The issue of classification is as old as psychiatry itself. As in other fields, knowledge of approach of the first psychiatrists has indeed started by a grouping and classification of individuals under their responsibility. Thereafter, it is often through new proposals nosographic different authors sought to translate their concepts of mental pathology.Meanwhile, in the late nineteenth century has expressed the desire to have a unified classification. It is this double movement as a result the complexity of the current situation. We will consider it, having in mind the specific problems of nosology in child psychiatry.
classification of speaking, involves an epistemological reflection on the status of signs (semiotics) and their groupings (syndrome, a disease) in the field of psychiatry. It should be remembered also that no classification and no semiotics same can not be free from theoretical and ideological preconceptions. Some authors adopt unreservedly, a medical model and defend a supposedly objective approach based on observation of behavior; those who, on the contrary, the clinic includes consideration of the unconscious and its effects, emphasize the subjective and intersubjective dimensions of any clinic.
At the same below this reflection, developed in other sections of this book, you have to stop for a moment on the preliminary issue of interest, but also the possible negative effects of psychiatric classification in children. The usefulness of nosographic approach is in fact doubted by many child psychiatrists even see it the risk that the award of a diagnosis helps determine pathological processes still unstructured. Potential disadvantages, or even the dangers of “labeling”, although actually exist. often cited in this regard, the studies on the effect “Pygmalion”, positive or negative bias judgment on the behavior or performance of a subject regardless of age, when the examiner has a prior information about him . This risk is increased by the clinical situation in child psychiatry: even if he has symptoms indicating an obvious pain, the child is rarely itself bearer of a complaint or a request. In fact, it is largely through discourse of the entourage that the practitioner will train clinical judgment and is still a family group that he is facing.Examples abound of situations in which the granting of a more or less sophisticated label behavior could prevent access to an understanding of its psychological meaning, by the entourage.
The criticism of classifications must be taken seriously and be reminded to warn against the possible misuse that may make.
However, one way or another classification appears unavoidable whenever one seeks to consolidate his clinical experience and theorize his own practice, and more, if one intends to communicate with other colleagues. In addition, child psychiatry, as much as the adult psychiatry, needs to develop its research and for this, clusters and specific case definitions are needed.
Classifications and their evolution:
There are several psychiatric classification systems that have, until recently, known parallel and independent developments. However, there a few years of mutual influence between the US and the classification of the World Health Organization (WHO), which tend to approach.
DSM-III AND IV
Until the third edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association was a simple glossary, few aired outside the United States. The DSM-III was breaking from previous classifications by introducing two fundamental changes:
– Firstly, each pathological entity described was defined by a set of criteria expressed in terms of behavior, with the intention to improve interrater reliability;
– Secondly, the terminology has been modified in several areas. The best-known change is the elimination of neurosis concepts, psychosis and reactive disorders that were, until then, the reference axes of psychopathology.
These terminological changes concerned the field of child psychiatry: new terms were introduced: ‘global development disorders “(pervasive developmental disorders, better translated later by PDD) appointing childhood psychoses specific; “Deficit attention disorder,” corresponding to the restlessness of French authors; “Separation anxiety”, hitherto psychopathological concept, taken as a syndrome.
After a successful edition (DSM III-R 1987) a deeper fourth amended edition was published in 1994.
Child psychopathology in the DSM-IV:
The DSM-III and IV devotes a chapter to the child “disorders usually diagnosed during childhood and adolescence”; it has ten sections. Relative to the DSM-III, there are many differences. The gender identity disorder contained in the chapters devoted to the child DSM-III are now grouped with all sexual disorders in adults. Most other changes are in the direction of a rapprochement with the WHO classification ICD-10. This is particularly the case for pervasive developmental disorders: This chapter contains a few details, and ICD-10 criteria are formulated very similarly.However, it still remains significant differences in the description of conduct disorder and attention deficit disorders.
Apart from these specific categories, the other chapters of the DSM apply regardless of age (an indication of changes in criteria based on age are given for certain syndromes, such as depression).
The DSM-III brought another innovation: a multiaxial system whose development continued in the following versions.
In DSM-IV five axes are listed as:
– Axis I:
· Clinical disorders;
· Other situations that may be subject to a clinical examination;
– Axis II:
· Personality disorders;
· Mental retardation;
– Axis III: General medical conditions;
– Axis IV: psychosocial and environmental problems;
– Axis V: Global Assessment of Functioning.
The emphasis is placed on the need to consider other aspects that categorical diagnosis to assess the situation of a patient. It is also important for the child, in which the characteristics of the family and social environment such as medical conditions are particularly important to consider. Other classifications have also followed this multiaxial approach.
The International Classification of Diseases of the WHO (ICD [in English: International Classification of Diseases] or DCI) is the successor of the former project “universal” classification.
Recall that ICD-9 (1975) introduced a few new entities for child psychiatry:
– Psychoses specific to childhood (including infantile autism);
– The specific emotional disorders of childhood;
– Unstable childhood.
Chapter 5 of the tenth version of the WHO classification (ICD-10), taking into account the classifications in different countries, has been visibly influenced by the terminology innovations and general design of the DSM-III. However, only the version for research includes criteria similar to those of the DSM. In the basic version for each item are given clinical descriptions together with guidelines for diagnosis.
Child psychopathology in ICD-10:
We must remember that the WHO psychiatric classification in fact corresponds to Chapter V “Mental and behavioral disorders” in general classification of all diseases and causes of death.
Chapter 5 of the ICD-10 only has two sections specifically dedicated to the child’s “psychological developmental disorders” and “emotional behavioral disorders and disorders with onset usually occurring in childhood” – mental retardation being treated in an autonomous chapter.
psychological developmental disorders include autism spectrum disorders. In this final chapter, ICD-10 has taken over the terminology and the overall design of DSM-III and DSM-III R. However, while DSM-III-R differed as Autistic Disorder and Pervasive Developmental Disorder not otherwise specified, ICD-10 introduced, next to the autistic disorder, several categories that were in any psychiatric classification far: hyperkinetic disorder with mental retardation and stereotyped movements, Rett syndrome and syndrome Asperger. These last two items were taken over by the DSM-IV.
The chapter “behavioral and emotional disorders with onset usually occurring in childhood” continues, with different combinations, many of the items of the DSM-III and DSM-III R. However, if we find the “hyperactive disorder attention deficit, “ICD-10 introduced a specific category for ‘hyperkinetic disorder associated with conduct disorder.”
The “conduct disorders” are subdivided in a different way from that adopted in the DSM-IV; Furthermore, ICD-10 introduced an additional group: “mixed disorders of conduct and emotions” in which are individualized, in particular, the “conduct disorder with depression”, a category that is not included in the DSM -IV.
It may be noted also that is found neither the “eating disorders” or the “sleep disorders” in the chapters on childhood (they are located in other chapters of the classification).
Finally, ICD-10 continues, unlike the DSM-IV, a chapter on the particular aspects of anxiety disorders in children under the term “emotional disorders with onset specific to childhood.”
Although it appears less explicit than for DSM-III and IV, ICD-10 may be a multi-axial use, to the extent that the collection systems used to associate several codes including if they are in different chapters. It is thus possible to use codes corresponding to somatic diseases and the “Z codes” of Chapter XXI: “Factors influencing health status and patterns of use of health services,” among which are cited situations psychosocial, important for child psychiatry.
FRENCH CLASSIFICATION OF MENTAL DISORDERS IN CHILD AND ADOLESCENT:
Only specific classification for children and adolescents, the Francophone Classification of Mental Disorders in Children and Adolescents (CFTMEA) – published in 1988 under the direction of R. Mises – is the shaping of a nosographic tradition that has developed during the development of child psychiatry in our country in the years 1960-1970, and it was already represented in the classification developed by the Centre Alfred Binet in Paris.
The list of proposed terms is accompanied by a glossary giving a brief description of each category and equivalencies with the terms of the ICD-10.
The CFTMEA, reference classification for the compilation of statistics of child and adolescent psychiatry sectors, subject to a broad consensus in our country, as shown by several surveys. She was admitted in conjunction with ICD-10, as a reference for recording the longitudinal diagnosis, through the application project PMSI in psychiatry.
The CFTMEA is also a multiaxale classification: next to the axis I which includes the clinical categories, it offers on the axis II coding somatic pathologies or family situations frequently associated with disorders seen in children.
The CFTMEA relies on a psychopathological reflection inspired by psychoanalysis. It favors the concept of psychopathological structure.
The first four chapters (psychoses, neurotic disorders, disorders of personality, reactive disorders) is the context of psychopathological organization in which the symptoms are. He asked the clinician to identify, to the extent possible, the disorders presented by the child in one of these categories are mutually exclusive of each other; it can thus be considered that this variation of normal.
The other categories are used to note the descriptive elements (functional disorders or symptoms) that can register in one of the structural organizations.
Axis 1 of the CFTMEA coming off a major revision; it aims to take better account of the baby’s condition and that of adolescents, along with a better compatibility with ICD-10.
This fourth revision called CFTMEAR 2000 introduces important innovations which focus exclusively on the axis I.
In Chapter 1, the style of early psychosis category now bears the joint statement pervasive developmental disorders;this highlights the similarity of the cases covering these two denominations; but without changing multifactor perspective offered, the etiological point of view, the French classification. Also included in the new version, Asperger’s syndrome and disintegrative disorder of childhood.
In the context of schizophrenia, important details concerning these disorders in adolescence. Finally, a detailed sub-category of mood disorders appears, to the extent that these temporarily obèrent the relationship to reality and associate, often in adolescence, psychotic manifestations.
Chapter 3 introduces a subcategory to behavioral dominant: it is for many cases where the organization boundary is expressed, especially among adolescents, for conduct disorder.
Chapter 4 is seen with a sub-category: post-traumatic stress disorder.
Chapter 7 addresses the orientations, increasingly widespread, which enhance the behavioral expressions. However, the French classification required to use this section in main category, in cases where the clinical study can rule out underlying pathology which controls the priority ranking in one of the first four categories of axis I: in this case, the behavioral expression appears in additional category.
Other innovations include the correspondence between the CFTMEA and ICD-10: they are now included in the glossary with each of the subcategories of the axis I. The different conceptions which specifiy ICD-10 and 2000 CFTMEA n ‘ not always permit strict equivalence, however significant progress has been made in the proposed matches.
Baby Axis I (complements Axis I generally):
A number of psychopathological situations involving very young children are already listed and therefore classifiable in the various chapters of the general classification, but recent developments in psychiatry baby necessitate the creation of a specific section for disorders of the very young children (0-3 years).
It is indeed to allow the clinician a clinically tracking easier and more congruent, given the evolution of knowledge in this field and to enable the classification of a certain number of situations that do not fit in within the general axis.
Psychiatry baby and early psychopathology are unique in that they impose center the semiotic look simultaneously on the baby itself, but also on the nature of the relationship between the baby and the adult who provides care and finally the reference adult (ie over the child’s relational environment).
While the baby clinic and the relationship require specific coding in axis I (axis I baby), the peculiarities of the environment can be coded using the axis II of the general classification to the extent that the concepts of traumatic stress, deficiency, abuse and parents in severe pain for example there are already considered.
Some situations may require double coding or more child (baby in axis I) and a quotation (in general I axis) corresponding to the problem of adults who provide adequate care ( “caregivers”).
Note that the concept of stress appear in both axis I baby (as a possible major etiological factor) and axis II (as associated factor).
Some chapters of baby psychopathology not yet the subject of an absolute consensus among clinicians and the proposals set out below are thus a starting material which needs to be progressively refined or reworked, depending advances that can not fail to take place in this area over the coming years.
Two notes about the axis I:
attachment disorders have not been identified as classificatory category.
It is known that despite the profound theoretical renewal has brought Bowlby’s theory, the different types of attachment patterns that have been described (secure attachment, insecure attachment, avoidant attachment, disorganized attachment) appear more like experimental categories as closely correlated categories with particular psychopathological profile.
That is still some children in secure attachment may well raise mental development disorders while some insecure or avoidant children in evaluation situation may well operate clinically satisfactory.
Only the disorganized type of scheme now seems to indicate a potential risk of clinical failure.
gender identity disorders have not either been retained, given the difficulty to identify the age of 3 years.
Despite the results set out by some studies, the majority of current clinical effect sets in doubt the very possibility of talking about gender identity disorders in pre-oedipal child.
At this time of life, alone would already spotted potential risk factors Description and predictive value are currently still highly questionable.
It is reported in the axis I of the general classification at the “gender identity disorder”, which precursors can optionally be included and listed before the age of 3 See Appendix.
Problems with current classifications:
INSTABILITY classification systems:
In 15 years, three versions of DSM and a version of the WHO classification have been published, with differences on the terminology as well as the extension of the categories (changes to the criteria). Thus in a study Volkmar et al DSM-III, DSM-III-R and ICD-10 were applied to the same group of patients with pervasive developmental disorders: DSM-III-R attributed the diagnosing autism in subjects 25% more than the other two classifications. We understand that such differences make it difficult to compare research done a few years away.
CONSIDERATION OF PARTIAL ASPECTS SPECIFIC PSYCHOPATHOLOGY CHILD:
DSM’s principled position as ICD-10, which recommend using, whenever possible, the same classes and the same criteria in children and adults, going against the current work to individualize the most specific aspects of child psychopathology. It leads to not consider the condition of the child only through the adult pathology and, in recent work, depression, obsessive disorders, anxiety disorders are discussed in children from adult criteria. This approach tends to focus on clinical events during childhood, announce a pathology in the long term, at the expense of other equally important aspects, which are linked to development
Among the specific areas of childhood, pathology infant is particularly poorly studied by all the current classifications.New classifications have been proposed for this age (see proposal on axis 1 baby).
The specifics of the pathology in adolescence were also insufficiently considered by the classifications available to date. The changes introduced in the revised version of the CFTMEA aim to correct this deficiency.
RECOGNITION OF DIAGNOSTICS:
As recalled Pull et al, construction of DSM-III and IV favored the establishment of criteria ensuring improved interrater reliability. But this does not resolve the question of the validity of the criteria or the categories defined by the classification. This is primarily based on the consensus of a number of experts. The competence of these specialists do not prevent the influence of ideological, cultural or professional practice rules that differ from one country to another: it probably has a different perception of psychotic or autistic disorder according we see patients occasionally as part of an evaluation review, which follows the psychotherapy or we see them daily as part of a day hospital. The actual validation categories is, as recalled Dugas and Zann, a complex process that involves both internal validation (consistency of symptoms – popular, especially with the help of statistical methods – Cluster analysis – which studying the correlation of symptoms on large groups) and external validation (epidemiological, longitudinal studies, genetic studies of familial clusters, biological studies etc). Research of this type are still rare.
PERSPECTIVE PARTICULAR GROUPS OR DIMENSIONAL:
Current classifications favor categorization syndromes, that is to say they consider the field of psychopathology formed as coherent entities, exclusive of each other, according to the medical model of disease entities (diseases). However, the dimensional point of view, another alternative of nosographic reflection is especially important to consider for the child. Most of the disorders described involve reference to development: either the symptom takes value only if reflect the normal development (eg phobic manifestations), or what is considered a symptom matches gap, with respect to a developmental standard. This is true in particular for disorders of the oral language development or written, or hyperkinetic disorder in which the various symptoms (inattention, hyperactivity, impulsivity) are to be evaluated, taking into account age. The use, as a diagnostic test, a statistical deviation from the average is just a convention transforming a dimensional parameter, so being in a continuum, creating a categorical criterion, more or less artificially, a discontinuity.
The dimensional axis of psychopathology also leads to evoke the concept of multi-dimensionality of certain conditions, including the concept of comorbidity – conceived as the juxtaposition of independent pathological phenomena – only a partial account. When experiencing a mental retardation coexists in two thirds of cases of infantile autism, should we not consider that we are dealing with a multifaceted pathology rather than just reporting the association of two syndromes (autism and mental retardation)?
Similarly, epidemiological studies show that in many cases, deficit disorder attention deficit hyperactivity is associated with other symptoms:
– Learning disorders (language delay, dysphasia) or written language, found in nearly 50% of cases;
– Behavioral disorders, including oppositional defiant disorder and conduct disorder. In the study by Biederman et al coexistence oppositional disorders reaches 65% of cases;
– Finally, in 25% to 30% of cases, it is reported the association of emotional disorders: anxiety disorders (generalized anxiety or phobia) or depressive disorders.
These data raise the question of the homogeneity of the hyperkinetic syndrome such as delineate the current classifications. In other words, is it justified to consider the hyperkinetic syndrome as a specific and coherent entity, which may be associated with other pathologies assumed to be independent, as suggested in the outcome statement of the DSM?
Is not it more relevant clinically to consider that besides the cases of hyperactivity “pure” relatively minority, there are other cases in which an unstable agitation comes integrate with a clinical picture behavioral disorders or anxiety disorders or depression?
HETEROGENEITY OF PSYCHIATRIC PATHOLOGY:
The DSM-IV as ICD-10 are so-called syndromic classifications, that is to say that arranging them under the same term “disorder” (disorder), they tend to put on the same plane of the nature of events very heterogeneous:
– Pathological organizations such as autism or schizophrenia;
– Deficiencies of scholastic skills in which it is difficult to separate from delayed development, pathologies, and socio-cultural or educational factors;
– Relational situations like sibling rivalry (item ICD-10);
– Improper conduct for which intervenes a multiplicity of relational and social factors.
These categories, all juxtaposed and critérisées in the same mode, are implicitly addressed by a medical model whose relevance is to discuss.
Note, however, interesting innovation of the DSM-IV, which offers additional codes, not critérisés for a number of “situations that may be subject to a clinical examination” (eg, sexual abuse the abuse, antisocial behavior, school problems, relationship problems, etc.).
The classifications are a framework upon which our abilities of perception and discrimination: the clinician – particularly if beginner – tends to retain the clinical reality that he may appoint and to overlook what he can not place under an existing label. In other words, nosography tends to create objects in the clinic.
The DSM-III and IV set out in the preamble warnings. It is stressed in particular that the appropriate use of that classification requires specialized clinical training. This warning seems more necessary than ever, especially in the field of child psychiatry including education, varies from one country to another – and even in our country from one faculty to another – is quite limited. insufficiently experienced professionals (general practitioners, pediatricians or other actors ‘primary’ health) may deliver diagnoses and treatments, from the mechanical application of the DSM or ICD criteria. We can also observe that ICD-10 as DSM since its third edition, is presented in a comprehensive manual probably promised to become major media teaching and clinical practice.
One can therefore conclude that the classifications are undoubtedly a useful tool, but perhaps not to put all hands and the abuse of which could be dangerous for your health!
Annex: Proposals for Axis I baby
Babies with autism or psychosis risk:
These babies whose early detection is essential for prevention activities to the extent that they are children whose development appears to have areas of vulnerability or fragility likely to commit to them in operation or organization autistic or psychotic.
Much research is currently underway to clarify or refine the boundaries of these groups of children whose future course can not be predicted or frozen in an ad that would crystallize that the mentioned risk.
A number of symptoms – including combinations can vary from one child to another – here must be worth a call.
Examples are cited:
– Avoidance or loss of sight. The look of the diversion pipes may have the same value by favoring the use of peripheral glance at the expense of the central sight (fear of being penetrated by the gaze of others);
– Maintaining beyond several weeks with an adhesive bidimensionality look no stable acquisition of a penetrating look into three-dimensionality;
– Early insomnia, sometimes massive time and calm (without appeal vis-à-vis the presence of adults);
– Severe primary anorexia;
– Clinical phenomena pseudosurdité. Monotonous cries, monotonous and without relational value or identifiable significant;
– The absence of introduction of stranger anxiety around the 8th month of life;
– Multiple phobias, variables, unusual and sometimes severe;
– Avoidance or withdrawal relational (excluding avoidance or withdrawals observed in cases of depression, fatigue or physical pain);
– The tone disorders (in hyper- or hypo) neuropediatric no recognized cause.
This is the grouping and spouse maintenance over time of a number of these symptoms that should alert the clinician.
“The baby’s depression may be linked to quantitative or qualitative deficiency relational situations” (M Ainsworth).
In case of qualitative relational deficiency, we include here situations of “empty behavior syndrome” and those of “white depression” described in L Kreisler depending on the time of onset and duration of the procedure prone position.
Symptoms to evoke depressive organization in the baby include:
– Psychic weakness: lack of vital energy that normally permeates the psychic functioning of the baby with lack of curiosity and openness towards the world of objects and to the own body (no introduction or gradual extinction of autoérotismes);
– Interactive withdrawal corresponding to a lack of commitment in the relational exchange;
– Psychomotor slowing with repetitive and partial movements, pausing before reaching their goal and with a predominant slow on the roots while the ends remain untied motor (unlike the slowdown asthenic);
– Psychosomatic disorders call or exhaustion: at the beginning of the depressive episode, there is a sense that the various functional disorders in children aim to revive the environment and to solicit his attention while at the after a certain period of evolution, recruited defenses are overwhelmed and functional disorders of the child then translate overflow and collapse of his psychosomatic balance;
– The lack of structuring of stranger anxiety.
Babies at risk of disharmonious evolution
At present, this is a waiting framework whose relevance is still questionable since it appears difficult to argue nosological affiliation between these clinical pictures and the group further limits pathologies.
These children are classified under “MultiSystem Developmental Disorders” (MSDD) in the classification “0 to 3”.
there is included children with severe disease, but not total, the ability to engage in emotional or social relationship, marked violations of the right to establish, maintain or develop certain forms of communication (body language, verbal and symbolic ), significant shortcomings in the treatment of various sensory information (auditory, visual-spatial, tactile, proprioceptive and vestibular example).
In the framework of Axis I (baby), here we take into consideration pretend stress states intervene as a major etiological factor and not only as an associated factor (then coded on Axis II).
Suspected before recollections more or less anxious, repetitive nightmares, distress behavior during a reminder of the trauma or unpredictable flashbacks, we consider as inclusion criteria decreased responsiveness or an obstacle to the rhythm development on at least the following criteria: enhancement of social withdrawal, affect field restriction, various temporary regressions, decrease or reduction of the usual fun activities.
Also considered as inclusion criteria, different symptoms of increased vigilance (night terrors, difficulty falling asleep, nighttime awakenings, disturbance in attention and concentration, hypervigilance and startle response) and the sudden or gradual onset of symptoms that did not exist before the traumatic event (aggression, fears, anxieties …).
Hypermaturity and pathological hyperprécocité:
These may involve all or some of the records cognitive, emotional or social development of the child. They can develop into sectors (surdons problems) or, conversely, overall. They may or may not be a response to parental psychopathology. In the first case, they have a conflicting value in the second case a developmental basis.
Various procurement delays (in the field of psychomotor development, language, cognitive …):
Refer to Class 6 Axis I General.
Psychosomatic disorders of the major functions (sleep, food):
Heading to consider when considered functional disorders do not fit into a depressive picture characterized.
One can not describe in absolute terms, a quality link would be “normal”. Only count the dynamic aspects in fact, open and creative parent-child relationship, including the mother-child relationship which is important as well to consider many possible variations of normal.
The pathology of the link refers to a double register, qualitative and quantitative.
The quantitative register link distortions implies the idea that a particular modality link becomes prevalent, repetitive and monotonous, permeating the adult-child relationship so that it freezes in so losing any degree of flexibility and freedom .
For examples, retiend for now the following topics:
– Variations of normal;
– Intrusive control;
– Adhesive relationship;
– Control disorders (hypersensitive, sub-reactive, impulsive, other);
– Chaotic relationship (disorganized, unclassifiable).