Classification, ICD, DSM - 5 and debates, Assessment, Observation, Diagnosis

(R. Hetherington, 2015, Personal Communication)

Psy 341S Psychopathology of Childhood

University of Toronto

Lecture 2 - 1.14.2015

There are two types of Classification Systems

Classification is putting things in their “chubby holes”. Really this process of categorical classification is considered diagnosis. You are practicing the clinician scientist model so the difference between clinical and scientific diagnosis is not so different.

When you are going through assessment you want to get past chubby holes and into how to best help the child who is in need of help. Assessments usually occur initially, usually involving rating scales and questionaires so you can see where the child sits and track the child’s progress. This may or may not lead to diagnosis.

Diagnosis involves collecting information, drawing conclusions, and finally placing them in a formal taxonomic diagnosis.

Criteria for Evaluation of Systems

(1) The categories must be clearly defined..

(2) The subcategories occur together to avoid hundreds of sub categories.

(3) The system should be reliable:

(a) inter-rater reliability which is two clinicians would diagnosis the same

(b) test-retest reliability which is that the results relate the same.

(4) System has to be valid. Otherwise logically consistent.

(5) System must have clinical utility

ICD International Classification of Disease and the history of DSM

(DSM - 1) In the 1960s APA came up with DSM that was largely psycho-dynamic.

(DSM-2) there was no information for children which was a real issue because the signs and symptoms of the disorder was very different. In

(DSM-3) was called the shopping list for mental disorder where people were given different categories. In (DSM-4) there was more specificity adding things like ADHD. There was field trails and deeper analysis due to the use of computers. Neurosis has disappeared and now is only found in the Five Factor models of personality but out of the DSM system.

(DSM - 4 - TR) Updated some findings and added some information about psychopathology in children. There is at this point 250 diagnosis categories and you can see by comparing number of disorder the list has grown. The possible issue though is that the diagnosis is still an art and the more disorders there are the higher the chances of overlap.

(DSM - 5) 2014, changed many early child psychopathology into neuro developmental disorders. This kind of falsely assumes we understand the biological facts of all these which may not be true. There is now some overlap like for example between motor system disorder with ADHD.

Replacing the Multi Axis Replacement and other Changes

Rather than the Axis codes using ICD codes. They tried to capture psychosocial and cultural factors with ICD codes. They got rid of Axis V used to give a Global Assessment Functioning (GAF) giving someone with GAF of 30 and then after treatment it was 60. The issue was that it could be misinterpreted so it got replaced with current functioning model.

There is considerable dedication to the cultural considerations because there is really not just one psychological experience. Writers have talked about applying American psyches to cultures around the world. He makes the point that hysterical leg paralysis on women gives a cultural straight jacket of gender oppression back then which don’t exist today.

An interesting story is a researcher who found it bizarre that Hong Kong anorexia which involves no active dieting but complaining about feeling a bloated stomachs. All this changed when a teenage girl died of starvation the media reported on DSM understanding. A couple years later as a consequence of the change in understanding there was a much larger increase in the number of young woman who had this illness.

Rutter's Recommendations for DSM-5

He advised removing of groupings and making it clear instead how it varies across the disorders. In addition, he wanted a dimensional approach with a categorical approach. Although categorical approach is useful often it’s hard to place whether an individual is in one or the other. This change was not applied, but personality disorders contains a dimensional aspect.

He wanted to do away with impairment arguing that you could have an impairment but not a disorder though this change has been done.

Conflicts in DSM - 5

Dr. Robert Spitzer writes that professionals have a tendency to further their paradigm making everyone fall into a disorder. Psychiatric diagnosis is can be just as dangerous of pharmaceutical. “Funding pharmas” do have a stake in funding research which would promote the use of medication. This has led to complications before and it is can be concerning.

Another criticism is on the Disruptive Mood Disorder with Deregulation argued as being too broad and easily over diagnosed. This was meant to replace the paediatric bipolar disorder which was a favorite before.

Another way to reduce diagnosis that got rid of classic autism, asperger syndrome, and PDD - NOS. The possible issue is that some children who have a learning disorder would not fall into Autism specturm disorder. Parents also wondered whether ASD hold a greater stigma than Aspergers since Aspergers was usually associated with less extreme symptoms than some of the other developmental disorders.

Talking about Psychopathology as Brain Disease

The argument perhaps it would be better to call psychopathology brain disorders which perhaps could limit stigma. Research has been done comparing stories told brain disease and others as psychosocial terms. The findings surprisingly that psychosocial explanations resulted in test subjects to treat confederates to be less harshness.

It’s also noted that people with Schizophrenia in developed countries suffer greater stigma. This is thought to be because non industrialized cultures perhaps communities might help the individual exercise the spirit gently which result to better social support.

Wadler argues that DSM - 5 could be losing older cultural explanations which could be giving psycho pathologies meaning.

Section 2 added and add Section 3 (needs more research)

Pedophilic disorder has now been added as a new edition. The legal defence is a complicated understanding drawing on where we draw the line.

Anxious depression was one category that needs more research. Internet use gaming disorder,

Major criticisms of DSM approach

Are mental disorders diseases? Further there is too many superficial description and does not capture of complexity of the disorder. What would perhaps make it even more complex is the extreme high rates of co-morbidity, but what is likely happening is neuro developmental pathway which expresses themselves differently.

The categorical approach can result in the denial of services. An individual may fall out of services they need despite having greater developmental challenges than individuals who benefit from help.

Dimensional Classification systems

The Child Behavior Checklist (CBCL, 1991) is used most widely used. There are about 2 others used by clinicians. These are found to be pretty robust clinically. There are externalizing problems and internalizing problems called broad band. They are also assessed withdrawn, anxious depressed, social problems, somatic complaints, tough problem, attention problems, delinquent behavior, aggressive behavior.

Labeling Problems and Virtues for Children

Shopping list used to find a disorder. All the individual attributes of the individual. ADHD for example is assumed to cause behaviors which is a logical fallacy because our studies only observe patterns with ADHD. Also there is the issue of reporting biases where women with ADHD would be less likely to be helped because she is not noticed.

Uniform categories allows leads to better research and correct intervention. Not to mention it is a short hand for professionals allowing for easier communication for research and clinical work.

Process of Diagnosing child

Professor was going into a school helping a child in grade 7 who could not read. After it was decided that it would a good idea to give a diagnosis to give the child help before he goes into high school. It involves presenting the information in front of a meeting with parents, parents, and superintendents.

Interview

Unstructured interview has the benefits of allowing the child in a natural setting while learning about the individuals beliefs and attitudes. To see if specific types of treatment is possible and what type of treatment is best used. Of course, unstructured interview are not as easy to study. It is also hard to develop the skills to do these interviews based on intuition and to prevent.

In semi-structured system that is highly valid. It would involve “Do you feel sad” “Do you feel moody”. The issue can be that the individual can get a sense of what is being asked so the professor actually prefers structured questions which seems less invasive.





Observation

An interval observation involves recording how often the child gets out the seats. It involves the counting of a number of specific targets. Interval events is for observing things that are common while event is for noting more special instances. Rating scales are also used which are a checklist. Children who are older may have an effect of observer effect though it usually isn’t an issue with younger children.

A benefit of this is that you can find the baseline and look at how modifying environment if you can reduce a behavior in an externalizing child. Disadvantages of this could involve difficulty defining behaviors such as not paying attention. There is also the issue of interpreting behavior.

Forms of Validity

1. Concurrnt validity,

2. predictive validity, do they predict how the child is going to do? Or is it just current?

3. construct validity, on for example to what extent is an IQ question not biased?

If we are to imagine trying to hit a target you want valid and reliable is both that it’s not biased (validity) and is precise (reliability).

Wechsler and Intelligence

Replaced DQ replacing mental age. “The aggregate or global capacity of the individual to act purposefully, to think rationally, and to deal effectively with his environment (Wechsler, 1944)”. He has has a test called the WWPSI-IV which overlaps the WISC-IV which is very popular and will be use in this course.

WISC-IV starts “In what way is wheel and a ball alike” then “in what way reality and dream alike?”