Child and adolescent psychopathology by Wilmhurst (second edition) – Summary chapter 3

The purpose of diagnosis is to classify the problem within the context of other known behavioural clusters or disorders for the purposes of being able to draw on clinical knowledge regarding potential aetiology, course and treatment alternatives. The purpose of assessment is to diagnose the nature of the problem to ensure that the most appropriate treatment can be selected.

There are three questions that need to be answered by the clinician after the assessment:

1. What are the characteristics of the child’s problem?
2. How should the problem be evaluated?
3. What are appropriate intervention strategies?

The diagnostic method can be used to predict what types of measures might be selected. Classifying child disorders can be done by using the categorical classification system or the empirical/dimensional classification system.

The diagnostic and statistical manual of mental disorders (DSM) and international classification of diseases (ICD) rely on the medical model (i.e. disorder is absent or present).

There are several common structured and semi-structured interviews that have been developed to assist with DSM classification (e.g. ADIS, NIMH DISC-IV, K-SADS). Heterogeneity in symptom presentation is important. In the DSM-V this is done by only using a subset of items which are required for a diagnosis.

Parent information appears to be a better predictor for youth externalizing problems but youth and parent information are equally effective in predicting internalizing disorders.

The dimensional or empirical approach looks at behaviour in terms of a continuum rather than in all-or-nothing categories. Maladaptive behaviours is conceptualized as symptom clusters, patterns or syndromes. It assesses behaviours through the use of behaviour rating scales or problem checklists (e.g. ASEBA, BASC-2).

The Achenbach system of empirically based assessment (ASEBA) includes rating scales for both parents and youth. It makes use of empirically validated behavioural categories (1), clinical cut-off scores (2) and T-scores (3). It has several syndrome scales and broadband scales (e.g. internalizing problems, externalizing problems, total problems). Besides that, it also includes adaptive functioning and social competence. One problem with rating scales is that the reliability of the behavioural observation depends on the rater’s perception which is prone to bias. Agreement among informants may be higher than correlations of observations from informants in different settings.

Compared to children with internalizing problems, children with externalizing problems are referred more often (1), have lower intelligence (2), academic acceptance (3) and social acceptance (3). Internalizing and externalizing problems can co-occur. It may be best if the description of a child’s mental health status includes nosology (i.e. meeting the diagnostic criteria yes or no) and information regarding the dimensional status.

The developmental framework is better suited by a continuum of severity approach (e.g. dimensional classification) as the categorical approach does not take the developmental stage into account. The DSM does not always take changing symptom presentations with age into account while this is necessary when approaching psychopathology from a developmental point of view. However, the DSM-5 improves on this in several ways:

1. Developmental and lifespan considerations
   The DSM-5 includes lifespan orientation starting with early onset disorders to adolescence and adulthood, finishing with later life disorders.
2. Comorbidity and clustering of disorders along internalizing and externalizing dimensions
   The DSM-5 has more emphasis on dimensional aspects of diagnosis and contextual factors are taken into account more.
3. Supporting diagnosis using dimensional cross-cutting symptoms measures
   The DSM-5 recommends targeting general symptoms common to several psychological disorders. This supports collecting information beyond matching symptom presentation to a diagnostic category.
4. Reconceptualization of childhood disorders and unique diagnostic criteria for some disorders with onset in early childhood
   The DSM-5 changed the category of some disorders to make it more fitting with childhood disorders and included unique diagnostic criteria (e.g. PTSD criteria for 6 years or younger).
5. Risk and prognostic factors
   The DSM-5 includes a section on risk and prognostic factors. This provides unique diagnostic considerations resulting from influences of temperament, environment and genes.
6. Clinical case formulation
   The DSM-5 emphasizes that one must not simply match the diagnostic criteria for a disorder and that a clinical case formulation needs to be developed (i.e. looking at predisposing, precipitating and perpetuating factors).

To come to a diagnosis, the clinician must assess the child (1), obtain information regarding environmental influences (2) and weigh the role of developmental considerations (e.g. child’s age) (3).

A multimethod assessment model needs to be taken into account to assess the nature of the problem (1), developmental limitations (2) and the need to verify the impact of environmental influences (3). It is the goal of the clinician to integrate the information from different sources. The clinical interview is a goal-directed interaction between the clinician and the client or an informant of the client.

The mental status evaluation uses a series of questions as probes to determine a child’s general orientation (1), long-term memory (2), short-term memory (3), insight (4) and attention (5). This can be used to assess brain injury or thought disorders.