychiatry includes adolescence, so in this review ‘¿child' will include all those of immature years. What Is a good taxonomy?
heedlessness. It follows that, as in this case, if the menu is long and the necessary symptoms few, children receiving the same diagnosis may have very different clinical pictures, and internal consistency will be low. (c) Specificity.
The diagnostic
elements
should tell
not only what the diagnosis is, but equally what it is not. Unfortunately, this has been one of the most overlooked principles in child taxonomy. Typically, any comparative group to test defining elements or correlates has been normal children, not children with other diagnoses. Such comparisons can only demonstrate abnormality, not specificity of diagnosis. Although ADHD virtually captured research in child psychiatry outside the UK by 1970, it is only recently, following the lead given by Sandberg
Szatmari (1992) adapted Quay's (1986a) elements of a good taxonomy as outlined below. (a) Re/iabiity(interdiagnoser, across time, and most important with children, across reporting sources). (b) Internal consistency (i.e. covariance of the elements). Not all symptoms need be found at all times but some degree of what Szatmari calls ‘¿hanging together' is essential. Landau et al (1991) have drawn attention to the threat to internal consistency posed by DSM—III—R's rejection of the ‘¿classical' (medical) taxonomic model in which a fixed set of pathognomonic symptoms is necessary and sufficient for diagnosis (American Psychiatric Association, 1987). Instead, in childhood disorders like attention deficit hyperactive disorder (ADHD) (hyperkinesis), DSM-III-R favours the ‘¿prototypal' model which uses what is known as the ‘¿Chinese menu' and Landau et a! (1991), a little less ethnically, utilise ‘¿polythetic' diagnostic criteria. In this, diagnosis is based on a selection of x symptoms from a list of
et a! (1980), that the specificity
n. For example, ADHD requires the presence of 8
is not fatal to a taxon, it just greatly reduces the diagnostic efficiency of that symptom. If the disorder to be diagnosed is rare, diagnostic efficiency must
of 14symptoms covering motor hyperactivity, inatten tion, distractibility, impulsivity, intrusiveness, and This paper was presented
as the Eli Lilly Lecture,
of characteristic
symptoms and correlates has been tested in any substantive way. In a review of the literature Werry et a! (1987) drew attention to the fact that many of the symptoms and correlates described as characteristic of ADHD had, in the past, often been stated to occur in other disorders. A comparative study of four diagnostic groups (Reeves et a!, 1987) added to but a handful of such studies at that time (see Sandberg et al, 1980; Werry et a!, 1987) in showing that only some of the putative characteristics were specific to ADHD and many defined being a patient, not any particular disorder. Lack of specificity also is seen in comorbidity or concurrence of diagnostic categories, such as conduct and attention-deficit disorders, or anxiety and mood disorders, and this is emerging as a major problem with DSM—III and DSM—III—R(American Psychiatric Association, 1980, 1987). However, sharing of symptoms between diagnoses
given to the Royal College of Psychiatrists,
472
22 January
1991.
473
CHILD PSYCHIATRIC DISORDERS be very high so as not to create false positives. A good example is suicidal thoughts, which occur about 1500 times more commonly than completed suicide in adolescents. Thus, on their own, suicidal thoughts are very efficient predictors of not committing suicide, but are seldom used that way clinically. Landau eta! (1991) and Milich eta! (1987) calculated
a clinician―—anytaxonomic system that cannot assist a clinician
to do just that
will not find
of defining symptoms and showed that some of the DSM—III—R symptoms of ADHD predict conduct disorder much more efficiently than ADHD-as forecast when DSM-III first appeared, by Quay (1979), Sandberg et a! (1980) and others. Shaffer
much acceptance. However, the taxonomic systems do better than many clinicians believe, if, as in medicine, they are limited to explaining the disease, not the whole person. Thus the label ADHD should be expected to explain only such limited things as the extent to which attention and motor overactivity will continue to depart from the norm in a general way, not every kind of trouble or mischief the child is going to get into. Nevertheless, we mut accept the implicit challenge by clinicians to develop a taxonomy of greater
eta! (1988) tried to estimate the power of predictors
explanatory
for adolescent suicide, many of which turn out to be of little value. There needs to be much more of this empiricism and less clinical intuition in choosing defining symptoms for child psychiatric disorders. (d) External va!idity. Without this, diagnosis is a meaningless label. Validity is found in information about epidemiological characteristics, associated clinical features, and most importantly of all, about aetiology, prognosis and treatment. Longitudinal studies such as those of clinic children by Robins (1979), of schizophrenic children by Eggers (1978), of hyperactive children by Weiss & Hechtman
this, more attention must be paid to traditional indicators of outcome and treatment such as pre morbid function and risk factors like family disadvantage, child abuse, and parental mental ill health, as multiaxial systems originally intended (see Werry, 1985).
conditional
positive and negative predictive power
power in the clinical situation.
To do
Taxonomic systems in child psychiatry DSM and lCD
These are medical, based on the disease model with its concepts of abnormality and discrete categories which speak to distinctive correlates, aetiologies, disorders by McGee et a! (1990) in New Zealand show just how meaningful diagnoses in children can courses and treatments. Both have sections which list be in describing prognosis. disorders, like autism, which are typically first or (e) Utility. This is a special and particularly only seen in childhood or adolescence. important kind of external validity which asks “¿what Despite great rivalry, apart from terminology and use is the diagnosis in the real world?―Utility may be number of subcategories, lCD and DSM are far reflected in scientific heuristics. For example ADHD more similar than different in the children's area (see has been a major impetus to taxonomy in child Werry, 1985; Quay, l986a; Rutter et a!, 1988), psychiatry in the last 20 years by stimulating the although ICD-9 (World Health Organization, 1978) development of measures for diagnosis and for the appears to have been less researched than DSM and measurement of change. It has also been elemental in there are suggestions that ICD—10(World Health the foundation of the now thriving field of paediatric Organization, 1986) is continuing this more intuitive psychopharmacology. Thus it could be argued that trend (Barkley, 1990). Both have some difficulties this makes ADHD a useful taxon whether it meets the created by deadlines imposed by the sponsoring criteria of reliability or validity or not. bodies (WHO or the American Psychiatric The most important aspect of utility in the end is Association), so that, where critical data are lacking, how a taxonomy works for clinician, parent and decisions have to be made by fiat. child. Unfortunately, clinicians have not liked DSM-III was more revolutionary than ICD-9 but, medical classification systems in child psychiatry as predicted by Achenbach (1980), Quay (1979), and (Quay, 1979), and when forced to use them, often Rutter & Shaffer (1980), this produced a number of use labels which are statements of their belief about unreliable new categories like oppositional disorder aetiology rather than true taxons—for example, (Werry et a!, 1983; Rey et a!, 1989; Schacher & adjustment disorders, V codes like ‘¿parent—childWachsmuth, 1990)and subcategories within conduct problem' (DSM—III), or family typologies like and child anxiety disorders (Werry et a!, 1983; Rey ‘¿enmeshed'. The reason is that current taxonomic et a!, 1989; Werry, 1991). labels often explain too little in practical clinical While it can be argued that the revolution that was terms. As Feinstein (1967, p. 27) put it, “¿the care of DSM-III was necessary, continuing enthusiasm for the patient is the ultimate specificact that characterizes change which also produced DSM—III—R is less (1986) and most recently of DSM-III
diagnostic
474
WERRY
defensible. This occurred just as research on DSM-III child categories was appearing and the changes were major, precipitate and did not undergo adequate trials (Cantwell & Baker, 1988; Rey, 1988). It is now being shown that this has resulted in major differences between DSM-III and DSM-III-R in types of patients and prevalences of a wide range of disorders (Hertzig et a!, 1990; Lahey et a!, 1990). Such a way of developing a taxonomy may be tradi tionally medical, but it has disastrous results on research which takes many years to plan, execute and publish and cannot function in ever-shifting sands. But there are some good aspects too, in that DSM has taken child psychiatry some distance away from its proclivity for theorising and guruism, and in one decade has spawned much good research in the taxonomy of childhood disorders. But there is a risk of premature closure in what was recently described as ‘¿the delusion of understanding'. While some believe it good that ICD-10 and DSM are moving together, Andreasen's (1987) review of different concepts of schizophrenia and Conners' (1992) review of mood disorders in children, make it clear that to jettison competing views to DSM is premature. Speaking of the history of physics and chemistry Brownoski (cited by Feinstein, 1967, p. 72) suggested that a “¿science which orders its thought too early is stifled―. But diversity so far has not led to comparative studies to see which taxons are better. A rare example is the UK/US study of attention deficit and conduct disorders (Prendergast et a!, 1988) which revealed not only long-posited differences but that American psychiatrists were not using DSM correctly. This suggests that much of the American literature on ADHD must be suspected as applying more correctly to conduct disorder and/or to the dual diagnosis, in lCD, called hyperkinetic conduct disorder (see Werry et a!, 1987).
that these dimensions are convergent with DSM-III diagnostic categories, suggesting that some of the rivalry between the two approaches is misplaced. The dimensional system is excellent for quantifi cation of abnormality along its axes (such as conduct problems, anxiety, etc.) and thus can be used in screening for disorder and as measures of treatment effects. They are better than medical systems at providing a comprehensive profile of the individual child, although the history of the MMPI should have taught that dimensional profiles like these are of limited use unless closely anchored to indicators for clinical action. Complex dimensional profiles still have some way to go to prove their direct clinical relevance to children. Clinical taxonomic systems Feinstein (1967) pointed out that the complicated medical taxonomic system of 17th-century medicine was a revolt against the theorising of the 16th, which failed because it was simply a very complex set of symptom clusters devoid of any clinical utility. Both DSM and dimensional systems have been at pains not to repeat the mistakes of the past and have actively sought clinical derivatives, but defmitionally,
they have not got much beyond purely symptom based criteria. One effort to develop a broad clinical taxonomy incorporating both DSM-III and the kind of information which most clinicians gather routinely about child, family, school etc. has been devised by Kiser & Pruitt (personal communication). It is unique in that child clinicians from all professions have been working together with researchers. However, to survive, this creative effort must now show that its clusters are reliable, internally consistent and externally valid.
Data-capture methods
Dimensional systems These are just as popular as lCD or DSM (Quay, 1986a).Unlike DSM or lCD, which are based on intu itive clinical wisdom, dimensional approaches usually use empirical multivariate statistical approaches to group symptoms-ordinarily derived from parent or teacher ratings (Quay, 1986a). The best known of these are the Achenbach Child Behavior Checklist, the Revised Behavior Checklist and the Conners Teacher and Parent Questionnaires (see Quay, 1986a). Unlike medical classifications, the dimensions are continuous so that each child has a score on each axis. Recent studies (Weinstein et a!, 1990) have shown
Although there has been much research on methods
of data capture such as questionnaires (Quay, 1979, 1986a), behavioural methods (Mash & Terdal, 1981; Rutter et a!, 1988; Werry & Wollersheim, 1989), neuropsychological and cognitive tests, and instrumentation (Pfadt & Tyron, 1983; Rutter et a!, 1988; Quay, 1986b), none of these methods
is orientated towards diagnostic systems like DSM and they are very properly regarded as only aids to ordinary history taking and examination. Yet, apart from Rutter & Graham's (1968) effort, there has been little research on the clinical interview in child psychiatry until recently (see Young et a!, 1987).
CHILD PSYCHIATRIC DISORDERS The huge US Epidemiologic Catchment Area (ECA) studies (Archives of Genera! Psychiatry, 1984) have made structured interviews widely acceptable and child psychiatry has begun to follow. Examples are K-SADS and the DIS-C modelled on adult equivalents and the purpose-built DICA (Diagnostic Interview for Children and Adolescents), all for DSM-III-R (see Ambrosini, 1992), and one currently under development by Angold, Rutter and colleagues to cover both DSM and ICD—lO. The study by Ambrosini et a! (1989), with its use of video recordings and sophisticated psychometric statistics, shows how far child taxonomy has come and should serve as a model for testing the reliability and validity of any interview. In his review, Ambrosini (1992) draws attention to the well known problems of unstructured inter views but points out that structured interviews carry their own problems—theyare time-consuming, cumbersome, inflexible, and unintelligent, and shift error from interviewer to respondent. They are most suited to lay interviewers used to reduce costs in epidemiological studies. The semi structured interview offers a compromise between the traditional free-floating and tightly structured interviews, although to achieve inter examiner reliability, clinical sophistication and intensive training of interviewers is needed (Ambrosini, 1992). Unfortunately, when child psychiatry teaches interviewing, it teaches the traditional interview, which is often highly idio syncratic to the teacher. It would be useful if this training were centred on a properly developed and tested interview. Child psychiatrists are heavily reliant on reports by caretakers such as parents and teachers. When there is conflict, how should the clinician put it all together? It is believed that reports by disinterested sources such as teachers should be more valid than those of parents, but discrepancy between sources is inevitable, since parent and teachers see children in different contexts (Achenbach et a!, 1987). Thus while there is poor agreement between sources such as parents and teachers, there is good agreement within sources (e.g. both parents). Thus, all are correct - and the problem is to decide how much of each is needed to make a robust diagnosis. In the end, the question is one for empirical research, not armchair hypothesising. Rutter and colleagues (Rutter eta!, 1970; Rutter, 1976) suggested that, in contrast to adolescents (Rutter eta!, 1976), children had little to add to what the adults about them provided, but recent research on depression and anxiety disorders in children suggests that reliance on adult sources alone may lead
475
to gross underestimates of dysphoria in childhood and adolescence (see Kazdin, 1987; Werry, l992b). Whether this under-reporting by adults weakens or strengthens the diagnosis of dysphoric disorders is unclear. For example, McGee et a! (1990) in New Zealand showed that while overanxious disorder rose markedly in adolescence with a marked gender shift towards females, these self-reports were often not matched by any objective social dysfunction such as school failure. Nurcombe et a! (1989) and others (Strober & Werry, 1985) have voiced concern about the increasing diagnosis of major depression in children based on self-report data. While some depression instruments show promise psychometri cally (e.g. Strober & Werry, 1985; Birleson et a!, 1987; Kazdin, 1987), the depression seems to lack essential validating criteria such as sensitivity to antidepressant treatments (Nurcombe et a!, 1989; Conners, 1992). Comorbidity It is often assumed that DSM—IIIcreated this problem by allowing multiple diagnoses. But there is an old study by Hewitt & Jenkins in 1947 (see Quay, 1979, 1986b) who found that less than 40% of children fitted neatly into one of their categories and the remaining 60% had to be classed as mixed disorders. The only reason comorbidity appears new, as Ambrosini (1992) points out, is because of the increasing use of structured interviews which do not allow diagnosers to circumvent the problem. Comorbidity is often seen as a lack of specificity or gross overlap in some disorders-as is true of some of the anxiety disorder subcategories and, probably, the very large overlap between anxiety and depressive disorders in children (Rey eta!, 1989; Werry 1991). It may also be due to overly sensitive thresholds yielding unacceptably high levels of disorder. This problem has plagued attempts to produce a child equivalent of the DIS (Shaffer, 1990) and is the reason that NIMH has been so far unable to proceed with ECA studies in children. But if clinics are reaching mostly children who are seriously disabled and/or have multiple problems it may not be a taxonomic defect but a clinical reality. The epidemiological study by Anderson et a! (1987) in New Zealand confirmed that only a minority of children had more than one disorder and that they were the most disabled and most deserving of care. (What was disturbing, however, was how few of these very disabled children actually got to clinics and how many of the less disabled did.) Neither is comorbidity a defect if it is revealing that many children seen by child psychiatrists do not have a
476
WERRY
major psychiatric disorder, but deviations of person ality, and for this group, the categorical view is less correct than a multidimensional model. This may be one reason that clinicians have such resistance to what they perceive as simplistic DSM or lCD labels. Summary
of reliability
and validity of disorders
There is now a solid set of epidemiological studies (see Anderson et a!, 1987; Costello 1989) to show that psychiatric disorder in children, confirmed by at least two sources, has at least a 5—7%point prevalence. But such figures are of less interest than which particular disorders make up this figure, how long each lasts, how disabling, how treatable, and how preventable they are. Adult disorder in childhood Apart from personality disorders, which are considered inappropriate in children in DSM—III,most adult disorders also occur in children but are infrequent before adolescence. Schizophrenia and bipolar mood disorder will be used as examples although what is said seems equally true of other disorders like obsessive compulsive disorder (Berg et a!, 1989). Adult disorders occurring in childhood appear qualitatively similar to those seen in adulthood (Berg eta!, 1989; Carlson, 1990; Werry et a!, 1991; Werry, 1992), validating
the decision in DSM—III to abolish such
There is now good reason to question the widely held view that early onset portends resistance to treatment and a worse prognosis than in young adults
(Berg eta!, 1989; Carison, 1990; Werry eta!, 1991). These disorders are disabling and difficult to manage whatever the age of onset and one must be careful not to confound duration of disorder with age of onset as has been done in the past for both schizophrenia (Werry eta!, 1991) and brain damage (Fletcher & Satz, 1983). While adult-type disorders are uncommon in children, they are frequent and disabling enough to provide one reason, among others, that child psychiatrists should keep up with developments in adult psychiatry. Otherwise adolescents are going to be admitted to adult wards where they are at risk of abuse by adult patients and of having their educational and special developmental needs neglected. However, adultomorphism in child psychiatry can go too far. In the US at the moment the rush to find unipolar depression, manic equivalents and panic disorder in children causes concern, since it is leading inexorably to pharmacotherapy in adults —¿ despite
the fact that results
as used of clinical
trials in children have been at best equivocal (see Nurcombe et a!, 1989; Carlson 1990; Conners, 1990;
Klein & Klein, 1990). Disorders usually beginning In childhood
separate categories as childhood schizophrenia or Can childhood-onset disorders be diagnosed re!iab!y? childhood depression. Developmental variations in symptoms are to be expected and are seen in early The answer to this is on the whole yes for major onset schizophrenia and bipolar disorder (Carison, disorders like autism (e.g. Volkmar et a!, 1988; Szatmari, 1990), attention deficit, conduct and 1990; Werry et a!, 1991) in less well formed delusions and more undifferentiated subtypes, making anxiety disorders (Werry et a!, 1983; Anderson the differentiation of the two disorders very difficult et a!, 1987; Reeves et a!, 1987; Rey et a!, 1988; Prendergast et a!, 1988; Ambrosini et a!, 1989) (Carlson, 1990; Werry et a!, 1991). Since both but reliability declines for subclassifications within disorders are usually life-long and first diagnosis such disorders as conduct and anxiety (Werry often is taken as being the correct one, it is impera tive, as originally counselled by Kraepelin, that all et a!, 1983; Rey et a!, 1988). As discussed above, cases be followed punctiliously for several years to there is often poor agreement between sources, especially adults and the children themselves (e.g. establish the correct diagnosis. Before adolescence, psychiatric disorders occur Anderson et a!, 1987; Ambrosini et a!, 1989). predominantly in boys, and there is more often a Also, beginning with the classic studies by Rutter family history than there is among adult sufferers —¿& Graham (1968), reliability has been demonstrated as frequently as 50% in bipolar disorder (Werry eta!, mostly only for colleagues working closely together 1991). In early-onset schizophrenia, premorbid and, increasingly, using structured interview techniques schizotypal personality and/or neurodevelopmental which are still too cumbersome for clinical use abnormality occur in over 50% of cases. These what happens to reliability with clinicians in findings (Carlson, 1990; Werry et a!, 1991) suggest general is less well known. It was not good in that early-onset disorders may offer unique research the UK—US collaborative study for DSM—III opportunities because of greater homogeneity and (Prendergast et a!, 1988) but field trials for ICD—9 in the UK gave a better result (Quay, 1979; Rutter less distortions of brain architecture and function et a!, 1988). from causes unrelated to the disorder per se.
477
CHILD PSYCHIATRIC DISORDERS Do the categories tell anything useful?
The answer must be an emphatic yes. However, as already pointed out, the problem for the clinician is that the answers are often rather too generalised and at best only probabilistic, in some instances at levels not very much above chance. The best information is prognostic. For example,
are only five treatments which can be said to have even pretentions to being diagnosis-specific in disorders originating in childhood —¿ stimulants for ADHD,
dopamine-blockers
(Cohen et a!, 1989;
although the underachievement which characterised their school careers is also seen in their employment (Weiss & Hechtman, 1986). On the other hand, conduct-disordered children have about a 50% chance of treading the downward slope to criminality, sexually transmitted disease, alcohol and drug abuse, morbidity and mortality from motor vehicle accident, suicide or homicide, and presumably into antisocial
Coming, 1990) and possibly habit reversal (Azrin & Peterson, 1989) for tics and Tourette's, Pfaundler's conditioning treatment for enuresis (Werry & Wollersheim, 1989; Berg, 1990),behavioural methods for weight gain in anorexia (Hsu, 1986)and, possibly, extinction procedures for some anxiety disorders (Werry & Wollersheim, 1989). Unfortunately, most are unsuccessful in many cases and are, in the main, only symptomatic and incomplete. Thus, the clinician is then left with a disabled child and distress or dysfunctional social environment. As a result, all disorders require much concomitant non-specific management to assist children, families and schools to cope, which is one of the reasons that the value
personality
of diagnosis is often lost both to the observer and
providing they do not also have conduct disorder, hyperactive children do well after leaving school
disorder
(Robins,
1979, 1991; Quay,
1986b; Kazdin, 1987; Shaffer eta!, 1988). Children with anxiety disorders generally do well (Robins, 1979; Quay & La Greca, 1986; McGee eta!, 1990; Werry, 1992b) although there is a group, the more severe, who do not (Gittelman, 1986). Tic disorder, elimina tion (Werry, 1986; Berg, 1990) and eating disorders (Hsu, 1980) mostly have a reasonably good prognosis
although again a more severe group does not. In aetiology, there is less certainty. Simplistically, child disorders can be sorted into primordially psychogenic and primordially biological. What has been described as the continuum of caretaking casualty (Sameroff & Chandler, 1975) or as family adversity is highly associated with conduct disorder
(Quay, 1986b; Werry eta!, 1987), although there are biogenic indicators
as well (Quay,
1986b; Robins,
1991). In the probably biogenic group (see Kreusi, 1990) are: (a) autism-some kind of early encephalo pathy from a variety of possible causes (Coleman & Gillberg, 1985); (b) ADHD—familialin some cases (Biederman eta!, 1990), most with a basic defect of information processing (Werry et a!, 1987; Van der Meer & Sergeant, 1988) which looks biogenic, and inconsistent but repeatedly found brain dysfunctions
(Schacher eta!, 1981; Zametkin & Rapoport, 1988; Zametkin et a!, 1990); (c) anxiety disorders which seem more linked (possibly genetically) to parental mood and anxiety disorders than to stressful life events (Reeves et a!, 1987; Anderson et a!, 1989); (d) Tourette's disorder is probably significantly familial and linked in some way to ADHD and other disorders like obsessive (see col. 1 Cohen eta!, 1989; Comings, 1990). Elimination and eating disorders are still clouded in mystery. However, the lodestar of diagnostic validity rests in specific and effective treatment. So far, there
the clinician. Of all the disorders of childhood, conduct disorder is both among the commonest and the most serious in immediate and ultimate consequences. Yet, it is virtually untreatable
and most of these children
will end up in the hands of society's minders (Quay, l986b; Kazdin, 1987). Here is a real challenge to child psychiatry, although most of us feel that the problem lies in civil turmoil or an unjust society against which, like the children affected, child psychiatrists are powerless. The link between child and aduft disorders The older literature suggested that there was little link between being seen in a clinic as a child and being a patient as an adult (Robins, 1979). However, as already discussed, when one looks at specific diagnoses, the situation is rather different some disorders such as the eating (Hsu, 1980), schizoid (i.e. schizotypal) (Wolff & Chick, 1980), psychotic (Robins, 1979; Werry et a!, 1991), conduct (Robins, 1979), obsessive-compulsive (Berg et a!, 1989), Tourette's (Werry, 1986; Cohen et a!, 1989; Comings, 1990) and even ADHD
can continue into adulthood (Weiss & Hechtman, 1986; Zametkin et a!, 1990). Also, there is retro spective evidence from adult patients with mood (Carlson, 1990), anxiety (Thyer et a!, 1985; Berg eta!, 1989), and antisocial disorder (Robins, 1979),
that these disorders often begin at least as early as adolescence and that the first manifestations often go undiagnosed. Child psychiatrists are fond of arguing for more resources on the grounds that they are preventing disorders later in life, but, beyond knowing that
478
WERRY
there is some link between child and adult disorders, we do not know how large the risks are. In order to maximise the efficiency of psychiatric services for children we need to know much more accurately who will get better without treatment, who is heading towards durable disorder, who will get real benefit from treatment, and what are risk and protective
factors.
All this calls for much more research. While longitudinal studies are the ideal, they are costly, their results take a long time to gather and attrition is a serious problem, although there have been, and now are, a number of studies in progress which, unlike
those in the past, are increasingly linked to psychiatric taxonomy. At a recent NIMH-sponsored meeting in Washington
on research
in child psychiatry,
Lee
Robins advocated the retrospective method as a practicable and valid complement to longitudinal studies. Another suggestion, from Rachel Klein, was that a serious effort should be made to examine the real distinctiveness of some child disorders by seeing whether or not adult criteria which have been develop mentally adjusted could be applied equally well—for example, to see if overanxious disorder of childhood
is really distinct from general anxiety disorder of adults. It could also be asked whether conduct disorder and antisocial personality disorder are not the same thing. The advantage of this kind of taxonomic parsimony is that it makes defining any connections with adult disorders much easier and clearer, to say
Conclusions
This brief overview has revealed that, like adult psychiatry, child and adolescent psychiatry has a taxonomy in which there are some disorders which are reliable, valid and useful, but that there are others which are of dubious status or about which little is known. The quality and quantity of good research in childhood taxonomy has risen dramatically since the appearance of DSM—IIIin 1980 and the future for this field of research looks bright. However, there is still
a large
shortfall
between
yields
from
taxonomic labels and the needs of clinical practice which requires diagnostic labels which are more comprehensive, less probabilistic and more certain in their information and which take account of children with problems or deviations of personality where the disorder model is less apposite. Competing systems
like
ICD—10, DSM—III and dimensional
systems need to compare and contrast their wares in an empirical and less nation- or profession-bound way, so that the clinician-consumer may take informed choices. In order to assist in this process, clinicians need to act more like interested parties and less like a cynical Greek chorus.
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While, as this review has shown, much about child disorders, many children clinics do not have true disorders but of living —¿ developmental conflicts with
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John S. Werry, MD, FRANZCP,Professor Emeritus of Psychiatry, University of Auckland, PB 92019, Auckland, New Zealand
Lecture
Child Psychiatric Disorders: Are They Classifiable? JOHN S. WEARY Classification
of child (including adolescent)
disorders
is reviewed
within six areas: requirements
for a good taxonomy, current systems of classification for children, data-capture methods, reliability and validity, the link between child and adult disorders, and directions for future developments. While substantial progress has been made, there is a continuing need for comparisons of different systems, more systematic yet practicable data capture, proper psychometric analyses of criteria and categories, intensive studies of clinical validity, closer attention to the similarity of, and links between, child and adult categories, and better definition and targeting of those disorders with a serious outcome.
To ask, as many adult psychiatrists do, whether child psychiatric disorders are classifiable, is to challenge the legitimacy of child psychiatry as a scientific discipline, since without taxonomy, there can be little science. This review will try to answer this scepticism by giving a Cook's tour of taxonomy, and thus hoping to show just how intellectually vigorous child psychiatry is, always remembering
that taxonomy is
but one small part of what child psychiatrists know and do. It should be made clear that child psychiatry includes adolescence, so in this review ‘¿child' will include all those of immature years. What Is a good taxonomy?
heedlessness. It follows that, as in this case, if the menu is long and the necessary symptoms few, children receiving the same diagnosis may have very different clinical pictures, and internal consistency will be low. (c) Specificity.
The diagnostic
elements
should tell
not only what the diagnosis is, but equally what it is not. Unfortunately, this has been one of the most overlooked principles in child taxonomy. Typically, any comparative group to test defining elements or correlates has been normal children, not children with other diagnoses. Such comparisons can only demonstrate abnormality, not specificity of diagnosis. Although ADHD virtually captured research in child psychiatry outside the UK by 1970, it is only recently, following the lead given by Sandberg
Szatmari (1992) adapted Quay's (1986a) elements of a good taxonomy as outlined below. (a) Re/iabiity(interdiagnoser, across time, and most important with children, across reporting sources). (b) Internal consistency (i.e. covariance of the elements). Not all symptoms need be found at all times but some degree of what Szatmari calls ‘¿hanging together' is essential. Landau et al (1991) have drawn attention to the threat to internal consistency posed by DSM—III—R's rejection of the ‘¿classical' (medical) taxonomic model in which a fixed set of pathognomonic symptoms is necessary and sufficient for diagnosis (American Psychiatric Association, 1987). Instead, in childhood disorders like attention deficit hyperactive disorder (ADHD) (hyperkinesis), DSM-III-R favours the ‘¿prototypal' model which uses what is known as the ‘¿Chinese menu' and Landau et a! (1991), a little less ethnically, utilise ‘¿polythetic' diagnostic criteria. In this, diagnosis is based on a selection of x symptoms from a list of
et a! (1980), that the specificity
n. For example, ADHD requires the presence of 8
is not fatal to a taxon, it just greatly reduces the diagnostic efficiency of that symptom. If the disorder to be diagnosed is rare, diagnostic efficiency must
of 14symptoms covering motor hyperactivity, inatten tion, distractibility, impulsivity, intrusiveness, and This paper was presented
as the Eli Lilly Lecture,
of characteristic
symptoms and correlates has been tested in any substantive way. In a review of the literature Werry et a! (1987) drew attention to the fact that many of the symptoms and correlates described as characteristic of ADHD had, in the past, often been stated to occur in other disorders. A comparative study of four diagnostic groups (Reeves et a!, 1987) added to but a handful of such studies at that time (see Sandberg et al, 1980; Werry et a!, 1987) in showing that only some of the putative characteristics were specific to ADHD and many defined being a patient, not any particular disorder. Lack of specificity also is seen in comorbidity or concurrence of diagnostic categories, such as conduct and attention-deficit disorders, or anxiety and mood disorders, and this is emerging as a major problem with DSM—III and DSM—III—R(American Psychiatric Association, 1980, 1987). However, sharing of symptoms between diagnoses
given to the Royal College of Psychiatrists,
472
22 January
1991.
473
CHILD PSYCHIATRIC DISORDERS be very high so as not to create false positives. A good example is suicidal thoughts, which occur about 1500 times more commonly than completed suicide in adolescents. Thus, on their own, suicidal thoughts are very efficient predictors of not committing suicide, but are seldom used that way clinically. Landau eta! (1991) and Milich eta! (1987) calculated
a clinician―—anytaxonomic system that cannot assist a clinician
to do just that
will not find
of defining symptoms and showed that some of the DSM—III—R symptoms of ADHD predict conduct disorder much more efficiently than ADHD-as forecast when DSM-III first appeared, by Quay (1979), Sandberg et a! (1980) and others. Shaffer
much acceptance. However, the taxonomic systems do better than many clinicians believe, if, as in medicine, they are limited to explaining the disease, not the whole person. Thus the label ADHD should be expected to explain only such limited things as the extent to which attention and motor overactivity will continue to depart from the norm in a general way, not every kind of trouble or mischief the child is going to get into. Nevertheless, we mut accept the implicit challenge by clinicians to develop a taxonomy of greater
eta! (1988) tried to estimate the power of predictors
explanatory
for adolescent suicide, many of which turn out to be of little value. There needs to be much more of this empiricism and less clinical intuition in choosing defining symptoms for child psychiatric disorders. (d) External va!idity. Without this, diagnosis is a meaningless label. Validity is found in information about epidemiological characteristics, associated clinical features, and most importantly of all, about aetiology, prognosis and treatment. Longitudinal studies such as those of clinic children by Robins (1979), of schizophrenic children by Eggers (1978), of hyperactive children by Weiss & Hechtman
this, more attention must be paid to traditional indicators of outcome and treatment such as pre morbid function and risk factors like family disadvantage, child abuse, and parental mental ill health, as multiaxial systems originally intended (see Werry, 1985).
conditional
positive and negative predictive power
power in the clinical situation.
To do
Taxonomic systems in child psychiatry DSM and lCD
These are medical, based on the disease model with its concepts of abnormality and discrete categories which speak to distinctive correlates, aetiologies, disorders by McGee et a! (1990) in New Zealand show just how meaningful diagnoses in children can courses and treatments. Both have sections which list be in describing prognosis. disorders, like autism, which are typically first or (e) Utility. This is a special and particularly only seen in childhood or adolescence. important kind of external validity which asks “¿what Despite great rivalry, apart from terminology and use is the diagnosis in the real world?―Utility may be number of subcategories, lCD and DSM are far reflected in scientific heuristics. For example ADHD more similar than different in the children's area (see has been a major impetus to taxonomy in child Werry, 1985; Quay, l986a; Rutter et a!, 1988), psychiatry in the last 20 years by stimulating the although ICD-9 (World Health Organization, 1978) development of measures for diagnosis and for the appears to have been less researched than DSM and measurement of change. It has also been elemental in there are suggestions that ICD—10(World Health the foundation of the now thriving field of paediatric Organization, 1986) is continuing this more intuitive psychopharmacology. Thus it could be argued that trend (Barkley, 1990). Both have some difficulties this makes ADHD a useful taxon whether it meets the created by deadlines imposed by the sponsoring criteria of reliability or validity or not. bodies (WHO or the American Psychiatric The most important aspect of utility in the end is Association), so that, where critical data are lacking, how a taxonomy works for clinician, parent and decisions have to be made by fiat. child. Unfortunately, clinicians have not liked DSM-III was more revolutionary than ICD-9 but, medical classification systems in child psychiatry as predicted by Achenbach (1980), Quay (1979), and (Quay, 1979), and when forced to use them, often Rutter & Shaffer (1980), this produced a number of use labels which are statements of their belief about unreliable new categories like oppositional disorder aetiology rather than true taxons—for example, (Werry et a!, 1983; Rey et a!, 1989; Schacher & adjustment disorders, V codes like ‘¿parent—childWachsmuth, 1990)and subcategories within conduct problem' (DSM—III), or family typologies like and child anxiety disorders (Werry et a!, 1983; Rey ‘¿enmeshed'. The reason is that current taxonomic et a!, 1989; Werry, 1991). labels often explain too little in practical clinical While it can be argued that the revolution that was terms. As Feinstein (1967, p. 27) put it, “¿the care of DSM-III was necessary, continuing enthusiasm for the patient is the ultimate specificact that characterizes change which also produced DSM—III—R is less (1986) and most recently of DSM-III
diagnostic
474
WERRY
defensible. This occurred just as research on DSM-III child categories was appearing and the changes were major, precipitate and did not undergo adequate trials (Cantwell & Baker, 1988; Rey, 1988). It is now being shown that this has resulted in major differences between DSM-III and DSM-III-R in types of patients and prevalences of a wide range of disorders (Hertzig et a!, 1990; Lahey et a!, 1990). Such a way of developing a taxonomy may be tradi tionally medical, but it has disastrous results on research which takes many years to plan, execute and publish and cannot function in ever-shifting sands. But there are some good aspects too, in that DSM has taken child psychiatry some distance away from its proclivity for theorising and guruism, and in one decade has spawned much good research in the taxonomy of childhood disorders. But there is a risk of premature closure in what was recently described as ‘¿the delusion of understanding'. While some believe it good that ICD-10 and DSM are moving together, Andreasen's (1987) review of different concepts of schizophrenia and Conners' (1992) review of mood disorders in children, make it clear that to jettison competing views to DSM is premature. Speaking of the history of physics and chemistry Brownoski (cited by Feinstein, 1967, p. 72) suggested that a “¿science which orders its thought too early is stifled―. But diversity so far has not led to comparative studies to see which taxons are better. A rare example is the UK/US study of attention deficit and conduct disorders (Prendergast et a!, 1988) which revealed not only long-posited differences but that American psychiatrists were not using DSM correctly. This suggests that much of the American literature on ADHD must be suspected as applying more correctly to conduct disorder and/or to the dual diagnosis, in lCD, called hyperkinetic conduct disorder (see Werry et a!, 1987).
that these dimensions are convergent with DSM-III diagnostic categories, suggesting that some of the rivalry between the two approaches is misplaced. The dimensional system is excellent for quantifi cation of abnormality along its axes (such as conduct problems, anxiety, etc.) and thus can be used in screening for disorder and as measures of treatment effects. They are better than medical systems at providing a comprehensive profile of the individual child, although the history of the MMPI should have taught that dimensional profiles like these are of limited use unless closely anchored to indicators for clinical action. Complex dimensional profiles still have some way to go to prove their direct clinical relevance to children. Clinical taxonomic systems Feinstein (1967) pointed out that the complicated medical taxonomic system of 17th-century medicine was a revolt against the theorising of the 16th, which failed because it was simply a very complex set of symptom clusters devoid of any clinical utility. Both DSM and dimensional systems have been at pains not to repeat the mistakes of the past and have actively sought clinical derivatives, but defmitionally,
they have not got much beyond purely symptom based criteria. One effort to develop a broad clinical taxonomy incorporating both DSM-III and the kind of information which most clinicians gather routinely about child, family, school etc. has been devised by Kiser & Pruitt (personal communication). It is unique in that child clinicians from all professions have been working together with researchers. However, to survive, this creative effort must now show that its clusters are reliable, internally consistent and externally valid.
Data-capture methods
Dimensional systems These are just as popular as lCD or DSM (Quay, 1986a).Unlike DSM or lCD, which are based on intu itive clinical wisdom, dimensional approaches usually use empirical multivariate statistical approaches to group symptoms-ordinarily derived from parent or teacher ratings (Quay, 1986a). The best known of these are the Achenbach Child Behavior Checklist, the Revised Behavior Checklist and the Conners Teacher and Parent Questionnaires (see Quay, 1986a). Unlike medical classifications, the dimensions are continuous so that each child has a score on each axis. Recent studies (Weinstein et a!, 1990) have shown
Although there has been much research on methods
of data capture such as questionnaires (Quay, 1979, 1986a), behavioural methods (Mash & Terdal, 1981; Rutter et a!, 1988; Werry & Wollersheim, 1989), neuropsychological and cognitive tests, and instrumentation (Pfadt & Tyron, 1983; Rutter et a!, 1988; Quay, 1986b), none of these methods
is orientated towards diagnostic systems like DSM and they are very properly regarded as only aids to ordinary history taking and examination. Yet, apart from Rutter & Graham's (1968) effort, there has been little research on the clinical interview in child psychiatry until recently (see Young et a!, 1987).
CHILD PSYCHIATRIC DISORDERS The huge US Epidemiologic Catchment Area (ECA) studies (Archives of Genera! Psychiatry, 1984) have made structured interviews widely acceptable and child psychiatry has begun to follow. Examples are K-SADS and the DIS-C modelled on adult equivalents and the purpose-built DICA (Diagnostic Interview for Children and Adolescents), all for DSM-III-R (see Ambrosini, 1992), and one currently under development by Angold, Rutter and colleagues to cover both DSM and ICD—lO. The study by Ambrosini et a! (1989), with its use of video recordings and sophisticated psychometric statistics, shows how far child taxonomy has come and should serve as a model for testing the reliability and validity of any interview. In his review, Ambrosini (1992) draws attention to the well known problems of unstructured inter views but points out that structured interviews carry their own problems—theyare time-consuming, cumbersome, inflexible, and unintelligent, and shift error from interviewer to respondent. They are most suited to lay interviewers used to reduce costs in epidemiological studies. The semi structured interview offers a compromise between the traditional free-floating and tightly structured interviews, although to achieve inter examiner reliability, clinical sophistication and intensive training of interviewers is needed (Ambrosini, 1992). Unfortunately, when child psychiatry teaches interviewing, it teaches the traditional interview, which is often highly idio syncratic to the teacher. It would be useful if this training were centred on a properly developed and tested interview. Child psychiatrists are heavily reliant on reports by caretakers such as parents and teachers. When there is conflict, how should the clinician put it all together? It is believed that reports by disinterested sources such as teachers should be more valid than those of parents, but discrepancy between sources is inevitable, since parent and teachers see children in different contexts (Achenbach et a!, 1987). Thus while there is poor agreement between sources such as parents and teachers, there is good agreement within sources (e.g. both parents). Thus, all are correct - and the problem is to decide how much of each is needed to make a robust diagnosis. In the end, the question is one for empirical research, not armchair hypothesising. Rutter and colleagues (Rutter eta!, 1970; Rutter, 1976) suggested that, in contrast to adolescents (Rutter eta!, 1976), children had little to add to what the adults about them provided, but recent research on depression and anxiety disorders in children suggests that reliance on adult sources alone may lead
475
to gross underestimates of dysphoria in childhood and adolescence (see Kazdin, 1987; Werry, l992b). Whether this under-reporting by adults weakens or strengthens the diagnosis of dysphoric disorders is unclear. For example, McGee et a! (1990) in New Zealand showed that while overanxious disorder rose markedly in adolescence with a marked gender shift towards females, these self-reports were often not matched by any objective social dysfunction such as school failure. Nurcombe et a! (1989) and others (Strober & Werry, 1985) have voiced concern about the increasing diagnosis of major depression in children based on self-report data. While some depression instruments show promise psychometri cally (e.g. Strober & Werry, 1985; Birleson et a!, 1987; Kazdin, 1987), the depression seems to lack essential validating criteria such as sensitivity to antidepressant treatments (Nurcombe et a!, 1989; Conners, 1992). Comorbidity It is often assumed that DSM—IIIcreated this problem by allowing multiple diagnoses. But there is an old study by Hewitt & Jenkins in 1947 (see Quay, 1979, 1986b) who found that less than 40% of children fitted neatly into one of their categories and the remaining 60% had to be classed as mixed disorders. The only reason comorbidity appears new, as Ambrosini (1992) points out, is because of the increasing use of structured interviews which do not allow diagnosers to circumvent the problem. Comorbidity is often seen as a lack of specificity or gross overlap in some disorders-as is true of some of the anxiety disorder subcategories and, probably, the very large overlap between anxiety and depressive disorders in children (Rey eta!, 1989; Werry 1991). It may also be due to overly sensitive thresholds yielding unacceptably high levels of disorder. This problem has plagued attempts to produce a child equivalent of the DIS (Shaffer, 1990) and is the reason that NIMH has been so far unable to proceed with ECA studies in children. But if clinics are reaching mostly children who are seriously disabled and/or have multiple problems it may not be a taxonomic defect but a clinical reality. The epidemiological study by Anderson et a! (1987) in New Zealand confirmed that only a minority of children had more than one disorder and that they were the most disabled and most deserving of care. (What was disturbing, however, was how few of these very disabled children actually got to clinics and how many of the less disabled did.) Neither is comorbidity a defect if it is revealing that many children seen by child psychiatrists do not have a
476
WERRY
major psychiatric disorder, but deviations of person ality, and for this group, the categorical view is less correct than a multidimensional model. This may be one reason that clinicians have such resistance to what they perceive as simplistic DSM or lCD labels. Summary
of reliability
and validity of disorders
There is now a solid set of epidemiological studies (see Anderson et a!, 1987; Costello 1989) to show that psychiatric disorder in children, confirmed by at least two sources, has at least a 5—7%point prevalence. But such figures are of less interest than which particular disorders make up this figure, how long each lasts, how disabling, how treatable, and how preventable they are. Adult disorder in childhood Apart from personality disorders, which are considered inappropriate in children in DSM—III,most adult disorders also occur in children but are infrequent before adolescence. Schizophrenia and bipolar mood disorder will be used as examples although what is said seems equally true of other disorders like obsessive compulsive disorder (Berg et a!, 1989). Adult disorders occurring in childhood appear qualitatively similar to those seen in adulthood (Berg eta!, 1989; Carlson, 1990; Werry et a!, 1991; Werry, 1992), validating
the decision in DSM—III to abolish such
There is now good reason to question the widely held view that early onset portends resistance to treatment and a worse prognosis than in young adults
(Berg eta!, 1989; Carison, 1990; Werry eta!, 1991). These disorders are disabling and difficult to manage whatever the age of onset and one must be careful not to confound duration of disorder with age of onset as has been done in the past for both schizophrenia (Werry eta!, 1991) and brain damage (Fletcher & Satz, 1983). While adult-type disorders are uncommon in children, they are frequent and disabling enough to provide one reason, among others, that child psychiatrists should keep up with developments in adult psychiatry. Otherwise adolescents are going to be admitted to adult wards where they are at risk of abuse by adult patients and of having their educational and special developmental needs neglected. However, adultomorphism in child psychiatry can go too far. In the US at the moment the rush to find unipolar depression, manic equivalents and panic disorder in children causes concern, since it is leading inexorably to pharmacotherapy in adults —¿ despite
the fact that results
as used of clinical
trials in children have been at best equivocal (see Nurcombe et a!, 1989; Carlson 1990; Conners, 1990;
Klein & Klein, 1990). Disorders usually beginning In childhood
separate categories as childhood schizophrenia or Can childhood-onset disorders be diagnosed re!iab!y? childhood depression. Developmental variations in symptoms are to be expected and are seen in early The answer to this is on the whole yes for major onset schizophrenia and bipolar disorder (Carison, disorders like autism (e.g. Volkmar et a!, 1988; Szatmari, 1990), attention deficit, conduct and 1990; Werry et a!, 1991) in less well formed delusions and more undifferentiated subtypes, making anxiety disorders (Werry et a!, 1983; Anderson the differentiation of the two disorders very difficult et a!, 1987; Reeves et a!, 1987; Rey et a!, 1988; Prendergast et a!, 1988; Ambrosini et a!, 1989) (Carlson, 1990; Werry et a!, 1991). Since both but reliability declines for subclassifications within disorders are usually life-long and first diagnosis such disorders as conduct and anxiety (Werry often is taken as being the correct one, it is impera tive, as originally counselled by Kraepelin, that all et a!, 1983; Rey et a!, 1988). As discussed above, cases be followed punctiliously for several years to there is often poor agreement between sources, especially adults and the children themselves (e.g. establish the correct diagnosis. Before adolescence, psychiatric disorders occur Anderson et a!, 1987; Ambrosini et a!, 1989). predominantly in boys, and there is more often a Also, beginning with the classic studies by Rutter family history than there is among adult sufferers —¿& Graham (1968), reliability has been demonstrated as frequently as 50% in bipolar disorder (Werry eta!, mostly only for colleagues working closely together 1991). In early-onset schizophrenia, premorbid and, increasingly, using structured interview techniques schizotypal personality and/or neurodevelopmental which are still too cumbersome for clinical use abnormality occur in over 50% of cases. These what happens to reliability with clinicians in findings (Carlson, 1990; Werry et a!, 1991) suggest general is less well known. It was not good in that early-onset disorders may offer unique research the UK—US collaborative study for DSM—III opportunities because of greater homogeneity and (Prendergast et a!, 1988) but field trials for ICD—9 in the UK gave a better result (Quay, 1979; Rutter less distortions of brain architecture and function et a!, 1988). from causes unrelated to the disorder per se.
477
CHILD PSYCHIATRIC DISORDERS Do the categories tell anything useful?
The answer must be an emphatic yes. However, as already pointed out, the problem for the clinician is that the answers are often rather too generalised and at best only probabilistic, in some instances at levels not very much above chance. The best information is prognostic. For example,
are only five treatments which can be said to have even pretentions to being diagnosis-specific in disorders originating in childhood —¿ stimulants for ADHD,
dopamine-blockers
(Cohen et a!, 1989;
although the underachievement which characterised their school careers is also seen in their employment (Weiss & Hechtman, 1986). On the other hand, conduct-disordered children have about a 50% chance of treading the downward slope to criminality, sexually transmitted disease, alcohol and drug abuse, morbidity and mortality from motor vehicle accident, suicide or homicide, and presumably into antisocial
Coming, 1990) and possibly habit reversal (Azrin & Peterson, 1989) for tics and Tourette's, Pfaundler's conditioning treatment for enuresis (Werry & Wollersheim, 1989; Berg, 1990),behavioural methods for weight gain in anorexia (Hsu, 1986)and, possibly, extinction procedures for some anxiety disorders (Werry & Wollersheim, 1989). Unfortunately, most are unsuccessful in many cases and are, in the main, only symptomatic and incomplete. Thus, the clinician is then left with a disabled child and distress or dysfunctional social environment. As a result, all disorders require much concomitant non-specific management to assist children, families and schools to cope, which is one of the reasons that the value
personality
of diagnosis is often lost both to the observer and
providing they do not also have conduct disorder, hyperactive children do well after leaving school
disorder
(Robins,
1979, 1991; Quay,
1986b; Kazdin, 1987; Shaffer eta!, 1988). Children with anxiety disorders generally do well (Robins, 1979; Quay & La Greca, 1986; McGee eta!, 1990; Werry, 1992b) although there is a group, the more severe, who do not (Gittelman, 1986). Tic disorder, elimina tion (Werry, 1986; Berg, 1990) and eating disorders (Hsu, 1980) mostly have a reasonably good prognosis
although again a more severe group does not. In aetiology, there is less certainty. Simplistically, child disorders can be sorted into primordially psychogenic and primordially biological. What has been described as the continuum of caretaking casualty (Sameroff & Chandler, 1975) or as family adversity is highly associated with conduct disorder
(Quay, 1986b; Werry eta!, 1987), although there are biogenic indicators
as well (Quay,
1986b; Robins,
1991). In the probably biogenic group (see Kreusi, 1990) are: (a) autism-some kind of early encephalo pathy from a variety of possible causes (Coleman & Gillberg, 1985); (b) ADHD—familialin some cases (Biederman eta!, 1990), most with a basic defect of information processing (Werry et a!, 1987; Van der Meer & Sergeant, 1988) which looks biogenic, and inconsistent but repeatedly found brain dysfunctions
(Schacher eta!, 1981; Zametkin & Rapoport, 1988; Zametkin et a!, 1990); (c) anxiety disorders which seem more linked (possibly genetically) to parental mood and anxiety disorders than to stressful life events (Reeves et a!, 1987; Anderson et a!, 1989); (d) Tourette's disorder is probably significantly familial and linked in some way to ADHD and other disorders like obsessive (see col. 1 Cohen eta!, 1989; Comings, 1990). Elimination and eating disorders are still clouded in mystery. However, the lodestar of diagnostic validity rests in specific and effective treatment. So far, there
the clinician. Of all the disorders of childhood, conduct disorder is both among the commonest and the most serious in immediate and ultimate consequences. Yet, it is virtually untreatable
and most of these children
will end up in the hands of society's minders (Quay, l986b; Kazdin, 1987). Here is a real challenge to child psychiatry, although most of us feel that the problem lies in civil turmoil or an unjust society against which, like the children affected, child psychiatrists are powerless. The link between child and aduft disorders The older literature suggested that there was little link between being seen in a clinic as a child and being a patient as an adult (Robins, 1979). However, as already discussed, when one looks at specific diagnoses, the situation is rather different some disorders such as the eating (Hsu, 1980), schizoid (i.e. schizotypal) (Wolff & Chick, 1980), psychotic (Robins, 1979; Werry et a!, 1991), conduct (Robins, 1979), obsessive-compulsive (Berg et a!, 1989), Tourette's (Werry, 1986; Cohen et a!, 1989; Comings, 1990) and even ADHD
can continue into adulthood (Weiss & Hechtman, 1986; Zametkin et a!, 1990). Also, there is retro spective evidence from adult patients with mood (Carlson, 1990), anxiety (Thyer et a!, 1985; Berg eta!, 1989), and antisocial disorder (Robins, 1979),
that these disorders often begin at least as early as adolescence and that the first manifestations often go undiagnosed. Child psychiatrists are fond of arguing for more resources on the grounds that they are preventing disorders later in life, but, beyond knowing that
478
WERRY
there is some link between child and adult disorders, we do not know how large the risks are. In order to maximise the efficiency of psychiatric services for children we need to know much more accurately who will get better without treatment, who is heading towards durable disorder, who will get real benefit from treatment, and what are risk and protective
factors.
All this calls for much more research. While longitudinal studies are the ideal, they are costly, their results take a long time to gather and attrition is a serious problem, although there have been, and now are, a number of studies in progress which, unlike
those in the past, are increasingly linked to psychiatric taxonomy. At a recent NIMH-sponsored meeting in Washington
on research
in child psychiatry,
Lee
Robins advocated the retrospective method as a practicable and valid complement to longitudinal studies. Another suggestion, from Rachel Klein, was that a serious effort should be made to examine the real distinctiveness of some child disorders by seeing whether or not adult criteria which have been develop mentally adjusted could be applied equally well—for example, to see if overanxious disorder of childhood
is really distinct from general anxiety disorder of adults. It could also be asked whether conduct disorder and antisocial personality disorder are not the same thing. The advantage of this kind of taxonomic parsimony is that it makes defining any connections with adult disorders much easier and clearer, to say
Conclusions
This brief overview has revealed that, like adult psychiatry, child and adolescent psychiatry has a taxonomy in which there are some disorders which are reliable, valid and useful, but that there are others which are of dubious status or about which little is known. The quality and quantity of good research in childhood taxonomy has risen dramatically since the appearance of DSM—IIIin 1980 and the future for this field of research looks bright. However, there is still
a large
shortfall
between
yields
from
taxonomic labels and the needs of clinical practice which requires diagnostic labels which are more comprehensive, less probabilistic and more certain in their information and which take account of children with problems or deviations of personality where the disorder model is less apposite. Competing systems
like
ICD—10, DSM—III and dimensional
systems need to compare and contrast their wares in an empirical and less nation- or profession-bound way, so that the clinician-consumer may take informed choices. In order to assist in this process, clinicians need to act more like interested parties and less like a cynical Greek chorus.
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