How can disorders be classified? - Chapter 5

What are the concepts of classification systems?

The terms classification, assessment and diagnosis are used to describe the process of description and grouping. Classification (or taxonomy) stands for creating large categories or dimensions of behavioural disorders. It is a system for describing phenomena. These systems are mostly for clinical or scientific purposes. A diagnosis is when a category or classification is considered applicable to an individual. Assessment refers to evaluating (young) people to facilitate classification and diagnosis and to make treatment plans.

Classification systems try to systematically describe a phenomenon. For example, biologists have classification systems for organisms, such as cold and warm-blooded animals. There are also systems for classifying psychological problems. These systems describe categories or dimensions of problem behaviour, emotions and / or cognitions.

A category is a discrete grouping, for example anxiety disorders, to which an individual belongs or does not belong. A dimension , on the other hand, is a continuous property that can occur in various sizes. For example, there are different degrees to which a child is anxious.

The categories or dimensions in a classification system must be clearly defined: the criteria must be explicitly named. In addition, a distinction must be made between the different categories. It must also be proven that a category or dimension actually exists, meaning that the characteristics used to describe a category or dimension must regularly occur together.

What is the importance of reliability and validity?

Classification systems must be reliable and valid. There are two types of reliability:

• Reliability based on consensus (interrater reliability ): the extent to which different diagnosticians use the same category to describe the behaviour of a person. This is the case, for example, if two researchers both think that a child has ADHD.
• Test-retest reliability: the extent to which the use of a category for a certain person is stable over time. If a child with ADHD is diagnosed, it is also expected that the child would also be diagnosed with ADHD in a second examination.

Validity refers to the extent to which a diagnosis provides us with more information than we initially had (before defining the category). Diagnoses must provide information about the origin, development and treatment of disorders. Another aspect of validity is the extent to which a description of a disorder is accurate.

The clinical utility of a classification system is assessed on the basis of the completeness and usability of the system in a practical scenario.

What is the Diagnostic and Statistical Manual of Mental Disorders (DSM)?

In the US, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is used most as a classification system. The International Classification of Diseases (ICD) is an alternative system that is also widely used. The Diagnostic Classification (DC) has been developed to classify the mental disorders of children between the ages of zero and three years old.

The DSM is a clinically derived classification system , based on the consensus of researchers that certain characteristics go together. Experts' committees propose concepts of disorders and choose diagnostic criteria.

In addition, the DSM is categorical : a child does or does not meet the criteria for a diagnosis. It is therefore assumed that there is a clear substantive difference between normal and abnormal behaviour and not a degree of difference. Categorical approaches therefore assume that a distinction can be made between qualitatively different types of disorders.

There have been several revisions of the DSM. The most recent revision is the DSM-IV. The DSM-IV contains information about a large number of disorders. These disorders are divided into different groups of related disorders. Every disorder has a description and a diagnostic criterion. In addition, information has been added about prevalence, the likely course of the disorder, cultural, age and gender-oriented information and any common characteristics (e.g. low self-confidence).

Initially, the classification of abnormal only focused on adult disorders and there was no comprehensive classification system for childhood and adolescent disorders. For some disorders the same criteria apply for children and adults and sometimes there are specific criteria for children.

Grouping of disorders

The disorders are grouped in the DSM-IV. Disorders within a group are seen as related by similar symptoms, cognitive processes, risk factors and the response to treatment, but different in the behaviour that’s showing.

Approach from the DSM

One of the aspects that is important when we talk about the approach to classification of the DSM is comorbidity. Of comorbidity (co-occurrence) occurs when a child meets the criteria of more than one disorder. This phenomenon causes some scientists to question the DSM as a classification system. Do these children really have multiple disorders or are there other explanations? There are several possible explanations for the occurrence of comorbidity:

• Many disorders have mixed patterns of symptoms. With mood disorders, for example, there is both depression and anxiety that can show social withdrawal.
• Disorders have shared risk factors: some risk factors lead to problems that are used to define multiple disorders.
• The presence of one disorder increases the risk of another disorder.
• The second problem is a later stage in a development process, in which previous problems may or may not persist. In this case, the diagnoses represent a developmental pattern of one common condition.

Difficulties

The DSM has been improved several times over the years. For example, empirical data has been used in a more consistent way and structured diagnostic rules have been drawn up. Yet there are still difficult issues:

• There are questions about the large number of categories of the DSM system. The behaviour of children may be called abnormal way too quickly.
• The reliability of the DSM system differs per disorder and the nature and source of the information. Characteristics of the young person, such as sex or ethnicity, or characteristics of the clinician can also influence reliability.
• There is the idea that the focus has been too much on reliability and that the DSM therefore does not always give an accurate picture of certain disorders.
• There are doubts about the validity of the DSM system. If there was a specific cause or treatment for each disorder, this would indicate validity. However, anxiety and depression, for example, have common genetic and neurobiological factors. In addition, a lot of medication is effective in treating multiple DSM disorders.
• The DSM promotes a medical model and emphasizes biological causes and treatments. This makes it seem as if a disorder is 'in' a child and there is little attention for interactions with the environment, culture, gender and age.
• There is also concern about the attention paid to gender, culture and age differences in the DSM. The DSM-IV has included differences in age, gender and culture for a number of diagnoses. However, diagnostic criteria are usually the same across all ages and across all cultures. This can have major consequences. For example, if fixed limits are used (a specific number of symptoms required to make a diagnosis), it may seem that the prevalence of a disorder differs according to age, gender and culture. The question is whether these are actual differences. For example, according to the DSM, ADHD is more common among boys than among girls. However, even non-deviant boys display more behaviour that resembles ADHD than girls. The gender difference can therefore be due to the fact that such behaviours occur more often in boys. Fixed limits not only affect prevalence figures, but also who is eligible for treatment.
• More attention needs to be paid to the interactions between culture, context and behaviour. Latin American adolescent boys, for example, have a greater tendency to abuse alcohol if there are lower amounts of traditional family values, cohesion and social control that in normal in their culture.
• The validity of the DSM is questioned in connection with the use of the categorical approach. For example, there are questions regarding the validity of the three subtypes of ADHD. Research has suggested that the subtypes should be better viewed as dimensions with a continuous distribution between clinical and non-clinical levels rather than as three separate categories. If continuous symptoms are reduced to a dichotomy with only a distinction between yes and no disorder, this can lead to less statistical power and misleading research results.

What is the empirical approach?

The empirical approach is an alternative to the clinical approach of, for example, the DSM. This approach uses statistical techniques to identify coherent behavioural patterns. A parent or other respondent provides information about the presence or absence of certain behaviour in the child. Three coded numbers are used for this: 0 = the behaviour does not occur with the child, 1 = the behaviour occurs to some extent with the child, 2 = the behaviour clearly occurs with the child. This information is obtained for a large number of young people. Factor analysis identifies groups of items that often occur together. This leads to factors (also called clusters). The term syndrome describes behaviours that often occur together.

The core of the empirical approach is therefore not formed by clinical consensus (the opinion of professionals), but by statistical information. With the empirical approach, evidence has been found for two general clusters of behaviours (broadband syndromes): (1) internalizing (anxious, withdrawn, depressed, shy and physical complaints) and (2) externalizing (aggressive behaviour and breaking the rules). Among other things, the Achenbach instruments are used to measure these two syndromes , such as the Child Behaviour Checklist (CBCL) for parents and the Teacher's Report Form (TRF) for teachers of children from 6 to 18 years and the Youth Self Report (YSR) for 11 to 18-year olds. These instruments can be scored so that they correspond to categories from the DSM.

In addition, there are eight empirical, less common syndromes found (narrowband syndromes):

• Internalizing:
• Anxious / depressed
• Retired / depressed
• Somatic complaints
• Mixed:
• Social problems
• Thought problems
• Attention problems
• Externalizing:
• Crossline behaviour
• Aggressive behaviour

The DSM versus the empirical classification system

There are several differences between the DSM and the empirical classification system:

• The DSM is based on clinical consensus and the empirical classification system on empirical consensus (empirical research data).
• The DSM is a categorical system and the empirical classification system is dimensional. In the dimensional approach, differences between people are quantitative rather than qualitative and the difference between normal and abnormal is related to moderation and not to type .
• The empirical classification system uses normative samples as a frame of reference to assess children's problems. These may, for example, be scores of young people who have or have not been referred. There are different norms for every gender in certain age groups and for different cultures.

Reliability and validity of the empirical approach

The test-retest reliability for the empirical approach is very high (0.8 to 0.9). The inter-assessor reliability is also reasonably good if two informants assess the behaviour of a child in the same situation. However, the inter-assessor reliability is much lower if the child is observed in two different situations. This does not have to be the result of the empirical approach but may be the result of differences in behaviour at different times, in different situations and in the presence of different people.

Various studies have demonstrated the validity of the empirical classification system. The same two general syndromes have been found in studies that use different measuring instruments, different types of informants and different samples. Studies from different cultures always show two similar syndromes, although there are probably cultural factors that contribute to the way a problem is expressed. Differences between children with high scores on different syndromes also say something about the validity of the empirical approach. The comparison between children that externalise and internalise shows that these children differ in the expression and regulation of emotion. Finally, syndromes discovered through the empirical approach can predict outcomes, such as future problems, and receiving psychological help. This fact supports the validity of the empirical and dimensional approach.

What is the influence of labels?

The purpose of classification is to facilitate the treatment of psychological problems. It is intended as a clinical and scientific venture but can also be considered as a social process. The diagnostic label places the child in a subgroup of individuals, which has implications for how he / she is approached by others. If the influence is negative, this may partly be due to the stigma associated with mental disorders. Stigmatisation refers to stereotypes, prejudices and discrimination that are associated with a socially devalued group. It is important to be aware that classification is meant for categorizing disorders instead of people. So it's better to say that James is dealing with aggressive issues rather than that James is an aggressive person.

Diagnosing someone with a mental disorder can have several negative consequences:

• Overgeneralization : people think that all children with ADHD are alike. Such an assumption leads to the individual child being ignored.
• Negative perceptions : if a child is known to have a disorder, it influences the way people think about their actions and performance.
• Biased expectations : the expectations of a child are influenced by the diagnosis. Others may start to behave differently based on the diagnosis, so that the child is influenced in such a way that he / she behaves consistently with these expectations.

However, labels do not always lead to negative expectations. Labels can provide an explanation for the problem behaviour of the child. This creates more understanding of his / her behaviour, which reduces negative responses and adjusts expectations and more appropriate.

Finally, there is some fear that diagnosing leads to a minimization of attention to the child's interpersonal and social context. Traditional diagnostic categories ignore the fact that the child is never the sole "owner" of the problems, but that at least one other person has the problem: the person who identifies or reports the problem. The way in which a child is described says just as much about both the descriptive person and the child's behaviour.

However, categorization is part of our thought pattern and contributes to an increase in knowledge. Not categorizing is neither desirable nor possible. It is therefore important to improve classification systems and to pay attention to social factors inherent in the use of categories, the social status that a label entails and the influence of labels on the child and family.

Assessment

Because behavioural disorders often consist of multiple components and are the result of multiple factors, it is important to perform a comprehensive assessment. Information must be obtained from different informants, as problems can vary per context or in the presence of different people. Informers can also each view behaviour in a different way. For example, a depressed mother will be less capable with dealing and / or tolerating excited behaviour than a stable father might be.

It is desirable to use evidence-based assessments : procedures based on empirical evidence and theories that support validity. If a treatment is taking place, the assessment must be continued to evaluate the effects of the treatment.

The interview, what do you do?

The general clinical interview

The most commonly used assessment method is the general clinical interview, in which information about a child is obtained in all areas of executive functioning. Most clinicians gather information about the nature of the problem, current circumstances, feelings, perceptions, attempts to solve the problem and expectations regarding treatment. This information can also be used to make a treatment plan. The general clinical interview is unstructured: there are no specific questions that the clinician must ask, no predetermined set-up and no clear-cut way of coding information. This does make it difficult to assess its reliability and validity.

The structured diagnostic interview

Structured diagnostic interviews are designed to increase the reliability of interviews. They are also used to make a diagnosis based on a certain classification system (for example the DSM), for research or as a screening instrument. Structured diagnostic interviews consist of fixed questions. There are rules for how the interview is conducted and coded.

Questionnaires and self-reporting

With queries or questionnaires , numbers are assigned to the child's behaviour based on the seriousness of these behaviours. There are general checklists and checklists for more specific problems. If several informants fill in the questionnaire, a good picture can be created of the situational aspects of problem behaviour. Differences in perceptions of two informants can provide important information to situational or interpersonal context of behaviour.

Also, self-reporting is a way to get more information about the functioning of a child. In this case, the child assesses his or her own behaviour. Parents can also be asked to fill in a questionnaire about themselves, to find out if they have similar problems. In addition, this information can be obtained about the feelings, attitudes and beliefs of the adult with regard to the child. This can provide information about the social environment and factors that can influence problem behaviour, but is often harder to do regarding the mental functioning of children.

What is important about observation?

Behavioural observation

Structured behavioural observations are an important aspect of the assessment process. With this the behaviour of the child is systematically observed. Behavioural observations are often done in the natural environment of the child. Sometimes the clinical or laboratory setting is adjusted to approach a natural environment. Observations can be made of discrete behaviours of the child, interactions between the child and peers (or parents) or complex interaction systems between family members.

The first step in a behavioural observation is to determine and define the behaviours that are to be observed. Observers are trained to use the system. The reliability, validity and clinical usability of observation systems are influenced by various factors, such as the complexity of an observation system and changes in the use of the system by an observer (observer drift) . Reactivity poses a challenge to the usability of an observation. This is the change in someone's behaviour if he or she knows that they are being observed. Good training, supervising the way an observer acts and using observers who are already in the situation (for example, a teacher) are ways to counteract the influence of these factors.

Projection material

Previously, projective tests were very popular. These tests are rarely used today because their reliability and validity are questioned. Projective tests are derived from the psychoanalytical idea that projection is used as a defence mechanism: one way the ego deals with unacceptable impulses is by projecting them on an external object. Children receive an unclear stimulus, which the child must interpret. For example, a child is asked at the Rorschach test what he / she sees in ten different ink stains. Children can also be asked to make a drawing themselves or to come up with a story for a picture.

Assessment of intellectual functioning

The evaluation of intellectual and academic functioning is an important aspect of almost all clinical assessments. Intellectual functioning is a central characteristic of disorders such as intellectual disability and learning disabilities but can also contribute to and be influenced by various behavioural problems. Compared to other assessment instruments, tests of intellectual functioning have better normative data and better reliability and validity.

Intelligence tests

The most commonly used assessment method for assessing intellectual functioning are tests of general intelligence, such as the Stanford-Binet and the Wechsler Intelligence Scale for Children (WISC). The outcome of an intelligence test is an intelligence score (IQ). The average IQ is 100 and an individual score reflects how far an individual scores above or below the average person of his or her age. There has been much criticism of the use of intelligence tests. Critics, for example, argue that the use of IQ scores has ensured that intelligence is seen as fixed characteristics rather than as a complex and subtle concept. In addition, it is claimed that intelligence tests are culturally biased.

Development scales

The intellectual functioning of very young children cannot be measured with an intelligence test. One can make use of development tests that give a developmental index instead of an intelligence score. Intelligence tests are mainly focused on language and abstract reasoning, while development tests mainly focus on sensory, motor and social skills. An example of this is the Bayley Scales of Infant and Toddler Development.

Power and performance tests

Power and performance tests are used to look at the performance of a child in a specific area. With this type of testing, for example, you can look separately at arithmetic skills and language skills.

How important is the assessment of physical functioning?

General physical assessment

An assessment of general physical functioning can provide information that is valuable in gaining insight into disturbed behaviour. For example, it can reveal genetic problems that can be treated through adaptations to the environment. For example, phenylketonuria (PKU) is a genetic disorder that is influenced by the diet. In addition, certain conditions can directly (for example, urinary tract infection that impedes toilet training) and indirectly (for example, a sick child who is overprotected by their parents) influence their functioning. An atypical or delayed physical development may also indicate developmental disorders.

Psychophysiological assessment

Psychophysiological tests are often used when parents or clinicians are concerned about the alertness level of a child. These tests can, for example, look at the functioning of the muscles, heart rate and breathing. Measurements of electrical activity in the autonomic nervous system, such as skin conduction, or in the central nervous system, such as an EEG, are often aspects of psychophysiological assessments.

Assessment of the functioning of the nervous system

Assessments of the functioning of the nervous system can provide information about the aetiology of the disorder and can provide insight into the mechanisms by which a treatment, in particular medication, has an effect.

Neurological tests measure the functioning of the nervous system. In an EEG or ERP, electrodes are attached to the head to measure the brain activity of a child when performing a task. Through EEG and ERP, more is now known about the functioning of the brain in children with ADHD, autism, language and learning disabilities, among other things.

These days, brain imaging is also often used to gain insight into the structure and functioning of the brain. There are different forms of brain imaging:

• MRI uses a magnetic field that is created around the brain. This magnetic field is made with radio waves and magnets. Brain cells respond to these radio waves and a three-dimensional photograph is made on the basis of them.
• fMRI uses the same technology as MRI, but this primarily focuses on subtle changes in oxygen levels in different areas of the brain. If certain areas of the brain are used to perform a task, this area receives more blood, increasing the oxygen content. The fMRI scanner detects these changes and takes pictures of the brain, indicating the areas in which there is activity.
• PET scans determine the extent to which different parts of the brain are active by measuring the consumption of oxygen and glucose. The more active a part of the brain is, the more oxygen and glucose is used. First, a small amount of a radioactive substance is injected into the blood. The activity of different parts of the brain is then measured when performing a task. On photos you can see which parts of the brain are active and to what extent on basis of their colours.

Neuropsychological assessments are made to assess characteristics such as attention, memory, learning and verbal skills. Based on an individual's performance on such tests, conclusions are drawn about brain functioning. A neuropsychological evaluation has different functions:

• Describing changes in psychological functioning as a result of changes in the central nervous system or other conditions.
• Assessing changes over time and developing a prognosis, for example predicting recovery from brain injury.
• Offering guidelines for a treatment plan.

Neuro-psychological evaluation of children is called paediatric neuropsychology . This is a whole different field of research.

What does intervention mean?

Intervention stands for both the prevention and treatment of psychological problems. Prevention refers to the prevention of psychological problems in individuals who are at increased risk of developing these psychological problems. Of treatment occurs when individuals (or symptoms) are a disorder programs to reduce (or eliminate) symptoms. This is possible with medication and therapy, for example.

Various intervention strategies can be used to help children and families. Primary forces are present in the youth, families, communities and cultures. In this summary, interventions from the most universally applicable prevalence (top) to the most specific ones (bottom) are: 

• Health promotion or positive development
• Universal prevention
• Selective prevention
• Indicated prevention
• Time-bound therapy
• Enhanced therapy
• Continuous care

A series of possible settings is described below in which the interventions can be carried out. From top to bottom, the first mentioned are the least restrictive intervention institutions, and the bottom ones the most restrictive.

• Home
• School
• The neighbourhood or neighbourhood
• A first-line clinic
• Outpatient mental health
• Day treatment program
• Residential care centre
• Hospital ward

In the book, there is a diagram of a circle. The interventions in the upper half of the circle are organized as follows: the most universally applicable ones are on the far left. The further you go to the right, the more the interventions shift to treatments for specific target groups. In the lower half of the circle there are various possible settings in which interventions can be offered. The inner circles indicate that the child's strengths are supported by the family and the community, which are influenced by cultural and ethnic differences. The different intervention strategies are considered to be complementary.

Interventions are based on programs that are proven to be effective, and make a difference in evidence-based interventions and evidence-supported interventions.

What does prevention mean?

Caplan's model has served as a general framework for thinking about prevention. In this model, a distinction is made between primary, secondary and tertiary prevention:

• Primary prevention: the prevention of disorders.
• Secondary prevention: shortening the duration of disorders through early referral, diagnosis and treatment.
• Tertiary prevention: reducing problems that are a side effect of the disorder. Examples of this are minimizing the negative influence of a diagnostic label or preventing a relapse after treatment.

The 'Institute of Medicine' makes a distinction between universal, selective and indicated prevention strategies:

• Universal prevention strategy: aimed at entire populations. Example: Encourage parents to promote exercise and healthy eating in their children to prevent obesity.
• Selective prevention strategy (high-risk prevention strategy): aimed at individuals with an above-average risk of a certain disorder. The intervention can, for example, be aimed at individuals with a biological disposition, a lot of stress or poverty.
• Indicated prevention strategy: aimed at individuals with mild symptoms, or with a biological predisposition to a disorder, but who do not yet meet the diagnostic criteria.

Why is therapy important?

Individual and group psychotherapy

With individual psychotherapy, only the psychologist and the child talk to each other. The advantage of group therapy is that it offers opportunities for social experiences. In addition, group therapy can be experienced as less threatening and a child sees that children other than him or herself also have similar problems.

Play therapy

Play is often used by psychologists for communicating with young children because it puts children at ease and is a familiar way for them to interact with adults. It is also possible to use game as a form of therapy.

Family therapy and parent training

Involving family members in the treatment process is consistent with the idea that a clinical problem exists in a social context. A commonly used form of therapy is parent training, where parents are taught effective parenting skills. This can reduce problem behaviour of the child.

Pharmacological treatment

A pharmacological treatment uses medication. Psychotropic or psychoactive medication influences mood and thoughts. Psychotropic drugs exert influence via neurotransmitters. They can influence the production, storage, secretion, activation, reuptake and receptors of neurotransmitters. The choice to use medication is determined by various factors, such as the nature of the problem, possible side effects, and racial / ethnic factors.