Diagnostic Dilemmas in Child and Adolescent Psychiatry by Perring Christian; Wells Lloyd;

Author:Perring, Christian; Wells, Lloyd;
Language: eng
Format: epub, pdf
Publisher: Oxford University Press
Published: 2014-03-14T16:00:00+00:00

Chapter 8

Psychiatric Nosology in Children and Adolescents: Past, Present, Future

Lloyd A. Wells

Introduction

Critiques of whichever nosological approach is applied to children and adolescents at virtually any time are usually abundant and ahistorical. There is always good reason for their abundance, and many of the critiques, though often dismissed derisively by advocates of the given nosology, tend to stand up well over time. The ahistorical nature of the critiques, however, is concerning, because they tend to be aimed at one specific diagnostic schema, when, in fact, they may have relevance to many. This is as true for the first classification efforts in child and adolescent psychiatry as it is for the DSM-5 (American Psychiatric Association 2013).

A system of nosology is an attempt to classify, and I suspect that a desire to classify is inherent to the human condition. Certainly, it is ubiquitous among the sciences, humanities, and helping professions. But if one is classifying rheumatic fever, one can include the pathogenic agent, the body’s known responses to the pathogenic agent, the symptoms of the disease as the patient experiences them, the signs of the disease as a third person can observe them—rash, fever, etc.—and the natural course of the disease with and without treatment. For such a disease, classification unfolds over time and is fluid; as more symptoms and signs emerge over time, there is growing confirmation of the diagnosis.

In psychiatry and child and adolescent psychiatry, the nosological system is often quite different from this. Nosology in medicine incorporates but is not limited to known etiology, while, in most cases, etiologies of psychiatric syndromes affecting children and adolescents are poorly known or unknown. While many very promising etiological hypotheses have been proffered for a myriad of child psychiatric syndromes, these are not yet anywhere close to the robustness of the Streptococcus bacillus in rheumatic fever and will not be in the near future.

As a result, the current accepted nomenclature in psychiatry and child and adolescent psychiatry consists of checklists of findings. In a manner somewhat reminiscent of the medieval schoolmen, a patient “has” a “disorder” (not a disease) if he or she has checks on a certain number of descriptors in one, two, or more checklists. This approach was developed over time by well-intentioned experts in very good faith, but the disorders are not scientifically derived but arrived at by consensus of experts, a process of field-testing, and, eventually, a vote in the American Psychiatric Association. The diagnoses are words—human creations, not necessarily biological phenomena—though there may sometimes be a heuristic association.

Strictly, then, one may assert at most that a constellation of feelings, thoughts, and behaviors meets criteria for the diagnosis of attention deficit hyperactivity disorder (ADHD), or autism, or bipolar disorder. But parents, relatives, and the children themselves, not understanding this difference in diagnostic methodology and being used to that used in the rest of medicine, conclude and state that after a diagnostic evaluation with a doctor, the child has ADHD, autism, or bipolar disorder. Sadly, some children reconstruct their identity on the basis of these diagnostic checklists.

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