Developmental psychopathology - the past

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Developmental psychopathology - the past

• 1654 The Massachusetts Stubborn Child Act -
  father could petition a magistrate to put a
  stubborn child to death
• Rie (1971) noted that no concept of disordered
  behavior in children could emerge so long as
  possession by the devil excluded other notions of
  causality
• most research has tested linear models to produce
  still photographs of moving targets

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Developmental psychopathology - classification

• Why classify mental disorders?
• human beings are natural categorisers - a form of
  communication
• the economic imperative - categorisation is a
  practical necessity to distinguish those in
  clinical need from those without clinical need
  (Sonuga-Barke, 1998)
• the knowledge imperative - classification lends
  itself to empirical study and has potential for
  understanding, change and refinement

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Developmental psychopathology - classification

• Why not classify?
• tension between need to classify and desire to
  maintain optimism
• tension between view that clear categories of
  disorder exist in reality versus a cut-off for
  impairment based on cultural norms and tolerances
  
• risk of the delusion of understanding
• concern that diagnostic labels may have negative
  impact ie. a secondary insult.

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Developmental psychopathology - classification

• System should have
• reliability (across time, situation and
  informant)
• internal consistency - symptoms hang together
• specificity - what the disorder is and what it is
  not
• external validity - aetiology, prognosis,
  treatment response
• utility- assists clinical management

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Developmental psychopathology

• Disorders are
• usually polygenic
• influenced by development ie. interactions
  between the biology of brain maturation and the
  mutlidimensional nature of experience
• influenced by environment and context
• result from multiple, reciprocal interacting risk
  factors and causal events
• have cognitive, affective, physiological and
  behavioural components

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Developmental psychopathology - classification

• Any system needs to account for
• development, eg.
• same symptom ? different or no disorder
• different symptom ? same disorder
• dynamic and interactive processes
• environment and context

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Developmental psychopathology -classification
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Developmental psychopathology
3 years
restlessness overactivity
ADHD
14 years
reduced emotional/ behavioural self-regulation
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Developmental psychopathology - classification

• Dimensional (eg CBCL, BASC, Connors)
• behaviours exist on continuous dimensions ie. all
  children have a score on each dimension
• clinical significance expressed as standard
  deviations from the mean
• Categorical (eg. DSM-1V, ICD10)
• pathology occurs in discrete categories
• presence of set number of specified symptoms
  establishes diagnosis

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Classification-dimensional

• use empirical multivariate statistical approaches
  to derive dimensions
• dimensions are continuous
• pathology differences in degree, rather than
  kind
• require fewer dimensions than categories, can
  weight severity
• cut points are arbitrary eg. time and culture
  bound,
• caseness is a function of deviation from a
  normal score, rather than level of impairment

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Externalising disorders

• most common presentation to child mental health
  services
• aggression
• oppositionality
• impulsivity
• anti-social behaviours eg. lying, stealing
• boys gt girls
• parent/teacher reports reliable, self reports
  underestimate symptoms

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Internalising disorders

• next most common presentation
• anxiety
• social withdrawal
• depression
• somatisation
• phobias
• boys ? girls, girls ? in adolescence
• need self report - parents/teachers underestimate
  symptoms

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Dimensional systems

• generate reasonable inter-rater agreement,
  (although internalising symptoms often
  under-recognised)
• too broad to provide information about aetiology,
  treatment response, prognosis
• often result in high estimates of caseness -
  Aust. community prevalence rates for total
  behaviour problems between 14-18 (Sawyer et al.
  2000 Zubrick et al. 1995
• give insufficient weight to clinical impairment

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Classification - categorical

• pathology differs in kind, not just in degree
• based on a medical model illness versus well
  being
• classification is based on informed clinical
  consensus
• provide reasonable prognostic information eg,
  ADHD improves, CD high risk of life-long
  pathology
• less reliable about treatment response, no
  assumptions about aetiology
• low inter-rater reliability
• prevalence estimates lower than with dimensional
  systems eg, MDD 2-5 CD ADHD 2-6

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Childhood disorders - DSM-1V

• Axis 1 codes for disorders first diagnosed in
  childhood
• learning
• motor skills
• communication
• pervasive developmental disorders
• ADHD
• feeding and eating
• tic
• elimination
• other eg. separation anxiety, selective mutism

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DSM-1V

• Use adult Axis 1 codes for
• mood disorders
• anxiety disorders
• adjustment disorders
• schizophrenia and other psychotic disorders
• substance abuse-related disorders

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DSM-1V

• based on belief that reliability is enhanced if
  classify on signs and symptoms rather than
  interpretation and inference
• but, symptoms still rated on cultural and
  temporal constructions of deviance eg often
• in fact, little evidence that day to day
  diagnostic reliability is actually achieved (may
  be better with training/semi-structured interview
  schedules).
• high levels of co-morbidity between, and
  heterogeneity within, disorders undermines the
  categorical approach Clark et al., 1995)

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James (7 years)

• History
• eldest of three, intact family, normal
  development
• Presenting symptoms (present 1 year)
• aggression eg. hitting peers, fighting
• stealing
• oppositional at home
• Diagnosis
• conduct disorder

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James

• Symptoms short lived (previously an assertive,
  active little boy but not oppositional or
  aggressive) ie. no evidence of geteic
  predisposition or biological risk factors such as
  difficult temperament, low intelligence.
• Symptoms context bound
• father lost job 12 months previously
• family move
• father - anger outbursts, punitive
• mother depressed/overwhelmed
• James struggling with reading

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James

• differential diagnosis
• reading disorder
• reactive situational stress disorder

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Developmental psychopathology

• ?10 of children have a diagnosable disorder that
  causes some level of impairment
• continuities and discontinuities but many
  children do not grow out of their disorder
• disorder may be stable but symptom patterns
  change
• attempt to classify limited by
• multiple pathways ? single disorder
• single pathway ? multiple disorders
• many children are untreated
• social changes may increase prevalence
• risk and resilience factors are emerging

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Developmental psychopathology - the future

• active child, active environment
• singular pathway and outcome models replaced by
  non-linear models capturing dynamic, interacting
  contextual, developmental and environmental
  influences
• improved methodology and assessment tools eg.
  genetics, neuroimaging, observation tools.

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Child assessment

• children rarely self refer
• development limits ability to provide information
  about self
• referral bias/scapegoating
• family system can be coded as a stressor (Axis
  1V), but not as patient
• poor agreement across sources (better within
  sources eg. parents)

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Child assessment

• scientist practitioner model - evidence based
• hypotheses formulated, tested and revised
• systematic analysis of the presenting problem

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Child assessment (Shapiro, 1997)

• genes
• pre perinatal
• injury/illness
• temperament, behaviour
• self concept, emotions
• phase/stage
• transitions
• family
• peers
• community

• biological
• psychological
• developmental
• social

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Childhood disorders - assessment

• Referral
• History
• Assessment
• Formulation
• Treatment/management

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Child assessment

• Referral
• By whom?
• characteristics of the referrer
• children do not self refer
• ethical implications
• Why now?
• contextual factors
• intercurrent stresses

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Child assessment

• History
• the story of the problem
• developmental history
• information from previous assessments
• medical information
• educational information

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Child assessment

• Collect information in multiple forms
• structured interviews
• standardised measures
• play
• drawing
• analogue scales
• direct observation across settings
• collect information from multiple informants

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Child assessment

• Presenting problem
• pre-disposing
• within child eg genes/intelligence/temperament
• family/contextual factors
• precipitating
• developmental transition
• environmental stressor/change
• perpetuating
• entrenched problem/expectancies
• discipline strategies eg. negative
  re-inforcement/communication patterns

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Child assessment

• Formulation
• integrative and conceptual
• multi-faceted
• synthesis of predisposing, precipitating, and
  perpetuating factors
• evidence based treatment/management plan

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Child assessment

• Treatment
• education and understanding
• environmental manipulations
• specific therapies eg. BT, CBT, psychotherapy
• parents (teachers) as co-therapists

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Child assessment

• Referral
• Opthalmologist
• Is Will as blind as he seems?
• Family/social

diabetes
7
5
IP
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Child assessment

• History
• no significant family history of physical, mental
  health or educational problems reported
• Will - congenital nystagmus, otitis media
• no symbolic, imaginative play, not interactive or
  explorative
• explained as secondary to physical problems

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Child assessment

• History (cont)
• kindergarten - resisted change, didnt understand
  turn taking, limited peer interaction ?- psych
  assessment, Average IQ, fastidious, but could
  accept re-direction
• 6 years - progressing well academically, no
  friends, parents concerned about low empathy,
  oppositionality
• Will - ? complaints of poor vision
• Psych referral - ODD (not OCD, AS), parenting
  strategies

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Child assessment

• History (cont) 8 years
• D of E assessment - WISC111
• Average IQ, suggested ASD assessment
• diagnosis of high functioning autism
• vision deteriorating
• Referral to RCH - 9 years
• is his blindness functional?

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Child assessment

• Assessment - neuropsychological
• pragmatic language deficits
• poor use of non-verbal cues
• but, inconsistent responses on visual tasks eg.
  Block Design SS 10
• executive deficits, including classic
  dissociation between knowing and doing

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Child assessment

• Assessment - emotional
• interactive, but reduced flexibility, spontaneity
• negative self-percept
• aware of difference
• unhappy, ? clinically depressed
• striking disparity between teacher and mother
  report

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Child assessment

• Assessment - family
• low parental enjoyment social ostracism
• mother tense despairing father distancing
  himself
• Will - conduit for family tension, the
  scapegoat
• other children idealised
• ? parental mental health - past/current

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Will

• Formulation
• ASD
• Conversion disorder - with sensory deficit
• Adjustment disorder with mixed anxiety and
  depressed mood
• parent/ child attachment, family interaction
• problems
• Treatment
• family therapy
• individual therapy social skills training

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Will

• diagnosis shopping
• discrepant information/formulation across sources
• under recognition of secondary conditions
• differential diagnosis

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Will

• Shift focus from assessment to therapeutic
  management
• assessment/treatment of mood state/family
  dynamics
• minimise focus on vision. Home and school to
  work on the assumption that Will can see.
  Modifications to the learning or physical
  environment only if explicitly requested by Will,
  provided with minimal attention and combined with
  positive attention for seeing