Is it hard being a Child psychiatrist?

Though child psychiatrists often enter the field to help young people and their families, it is difficult for some to maintain stable boundaries between personal and work lives . Regularly seeing children who have depression, anxiety or severe behavior disorders can wear on even the strongest professional's psyche.

What is the child and adolescent psychiatric assessment?

The Child and Adolescent Psychiatric Assessment (CAPA) is an interviewer-based structured psychiatric interview that collects data on the onset dates, duration, frequency, and intensity of symptoms of a wide range of psychiatric diagnoses (Table 1) according to DSM-IV, DSM-III-R, or ICD-10 criteria.

What are the mental health problems in childhood and adolescence?

The most common mental illnesses in adolescents are anxiety, mood, attention, and behavior disorders . Suicide is the second leading cause of death in young people aged 15–24 years.

Child and Adolescent Psychiatry - docshare.tips (2023)

Child and Adolescent Psychiatry

Child and Adolescent Psychiatry
Edited by

Michael Rutter
CBE, MD, FRCP, FRCPsych, FRS, FMedSci

Professor of Developmental Psychopathology Social, Genetic and Developmental Psychiatry Research Centre Institute of Psychiatry London

Eric Taylor
MA, MB, FRCP, FRCPsych, FMedSci

Professor of Child and Adolescent Psychiatry Department of Child and Adolescent Psychiatry Institute of Psychiatry London

FOURTH EDITION

Blackwell Science

© 1976, 1985, 1994, 2002 by Blackwell Science Ltd a Blackwell Publishing Company Blackwell Science, Inc., 350 Main Street, Malden, Massachusetts 02148-5018, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Science Asia Pty Ltd, 550 Swanston Street, Carlton South, Victoria 3053, Australia Blackwell Wissenschaft Verlag, Kurfürstendamm 57, 10707 Berlin, Germany The right of the Author to be identiﬁed as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published 1976 Second edition 1985 Reprinted as paperback 1987, 1990, 1991 Third edition 1994 Reprinted 1995 Reprinted as paperback 1995, 1998, 2000 Fourth edition 2002 Reprinted 2003 ISBN 0-632-05361-5 A catalogue record for this title is available from the British Library Library of Congress Cataloging-in-Publication Data Child and adolescent psychiatry / edited by Michael Rutter, Eric Taylor.—4th ed. p. ; cm. Includes bibliographical references and index. ISBN 0-632-05361-5 (printed case)— ISBN 0-86542-880-8 (pbk.) 1. Child psychiatry. 2. Adolescent psychiatry. I. Rutter, Michael, 1933– II. Taylor, Eric A. [DNLM: 1. Mental Disorders—Adolescence. 2. Mental Disorders—Child. 3. Adolescent Behavior. 4. Developmental Disabilities. WS 350 C53503 2002] RJ499 .C486 2002 618.92¢89—dc21 2001037921 Set in 9/12 Sabon by SNP Best-set Typesetter Ltd., Hong Kong Printed and bound in Great Britain at Bath Press, Bath For further information on Blackwell Science, visit our website: www.blackwell-science.com

Contents

Contributors, vii Preface to the Fourth Edition, xii Preface to the First Edition, xiv Part 1: Clinical Assessment Classiﬁcation: Conceptual Issues and Substantive Findings, 3 Eric Taylor & Michael Rutter Clinical Assessment and Diagnostic Formulation, 18 Michael Rutter & Eric Taylor Diagnostic Interviews with Parents and Children, 32 Adrian Angold Case Identiﬁcation in an Epidemiological Context, 52 Eric Fombonne Rating Scales, 70 Frank C. Verhulst & Jan Van der Ende Psychological Testing and Observation, 87 Joseph Sergeant & Eric Taylor Applied Scientiﬁc Thinking in Clinical Assessment, 103 Michael Rutter & William Yule Children’s Testimony, 117 Stephen J. Ceci, Livia Gilstrap & Stanka A. Fitneva Family Interviewing: Issues of Theory and Practice, 128 Ivan Eisler Physical Examination and Medical Investigations, 141 Anthony Bailey Clinical Neurophysiology, 161 Colin D. Binnie, Steward C. Boyd, Renzo Guerrini & Ronit Pressler

2 3 4 5 6 7 8 9 10 11

18 Bereavement, 299 Dora Black 19 Development and Psychopathology, 309 Michael Rutter 20 Child Abuse, 325 Robert E. Emery & Lisa Laumann-Billings 21 Child Sexual Abuse, 340 Danya Glaser 22 Residential and Foster Family Care, 359 Alan Rushton & Helen Minnis 23 Adoption, 373 Nancy J. Cohen 24 History of Child and Adolescent Psychiatry, 382 Michael Neve & Trevor Turner

Part 2: Inﬂuences on Psychopathology 12 Genetics of Normal and Abnormal Development, 185 Peter McGufﬁn & Michael Rutter 13 Molecular Genetic and Chromosomal Anomalies: Cognitive and Behavioural Consequences, 205 David H. Skuse & Jonna Kuntsi 14 Brain Disorders, 241 Robert Goodman 15 Chronic Adversities, 261 Ruth J. Friedman & P. Lindsay Chase-Lansdale 16 Culture, Ethnicity, Society and Psychopathology, 277 Michael Rutter & Anula Nikapota 17 The Role of Acute Life Stresses, 287 Seija Sandberg & Michael Rutter

Part 3: Clinical Syndromes 25 Syndromes of Hyperactivity and Attention Deﬁcit, 399 Russell Schachar & Rosemary Tannock 26 Conduct and Oppositional Disorders, 419 Felton Earls & Enrico Mezzacappa 27 Substance Use and Abuse: Epidemiology, Pharmacological Considerations, Identiﬁcation and Suggestions Towards Management, 437 Warren A. Weinberg, Caryn Harper & Roger A. Brumback 28 Substance Use and Abuse: Causal Pathways Considerations, 455 Michael Rutter 29 Affective Disorders, 463 Richard Harrington 30 Anxiety Disorders, 486 Rachel G. Klein & Daniel S. Pine 31 Adjustment Disorders, 510 Peter Hill 32 Post-Traumatic Stress Disorders, 520 William Yule 33 Suicide and Attempted Suicide, 529 David Shaffer & Jennifer Gutstein 34 Anorexia and Bulimia Nervosa, 555 Hans-Christoph Steinhausen 35 Obsessive-Compulsive Disorder, 571 Judith Rapoport & Susan Swedo 36 Tic Disorders, 593 James F. Leckman & Donald J. Cohen v

CONTENTS

37 Schizophrenia and Allied Disorders, 612 Chris Hollis 38 Autism Spectrum Disorders, 636 Cathy Lord & Anthony Bailey 39 Speech and Language Difﬁculties, 664 Dorothy Bishop 40 Reading and Other Learning Difﬁculties, 682 Margaret J. Snowling 41 Mental Retardation, 697 Fred Volkmar & Elisabeth Dykens 42 Personality and Illness, 711 Janette Moore & Anne Farmer 43 Disorders of Personality, 723 Jonathan Hill 44 Gender Identity Disorder, 737 Ken J. Zucker 45 Feeding and Sleep Disorders, 754 Alan Stein & Jacqueline Barnes 46 Attachment Disorders of Infancy and Childhood, 776 Thomas G. O’Connor 47 Wetting and Soiling in Childhood, 793 Graham Clayden, Eric Taylor, Peter Loader, Malgorzata Borzyskowski, Melinda Edwards 48 Psychiatric Aspects of Somatic Disease and Disorders, 810 David A. Mrazek 49 Psychiatric Aspects of HIV/AIDS in Childhood and Adolescence, 828 Jennifer Haven, Claude Ann Mellins & Joyce S. Hunter 50 Psychiatric Aspects of Speciﬁc Sensory Impairments, 842 Peter Hindley & Tiejo van Gent 51 Implications for the Infant of Maternal Puerperal Psychiatric Disorders, 858 Maureen Marks, Alison E. Hipwell & the late R. Channi Kumar Part 4: Approaches to Treatment 52 Prevention, 881 David Offord & Kathryn J. Bennett 53 Behavioural Therapies, 900 Martin Herbert 54 Cognitive-behavioural Approaches to the Treatment of Depression and Anxiety, 921 David A. Brent, Scott T. Gaynor & V. Robin Weersing

55 Problem-solving and Problem-solving Therapies, 938 Bruce E. Compas, Molly Benson, Margaret Boyer, Thomas V. Hicks & Brian Konik 56 Parent Training Programmes, 949 Stephen Scott 57 Family Therapy, 968 Brian W. Jacobs & Joanna Pearse 58 Individual and Group Therapy, 983 Brian W. Jacobs 59 Pharmacological and other Physical Treatments, 998 Isobel Heyman & Paramala Santosh 60 Treatment of Delinquents, 1019 Sue Bailey 61 Provision of Intensive Treatment: Inpatient Units, Day Units and Intensive Outreach, 1038 Jonathan Green 62 Paediatric Consultation, 1051 Paula Rauch & Michael Jellinek 63 Local Specialist Child and Adolescent Mental Health Services, 1067 Peter Hill 64 Practice in Non-medical Settings, 1077 A. Rory Nicol 65 Primary Health Care Psychiatry, 1090 M. Elena Garralda 66 Genetic Counselling, 1101 Emily Simonoff 67 Services for Children and Adolescents with Severe Learning Difﬁculties (Mental Retardation), 1114 Sarah H. Bernard 68 Special Educational Treatment, 1128 Patricia Howlin 69 Cultural and Ethnic lssues in Service Provision, 1148 Anula Nikapota 70 Child Protection, 1158 Kevin Browne 71 The Law Concerning Services for Children with Social and Psychological Problems, 1175 Michael Little Index, 1189

Contributors

Adrian Angold BSc, MB BS, MRCPsych
Associate Professor of Psychiatry and Behavioral Science, Center for Developmental Epidemiology, Box 3454, Duke University Medical Center, Durham, NC 27710, USA

Dora Black MB, BCh, FRCPsych, FRCPCH, DPM
Honorary Consultant Child and Adolescent Psychiatrist, Traumatic Stress Clinic, London WIT 4PL

Anthony Bailey BSc, MB BS, MRCPsych, DCH
MRC Clinical Scientist and Consultant Psychiatrist, Social, Genetic and Developmental Psychiatry (SGDP) Research Centre, Institute of Psychiatry, 5 Windsor Walk, London SE5 8BB

Malgorzata Borzyskowski FRCP, FRCPsych Consultant Neuro-Developmental Paediatrician, Guy’s and St. Thomas’ Trust, Newcomen Centre, Guy’s Hospital, London SE1 9RT Stewart G. Boyd MD Consultant Clinical Neurophysiologist, Department of Clinical Neurophysiology, The Hospital for Sick Children, Great Ormond Street, London WC1N 9NX Margaret Boyer BA
Doctoral Student in Clinical Psychology, Department of Psychology, University of Vermont, Burlington, VT 05405, USA

Sue Bailey MB, ChB, FRCPsych Consultant Adolescent Forensic Psychiatrist, Adolescent Forensic Service, Mental Health Services of Salford NHS Trust, Bury New Road, Prestwich, Manchester M25 3BL Jacqueline Barnes BSc, MSc, PhD
Senior Lecturer in Psychology, Leopold Muller Centre for Child and Family Mental Health, Paediatrics and Child Health, Royal Free & University College Medical School, University College London, Rowland Hill Street, London NW3 2PF

Kathryn J. Bennett PhD
Associate Professor, Department of Clinical Epidemiology and Biostatistics, Room 3V4D, Canadian Centre for Studies of Children at risk, McMaster University, 1200 Main St W, Hamilton, Ontario L8N 3Z5, Canada

David Brent MD, MS Hyg Academic Chief, Child and Adolescent Psychiatry and Professor of Psychiatry, Pediatrics and Epidemiology, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Suite 112, Pittsburgh, PA 15213, USA Kevin Browne PhD, CPsychol
Professor of Forensic & Family Psychology, University of Birmingham, Edgbaston, Birmingham B15 2TT and Advisor to the World Health Organisation Regional Ofﬁce for Europe, Copenhagen

Molly Benson BA
Doctoral Student in Clinical Psychology, Department of Psychology, University of Vermont, Burlington, VT 05405, USA

Sarah H. Bernard MD, MRCPsych, DRCOG
Consultant Psychiatrist, Learning Disabilities Team, Children’s & Adolescents Department, The Maudsley Hospital, Denmark Hill, London SE5 8AZ

R. Brumback MD
Professor and Chairman Department of Pathology, Creighton University School of Medicine, St Joseph Hospital, 601 N. 30th Street, Omaha, NE 68131, USA

Colin D. Binnie MD, MA, FRCP Professor of Clinical Neurophysiology, Department of Clinical Neurophysiology, Division of Neurosciences, Guy’s, King’s & St Thomas’ School of Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS Dorothy V.M. Bishop MA, DPhil Wellcome Principal Research Fellow, and Professor of Developmental Neuropsychology, Oxford Study of Children’s Communication Impairments, Department of Experimental Psychology, University of Oxford, South Parks Road, Oxford OX1 3UD

Stephen J. Ceci PhD The Helen L. Carr Professor of Developmental Psychology, Department of Human Development, Cornell University, Ithaca, NY 14853, USA P. Lindsay Chase-Lansdale PhD
Professor of Developmental Psychology, School of Education and Social Policy Faculty Fellow, Institute for Policy Research, Northwestern University, 2040 Sheridan Road, Evanston, IL 60208-4100, USA

vii

CONTRIBUTORS

Graham Clayden FRCP, FRCPCH
Reader and Consultant Paediatrician, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH

Ruth Friedman MA, PhD
Legislative Associate, Democratic Staff, House Committee on Education and the Workforce, US House of Representatives, 1107 Longworth House Ofﬁce Building, Washington, D.C. 20515, USA

Donald J. Cohen MD (deceased)
Director, Child Study Center, Yale University School of Medicine, 230 South Frontage Road, New Haven, CT 06520-7900, USA

M. Elena Garralda MD, MPhil, FRCPsych, FRCPCH
Professor of Child and Adolescent Psychiatry, Faculty of Medicine, Imperial College, St Mary’s Campus, Norfolk Place, London W2 1PG

Nancy J. Cohen PhD, CPsych
Director of Research, Hincks-Dellcrest Institute, 114 Maitland Street, Toronto, Ontario M4Y 1E1, Canada

Scott T. Gaynor PhD
Assistant Professor of Psychology, Western Michigan University, Department of Psychology, 1903 West Michigan Avenue, Kalamazoo, MI 49008-5439, USA

Bruce E. Compas PhD
Professor of Psychology, Medicine, and Pediatrics, Department of Psychology, University of Vermont, Burlington, VT 05405, USA

Elisabeth Dykens PhD Professor of Psychology, University of California Los Angeles, Neuropsychiatric Institute, 760 Westwood Plaza, Los Angeles, C A 90024, USA Felton Earls MD
Professor of Social Medicine, Project on Human Development in Chicago Neighborhoods, Harvard Medical School, 1430 Massachusetts Avenue, 4th ﬂoor, Cambridge, MA 02138, USA

Tiejo van Gent MD Head of the Department for the Deaf and Hard of Hearing, Academic Centre for Child and Adolescent Psychiatry (Curium), Oegstgeest, The Netherlands, and Associate Professor of Child and Adolescent Psychiatry, University of Leiden, The Netherlands Livia L. Gilstrap MA Advanced Doctoral Candidate, Department of Human Development, Cornell University, Ithaca, NY 14853, USA Danya Glaser MB, DCH, FRCPsych
Consultant Child and Adolescent Psychiatrist, Department of Psychological Medicine, Great Ormond Street Hospital for Children, London WC1N 3JH

Melinda Edwards BSc, DipClinPsych
Consultant Clinical Psychologist, Guy’s and St. Thomas’ Trust, Bloomﬁeld Centre, Guy’s Hospital, London SE1 9RT

Ivan Eisler MA, PhD, CPsychol
Senior Lecturer in Clinical Psychology and Course Chair MSc in Family Therapy, Psychotherapy Section, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

Robert Goodman PhD, FRCPsych, MRCP Professor of Brain and Behavioural Medicine, Department of Child and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF Jonathan Green MB BS, FRCPsych
Senior Lecturer and Honorary Consultant in Child and Adolescent Psychiatry, University of Manchester and Manchester Children’s University Hospitals, Academic Department of Child and Adolescent Psychiatry, Booth Hall Children’s Hospital, Blackley, Manchester M9 7AA

Robert E. Emery PhD
Professor, Director of Clinical Training, and Director of the Center for Children, Families and the Law, Department of Psychology, Gilmer Hall, Box 400400, University of Virginia, Charlottesville, VA 22904-4400, USA

Anne Farmer MD, FRCRsych
Professor of Psychiatric Nosology, Social, Genetic and Developmental Psychiatry (SGDP) Research Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

Renzo Guerrini MD Professor of Paediatric Neurology, Department of Neurology, The Hospital for Sick Children, Great Ormond Street, London WC1N 9NX Jennifer Gutstein BA
315 College Road, Bronx, NY 10471, USA (formerly Research Assistant, Columbia University, 1051 Riverside Drive, Unit 78, NY 10032, USA)

Stanka A. Fitneva MA Advanced Doctoral Candidate, Department of Human Development, Cornell University, Ithaca, NY 14853, USA Eric Fombonne MD
Professor of Child and Adolescent Psychiatry, McGill University, and Director of Child and Adolescent Psychiatry, Montreal Children’s Hospital, 4018 Ste-Catherine West, Montreal, Québec H3Z 1P2, Canada

Caryn Harper MS Faculty Associate, Department of Neurology, University of Texas Southwestern Medical Center at Dallas, Exchange Park, Suite 13350, 6303 Forest Park, Dallas, TX 75390-9119, USA

viii

CONTRIBUTORS

Richard Harrington MB, ChB, MD, FRCPsych Professor of Child and Adolescent Psychiatry, University of Manchester, Department of Child & Adolescent Psychiatry, Royal Manchester Children’s Hospital Pendlebury, Manchester M27 4HA Jennifer Havens MD
Assistant Professor of Clinical Psychiatry, Columbia University College of Physicians & Surgeons, Children’s Hospital of New York Presbyterian, Room 619 North, 3959 Broadway, New York, NY 10032, USA

Joyce S. Hunter DSW
Assistant Clinical Professor, Psychiatric Social Work, Department of Psychiatry, College of Physicians & Surgeons, and Assistant Professor of Public Health, Sociomedical Sciences, Columbia University, New York; Director, Community Liaison Program, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Unit 29, 1051 Riverside Drive, New York, NY 11104, USA

Brian W. Jacobs MA, MRCP, DCH, FRCPsych Consultant Child and Adolescent Psychiatrist, Children’s Department, The Maudsley Hospital, Denmark Hill, London SE5 8AZ Michael Jellinek MD
Professor of Psychiatry and of Pediatrics, Harvard Medical School, and Chief, Child Psychiatry Service, Massachusetts General Hospital, Bullﬁnch 351, Fruit St, Boston, MA 02114, USA

Martin Herbert PhD, FBPS
Emeritus Professor of Clinical and Community Psychology, Exeter University, School of Psychology, Exeter University, Exeter

Isobel Heyman MB BS, PhD, MRCPsych Consultant Child Psychiatrist, Department of Child and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF Thomas V. Hicks BA
Doctoral Student in Clinical Psychology, Department of Psychology, University of Vermont, Burlington, VT 05405, USA

Rachel Klein PhD
Professor of Psychiatry, New York University, Child Study Center, 550 First Avenue, New York, NY 10016, USA

Brian Konik BA
Doctoral Student in Clinical Psychology, Department of Psychology, University of Vermont, Burlington, VT 05405, USA

Jonathan Hill BA, MBBChir, MRCP, MRCPsych
Professor of Child and Developmental Psychiatry, University of Liverpool, University of Child Mental Health, Mulberry House, Royal Liverpool Children’s Hospital, Alder Hey, Eaton Road, Liverpool L12 2AP

R. Channi Kumar MD, PhD, FRCPsych (deceased)
Professor of Perinatal Psychiatry, Section of Perinatal Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

Peter Hill MA, MB, BChir, FRCP, FRCPsych, FRCPCH
Professor of Child and Adolescent Psychiatry, Department of Psychological Medicine, Great Ormond Street Hospital for Children, London WC1N 3JH

Jonna Kuntsi BSc, MSc, PhD, CPsychol Lecturer, Social, Genetic and Developmental Psychiatry (SGDP) Research Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF Lisa Laumann-Billings PhD Postdoctoral Fellow, Prevention Research Center for Family and Child Health, University of Colorado Health Sciences Center, 1825 Marion Street, Denver, Colorado 80218, USA James F. Leckman MD
Neison Harris Professor of Child Psychiatry, Pediatrics and Psychology, Room I-265 SHM, Child Study Center, Yale University School of Medicine, 230 South Frontage Road, New Haven, CT 06520-7900, USA

Peter Hindley BSc, MRCPsych, CACDP Stage III
Consultant and Senior Lecturer in Child and Adolescent Psychiatry, Department of Psychiatry, St Georges Hospital Medical School, Cranmer Terrace, London, SW17 0RE

Alison E. Hipwell BSc, MA, PhD, ClinPsyD
Assistant Professor, Pittsburgh Girls Study, Western Psychiatric Institute and Clinic, 4415 Fifth Avenue, Suite 134, Pittsburgh, PA 15213, USA

Michael Little BA, PhD
Researcher, Chapin Hall Center for Children at the University of Chicago and Researcher, Dartington Social Research Unit, Warren House, Dartington, Totnes TQ9 6EG

Chris Hollis MB BS, BSc, PhD, DCH, MRCPsych
Professor of Child & Adolescent Psychiatry, Developmental Psychiatry Section, Division of Psychiatry, South Block, E Floor, Queen’s Medical Centre, Nottingham NG7 2UH

Peter Loader MB BS, FRCPsych
Senior Lecturer in Child and Adolescent Psychiatry, Guy’s, Kings’ & St. Thomas’ School of Medicine, Honorary Consultant in Child and Adolescent Psychiatry, South London and Maudsley NHS Trust, Department of Child and Adolescent Mental Health, 35 Blackprince Road, London SE11 6JJ

Patricia Howlin BA, MSc PhD, FBPS
Professor of Clinical Psychology, St Georges Hospital Medical School, Psychology Department, Cranmer Terrace, London SW17 0RE

CONTRIBUTORS

Catherine Lord PhD Professor and Director of University of Michigan Autism & Communicative Disorders Center (UMACC), 1111 Catherine Street, Ann Arbor, MI 48109, USA Maureen Marks DPhil, CPsychol, AFBPS, MBPAS
Senior Lecturer, Sections of Perinatal Psychiatry and Psychotherapy, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

David Offord MDCM, FRCP(C)
Director, Canadian Centre for Studies of Children at Risk McMaster University, & Hamilton Health Sciences Corporation, 1200 Main St W, Hamilton, Ontario L8N 3Z5, Canada

Joanna Pearse RMN, CQSW, DipFT
Family and Systemic Psychotherapist, The Maudsley Hospital, South London and Maudsley NHS Trust, Denmark Hill, London SE5 8AZ

Peter McGufﬁn MB, PhD, FRCP, FRCPsych, FMedSci
Professor of Psychiatric Genetics and Director, Social, Genetic and Developmental Psychiatry (SGDP) Research Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

Daniel S. Pine MD
Chief, Section on Development and Affective Neuroscience, Mood and Anxiety Disorders Program, National Institute of Mental Health, 9000 Rockville Pike, Building 1, Room B3-10, Bethesda, Maryland 20892, USA

Claude Ann Mellins PhD Assistant Professor of Clinical Psychology, Department of Psychiatry, Columbia University, and Research Scientist, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, PO Box 15, 1051 Riverside Drive, New York, NY 10032, USA Enrico Mezzacappa MD Assistant Professor of Child Psychiatry, Department of Psychiatry, The Children’s Hospital, Boston, MA, USA Helen Minnis MD, PhD
Specialist Registrar and Research Fellow, Department of Child and Adolescent Psychiatry, Caledonia House, Yorkhill NHS Trust, Glasgow G3 8SJ

Ronit Pressler MD
Chadburn Lecturer in Clinical Neurophysiology, Department of Clinical Neurophysiology, Division of Neurosciences, Guy’s, King’s & St Thomas’ School of Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS

Judith L. Rapoport MD
Chief, Child Psychiatry Branch, Bldg 10 National Institute of Mental Health, 10 Center Drive, MSC 1600, Bethesda, MD 29892, USA

Paula K. Rauch MD
Director, Child Psychiatry Consultation Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA

Janette Moore MSc, MRCPsych Social, Genetic and Developmental Psychiatry (SGDP) Research Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF David A. Mrazek MD, FRCPsych
Chair of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA

Alan Rushton BA, CQSW, PhD
Senior Lecturer in Social Work, Section of Social Work and Social Care, Health Services Research Department, The David Goldberg Centre, Institute of Psychiatry, De Crespigny Park, London SE5 8AF

Michael Rutter CBE, MD, FRCP, FRCPsych, FRS, FMedSci
Professor of Developmental Psychopathology, Social, Genetic and Developmental Psychiatry (SGDP) Research Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

Michael Neve MA, PhD Senior Lecturer in the History of Medicine, Wellcome Trust Centre for the History of Medicine, University College London, Euston House, 24 Eversholt Street, London NW1 1AD A. Rory Nicol MPhil, FRCP, FRCPsych, FRCPCH
Visiting Professor, WHO Collaborating Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London, SE5 8AF

Seija Sandberg MD Consultant and Senior Lecturer, Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, Wolfson Building, 48 Riding House Street, London W1N 8AA Paramala Santosh MD, MRCPsych Lecturer, Department of Child and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF Russell Schachar MD, FRCP(C)
Professor, Department of Child Psychiatry, The Hospital for Sick Children, University of Toronto, Toronto, M5G 1X8, Canada

Anula Nikapota FRCPsych Honorary Senior Lecturer, Institute of Psychiatry, London, and Consultant in Child and Adolescent Psychiatry, Lambeth Child and Adolescent Community Mental Health Service, South London and Maudsley NHS Trust, 19 Brixton Water Lane, London SW2 1NN Thomas G. O’Connor PhD Senior Lecturer, Department of Child and Adolescent Psychiatry and Social, Genetic and Developmental Psychiatry (SGDP) Research Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF
x

Stephen Scott BSc, FRCP, MRCPsych Senior Lecturer and Consultant in Child and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

CONTRIBUTORS

Joseph Sergeant PhD Professor of Clinical Neuropsychology, Department of Clinical Psychology, Faculty of Psychology, University of Amsterdam, Roetersstraat 15, 1018 WB Amsterdam, The Netherlands David Shaffer MB BS, FRCP, FRCPsych Irving Philips Professor of Child Psychiatry, Columbia University, College of Physicians & Surgeons, New York State Psychiatric Institute, Division of Child Psychiatry, 722 West 168th Street, New York, NY 10032, USA Emily Simonoff MD, MRCPsych Professor of Child and Adolescent Psychiatry, Department of Child and Adolescent Psychiatry, Guy’s, Kings’ & St Thomas’ Medical Schools, The Munro Centre, Kings College London, 66 Snowsﬁelds, London SE1 3SS David H. Skuse MD, FRCP, FRCPsych, FRCPCH Professor of Behavioural Sciences, Behavioural Sciences Unit, Institute of Child Health, 30 Guilford Street, London WC1N 1EH Margaret J. Snowling PhD, DipClinPsych, FBPsS
Professor of Psychology, Department of Psychology, University of York, Heslington, York YO10 5DD

Trevor Turner MD FRCPsych
Honorary Senior Lecturer at St Bartholomew’s and The Royal London School of Medicine and Dentistry, Honorary Senior Research Fellow at the Wellcome Trust Centre for the History of Medicine at UCL, Department of Psychological Medicine, William Harvey House, St Bartholomew’s Hospital, London EC1A 7BE

Jan Van der Ende MS Research Psychologist, Erasmus Medical Center/Sophia Children’s Hospital, Rotterdam, The Netherlands Frank C. Verhulst MD, PhD Professor and Director of Child and Adolescent Psychiatry, Erasmus Medical Center/Sophia Children’s Hospital, Rotterdam, The Netherlands Fred Volkmar MD Professor of Child Psychiatry, Pediatrics and Psychology, Yale University School of Medicine, New Haven, CT 06520, USA V. Robin Weersing PhD Postdoctoral Fellow, Child Psychiatry, Western Psychiatric Institute Clinic, 3811 O’Hara Street, Suite 112, Pittsburgh, PA 15213, USA Warren A. Weinberg MD
Professor of Neurology and Pediatrics, Director of Pediatric Behavior Neurology Program, Division of Pediatric Neurology, Department of Neurology, University of Texas Southwestern Medical Center at Dallas, 6303 Forest Park, Suite 13.350, Dallas, TX 75235-9119, USA

Alan Stein MB BChir, FRCPsych
Professor of Child and Adolescent Psychiatry, Section of Child and Adolescent Psychiatry, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX

Hans-Christoph Steinhausen MD, Dipl Psych, PhD
Professor and Head of Department of Child and Adolescent Psychiatry, University of Zurich, Neumuensterallee 9, Postfach CH-8032 Zurich, Switzerland

Susan E. Swedo MD Chief, Pediatrics and Developmental Neuropsychiatry Branch, MSC 12 Building 10, National Institute of Mental Health, 10 Center Drive, Bethesda, MD 20892, USA Rosemary Tannock PhD
Senior Scientist, Brain and Behavior Research Program, The Hospital for Sick Children and Associate Professor of Psychiatry, University of Toronto, Toronto, M5G 1X8, Canada

William Yule MA, DipPsychol, PhD, FBPsS, C. Psychol
Professor of Applied Child Psychology, Department of Psychology, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

Eric Taylor MA, MB, FRCP, FRCPsych, FMedsci
Professor of Child and Adolescent Psychiatry, Department of Child and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

Kenneth J. Zucker PhD, CPsych
Psychologist-in-Chief, Centre for Addiction and Mental Health, and Head, Child and Adolescent Gender Identity Clinic, Child Psychiatry Program–Clarke Division, 250 College St, Toronto, Ontario M5T 1R8, Canada

Preface to the Fourth Edition

The rate of change in child and adolescent mental health has accelerated in the years between the third and fourth editions of this book. Nearly every chapter has had to be completely rewritten and reconceptualized to take account of substantial research and clinical advances; the preparation of this volume has correspondingly been an exciting and encouraging (albeit challenging) task. In this preface, we pick our some of the main factors that are driving this development. This edition differs from its predecessors in seven main respects. First, it reﬂects real gains in empirical knowledge and conceptual understanding. These are evident in all chapters throughout the book. Second, there is an extended range of chapters on measurement issues, a ﬁeld in which considerable progress has been made. Third, we have sought to balance ‘academic’ advances with an equally detailed attention to clinical skills and clinical application. That is evident through the book but is also indexed by new chapters on diagnostic formulations and on the applied science aspects of clinical assessment. Fourth, we have endeavoured to introduce a greater developmental orientation; again, this is reﬂected both in many individual chapters and in a new chapter on this consideration. Fifth, we have sought to pay greater attention to sociocultural and ethnic issues and have added two chapters dealing speciﬁcally with these features. Sixth, there is greater attention to genetic ﬁndings and their implications, with a detailed discussion of misunderstandings about supposed genetic determinism and the possible misuse of genetics, as well as the huge clinical potential that is likely to follow genetic advances. Finally, the trend for an increasing international, and interdisciplinary, authorship that has applied over the ﬁrst three editions has been further extended. This reﬂects not only the wide distribution of centres of excellence in the ﬁeld of mental health but also the increasing cooperation and collaboration among such centres. The gains in knowledge over the last few years have been driven both by the accumulation of scientiﬁc research and by changes in the wider society. One research development with high impact has been the advance of the methodology of assessment. Reliable instruments for data capture, and agreed criteria for disorders, have made knowledge more public. This in turn is driving both an increase in replicable ﬁndings about disorders and an increase in the practical application of quantitative measures to clinical assessment. Many clinics, for example, now apply schemes of assessment that were originally worked out for research purposes. Advances in basic scientiﬁc knowledge have also provided some inﬂuential changes in the ﬁeld. The pervasiveness and imxii

pact of genetic contributions to disorder have been increasingly recognized: twin and adoptive studies have clariﬁed both the genetic and the environmental inﬂuences on the common problems of mental health, and an increasing range of uncommon single-gene inﬂuences have been identiﬁed. The mapping of the human genome and the use of molecular chemistry to clarify the modes of expression of genetic variations have added an immediate relevance to genetic investigations and it seems certain that these will continue. Of course, the application of this knowledge to the clinic is for the most part conﬁned to the advice and explanations that clinicians provide. Indeed, it is necessary to caution against a narrowly deterministic notion of how genes inﬂuence psychopathology. Even for the simplest genetic inﬂuences, their expression is strongly inﬂuenced by the actions of other genes and by interactions with the environment. The relationships between genotype and phenotype will need a great deal more understanding, and for the multifactorial disorders with which psychiatry usually deals their complexity may bafﬂe our understanding for some time to come. The rapid development of neuroimaging techniques is also full of promise for the future, and the chapter on physical investigations has correspondingly been expanded substantially. The availability of techniques (such as magnetic resonance) that do not depend upon ionizing radiation has allowed their application to young people, and the psychiatry of childhood has therefore started to be changed by the understanding of the brain that has informed adult psychiatry for decades. For this, as for genetic advances, the major immediate impact has been intangible: it has created a climate of opinion in which the disorders of mental health are seen in the context of neurobiology. The use of psychotropic drugs for young people has increased considerably in most countries over the last ten years. This increase is not primarily because new and more satisfactory drugs have been introduced but, rather, it has arisen as a result of an increased professional readiness to prescribe, and this in turn may follow as much from beliefs about causality as from improved knowledge of indications. Indeed, there may be a risk of a professional and practical division between a biologically oriented psychiatry and a group of disciplines focusing on psychosocial inﬂuences. Any such split would weaken understanding and practice. The authors in this volume come from a wide range of professional disciplines, but all have been at pains to bring together different perspectives and indicate how different approaches can ﬁt together. Developmental psychopathology, still a young science, is making it possible for clinicians to make more informed judgements

PREFACE TO THE FOURTH EDITION

about the future course of disorder and the inﬂuences upon it that need to be assessed. The impact of deprivation and adversity is better understood, and advice to social work agencies and law courts has changed accordingly. The psychological understanding of what is altered in the neurodevelopmental disorders has pressed on, and has been one of the agents of change in the ascertainment and treatment of pervasive developmental disorders. The increased recognition of depressive disorders in young people owes a good deal to the clariﬁcation of their longitudinal course. The developmental issues involved in psychopathology have received increased attention in this edition, both in disorderoriented chapters and in a new chapter bringing them together. The increase in randomized controlled clinical trials is making the foundations of treatment ever more explicit. For the most part, it is still the case that evidence for any one disorder comes from a number of small trials with varying methodology. Indeed, the differences are so substantial that it has not yet been possible to base all treatment recommendations on systematic and quantitative meta-analytic reviews. Rather, authors have made critical narrative reviews about the evidence base and their recommendations are based on clinical expertise as well as the published literature. Nevertheless, it is plain from the chapters on treatments and services that evaluative research is increasingly the basis of guidelines. Many of the factors driving change have been social and economic rather than scientiﬁc. Health care purchasers have become more organized, better informed, and increasingly concerned to contain the costs of health care. The results, whether in managed care or publicly funded services, includes pressure on providers to follow agreed guidelines and even detailed protocols in management regimes. This can have advantages: treatment recommendations should of course be explicit and challengeable, and there are too many areas noted in this volume where common clinical practices still fall well short of good practice guidelines. But there are dangers if protocols are applied mechanically and without sufﬁcient consideration of individual variability. It remains the case that treatment should be focused on the individual, not the disorder. Our authors have correspondingly emphasized the principles underlying assessment and treatment rather than a set of rules, and they have borne in mind the great variety of ways in which health care is organized. Furthermore, protocols that are not based on sound evidence are very likely to be counterproductive, and the chapters of this book have striven to indicate the extent to which recommendations are based on public and reliable evidence and therefore the conﬁdence that can be placed in them. The information revolution has combined with other forms of social change to make a different relationship between the consumers and the providers of health care. In principle, there is everything to welcome in the increasingly active and well-informed participation of families in treatment decisions. But the heterogeneity and volume of health information available, for instance on television and the Internet, brings its own problems. Myths spread as quickly as truths. Our authors have often found it hard to recommend sources of health information for the pub-

lic that are clear, accessible and authoritative. The problem of improving the quality as well as the quantity of public information about mental health remains unsolved. The need for authoritative and integrative texts for professionals remains strong. The changing face of child and adolescent psychiatry is reﬂected in changes of authors for a good number of the chapters, and we should like to take this opportunity of expressing our deep gratitude, not only to the contributors to this edition but to those who created the previous three editions. Most especially, we are personally as well as editorially indebted to Lionel Hersov for his wise and supportive editorship over the whole of the earlier history of this work and for his contribution to its success.

Acknowledgements
We are most appreciative of the authors’ expertise and effort, and of their constructive responsiveness in dealing with the many editorial suggestions on possible new material that needed adding, topics that required strengthening, extended international coverage that was desirable, clariﬁcations that would help readability and integrations across chapters. We note with great sadness the premature deaths of Channi Kumar and Donald Cohen during the course of producing the book. Both were at a peak in their careers. The world is much indebted to Channi Kumar for his pioneering work in developing and championing the ﬁeld of perinatal psychiatry, and to Donald Cohen for his bridging of psychoanalysis and biological research, as well as for his international leadership in child and adolescent psychiatry as a whole. The production of the book has been very much a team effort, and we have been fortunate in having such a good team to work with. Special thanks are due to Rachel Mawhood who exercised overall administrative responsibility for the complex enterprise of checking chapters prior to submission to the publishers, and to Gill Rangel who had the comparable responsibility for the task of checking and collating proofs (as well as much detailed work on individual chapters prior to submission). Both stages needed to run smoothly to a tight timetable and it was crucial to keep an eagle eye for inconsistencies or inaccuracies. We are also most grateful to Alice Emmott for her efﬁciency in translating the manuscripts into the printed page. Authors will be well aware of the care with which these multiple tasks were undertaken. Thanks also go to Angela Cottingham for her professionalism in preparing the index. Expert referees who commented on individual chapters were very helpful, but must remain anonymous. The editorial team also owes much to Jenny Wickham who had the main responsibility for dealing with several individual chapters but who also played a full role as a member of a cohesive, effective administrative team. We would also like to express particular thanks to David Shaffer for most helpful guidance and suggestions on authors during the planning stage of the book. Michael Rutter Eric Taylor xiii

Preface to the First Edition

These are exciting times for anyone working in the ﬁeld of child psychiatry. A wider understanding of child development now throws a clearer light on deviations from the normal pattern; knowledge of the nature and causes of psychiatric disorders in childhood is steadily increasing; new and effective methods of treatment are evolving; and clinical and education services for children with mental disorders are growing in scope and sophistication. The ﬁrst academic departments of child psychiatry in the United Kingdom are now established to meet the needs for teaching and research and to add to the existing body of knowledge. A serious concern to raise training standards in the specialty has led to recommendations on the range of content of training and a national exercise to visit and appraise all training schemes is under way. For these reasons the time seemed ripe for a new and different textbook of child psychiatry. Our aim has been to provide an accurate and comprehensive account of the current state of knowledge through the integration of research approaches and ﬁndings with the understanding that comes from clinical experience and practice. Each chapter scrutinizes existing information and emphasizes areas of growth and fresh ideas on a particular topic in a rigorous and critical fashion, but also in practical vein to help clinicians meet the needs of individual children and their families. In planning the book we had to decide how to choose authors of individual chapters. Obviously we wanted colleagues who had made important contributions in their ﬁelds of interest and who could write with authority and knowledge. We were fortunate in our choice and we are deeply indebted to all of them. We also decided that it would be appropriate to invite contributions from those who had worked at The Bethlem Royal and The Maudsley Hospital or its closely associated postgraduate medical school, The Institute of Psychiatry. Over the years ‘The Maudsley’ has played a major role in training psychiatrists from all parts of the world and members of its staff have been among the leaders in both research and clinical practice. The fact that we have all worked at the same institution has produced some similarities: a ﬁrm acceptance of the value of interdisciplinary collaboration; an intense interest in new ideas and creative thinking; a commitment to the integration of academic and clinical approaches; a concern for empirical ﬁndings; and a belief in the beneﬁts that follow from open discussion between people who hold differing views. As all of us work with children we have a common concern with developmental theories and with the process of development. However, as will also be xiv

apparent, we do not share any single theoretical viewpoint. A variety of theoretical approaches are represented in the chapters which also reﬂect a differing emphasis on biological, sociocultural, behavioural and psychodynamic aetiologies and formulations. It is also ﬁtting that this book should be based on The Joint Hospital as it has player such an important part in the development of child psychiatry. Children with psychiatric disorders were ﬁrst seen at The Bethlehem Royal Hospital as long ago as 1800 and Henry Maudsley was unusual among the psychiatrists of his day in appreciating the importance of psychiatric disorders arising in childhood. In his Physiology and Pathology of Mind, published in 1867, he included a 34-page chapter on ‘Insanity of early life’. The Maudsley Hospital ﬁrst opened its doors just over half a century ago, children have always been included among its patients and the Children’s Department became ﬁrmly established during those early years. Since then, and especially with the ﬁrst British academic appointment in child psychiatry at the Institute of Psychiatry in the 1950s, it has trained many child psychiatrists who now practise in all parts of the globe. The book is organized into ﬁve sections. The ﬁrst eight chapters review different inﬂuences on psychological development in childhood and are followed by three that discuss the foremost developmental theories. A third section describes some of the crucial issues in clinical assessment and the fourth deals systematically with the various clinical syndromes and their treatment. The ﬁnal section comprises six chapters that bring together knowledge on some of the main therapeutic approaches. We have sought to include most of the topics and issues that are central to modern child psychiatry, but there has been no attempt to cover all known syndromes and symptoms. Instead, the focus has been on concepts and methods with special emphasis on those areas where development of new ideas or knowledge has been greatest. We hope that the book’s contents will be of interest and use to all those professionally concerned with the care, study and treatment of children with psychiatric disorders. We will be satisﬁed if, in the words of Sir Aubrey Lewis, it also helps the psychiatrist in training to acquire ‘reasoning and understanding’ and ﬁts him ‘to combine the scientiﬁc and humane temper in his studies as the psychiatrist needs to’. M. Rutter L. Hersov

PART ONE

Clinical Assessment

Classiﬁcation: Conceptual Issues and Substantive Findings
Eric Taylor and Michael Rutter

Uses and abuses of classiﬁcation
A classiﬁcation is more like a language than a collection of objects. It supports communication and provides an aid to thinking about complex problems. The virtues of a good scientiﬁc classiﬁcation are clarity, comprehensiveness, acceptability to users and ﬁdelity to nature; a scheme should change as understanding alters. Each class in the scheme is a concept, not a thing. Its value is in relating individual cases to others, and a scientiﬁcally powerful class will do so in ways that are important to the user and include a good deal of meaning. When a case is assigned to a powerful class, many predictions follow. Students of mental health face a remarkably broad collection of phenomena, the sort of classiﬁcation they need will vary for different purposes, and therefore any one scheme is bound to be a compromise. Early attempts at classifying children’s disorders were strongly based on psychoanalytic theory (Freud 1965; Group for the Advancement of Psychiatry 1966). However, this was theory without strong empirical foundations and it soon became evident that different practitioners used the concepts in rather different ways. The reliability among raters was found to be very low for diagnoses based on theoretical concepts (Rutter et al. 1969); by contrast, reasonable agreement could be reached on the description of what mental problems were actually being presented. The overriding need for clarity in communication therefore gave rise to a change of approach. Modern schemes, which can be taken to date from DSM-III (American Psychiatric Association 1980) and ICD-9 (World Health Organization 1977, 1978) are founded mostly, though not exclusively, on descriptions of patterns of symptomatology. However, they are not intended to end there. The classic instance of psychiatric classiﬁcation is Kraepelin’s distinction between schizophrenia and manic-depressive psychosis; it was justiﬁed by the prediction from symptom pattern to developmental course. The justiﬁcation of child psychiatric classes is their ability to predict signiﬁcant aspects of course, causes and response to intervention (Rutter 1965, 1978). As understanding develops, these aspects are likely to play a stronger part in the deﬁnition of concepts of disorder.

groups of children that are reasonably homogeneous with respect to what is being investigated. The replicability of their group deﬁnitions will affect the use that others can make of their results. They are also likely to be interested in the testable predictions that derive from a classiﬁcation. In mature sciences, a classiﬁcation can itself be a scientiﬁc tool, as in cladistics where the relations of bodily structure among animals are a means for studying evolutionary descent. This is occasionally the case in psychopathology, when similarities between obsessions and stereotypies led to trials of a treatment for one condition in the other, or similarities between the symptoms of mania and attention deﬁcit hyperactivity disorder (ADHD) led to cross-disorder neurochemical studies. For all these purposes, precision and replicability are the key requirements. Often it will not matter very much if many cases are left unclassiﬁed, so long as those that are classiﬁed are done so accurately but researchers also want their conclusions to guide practice, and therefore they wish to choose classes that practitioners will recognize and use.

Clinical purposes
Practitioners need to know how to apply research ﬁndings to an individual case, so a widely accepted classiﬁcation scheme is indispensable. For them, a scheme leaving many cases unclassiﬁed has serious drawbacks because it cuts the bridge between their practice and the research that should inform it. Indeed, if research deﬁnitions have drifted too far from clinical ones, it may be quite misleading to generalize lessons from strictly deﬁned research groups to broader and vaguer clinical ones. They have other needs for classiﬁcation: for example, in communication between clinicians, statistical record-keeping and audit, for which homogeneity of groups in severity and responsiveness to intervention may be more important than homogeneity with respect to cause. In communication with users and carers, they may use an implicit system of classiﬁcation that is based upon lay as well as scientiﬁc concepts; as when the idea of a minimal brain dysfunction, although discredited scientiﬁcally, supposedly is still found useful in explanation.

Abuses Research purposes
Researchers into the psychopathology of young people need good diagnostic schemes for several purposes. They often need Classiﬁcations, like other useful tools, can be abused. Critics have attacked the abuses of psychiatric categorization from various points of view. The critiques are important to heed because they carry lessons for practice. They caution, for example, 3

CHAPTER 1

that it is possible to reify a diagnosis and exaggerate the power of the concept. Psychiatric categories may come to be regarded by long familiarity as things rather than as concepts. This would occur if, for example, a teacher protests that an inattentive and impulsive child does not ‘really’ have ADHD because the cause lies in the social situation; or if children with a disproportionate difﬁculty in learning to read were to be denied speciﬁc educational help on the grounds that they did not ‘really’ have a speciﬁc learning disability because there was no evidence of neurological abnormality. It needs to be kept in mind that psychiatric diagnoses are usually descriptive, not explanatory. ‘ADHD’ is a description of the behaviour of a child who is inattentive and impulsive, not a disease that explains why the child behaves in that way. A diagnostic label may also be misleading by lumping unlike things together. For example, it has been noted several times that tricyclic antidepressants are very frequently prescribed for children with major depressive disorders in spite of the evidence base that indicates that they are usually ineffective in depressed children. The practice seems to be maintained by the use of the diagnostic concept derived from adult psychopathology without sufﬁcient recognition of a crucial age difference with respect to tricyclic medications. Another adverse effect of diagnosis is the obscuring of assumptions that are involved. Sonuga-Barke (1998) has reemphasized the psychopathologist’s fallacy — that because a child has been brought as a patient there must be something wrong with him or her. Impulsiveness, for example, is not necessarily an organismic dysfunction; it may, under some conditions of reward, represent an adaptive adjustment to the environment. Therefore one needs to keep in mind the full range of problems that present; for example, to classify social stressors as well as behavioural patterns. Similarly, a diagnosis may hide heterogeneity. Children with a disorder are not all the same. To take just one example of this truism, the intelligence of children with Down syndrome (which is not usually inherited) still shows strong genetic inﬂuences, because the differences of intelligence within children who have Down syndrome are marked and are partly determined by the same factors that determine intelligence in the general population. The corresponding caution is that disorders are the subject of classiﬁcation, not people. Descriptors, such as ‘the autistic’ or ‘the brain damaged’, seem to imply that all affected people are similar and that the disorder represents all that is important about the individual. This serves to reinforce false overgeneralization and stereotyping; phrases such as ‘people with autism’ are to be preferred. Other problems in developing classiﬁcations, such as cultural dependence, will be considered throughout this chapter. The recognition of abuses is not a reason to abandon classiﬁcation. It would be impossible to do so if we are to maintain the possibility of learning and teaching about disorder. However, it does underline the need to appreciate the strengths and the weaknesses of particular classiﬁcatory schemes. This chapter describes scientiﬁc issues in identifying and arranging the taxons (which 4

are the units of a scheme of classiﬁcation and may be categories or dimensions), and in assigning individual cases to the taxons, and some practical issues in the application of their results.

Types of classiﬁcation
Categories and dimensions
The choice of a categorical or a dimensional system of ordering has generated much debate (Sonuga-Barke 1998). A thoroughgoing categorical arrangement is often described, although only by its detractors, as a medical model. This is a highly misleading view of medicine, which incorporates dimensional as well as categorical approaches. One example would be that of blood pressure, which is a dimension distributed continuously in the population; elevated blood pressure (hypertension) is a diagnostic category, but it is based on the quantitative idea of the degree of elevation that entails signiﬁcant risk and at which treatment is justiﬁed. Another example is that of anaemia; not only are levels of haemoglobin continuously distributed, but the level that is judged to be a problem to treat will depend upon other factors, such as the cause and the society in which it is encountered. Nevertheless, it is plain that there are many constraints on clinicians’ thinking that favour a set of categories. The output from many clinical encounters is a set of categorical decisions: a child either is, or is not, prescribed a drug; or admitted into a treatment programme; or taken into care. It is therefore convenient, though obviously not essential, for diagnostic thinking to fall into the same mode. The convenience may be more apparent than real. It invites an immediate abuse, in which the treatment is determined directly and exclusively by the diagnosis. This possibility becomes all too real in some types of practice. The need of busy clinicians for simple rules of thumb, and the wish of some purchasers of health care to restrict treatment to mechanically deﬁned groups and protocols, can lead to a lack of careful planning of care for the individual case. It is sometimes said that categorical thinking is inherent in the human mind. It arises in the ﬁrst months of life (Blewitt 1994); in adults it is deeply rooted, to the extent that formless sets of stimuli are often perceived as consisting of component categories, and categorical thinking characterizes the lay theories through which non-experts perceive psychological abnormality (Schoeeman et al. 1993). Even if this is the natural tendency of the mind, especially when coping with complex information under pressure to make decisions, it is not necessarily the best approach. Artiﬁcial intelligence can increasingly be used to assist in handling complex information sets, and need not be constrained by human inﬁrmity. Categories have other practical advantages (Klein & Riso 1996); a single term, if carefully chosen, carries a great deal of meaning very conveniently and will be much more tractable in communication with parents and teachers than a large set of dimensional scores. These advantages have ensured that diagnostic schemes are mostly categorical; and dimensional ordering is

CLASSIFICATION: CONCEPTUAL ISSUES AND SUBSTANTIVE FINDINGS

for the most part either secondary or rather tentative and speculative (e.g. Appendix B of DSM-IV: American Psychiatric Association 1994). Dimensional thinking has been more attractive to contemplative researchers, especially those dealing with graded environmental stressors, be they physical or psychosocial. However, dimensional liability is also a key feature in genetic thinking, despite the fact that individual alleles are either present or absent (see McGufﬁn & Rutter, Chapter 12). Which type of thinking maps most helpfully on to the causes of disorder is not obvious, and may well differ for different kinds of psychopathology. Nevertheless, throughout medicine, even when dealing with categorical disease states, dimensional risk factors are the rule rather than the exception. The distinctions between categories and dimensions should not be exaggerated. Generally, each can be translated into the other. A category can be expressed as a set of dimensional scores, and a proﬁle of dimensional scores is a category. Indeed, the degree to which an individual case ﬁts a category can itself be a dimensional construct, and should perhaps be considered as such more often. Sometimes it is preferable to use both ways of thinking about a single domain. IQ is better conceived as a dimension when the purpose is to predict educational achievement; but low IQ (e.g. below 50) is better thought of categorically when the purpose is to consider whether structural disorder of the brain is likely to be present (see below). Hypertension is conveniently regarded as a diagnostic category when the purpose is to select cases for treatment; as a dimension when analysing the physiological reasons for changes in blood pressure; and as a category again when considering the different factors determining variations in the most severely affected cases at the top of the range. Another conceptual problem arises because an undoubtedly discrete cause may give rise to a continuum of problems at the level of behavioural expression. For example, the two genes known to give rise to tuberous sclerosis can both be associated with a very wide range in the severity and type of the resulting psychological disorder. This is not strange; their effects in giving rise to physical changes, such as the characteristic malformations in the brain, vary greatly between individuals. It would have been quite wrong to conclude from the continuously distributed range of severity of psychological disorder associated with tuberous sclerosis that the underlying cause would also be graded in severity. In spite of the difﬁculties involved, the testing of assumptions about the nature of the underlying problems is important. For example, it is likely to guide research strategy in investigating a genetic contribution to disorder (see McGufﬁn & Rutter, Chapter 12). One classic research strategy has been to examine distributions of cases along a continuum of severity to see if there is a discontinuity between normality and pathology, such as a bimodal distribution. Most rating scales, for example, have indicated that hyperactive behaviour is distributed continuously, with progressively fewer cases at successively higher levels of deﬁnition and no sign of a ‘hump on the graph’ (Taylor et al. 1991). This is technically and conceptually problematic. The power of

tests for mixed distributions is low (Meehl 1995) and even very large numbers of cases can fail to give unequivocal answers. Random error in the measurement of properties will blur the sharpness of any distinctions based upon them. Severity in itself may not be the grounds for deﬁnition of a separate category. For example, the identiﬁcation of a poor-outcome subgroup in early onset schizophrenia is based upon a qualitative difference — the presence of neurocognitive changes — rather than on the severity of ‘schizophrenic symptoms’ (see Hollis, Chapter 37). Some investigators have compared the effect size of a continuous measure with a categorical one in predicting an external association such as outcome. For example, Fergusson & Horwood (1995) argued on this basis that a dimensional measure of disruptive behaviour in childhood gave a better prediction of adolescent outcome than a discrete category of childhood disorder. This may say more about the power of alternative statistical methods than about taxonomy; and it ignores the possibility that a strongly predictive category of antisocial behaviour may be present, but one that is based upon the type of problems rather than the severity of disruptiveness. This was, for example, the conclusion of Bergman & Magnusson (1997) in another longitudinal study, predicting antisocial outcome, that included a wider range of possible predictors, physiological as well as behavioural. Mofﬁtt (1993) also concluded, from analysis of the longitudinal course of a population cohort of boys, that an antisocial outcome in adult life was characteristic, not so much of the boys who had been the most disruptive adolescents, but those who had had the combination of early onset and neurodevelopmental impairments. Another research strategy has been to examine the distribution of cases against a measure of presumed aetiology and to seek a point of discontinuity; for example, in comparing successive levels of deﬁnition of hyperactivity against measures of neurodevelopmental delay and reporting that the putative risk factor was more common only in the most severe subgroup of ‘hyperkinetic disorder’ (Taylor et al. 1991). This strategy shares the limitations of the ﬁrst, and entails the further doubt of whether the risk factor chosen is truly causative. It may become more feasible as more speciﬁc causes are discovered — such as molecular genetic abnormalities. Other genetic strategies have already been elegantly employed in twin designs. Eaves et al. (1993) went beyond the deﬁnition on the basis of single cut-off scores, and applied a latent class analysis to ADHD symptoms in a comparison of monozygotic and dizygotic twins. They successively ﬁtted models assuming different numbers of classes, and found the best ﬁt with a model of three separate classes. Gjone et al. (1996) addressed a similar question by comparing group heritability with individual heritability of ADHD symptoms in a twin study using multiple regression techniques (De Fries & Fulker 1988). Their conclusion was different. The extent to which cotwins show a regression to the mean in their scores did not function differently at the extremes of the distribution. This was in keeping either with a more dimensional view — with heritability similar across the whole continuum — or with a single, very common category. The issues are not resolved, even for this 5

CHAPTER 1

rather well-studied condition; and indeed the method can require troublesomely large numbers. But genetic strategies such as these, especially when they can be applied to test hypothesized qualitative distinctions of severity, seem to offer encouraging future advances. In short, the choice of dimensions against categories is complex, hard to resolve, and likely to be different for different conditions. Mixed classiﬁcation systems are likely to develop, in which some types of problems are subclassiﬁed by severity and others by type. For the moment, there are so many uncertainties about whether dimensional or categorical arrangements better represent nature that a deeper pathogenetic understanding will be needed before the question is resolved.

Multiaxial classiﬁcation systems
Categorical classiﬁcations can be based on allotting cases to the single category they best ﬁt, or on multiple categorization — a case may be simultaneously classiﬁed in several ways. Powerful classiﬁcations, such as those of botany, aim for a set of mutually exclusive categories that are collectively exhaustive. Every case then falls into one, and only one, class. This would be an idealized view of medicine, because in practice multiple diseases are often present in the same person — sometimes because one kind of adversity tends to entail others. It can be a good discipline to try to ﬁt multiple problems into a single pattern, but it is also important to detect a secondary disease even when it is masked by a more obvious one. One kind of multiplicity is obviously necessary; different domains of problems need different classiﬁcations. It makes no sense to ask whether a child has asthma or intellectual retardation. They constitute problems of different types, and are best considered on separate axes. Field trials of early versions of the International Classiﬁcations of Disease (ICD) (Rutter et al. 1969; Tarjan et al. 1972) indicated that many disagreements between clinicians were of this type and, correspondingly, that reliability among diagnostic raters could be increased if they were not asked to choose between, say, autism and severe intellectual retardation, but were allowed to choose both, one on an axis of psychiatric disorder and the other on one of intellectual ability. This not only increases agreement, but provides a richer conceptualization and an opportunity to code and examine the extent to which, in this example, intellectual ability modiﬁes the course and treatment response of autism. A multiaxial system embodies this conceptual reﬁnement; it differs from a multicategory system in that every axis needs a coding (even if the coding is of ‘no abnormality’). Axes of psychiatric syndromes, somatic diseases, psychosocial stressors and severity of impairment have been incorporated in the multiaxial version of ICD-10 (WHO 1992, 1993). Speciﬁc learning disabilities and intellectual impairments are dealt with in rather different ways by DSM-IV and ICD-10 (in which they are independent axes); the important feature is that both, in different ways, allow the clinician to record, systematically and separate6

ly, the extent to which both general and speciﬁc learning impairments are present. Multiaxial systems of classiﬁcation have become the norm in child/adolescent psychiatry for ﬁve main reasons. First, they avoid false dichotomies resulting from having to decide between two diagnoses that do not, in any meaningful sense, constitute alternatives. The example given of autism or mental retardation illustrates the point. The ﬁrst gives information on the clinical syndrome whereas the second describes the level of intellectual impairment. Secondly, because there has to be a coding on each and every axis, the classiﬁcation provides information that is both more complete and less ambiguous. Thus, in a multicategory system the absence of a coding of mental retardation could mean that the child had normal intelligence, or that the child was mentally retarded but the clinician did not consider that it was relevant to the referral problem, or that the diagnosis was omitted by error. Such an ambiguity could not arise with a multiaxial system. Thirdly, it avoids artefactual unreliability resulting from differing theoretical assumptions. Thus, psychosocial adversity would be coded as present by both the clinician who viewed it as the main cause and by the clinician who saw it as only a minor contributor. The same would apply to somatic conditions such as cerebral palsy or diabetes. Fourthly, it provides a means by which to note systematically, not only the presenting clinical picture, but also possible causal factors (or factors likely to inﬂuence prognosis or response to treatment) and degree of overall psychosocial impairment. Finally, because of these features it represents a style of thinking that is much closer to most clinician’s preferred style of conceptualization than is the case with a system that forces everything into the Procrustean bed of a diagnosis based only on symptom pattern.

Handling of comorbidity: single vs. multiple category systems
Another kind of multiplicity is provided by the co-occurrence of two different types of symptom pattern, such as major depression and conduct disorder. The key issue is whether, in reality, these represent varied manifestations of the same disorder, the simultaneous presence of two conditions that happen to have arisen in the same individual quite independently, the fact that the two disorders share some of their risk factors, or some mechanism by which one disorder creates a risk for the other (Caron & Rutter 1991; Rutter 1997). Such comorbidity (meaning the situation in which two or more separate and independent disorders are present in the same person) is almost the rule in the ﬁeld of psychopathology (Angold et al. 1999). It complicates the diagnostic process throughout medicine. On the other hand, the reasons for the associations among disorders can also provide valuable clues to the understanding of pathogenesis. The presentation of several patterns of disturbance by the same person may not be caused only by comorbid disorders; and in practice the term ‘comorbidity’ is often applied more broadly, to all the possible reasons for apparent associations between disorders. Comorbidity is less common in epidemiological studies

CLASSIFICATION: CONCEPTUAL ISSUES AND SUBSTANTIVE FINDINGS

than in clinic surveys, because referral and other biases play a part in generating — or obscuring — associations in clinic attenders. It has long been known that comorbid disorders will always be misleadingly frequent in clinic groups, if either condition can lead to referral (Berkson 1946). However, it is plain that overlap is very common in epidemiological series, even if less dramatically so than at clinics, so these kinds of bias cannot be the whole story. Sometimes the overlap stems from imperfections in the deﬁnitions of disorder, so that the same criteria are common to more than one condition, as when symptoms of overactivity are included in the deﬁnitions both of mania and of ADHD. Sometimes an apparent association arises because of a lack of clarity about the boundaries of disorders. Obsessive-compulsive symptomatology may, for example, sometimes arise only in the course of a depressive disorder and remit with it. Similarly, the complications of a disorder may sometimes, and misleadingly, appear as a separate problem; people with long-standing obsessive-compulsive disorder may become depressed as a reaction to their predicament. Sometimes an association between disorders arises because they are both consequences of an underlying, and more fundamental psychopathological liability. For example, autistic and hyperactive features are quite commonly found together in children with diffuse disease or disorder of the brain. Evidence can be quite conﬂicting about the reasons for associations, and they may vary from one centre to another. For example, there is an undoubted link between Tourette disorder and ADHD, but some investigators ﬁnd that this reﬂects genetic cosegregation, others that it does not (see Leckman & Cohen, Chapter 36). However, comorbidity can also arise because one disorder represents an early manifestation of the other; this seems to be the case with generalized anxiety and depressive disorder (Silberg et al., 2001), and with oppositional/deﬁant disorder and conduct disorder (Lahey et al. 1999; Eaves et al., 2000). In this circumstance, at the point of transition, both ‘disorders’ — actually both manifestations of the same disorder — may cooccur. Alternatively, the presence of one disorder may, through its effects, provide a risk mechanism for another condition. Possibly, this is one reason why antisocial behaviour predisposes to depressive symptomatology. Antisocial individuals act in ways that create interpersonal and social stress situations (Robins 1966; Champion et al. 1995). Fuller consideration of the reasons for comorbidity and investigational strategies are provided by Caron & Rutter (1991) and Rutter (1997). Classiﬁcation schemes need to be able to change to reﬂect advancing knowledge, and to be ﬂexible enough to accommodate the differing reasons for the coexistence of mental disorders. In the meanwhile, classiﬁcation systems have to have rules on how to deal with comorbidity. Both ICD-10 and DSM-IV accept the need to be able to make multiple diagnoses if it is clear that the individual truly does have two or more separate conditions. After all, in most circumstances, it cannot be supposed that the presence of one disorder protects against others, although that can happen. Accordingly, someone with, say, autism or schizo-

phrenia, will sometimes develop some other mental disorder if they experience the risk factors for it. It is necessary to be able to record that that is the case. A strict single category system would be unworkable and neither of the main systems have such a requirement. Nevertheless, there is a dilemma on how to classify when there is uncertainty on whether or not the two conditions are truly separate and independent. ICD-10 and DSM-IV differ somewhat in their approach (see Rutter & Taylor, Chapter 2). Both provide for a hierarchical approach in a few instances (see below) and both provide a few mixed categories when there is good evidence that they both represent a single disorder (e.g. mixed episode of mania and depression). However, ICD-10 has rather more mixed categories (e.g. mixed anxiety and depressive disorder and depressive conduct disorder). The rationale is that the weight of evidence suggests either that there is something distinctive about the admixture, as compared with the situation when either condition occurs on its own, or that the same disorder commonly gives rise to this admixture of symptoms. It provides an economical way of communicating and it is a practice that is common in medicine. However, it has two possible disadvantages. First, the overall placement of the combination category in the classiﬁcation system carries messages that may be misleading. Thus, in ICD-10, mixed anxiety and depression is classiﬁed as a variety of anxiety disorder, although the evidence suggests that it is more likely to represent a mood disorder (see Harrington, Chapter 29). Depressive conduct disorder is classiﬁed as a variety of conduct disorder which does seem to be better justiﬁed in that research ﬁndings suggest that conduct disorder has much the same set of correlates and much the same outcome, irrespective of the co-occurrence of depression (Rutter et al. 1970), although there are some differences (Simic & Fombonne, 2001). On the other hand, the evidence is inconsistent on whether the presence of conduct disorder alters the meaning of the depression (Fombonne et al., 2001a,b). Secondly, it limits ﬁner distinctions, such as between the subvarieties of anxiety disorder that may be associated with either conduct disorder or major depression. The availability of mixed categories in ICD-10 is quite limited, however, and the bigger difference from DSM-IV lies in the approach to mixed symptom patterns that are not covered by a combination category. ICD-10 is not entirely explicit in how they should be dealt with but the implicit expectation is a proﬁle recognition or prototypic approach. Thus, if the main picture is one of severe depression, but there are marked obsessional features that ebb and ﬂow with ﬂuctuations in the depression, the mood disorder only would be the expected diagnosis. By contrast, DSM-IV would code obsessional disorder in addition (if the criteria were met) unless the content was mood-speciﬁc (as, for example, with a guilty rumination). The ICD-10 prototypic approach probably closely approximates ordinary clinical practice. The main problem is that it has proved difﬁcult to make prototypes sufﬁciently explicit that they will always be used in the same way. For example, Asperger syndrome has been conceptualized on the basis of clinical case descriptions (see 7

CHAPTER 1

Lord & Bailey, Chapter 38) but this has led to rather varied diagnostic sources on both the history of the concept and the experience of the clinicians using it. With DSM-IV the mixture of two or more symptom patterns leads to the coding of as many diagnoses as there are patterns. This has the advantage of not requiring hierarchical judgements about which pattern is primary when in reality it may be very hard to tell, and it also succeeds in retaining a good deal of information when many patterns are present and no single category would convey them all. On the other hand, there are practical drawbacks to such a scheme. It encourages an unchallenged assumption that they are indeed independent patterns and that each can be dealt with in the same way as if there were no other problems. Alternatively, after multiple diagnoses are made, the clinician may then after all resort to a superordinate singlecategory way of thinking in which every possible proﬁle has its own place. The coexistence of many diagnoses can be confusing and work against the key purposes of clarity and understanding how the research literature may apply to a particular child. It does not allow for the possibility of artefactual associations (see below). Furthermore, it is cumbersome, and perhaps impossible, for a clinician to review the presence or absence of every possible category and clinicians vary a good deal in their willingness to record symptom patterns that are not the main presentation (Rutter et al. 1975).

reactive attachment disorder if a pervasive developmental disorder is present. The general assumption that severe and pervasive mental disorders may often give rise to secondary symptom patterns is well based. The problem is that the evidence to justify hierarchies is generally rather thin and neither DSM-IV nor ICD-10 is consistent in its approach.

Polythetic/monothetic classes
Almost all medical classiﬁcations are polythetic. That is, cases are deﬁned on the basis of having many, but not all, of a list of speciﬁed attributes in common. That is because variability in manifestation is a general biological feature, even with diseases solely caused by one major gene. In the neuropsychiatric arena, such variability is evident in marked degree with conditions such as tuberous sclerosis or the fragile X anomaly (see Skuse & Kuntsi, Chapter 13). There is similarly great variability in the manifestations of autism, as shown by the genetic ﬁndings (see Lord & Bailey, Chapter 38). The phenotype extends from severe handicap to quite subtle disturbances of social function. It would not therefore be reasonable to require that the disorder in any particular individual had to have all the diagnostic features. The trouble is that, in the absence of a diagnostic test of some kind, there are real difﬁculties in deciding both how varied the manifestations could be and where and how the boundaries should be drawn. Latent class analyses may help but what are really required are external validators (see below).

Hierarchical classiﬁcation systems
Most classiﬁcation schemes make some use of hierarchies based on a view that some conditions are fundamental and that, if others are present, they are likely to derive from the fundamental condition. The implication is that the former includes and accounts for the latter. Foulds (1976), for example, presented rating scale data from adult psychiatric inpatients to argue that the symptoms of people with schizophrenia usually included depression and anxiety; that those of people with depression did not usually include those of schizophrenia but did include anxiety; whereas people with anxiety did not usually show either depression or schizophrenia and were therefore at the bottom of a hierarchy of schizophrenia–depression–anxiety. There are evident dangers of circular reasoning, but with care the predictions can be tested. Clearly, this type of prediction would be unlikely to give a complete account of child psychopathology; but could be practical within groups of children sharing risk factors, such as diffuse brain damage, or with problems in a particular domain, such as hyperactivity (Taylor 1986). Thus, DSM-IV excludes the diagnosis of generalized anxiety disorder if it occurs exclusively during a mood disorder, or a psychotic disorder (such as schizophrenia) or a pervasive developmental disorder (such as autism), and ICD-10 does so if the criteria for a panic disorder or an obsessive-compulsive disorder are met. Both DSM-IV and ICD-10 exclude the diagnosis of autism if Rett disorder is present, and exclude the diagnosis of

Lumping, splitting and empirical justiﬁcation
There can be no one answer to the question of whether it is better to have a relatively small number of well-validated diagnoses or, rather, a large number that provides ﬁner clinically useful distinctions that lack adequate empirical justiﬁcation. Much depends on the purpose to which the classiﬁcation is to be put. The most crucial distinction is between classiﬁcations to facilitate communication, and those designed to test out the meaningfulness of new ways of grouping and splitting disorders (Stengel 1959). The latter have been crucial in the identiﬁcation of new syndromes (see Rutter & Taylor, Chapter 2, for examples). It would make no sense to conﬁne researchers to the prevailing classiﬁcations. On the other hand, researchers have to communicate their ﬁndings to others and it would be equally unhelpful to have a proliferation of ‘private’ classiﬁcations.

Subclassiﬁcation using dimensions
There are many examples in medicine of dimensional approaches being used as a supplement to a categorical classiﬁcation. For example, respiratory physicians make more use of dimensional measures of lung function in considering clinical management and prognosis than they do of whether or not the criteria for chronic bronchitis or emphysema are met. Similarly, oncologists regularly grade the degree of malignancy of tumours and

CLASSIFICATION: CONCEPTUAL ISSUES AND SUBSTANTIVE FINDINGS

cardiologists measure the degree of occlusion of coronary arteries and the degree of exercise tolerance. The multiaxial system in child psychiatry (World Health Organization 1996) provides a similar facility with respect to degree of social impairment and intellectual level and DSM-IV provides a means of coding the severity of disorders, as well as the extent to which a disorder is in remission. Similarly, in dealing with schizophrenia it is helpful to differentiate between positive and negative symptoms (see Hollis, Chapter 37). Some of these further differentiations, both categorical and dimensional, have become standardized and quantiﬁed in ways that are used routinely, but others are still in the course of development. However, what is clear is that there is an important place for functional subclassiﬁcation that falls somewhere between overall diagnostic classiﬁcations and individual diagnostic formulations (see Rutter & Taylor, Chapter 2).

pattern without regard to either age of onset or generalized anxiety. Whether or not the developmental approach of ICD-10 is helpful remains uncertain. Research could resolve the issue but, unfortunately, researchers tend to have an allegiance to one scheme over the other rather than a commitment to test the validity of different diagnostic approaches. In addition to these deliberate differences, there are other minor differences which, although trivial in themselves and seemingly inadvertent in their origins, have been found to have major implications (Kendell 1991) as shown, for example, by the ﬁndings with respect to post-traumatic stress disorder (PTSD). A difference between the two schemes in relation to just one item (numbing of general responsiveness) had a dramatic effect on concordance between the two schemes (Andrews & Slade 1998).

Culture-speciﬁc categories ICD-10 and DSM-IV
ICD-10 (World Health Organization 1992, 1993) and DSM-IV (American Psychiatric Association 1994) constitute the two major psychiatric classiﬁcations used throughout the world. Their predecessors (ICD-9 and DSM-III) were very different from one another and strenuous efforts were made to bring ICD10 and DSM-IV much closer together. Those efforts were successful in all sorts of important ways that constituted a major step forward in achieving better international understanding and communication. Nevertheless, there are some differences. Mention has already been made of the difference in approach to comorbidity and an equally important difference is that DSMIV has one scheme that is designed for both research and routine clinical usage, whereas ICD-10 has two separate but interlinked schemes for these two rather different purposes, the research version being closer to DSM-IV. There is something to be said in support of deliberate differences when evidence is lacking to decide which of two alternatives is to be preferred. Further research comparing the two systems should provide for an empirically based choice in the future. For example, the two schemes differ in the rules to be followed in the diagnosis of ADHD. The symptom lists are almost identical but the two systems have different requirements for pervasiveness across situations, whether all problems or only some need to be present, and on the use of exclusion criteria in relation to comorbidity. The consequence is that hyperkinetic disorder in ICD-10 is a subcategory of ADHD in DSM-IV, the grounds for translating one into the other are reasonably clear, and the research ﬁndings to compare the two should be informative. The two schemes also differ in how they deal with emotional disorders with an onset in childhood. ICD-10 makes a distinction between separation anxiety that represents an exaggeration or prolongation of a normal stage of emotional development (operationally deﬁned as requiring an onset before age 6 years and absence of a generalized anxiety disorder) whereas DSM-IV makes the diagnosis solely on the basis of symptom There are many syndromes that have been particularly, or exclusively, associated with particular cultures or populations. ‘Brain fag’ in West African students and both ‘koro’ and ‘latah’ in Indonesia constitute well-known examples. Such syndromes continue to have a controversial status. Both ICD-10 and DSM-IV have appendices dealing with them but neither provides a satisfactory solution for their handling. Clearly, some represent culturally inﬂuenced variations in the manifestations of well-validated disorders (see Rutter & Nikapota, Chapter 16). Thus, there are variations in the terms people use to describe depressive feelings (Kleinman & Good 1985) and in the signiﬁcance attached to anxiety and to oppositional behaviour in childhood (Weisz et al. 1993). It is important that clinicians are aware of these variations if they are to avoid mistaken references (Bhugra & Bhui 2000; Canino & Bravo 2000; Cohen & Kasen 2000). However, it is also possible that there could be disorders that are truly different and found only in certain populations if they derive from risk factors that are conﬁned to those populations. Empirical ﬁndings that could test that possibility are largely lacking.

Validation of diagnostic categories
Basis for diagnosis
The ﬁrst systematic attempt to bring some sort of order into the classiﬁcation of child psychopathology was provided by Hewitt & Jenkins’s (1946) factor analysis of symptoms and linking of factors with differences in psychosocial circumstances. Their differentiation of emotional disturbance and disruptive behaviour, both on the grounds of intercorrelations among symptoms (that is, they ‘hung together’ in ways that separated the two), and different correlations with family features, has been amply conﬁrmed in numerous subsequent studies. In the last few decades, more sophisticated multivariate analyses have led to

CHAPTER 1

the derivation of a much larger number of syndromes based on symptom proﬁles (Achenbach & Edelbrock 1978; Achenbach 1988, 1995). They bear some resemblance to the diagnostic categories in modern psychiatric classiﬁcations but it is not evident that the multivariate dimensions have any strong advantages over the latter and they have not led to much research testing diagnostic validation. Nevertheless, what the two have in common is the use of groupings based on patterns of symptomatology. The Washington University group were pioneers in the development of systematic rules for psychiatric diagnosis in the adult ﬁeld (Feighner et al. 1972) and Cantwell (1975) extended the model to child psychiatry. Both DSM-IV and ICD-10 have adopted this phenomenological approach. Without doubt it has aided comparability across centres in diagnostic usage. However, real comparability requires both the use of standard diagnostic instruments and application of diagnostic criteria (see Angold, Chapter 3; Cantwell 1988). A greater problem has come from the assumption that diagnoses should be based only on cross-sectional patterns of symptomatology, as if this was an end in itself. It is not enough that diagnoses differ in symptomatology; if those differentiations are to have any meaning they must be validated by criteria that are external to the symptomatology and which have clinical meaning and utility (Rutter 1965, 1978; Rutter & Gould 1985; Cantwell & Rutter 1994). Clinicians sometimes assume that an ideal classiﬁcation should be based on aetiology; however, that is not so. Most successful medical diagnoses are based instead on the underlying pathophysiology that gives rise to the clinical syndrome. Thus, diabetes is deﬁned in terms of the metabolic abnormality and not which pattern of susceptibility genes is present. Similarly, ischaemic heart disease is based on the process of occlusive atheroma and not on the presence of key risk factors, such as high cholesterol levels, smoking or genetic liability. The key consideration is that most disorders are multifactorial and cannot therefore be classiﬁed on the basis of a single main cause. Elucidation of causal factors is important because it is likely to lead to an understanding of the basic pathophysiology (Rutter & Plomin 1997). However, it needs to be recognized that there may be more than one causal route to the same syndromic endpoint (Rutter 1997). The consequence of these considerations is that the goal must be the identiﬁcation of the underlying pathophysiology of mental disorders, rather than ﬁnding the single main cause. We are a long way from reaching that goal at the moment. For the same reason, there cannot be any one validating test against some hypothetical gold standard. Instead, there has to be recourse to multiple validating approaches with the hope, and expectation, that when they all point in the same direction, it is likely that the diagnosis has some meaningful discriminative validity. Accordingly, we summarize such evidence brieﬂy before seeking to draw conclusions on the current state of play on diagnostic validity. When the research ﬁndings were reviewed in previous editions (Rutter & Gould 1985; Cantwell & Rutter 1994), or elsewhere, we simply refer to these reviews but we note the main new ﬁndings. 10

Biological ﬁndings
In many respects, the clearest biological distinction is between severe mental retardation (IQ below 50), mild mental retardation (IQ 50–69) and the range of normal intelligence (Rutter & Gould 1985; Cantwell & Rutter 1994; Simonoff et al. 1996). Individuals who are severely retarded have a much reduced fecundity and life expectancy, the great majority show gross neuropathological abnormalities of the brain, and most have either clinical brain disorders (such as cerebral palsy or epilepsy) or marked congenital abnormalities. Their social class background is generally similar to that of the general population. By contrast, most people with mild retardation show a normal fertility pattern and a normal life expectancy, but to a marked extent they are disproportionately likely to come from a socially disadvantaged background. The genetic inﬂuences are more likely than in the case of severe retardation to reﬂect many genes operating as part of a multifactorial liability, and thus constitute the end of a continuum on the dimension reﬂecting normal variations in intelligence. Nevertheless, a substantial minority (the precise proportion is not known) have the same major genetic mutations as those found with severe retardation. That would be so, for example, with Down syndrome, tuberous sclerosis, fragile X and Williams syndrome. Accordingly, the validation is more accurately expressed in terms of a two-group differentiation that is roughly indexed by IQ level, rather than in terms of a severe vs. mild retardation split (see Volkmar & Dykens, Chapter 41). Autism is differentiated from the broad run of other psychiatric disorders by its reduced life expectancy, mainly as a result of deaths associated with epilepsy (Isager et al. 1999), and by the high rate of epilepsy (about 25%). It does not differ from mental retardation in either respect but it does differ with respect to the age of onset of epilepsy (Rutter 1970; Gillberg & Steffenburg 1987; Volkmar & Nelson 1990). In autism, the peak is in late adolescence/early adult life, whereas in mentally retarded individuals it is in early childhood (Richardson & Koller 1992), as it is also in individuals of normal intelligence (Cooper 1965). Neuropathological studies are few, but the ﬁndings do not reﬂect the gross pathology that is typical of severe retardation (see Lord & Bailey, Chapter 38). Also, whereas small head size is associated with mental retardation, a larger than normal head size is more characteristic of autism (Woodhouse et al. 1996; Fombonne et al. 1999). Biological ﬁndings are distinctly less helpful in differentiating among other disorders. Abnormalities on both structural and functional imaging are found in many cases of autism (see Lord & Bailey, Chapter 38), schizophrenia (see Hollis, Chapter 37), hyperkinetic disorder (see Schachar & Tannock, Chapter 25) and obsessive-compulsive disorder (see Rapoport & Swedo, Chapter 35), for example, and the ﬁndings provide a substantial case for a neural basis for the disorders, at least as a contributory factor in aetiology. Much the same applies to the positive ﬁndings with respect to neurodevelopmental impairment. Three main problems arise with any use of these ﬁndings for valida-

CLASSIFICATION: CONCEPTUAL ISSUES AND SUBSTANTIVE FINDINGS

tion. First, the speciﬁcs of the abnormalities found are rather inconsistent within diagnoses (Bailey et al. 1996, with respect to autism; Eliez & Reiss 2000, with respect to magnetic resonance imaging ﬁndings across a range of disorders). Secondly, the associations have only limited diagnostic speciﬁcity. Thirdly, there have been rather limited direct comparisons across diagnostic groups. We do not know, for example, whether the ﬁndings in relation to autism might not apply also to, say, anxiety disorders or tics. Accordingly, the most that can be said is that the biological ﬁndings suggest that neural abnormalities are particularly likely to be found in some of the most severe psychiatric disorders, and there are a few pointers to possible diagnostic speciﬁcity, but the ﬁndings provide at best only weak evidence of diagnostic validation. To some extent, similar problems apply to the associations between neurodevelopmental impairment — as indexed by motor delay and language impairment — and schizophrenia (McDonald et al. 2000). Thus, although the associations are weaker, those seem to apply also to bipolar psychoses (although probably not to other forms of emotional or behavioural disturbance; Cannon et al., in press). The associations between schizophrenia and obstetric complications or congenital anomalies are weaker (Byrne et al. 2000; Kendell et al. 2000) and even less ‘diagnosis-speciﬁc. Life-course-persistent antisocial behaviour differs from that which is adolescence-limited in its association with neurodevelopmental impairment (Mofﬁtt et al. 1996; Rutter et al. 1998; Mofﬁt et al., 2001).

ter 59). There had been a hope that the response might nevertheless help in differentiating ADHD from restlessness/inattention caused by high anxiety. Early studies indicated a lesser effect of stimulants in the presence of high anxiety (see Schachar & Tannock, Chapter 25) but this was not found in the recent US multicentre trial (March et al. 2000).

Genetic/family study ﬁndings
Findings from twin, adoptee and family studies have been crucial in establishing some very important differences among diagnostic groups. Schizophrenia tends to breed relatively true, with associations that extend to schizotypal and paranoid disorders but not much wider than that (see Hollis, Chapter 37; Kendler et al. 1995). The same applies to autism and its broader phenotype (Bolton et al. 1994, 1998; Bailey et al. 1995; see also Lord & Bailey, Chapter 38). There is no evidence of any genetic association between schizophrenia and autism. Affective disorders similarly show a substantial familial loading for depression, but also for generalized anxiety disorders, with twin data suggesting a substantial shared genetic liability (Kendler 1996). Twin data also raise queries about whether prepubertal depression is the same disorder as major depression starting in adolescence or adult life (see Harrington, Chapter 29; Thapar & McGufﬁn 1994; Silberg et al. 1999, 2001). The ﬁndings are not clear-cut on whether bipolar disorders and unipolar depression are genetically distinct (see Harrington, Chapter 29; Silberg & Rutter, in press), but they may be. Some overlap is, of course, to be expected because some cases of unipolar depression are bound to represent bipolar disorders that have not yet included a manic episode. The heritability of bipolar disorder is clearly much greater than that of the ordinary run of unipolar disorder, but whether this reﬂects a different condition or a more severe variant of the same disorder is the unresolved query. Attention deﬁcit disorders with hyperactivity clearly stand out as having a substantively higher heritability than that for other disorders involving disruptive behaviour (Thapar et al. 1999). On the other hand, to an important extent, they share the same genetic liability (Eaves et al., 2000; Nadder et al., in press), but the ﬁndings also raise queries about the validity of a qualitatively distinct diagnosis of ADHD, because the heritability of hyperactivity seems much the same throughout its range (Levy et al. 1997) and because of the shared genetic liability with other disorders of behaviour. However, from a genetic perspective there is no justiﬁcation for differentiating between oppositional/deﬁant disorder and conduct disorder (Eaves et al., 2000). The genetic ﬁndings on Tourette syndrome are mainly of interest in relation to validity because they suggest some overlap with both multiple chronic tics and obsessive-compulsive disorder. Genetic ﬁndings on other disorders (see chapters throughout the book) all indicate a signiﬁcant genetic component but they are less informative on discriminative diagnostic validity, apart from the ﬁndings in adults (Kendler et al. 1992) suggesting that the speciﬁc phobias may be relatively distinct from general11

Drug response
It might be expected that drug responses would help greatly in diagnostic validation but, regretfully, they do not. The generally marked beneﬁcial response to neuroleptics in the case of schizophrenia constitutes a partial exception (see Hollis, Chapter 37). Although these classes of drugs carry some beneﬁts in other disorders (see Heyman & Santosh, Chapter 59), their efﬁcacy in schizophrenia is substantially greater. Several problems arise with respect to the use of drug response as a diagnostic validator. First, and most importantly, most drugs have several distinct therapeutic actions. For example, tricyclics have independent effects on disorders as diverse as depression, ADHD and nocturnal enuresis (see Heyman & Santosh, Chapter 59). Secondly, in many cases the therapeutic effects fall far short of the dramatic. There are substantial beneﬁts at the group level but these are not sufﬁciently great at the individual level to help much in diagnosis. Most especially, the fact that someone who is depressed does not return to a normal mood following administration of antidepressants by no means rules out the diagnosis of depression. Marked individual variations in drug response are common throughout medicine. Thirdly, many drugs appear to affect behaviours rather than diagnosis-speciﬁc pathophysiologies. Thus, the effects of stimulants on inattention/overactivity are qualitatively much the same, albeit quantitatively less marked, in individuals who do not have ADHD as in those who do (see Schachar & Tannnock, Chapter 25; Heyman & Santosh, Chap-

CHAPTER 1

ized anxiety and from panic disorder. Rett syndrome is probably distinctive through its association in some cases with a speciﬁc genetic mutation (Amir et al. 1999) but to date there have been no studies testing for its association with other psychiatric conditions.

in having a much weaker male preponderance (Mofﬁtt et al., 2001). Rett syndrome is unique in being conﬁned — or almost conﬁned — to females (see Lord & Bailey, Chapter 38).

Course of disorder
The long-term course of disorders also helps sort out diagnostic distinctions. The plateau of developmental progress and loss of purposive motor skills associated with Rett syndrome (see Lord & Bailey, Chapter 38) makes it quite distinct. Adult outcome ﬁndings (Rutter 1995) are relevant in showing the major continuities between depression in childhood/adolescence and recurrent depression in adult life (Harrington et al. 1990; Weissman et al. 1999a,b; Fombonne et al., 2001a,b); similarly, strong continuities between antisocial behaviour, including conduct and oppositional/deﬁant disorders, and personality disorders in adult life (Rutter et al. 1998); the strong persistence of autism (see Lord & Bailey, Chapter 38); the relatively strong persistence of schizophrenia (see Hollis, Chapter 37), of obsessive-compulsive disorders (see Rapoport & Swedo, Chapter 35), and of tics/Tourette syndrome (see Leckman & Cohen, Chapter 36). There are fewer data on anxiety disorders but, although there is some overlap with depression, speciﬁc phobias seem somewhat distinct (see Klein & Pine, Chapter 30).

Psychosocial risk factors
On the whole, there is relatively little diagnostic speciﬁcity with respect to the psychopathological risks associated with psychosocial stress and adversity (see Friedman & Chase-Lansdale, Chapter 15; Sandberg & Rutter, Chapter 17). However, there are two important exceptions. First, severe institutional deprivation in the early years of life has a relatively speciﬁc association with syndromes involving disinhibited attachment (see O’Connor, Chapter 46; Rutter et al., 2001). Secondly, severe and acute stress experiences of an exceptional kind are particularly likely to lead to post-traumatic stress disorder phenomena (see Yule, Chapter 32). There is also some tendency for psychological loss stresses to lead to depression and danger-type stresses to lead to anxiety (see Sandberg & Rutter, Chapter 17). Family conﬂict, discord and hostility are also more likely to lead to antisocial behaviour than to emotional disturbance; the same applies to social disadvantage (Rutter et al. 1970). Within antisocial disorders, life-course-persistent varieties show a stronger association in serious family adversities than that found with adolescence-limited varieties (Rutter et al. 1998).

Summary of validity inferences
Putting together the evidence discussed above, it is possible to arrive at a threefold division of disorders into those that are reasonably well-validated; those with pointers suggesting possible validity; and those where the evidence indicates that the categorical subdivisions are probably invalid. The ﬁrst group clearly contains autism and autism spectrum disorders (considered together), schizophrenia and schizophrenic spectrum disorders (again as a grouping), depressive disorders, hyperkinetic behaviour as a feature that differentiates it from other disorders of disruptive behaviour, oppositional and conduct disorders (considered together) and Rett syndrome. A range of contrasting approaches all provide good evidence of discriminative validity. The same applies to the distinction between the usually severe mental retardation that is associated with gross neuropathology and the usually mild retardation that is not. The second cluster of possibly valid syndromes includes obsessive-compulsive disorder, eating disorders (pooling anorexia and bulimia nervosa), tics and Tourette syndrome, speciﬁc phobias, post-traumatic stress disorder, disinhibited attachment disorder, bipolar affective disorders, and the distinction between life-course-persistent and adolescent-linked antisocial behaviour. As brieﬂy noted above, in each instance there is some evidence of discriminative validity but it is either less consistent or it spans fewer research approaches. From a practical point of view, these provide sufﬁcient grounds for retaining the di-

Cognitive correlates
Autism stands out from other psychiatric disorders both because of its particularly strong association with general cognitive impairment and its relatively speciﬁc association with theory of mind deﬁcits (see Lord & Bailey, Chapter 38). ADHD is also relatively distinctive, but to a much lesser degree, through its association with mild cognitive impairment (Fergusson et al. 1993; see also Schachar & Tannock, Chapter 25). To a lesser extent, schizophrenia is also associated with a slightly below average IQ before the onset of the psychosis (Tarrant & Jones 2000).

Epidemiology
The two epidemiological features that are of greatest value with respect to diagnostic validity are age of onset and sex ratio. Interestingly, they go together to a considerable extent. Thus, disorders involving neurodevelopmental delay, such as developmental disorders of language, autism, ADHD, and lifecourse-persistent antisocial behaviour, characteristically begin early in life and are much more common in males. Emotional disorders beginning in adolescence, such as depression and eating disorders, by contrast, tend to be much more common in females (see Rutter & Taylor, Chapter 2). Antisocial behaviour beginning in adolescence also differs from earlier onset varieties

CLASSIFICATION: CONCEPTUAL ISSUES AND SUBSTANTIVE FINDINGS

agnostic category, even though there are important questions to be tackled. The third cluster of probably invalid categories is less easy to deal with, if only because of the usual problem of knowing how much weight to attach to a lack of evidence of a meaningful difference, when new research could change that situation completely. Nevertheless, it is important to be aware that our usage of prevailing classiﬁcations means that we are making distinctions that, at least currently, lack substance. That applies to most of the detailed subclassiﬁcations, such as those among anxiety disorders or those among pervasive developmental disorders (PDD), Rett syndrome apart. It deﬁnitely does not mean that we should necessarily switch to some broader category. Thus, although there is no good evidence that the distinction between, say, autism and Asperger syndrome or atypical autism means much, the evidence on discriminative validity applies to the more narrow category of autism and not to the broader category of PDD. Also, up to now it has proved quite difﬁcult to provide either a clear conceptualization or precise application of the criteria for the broader category. The issue is the one that pervades psychiatry: namely, uncertainty on the boundaries of a syndrome when the deﬁning pathophysiology is unknown. It should be added that this uncertainty applies in some (often major) degree to most of the conditions for which there is no evidence of validity. A second group of probably invalid categories includes syndromes that are clinically striking but for which the external correlates provide little support for basic differences from other diagnostic categories. Selective mutism and conversion reactions fall into that group. In both cases, the distinctiveness of the clinical picture and the particular therapeutic challenges it presents probably warrant the retention of the category. However, the same might have been said of school refusal (Hersov 1977) and that no longer has a place in most classiﬁcation schemes (Elliott 1999). Then there are categories that derive from theoretical concepts but which lack satisfactory diagnostic criteria that would allow the testing of validity. Inhibited attachment disorder (see O’Connor, Chapter 46) is a diagnosis of that type and many would argue that borderline personality disorder is too (see J. Hill, Chapter 43). Certainly, subdivisions among personality disorders remain rather unsatisfactory. It should be added that epidemiological ﬁndings indicate that there are quite a few children with psychosocial impairment but whose mental health problem does not fulﬁl any particular diagnostic category. Moreover, they have a mental health outcome, at least in the short term, that is as poor as those with a diagnosis (Angold et al. 1999). Evidently, there is a need for some sort of residual psychopathological category. Finally, it is necessary to return to the uncertainties when deciding between categorical and dimensional approaches. ADHD disorders well illustrate this dilemma (see Schachar & Tannock, Chapter 25). Most of the biological validity evidence, such as the neuroimaging ﬁndings and associations with motor and language problems, applies to a relatively narrow diagnos-

tic category, but most of the genetic ﬁndings point to a dimensional liability (Levy et al. 1997). Of course, it may well be that there is both a qualitatively distinct disorder and a risk dimension, which look similar but which differ in their pathophysiology.

Agreement on clinical psychiatric diagnoses
Diagnostic ratings by experienced clinicians show at least a modest concordance. Limited agreement within panels of independent clinicians has been found over the years: for DSM-III (Mattison et al. 1979; Mezzich et al. 1985; Prendergast et al. 1988) and for ICD-9 (Gould et al. 1988; Prendergast et al. 1988; Remschmidt 1988). Field trials for DSM-IV reported better agreement, but on the basis of self-selected pairs of psychiatrists who made diagnoses on selected patients. The shortcomings of this strategy were pointed out by Rutter & Shaffer (1980), who noted that one would expect clinicians working together to have similar diagnostic practices. Further work needs to be carried out before the language of child psychiatry becomes sufﬁciently explicit to sustain scientiﬁc progress. On the other hand, good diagnostic agreement can be achieved by independent research teams that have agreed supplementary criteria in advance (Prendergast et al. 1988). This satisfactory agreement is comparable with that obtained by studies in which two clinicians from the same centre rated cases with fuller information (Stroeber et al. 1981; Werry et al. 1983). The conclusion seems to be that training can improve diagnostic reliability to a satisfactory level, so the goal of an adequate system is not impossibly distant. The increased clarity of diagnostic rules in ICD-10 has been reported to increase interrater reliability, though the overall accuracy still leaves much to be desired (Steinhausen & Erdin 1991). Other procedures that have been reported to enhance reliability are the use of a standard coding form after interview (Beitchman et al. 1989) and the use of a multiaxial system (Skovgaard et al. 1988).

Clinical diagnosis and formulation
The clinical diagnosis is made for purposes of convenient and economical communication, for statistical recording and purposes of audit. Diagnosis is seldom the automatic generator of a plan for management. A child with autism and repetitive selfinjury should not be treated in the same way as a person with autism who does not show challenging behaviour; a child with ADHD who is socially competent and valued should not receive the same management as one who is severely impaired in social role performance. Pervasive variables, such as IQ and peer relationships, are important predictively, even if their lack of discriminative validity means that they do not enter into current deﬁnitions. The diagnosis is just one of several aspects of the case

CHAPTER 1

that guide decision-making. It functions like a map for navigators, to help them know what they are likely to encounter. Ignoring it is like going to sea without a map; relying upon it to dictate treatment is more like the action of a navigator who never looks at the ocean to spot approaching vessels or the danger of icebergs. There is a potential danger in the development of treatment protocols or payment plans that are based solely upon diagnosis: they may inhibit the process of tailoring services to individual needs. The product of assessment should therefore be not only a categorization, but a full clinical formulation. The point is so important that a separate chapter (see Rutter & Taylor, Chapter 2) considers the development of clinical formulations that bring out what is individual and special about the problems faced by a child. The clinical formulation encompasses more information than the diagnosis. It is a convenient way of combining dimensional with categorical information, and it allows for the inclusion of information that may determine clinical decision-making even if it does not enter into the diagnosis. It should include a problem list, a description of the child’s proﬁle of disturbance on the major types of behavioural change, cognitive abilities and impairment, strengths and weaknesses in the family and school environment, and any relevant risk factors. A formulation can also indicate uncertainties or missing information, and the possible needs for review. It allows, for instance, judgements to be recorded about the conﬁdence with which different aspects of the case have been assessed. This in turn directs the clinician’s attention towards re-evaluations that may need to be made in the management of a case, and avoid perseveration on an initially erroneous judgement. It allows for plans to be made for the management of a case falling short of diagnostic criteria. Rather similarly, it allows a case to be detected as having a deﬁnite problem even if the exact nature of the problem does not ﬁt current diagnosis. Another function of the clinical formulation is to record judgements about the developmental signiﬁcance of clinical ﬁndings. The ‘psychosocial’ axis of the ICD refers to stressors that may affect the child. Reliability for research purposes is enhanced if one codes only their presence or absence rather than their role in aetiology. The formulation of the case can and should include judgements concerning the impact of those stressors upon the child’s development (see Sandberg & Rutter, Chapter 17). The clinical formulation also permits the clinician to record judgements about the weight to be given to different aspects of the case. For example, within a multicategory scheme such as DSM-IV, it will be commonplace for a referred child to receive several diagnoses. Serious errors of judgement could be made if it were assumed that each diagnosis had the same signiﬁcance as it would have in a non-comorbid case and that each diagnosis could be treated independently. A child with autism who is afraid of going out of doors may have come to that state through a very different route from one with simple social phobia and may need a different approach in treatment. 14

Conclusions
The development of agreed and reasonably reliable diagnostic schemes has been essential for beginning a scientiﬁc understanding of child mental health problems. Cross-sectional symptom patterns have been the foundation for this advance. Succeeding chapters describe the considerable progress that has been made in the accuracy and reliability with which symptoms are elicited. Several sources of developing knowledge can now be expected to have a great impact on the details and the principles of classiﬁcations. Advancing knowledge of patterns of inheritance is likely to lead to some redeﬁning of the boundaries of disorder. The long-term process of mapping genotypes to phenotypes will probably produce new diagnostic entities and lead to some regrouping of old ones. Advances in neuropsychological understanding about the bases of a disorder may lead to altered views about what constitute its key features. New treatments will call for new categorizations of the groups of patients to whom they are relevant. The nosological study of comorbid groups will clarify how the overlap of different symptom patterns should be handled. Developmental psychopathology will produce knowledge about the interaction of risk and protective factors that allow a richer classiﬁcation of the factors operating on a child and the developmental tracks that children may take. These foreseeable advances have in common the increasing integration of other sources of information with current symptomatology as the basis of classiﬁcation. It seems certain that sound classiﬁcation will remain a necessary condition for progress.

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CLASSIFICATION: CONCEPTUAL ISSUES AND SUBSTANTIVE FINDINGS S.H. Goodman & I.A. Gotlib) American Psychological Association, Washington D.C. Silberg, J., Pickles, A., Rutter, M. et al. (1999) The inﬂuence of genetic factors and life stress on depression among adolescent girls. Archives of General Psychiatry, 56, 225–232. Silberg, J., Rutter, M. & Eaves, L. (2001) Genetic and environmental inﬂuences on the temporal association between earlier anxiety and later depression in girls. Biological Psychiatry, 49, 1040–1049. Simic, M. & Fombonne, E. (2001) Depressive conduct disorder: symptom patterns and correlates in referred children and adolescents. Journal of Affective Disorders, 62, 175–185. Simonoff, E., Bolton, P. & Rutter, M. (1996) Mental retardation: genetic ﬁndings, clinical implications and research agenda. Journal of Child Psychology and Psychiatry, 37, 259–280. Skovgaard, A.M., Isager, T. & Jorgensen, O.S. (1988) The reliability of child psychiatric diagnosis: a comparison among Danish child psychiatrists of traditional diagnoses and a multiaxial diagnostic system. Acta Psychiatrica Scandinavica, 77, 469–476. Sonuga-Barke, E.J. (1998) Categorical models of childhood disorder: a conceptual and empirical analysis. Journal of Child Psychology and Psychiatry, 39, 115–133. Steinhausen, H.C. & Erdin, A. (1991) The inter-rater reliability of child and adolescent psychiatric disorders in the ICD-10. Journal of Child Psychology and Psychiatry, 32, 921–928. Stengel, E. (1959) Classiﬁcation of mental disorders. Bulletin of the World Health Organization, 21, 601–663. Stroeber, M., Green, J. & Carlson, G. (1981) Reliability of psychiatric diagnosis in hospitalized adolescents: inter-rater agreement using DSM-III. Archives of General Psychiatry, 38, 141–145. Tarjan, M.D., Tizard, J., Rutter, M. et al. (1972) Classiﬁcation and mental retardation: issues arising in the Fifth WHO Seminar on Psychiatric Diagnosis, Classiﬁcation and Statistics. American Journal of Psychiatry, 128 (Suppl.), 34–45. Tarrant, C.J. & Jones, P.B. (2000) Biological markers are precursors to schizophrenia: speciﬁcity, predictive ability, and etiological signiﬁcance. In: Child Onset of ‘Adult’ Psychopathology: Clinical and Research Advances (ed. J. Rapoport), pp. 65–102. American Psychiatric Press, Washington D.C. Taylor, E. (1986) Subclassiﬁcation and diagnosis. In: The Overactive Child: Clinics in Developmental Medicine No. 97 (ed. E. Taylor), pp. 174–191. MacKeith Press/Blackwell Scientiﬁc Publications, London/Oxford. Taylor, E., Sandberg, S., Thorley, G. & Giles, S. (1991) The Epidemiology of Childhood Hyperactivity. Maudsley Monograph No. 33. Oxford University Press, Oxford. Thapar, A. & McGufﬁn, P. (1994) A twin study of depressive symptoms in childhood. British Journal of Psychiatry, 165, 259–265. Thapar, A., Holmes, J., Poulton, K. & Harrington, R. (1999) Genetic basis of attention deﬁcit and hyperactivity. British Journal of Psychiatry, 174, 105–111. Volkmar, F.R. & Nelson, D.S. (1990) Seizure disorders in autism. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 127–129. Weissman, M., Wolk, S., Goldstein, R. et al. (1999a) Depressed adolescents grown up. Journal of the American Medical Academy, 281, 1707–1713. Weissman, M., Wolk, S., Wickramaratne, P. et al. (1999b) Children with prepubertal-onset major depressive disorder and anxiety grown up. Archives of General Psychiatry, 56, 794–801. Weisz, J.R., Suwanlert, S., Chaiyasit, W., Weiss, B., Achenbach, T.M. & Eastman, K.L. (1993) Behavioral and emotional problems among Thai and American adolescents: parent reports for ages 12–16. Journal of Abnormal Psychology, 102, 395–403. Werry, J., Methren, R.J., Fitzpatrick, J. & Dixon, H. (1983) The inter-rater reliability of DSM-III in children. Journal of Abnormal Psychology, 11, 341–354. Woodhouse, W., Bailey, A., Rutter, M., Bolton, P., Baird, G. & Le Couteur, A. (1996) Head circumference in autism and other pervasive developmental disorders. Journal of Child Psychology and Psychiatry, 37, 665–671. World Health Organization (1977) Manual of the International Statistical Classiﬁcation of Diseases, Injuries and Causes of Death (9th revision), Vol. 1. WHO, Geneva. World Health Organization (1978) Manual of the International Statistical Classiﬁcation of Diseases, Injuries and Causes of Death (9th revision), Vol. 2. WHO, Geneva. World Health Organization (1992) The ICD-10 Classiﬁcation of Mental and Behavioural Disorders: B. Clinical Descriptions and Diagnostic Guidelines. WHO, Geneva. World Health Organization (1993) The ICD-10 Classiﬁcation of Mental and Behavioural Disorders: B. Diagnostic Criteria for Research. WHO, Geneva. World Health Organization (1996) Multiaxial Classiﬁcation of Child and Adolescent Psychiatric Disorders: The ICD-10 Classiﬁcation of Mental and Behavioural Disorders in Children and Adolescents. Cambridge University Press, Cambridge.

Clinical Assessment and Diagnostic Formulation
Michael Rutter and Eric Taylor

Initial questions regarding referral
Any clinical appointment will have been initiated by someone making a referral and usually that will involve some form of focused question, although the extent to which this is made explicit is likely to vary among referrals. In the case of children and younger adolescents, it will be rather unusual for the young people themselves to have initiated referral, but that may sometimes be the case. Although the clinician is likely to wish to organize the initial assessment around the question as to whether the child has a clinically signiﬁcant disorder and, if there is such a disorder, what its nature is, that may or may not be the question that is uppermost in the mind of the person making the referral. The main concern may be what the family or school should do about a particular behaviour that is causing concern in that setting. Alternatively, there may be questions over particular administrative decisions, such as whether the school the child is attending is most appropriate, whether there is a need for exclusion from school, or whether the child should be removed from the family. In other cases, the referral may be to request an opinion that is relevant to a court case involving either child care or the child’s responsibility for some criminal act or possible need to respond to such an act with some form of therapeutic intervention. In yet other cases, there may be an implicit query as to the meaning of the child’s behaviour — perhaps as to whether or not it represents an early manifestation of some serious mental disorder (such as schizophrenia or autism) that is thought to run in the family. Another possibility is that the main problem concerns disturbed family function that happens to have involved the child in some way (Shepherd et al. 1971). If so, there is the need to understand why this child has been referred at this time in this way. It is quite common, too, for different people to have quite discrepant views as to what is the problem and what needs to be done about it. Thus, the father and mother may be at loggerheads over this, their views may be different from those of the child, and all of these may differ from the perspectives of the school, the social services or the family doctor. Because of all of these uncertainties, and the wide range of possibilities, it is crucial for any assessment to begin with some procedures designed to clarify questions about the referral (Kanner 1957; Rutter 1975). Who initiated the referral? Why was the referral made? Why was the referral made now? Whose problem is it? What are the key concerns or questions to which people want a response? Are there administrative decisions that hang on the assessment and, if so, what are they? 18

To some extent, these questions can be clariﬁed through obtaining relevant reports in advance of the interview for diagnostic assessment. This needs to be done through discussion with the family and with their approval. However, it is desirable to have available at the time of the ﬁrst interview relevant reports from the school, from any social agencies that have been involved, from previous medical assessments, and from psychological and educational evaluations. As well as clarifying the reasons for referral, the initial assessment needs to be planned in such a way as to provide information on how the members of family interact with one another and how they deal with each others’ concerns. The aim is to identify possible strengths and limitations in the family and to understand their ways of functioning in order that this may be taken into account in planning therapeutic interventions.

Observations of the family
Observations need to begin with the ways in which the communications — either by letter or telephone call — were dealt with prior to the ﬁrst interview (Cox & Rutter 1985). Who took the lead? What was the style used? What implications might there be for either the parents’ attitudes towards their children or towards professionals. Similar questions need to be considered in relation to observations in the waiting room. If the availability of chairs provided open choice, how did the family choose to sit? What was the style of interactions among family members while waiting to be seen and how did they respond to meeting the clinicians? How did they spend their time in waiting and what were they doing when the clinician went to collect them for interview? Regardless of how later stages of the assessment are to be undertaken, it is usually informative to have a brief meeting with the family all together in order to clarify these sort of issues and also to explain how the assessment will be organized and who will be seeing who for what purpose. Similar queries to those posed in relation to the waiting room arise with respect to the seating in the interview room. If the aim is to assess family interaction, it is crucial that the interview questions be addressed to the family as a whole, rather than singling out individual family members for their views. Often it may be better to put the query in the form of a questioning statement of a general kind, rather than a speciﬁc enquiry. Thus, the clinician may say something like: ‘I wonder how much you talked together about coming to

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see me today?’ or there could be a general question such as ‘Have you had a family discussion about the reasons for coming here today?’ Many parents are likely to have the cultural expectation that they, rather than the child, should answer the clinician’s questions and, in interpreting how they respond, it is important to take that into account. Nevertheless, direct questions to the child in this initial family session may make him or her feel put on the spot and, thereby, uncomfortable. Again, a more general style of bringing the whole family into the interview may be preferable (see Eisler, Chapter 9, for a fuller discussion of family interviewing). For example, if someone has responded with a ﬁrm answer on expectations or the reasons for coming, the interviewer might say something like: ‘I wonder whether everyone in the family sees things in this way?’ It is helpful to note how much the parents provide the child with ‘space’ to express his or her own views. How do the parents react if the child puts things in oppositional or confrontational ways? How do members of the family react when someone is expressing feelings of distress, anger or resentment? What are the patterns of eye to eye gaze among family members? What are their facial expressions and body gestures? Although it is usually a mistake to move quickly into interpretations, it may be helpful to make observations or express reactions as a means of getting the family to talk about the situation. Thus, the clinician may say things such as, ‘That appears to be a very difﬁcult situation’ or ‘It feels as if that was awkward for you to talk about’ or ‘It sounds as if that came as a bit of a surprise to you’. Depending on how the interview progresses, it may be appropriate to move on to direct questions about some aspect of the referral. For example, if the school or social services initiated the referral, the family may be asked how they felt about whatever it was that precipitated the referral. Was that something that they, too, were concerned about or did they see it rather differently? Similarly, if the parents have initiated referral because they were worried about some aspect of the child’s behaviour or emotional state, it may be important to ask the child directly whether this was something he or she was concerned about. Younger children should not be expected to sit still during the interview and the interviewer needs to decide in advance what toys or play materials will be made available for the children. The interview provides the opportunity of seeing what the children decide to do and also whom they talk to or whom they turn to during the interview. How do the parents respond if the child seems distressed or is behaving in a disruptive way? Again, it is necessary to recognize that there may be culturally inﬂuenced expectations as to how the parents should behave. If the clinician wants the parents to be able to respond to the child it may be appropriate to say that directly by indicating ‘It’s okay if you want to respond to (child’s name) while we’re talking’ or ‘By all means go to (child’s name) if you’d feel more comfortable doing that’.

Interview with the child
Angold (Chapter 3) describes the approaches to be used in inter-

viewing children. As he notes, interviews with older children and adolescents can follow rather similar approaches to those used with adults, but various adaptations are needed with young children. Several points warrant emphasis in that connection. First, it is usually helpful to be able to assess children’s behaviour, styles of social interaction and ways of talking, in several contrasting situations. Thus, it is usually desirable to have an opportunity of seeing the child with the rest of the family. Psychological testing will provide the quite different stimulus of a series of structured tasks requiring the child’s engagement and attention. Psychological testing should always include a careful description of the child’s behaviour and social interactions, as well as test performance (see Sergeant & Taylor, Chapter 6). The interview with the child will be different yet again in providing a dyadic interaction opportunity but of a much less structured kind. Particularly at the beginning of the interview, the style needs to be such as to encourage the child to express his or her own concerns and this needs to proceed to a more systematic approach to speciﬁc behaviours and feelings. Ceci et al. (Chapter 8) describe some of the considerations that apply particularly to the interviewing of young children. On the whole, free descriptions in answer to open questions provide accounts of behaviour that are most accurate and least prone to distortion. On the other hand, these tend to be very lacking in detail and, almost always, it will be necessary to follow with more speciﬁc questions. As Angold (Chapter 3) points out, however, it is important that this be done in a way that does not provide a lead to speciﬁc answers. People of all ages are open to the inﬂuence of suggestion but this is particularly the case with younger children (see Ceci et al., Chapter 8). Variations in the style of child interview and observation are needed when the child has some handicap in their communication and social skills and when the clinical issues require a focus on particular forms of behaviour that may not be tapped adequately in an ordinary interview. The Autism Diagnostic Observation Schedule (ADOS) provides an example of the former (DiLavore et al. 1995; Lord et al. 1989, 2000). This was developed as a set of social/communicative situations that provide a ‘press’ or expectation for either social/communicative responses or overtures. A generic version of the test with four modules adapted to children of different communicative levels is now available (Lord et al. 2000). It was initially developed primarily for research purposes but specialized clinics are now increasingly using it for clinical assessments. Even if the standardized half-hour assessment is not used clinically, the principles are certainly relevant to any form of clinical diagnostic interview with children or adults for whom the diagnosis of some form of pervasive developmental disorder has been raised (see Lord & Bailey, Chapter 38). There is a similar need to adapt interview approaches for children with seriously impaired hearing or vision (see Hindley & van Gent, Chapter 50). The need to consider how assessments should be adapted for particular purposes is exempliﬁed by the approaches needed for the assessment of possible attachment disorders (see O’Connor, Chapter 46). The concept of these disorders is that they are char19

CHAPTER 2

acterized by pervasive problems in selective attachment. The disinhibited variety of attachment disorder might be thought to comprise a relative lack of selective attachments, and the inhibited variety both a lack of security provided by established selective attachments and by various abnormal features. So far as the disinhibited variety is concerned, there are two features that particularly require attention. The ﬁrst concerns the child’s response to a stranger and the degree to which this lacks the normal wariness, plus the extent to which there is an inadequate appreciation of social boundaries and an unusual degree of physical closeness or contact before a relationship has been established. In addition, there may be a lack of selectivity in going to the principal caregivers for security or comfort and it is important that the child’s response to family members be observed, as well as the response to a stranger. It might be thought that the Strange Situation (Ainsworth et al. 1978) ought to be the most appropriate way of determining whether or not there is an inhibited attachment disorder, but it has severe limitations for this purpose. On the face of it, the category of ‘disorganized’ attachment might seem to be the nearest equivalent of a clinical diagnostic concept. However, it seems that the category of disorganized attachment occurs much more frequently than would be expected for the diagnosis of inhibited attachment disorder (van Ijzendoorn et al. 1999). It is clinically appropriate to base assessments on the way the child responds to reunions after separation, but the Strange Situation procedure was designed only for very young children and it is not likely to have the same meaning in older ones. What is needed clinically is a form of assessment that provides the opportunity to assess the child’s reaction to strangers (the clinicians ﬁll that role), responses to separations from and reunions with the parents (taking the child to be seen on his or her own and returning later serves that purpose); and the child’s use of the parents as a secure basis (a joint family interview is useful in that connection). Whatever the age of the child, and whatever the clinical issue, it is important that the interview combines an appropriate degree of structure and standardization (which is essential for comparability across children) and sensitivity to the unexpected and to the individual issue. The latter have been most studied in relation to the interviewing of parents in a clinical setting (Cox et al. 1981; Rutter et al. 1981) in which one of the most striking ﬁndings was the very high frequency of clinically signiﬁcant information of an unusual kind that would be most unlikely to have been picked up by conﬁning questioning only to predetermined topics. The same consideration certainly applies to interviews with children. It is very important for clinicians to be sensitive to the cues provided by children and these will need to be followed through in whatever way seems most appropriate to the individual situation. This need applies even more to what children say about their psychosocial circumstances than it does to what they say about psychopathology (see below).

Parental interview
Angold (Chapter 3) outlines in some detail the approach that 20

needs to be taken when interviewing parents. The main focus in Chapter 3 is on the assessment of psychopathology and the additional point that needs to be made here is that, in planning therapeutic interventions, several other features need to be considered. To begin with, it is essential to determine what it is about the child’s behaviour or feelings or social interactions that is of the greatest concern to the parents. It may not necessarily be the feature that the clinician considers to be of the greatest psychopathological importance but, ordinarily, it is sensible that early therapeutic interventions be recognized by the parents as addressing their concerns. In addition, it is important to ﬁnd out how the parents, and other people, have tried to deal with the concern. How have they tried to respond and what success or otherwise have their approaches achieved? If adequate use is to be made of this in therapeutic planning, it will be essential to move beyond a general answer (such as admonish the child, or comfort him or her, or try to be understanding) and, instead, obtain a more detailed sequential account of how this has been done. What did they do and what was the child’s response? If certain approaches did not work, did they persist (and if so, for how long and under what circumstances) or did they keep changing? A closely related issue is the impact that the child’s disturbance has had on them and on the rest of the family. In dealing with the development of the disorder, attention needs to be paid to possible predisposing factors in life circumstances or physical state. Before proceeding with speciﬁc questioning, it is usually better to elicit the parents’ views on what might have been important. There is then the functional analysis of the behaviour that is causing concern (see Herbert, Chapter 53). In other words, what are the features that seem to make the behaviours of concern more likely or less likely to occur? What circumstances seem to improve the situation? Questions regarding the degree to which behaviours are situation-speciﬁc or pervasive are important, not only for their implications with respect to severity (see Angold, Chapter 3) but also in terms of features in the environment that may act as a risk or protective factor. There are important advantages in making sure that children are seen with their parents for part of the diagnostic assessment. However, people do not behave, or talk, in the same way when seen on their own as when seen as part of a family group. Accordingly, it is usually desirable for part of the assessment time to be spent in seeing the child on his or her own and similarly for the parents to be seen separately. Not only may this provide information that would not be obtained quite so readily in a family setting, but it also makes explicit a concern to pay attention to family members as individuals as well as part of a group. Some clinicians prefer to conduct the whole of the diagnostic assessment interview in a conjoint family setting but, in our view, this has disadvantages with respect to information gathering. A similar decision needs to be made as to whether both parents should be seen together or whether there should be some time with each parent separately. Our usual practice is to follow parental preferences in the ﬁrst instance but to be alert to cues that suggest that it may be necessary to see parents on their own for a brief period in addition. However, it should be noted that

CLINICAL ASSESSMENT AND DIAGNOSTIC FORMULATION

one study (Cox et al. 1995) showed that families did not respond well to a change of style from family to individual, or vice versa, when making the transition from diagnostic assessment to therapeutic intervention.

School reports
It is always desirable to obtain a school report, preferably in advance of the ﬁrst interview with the family, but after obtaining their agreement that the school may be contacted. Children may well behave differently at school from the way they do at home and it is important to obtain an account of scholastic functioning; educational difﬁculties are frequently associated with psychopathology. There are some advantages in using a standard questionnaire as part of the reporting from school (see Verhulst & Van der Ende, Chapter 5). However, a questionnaire is never adequate on its own: it is crucial for teachers to be able to express their own concerns which may involve features that are outside the coverage of the questionnaire; it is important to consider changes over time and not just present behaviour; and it is important to ﬁnd out how school has dealt with difﬁculties and how the child has responded to whatever actions were taken. There may be speciﬁc queries that arise out of the diagnostic assessment and, when that is the case, it may be useful for a member of the clinical team to contact the school directly in order to discuss the points that have arisen. Particularly when there seems to be a major discrepancy between the accounts of the child’s behaviour at home and at school, visits to both settings to observe what is happening may be informative.

ﬂect social features of the situation? What are the implications for the situational factors that seem to facilitate better performance? A crucial part of any psychological assessment concerns the evaluation of the likely validity of the ﬁndings. Attention needs to be paid to the extent to which it was possible to engage the child in the relevant tasks, noting whether disturbed behaviour may have interfered with task performance. Particularly in the case of young children for whom there is a query regarding possible severe mental retardation, it is important to note how the child dealt with the situation as a whole, and with the task presented. A clear enquiring curiosity about the environment, a systematic problem-solving approach, and initiative combined with imagination in dealing with test materials, would all raise questions about the validity of a very low test score. Obviously it is necessary to consider whether overall task performance has been constrained because of speciﬁc difﬁculties in functions such as language, motor coordination or vision. In terms of the predictive validity of scores, consideration also needs to be given to the possibility that current cognitive functioning has been impaired as a result of severely disadvantageous rearing experiences that no longer apply. In short, test scores provide invaluable information but they need to be interpreted in relation to the assessment as a whole.

Medical examination and testing
The considerations that apply to medical examination and possible testing are discussed by Bailey (Chapter 10). The principles that should underlie decision-making on this issue are those that apply in any clinical assessment. The most fundamental requirement is that a thoughtful and systematic history-taking should be used as a guide to the possibility that somatic problems may be relevant to the psychopathology that has been the focus of the referral. When there is nothing in the history to suggest the presence of a possibly relevant somatic condition, it is sufﬁcient to measure the child’s height and weight, and to undertake a screening neurodevelopmental examination that does not require the child to undress fully. Questions should be asked to determine pubertal status but, unless it appears likely to be speciﬁcally relevant, there is no need to undertake a physical examination for this purpose. When the child has a possible global or speciﬁc developmental delay, or a disorder such as autism (see Lord & Bailey, Chapter 38) or hyperkinetic disorder (see Schachar & Tannock, Chapter 25), a rather fuller assessment is necessary (see Bailey, Chapter 10; Volkmar & Dykens, Chapter 41). This needs to be guided by leads provided in the history but routine assessment for somatic conditions (such as tuberous sclerosis or chromosomal abnormalities) for which there may not be leads in the history, and which have a signiﬁcant association with psychopathology, need to be covered by the appropriate screening examinations and tests. It is important to bear in mind the possibility of relevant general medical conditions, as well as 21

Psychological testing
Sergeant & Taylor (Chapter 6) provide an account of both the approach that needs to be taken to psychological testing and of its role in the overall diagnostic assessment. As they note, a key part of the psychological evaluation concerns the psychologist’s observation of the child’s behaviour in relation to the tasks that have been given and in relation to the social encounter with the psychologist. This is important because of the information that it provides about the child’s psychological functioning generally, and not just because of its importance in relation to the interpretation of the psychological test ﬁndings. So far as the latter are concerned, it is essential in all cases to consider whether the scores are consistent with the account of the child’s performance given by the parents and by the school and in keeping with the clinician’s observations of the child. Of course, it is to be expected that there will not be perfect agreement across all assessments but, if there are major discrepancies, that always has to be a matter for further study. If the child’s performance during standardized testing was markedly better or markedly worse than that expected on that basis of other people’s reports, what is the explanation? Does it reﬂect differences in the cognitive demands in the several situations, or does it re-

CHAPTER 2

those directly involving the central nervous system (see Goodman, Chapter 14). Possible endocrine problems in relation to the differential diagnosis of eating disorders should be considered (see Steinhausen, Chapter 34). Appropriate medical assessments are essential when there are symptoms affecting somatic functions, because this could result from somatic disease. Early studies of so-called hysterical conversion reactions in both children (Caplan 1970) and adults (Slater 1965) have shown the relatively high frequency with which these were wrongly diagnosed as psychogenic in origin, as shown by the clear emergence of underlying physical disease of a directly pertinent kind during the course of follow-up. With proper clinical assessment, such misdiagnoses nowadays should be much less common, but clinicians need to be aware of the possibility (see Mrazek, Chapter 48).

Presence/absence of clinically signiﬁcant psychopathology
Because most psychiatric disorders do not include pathognomonic qualitatively abnormal features that cannot be found in normal children or adolescents, a key basic question has to be whether the severity or nature of psychopathology is such as to be clinically signiﬁcant. Necessarily, that query comprises two somewhat different issues. First, there is the question of whether the problems being considered are causing signiﬁcant suffering for the individual or signiﬁcant distress for others. Secondly, there is the question of whether the psychopathology is such as to fall outside the normal range of behaviour, or which carries with it a signiﬁcant likelihood of recurrent or chronic malfunction. Clinical intervention will sometimes be indicated when the answer to one of the questions is in the afﬁrmative but in the negative to the other. Thus, a serious grief reaction following the death of a loved one is quite common in normal individuals but it may warrant offering appropriate counselling (see Black, Chapter 18), even though it may not be a psychiatric disorder in the normal sense of the word. Similarly, many parents present at health clinics with their child’s difﬁculties in eating or sleeping, which are essentially normal, but are yet causing major family disruption. Appropriate guidance and help may well be needed in such circumstances (see Stein & Barnes, Chapter 45). Angold (Chapter 3) considers the features that need to be considered when deciding whether emotional disturbance amounts to a clinically signiﬁcant disorder. The question is an important one because anxiety, depression and fears are a normal part of the human condition that most people experience at some time. The considerations to be taken into account include: whether there has been a substantial change from the person’s usual mental state; whether the intensity of the emotions goes beyond the range of normal variation; whether the person is able to control the unpleasant emotions by means of distraction or engagement in pleasurable activities; whether the emotions intrude into and interfere with normal life functioning; and whether the emotions are pervasive across situations. Somewhat similar criteria 22

apply to overactivity/inattention but with the difference that, because these are usually ﬁrst manifest in the preschool years, there will not usually be a recognizable change from any previous normal pattern. The assessment of disruptive behaviour is rather less straightforward because the child may not perceive that there is a need to control such behaviour. From the time of the Isle of Wight studies (Rutter et al. 1970) onwards, the degree to which psychopathology gives rise to impairment of psychosocial functioning has been a key consideration in the assessment of clinical signiﬁcance. There was a further impetus to use such a criterion from the epidemiological evidence that some forms of symptomatology, particularly speciﬁc phobias, were present in what seemed to be an absurdly high proportion of the population if impairment was not taken into account (Bird et al. 1990; Bird 1999). This has appeared a reasonable approach because, if psychopathology is not impairing functioning, there would not seem to be much need for intervention. Epidemiological ﬁndings have been consistent in showing that there are substantial differences among different forms of psychopathology in the extent to which there is associated impairment. Quite a few children show psychosocial impairment associated with psychopathology but without the required number of symptoms to fulﬁl the criteria for a speciﬁc diagnosis (Angold et al. 1999b). When this is the case, intervention may well be justiﬁed. The presence of marked symptoms in the absence of impairment is most frequently seen in relation to speciﬁc phobias (Simonoff et al. 1997). Conversely, it is rather unusual for there to be multiple symptoms of depression without there being any impairment (Pickles et al., 2001). However, the diagnosis here is made not just on the severity of negative mood, but also on associated phenomena such as self-depreciation, feelings of guilt, feelings of hopelessness about the future, and suicidal thoughts or actions. The need to consider associated symptomatology constitutes a key element in diagnosis. Thus, clinically signiﬁcant developmental disorders of language need to be differentiated from normal variations in language development on the basis of the breadth of affected language functions (e.g. including understanding as well as use of spoken language), impaired use of language-related skills in make-believe play, difﬁculties in the control of motor movements associated with spoken language (as with drooling), and associated socioemotional or behavioural problems (Rutter 1987). Although certainly a useful criterion to employ, there are both logical and practical problems associated with giving it too high a priority. First, from a medical perspective, it would seem foolish to say that a person did not have a disorder because they were not impaired if there were signs or symptoms (or test ﬁndings) indicating an obviously pathological condition. Thus, someone with diabetes, whose condition has been shown by the appropriate laboratory tests, would still be diagnosed as having diabetes even if functioning was unimpaired because symptoms were well controlled by diet or the use of insulin. The same would clearly apply in the case of schizophrenia that was well controlled by appropriate medication. In these instances,

CLINICAL ASSESSMENT AND DIAGNOSTIC FORMULATION

however, the abnormality is evident in terms of qualitatively abnormal ﬁndings, as evident either by history or present status, or both. The second concern is that a person may cope successfully with their disorder to the extent that symptoms are not manifest because the situations that elicit them have been avoided. There will not be psychosocial impairment if the person’s life is so organized that the issues do not arise. This most obviously applies in the case of certain phobias. Thirdly, the degree to which there is psychosocial impairment will inevitably be inﬂuenced by social circumstances. Many decades ago Wootton (1959) pointed to the absurdity of rates of disorders going up and down according to ﬂuctuations in the employment rate. She noted too the major difﬁculties in basing a diagnosis of psychiatric disorder on the extent to which it caused problems for other people. This has been a problematic issue in deciding whether conduct disorders should be regarded as psychiatric conditions (Hill & Maughan 2001). In this case, what is a persuasive argument in favour of regarding it as a disorder is the extensive evidence of impaired personal functioning in both childhood and adult life, including an increased risk of suicide and of other forms of psychopathology. Although qualitative abnormalities are not a feature of most psychiatric disorders in childhood or adolescence, they are present in some. For example, the pattern of socioemotional deﬁcits shown by individuals with autism is one that would be abnormal at any age (see Lord & Bailey, Chapter 38). The same applies to the thought disorder, negative symptoms, and delusions/hallucinations found in schizophrenia (see Hollis, Chapter 37). The situation is not quite so clear-cut with obsessive-compulsive phenomena but, although ruminations and minor checking behaviour may be regarded as falling within the normal range of variation, that is not the case with overt compulsive rituals of a marked kind (see Rapoport & Swedo, Chapter 35). Somewhat similar considerations apply to Tourette syndrome and chronic multiple tics (see Leckman & Cohen, Chapter 36). Particular care needs to be taken in eliciting detailed descriptions of such qualitatively abnormal features because, if people have not experienced these phenomena, they may interpret the questions as referring to the more normal features that are within their experience (see Angold, Chapter 3).

for a major depressive disorder, and it is noteworthy that the research diagnostic criteria specify 4 weeks, rather than 2 (Mazure & Gershon 1979). Also, 2 years seems an incredibly long time to require a dysthymic disorder to last in order to regard it as meeting criteria. A further problem is that, even with high quality research interviewing that involves a speciﬁc focus on personalized timing, the reliability of the timing of onset of disorder has proved rather poor (Angold et al. 1996). In all probability, this is not mainly because people ﬁnd it difﬁcult to remember some clearly identiﬁable time when a disorder began, but rather because many disorders do not have a clear-cut onset. Frequently, symptomatology builds up over time with several points at which new symptoms become apparent and/or when psychosocial impairment ﬁrst becomes evident (Rutter & Sandberg 1992; Sandberg et al., 2001). Clearly, it is important for clinicians to obtain as good an account as possible of how psychopathology developed over time and to seek to identify times that might be conceptualized as either an onset of disorder or a clear worsening of disorder. However, from a clinical perspective it is less appropriate to follow DSM-IV rules about duration in a slavish fashion than it is to decide that the symptoms constitute something that manifestly falls outside the range of normal variation for that person and which either involves qualitative abnormalities or has interfered with psychosocial functioning to a substantial extent.

Nature of the mental disorder
If the assessment has indicated that there is a signiﬁcant psychopathological disorder, the next question is what form it takes, and what diagnosis or diagnoses may be applied to it (see Taylor & Rutter, Chapter 1). ICD-10 (World Health Organization 1992) and DSM-IV (American Psychiatric Association 2000) adopt different approaches to this issue. Both accept the frequency with which mixed patterns of symptomatology occur but they deal with them in different ways. DSM-IV takes the line that, in most cases, good wellvalidated empirical evidence is lacking on how to decide on the precedence to be given among differing patterns of symptomatology. Accordingly, rather than make arbitrary decisions on some hierarchy, for the most part the clinician is expected to diagnose as present any pattern that meets the criteria for a diagnosis. The inevitable consequence of this approach is that comorbidity (the co-occurrence of two or more supposedly separate disorders) is exceedingly common (Caron & Rutter 1991; Angold et al. 1999a). Indeed, it is quite frequent for individuals to receive three or four or even more diagnoses. The merit of this approach is that it provides a means of noting the mixed patterns of psychopathology without having to invoke hierarchical rules for which there is a lack of good supporting evidence. The disadvantage is that it implies that a high proportion of patients have multiple separate conditions. Common sense indicates that that is not likely to be true with most children in community clinics. 23

Duration and timing of disorder
Classiﬁcation systems have often used duration of disorder as a key criterion by which to determine whether or not psychopathology is clinically signiﬁcant. For example, DSM-IV (American Psychiatric Association 2000) has speciﬁed a minimum duration of 2 weeks for a major depressive disorder, 1 month for a generalized anxiety disorder, 6 months for a conduct disorder or a generalized anxiety disorder, and 2 years for a dysthymic disorder (but no duration is speciﬁed for anorexia nervosa). It is immediately obvious that there is an essentially arbitrary nature to the choice of these time periods. Thus, most clinicians would regard 2 weeks as a rather short period of time

CHAPTER 2

ICD-10, by contrast, takes the line that, ordinarily, one should assume that there is just one condition, unless there are good grounds for supposing the true occurrence of several. What this means in practice is that the clinician is expected to consider the psychopathology as a whole and then decide which diagnosis constitutes the ‘best ﬁt’ to the pattern seen in the individual case. There is little doubt that this conceptualization is likely to be valid, but the problem lies in the lack of good empirical bases for many types of decision-making that are required. Two particularly common examples may be used to illustrate the dilemmas. Numerous studies have shown the high frequency with which anxiety symptomatology and depression symptomatology co-occur (see Harrington, Chapter 29; Klein & Pine, Chapter 30) and the same applies to the overlap between oppositional/deﬁant behaviour and conduct problems (see Earls & Mezzacappa, Chapter 26). In both cases, research ﬁndings clearly point to the need to take a developmental perspective. Longitudinal studies have shown that a common sequence is for anxiety disorders in middle childhood to lead on to depressive disorders in adolescence or early adult life (Kovacs et al. 1989; Weissman 1990; Orvaschel et al. 1995; Wickramaratne & Weissman 1998). Twin studies in both children (Thapar & McGufﬁn 1997) and adults (Kendler 1996) have shown that to a very considerable extent anxiety and depression share the same underlying genetic liability. This is probably indexed to a considerable extent by the personality trait of neuroticism (Kendler 1996). That does not necessarily mean that anxiety disorders and depressive conditions should be regarded as synonymous because both involve environmental, as well as genetic, risk factors. There is some evidence in both children and adults (see Sandberg & Rutter, Chapter 17) that they are associated with rather different forms of precipitating stress experiences (psychological loss predominating in the case of depression and threat in the case of anxiety). Longitudinal twin data (Silberg et al., 2001) are informative in showing that early anxiety problems are associated with postpubertal depression and that a shared genetic liability is important in that link. The diagnostic problem at the time of clinic assessment, however, has to focus on the slightly different issue of overlapping symptomatology at the same point in time. Regardless of which diagnostic convention is followed, it is important for the clinician to assess the relative importance of anxiety and depression in relation to the clinical picture as it presents at that time. It will be necessary to take account of both sorts of psychopathology in deciding how to intervene therapeutically but, in so far as medication is used, it is clear that antianxiety drugs are not a good way of treating depression, but that antidepressants may be effective in reducing anxiety as well as depressive phenomena (see Harrington, Chapter 29). Somewhat comparable issues arise with respect to oppositional/deﬁant conduct problems. The two frequently co-occur, but longitudinal studies show the frequency with which oppositional/deﬁant behaviour in early childhood leads on to conduct disorders in later childhood or adolescence (Hinshaw et al. 1993). Because transitions in psychopathology tend to take 24

place over lengthy periods of time, it follows that it is likely that there will be many instances in which the child has a mixture of the two types of problem behaviour but below the threshold for each, because one disorder is gradually being taken over by the other. That is exactly what the ﬁeld studies for DSM-IV showed (Lahey et al. 1998). Moreover, twin studies have shown that the two forms of symptomatology share the same genetic liability to a very considerable extent (Eaves et al., 2000). The implication is that, in reality, these are probably somewhat different manifestations of the same basic psychopathology, rather than two different conditions with different causes and different implications for treatment (see Earls & Mezzacappa, Chapter 26). Similar issues arise with respect to the evidence that overactivity/inattention in early childhood carries with it a substantially increased risk for later antisocial behaviour (Rutter et al. 1998a). These associations extend well beyond the diagnostic boundaries, at least of hyperkinetic disorder as conceptualized in ICD-10. It is noteworthy that the strong genetic component in hyperactivity seems to apply across a broad range (to a dimensional variation in this characteristic) and not just to an extreme disorder (Thapar et al. 1999). There may well be good grounds for retaining a concept of hyperkinetic disorder as a separate categorical condition (see Schachar & Tannock, Chapter 25) but there is also a need to recognize the prognostic importance of patterns of overactivity and inattention that fall short of the diagnostic criteria for that disorder. Again, the clinical need, regardless of which set of diagnostic conventions are followed, is for the clinician to try to decide the meaning and mechanisms underlying the mixed pattern of symptomatology. Twin data indicate that both forms of symptomatology share a common genetic liability to a considerable extent (Nadder et al., in press), even though oppositional/deﬁant and conduct problems are, to an important extent, separate from hyperactivity (Nadder et al., 2001). The need to sort out meaning and mechanisms goes well beyond decisions on which diagnostic conventions to follow. A more basic hypothesis-testing approach to diagnostic assessment is fundamental to the diagnostic enterprise. For example, although not well reﬂected in either of the two main classiﬁcation systems, it is important to differentiate among the various causes of faecal soiling (Rutter 1975). This may arise, for example, because the child has failed to gain bowel control. Alternatively, control may well have been achieved and maintained, with the disorder lying in the deposition of faeces in inappropriate places, rather than in any lack of or loss of control. A third possibility is that there has been faecal retention leading to gross distension of the bowel and partial blockage. In these circumstances, faecal soiling may arise because there has been an overﬂow of faeces stemming from the prior distension. In order to differentiate among these possibilities, careful assessment is needed of whether or not the faeces are normal in form and consistency; whether there is a history of previous normal bowel control; whether the soiling has been preceded by patterns of retention or other abnormalities in bowel functioning; and whether the deposition of faeces is essentially random, accord-

CLINICAL ASSESSMENT AND DIAGNOSTIC FORMULATION

ing to where the child happens to be at the time that the bowels are opened, rather than selectively placed in situations having psychological meaning. Clearly, the therapeutic interventions need to be chosen on the basis of the type of disorder represented by the soiling (see Clayden et al., Chapter 47). A decision tree approach may also be very useful in the assessment of developmental disorders of language (see Bishop, Chapter 39). When the diagnostic issue concerns some pattern of psychopathology associated with the language delay, it is helpful to tackle the decision-making in stepwise fashion (Rutter 1985). Thus, it is usually best to begin by determining the child’s overall level of cognitive functioning, going on to consider whether language skills are signiﬁcantly below those of other aspects of cognitive functioning. The question then is whether the psychopathology shown is outside the range of normal behaviour expected in relation to the child’s overall mental age and overall level of language functioning. If it is outside that range, rather than move on straight away to consider the complete list of possible psychiatric diagnoses, it is generally helpful to question whether the behaviours are of a kind that might be found in any child (the usual run of emotional problems and disorders of disruptive behaviour, etc.) or whether the pattern is qualitatively different in a way that is associated with pervasive developmental disorders. It is then easier to move on to a consideration of which particular diagnostic concept best ﬁts the picture in the light of that decision. The possibility that the disorder is not represented at all in the current classiﬁcation system should also be considered. As Kanner aptly put it in the title of one of his papers on differential diagnosis, ‘The children haven’t read those books’ (Kanner 1969). The point that he was making was that there is a most imperfect match between the neat diagnostic descriptions given in textbooks and the clinical presentations seen in referred patients. The usual explanation will be that the person has a somewhat atypical variety of a well-recognized well-validated disorder. Nevertheless, the last half century has seen the recognition for the ﬁrst time of several disorders of considerable importance. Kanner’s (1943) identiﬁcation of autism is the most striking example, but it is closely followed by the identiﬁcation of Rett syndrome (Rett 1966; Hagberg et al. 1983). Both Asperger syndrome (Asperger 1944) and Wolff’s concept of schizoid disorder of childhood (Wolff & Chick 1980; Wolff 1995) constitute other variants within the realm of what might be regarded as autism-spectrum disorders. ‘New’ conditions are by no means restricted to this group of pervasive developmental disorders. Russell’s (1979) identiﬁcation of bulimia nervosa and Meadow’s (1977) account of the Munchausen by proxy syndrome constitute other important examples of a very different kind. The concept of attachment disorders (see O’Connor, Chapter 46) constitutes yet another example. More recent, and therefore less validated, examples are also provided by the quasi-autistic pattern seen in some children who have experienced profound institutional deprivation (Rutter et al. 1999a); the social abnormalities that have been found to be associated with severe developmental disorders of receptive language

(Howlin et al. 2000; Mawhood et al. 2000); and the autistic-like patterns seen with some cases of congenital blindness (Brown et al. 1997). Not all of these patterns of psychopathology constitute well-validated syndromes but the general point remains: clinicians must always be on the alert for unusual patterns that do not ﬁt existing diagnostic conventions. In some cases, the clinical question may refer to a particular phenomenon rather than a pattern of psychopathology. For example, during the 1980s there was some excitement over reports that autistic children who could not speak could nevertheless communicate at a high level when given assistance through a range of techniques that came to be called ‘facilitating communication’. The children were said to communicate by guiding someone else’s arm to point to letters to spell out words, or some other comparable means of communicating via another person, called a facilitator. The key to sorting out the validity of these claims (in the individual case just as much as in the studies of groups) lay in setting up a situation in which the information available to the child and the information available to the facilitator was different. When this was done it became apparent that the communications were being determined by the facilitator rather than the handicapped child (Rutter et al. 1998b). Comparable issues arise in relation to the diagnosis of selective mutism (see Bishop, Chapter 39), a syndrome characterized by a high degree of selectivity in circumstances of talking. In both instances, as in experimental studies more generally, the need is to design a situation in which children can and do succeed but do so in ways that are informative on the mechanisms involved. Thus, in the case of selective mutism, the need is to be able to demonstrate that the children can use spoken language in particular circumstances, just as much as showing that they do not use spoken language in other situations.

Psychosocial assessment
Psychosocial risks are important in the development of psychopathology (see Friedman & Chase-Lansdale, Chapter 15; Sandberg & Rutter, Chapter 17). It is important therefore that the diagnostic assessment provides an efﬁcient, reliable and valid means of assessing the presence of psychosocial risk factors. However, it should not be seen as exclusively related to questions of causation. In planning psychological interventions (when indicated) it is important to identify possible protective mechanisms, as well as risk features. Moreover, it is necessary to assess risk and protective factors, not only in terms of what is happening within the family, but also what is happening within the peer group, school and community (Rutter et al. 1998a; Shonkoff & Phillips 2000). Furthermore, the psychosocial assessment needs to include both past experiences and current circumstances. On the whole, most early experiences do not have enduring effects that are independent of later psychosocial circumstances (Clarke & Clarke 2000). Nevertheless, profoundly depriving experiences can have major sequelae that persist long after children have ceased to suffer deprivation and have had 25

CHAPTER 2

good rearing experiences in a well-functioning family (Rutter et al., in press, a). Similarly, there may be enduring effects of seriously abusive experiences (see Emery & Laumann Billings, Chapter 20; Glaser, Chapter 21). The same applies to some instances of very severely traumatic experiences in relation to persisting post-traumatic stress disorder (see Yule, Chapter 32). A key consideration with respect to all these experiences, risk and protective, is the need to appreciate that the experiences cannot be thought of as impinging on a passive organism. Children, and adults, think and feel about what they experience and the cognitive/affective sets that they develop (or internal working models) may be very important in determining the consequences of such experiences. What this means is that the assessment needs to determine both how children have coped with their experiences (see Compas et al., Chapter 55) and what they have thought about what has happened to them and how they view their current experiences. Research over recent decades has made it abundantly clear that genetic factors play an important part in the origins and persistence of all forms of behaviour, including all forms of psychopathology (Rutter et al. 1999b,c; see McGufﬁn & Rutter, Chapter 12). The ﬁndings are of major clinical importance for several rather different reasons. They show the importance of recognizing the inﬂuence of genetic susceptibilities with respect to individual differences in the liability to psychopathology. That means, amongst other things, that any adequate diagnostic assessment will need to include systematic questioning with respect to a family history of psychopathology. Particular attention needs to be paid to disorders in parents and in siblings, not just because they are the closest relatives with respect to genetic inheritance, but also because mental disorders in the immediate family will involve environmentally mediated, as well as genetically mediated, psychosocial risks (Rutter 1989). Thus, parental mental disorder is associated with a substantially increased risk of family discord and family breakdown, and also focused hostility on individual children (Rutter et al. 1997). It is important to assess the ways in which parental mental disorder impinges on the family and not just be content with recognizing its presence. The risks may also involve physical risk factors in relation to substances that cross the placental barrier during pregnancy. Thus, high levels of alcohol ingestion in the early months of pregnancy may lead to the neurodevelopmental abnormalities associated with fetal alcohol syndrome (Spohr & Steinhausen 1996; Stratton et al. 1996). There may also be effects from taking recreational drugs or prescribed medications (Singer et al. 1997; Delaney-Black et al. 2000; see also Marks et al., Chapter 51). The extent to which there is enquiry about mental disorders occurring in second- and third-degree relatives needs to be guided by the particular clinical problem. However, it should be routine to ask about the occurrence of major mental disorders or developmental problems in both sides of the family. Genetic testing (using cytogenetic and molecular genetic methods) is not part of routine assessment but it is important in some circumstances (see Skuse & Kuntsi, Chapter 13) and could become more generally applicable in the future. 26

Research methods that provide systematic standardized assessments of psychosocial features are too time-consuming for use in most clinics. Nevertheless, they do provide helpful guides on how such routine clinical assessments should be undertaken. As with the assessment of psychopathology, the agreement between the reports of parents and children tends to be modest to moderate at best (Rutter et al. 1970; Achenbach et al. 1987; Simonoff et al. 1997; Borge et al., 2001). That is partly because parents will not know about the full range of children’s experiences outside the home, partly because their perspectives may not be the same, and partly because some disorders may be relatively situation-speciﬁc (Cox & Rutter 1985). The implication is that some assessment of psychosocial risk and protective experiences needs to be obtained from both parents and children. The classiﬁcation of psychosocial experiences developed by the World Health Organization (van Goor-Lambo et al. 1990) provides some guidance on the range of experiences that need to be considered and there are standardized interviews that cover most of the relevant experiences (Sandberg et al. 1993). However, the research ﬁndings from studies that have used designs that can separate environmental from genetic mediation (Rutter et al., in press, b) suggest that the experiences carrying the greatest psychopathological risk mainly concerns marked negativity in close personal relationships, a lack of continuity in personalized caregiving, a lack of appropriate learning experiences, and participation in social groups with a deviant ethos, attitudes or styles of behaviour (Rutter 2000a). Although not much investigated in genetically sensitive designs, it is likely that parental monitoring and supervision of children’s behaviour are also important in relation to antisocial problems (Rutter et al. 1998a; but see Stattin & Kerr 2000 with respect to the role of children’s disclosures). In relation to all these experiences, it is necessary to determine the ways in which such experiences impinge on the individual child, and are responded to, and not just the experiences as they affect the family as a whole. Although excessive claims have been made about the preponderant importance of child-speciﬁc experiences (Rutter et al. 1999a; Reiss et al. 2000), it is the risks as they affect the individual child that are important, even if they impinge similarly on other children in the same family. In that connection, the research evidence suggests that it is often useful to make direct comparisons among children in the family with respect to features such as whether one is more likely to be criticized than others, or is more frequently favoured, or is more likely to be involved in relevant risk or protective experiences in the family (Carbonneau et al., 2001 & submitted). In addition, research has shown how much can be inferred from the ways in which a parent talks about the children. This was ﬁrst demonstrated in the Camberwell Family Interview (Brown & Rutter 1966; Rutter & Brown 1966) but has been developed as a much briefer assessment in relation to the 5-min speech sample (Magaña et al. 1986). The implication is that it is important to have a time during the assessment when parents are asked neutral questions about their children, not just questions focusing on problems. Thus, it is helpful to get parents to talk about what

CLINICAL ASSESSMENT AND DIAGNOSTIC FORMULATION

their children are like as individuals, how easy they are to be friendly and affectionate with, what is their most striking individual characteristic, etc. The same, of course, applies similarly to the ways in which children talk about their parents and about their siblings.

Diagnostic formulation
Diagnoses serve the important role of providing a succinct summary of the key clinical features that are held in common with disorders experienced by others (see Taylor & Rutter, Chapter 1). This is a most important purpose and one that is central to communication among clinicians, just as much as among researchers. Multiaxial systems of classiﬁcation can go somewhat further because they serve to classify relevant psychosocial situations that may have played a part in either causation or which may be pertinent with respect to therapeutic planning, as well as intellectual level and a level of adaptive functioning. By considering the information included across a complete range of axes, quite a lot of clinically relevant information can be summarized succinctly. Nevertheless, that is not quite the same thing as developing hypotheses about causal processes and hypotheses about therapeutic interventions. For example, suppose it has been found that the child has cerebral palsy. As outlined by Goodman (Chapter 14) there is good epidemiological evidence that this is associated with a substantial increase in psychopathological risk in groups of children with this condition. However, the risk could come about through several different routes, each of which have different implications for intervention. Thus, in some instances, the main risk may derive from the electrophysiological disturbance associated with frequent, poorly controlled epileptic attacks. In other cases, the risk may stem from impaired cognitive skills and from the educational difﬁculties to which they may give rise. In some cases there may be relatively direct neural effects of brain dysfunction, as exempliﬁed in so-called frontal lobe syndromes exhibiting social disinhibition that sometimes occur after severe head injuries (Rutter et al. 1983). In yet other cases, the psychopathological risk may derive from the child’s negative self-image as a result of his or her physical limitations, or perhaps from parental overprotection that came about as a way of dealing with a physically handicapped child. In yet other cases, the cerebral palsy may be a relatively incidental ﬁnding that has no particular relevance to the mental disorder. When dealing with a single case, it is difﬁcult to have hard evidence to enable a choice between these alternatives, but it is important for the clinician to have a view on the likely importance of different mechanisms. Closely comparable issues arise with respect to psychosocial risk factors. If the mother is alcoholic, did the psychopathological risk derive from the child’s in utero exposure to high levels of alcohol, from the genetic susceptibility, or from the family disruption and poor parenting to which the alcoholism may have given rise. In considering causal processes, crucial distinctions

need to be drawn between distal and proximal risk processes (Rutter et al. 1998a) and also between inﬂuences on the initiation of the child psychopathology and the processes that are currently maintaining it. Thus, poverty and social disadvantage are associated with an increased risk of mental disorders in childhood, but most of the risks seem to be indirectly mediated. The overall disadvantageous social circumstances do not, in themselves, cause psychopathology but they do make good parenting more difﬁcult and the main risks stem from the parenting problems (Conger et al. 1992, 1993). In the same sort of way, parental loss and parent–child separations are associated with an increased risk of antisocial behaviour but, again, this seems to be largely because of the associated family discord and conﬂict (Rutter 1971; Fergusson et al. 1992). Furthermore, although family conﬂict is associated with an increased risk of psychopathology, it seems that this largely comes about when the conﬂict leads to negativity that is focused on that particular child (Reiss et al. 1995). In these examples, the global family situation needs to be thought of as a risk indicator, rather than an immediate risk mechanism. It is implicated in the causal processes but largely because it predisposes to other psychosocial features that constitute a more direct psychopathological risk. It is by no means easy to make these distinctions in the individual case, or even at a group level, but it is important when trying to decide how best to intervene. The distinction between initiatory or provoking risk factors and factors concerned with the maintenance of a disorder is somewhat different. For example, an extremely traumatic experience may precipitate a post-traumatic stress disorder (see Yule, Chapter 32) but some individuals recover quite quickly whereas others go on suffering for several years afterwards. In most cases, the difference between recovery and persistence is likely to lie less in the severity of the initial experience than in how the person thinks about that experience and how they have dealt with it. The original traumatic experience cannot be taken away but the person may be helped to deal better with both the thought patterns and emotional reactions to which the experience gave rise. In other cases, it may be helpful to differentiate between the factors that played a major part in the timing of the onset of disorder and those that were responsible for the increased liability that led to the disorder occurring at all (see Sandberg & Rutter, Chapter 17). Thus, severely threatening life events (such as psychological loss or humiliation) may precipitate the onset of a depressive reaction or the initiation of a particular behaviour such as a suicidal act (see Shaffer & Gutstein, Chapter 33). On the other hand, the overall susceptibility to disorder may have more to do with the associated chronic psychosocial adversity than with the time-limited acute event itself. One of the important ﬁndings in life events research is the high frequency with which seriously negative events derive out of chronic psychosocial adversity. Both are important but they may serve a somewhat different risk role. Clearly, the proximal risk mechanisms involved with the maintenance disorder must play a major part in determining the therapeutic hypotheses that constitute the basis for planning 27

CHAPTER 2

treatment. However, several other matters have to be taken into account. To begin with, it is necessary to consider possible protective mechanisms, as well as risk processes (Rutter 1990). As in the broader consideration of features associated with resilience (Rutter 1999, 2000b), such possible protective processes may reﬂect a quite diverse range of features. Thus, the strengths may lie in the child’s temperamental qualities and/or coping skills (Sandler et al. 2000), in the presence of a particularly good close relationship in or outside the family, of compensating good experiences at school or in the peer group, or in a possible change of pattern in family functioning. Thus, if one parent is particularly under stress, the other parent may be encouraged to take a greater role in parenting. The point is that the clinician needs to think broadly about the child’s psychosocial situation in order to identify possible strengths and protective possibilities. In planning any intervention, it is as necessary to decide which features are modiﬁable as it is to determine which are the risk and causal mechanisms. Thus, it is necessary to decide whether the intervention should focus primarily on working with the child, the parents, the family as a whole, the school, or trying to change other aspects of the broader environment. Of course, the treatment strategy may involve more than one of these avenues. One aspect of deciding about openness to modiﬁability concerns different perceptions of the child and of what needs to be done. Part of the same issue concerns a decision on what are realistic goals. The aim must be to provide relief for the child’s suffering in the ﬁrst instance, but restoration of full normality may not be a realistic goal (for example, only rarely would it be so in the case of autism; see Lord & Bailey, Chapter 38). Similarly, the intervention may not necessarily focus on the hypothesized basic causal process. Again, to use the example of autism, there would be general acceptance that this is a neurodevelopmental disorder but, equally, the evidence suggests that behavioural/educational interventions working with parents and teachers currently provides the best opportunities for reducing handicaps, even though autism has clearly not been caused by the lack of such experiences. Another decision concerns whether or not to use medication and, if medication is used, how it should be employed and when it should be introduced. There are no drugs that are curative for child psychiatric disorders but there are several conditions for which medication has been shown to produce worthwhile beneﬁts. These include depressive disorders (see Harrington, Chapter 29), obsessive-compulsive disorders (see Rapoport & Swedo, Chapter 35), tics and Tourette syndrome (see Leckman & Cohen, Chapter 36), schizophrenia (see Hollis, Chapter 37) and hyperkinetic disorders (see Schachar & Tannock, Chapter 25). They may also provide symptomatic beneﬁts in other disorders. Decisions on drug usage are inﬂuenced, among other things, by the severity of overall impairment and the particular pattern of symptomatology. Thus, stimulants seem to work less well when hyperactivity is accompanied by marked anxiety (see Schachar & Tannock, Chapter 25), and antidepressants are more likely to be effective when the depression is accompanied 28

by vegetative symptoms, such as sleep and appetite disturbance, and psychomotor retardation (see Harrington, Chapter 29). In most cases, medication needs to be combined with some form of psychological or educational intervention. Although medication brings marked beneﬁts, it does not restore normality by itself and steps may be needed to help the child and/or family cope more effectively and deal with any life situations or circumstances that provide psychopathological risk. Such interventions may only involve guidance or counselling of some kind but, in other cases, more intensive psychological intervention may be indicated. Decisions should be guided by what seem to be risk features, either in the psychosocial situation or the child’s style of thinking, or perhaps of behaviour. It should be added, however, that the use of medication will carry psychological messages and that, unless carefully handled, these can undermine the psychological intervention (see Craighead et al. 1981 for an example in relation to dieting). The implication is not that different forms of intervention should not be combined, but rather that the clinician needs to present the combination in an appropriate way. However, it should not be thought that drugs will only inﬂuence somatic features and not cognitions. The use of antidepressants in adult depression makes it clear that this is not the case (see Harrington, Chapter 29). Equally, it should not be supposed that psychological treatments cannot inﬂuence somatic functioning. The effects of psychological treatments in obsessivecompulsive disorder, in terms of their effects on functional imaging ﬁndings, negate that expectation (Baxter et al. 1992). Nevertheless, in relation to hypotheses about maintaining factors, the clinician will wish to take decisions on the appropriate choice, and mixture, of therapeutic interventions. It is important that this is done in a way that will indicate whether the therapeutic hypothesis is correct or needs modiﬁcation as a result of the response to intervention. Research ﬁndings are not as helpful as one might wish in the choice of which particular kind of psychological treatment to use. Although the evidence is reasonably consistent that focused goal-orientated interventions work better than more general open-ended ones (Rutter 1982), that would seem to suggest that the speciﬁcs of the treatment are important and that general support is not enough. On the other hand, although the range of comparisons remains more limited than one would like, the evidence does not indicate that, for any disorder, one particular style of psychological treatment is clearly generally better than others. Moreover, even when treatment is given by experienced clinicians with an investment in more intensive treatments, studies with both young people (Le Grange et al. 1992) and adults (Wallerstein 1986) have shown that skilled counselling may be as effective as more intensive psychological interventions that are designed to get more into the heart of the psychological problem. Although it should certainly not be supposed that simple treatments are always to be preferred, the ﬁndings do indicate that more complicated and intensive ones are not necessarily better. Decisions on the particular form of psychological intervention need to be guided by the nature of the

CLINICAL ASSESSMENT AND DIAGNOSTIC FORMULATION

psychological difﬁculties, the personal characteristics and preferences of the individual child and family, and the preferences of the clinician in terms of skills, experience and preferred mode of working. Nevertheless, cost–beneﬁt considerations are important and the choice of a more prolonged treatment over a shorter one always needs to be justiﬁed.

Conclusions
In this chapter, we sought to bring together some of the main considerations that should guide the approach to diagnostic assessment and the planning of treatment. Research ﬁndings are informative in providing guidance on some of the methods of assessment that work better than others and undoubtedly indicate the value of a systematic approach to the degree of standardization. But it is essential to be responsive to the individual needs and circumstances of each patient, to pick up cues and adapt assessment procedures accordingly. With respect to both diagnosis and the planning of treatment, it is also important to adopt a problem-solving hypothesis-generating, and hypothesistesting, style. The gathering of factual data on psychopathological signs and symptoms and on risk and protective circumstances constitutes the essential basis. On this basis, it is important to seek to tell a ‘story’ about causal processes and to use that ‘story’ to plan a treatment strategy and to do so in a way in which the response to treatment indicates whether or not the therapeutic hypothesis was correct.

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Diagnostic Interviews with Parents and Children
Adrian Angold

The purposes of the diagnostic interview
The clinical interview is the primary diagnostic tool in child and adolescent psychiatry, as in the rest of clinical medicine. Its ﬁrst purpose is to collect information that will assist in the tasks of making a diagnosis and formulating and implementing a treatment plan. With the ofﬁcial adoption of more fully deﬁned phenomenologically based ofﬁcial psychiatric nosologies (World Health Organization 1992, 1993; American Psychiatric Association 1994) and the introduction and increasingly widespread use of structured interviews, the diagnostic process has become more consistent over the last 20 years. Phenomenological diagnosis requires that information be collected in a coherent and consistent fashion, and thus sets the predominant style of the interview. The basic format is one of sensitive guidance by the clinician, rather than a free format in which parents or children simply play or discuss whatever occurs to them. The clinician guides, organizes and structures the collection of information in a way that is sensitive to the child’s and parent’s problems and concerns. This approach is very different from that of the ‘nondirective’ interviewer, who attempts to act as a sympathetic observer or sounding board and ‘interprets’ the material presented by the respondent. It has been shown that even supposedly ‘nondirective’ interviews are more directed than was once thought (Truax 1966, 1968), because the use of ‘uh huh’s’ and the timing of reﬂections on what the patient has said, serve as strong indicators of the clinician’s real interests. However, a good interview also aims to achieve several other objectives apart from discovering the ‘facts’ about a patient. A diagnostic interview is often the initial contact between child or parent and clinician, and then it is the ﬁrst step in establishing a treatment alliance with the clinical team. The same clinician may provide psychotherapy for one or more family members later on, so the diagnostic interview also represents a ﬁrst step in the formation of a therapeutic relationship. All too frequently the initial diagnostic assessment is the only contact an individual or family has with the clinical team, as many never return for treatment. With this in mind, it is important to avoid increasing the barriers to future treatment-seeking by providing a good experience of psychiatric services. For all these reasons, and because of the need to ask about emotionally sensitive material, the clinician should approach the task of collecting information in such a way as to assure the family of a genuine interest in their problems and sympathy with their difﬁculties. Under the best circumstances, the product of such interviews is not only much 32

relevant information, but also the family leaving the ofﬁce with a sense that something important about their problems has been understood by someone who cares and is willing (and perhaps able) to help. The respondent’s behaviour in the interview is another important source of diagnostic information. Thus, the art of good clinical interviewing lies in the ability to combine the efﬁcient collection of reported information, an observant eye, and the projection of interest and concern about the child’s problems.

The need for multiple informants
Until the late 1960s, in both clinical practice and research, interviews and questionnaires directed to a parent or teacher about a child’s behaviour and observation of the child’s behaviour were the predominant methods of assessment in child and adolescent psychiatry. Verbal information from the child was typically regarded as being only supplemental, or material for psychodynamic interpretation (Lapouse 1966). In standard texts, much more attention was paid to playing with the child than to the collection of information through direct questioning. In 1968, a key transitional paper reported on the reliability and validity of the Isle of Wight interview with the child (Rutter & Graham 1968). Here the behaviour of the child in a face-to-face interview was examined directly, but it is notable that not much was made of the factual content of what the child said. Herjanic et al. (1975) answered the question ‘are children reliable reporters’ of factual information in the afﬁrmative, on the basis of ﬁndings from the use of an early structured interview. Since then, a great deal of work has conﬁrmed the importance of children’s self-reports as a source of factual information, with the result that fact-ﬁnding (as opposed to interpretative) interviews with both parents and children are now regarded as being of equal weight in the diagnostic process, at least from late childhood to late adolescence. The one exception is in the evaluation of attention deﬁcit hyperactivity disorder (ADHD) symptoms, where child reports have been found to be of little help (Loeber et al. 1991). Even here the growth of interest in ADHD in adolescence and adulthood has led to the development of new measures in this area, as in the recent revisions of the Conners’ rating scales (Conners 1997). This emphasis on the factual content of the history given by the child does not imply that clinical observation of the child’s behaviour is not of great value; it is, as we shall see later.

DIAGNOSTIC INTERVIEWS WITH PARENTS AND CHILDREN

Disagreement among informants and implications for combining information from multiple informants
Until the 1980s, agreement between child and parent reports of symptomatology was widely regarded as being a test of the validity of child reports (Rutter & Graham 1968; Herjanic et al. 1975). However, subsequent research using all sorts of measures soon showed that only low levels of agreement among informants (correlation coefﬁcients around 0.3 for agreement among children, parents and teachers) could be expected (Reich et al. 1982; Stanger & Lewis 1993). It is now considered that low levels of agreement amongst different informants about the child’s clinical state are to be expected and do not invalidate the reports of any of them. Rather, each key informant (typically, child, parent and teacher) is seen as presenting a particular view of the child’s problems. Indeed, it is precisely because agreement among informants is low that multiple informants are needed. Were agreement very high, taking the history from more than one informant would be redundant. The problem is that disagreement among informants means that one has to decide how to weight the information from each informant in arriving at a diagnosis. Because it is uncommon for informants to invent ﬁctitious symptoms (though sometimes they do, and it is as well to be on the lookout for inconsistencies that may tip one off here), the simple rule of regarding a symptom as being present if any informant reports it usually sufﬁces well enough. When symptoms are combined to make diagnoses, the usual procedure is to ‘ignore’ the source, and to add up all positive symptoms from any source. Thus, a diagnosis of a major depressive episode (which requires the presence of at least ﬁve symptoms) might be made on the basis of three relevant symptoms being reported by the child (say, depressed mood, anhedonia and excessive guilt), with two other relevant symptoms (perhaps sleep and appetite disturbances) being reported by the parent. Though some interview developers have recommended ‘reconciliation’ discussions involving the interviewer, the parent and the child to clear up discrepancies between their reports, such discussions are problematic in several ways. First, to achieve their purpose, one informant must modify his or her story, but that means admitting being wrong, or at least uninformed. Requiring such admissions at the start of the therapeutic process will often not be helpful, although confronting individuals with different perceptions of their behaviour may be an important part of the therapeutic strategy beyond the initial diagnostic stage. Secondly, it offers a chance for family members to become engaged in arguments with one another — again, something not helpful to the initial phenomenological diagnostic process. Thirdly, the knowledge that such a discussion will occur could cause informants (e.g. drug-using adolescents) to withhold important information that they did not wish other informants (such as their parents) to hear about. Finally, in most research applications, one wishes to assure informants that what they say will not be revealed to anyone else, in which case a ‘reconciliation’ interview is ruled out. There are also situations in which consideration of the differ-

ences between informants’ reports may be of interest. Another way of saying that different informants present different ‘views’ of a child’s problems is that different informants provide information about different aspects of the child’s emotions and behaviour, even when each provides that information using the ‘same’ scale. Looked at in this way, it comes as no surprise that sometimes the correlates of reports of child psychopathology from different informants differ. For instance, the enormous increase in the rate of depression in girls during puberty seems to be accounted for by changes in self-reports of depressive symptoms, while parent reports do not change very much (Angold et al. 1991). An even more striking example is provided by the substantial differences in patterns of genetic and environmental effects resulting from the analysis of ratings of the ‘same’ phenomena by different reporters (mothers, fathers, teachers and children) in the Virginia Twin Study of adolescent behavioural development (Eaves et al. 1997). Such differences raise a number of interesting scientiﬁc questions about exactly what different informants are telling us about, but in everyday clinical practice, the usual ‘either/or’ combination rule sufﬁces for the most part. However, it is worth noting an important exception — the case in which parental reports are uncorroborated by any other source, including the clinician’s observation of the child. Here, the possibility of Münchausen syndrome by proxy should come to mind (Schreier 1997).

Implications of comorbidity for diagnostic interviewing
Research over the last decade or so has demonstrated beyond doubt that diagnostic comorbidity (the presence of symptoms meeting criteria for multiple diagnoses) is extremely common (Angold et al. 1999a), so the task of the assessment is not to ﬁnd the single diagnosis that best accounts for all the symptoms. Rather the question is which disorders can the child be said to suffer from, no matter how many they may be. As far as assessment is concerned this means that once one has decided that the child is depressed, one cannot then skip over the assessment of, say, disruptive behaviour, because a depressed child is also very likely to be oppositional, or conduct disordered, or a substance abuser as well.

Potential problems with using children younger than 9 as key informants
After the age of 9, the diagnostic interview with the child proceeds along much the same lines as is familiar from interviews with adults, as far as its structure is concerned. However, substantial differences in the case-mix to be expected in child psychiatric clinics and adult clinics (and in the child and adult general populations for that matter) have a substantial effect on the content of a typical child evaluation. In children, for instance, psychotic disorders are rare, but attention deﬁcit/hyper33

CHAPTER 3

activity problems are common. Although it is possible to demonstrate increased rates of forgetting in younger children in formal memory tests (Brainerd & Ornstein 1991; Ornstein et al. 1992) it seems that rates of forgetting are not markedly different, at least from the age of 6 to adulthood. Even 3-year-olds have been shown to be capable of remembering some events that occurred as much as a year before the interview (Pillemer & White 1989), though many such memories contain erroneous elements. In both adults and children, there is a tendency to conﬂate memories of repeated events into ‘scripts’ that provide a generalized memory of such events (Nelson et al. 1983; Saywitz 1987), incorporating features from a number of speciﬁc instances. Though there have been concerns about the accuracy with which children and adolescents can date events and the onsets of symptoms in their lives, there is little evidence that after the age of 9 they are any worse than adults at this task (Angold et al. 1996a). The adult literature suggests that it is easier to recall that something happened than when it happened, and major events are more likely to be remembered than minor events. The work of Cannell et al. (1977) in relation to the adult household survey suggests high rates of forgetting minor health problems (like headaches) over periods as short as 1 week, and substantial under-reporting of even major events by 1 year. Before the age of 8 or 9, ‘adult-style’ diagnostic interviews work very poorly. The problem is that younger children are incapable of providing the detailed information about onset, timing, duration and co-occurrence of symptoms that are required to meet standard criteria for a full diagnosis. However, we should also remember that older children and adults also often have difﬁculty with providing this sort of information (Breton et al. 1995; Schwab-Stone et al. 1994; Angold et al. 1996a), so the problem is one of degree, rather than kind. Nevertheless, children 8 years old and younger can describe fears and worries, mood states and covert antisocial behaviours (such as substance use, lying or stealing) that may not be apparent to any adults. If questioned sensitively and carefully, and without leading, they can often provide sufﬁcient detail to help with diagnostic evaluation. Children themselves may also be the only available sources of information about physical and sexual abuse, though here particularly careful interviewing is needed (Steward & Steward 1996; Bruck et al. 1998; see also Ceci et al., Chapter 8). Progress has also been made in developing approaches to collecting information from children that go beyond the ‘adultstyle’ question and answer formats, such as the MacArthur Story-Stem Battery (Warren et al. 1996, 2000) in which the interviewer uses toys to act out the beginnings of stories which the child is then asked to complete. The videotapes of these interactions can then be scored to provide indices of a variety of internal states. The Berkeley Puppet Interview (Measelle et al. 1998) employs two puppets to express two moods/states, and the child then indicates the puppet most like him- or herself, thereby providing self-report assessments of perceived academic functioning, social relationships, depression, anxiety and aggression/ hostility. Some simpler ‘questionnaires with pictures’ have also shown promise with preschool-age children in relation to 34

the assessment of depression and anxiety (Martini et al. 1990; Ialongo et al. 1993). However, none of these methods is capable of yielding all the information necessary for a DSM-IV (American Psychiatric Association 1994) or ICD-10 (World Health Organization 1992, 1993) diagnosis, and there is no general agreement about how such information should be incorporated into the overall diagnostic assessment. A great deal of work needs to be carried out to place the diagnosis of younger children on an equal footing with that of later childhood. From the age of 3 until the teenage years, there is an increase in the amount of information provided in free recall situations. Though younger children provide less information, they are no less accurate in their recall than older children and adults. The use of open questions is therefore the starting point for good interviewing, whether of children or adults about their children. When closed questions, and especially forced-choice question formats are used, younger children (including preschool-age children) can usually provide more information than in the free recall situation (Ornstein et al. 1992). However, they are also more likely to provide erroneous information (Bruck et al. 1998). This is not to say that closed questions do not have an important place in the clinical interview, but they are best used to ﬁll in the gaps in the information provided in response to open questions, or to clarify confusion, rather than constituting the basic approach. While preschool-age children are more likely to incorporate erroneous material introduced through repeated questioning, suggestion and leading questioning than older children, such techniques also induce reporting errors in older children, and even adults. There is no place for such techniques in psychiatric interviewing at any age (Bruck et al. 1998).

The need for a structured approach to diagnostic interviewing
It should be noted that structured interviews were originally developed because researchers were aware that clinicians unaided by such instruments tended to operate in an idiosyncratic fashion (Cantwell 1988; Gould et al. 1988; Remschmidt 1988), and to adopt inefﬁcient decision rules in coming to a diagnosis. It was also apparent that there was a tendency to focus on a particular set of problems without giving adequate weight to an exploration of the full range of symptomatology. Both of these problems are typical of unstructured medical decision-making in general. Other general human information processing characteristics that may endanger the diagnostic process include ‘illusory correlation’ (Chapman & Chapman 1967), in which the expectation that a correlation exists between two phenomena leads to the imputation of the presence of a second phenomenon from the observed presence of the ﬁrst. People also appear to have great difﬁculty identifying correlations when they really do exist in the phenomena that they are observing (Chapman & Chapman 1971). Thus, the observation that a child had made a suicide attempt might lead a clinician who believes that such actions are related to depression to assume that the child must be

DIAGNOSTIC INTERVIEWS WITH PARENTS AND CHILDREN

depressed, and to interpret any hint of sadness as conﬁrming this supposition. This latter tendency to weight information that ﬁts in with expectations is also called the ‘conﬁrmatory bias’ (Tversky & Kahneman 1974). Its corollary is that information that does not ﬁt in with expectations tends to be ignored (thus our clinician might fail to take a careful history of behaviour problems, which would be a serious mistake, because suicidality is also strongly related to conduct problems). Conﬁrmatory bias has also been identiﬁed as a real problem in the collection of evidence of abuse from young children (Bruck et al. 1998). The ‘representativeness heuristic’ (Tversky & Kahneman 1974) may also bias clinical judgements when a child has the characteristics of a particular group (say, children with conduct disorder), leading the clinician to impute to the child other characteristics of conduct-disordered children, which actually do not apply to that individual (see Achenbach 1985 for a basic introduction to the application of decision-making analysis to the assessment of psychopathology; Sox 1987; Dawes 1988 for more advanced treatments). That these effects occur in ordinary clinical practice is indicated by Costello’s (1982) examination of diagnostic case conferences at a major child psychiatric centre (described in Cantwell 1988), whereas Bird et al. 1992) found that clinicians were less likely to assign certain comorbid diagnoses than a computer algorithm incorporating the DSM-III diagnostic rules, when both made diagnoses based on the same information. In arguing that a structured approach to diagnostic interviewing is necessary, I do not mean to imply that the use of any recognized structured interview is mandatory, although I do believe that the growing practice of using such interviews in clinical situations is to be applauded. Rather, I mean that good diagnostic practice demands the adoption of an organized, coherent, repeatable interview structure that avoids the information collection biases inherent in the unstructured diagnostic process. In this the psychiatric history is no different from the history taken in any other branch of medicine. As a variety of structured interviews have been developed to deal with these problems, they provide helpful information about ways that individual clinicians can develop their own structured approach to diagnostic interviewing.

disconﬁrmatory information is combined to produce a ﬁnal diagnosis. Goals 1, 3 and 4 are achieved by all the major diagnostic interviews in rather similar ways; all cover at least the most common DSM or ICD diagnoses, and all have a set of rules, often computer algorithms, for combining the information collected to make diagnoses. However, goal 2, deﬁning how the information is to be collected, has led to two quite different approaches to structured interviewing. These two methods have been dubbed ‘interviewer-based’ (or sometimes ‘investigator-based’) and ‘respondent-based’ (Angold et al. 1995). Respondent-based interviews have often been referred to as being ‘highly structured’, while interviewer-based interviews have been called ‘semistructured’. These are misnomers, because the issue is not how much structure is present, but what is structured.

Interviewer-based and respondent-based interviews
Interviewer-based interviews
In an interviewer-based interview, the mind of the interviewer is structured. In essence, the interview schedule serves as a guide to the interviewer to help him or her determine whether a symptom is present; the interviewer makes that decision on the basis of information collected from the patient or other respondent. Deﬁnitions of symptoms are provided, and the interviewer is expected to question until he or she can decide whether a symptom meeting this deﬁnition is present. This group of interviews includes the Anxiety Disorders Interview Schedule (ADIS; Silverman & Nelles 1988; Silverman & Rabian 1995), the Child and Adolescent Psychiatric Assessment (CAPA; Angold & Costello 2000), the Child Assessment Schedule (CAS; Hodges et al. 1982; Hodges 1993), the paper and pencil (not the computerized) versions of the Diagnostic Interview Schedule for Children and Adolescents (DICA; Reich 2000) and its close relative, the Missouri Assessment of Genetics Interview for Children (MAGIC), the Interview Schedule for Children and Adolescents (ISCA; Sherrill & Kovacs 2000), the various versions of the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS; Ambrosini 2000), and the Pictorial Instrument for Children and Adolescents (PICA-IIIR; Ernst et al. 2000). All of these interviews, except the PICA-IIIR, make a wide range of DSM-IV diagnoses, and have components for assessing psychosocial impairment resulting from psychiatric symptoms and disorders. The PICA-IIIR is unusual in that it provides a series of pictures meant to illustrate particular forms of psychopathology around which the interview is structured. However, it is suitable for use only by clinicians and has been little tested. The DICA has also been used with children younger than 6 years, although special training is required for its administration in such situations. Interviewers are instructed to ignore the usual questioning format laid out in the schedule and use their own questions. The result is that much of the usual structure of the DICA is jettisoned, with unknown results for reliability or validity. Various other interviews exist for specialized purposes (such as the 35

Review of the current status of structured diagnostic psychiatric interviews for child and adolescent disorders
All structured diagnostic interviews seek, by whatever means, to achieve the following goals (which should also be the goals of every diagnostician): 1 structure information coverage, so that all interviewers will have collected all relevant information from all subjects; 2 deﬁne the ways in which relevant information is to be collected; 3 make a diagnosis only after all relevant conﬁrmatory and disconﬁrmatory information has been collected; and 4 structure the process by which relevant conﬁrmatory and

CHAPTER 3

Autism Diagnostic Interview, ADI; Lord et al. 1994), but they will not be discussed further here. Among interviewer-based interviews there are two subtypes: glossary-based and non-glossary-based. The K-SADS-P IVR and the CAPA (and the ADI) are glossary-based. They provide detailed written symptom deﬁnitions and rules for coding level of symptom severity and impairment resulting from symptomatology. The MAGIC provides a detailed procedural glossary (as opposed to the deﬁnitional glossaries of the CAPA and K-SADSP IVR), which is a mine of information on good interviewing technique. The other interviews mentioned above (including various other versions of the K-SADS) provide much less deﬁnitional information to guide the interviewer and can be regarded as being non-glossary-based. More detailed comparisons among the members of this group of interviews can be found in Angold & Fisher (1999).

Respondent-based interviews
In a respondent-based interview, it is the questions put to the respondent that are structured; prescribed questions are asked verbatim in a preset order, and the interviewee’s responses are recorded with a minimum of interpretation or clariﬁcation by the interviewer. Thus, although one knows exactly what has been asked in each interview, there is no control over differences in how subjects interpret questions or respond to them. It has been shown that, in the case of ‘bizarre’ phenomena (such as obsessive-compulsive symptoms), respondents’ thresholds for answering questions about them in the afﬁrmative are much lower than is helpful (far more cases are identiﬁed than really exist; Breslau 1987). There are two types of respondent-based interviews: pure verbal interviews and pictorial interviews. The former are like adult diagnostic interviews, and most of the interviewer-based interviews, in that they rely solely on verbal questioning without visual aids. The pictorial interviews involve showing children cartoon pictures intended to illustrate the questions being asked. The Diagnostic Interview Schedule for Children (DISC; Shaffer et al. 1999, 2000) is the most widely used pure verbal interview. The current version is the DISC-IV. A great advantage of the respondent-based approach is that it lends itself easily to computerization. Questions are arranged in unvarying logical sequences in such an instrument, with stem questions followed by sequences of further questions contingent upon the answers to the stems. Software is available to allow the presentation of such interviews on a personal computer. Computerization can be achieved at two levels. Computer-assisted psychiatric interviews (CAPI) employ an interviewer to read questions from the screen and enter the appropriate codes into the computer as the interview progresses. The machine takes the interviewer to the appropriate stem questions, and stores the responses in a database. There is no need for bulky interview schedules to be copied and carried around, and data entry is completed during the interview. Furthermore, the computer will not accidentally skip parts of the interview, or vary the order of its presentation. 36

The next level of computerization is referred to as computeradministered survey interviewing (CASI). Here no interviewer is used at all; digitized audio recordings of the questions (sometimes even with digitized video of an interviewer) are played back by the computer as the written form of the question is displayed. The respondent enters a response to the question, which is saved to the database. The DISC has become progressively more complex over the last 20 years (largely because of the everincreasing complexity of the DSMs), and the DISC-IV is now expected to be completed in its CAPI format, because it is really too difﬁcult to administer it effectively in a paper-and-pencil format. There is also a CAPI version of the DICA, but this differs from paper-and-pencil version of the interview in being fully respondent-based (Reich et al. 1995). The advantage of computerizability is somewhat offset from a clinical perspective by the fact that clinicians ﬁnd the task of completing a long respondent-based interview rather tedious. If they go off interview to follow-up on particular clinical leads in their own way, the strengths of a respondent-based interview are vitiated. In general, the interviewer-based format is more suitable for clinical use by clinicians. However, we have reached the point where it is feasible to have parents and children complete a diagnostic interview, such as the DISC, before they see a clinician at all. The possible output from the DISC is almost inﬁnitely ﬂexible, and requires only programming to allow the production of reports tailored to particular clinical needs that can be generated immediately the interview is ﬁnished. Equipped with such a report, a clinician familiar with one of the interviewer-based interviews would then be starting with a very respectable initial diagnostic formulation to guide further elucidation of the clinical status of the child. The Children’s Interview for Psychiatric Symptoms (ChIPS; Weller et al. 2000) was designed as a screening tool covering 20 DSM-IV Axis 1 disorders. ‘Cardinal questions’ concerning symptoms most often seen in children with a particular disorder are asked at the beginning of each section. If the answers to these screening questions are in the negative, then the rest of that section is skipped. The pictorial interview that makes the nearest approach to a DSM diagnosis is the Dominic-R (Valla et al. 2000), which is intended for use with 6–11-year-olds. Pictures representing psychopathology relevant to seven diagnoses are shown to the child, and questions about whether each symptom is present are read at the same time. Because no frequency, duration or onset data are collected, it is not yet clear how such information should be combined with diagnostic information from other sources. However, this should not be seen as a criticism of the measure, rather it shows how limited our understanding of psychopathology in younger children really is.

Interview time frames
One very important difference among the interviews considered here is the wide range of time frames they cover. The K-SADS interviews, the ADIS, the CAS, the Dominic and the ISCA all focus

DIAGNOSTIC INTERVIEWS WITH PARENTS AND CHILDREN Abbreviations: ADHD, attention deﬁcit hyperactivity disorder; ADIS, Anxiety Disorders Interview Schedule; CAS, Child Adolescent Schedule; CAPA, Child and Adolescent Psychiatric Assessment; CD, Conduct disorder; DICA, Diagnostic Interview Schedule for Children and Adolescents; DISC-IV, Diagnostic Interview Schedule for Children-IV; GAD, generalized anxiety disorder; ISCA, Interview Schedule for Children and Adolescents; K-SADS, Kiddie Schedule for Affective Disorders and Schizophrenia; MDD, major depressive disorder/episode; OAD, overanxious disorder; ODD, oppositional/deﬁant disorder; PTSD, post-traumatic stress disorder; SA/D, substance abuse or dependence.

Table 3.1 Test–retest reliabilities (kappas) of diagnoses in clinical samples from the instruments considered in this chapter (where available).

Social phobia

Reliability and validity of structured diagnostic interviews
Table 3.1 shows the results of studies of the test–retest reliabilities (kappas) of diagnoses measured by the instruments considered in this chapter. It can be seen that all do a reasonably good job, and that there is not much to choose between them, so far as test–retest reliability of diagnosis is concerned. These reliability coefﬁcients are similar to those reported for psychiatric interviews with adults. Reliabilities for scale scores derived from these interviews are typically rather better than they are for diagnosis, and it is important to remember that some of the unreliability of diagnostic measures is a product of the diagnostic system itself, with its numerous details relating to onset dates, durations of symptoms and the like — information that humans do not remember very well, no matter what their age. One often sees reports of interrater reliabilities in the interview literature. However, interrater reliability is not a very useful index of interview performance. With respondent-based interviews it tests nothing but whether one interviewer can read aloud adequately while another ﬁlls in a form containing the answers to the questions. In an interviewer-based interview the questions are not ﬁxed, and so different interviewers could use different questions to elicit the same information. As the interrater reliability paradigm uses multiple raters to score the same videotaped interview, this major source of potential unreliability is eliminated, with the result that the interrater reliability is likely to substantially overestimate the reliability of the interview in actual use. A problem with the test–retest assessment of reliability is that it requires that the interview be repeated within a short period of time. With both questionnaires and interviews one ﬁnds that fewer symptoms are endorsed at the second interview than at the ﬁrst (Angold et al. 1996b; Lauritsen 1998; Lucas et al. 1999;

Simple phobia

0.73 0.84 0.81 0.78 0.79 0.38 0.78 0.83 0.89 0.90 0.70 0.85 0.85 0.82 0.82 ISCA child only 0.64 ADIS combined P & C 0.77 0.90 0.54 1.0 1.0 0.90 K-SADS-PL lifetime K-SADS-PL current CAPA child only K-SADS-P IIIR K-SADS-P DICA CAS

Separation anxiety disorder

GAD/OAD

MDD

Dysthymia/minor depression

Any depression

DISC-IV combined P & C

0.65

0.58

0.51

0.86

0.48

on the child’s ‘current’ status, though the deﬁnition of ‘current’ is largely unspeciﬁed. The K-SADS-PL and K-SADS-E also explore lifetime histories of ‘worst’ episodes, while the ISCA also provides for assessment of lifetime disorder, and an ‘interim’ version provides an assessment of current status plus the child’s status in the interim between the current assessment and the last assessment, for use in follow-up studies. The DICA and MAGIC adopt a lifetime time frame as their standard format. Here there is always a lifetime focus, but for some disorders an additional shorter time frame is also included. For instance, in the depression section, the MAGIC asks about the ‘past month’ as well as whether the child has ‘ever’ had symptoms. The CAPA covers a ‘primary period’ of 3 months, but also asks whether certain uncommon symptoms (such as suicide attempts) have ever occurred, and a version that provides lifetime coverage of major episodes of certain disorders is also available. The full DISC-IV can be used to assess either the last month or the last year, and also offers a module to determine whether certain syndromes that did not occur during the preceding year had occurred at any point since the age of 5.

SA/D

ODD

1.0

0.46

0.74

0.77

0.61

ADHD

0.83

0.55

0.63

0.91

0.55

0.43

PTSD

1.0

0.67

Any anxiety disorder

0.60

0.64

0.80

0.24

0.72

0.60

0.76

0.64

0.75

0.62

0.55

0.59

CHAPTER 3

Piacentini et al. 1999). There are many possible explanations for this effect (Jensen et al. 1992), but current evidence suggests that the results of the ﬁrst interview are probably the most accurate representation of reality. The usual interpretation of test–retest reliability statistics — such as Cohen’s kappa for categorical data (such as diagnoses) and the intraclass correlation coefﬁcient (ICC) for continuous data (such as scale scores) — involves the supposition that the relationship between scores at the ﬁrst interview and those at the second involves two components: agreement and random error. The presence of a consistent difference between ﬁrst and second interviews indicates that such statistics underestimate the ‘true’ (and unmeasurable) reliability of both interviews and psychopathology scales. Despite enormous efforts on the part of interview developers, it cannot be said that the reliability of diagnostic interviews has increased much over the years. We now have a fairly mature interview technology, and new developments leading to major increases in reliability are unlikely to occur. The current arsenal of diagnostic interviews probably offers as good reliability as can be achieved with this approach. The problem with trying to assess the validity of psychiatric interviews is that there is no non-interview test for most psychiatric disorders. The structured interview itself has become the closest approximation we have to a ‘gold-standard’. So how are we to ‘validate’ the diagnoses obtained from such interviews? This is a version of a very old problem in psychology; one that led to the concept of construct validity. The key idea is that the validity of an instrument for the measurement of a psychological construct resides not in some single agreement coefﬁcient with one external standard, but in the instrument’s performance within the nomological net of theory and empirical data concerning the construct or constructs that the instrument purports to measure (Jenkins 1946; Anastasi 1950; Gulliksen 1950; Peak 1953; Cronbach & Meehl 1955; Weitz 1961; Wallace 1965; Novick 1985; Anastasi 1986). As Gulliksen (1950) remarked, ‘at some point in the advance of psychology it would seem appropriate for the psychologist to lead the way in establishing good criterion measures, instead of just attempting to construct imperfect tests for attributes that are presumed to be assessed more accurately and more validly by the judgement of experts.’ Structured interviews were developed because of the poor psychometric properties of unaided clinical diagnosis, so comparisons with clinical judgement are a ﬂawed test of diagnostic interview validity. In considering the validity of any interview, we should take a construct validation approach, and describe what we currently know about it in relation to the nomological net pertaining to child and adolescent psychiatric diagnosis. So far, only the developers of the CAPA have explicitly laid out the evidence for the validity of the CAPA using this approach, but most of the interviews considered here can point to similar chains of evidence. To give a ﬂavour of the sort of evidence relevant to construct validation, the following ﬁndings have been adduced as construct validators of the CAPA. 1 Diagnostic rates and age and gender patterns of disorder 38

given by the CAPA are consistent with those found using other interviews. 2 Patterns of diagnostic comorbidity are consistent with those found by other interviews. 3 Symptomatic diagnoses are associated with psychosocial impairment. 4 Parent and child reports of psychopathology on the CAPA are related to parent and teacher reports of problems on wellestablished scales for detecting psychopathology. 5 Children with CAPA-identiﬁed disorders use more mental health services than children without diagnoses. 6 CAPA-diagnosed children tend to come from families with a history of mental illness. 7 There is genetic loading for a number of CAPA scales scores and diagnoses. 8 CAPA diagnoses show consistency over time. 9 CAPA diagnoses predict negative life outcomes (Angold & Costello 2000). 10 Different CAPA diagnoses are differentially related to the physiological changes of puberty (Angold et al. 1999b). The need is for a change from concentration on single correlation coefﬁcients, describing the interview’s level of agreement with ‘experts’ as evidence of validity, to concentration on comparisons of the information collection properties of different measures. In deciding which interview will be best for any clinical or research application, the key question is ‘Which collects the information I want in the way that I want to collect it in a reasonably reliable and efﬁcient manner?’ A second useful question is ‘Is there any strong reason (practical or based on research on the instrument’s properties) why I should not use this instrument?’ The current evidence certainly does not support the notion that any single interview is ‘best’ for all applications. It is worth bearing in mind that low ‘validity’ coefﬁcients may also be the product of the diagnostic system. A perfect measure of an invalid diagnosis will still produce an invalid diagnosis, so some of the problems with validity typically attributed to our interviewing technology should probably be placed at the door of the nosologies instantiated by the interviews (Robins 1985).

Clinical interviewing style
Open and closed questions
The distinction between open and closed questions is not absolute, but open questions are those that offer the chance to provide a wide range of answers or free-recall descriptions of phenomena, while closed questions call for one of a limited set of responses. For example, an open question response to being told by a child that he or she had received a bad school report might be ‘how did you feel about your bad grades?’, whereas ‘did your bad grades make you feel unhappy?’ would be a closed question. If a child had just admitted to stealing, responding with ‘tell me more about that’ involves an open question, whereas ‘what did you steal’ is a closed question. Basically, closed questions call for

DIAGNOSTIC INTERVIEWS WITH PARENTS AND CHILDREN

a yes/no answer or a date, frequency, duration, or other quite speciﬁc piece of information, while open questions give the opportunity for the child to provide a description of his or her behaviour and feelings. The work of Cox and Rutter and their colleagues offers some direct guidance on the best ways to use these different sorts of questions with adults and, in the light of the literature on children’s memory cited above, there is little reason not to use a similar approach with children. In general, most factual information was collected when a systematic approach that relied heavily on open questions was used. Furthermore, this approach was also conducive to parental expressions of emotion, because it involved less talking on the part of the interviewer and gave more time for parents to discuss their concerns. A non-interventionist approach resulted in the provision of less relevant information, while challenging interpretations and a confrontational style proved less effective in eliciting emotions (Cox et al. 1981a–c; Hopkinson et al. 1981; Rutter & Cox 1981; Rutter et al. 1981). This is not to say that closed questions do not have an important place in the clinical interview, but they should be used to ﬁll in the gaps in the information provided in response to open questions, or to clarify confusion, rather than constituting the basic approach. Sometimes it seems as though it might be quicker to ask a set of speciﬁc questions, especially when working through a set of diagnostic criteria; however, this is rarely the case. If open questions are well thought out, respondents will often provide much of the necessary information spontaneously, so that only a few follow-up questions need be asked. Thus, open questions may actually save time, and simultaneously avoid a barrage of closed questions that may seem to respondents to reﬂect the clinician’s needs more than their own.

time. Consider the question, ‘When you got your school report were you worried, or angry, or didn’t you care?’ Such a question will often draw an answer like ‘yes’ or ‘no’, but one cannot tell what that answer refers to — it could refer any combination of worrying, anger or insouciance. The operation of the recency effect means that it is quite likely that the response refers to the last part of the question, but the only way to be sure is to ask speciﬁc questions about worrying, anger and not caring. As this could have been done in the ﬁrst place, the multiple question has only served to waste time. Double and multiple questions also place an increased load on the cognitive capacities of the respondents, because they must remember several options in order to choose among them. Thus, double and multiple questions join leading questions as major interviewing sins. Though multiple questions cause problems, the same cannot be said of ‘redundant’ questions: questions that contain two presentations of the same item, as in ‘Did you feel angry about your report . . . did it make you angry at all?’ The adult survey literature (Cannell et al. 1977, 1992) suggests that such redundancy can actually be helpful, and the same may be true in interviewing children, though this issue does not appear to have been studied speciﬁcally.

Multiple choice questions
Multiple choice questions are a subset of closed questions that have a place when regular open and closed questions fail to provide an adequate answer. For instance, if one asks about the frequency of temper tantrums, and the child says he or she ‘doesn’t know’, a question like ‘Well, is it every day, once a week or once a month?’ can be helpful. However, such multiple choice questions may not include the proper range of choices. What is the right answer if tantrums actually occur only a couple of times a year, or if they occur many times a day? It is usually necessary to ask a supplementary question or two to clarify these points, so multiple choice questions are relatively inefﬁcient, though they may be the only way to get the necessary information. They also have a second drawback in that, like multiple questions, they require the child to hold the available choices in memory before selecting among them. It has already been noted that the multiple choice format leads to the reporting of more incorrect information in younger children.

Leading questions
Leading questions are sometimes confused with closed questions, but whereas the latter are a necessary part of interviewing technique, leading questions have almost no place at all in psychiatric interviewing, for the simple reason that one can never believe the answer to such a question, especially in the case of young children. A leading question is one that directly suggests its answer. For example, to return to the child with problems at school, a response like ‘I expect that made you feel pretty unhappy, didn’t it’, places the child in the position of having to disagree with the interviewer if he or she really did not care about his or her grades. We have already noted that young children may be prone to respond with what they believe is being demanded of them, so we can expect agreement, even if the child was, in fact, angry or completely unconcerned. On the other hand, such a question provides a golden opportunity for an oppositional adolescent to demonstrate how wide of the mark the interviewer was, regardless of his or her actual feelings about school.

Repeated questions
Asking the ‘same’ question with some rewording can be helpful in allowing increased time and cognitive processing to be allocated to providing an appropriate answer. However, frequently repeated questioning, especially when combined with leading questions or other suggestive techniques, and failure to pay attention to disconﬁrmatory information also appears to be a good way to generate false reports. Indeed, in the sexual abuse arena, some authors have suggested that the retraction of previously made accusations is a typical part of the process of dealing with having been abused (hence, such retractions appear almost 39

Double and multiple questions
A double question asks about two different things at the same

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to become conﬁrmatory evidence). However, studies of conﬁrmed sexual abuse have found that such retractions are uncommon (occurring in 3–8% of cases) (Bruck et al. 1998). As with other sorts of statements, inconsistency in the reporting of abuse by a particular informant should lead one to question the accuracy of those reports.

Inappropriately worded questions
In most circumstances, it is best to use simple words and short sentences. It is also important to be on the alert for possible misunderstanding. Here again the open question approach, with its emphasis on getting descriptions of experiences and behaviour, helps to ensure that both interviewer and interviewee are talking about the same thing.

Organizing the interview
So far, we have examined some basic interviewing techniques. The next question is how to organize these into a coherent interview in a clinical setting.

Beginning the interview
The ﬁrst task is to get the interviewee into a conducive situation: somewhere quiet, private and undistracting. The presence of large numbers of interesting toys should be avoided in interviews with children. The child often does not know why he or she is talking to the interviewer, as parents may have told the child that he or she is going to the dentist or some other ﬁction. The ﬁrst step, then, is to clarify why the child thinks he or she is seeing you, and to allay fears that injections or extractions are just around the corner. Even if the child has a reasonable notion of where he or she is, his or her ideas about why he or she is there may differ dramatically from the actual reasons for referral. The next step is to explain why you think that the child is there, to explain the purpose of the interview, and to give a brief description of what it will be like. Similarly, parents who have come at the behest of another agency may have only a dim understanding of why they are there, so, again it is helpful to outline what the purpose of the visit is at the beginning. As an immediate barrage of questions about emotionally loaded topics is likely to be very off-putting, it is usually best to begin with some questions that allow the respondent to describe the family situation, the things the referred child enjoys doing and is good at, and what his or her social life is like. If the child is aware that he or she has problems, a brief description of how he or she sees those problems can be helpful. By this point, both the respondent and the interviewer should have a fairly good idea of what to expect from one another, so the interviewer can formulate a plan for the rest of the interview. If it has become clear that some topics are a source of discomfort or avoidance, it is best to steer away from these at the start, and to begin with less threatening material, allowing a sense of 40

trust to develop. On the other hand, some respondents (especially parents) are keen to get right down to a description of what bothers them most. In either case, following the respondent’s leads and exploring his or her problems in the order in which they come up is a good strategy. However, in being sensitive to the respondent’s ordering of the material, it is important not to allow the interview to become incoherent. Once a topic (such as symptoms of depression) has been begun, it is usually best to continue with it until all the necessary information has been collected. Otherwise it is very likely that important questions will be forgotten in jumping from topic to topic. There is nothing wrong with telling the respondent that you will come back to a different topic later (as long as you do). Those just beginning work in child and adolescent psychiatry usually do not know what all the relevant symptoms are, and here the use of a simple checklist (for the interviewer, not the respondent) based on the DSM or ICD criteria can be very helpful. However, these criteria give no guidance as to how to turn them into suitable questions, and familiarity with a well-structured interview helps to ﬁll this gap. If the respondent has previously completed a symptom checklist, it is a good idea to have looked it over before starting the interview. It is vital that the diagnostic criteria are not allowed to become a straitjacket for the interview. It is all too easy to emerge with more or less accurate diagnoses but little idea of what the child is actually like. Much goes into good treatment planning besides the diagnosis. Common child psychopathology is divided into two broad domains: emotional and behavioural disorders, and the next two sections discuss some general principles for assessing symptoms in these areas.

Emotional disorders
The central distinctions to be made here are between moods or affects, thoughts and behaviours, and impairments secondary to the ﬁrst three. The distinction between moods and thoughts is the most difﬁcult to maintain in practice, largely because English does not clearly distinguish between them in everyday speech. For instance, it is usual to ask whether someone ‘felt’ guilty rather than whether they ‘had guilty thoughts’, though the latter is more accurate. When interviewing one must use everyday language, but it is important to be clear that while ‘feeling guilty’ may be evidence of a depressive disorder, it is not the same thing as depressed mood. It is quite possible to have an overdeveloped sense of guilt without depressed mood and vice versa. Thus, some common questions like ‘Did you feel bad about that?’ must be treated with caution, because an afﬁrmative response could refer either to a mood state (as in ‘That made me feel unhappy’), or a cognitive state (as in ‘That induced the thought that I had done something bad or wrong’). Similarly, worrying (a cognitive symptom) must be distinguished from anxiety (a mood state). While at ﬁrst these distinctions may seem to be splitting psychopathological hairs, they are diagnostically important, and of direct relevance to treatment; consider, for example, cognitive

DIAGNOSTIC INTERVIEWS WITH PARENTS AND CHILDREN

therapy for depression, which focuses directly on thought processes, rather than the mood state itself.

When is an emotional ‘symptom’ abnormal?
One problem with emotional symptoms is that they are often extremes of normal emotions. This presents no problem when someone reports that they have been depressed all day, every day, for 2 months, and that before that they were of a cheerful disposition. Unfortunately, things are not always so simple. In the absence of a detailed epidemiological literature describing how much time the average child spends feeling depressed, or worrying, it is necessary to have some general rules of thumb for deciding what is abnormal. 1 Look for changes in state or failure to make normal developmental progress. A description of a marked change in state, especially if it is of relatively acute onset, is strong evidence for the pathological status of a symptom. However, it has to be said that in developmental psychopathology, acute onsets are the exception rather than the rule. Symptoms may also have begun years before the child presents for help. However, if care is taken to get adequate descriptions, and the respondent is encouraged to think hard about whether and when a change occurred, it is usually possible to determine whether a symptom represents a change from some previous state. Some symptoms represent the inappropriate continuation of a state that is normal in earlier life. Separation anxiety is the paradigmatic example here. Most children show separation and stranger anxiety in their second year, and many are unhappy about leaving their parents on ﬁrst going to school. However, much more independence is expected of teenagers, and in a 12year-old a wish to sleep with her parents, because she is afraid to sleep alone, would be distinctly abnormal. 2 How long do bouts of the symptom last, and how often do they occur? Most people worry or feel depressed sometimes, but these are evanescent phenomena. They are only symptomatic when present for an inordinate amount of time. Once again, we lack data on how much worrying is normal, but can determine how much time (average length of bout of worrying ¥ number of bouts per week) has been spent worrying and make a common sense judgement about whether this is pathological. 3 Is the symptom intrusive into other thoughts and activities? A symptom that disappears as soon as something comes along to take an individual’s mind off it, is unlikely to be of psychopathological import, so it is important to ask whether symptoms intrude into, or interfere with, other activities. Worrying that interferes with concentrating on schoolwork represents a problem, whereas worries that disappear as soon as there is a job to be done probably do not. 4 Is the symptom controllable? If a child can get rid of a symptom by thinking about, or doing, something else, then one can usually be fairly sure that it is not psychopathologically signiﬁcant. Intrusiveness and uncontrollability are very closely related ideas and, in general, both will be reported in relation to important symptoms.

5 Is the symptom generalized across more than one activity? A ‘symptom’ that is restricted to a single activity (such as worrying about a maths test just before it, but only then) is usually not a marker for a clinically relevant problem. In the case of speciﬁc phobias, a child who is frightened of dogs only when a dog is barking at them, is unlikely to encounter many problems, while the child who is afraid of dogs whenever he or she is out in the street, regardless of the presence of a dog, can be regarded as being symptomatic.

Behavioural problems
An overlapping set of considerations is of primary relevance for behaviour problems. Some undesirable behaviours are normal (such as disobedience or lying) when they occur at low frequency, and should only be regarded as ‘symptoms’ when they occur often. In such cases, frequency, controllability and generalization are relevant, but bout duration and intrusiveness are not. Until recently, information about the frequency of oppositional/deﬁant disorder (ODD) symptoms in the community have not been available, so clinicians have had no choice but to rely on their own judgement in determining whether such symptoms were present. Angold & Costello (1996) recently presented general population norms for ODD symptoms in 9–14-year-olds and, based on 90th percentile cutpoints, suggested that these symptoms should be regarded as ‘often’ occurring as follows. Spitefulness and vindictiveness and blaming others should occur at least once every 3 months; being touchy or easily annoyed, losing temper, arguing with adults, and defying or refusing adults’ requests should occur at least twice a week; and being angry and resentful or deliberately annoying others should occur at least four times per week. Now we can expect that, at other ages, different normative values would be more appropriate, and it is to be hoped that such norms will be forthcoming. However, it is also important to consider some other characteristics of antisocial behaviours. 1 Response to admonition. Here, two levels of non-response may be discerned; some children simply do not do as they are told, while others actively challenge their admonisher (for instance by swearing at, or hitting, a teacher). It is also worth noting that clinical experience indicates that many children with marked attentional and activity problems are poor reporters of their behaviour in this respect. It is not uncommon for such children to report that they are not ﬁdgety and have no difﬁculty remaining seated when told to do so, despite the fact that they have spent most of the interview wandering around the ofﬁce, in the face of repeated requests that they should sit down. They may also seem to be unaware of their social skills defects, so it is important to get detailed descriptions of how they interact with their reported ‘best friends’. 2 In what situations did the behaviour occur? Three general settings may be distinguished as: (a) home; (b) school; and (c) elsewhere. Determining where problematic behaviour occurs has important treatment implications, and also seems to have some 41

CHAPTER 3

prognostic importance, in that pervasively disturbed children appear to have more persistent problems and do worse in young adulthood. 3 Was the child usually alone or in company when performing antisocial acts? Such information is helpful in determining the degree to which the child’s social environment may be contributing to his or her antisocial behaviour. 4 Who was the victim of the antisocial acts? Here distinctions may be made between (a) community property (as in vandalizing park benches); (b) the property of individuals not known to the child (as in shoplifting); and (c) the property of individuals known to the child (as in stealing from mother’s purse). Many types of antisocial acts are considered abnormal whenever they occur (armed robbery, for instance), and are not at all uncommon in some psychiatric settings (such as substance abuse treatment programmes), so it is important to ask teenagers about these sorts of activities. In many areas, it is also common for teenagers, and even younger children, to carry weapons, and to use them, so it is worth asking about this as well. In countries where guns are freely available, it is also important to know whether the child has access to guns, especially if the child is at risk of making a suicide attempt. Parents should then be advised to eliminate the child’s access to weapons (preferably by removing them from the house).

alization are also common effects of certain drugs (such as cannabis and LSD) and the possibility of drug use should be investigated when these states are reported. Premonitions of events are also often described by quite normal people, and should only be regarded as being psychotic phenomena when they clearly fall outside the normal range of experiences for the cultural group to which the child belongs. In most cases, consideration of the overall clinical picture will ensure that these phenomena are interpreted appropriately. Many of these psychopathological distinctions are relatively subtle, and parents can usually provide only very limited descriptions of such phenomena. Here (as with adults), there is no substitute for the direct face-to-face mental status evaluation of the child, supplemented by longer term clinical evaluation.

Impairment of psychosocial functioning
Psychiatric disorders impact on a person’s ability to function at their highest level in the psychosocial environment, and it is vital to assess the degree to which such functioning is impaired. Here the main areas of concern are school (or work) performance and behaviour, peer relationships, social and spare-time activities, and relationships within the family. Relying solely on symptom ratings and DSM-III for diagnosis has been found to lead to ridiculously high rates of diagnosis in epidemiological studies using respondent-based interviews and one strategy for producing more sensible estimates has been to require some degree of psychosocial impairment to be present if a diagnosis is to be made (Bird et al. 1988). In clinical settings, most patients have some degree of impairment, so the issue of using impairment as a measure of severity looms larger there. The same may be said of glossary-based interviewer-based interviews (CAPA or K-SADS-P IVR) that do not require the use of additional impairment criteria to compensate for symptomatic overdiagnosis. Several approaches have been adopted to the measurement of impairment (reviewed in Costello et al. 1998). The ﬁrst is to consider the patient’s overall level of functioning, by combining information about symptomatology and psychosocial impairment into a single rating. The Children’s Global Assessment Scale (Shaffer et al. 1983; Bird et al. 1987) and the Columbia Impairment Scale (Bird et al. 1993, 1996) are the best examples. These instruments, based on the DSM-IIIR Axis V, provide simple, reliable scales, and can be coded after all the symptom information about the child has been gathered. More molecular assessments of impairment are available from the Social Adjustment Inventory for Children and Adolescents (SAICA; John et al. 1987), which is a 20-min interview schedule that includes ratings of a number of psychosocial problems. It also includes items that are ordinarily regarded as conduct problems, and usually covered in the exploration of symptomatology. However, it is quite possible to use the nonsymptom items alone, although the usual scoring system does not adopt this approach. The same applies to the more extensive Child and Adolescent Functional Assessment Scale (Hodges et

Delusions, hallucinations and other symptoms of serious psychopathology that may be confused with normal phenomena
Children and adolescents may manifest all the symptoms characteristic of adult disorders such as schizophrenia or bipolar disorders. Disorders involving hallucinations and delusions are uncommon in childhood, but both become more common in adolescence. In childhood especially, great care must be taken in establishing the presence of delusions and hallucinations, because a number of other phenomena can easily be confused with these very serious symptoms. In particular, hypnogogic hallucinations (vivid true hallucinations occurring when falling asleep) and hypnopompic hallucinations (vivid true hallucinations occurring on waking up) are normal phenomena. In general, hallucinations occurring only when the child is in bed should not be regarded as evidence of the presence of major disorders, even if the child insists that he or she was not falling asleep or waking up when they occurred. Care also needs to be taken not to mistake eidetic imagery, imaginary companions, elaborated fantasies, perceptual illusions, seizure phenomena, drug-induced experiences, subcultural beliefs, and hallucinations accompanying toxic encephalopathies, for manifestations of delusional or hallucinatory psychopathologies. Déjà vu, jamais vu, derealization and depersonalization are states that most people experience from time to time, but sometimes occur in schizophrenia, schizo-affective states and bipolar disorders. Once again, it is important to get a clear description of the phenomena, and to pay particular attention to how often they occur and how long they last. Derealization and deperson42

DIAGNOSTIC INTERVIEWS WITH PARENTS AND CHILDREN

al. 1998). When the developmental impairment of younger children and those with mental retardation is at issue, the Vineland Adaptive Behaviour Scales (Sparrow et al. 1984; Sparrow & Cicchetti 1989; Cicchetti et al. 1991) are without peer, although some scales also include what, from a psychiatric perspective, are better regarded as being symptoms rather than impairments. An alternative approach is provided by the CAPA and DISCIV, which calls for separate ratings of psychosocial impairment, secondary to psychiatric symptomatology, in a number of domains. In this case, the symptom ratings are separated out from the impairment ratings and the contributions of particular symptom areas to the overall degree of impairment are assessed. This can be helpful with children with multiple problems, because it gives an idea of which areas of symptomatology are most responsible for any psychosocial difﬁculties, and this may help in deciding where to begin as far as treatment is concerned. The K-SADS-P adopts a somewhat different approach by including aspects of psychosocial functioning in a number of the ratings of speciﬁc symptoms (Chambers et al. 1985). The strength of this combined technique is that it provides an overall clinical summary of how ‘disturbed’ the child is, and it is widely used in both clinical practice and research. However, because symptoms and psychosocial impairments are conﬂated in the ratings, it is impossible to look at each dimension separately.

than this in children because it has been found that the age at which children and adolescents were interviewed about their depressive psychopathology had a signiﬁcant effect on the rates at which they reported depressive symptoms and the reported timing of their ﬁrst episodes and worst episodes of dysphoria, with girls around the age of 16 reporting earlier episodes than either younger or older girls (Angold et al. 1991). This age group also reported a higher level of current symptoms, so it may be that the ﬁnding from adults that being currently depressed increases the chance of reporting a previous depression holds in children too. As long as these caveats are borne in mind, a lifetime history is well worth taking, but it must be remembered that negative responses are not as reliable as positive ones.

Special interviewing situations
Children with limited understanding: the young and the mentally retarded
Any interview is an exercise in verbal skills, and it is important to be sensitive to verbal limitations in those being interviewed. Young children are unlikely to provide much information in a free-recall setting, and the same is true of the mentally retarded. These groups also have shorter attention spans, and usually cannot be expected to sit for 2 h of interview without breaks. However, they may well be the only available sources of information about their inner lives. The temptation for the clinician when dealing with individuals who can provide only limited detail in response to openended questions is to ask a lot of closed questions, and this often leads to the use of leading questions in order to make it ‘easier’ for the individual to respond. However, these groups are particularly likely to respond to such questioning by supposing that they are expected to agree with the interviewer, and mistakenly trying to oblige in this way. While there may be no way around the need to ask greater numbers of closed questions, every attempt should be made to get as good descriptions as possible of the phenomena that the child is referring to, so as to avoid confusion. It is also important to try to check that the words that the child is using to describe their inner world are being used in the same way that we would use them. Thus, a 4-year-old’s ‘worry’ might be our ‘frightened’ or ‘depressed’. It can be helpful to ﬁnd situations in which one can be fairly sure that a child was feeling a particular emotion (like sadness), and then ask whether the feeling they are talking about now is the same as that. In fact, this problem is not qualitatively different from the general issue of making sure that both parties in the interview mean the same thing, but it is quantitatively more demanding. Additional tools may be helpful in getting descriptions of events that occurred; using play-like materials, such as puppets, toy houses, or photographs of individuals involved in events may be useful. Drawing is also a time-honoured modality in child psychiatry, and can be useful here. The aim is to 43

Lifetime histories
Two studies (Orvaschel et al. 1982; Fendrich et al. 1990) have found that the kappas for child reports of known depressive episodes reported on between 6 months and 2 years later were around 0.6. Fendrich et al. (1990) also present evidence of reasonable stability for diagnoses of conduct disorder, attention deﬁcit disorder and substance abuse, but poor stability for anxiety diagnoses. However, it is important to remember that the usual form of instability is failure to recall a previous episode; few symptoms are ‘invented’. The use of scripts means that a series of events may be conﬂated into a single memory, so very accurate dating may not be attainable. However, recent work in the survey literature suggests that attempts to ‘decompose’ such memories into a series of more speciﬁc instances can be surprisingly successful. Likewise, tying the onsets of symptoms to events, such as birthdays and school terms, can also lead to ﬁnergrained dating than seemed possible at the beginning of the interview. It is usually possible to determine the age by which a symptom was deﬁnitely present, which is certainly better than nothing. In general, the further back in time one goes the more information is lost although, for events of major signiﬁcance, the degree of decrement after the ﬁrst year may be small. It is also important to remember that in adults, for most memories, there is a ‘brought forward’ effect, by which events are remembered as having happened more recently than was the case, although there are exceptions to this rule, as in the case of memories for certain developmental milestones in one’s children (Hart et al. 1978), and there is no reason to suppose that this is not the case in children too. In fact, the situation may be more complicated

CHAPTER 3

provide a focus for cognitively reconstructing the situation to be remembered. However, it is important to recognize that the aim, in this case, is to help the child to remember and not to make interpretations. The degree to which these aids generate misleading, as well as accurate information has not been adequately tested.

Romanczyk 1987 on juror’s reactions to child witnesses; also Ross et al. 1987; Ornstein et al. 1997).

Children who ‘don’t know’
All child psychiatric clinicians have been faced with children who resolutely ‘don’t know’. In such cases, persistence can make a huge difference, particularly with information about duration, frequency and the timing of symptom onsets. It may also be the case that some children really do not know how to answer questions like ‘How have you been feeling lately?’, because they are unfamiliar with describing their feelings. In such cases, more focused questions (such as ‘Have you been feeling miserable?’) can help by providing a series of categories that children can use to describe their feelings. Thus, the ubiquitous ‘boredom’ of adolescence may be reducible to a number of more sharply focused states, when a framework for more accurate descriptions is offered.

Investigation of abuse
Now that greater attention is being paid to the problems of physical and sexual abuse, an increased load has been placed upon the clinical interview, and a new set of demands are being made on the ‘evidence’ collected. In collecting material that may be called into evidence it is particularly important that leading questions or other ‘suggestive’ strategies should be avoided because, in some well-publicized cases, such material has led to children’s testimony being rejected (Cole & Loftus 1987). In dealing with issues that may be frightening or embarrassing, or about which the child may have been threatened should he or she ever reveal what happened, there is naturally a wish to make it as easy as possible to give a full description. Furthermore, as most young children lack an adequate anatomical vocabulary to describe sexual abuse, the use of anatomically ‘correct’ dolls or pictures to allow children to demonstrate what happened has become fashionable, and has received research support (Steward & Steward 1996). However, some have argued that such dolls (with their obvious protuberances and oriﬁces) themselves suggest certain forms of play that may then be misinterpreted as evidence of sexual abuse (King & Yuille 1987). Indeed, experimental studies have found that, while the use of props such as dolls can increase accurate positive reports, they can also increase the incidence of problematic reports (reports of things known not to have happened) (Ornstein et al. 1997; see also Ceci et al., Chapter 8). Case reviews of sexual abuse records have suggested that fabrications of stories of sexual abuse are rare, and that such fabrications are usually begun by an adult when they occur (Jones 1985). The deﬁnitive answers to the best way to collect evidence of abuse are still some way off, but at present an acceptable approach seems to be to use ordinary good interviewing strategies as far as possible and to supplement these with descriptions using anatomically correct dolls or pictures when necessary, always bearing in mind that the child must understand that one is asking ‘What actually happened’ rather than ‘What can you do with these dolls’ (Steward & Steward 1996). As defence lawyers are almost certain to make the claim that evidence of abuse was obtained by the use of leading questions and techniques that relied on the child’s supposed suggestibility, it is important to be sure that this was not the case, and the best way of doing this is to record (preferably on videotape) exactly what happened in the interview. When this is not possible, it is important to record both the questions asked and the answers obtained (see Bruck et al. 1998 for helpful discussions of the implications of memory development research for children’s testimony; Leippe &

The psychodynamic interview
Psychodynamic psychotherapy uses an interview format as its central modality. However, the aims of such interviews are rather different from those of the diagnostic clinical interview. The emphasis is not on collecting ‘facts’ in an efﬁcient manner, but on engaging the child in an exploration of his or her own inner world and attempting to understand how that world combines fantasy and reality in relation to experience and behaviour. It is therefore usual for the therapist to be much less active and to allow the child to play and draw quite freely. The therapist provides interpretations that represent attempts to understand the meaning of the child’s experiences within the framework of psychodynamic theory. This is not the place to explore the intricacies of psychodynamic technique, but it should be borne in mind that these differences in aim and practice mean that a psychodynamically orientated interview is unlikely to provide the best means of collecting the information necessary to make a phenomenological diagnosis; that is not its purpose. Although the phenomenological interview is not the best method for psychodynamic interpretation, it is important that a sense of trust and understanding be generated in such interviews, so as not to compromise later psychodynamic work. Many of the techniques involved in a good phenomenological interview may be seen as laying the groundwork for psychodynamic therapy and there is no reason to see the two as being in opposition (see Jacobs, Chapter 58, for a discussion of some further aspects of psychodynamic psychotherapy).

Projective testing
The aim of projective testing is to provide a child with an ambiguous stimulus, and then to use the responses to indicate underlying problems. At the simple end of the spectrum, children have been asked for years what their ‘three magic wishes’ would

DIAGNOSTIC INTERVIEWS WITH PARENTS AND CHILDREN

be, and it has been shown that the magic wishes of psychiatrically referred children differ in content from those of normal controls (Winkley 1982) in frequently containing wishes related to real problems. However, it has not been shown that these same problems could not have been uncovered by simply asking the child about his or her problems in a straightforward way. The same applies to the standardized scoring schemes developed for the Thematic Apperception Test (TAT; Winter 1999) or the Rorschach Inkblot Test (Exner & Weiner 1995), and herein lies the issue with projective testing in general. In a thorough review of the literature on the subject, Gittelman-Klein (1978) concluded that there was no evidence that such testing revealed any information that was either not already known to the clinicians before testing or could not have been discovered by the simpler means of asking about it directly. If the aim is to explore a child’s fantasy life, particularly as part of psychodynamically orientated play therapy or psychotherapy, then projective techniques clearly have an important part to play, and Winnicott’s (1971) famous interactive squiggle game and talking about drawings can certainly serve to initiate and maintain psychotherapeutic interactions.

need to engage parents in helping the child to separate, and this provides an opportunity to observe parental responses. During the interview a child will often become more anxious, and ask to see his or her parents. If this anxiety seems likely to disrupt the interview, then a quick visit to the parents will usually settle things down for a while. Sometimes the level of anxiety is such that a child simply cannot be interviewed when the parents are absent, in which case there is no alternative to conducting the interview with them in the room. Other children who have experienced multiple caregivers will separate with undue ease, and may end up trying to sit on the interviewer’s knee and shower him or her with kisses. A ﬁrm, but friendly, attempt to get the child to adopt more suitable seating usually has the desired effect.

Physical appearance
The physical appearance of the child may provide indications of abuse (e.g. bruising) or neglect (such as dirty, ill-ﬁtting clothes or signs of malnourishment). Signs of genetic abnormalities (such as low-set ears) or other deformities should also be looked for (see A. Bailey, Chapter 10). Sometimes oddities of dress, hairstyle or make-up may be helpful in identifying deviant subculture membership, or even psychosis.

Observations of behaviour
Observation of the child’s behaviour is a central focus of the diagnostic interview. Indeed, with some very disturbed children, it may contribute the most signiﬁcant material. All clinicians associated with the child should make a point of keeping in mind a checklist of the behavioural areas outlined below, so that the child’s behaviour can be compared across the various settings or ‘stimulus conditions’ provided by the clinic. Such observations should begin in the waiting room, which may offer an opportunity to observe the child’s initial mode of interaction with completely unfamiliar adults and peers. A number of dimensions should be considered, including separation responses, physical appearance, motor behaviour, form and content of speech, the quality of social interactions, affective behaviour, level of consciousness and developmental level. Although this section concentrates on observation of the child, it is also important to bear in mind that an interview with a parent about the child also provides an opportunity to conduct a mental status examination of the parent. As parental psychiatric disorders are major risk factors for child psychiatric disorders, such an evaluation is important for the development of a full diagnostic formulation. Child psychiatric disorders also have signiﬁcant impacts on parents’ lives, emotionally, socially and ﬁnancially (Angold et al. 1998), and the clinician should also take care to ﬁnd out whether such impacts are present in each case.

Motor behaviour
A number of motor abnormalities that may have psychiatric signiﬁcance may be observed. The most common example is the restlessness, ﬁdgetiness and distractibility of hyperactivity, which needs to be distinguished from manic motor excitement. Depression may be accompanied by motor slowness and underactivity and, in very rare cases, primary obsessional slowness may occur in severe obsessive-compulsive disorder. Obsessivecompulsive disorders may manifest as compulsive acts or rituals, which must be distinguished from motor stereotypies, tics and mannerisms. Potentially self-injurious behaviour such as head-banging or self-biting may occur (usually in mentally retarded subjects), and catatonic states may even more occasionally be observed. The clinician should also be on the alert for medication-induced movement disorders (such as the tremor of lithium intoxication or the choreo-athetoid movements of tardive dyskinesia), and symptoms and signs of drug or alcohol use.

Form of speech
Speech disorders, such as stuttering, cluttering and articulation defects, should be noted if they occur, because they may require specialist treatment. A number of psychiatric disorders also produce abnormalities in the form of speech, such as the low volume mumbling of some socially anxious or depressed individuals, the slowness of speech of psychomotor retardation, manic pressure of speech, and the prosodic abnormalities that may occur in

Separation responses
The younger the child, the more likely he or she is to protest against separation from parents, so the interviewer may also

CHAPTER 3

some psychotic states or autism. Vocal tics may occur alone or in combination with motor tics.

reading, writing, mathematical and drawing abilities can indicate the presence of obvious delays or deﬁcits.

Content of speech
A range of speech content abnormalities may be observed, including the neologisms, incoherence and poverty of content that may occur in schizophrenia, and manic ﬂight of ideas. Unusual grammatical forms (such as the pronominal inversions of autistic children) may occur, and verbal stereotypies and the occurrence of self-directed speech should also be watched for.

How long should the interview last?
This chapter has indicated that diagnostic interviews are intensive and extensive data-gathering exercises. They cannot therefore be completed in a few minutes. A proper psychiatric assessment cannot be encompassed within the frame of a typical paediatric consultation. With good interviewing skills, a full diagnostic interview can usually be completed in an hour and sometimes much less, but when substantial comorbidity is present considerably longer than this may be needed. Allowance also needs to be made for the poor attention spans of many disturbed children (and many of their parents), and it is better to allow breaks during the interview than to plough ahead in the face of waning attention. As elsewhere in medicine, the failure to take a good history, and conduct an adequate examination, leads to diagnostic and treatment mistakes. Indeed, in psychiatry, which relies much less on laboratory studies than many other branches of medicine, it is even more critical to spend the necessary time and effort to learn how to interview proﬁciently, and then to apply this learning to every patient.

Social interaction
An interview is a social interaction, and can provide a good deal of information about a child’s social abilities. Both verbal and non-verbal social functioning should be considered. How readily does the child provide information? Does the child engage in normal reciprocal social communication with good articulation of both verbal and non-verbal interchanges? Are the child’s overtures and responses appropriate to the interview situation or is the child overly withdrawn, overly friendly or socially inappropriate or odd? Is the pattern of eye contact unusual in any way? Does the child maintain an appropriate social distance? Is the child unusually disinhibited, aggressive or oppositional during the interview? Is there unusual preoccupation with idiosyncratic special interests? What is the overall quality of the rapport between the interviewer and the child?

Family interviews
So far, this chapter has considered interviews mostly from the perspective of gathering reported ‘facts’ from multiple informants, using more or less structured approaches. However, in clinical practice it is important to be aware that information of a different sort can be obtained from interviews involving more than one family member. Given the difﬁculty of getting whole families to turn up for clinical assessments, such interviews will often involve only one parent and the child, but that is still a very useful combination. Here the focus is on observing how family members interact with one another, and the ways in which symptoms are manifested in such interactions. As a starting point, the clinician needs to provide a structure within which interactions can be observed, and the information collected in separate interviews with the parent and child is helpful here, because it will have indicated the key issues that have resulted in a clinic appointment. The fact that the parent and child often have not reported the same things provides one starting point. One can simply ask each informant why the other mentioned something that they did not (in the clinical setting one rarely guarantees conﬁdentiality among family members). The aim here is not speciﬁcally to ‘reconcile’ reports (though that may be a useful by-product), but to observe how the family deals with the conﬂict implicit in the question. A well-known pattern often seen in families with children with behavioural problems is for disagreements to escalate into angry coercive exchanges (Patterson 1981). Such patterns are susceptible to amelioration by family behavioural techniques (Patterson & Reid 1973; Patterson et al. 1981). It will often be the case that information collected in

Affective behaviour
Though many children are shy, anxious or sullen at the beginning of an interview, most ‘warm up’ after a little while and it then becomes possible to determine whether there are signs of affective dysfunction. Does the child smile and laugh appropriately and show a normal range of facial expressions and emotional responses? Are there any signs of overly expansive mood? Is the predominant facial expression one of sadness or anxiety? Are there any visible signs of autonomic disturbance, such as sweating or hyperventilation? Is the child frequently tearful, irritable, suspicious or perplexed? Is affective behaviour appropriate to the material being discussed, and does the child show a full range of affective responses? Is the child’s mood abnormally labile?

Level of consciousness
In most circumstances, clouding of consciousness will be obvious. However, on rare occasions, previously unrecognized absences can be spotted by a careful interviewer.

Developmental level
A full developmental assessment requires expertly administered standardized testing, but a brief evaluation of a child’s verbal, 46

DIAGNOSTIC INTERVIEWS WITH PARENTS AND CHILDREN

family interviews will have an important place in the design of the eventual treatment plan, regardless of the diagnosis. If both parents are present, it is also important to keep an eye on the interactions between the parents (and each parent’s apparent mental state), because the child’s problems are often associated with parental and interparental problems, which may themselves merit speciﬁc treatment. Similarly, when the patient’s siblings are also present, it is helpful to compare their behaviour with the referred child’s. The ostensible patient may not be the only one with problems (or even the greatest problems). More structured tasks that the mother and child or whole family are required to work together on can also be very revealing; for instance, in identifying the withdrawal, negativity and hostility often displayed by depressed parents towards their children (Zahn-Waxler et al. 1990). For research purposes, a huge variety of observational coding schemes is available but, in the clinical setting, straightforward observations of the characteristics of interactions still have an important place in the overall diagnostic assessment. An interview with the family also provides a rather different sort of setting for the child than the highly formalized one-onone diagnostic interview with the clinician. It is important to observe whether the child behaves differently in these two settings, and any others that may be encountered in the clinic; such as interactions during psychological testing. Sometimes a child whose behaviour was well under control in the one-on-one structured interview or testing setting manifests far more disturbed behaviour with the family. If it turns out that a similar pattern is manifested at school, then interventions aimed at providing more structured interactions at home and at school may be warranted. Different phases of the assessment process are often conducted by different individuals, and here again it is important to evaluate the degree of consistency of behaviour with different individuals across situations. If there is considerable variation across settings and individuals it is important to try to identify the characteristics of those settings and individuals that are associated with problematic as opposed to adaptive behaviour.

than do Western European or American parents. Thus, a given level of conduct disturbance may be more deviant (compared with the rest of the population) in a Thai child than a Dutch child. In such a circumstance it is easy to imagine that a Thai parent, aware that the child was highly deviant within his or her culture, could seem to be making a fuss over nothing as far as a Dutch psychiatrist used to Dutch norms was concerned. A second example concerns sleep patterns. Nearly all of the literature on sleep and its disorders concerns sleep patterns typical in the industrialized West, but there are many populations where sleeping continuously for 8 h at a ﬁxed time each day would be regarded as being highly abnormal (Worthman & Melby, in press). Indeed we have only to consider what ‘good British parents’ thought of as a proper bedtime for a 2-year-old in the 1950s and the typical practice of parents today, to realize that ‘good parenting’ is a moving target, not a ﬁxed pattern of practice. Even within cultures there are subgroup differences in what is regarded as being appropriate parental behaviour. For instance, in the areas of the rural southeastern USA where much of my research is conducted, many well-adjusted parents of well-adjusted children, heeding the biblical injunction not to ‘spare the rod and spoil the child’ are willing to take a belt to their child for serious infractions of discipline. My experience is that few British social workers would be comfortable with such behaviour. However, such disciplinary practices were pretty much universal in the West until the second half of the twentieth century, and it is by no means apparent that reductions in the use of physical discipline in many quarters have led to reductions in child psychiatric morbidity. The point here is not to encourage the use of corporal punishment, but to emphasize that as clinicians and researchers we need to remain aware that the boundaries of individual and family pathology are to some extent culturally determined, and that we should not make the mistake of labelling all differences from today’s middle-class, Caucasian, industrialized Western norms of behaviour as ‘pathology’. By that standard, most of our own great grandparents bordered on being child abusers.

Cultural and subcultural variations in behaviour
Any assessment of type and severity of psychopathology, no matter how structured or unstructured, relies upon explicit or implicit suppositions about the limits of ‘normality’ and the borders of pathology. As the vast majority of empirical research on psychopathology has been conducted in the USA and Western Europe, most of the constructs familiar to clinicians dealing with child and adolescent psychopathology have been derived from clinical experience with children from those areas. Although there has been rather little cross-cultural research on psychopathology, there are indications that there are national differences in patterns of presentation. For instance, Thai parents report lower levels of conduct problems in their children

Future directions
It is my opinion that structured psychiatric interviews for parents and children aged 9 and above are now probably as good as they can be. Many years of work have gone into producing the interviews we have today, and there is little evidence that recent enormous efforts to further ‘improve’ such measures have had much effect on their reliability, although they have succeeded in making some interviews much longer than they used to be. As we learn more about psychopathology we need to modify our measures’ content to reﬂect what we need to measure, but the basic principles used to design new or revised modules will remain the same (and will work just as well or poorly as they do now). What is needed is to extend the range of structured assessments down to younger ages. There is startlingly little research 47

CHAPTER 3

on preschool psychopathology, for instance, and it was only in 2000 that the ﬁrst structured parent report diagnostic interview speciﬁcally designed for use with this age group became available. A good deal of work still needs to be carried out to determine what forms of information from the child and caretakers other than parents can usefully be integrated into diagnostic assessments. Now that a range of very extensive diagnostic measures is available, it is time to move them out of the research ﬁeld and into ordinary clinical practice. It seems odd that the unstructured clinical interview has been almost entirely supplanted for research purposes because of its well-documented inadequacies as a data-gathering and diagnostic procedure, but continues to be the main assessment tool in clinical practice, where good phenomenological assessment is of the greatest importance. All clinicians dealing with psychopathology can beneﬁt from training on an interviewer-based structured interview (particularly one of the glossary-based interviews), and it is to be hoped that such training will soon become part of all training programmes for clinicians who deal with child psychopathology (as it is already in some). However, it must be admitted that the time to conduct a full psychiatric assessment is not always available, and when that is the case it would be helpful to have shorter interviews available to serve as screening tools. At the time of writing, work is happily beginning on a version of the DISC to fulﬁl this function. The idea here is not to encourage slavish dependence on any particular structured interview or other assessment technique, but to use the strengths of standardized interviews to underpin further explorations of the nature and meaning of psychopathology by clinicians with a solid understanding of the principles of good interviewing and the phenomenological approach to psychiatric diagnosis. Methodologically, we have come a long way in the last 30 years, and it is time to bring the beneﬁts of methods ﬁrst derived for research purposes to all of our patients and clients.

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Rutter, M. & Cox, A. (1981) Psychiatric interviewing techniques. I. Methods and measures. British Journal of Psychiatry, 138, 273– 282. Rutter, M. & Graham, P. (1968) The reliability and validity of the psychiatric assessment of the child. I. Interview with the child. British Journal of Psychiatry, 114, 563–579. Rutter, M., Cox, A., Egert, S., Holbrook, D. & Everitt, B. (1981) Psychiatric interviewing techniques. IV. Experimental study: four contrasting styles. British Journal of Psychiatry, 138, 456–465. Saywitz, K.J. (1987) Children’s testimony: age-related patterns of memory errors. In: Children’s Eyewitness Memory (eds S.J. Ceci, M.P. Toglia & D.F. Ross), pp. 6–52. Springer-Verlag, New York. Schreier, H.A. (1997) Factitious presentation of psychiatric disorder: when is it Munchausen by proxy? Child Psychology and Psychiatry Review, 2, 108–115. Schwab-Stone, M., Fallon, T., Briggs, M. & Crowther, B. (1994) Reliability of diagnostic reporting for children aged 6–11 years: a test–retest study of the Diagnostic Interview Schedule for Children — Revised. American Journal of Psychiatry, 151, 1048–1054. Shaffer, D., Gould, M.S., Brasic, J. et al. (1983) A children’s global assessment scale (CGAS). Archives of General Psychiatry, 40, 1228–1231. Shaffer, D., Fisher, P.W. & Lucas, C.P. (1999) Respondent-based interviews. In: Diagnostic Assessment in Child and Adolescent Psychopathology (eds D. Shaffer, C.P. Lucas & J.E. Richters), pp. 3–33. Guilford Press, New York. Shaffer, D., Fisher, P., Lucas, C.P., Dulcan, M.K. & Schwab-Stone, M.E. (2000) NIMH Diagnostic Interview Schedule for Children version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 28– 38. Sherrill, J.T. & Kovacs, M. (2000) Interview schedule for children and adolescents (ISCA). Journal of the American Academy of Child and Adolescent Psychiatry, 39, 67–75. Silverman, W.K. & Nelles, W.B. (1988) The Anxiety Disorders Interview Schedule for Children. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 772–778. Silverman, W.K. & Rabian, B. (1995) Test-retest reliability of the DSMIII-R childhood anxiety disorders symptoms using the Anxiety Disorders Interview Schedule for Children. Journal of Anxiety Disorders, 9, 139–150. Sox, H.C. Jr (1987) Decision analysis: a basic clinical skill? New England Journal of Medicine, 316 (5), 271–272. Sparrow, S.S. & Cicchetti, D.V. (1989) The Vineland Adaptive Behavior Scales. In: Major Psychological Assessment Instruments (ed. C.S. Newmark), pp. 199–231. Allyn & Bacon, Needham Heights, MA. Sparrow, S., Balla, D. & Cicchetti, D. (1984) Vineland Adaptive Behavior Sales: Interview Edition Expanded Form Manual. American Guidance Service, Circle Pines, MN. Stanger, C. & Lewis, M. (1993) Agreement among parents, teachers, and children on internalizing and externalizing behavior problems. Journal of Clinical Child Psychology, 22, 107–115. Steward, M.S. & Steward, D.S. (1996) Interviewing young children about body touch and handling. Monographs of the Society for Research in Child Development, Serial No. 248, 61, 1–236.

DIAGNOSTIC INTERVIEWS WITH PARENTS AND CHILDREN Truax, C.B. (1966) Reinforcement and non-reinforcement in Rogerian psychotherapy. Journal of Abnormal Psychology, 71, 1–9. Truax, C.B. (1968) Therapist interpersonal reinforcement of client self-exploration and therapeutic outcome in group psychotherapy. Journal of Counseling Psychology, 15, 225–231. Tversky, A. & Kahneman, D. (1974) Judgement under uncertainty: heuristics and biases. Science, 185, 1124–1131. Valla, J.-P., Bergeron, L. & Smolla, N. (2000) The Dominic-R: a pictorial interview for 6- to 11-year-old children. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 85–93. Wallace, S.R. (1965) Criteria for what? American Psychologist, 20, 411–417. Warren, S.L., Emde, R.N. & Sroufe, A. (2000) Internal representations: predicting anxiety from children’s play narratives. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 100–107. Warren, S.L., Oppenheim, D. & Emde, R.N. (1996) Can emotions and themes in children’s play predict behavior problems? Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1331–1337. Weitz, J. (1961) Criteria for criteria. American Psychologist, 16, 228–231. Weller, E.B., Weller, R.A., Fristad, M.A., Rooney, M.T. & Schecter, J. (2000) Children’s interview for psychiatric syndromes (ChIPS). Journal of the American Academy of Child and Adolescent Psychiatry, 39, 76–84. Winkley, L. (1982) The implications of children’s wishes — research note. Journal of Child Psychology and Psychiatry, 23, 477–483. Winnicott, D.W. (1971) Therapeutic Consultations in Child Psychiatry. Hogarth Press, London. Winter, D.G. (1999) Linking personality and ‘scientiﬁc’ psychology: the development of empirically derived Thematic Apperception Test measures. In: Evocative Images: the Thematic Apperception Test and the Art of Projection (eds L. Gieser & M.I. Stein), pp. 107–124. American Psychological Association, Washington D.C. World Health Organization (1992) ICD-10: the ICD-10 Classiﬁcation of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Geneva. World Health Organization (1993) The ICD-10 Classiﬁcation of Mental and Behavioural Disorders: Diagnostic Criteria for Research. World Health Organization, Geneva. Worthman, C.M. & Melby, M. (in press) Toward a comparative developmental ecology of human sleep. In: Adolescent Sleep Patterns: Biological, Social, and Psychological Inﬂuences (ed. M.A. Carskadon). Cambridge University Press, New York. Zahn-Waxler, C., Iannotti, R.J., Cummings, E.M. & Denham, S. (1990) Antecedents of problem behaviors in children of depressed mothers. Developmental Psychopathology, 2, 271–291.

4
Introduction

Case Identiﬁcation in an Epidemiological Context
Eric Fombonne

This chapter addresses the issues raised by the assessment of psychopathology within a broader, epidemiological context. The principles underlying the clinical assessment of children in a clinical context are addressed in a preceding chapter (Rutter & Taylor, Chapter 2). The focus here is on the use of assessment methods within studies requiring the investigation of large samples of children seen in their natural home and school environments. Some achievements of 40 years of epidemiological research in child psychiatry are reviewed brieﬂy. Attention is paid to the design of surveys and to prevalence ﬁndings on global psychiatric morbidity (ﬁndings on speciﬁc disorders are discussed in other chapters). In the second section, key concerns are addressed regarding: the deﬁnition and assessment of child psychopathology in relation to the differentiation between normal and abnormal development; the use of dimensional or categorical approaches to case deﬁnition; the need to use impairment measures and to combine data from multiple informants; the need to take into account the high rates of comorbidity between disorders; and the implications of pervasiveness or situational speciﬁcity of behaviours in estimating rates and risk associations for psychiatric disorders. The third section addresses more specialized issues pertaining to psychometric theory and the measurement of performances of instruments; the assessment of special groups, such as young children or those from different cultural backgrounds; the use of computerized assessments and the development of clinical databases useful for clinical epidemiology.

Epidemiological investigations of child psychopathology
Conceptual/methodological issues
Child psychiatric epidemiology started in the mid-1960s with the British Isle of Wight surveys (Rutter et al. 1970, 1976). Prior to this landmark study, there had been few investigations of rates of psychopathology in general population samples. The survey by Lapouse & Monk (1958) is a notable exception. It emphasized the high prevalence of fears and worries and the discrepancies in rates of problems according to the informant. Most knowledge at the time relied on observations drawn from 52

clinical case series. Behaviours were interpreted and theoretical inferences were made without having a proper calibration system allowing a focus on those behaviours that discriminated best between children seen in clinics and non-referred children. Epidemiology, with its focus on general population samples and on comparisons between individuals with or without disorders, provided an obvious tool for the empirical investigation of child psychopathology. The Isle of Wight surveys had key design characteristics that provided a model for surveys in the years after (Rutter 1989). A two-phase design was used with a systematic questionnaire screening of a large sample, followed by in-depth assessments administered in a subsample selected according to their positive and negative results at screening. Multiple informants were used at both phases, involving parents, teachers and children. The value of asking children direct questions was established and interviews subsequently replaced the old indirect techniques (projective tests and free play) as investigation tools. Questionnaires and diagnostic interviews of known reliability and validity were employed to gather data. Caseness was deﬁned according to both a recognizable behavioural pattern and evidence of impairment in the child’s functioning. The surveys also adopted longitudinal approaches to measure prospectively risk factors and chart the natural history of disorders, and behavioural measures were related to neurological and educational risk factors. These methodological advances have been developed further in the series of surveys conducted since. The planning of epidemiological studies requires precise methods to ascertain ‘cases’ of the disorder under study (Verhulst & Koot 1995). This implies two related activities. First, a deﬁnition of ‘caseness’ must be adopted at the outset. Its nature should be shaped by the goals of the survey. A survey of autism to identify representative cases for inclusion in genetic studies will require detailed phenotypic assessments, precise diagnostic subtyping and exclusion of autistic syndromes associated with known medical disorders. If, on the other hand, the goal of the study is to generate estimates of special educational needs for service planning, then a less detailed and broader approach to ‘caseness’ such as the ‘triad of impairments’ (Wing & Gould 1979) may be sufﬁcient. Following the adoption of the most appropriate concept of the disorder, decisions must be made about the choice of various assessment procedures and instruments. Guidelines to select instruments are provided in Appendix 1. Secondly, once a case deﬁnition has been established, case

CASE IDENTIFICATION IN AN EPIDEMIOLOGICAL CONTEXT

identiﬁcation methods are selected. This involves sampling techniques that aim to provide a sample that will allow inferences about rates and correlates of disorders in the target population. Adequate sampling techniques are mandatory in order to provide unbiased estimates of the rates and the risk factors associated with disorders. The drawing of a sample requires the availability of a sampling frame and of sampling units covering the population of interest (Boyle 1995). In child psychiatry, surveys have often relied upon school rosters (Fombonne 1994) because, with compulsory education, they provide comprehensive sampling frames. Alternatively, households may be used as sampling units (Bird et al. 1988; Meltzer et al. 2000). These will still miss a small proportion of children, such as homeless or street children (Bird et al. 1988) or children from families who migrate seasonally for employment reasons. Children in long-term residential facilities may also be overlooked. The extent to which these sampling limitations will bias ﬁndings will depend on the strength of the association between a psychiatric disorder and these psychosocial circumstances. Sampling techniques vary from simple random sampling to more complex stratiﬁed or cluster sampling strategies that aim to increase the precision of estimates, while optimizing survey resources and reducing costs. In selecting children for inclusion in the study sample, it is crucial to note the probability for each child to be selected, so that subsequently these probabilities can be used to weight the ﬁgures (usually with weights that are the inverse of the sampling fraction) for extrapolation to the target population. This allows oversampling of some subgroups without distortion of the ﬁnal estimates provided that proper weights are devised and applied. The analysis of two-phase or more complex survey designs is discussed by Pickles (1998) and by Dunn et al. (1999). Methods for dealing with missing data are crucial and have been addressed more efﬁciently in recent surveys. Survey participation rates have generally been high, often well over 80%. Bias in the estimates of prevalence and risk associations might result, nevertheless, if those who do not participate have higher rates of disorders, more severe disorders or disorders arising through different mechanisms. Empirical ﬁndings indicate that it should be expected that non-respondents will differ systematically from respondents (Cox et al. 1977). Fombonne (1994), in a French survey, found that behavioural disturbance was some 60% higher among non-participants than participants, but it was possible to correct for this bias in the ﬁnal prevalence estimation. Similarly, attrition bias in longitudinal studies may attenuate predictions regarding the persistence of disorders over time (Boyle et al. 1991). However, it will be possible to correct for non-respondents’ levels of psychopathology, when there are data on them either from records or from earlier points of data collection. Missing data can also occur at the item level with respondents omitting items on a checklist or failing to answer all questions in an interview. This may jeopardize data collection (if incomplete screens are deemed ineligible for further interview) or analysis (if incomplete interviews are not dealt with separately). Sophis-

ticated statistical techniques are available to take account of missing data according to the reasons that they are missing (Kalton 1983; Little & Rubin 1987).

Findings from cross-sectional epidemiological surveys
Epidemiological surveys to assess prevalence usually rely on cross-sectional methods. Numerous prevalence surveys have now been conducted across the world (Brandenburg et al. 1990; Canino et al. 1995; Verhulst & Koot 1995; Bird 1996; Roberts et al. 1998). Table 4.1 presents the main results of some selected recent surveys. The rates for speciﬁc disorders are discussed in the chapters dealing with them. Some key ﬁndings from longitudinal investigations are noted in Rutter, Chapter 28; Rutter, Chapter 19; and Taylor & Rutter (Chapter 1). The rates of disorder in Table 4.1 results underscore the most important ﬁnding, that psychopathology in young people is common, most studies estimating the prevalence to be between 10 and 20%. Verhulst & Koot (1995) reviewed 49 surveys and computed an average rate of 12.9%. Emotional disturbances and disorders of disruptive behaviour are equally common (with rates of 6–8%; see Table 4.1). It should be noted that many of these surveys will not have included neurodevelopmental disorders, such as autism, and may not have picked up psychotic disorders with an onset in late adolescence. Community samples have also shown that only a small proportion (typically between 10 and 30%) of children with disorders have had contact with specialist mental health services. Thus, in the recent British nationwide survey of 10 000 5–15-year-olds (Meltzer et al. 2000), 27% of children with a psychiatric disorder had been in contact with specialist health care services and 30% had had no contact with any sort of professional. Similar ﬁgures have been reported in other studies (Offord et al. 1987; Costello & Janiszewski 1990; Zahner et al. 1992; Leaf et al. 1996). Disorders involving disruptive behaviour (Verhulst & Koot 1992; Meltzer et al. 2000), and those that are severe or of long duration (Whitaker et al. 1990), are more likely to be referred. However, contextual factors (such as parental psychopathology) and family features also inﬂuence referral (Jensen et al. 1990). The ﬁndings indicate the need for caution in extrapolating from clinical samples or experience. Children seen in clinics often differ in systematic ways from non-referred children with comparable levels of psychopathology. Epidemiological ﬁndings are needed for the development of psychopathological models.

Issues in case deﬁnition
Normality and disorder
All epidemiological surveys have shown the high frequency of individual items of emotional or behavioural difﬁculties (Rutter et al. 1970; Shepherd et al. 1971; Achenbach & Edelbrock 53

Table 4.1 Prevalence ﬁndings from recent epidemiological surveys. Prevalence

54
Site North Troendelag, Norway Dunedin, New Zealand Ontario, Canada 4–16 2 679 Structured interview/DSM-III like DISC/ DSM-III Clinical interview/ICD-9 Isle of Wight interview/ ICD-9 Isle of Wight interview/ ICD-9 DISC/ DSM-III-R – 3 months 3 months 6 months 6.0 — 6 months — 6 months — 11 925 DISC-C/ DSM-III 1 year 7.3 11.6 — 10 1 510 Isle of Wight interview/ICD-9 3 months — — Age N Instruments/diagnosis Period Any emotional disorder Any behavioural disorder Any disorder 5.4 17.6 18.1 Puerto Rico Mannheim, Germany Gunma prefecture, Japan Dublin, Ireland 9–12 2 029 12–15 1 999 8 1 444 4–16 777 — 6.0 — 17.9 16.2 15.0 — — 25.4 Christchurch, New Zealand Oregon, USA Chartres, France Great Smokey Mountains, North Carolina, USA Nationwide, the Netherlands Virginia, USA Zurich, Switzerland 7–16 1 964 8–16 2 762 13–18 780 DISC C & P/ DSM-III-R CAPA/DSM-III-R DISC-P/DSM-III-R 9,11,13 4 500 CAPA/ DSM-III-R 6–11 2 441 ICD-9/Isle of Wight module 16–18 1 710 K-SADS/ DSM-III-R 15 986 — — 22.1 C 13.0 P Current 3 months 3 months — 5.9 6.8 1.8 6.5 6.6 9.6 12.4 20.3 6 months — 7.9 C or P 0.9 C & P 3 months 6 months 8.9 — 7.1 6.5 35.5 C or P 4.0 C & P 14.2 22.5 Quebec, Canada 6–14 2 400 Dominic-DISC2/ DSM-III-R 10 438 DAWBA/ICD-10 6 months — — 19.9P 15.8C 3 months 4.3 5.8 9.5 Nationwide, England and Wales 5–15

CHAPTER 4

Authors/year

Vikan (1985)

Anderson et al. (1987)

Offord et al. (1987)

Bird et al. (1988)

Esser et al. (1990)

Morita et al. (1990)

Jeffers & Fitzgerald (1991)

Fergusson et al. (1993)

Lewinsohn et al. (1993)

Fombonne (1994)

Costello et al. (1996)

Verhulst et al. (1997)

Simonoff et al. (1997)

Steinhausen et al. (1998)

Breton et al. (1999)

Meltzer et al. (2000)

C, based on child as informant; P, based on parent as informant.

CASE IDENTIFICATION IN AN EPIDEMIOLOGICAL CONTEXT

1981). However, whereas some have a strong association with psychiatric disorders, others do not. Thus, in the Isle of Wight survey, thumb-sucking, nail-biting and bilious attacks all had very weak associations with psychiatric disorders (Rutter et al. 1970). Similarly, item scores for asthma and allergy have been removed from the computation of the total score of the Child Behaviour Checklist after consistent evidence that these were not associated with psychiatric referral. By contrast, the symptom of depressed mood has been shown to account for much of the variance in comparisons of matched samples of non-referred and referred children (Achenbach & Edelbrock 1981; Fombonne 1992). However, continuities and discontinuities between individual symptoms and disorders may involve crucial transitions. Thus, depressed mood is experienced by about a third of adolescents in the general population (Petersen et al. 1993) but the rate of depressive disorder is only about 5% (see Harrington, Chapter 29). Similarly, some half of female adolescents diet but anorexia nervosa occurs in less than 1% (Fombonne 1995; see also Steinhausen, Chapter 34). The situation with substance use and abuse (see Rutter, Chapter 28; Weinberg et al., Chapter 27) and with disruptive behaviour (see Earls & Mezzacappa, Chapter 26) is directly comparable. Many problem behaviours have a continuous distribution in the population and quantitative, rather than qualitative, deviance often deﬁnes psychopathology.

weaknesses. The chief decision issue with interviews is whether to use an investigator-based interview that obtains descriptions of behaviour that are rated using a standardized research-driven concept or a respondent-based approach that obtains yes/no answers to carefully structured questions. As Angold (Chapter 3) discusses, each has its own merits and researchers will need to consider carefully which is most likely to meet the needs for the particular investigation to be undertaken. A further decision is needed on whether to choose a broad-based measure designed to tap all the common varieties of psychopathology or rather to use one or more focused instruments. The former will meet most needs but is less suitable for uncommon or unusual disorders, such as autism, schizophrenia or Tourette syndrome. Whatever the particular choice of instrument, investigators will usually need to test their chosen set of measures and data collection procedures in pilot studies of adequately sized samples to determine the procedural feasibility and its acceptability by respondents. Pilot studies should be analysed carefully using quantitative methods whenever appropriate.

Impairment
The importance of including impaired functioning in case deﬁnition was well shown in Bird et al.’s (1988) general population epidemiological study. The prevalence of psychiatric disorder was 50% if assessed on the basis of symptoms alone, without taking account of impairment, but 18% if the latter was required for case deﬁnition (Bird et al. 1988). Similar results have been found in other studies (Bird et al. 1996; Simonoff et al. 1997). The need to assess functional impairment is now generally accepted, but it has proved more difﬁcult to deﬁne and measure it in a valid fashion. Impairment is related to concepts of role performance that reﬂect the individual’s adaptation into his social environment (Bird 1999). This must be related to developmental level and sociocultural context. Typically, impairment resulting from psychopathology is assessed in four domains: interpersonal relationships; academic/work performance; social and leisure activities; and ability to enjoy and obtain satisfaction from life. These need to be evaluated with respect to functioning at home, school and in the community. In earlier epidemiological surveys (Rutter et al. 1970), and in most classiﬁcation schemes (World Health Organization 1992; American Psychiatric Association 1994), the assessment of impairment was largely left to a global clinical judgement by the interviewer. In the early 1980s, instruments were developed to address this issue with the development of the Children’s Global Assessment Scale (Shaffer et al. 1983). This instrument was shown to have adequate psychometric properties but it still relied on an experienced clinician, and did not specify how impairment data should be obtained. Further developments of this scale led to a simpliﬁed non-clinician version (Bird et al. 1996; Bird 1999). Another instrument, the Columbia Impairment Scale (CIS; Bird et al. 1993), was devised to be completed by both parent and adolescent respondents; it has the advantage of 55

Categories and dimensions
Because of this, most epidemiological studies use a mixture of dimensional and categorical approaches. The former are needed both to assess symptom severity and to allow the adoption of different cut-offs for different purposes. The latter is required for clinical decision-making with respect to individual diagnosis and service planning (see Taylor & Rutter, Chapter 1). The issues are not speciﬁc to psychopathology; rather, they apply throughout most of medicine (as exempliﬁed by asthma, hypertension, anaemia, diabetes and occlusive coronary artery disease — all of which have dimensional parallels). It is sometimes assumed that dimensional measures are synonymous with questionnaires and categorical ones with interview assessments, but that is not so. All standardized interviews (see Angold, Chapter 3) provide for various forms of quantiﬁcation of severity or numbers of symptoms. Conversely, most questionnaires (see Verhulst & Van der Ende, Chapter 5) provide the means for deriving categories from dimensional scores. The most appropriate choice of measure constitutes a crucial step in any epidemiological study (Table 4.2). Choice should be driven by the main purposes of the study. Questionnaires have all the advantages of economy and simplicity and may be the ﬁrst preference if the goal involves only group differences and trends. They will almost always be used in the ﬁrst screening phase of multistage studies. However, they are less suitable for individual diagnosis or for the assessment of uncommon disorders involving qualitative departures from normality. Standardized interviews have the opposite set of strengths and

CHAPTER 4

being brief and providing scores for speciﬁc domains. Preliminary data suggest that it is a useful measure with the parent CIS having consistently better validity than the children’s version. Other instruments, such as the Social Adjustment Inventory for Children and Adolescents (John et al. 1987) and the Child and Adolescent Functional Assessment Scale, were reviewed by Bird (1999). The issues to be addressed still include: (i) the differentiation between impairment and psychiatric symptoms (for example, aggression to peers is both a symptom of conduct disorder and a reﬂection of impaired functioning with respect of peer relationships); (ii) how to determine causal connections between symptoms and impairment (preliminary ﬁndings suggest that informants found this difﬁcult (Bird 1999) and interrater agreement was low (Sanford et al. 1992)); and (iii) the difference between impairment and symptom severity. Pickles et al. (2001) found that depressive symptoms predicted later depression equally well with and without the presence of impairment; by contrast, the predictive power of conduct symptoms was increased in the presence of impairment. Angold et al. (1999a) found, in a community study, that over a ﬁfth of children showed impairment even though their number of symptoms fell below speciﬁed cut-offs for diagnosis. These impaired children with subthreshold disorders were likely later to be referred to services. Conversely, disorders without impairment tended to have a good outcome (Costello et al. 1999). The ﬁndings from the Ontario study tell much the same story (Sanford et al. 1992). Diagnostic interviews now include separate measures of impairment associated with disorders and symptoms (Angold & Costello 2000; Shaffer et al. 2000; see also Angold, Chapter 3). However, research is still needed on the origins of impairment; it cannot be presupposed that they will necessarily be the same as for symptoms.

risk of recurrence in adult life (Weissman et al. 1999a; Fombonne et al., 2001) whereas the course and correlates of depression beginning before puberty is rather different (Harrington et al. 1997; Rende et al. 1997; Weissman et al. 1999b). The timing of onset is also crucial in order to explore the direction of causal effects in patterns of comorbidity (see Rutter, Chapter 28). The demonstration that ADHD is a risk factor for later conduct disorder, but that the reverse does not apply (Taylor et al. 1996; Taylor 1999), and that dysthymic disorder is a gateway to major depressive disorders (Kovacs et al. 1994), provide examples of this issue. Retrospective assessment of age of onset is also an issue in adult studies (Kessler et al. 1999), particularly as accurate assessment of this variable can inﬂuence results from familial studies (Schurhoff et al. 2000) and from studies of secular trends (Simon & Von Korff 1992). One way to avoid the problem of unreliability in the timing of onsets is to use lifetime prevalence estimates (Lewinsohn et al. 1993). These have the advantage of avoiding the problem of unreliability in the timing of onset and are probably the best approach for disorders present at the time of assessment. Doubts arise over the reliability and validity of reports of past disorders that are no longer present. Such doubts probably apply less to disorders in childhood than in adult life because time spans are shorter and because multiple instruments are available.

Comorbidity
The high frequency of co-occurrence of two supposedly separate forms of psychopathology was noted in the Isle of Wight studies over 30 years ago (Rutter et al. 1970). However, it is only in the last 15 years that it has received much conceptual attention and empirical study (Achenbach 1991a; Caron & Rutter 1991; Hinshaw et al. 1993; Nottelman & Jensen 1995; Rutter 1997; Angold et al. 1999b;). In their thorough review of the topic, Angold et al. (1999b) concluded that artefacts cannot account entirely for the frequency and patterns of comorbidity, and that mechanisms underlying comorbid presentations should be studied more systematically, preferably with epidemiological samples. The classiﬁcation issues associated with comorbidity are discussed by Taylor & Rutter (Chapter 1) and the use of longitudinal data to study causal mechanisms is discussed by Rutter (Chapter 28) in relation to depression and substance abuse. Several research ﬁndings show how comorbidity may carry meaning. For example, the results of a family study of depression changed once comorbidity in the probands was properly taken into account (Merikangas et al. 1998) and a trend emerged for a positive drug response to tricyclic antidepressants in noncomorbid depressed subjects when results from a clinical trial were stratiﬁed according to the presence or absence of comorbid conduct disorder (Hughes et al. 1990). However, in order to undertake research using comorbidity it is necessary that the epidemiological studies methods of measurement are adequate for dealing with the assessment of psychopathology that involves comorbid patterns.

Age of onset
Age of onset is a deﬁnitional feature of several disorders. Enuresis cannot be diagnosed before the age of 5, attention deﬁcit hyperactivity disorder (ADHD) symptoms must exist before age 7 and Asperger syndrome is differentiated from highfunctioning autism by the absence of a signiﬁcant language delay by the age of 3. Age of onset is usually assessed retrospectively. However, the interrater and retest reliabilities of age of onset have been found to be poor outside the last 3 months for disorders with a recent onset and outside 1 year for those with a longer duration (Angold et al. 1996). Imperfect measurement of onset and offset of disorder can therefore inﬂuence prevalence estimates which are contingent upon speciﬁc time periods. Age of onset also indexes differential outcomes. Mofﬁtt (1993) found that conduct disorders with an adolescent onset differed from early-onset conduct problems, with the latter more likely to be associated with neuropsychological impairments and with a worse long-term outlook. Similarly, adolescent-onset depression is associated with a particularly strong

CASE IDENTIFICATION IN AN EPIDEMIOLOGICAL CONTEXT

Situation and multiple informant speciﬁcity
From the Isle of Wight studies onwards, it has been evident that the agreement on childhood psychopathology between different informants is typically low, and is only moderate at best. Thus, in an epidemiological survey of 6–11-year-olds, only a quarter of children scoring above the cut-off on at least one screening measure were scoring above threshold on both parent and teacher questionnaires (Fombonne 1994). In a meta-analysis of 119 studies, Achenbach et al. (1987) found that the agreement was best (ª 0.60) when the pairs of informants had similar roles in relation to the child (such as with mother–father or teacher–teacher) whereas the mean correlation fell to the 0.20s for other types of pairs (such as parent–child or parent–teacher). There are many possible reasons for this low agreement between informants. These include: random error in measurement; different perceptions of behaviour according to the perspective of the observer; different frames of reference; and variations in the child’s behaviour according to both setting and interpersonal features. The relative importance of these different possibilities is not known. However, it is clear that multiple informants are essential for any adequate epidemiological study. That is partly because each informant contributes uniquely to the measurement of psychopathology, as well as contributing to shared variance; because when studying the correlates of disorder it is necessary to go across informants, or use composite ratings, in order to avoid halo effect artefacts; and because of the importance of differentiating between situation-speciﬁc and pervasive disorders (Schachar et al. 1981). That leaves open the crucially important, but largely unresolved question of how to combine the data from different informants and from different settings. Although there is some evidence that different informants have different strengths, only rarely will it be desirable to adopt a hierarchical approach in which the report of one informant is automatically given precedence over those of others. Nevertheless, child self-reports are particularly important for the assessment of mood disturbances (see Harrington, Chapter 29). Conversely, they are of very limited use for the assessment of hyperactivity (see Angold, Chapter 3; Schachar & Tannock, Chapter 25). On the whole, teachers are better at the assessment of disruptive behaviour than they are of depressed mood. As the ﬁndings from Verhulst et al. (1997) show dramatically (see Table 4.1), prevalence ﬁndings are often hugely affected by how multiple ratings are dealt with. Clinical interviewers usually use their ‘best’ judgement in order to weigh the symptoms endorsed by each informant, resolving discrepancies by personal rules derived from a combination of experience and theoretical predictions. This is likely to result in different clinicians combining data in different ways. Another approach is trying to seek to resolve discrepancies between informants through a conjoint interview involving different informants (such as parent and child). This might be helpful in eliminating some errors brought about by mis-

comprehension and ‘reconciling’ the informants (Angold et al. 1999b). However, the method is far from free of problems, most especially in giving rise to delicate situations that threaten to broach conﬁdentiality. Nevertheless, this judgement method is recommended for the use of some diagnostic interviews, such as the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS; Ambrosini 2000), in order to allow the generation of a single unique score for each symptom rating. A third commonly used approach uses computer generation of diagnoses based on predeﬁned algorithms. The method has the advantage of accuracy and speed. However, the algorithms must deal with differences in reporting by informants according to speciﬁed rules. Usually, a symptom is counted as positive when it is reported by at least one informant: the so-called ‘or’ rule (Bird et al. 1992). This technique typically leads to high numbers of generated diagnoses. For dimensional assessments, Achenbach (1991b) has revised the data collected through his set of questionnaires in order to solve this cross-informant problem. Based on systematic analyses of the Child Behaviour Checklist (CBCL), the Teacher Report Form (TRF) and the Youth Self Report (YSR), he identiﬁed common syndromes on each of these questionnaires, and core syndromes that appeared consistent across sex and age subgroups. He then selected a set of cross-informant core syndromes that spanned at least two instruments. These were subsequently scaled with the relevant normative sample. This approach does not resolve the problem of how to combine data from discrepant informants but it helps in increasing the interpretability of a proﬁle of scores for a given child (Achenbach 1991b, 1995). More sophisticated statistical techniques are available to researchers to deal with the measurement problems associated with multiple data sources and discrepancies between informants (see below).

Measurement
At the core of medicine, and of any scientiﬁc enquiry, is measurement theory (see also Sergeant & Taylor, Chapter 6). In essence, this speciﬁes the relationship between a conceptual construct and empirical measures. With respect to psychopathology, the construct cannot be directly observed, as through a pathognomonic test. There is a good deal of evidence for some of the key psychiatric diagnostic concepts, such as autism or schizophrenia (see Taylor & Rutter, Chapter 1). Nevertheless, there has to be an empirical means of going from observables (whether those be signs or symptoms), to the postulated diagnostic entity. Child psychiatry research has progressed tremendously in that direction over the last two decades. Far from being a question mattering uniquely to researchers, the same measurement considerations and needs apply to everyday clinical practice. In that sense, the choice is not between measuring or not (or between research and clinical practice), but rather between measuring with known and replicable procedures or not.

CHAPTER 4

Concepts of validity and reliability
Two major properties, validity and reliability, are examined in the evaluation of assessment procedures (instruments or simple clinical judgement) for which Fig. 4.1 provides a convenient representation. Data collected as part of clinical or research assessments can be seen as empirical indicators of the underlying (unobserved) constructs of interest. Reliability is the tendency of measures to yield consistent results over repeated trials. Reliability concerns the replicability of measures and the extent to which each measurement is affected by random error. Reliability can therefore be examined empirically (see bottom level on Fig. 4.1). Typical procedures to estimate reliability are the test–retest paradigm, interrater agreement, and techniques based on correlations between subsets of instruments (split-half reliability) or among items composing a questionnaire (internal consistency). The reliability of the measurement is assessed within each procedure by speciﬁc statistics, such as the kappa coefﬁcient for categorical measurements (Spitzer & Fleiss 1974), the intraclass correlation coefﬁcient for quantitative scores (Bartko 1976) and other statistics (e.g. Cronbach’s (1951) alpha coefﬁcient). Reliability is a necessary condition, but not a sufﬁcient one, for validity. If empirical indicators are unduly contaminated by random error (so that measurements cannot be replicated), then the question of their relationship to the constructs that they are purported to tap cannot be assessed meaningfully. On the other hand, high replicability does not necessarily mean good validity. Validity concerns the crucially important relationship between the empirical observables and the postulated latent construct (in this case diagnosis) as represented by the connections between the bottom and top levels on Fig. 4.1. Several types of validity have been described. Content validity is concerned with the extent to which an instrument is representative of the universe of indices that are related to the concept measured. It is usually assessed by reliance on experts or on agreement with established instruments tapping the same concept. Criterionrelated validity is the most empirical form of validity. It allows

an index to be compared to an independent external criterion thought to assess the same concept. This can be either concurrent or predictive. Construct validity is the most elusive and theoretical type of validity. It concerns the extent to which individual items or measures intercorrelate or group together to produce derived higher order constructs. Factor analysis has often been used for this purpose in the ﬁeld of psychopathology. Thus, numerous factor analyses of questionnaires have consistently identiﬁed separate dimensions (or constructs) of psychopathology (such as attention problems, conduct symptoms or emotional disturbances). These tend to map onto a broad bipartite division into internalizing/emotional problems and externalizing/disruptive behaviours (Achenbach & Edelbrock 1978; Elander & Rutter 1995). Consistency of these factor analyses results has been taken as evidence of the construct validity of these psychopathology dimensions.

Diagnostic reliability
Since the ﬁrst collaborative efforts sponsored by the World Health Organization to improve diagnosis in psychiatry, reliability studies have been undertaken to examine interrater agreement and to improve the deﬁnition, and thereby the diagnostic reproductibility of disorders (Rutter et al. 1969, 1975). In the late 1970s, with the development of research diagnostic criteria (Spitzer et al. 1978) and of standardized diagnostic interviews, emphasis was placed on the development of operational diagnostic criteria. This was embodied in the DSM-III (American Psychiatric Association 1980) and its successors and in the clinical and research versions of ICD-10 (World Health Organization 1992, 1993). Studies of the reliability of child psychiatric diagnoses have been conducted with various schemes and instruments, giving rise to broadly similar overall conclusions (Rutter et al. 1988; Shaffer et al. 1999). The concept of reliability involves three rather different potential sources of error or variability: information variation (features to do with how data are collected); interpretation variance (how data are weighted and put together); and criterion variance (how algorithms are used to produce diagnoses). These need to be assessed in different ways. The ﬁrst may be examined through test–retest studies to examine the extent to which the same answers are obtained on two consecutive occasions. On the whole, the ﬁndings have been of moderate to good reliability that is higher for symptom dimensions than for categorical diagnoses (Shaffer et al. 1999). It is affected, however, by the tendency for informants to report less psychopathology on the second occasion (Piacentini et al. 1999; Shaffer et al. 1999). This is more pronounced with highly structured interviews but can be reduced somewhat by attention to details of wording of questions and interview organization (Lucas et al. 1999). Interpretation variance can be assessed by determining the extent to which two informants agree (see above), or two investigators agree on their ratings of behavioural descriptions (Strober et al. 1981; Werry et al. 1983; Gould et al. 1988; Pren-

V4 V2 V3 V1
validity

Latent variables

Vn
bi

Indicators:

I1
e1 reliability

I2
e2 reliability bias

I3
e3

Observed variables

Fig. 4.1 Measurement model.

CASE IDENTIFICATION IN AN EPIDEMIOLOGICAL CONTEXT

dergast et al. 1988), or two different diagnostic instruments give the same answer. Typically, this form of variance is greater — particularly across informants and across instruments. Criterion variance needs to be evaluated by comparing different ways of putting the data together. Standardization aims to keep this to a minimum but it is clear that different systems often give different answers (see, for example, the ﬁndings with respect to age of onset in ADHD (Applegate et al. 1997), number of symptoms in antisocial diagnoses (Lahey et al. 1994) or diagnostic algorithms in autism (Volkmar et al. 1994)).

Diagnostic validity
Diagnostic validity concerns the extent to which a diagnostic construct truly reﬂects a syndrome that is different from others. The testing of validity therefore requires research that examines correlates of diagnosis with respect to basic features that are external to the behaviours that deﬁne the hypothesized diagnostic construct (Rutter 1978). Such correlates might include genetic inﬂuences, neuropathology, biological indices, course and response to speciﬁc treatments. The evidence on such validity is discussed by Taylor & Rutter (Chapter 1). From a measurement perspective, validity concerns the extent to which empirical measures tap the crucial features that provide the basis of the diagnostic construct: the vertical connections between the top level (the latent construct) and the bottom level (empirical measures) in Fig. 4.1. The main measurement issue concerns the possible operation of biases in those vertical connections (expressed as Vn in Fig. 4.1). The main, possibly biasing factor considered up to now has been the mental state of the informant. Thus, there has been concern that a depressed mother might over-report psychopathology in her child (Brewin et al. 1993). To test that possibility it is necessary to determine whether maternal depression alters the pattern of associations between maternal reports of child psychopathology and teacher or child reports (Chilcoat & Breslau 1997). The key statistic here relates to pattern differences and not to correlations as such. Thus, with respect to maternal depression the issue is whether a difference in child psychopathology is found on maternal reports that is not evident on reports from others. If there is, a bias is suggested. The weight of evidence from a range of studies indicates that there is some biasing effect, although not a great one. Recently, attention has broadened to consider whether depression in one parent alters the rating of the other parent by virtue of its inﬂuence on the overall family context (Borge et al., 2001). Preliminary ﬁndings suggest that possibly it may, although further research is needed to investigate the matter. A comparable rating bias concern was raised with respect to possible contrast effects in parental ratings of twins. Thus, it was hypothesized that parents, in their ratings, might exaggerate differences between dizygotic (non-identical) twins. Again, the test involves pattern effects in relation to the others. Such contrast effect biases have been found with respect to parental ratings of hyperactivity but, interestingly, not of other forms of disruptive behaviour (Simonoff et al. 1998).

Other examples of such possible rating biases concern the effects of a person’s current social situation and mental state on their retrospective rating of negative childhood experiences (Maughan & Rutter 1997). Findings suggest that there is a slight tendency for people who are doing well to under-report past adversities but no tendency for people who are doing well to over-report. Obviously, to test this possibility, it is necessary to have longitudinal data involving contemporaneous measurement of the adverse experiences. Yet another example concerns the possibility that people with a mental disorder may overreport comparable disorders in relatives (Kendler et al. 1991; Rende & Weissman 1999). In all these examples the tests have involved some form of pattern difference that involves comparisons among different informants. Usually, the biases found have been small, but equally they have not been zero. The implication is that investigators need to use multiple informants and need to test for such possible biases, statistically correcting for them when required.

Latent variable models
Historically, researchers tended to deal with these measurement problems either by choosing what seemed to be the ‘best’ informant or alternatively by combining the ratings in some way (such as by adding them together or counting a report of a behaviour if it comes from just one of a number of informants). Such composite strategies have the advantage of simplicity and, for this reason, they continue to have a worthwhile place in research. However, they fail to make use of all the data, they do not deal quantitatively with possible biases, and they do not remove random measurement error. Latent variable models were developed to deal with these issues (see Fergusson 1995, 1997 for clear descriptions of the rationale and the assumptions involved). In brief, multivariate statistics are used to infer the latent construct (which can be either dimensional or categorical) that underlies the associations among a variety of behavioural measures. The focus is on the variance that is shared across measures — in effect putting to one side that which is unique to just one measure on the ground that, whatever its intrinsic importance, it is not measuring that which is common across measures. This ‘special’ element is not ‘thrown away’ but, rather, it can be isolated and examined in its own right. Latent variable methods have another key feature: they take into account prior probabilities. For example, let us take a child in a longitudinal study who has three positive ratings, one negative, and then two more positive ones and compare him with a child who has six negative ratings. Intuition and common sense tells one that the fourth rating of the ﬁrst child is much more likely to be a false negative than the fourth rating of the second child. In coming to that judgement, we use what we know about the ﬁndings at other data points. Latent variable methods do the same but in a quantitative mathematical fashion. Although certainly not a ‘cure-all’ for measurement problems, latent variable methods have very considerable strengths and are likely to be employed more in the future. The main ‘health warnings’ 59

CHAPTER 4

regarding their use is that there should be caution if the shared variance among measures is very low (because the latent construct will tap so little of the individual differences in the psychopathology of interest; see Simonoff et al. 1998 for an example), and that there needs to be an awareness that modelling methods will sometimes discard features because their effects fall short of statistical signiﬁcance, even though the evidence limits tell one that there might be a substantial true effect (see Rutter et al. 1999, 2001 for a discussion of the matter in relation to genetic modelling). Applications of latent construct measures in child psychiatry include studies of the impact of maternal depression on ratings of child psychopathology (Boyle & Pickles 1997a,b), the crossinformant correlations of behavioural reports (Fergusson & Horwood 1987a,b), or the adult outcomes of antisocial behaviour (Zoccolillo et al. 1992).

Cut-offs, sensitivity and speciﬁcity
Dimensional measurements (whether by questionnaire or interview) lead to total scores ranging from a minimum (usually implying normality) to a maximum (mostly implying psychopathology). For both clinical and research reasons, investigators may want to transform these scores into categories (e.g. inferred normality vs. inferred disorder). Note that the category has to be inferred, rather than measured directly (unless of course there is a pathognomonic test, which there is not so far for any child psychiatric disorder). The measurement question concerns the probability that any given score on a measure means that the psychopathology warrants a ‘caseness’ designation — in other words, what score provides the best discrimination between cases and non-cases as assessed in some other way. All cutoffs, of course, result in some degree of misclassiﬁcation. Figure 4.2 depicts a fairly common situation in which scores among normals (non-cases) are plotted next to those with a disorder (cases). Any cut-off will partition a sample into four groups, designated false and true positives and false and true negatives. Various indices can be used to summarize the data in this situation (see Appendix 1). A Receiving Operating Characteristics (ROC)

analysis provides a convenient way of assessing this trade off mathematically in order to select an optimal threshold (Fombonne 1991; see also Verhulst & Van der Ende, Chapter 5). It simply plots sensitivity on one axis of a graph and speciﬁcity on the other and uses the resulting curve to identify the best cutpoint. However, it does more in that it takes into account the prevalence of the disorder, the severity of cases under detection, and the consequences of all types of misclassiﬁcation errors (Hsiao et al. 1989; Fombonne 1991). ROC analyses have been a huge help in decision-making with respect to using scores to infer categories. However, two points require emphasis. First, measurement error is the rule rather than the exception and its inﬂuence must always be recognized in any interpretation of data. Scores above a cut-off point that has been empirically set by ROC analyses do not mean that a disorder is deﬁnitely present. All they indicate is that, using the particular measures in question, the probability of a good differentiation between caseness and normality is optimal; but it is a probability and not a certainty. A mechanical use of instruments to provide diagnoses should be proscribed. Secondly, the various properties of sensitivity, speciﬁcity, positive predictive value and so forth (see Appendix 2) are contextspeciﬁc and not inherent qualities of the instrument. A cut-off that works well in a clinical context may not be at all satisfactory in a community survey. That is because probabilities are greatly inﬂuenced by population base rates for the disorder being measured. For example, Berument et al. (1999), in their analysis of the Autism Screening Questionnaire (ASQ) found that the score that best differentiated autism from other spectrum disorders was much higher than that which was best differentiating autism from uncomplicated mental retardation or developmental language disorders. Some instruments are much more valid than others and attention needs to be paid to their technical properties. Nevertheless, the measuring device has no absolute intrinsic validity. Rather, its validity will ﬂuctuate according to the goals and context of the assessment.

Norms
Reference to normative data is implicit in the assessment of psychopathology. However, it was only in the late 1950s that systematic surveys of children’s behaviours and emotions were undertaken on large samples of non-referred children (Lapouse & Monk 1958, 1959). The epidemiological surveys of child psychiatric disorders that followed helped to promote knowledge of normative behaviour at different ages with the useful development of standardized questionnaires for use with multiple informants (Rutter et al. 1970; Achenbach & Edelbrock 1981; Verhulst & Koot 1995; see also Verhulst & Van der Ende, Chapter 5). Increasingly, data from large representative samples of non-referred children have been used to calibrate measures in order to provide the best identiﬁcation of probably psychopathology. Verhulst & Van der Ende (Chapter 5) summarize both the research approaches and the ﬁndings for a range of measures. Much has been achieved, yet some care is needed in

Cases True positives (TP) False negatives (FN)

False positives (FP) True negatives (TN) C: recommended cut off
C

Normals

Fig. 4.2 Distribution of scores in normals and cases.

CASE IDENTIFICATION IN AN EPIDEMIOLOGICAL CONTEXT

using these norm-referenced assessments. Not all standardizations have used fully representative general population samples. There must be reservations about generalizability when convenience samples have been used. Norms are derived from particular regional or national samples and the query is whether it is justiﬁable to extrapolate to other regions or countries. For example, a 10–15-point difference in mean CBCL total scores has been reported among American, Australian (Achenbach et al. 1990a), French (Stanger et al. 1994) and Puerto Rican children (Achenbach et al. 1990b). The question is whether these differences reﬂect true regional differences in psychopathology or rating tendencies that have been inﬂuenced by cultural contextual features. Both possibilities have to be considered seriously but their differentiating requires the use of external validators of some kind. The Isle of Wight–Inner London comparison indicated that a true difference in rate of psychopathology was likely (Rutter & Quinton 1977) whereas the UK–Hong Kong comparison with respect to hyperactivity suggested a rating difference effect (Leung et al. 1996). Investigators are well advised to be cautious about assumptions that one set of norms can be generalized to different populations. Similar issues concern extrapolations from one large representative population to subgroups within. For example, are associations between social class and behavioural disturbance (Achenbach & Edelbrock 1981; Fombonne 1992) a true reﬂection of valid differences or a contextual rating bias effect? The same applies to age and gender differences. An automatic assumption that subgroup norms should be used or that any differences from total population norms are necessarily valid should be resisted. As ever, external validation is essential. Norms apply to one particular point in time. Evidence has accumulated that there have been secular changes in the incidence of various psychosocial disorders (Rutter & Smith 1995; Fombonne 1998a,b) and of individual behavioural problems. Achenbach & Howell (1993) compared two large representative samples of American youth surveyed 13 years apart and found increased scores on 46 of 118 behavioural problems and on all scale scores (the mean total score increasing from 18 to 24.2) in the most recent birth cohorts. Periodic recalibration of instruments is necessary in child psychopathology just as it is for other measures, such as psychometric tests (Flynn 1987; Fuggle et al. 1992) or physical indices such height, weight, head circumference and pubertal maturation (Fredriks et al. 2000).

ment in the child interacts with characteristics of family dysfunction to increase the risk of psychopathology 5 years later (Maziade et al. 1987); and a shy inhibited style of interaction predicts later onset of anxiety disorders in childhood (Kagan et al. 1998). Evidence has accumulated that developmental disorders usually identiﬁed in the early years have short (Stevenson et al. 1985) and long-term consequences (Mawhood et al. 2000) with respect to psychosocial disturbances and functioning. Long-term follow-up of birth cohorts have also shown continuities between preschool behaviour and adult psychopathology (Caspi et al. 1996). Thus, identiﬁcation of preschool problems is important, especially because early intervention might be more effective in the case of some disorders (Rogers 1998). However, there are particular challenges in the assessment of preschool-age children (Mayes 1999). Infants and toddlers present with disturbances that tend to be closely associated with somatic development. Thus, feeding and sleeping difﬁculties are common in this age group (see Stein & Barnes, Chapter 45). It is also an age when the effects of prenatal/perinatal risk factors may be particularly marked. As implied in Winnicott’s (1965) remark that ‘there is no such thing as a baby’, infants’ behaviour is closely intertwined with interactions with their caregivers. Accordingly, it is necessary to consider the extent to which any disturbance reﬂects psychopathology in the child rather than difﬁculties in a dyadic relationship (see O’Connor, Chapter 46). Speciﬁc developmental delays, such as language or social relationship, are ﬁrst evident in the preschool years and call for a multifaceted developmental assessment (see Bishop, Chapter39; Lord & Bailey, Chapter 38). The American Academy of Child and Adolescent Psychiatry (1997) has issued guidelines on standards of practice for the assessment of infants and toddlers. Very few dimensional measures assessing behavioural/emotional deviance have been properly validated for children below the age of 4. Current diagnostic schemes have acknowledged limitations for use with very young children (Emde et al. 1993). Scales such as the Temperament and Atypical Behaviour Scale (TABS; Bagnato et al. 1999) and classiﬁcations such as the Zero to Three Diagnostic Classiﬁcation (Zero to Three 1994) have been developed for infants and toddlers but they are based on particular conceptual frameworks and are closely linked to intervention strategies. The value of these measures and systems remains to be established.

Cultural and ethnic minorities issues
Most industrialized societies today are multicultural, multiethnic and multilingual, which has important implications for clinical practice (see Rutter & Nikapota, Chapter 16; Rutter & Taylor, Chapter 2). It also has implications for the assessment of psychopathology by means of standardized interviews or questionnaires, as noted a quarter of a century ago by Warwick & Lininger (1975). It would be a mistake to exaggerate the methodological difﬁculties. Rating scales have usually been found to function in much the same way across cultures (Verhulst & Achenbach 1995; Weisz & Eastman 1995; Crijnen et al. 61

Assessment of young children
Epidemiological investigations of preschool samples have been surprisingly few (Earls 1980; Richman et al. 1982; Pianta & Castaldi 1989; Pianta & Caldwell 1990; Cohen & Bromet 1992; van den Oord et al. 1995; Lavigne et al. 1996). Nevertheless, studies have shown that psychiatric disorders starting in the preschool years show a high degree of persistence over time and that their course is systematically associated with identiﬁable risk and protective factors. For example, a difﬁcult tempera-

CHAPTER 4

1999) with, for example, comparable gender differences (Achenbach et al. 1990a; Stanger et al. 1994; Crijnen et al. 1999). Nevertheless, three issues require attention. First, there is a concern to ensure linguistic equivalence (see Verhulst & Van der Ende, Chapter 5). This is usually accomplished by a series of back-translations from one language to the other by independent bilingual translators who are familiar with the psychopathological concepts. The last speciﬁcation is important to ensure that the appropriate words are selected to tap the intended meaning. This is relevant, too, in relation to the need to ensure equivalence between American and British versions of instruments. The problem does not mainly lie in there being different words for the same thing in the two countries; most people are aware of these. The main hazard is provided by words that are the same but have a different meaning in the two countries. For example, ‘quite’ adds emphasis in the USA, but usually reduces emphasis in the UK, although in certain contexts the reverse applies. The problem of moving across languages is even greater and it is crucial that the translators appreciate the intended meaning in relation to psychopathology. Issues in relation to the translation of diagnostic interviews for Hispanics were described by Canino & Bravo (1999) and examples of translation inaccuracies and of their effects on deviance scores were noted by Woodward et al. (1989). Secondly, there is the question of conceptual and perceptual equivalence. Thus, Weisz et al. (1988) reported differences between Thai and American adults in their concern over particular behaviours; Lee (1991) queried whether a morbid fear of fatness had the same implications for anorexia nervosa in Hong Kong as it does in Western societies; and King & Bhugra (1989) posed the same question with respect to questions on dieting when used in cultures where this is part of religious practice. It cannot be claimed that there is an adequate database to show either the importance of these concerns or how they are best dealt with, but investigators need to be alert to their possible effects on measurement. They are likely to have effects because most ratings involve an explicit or implicit comparison with some norms, the behaviours being normal at a low level but abnormal at some higher level. Thirdly, there is diagnostic equivalence. As Taylor & Rutter (Chapter 1) note, some cultures have syndromes that appear to have no obvious equivalent in other cultures, although systematic evidence on this is largely lacking. From a measurement perspective, perhaps the key point is that when different cultures express the same disorder through differently expressed manifestations, there needs to be caution in the application of diagnostic algorithms. For example, there is evidence that cultures vary in the extent to which they express depression in reports of feelings of misery; some are more likely to report these in terms of somatic complaints (Kleinman & Good 1985). Similar issues arise with respect to age variations, as reﬂected in the different role given to irritability in the diagnosis of depression in childhood and in adult life (American Psychiatric Association 1994). Once more, there is at least as much of a danger of wrongly as62

suming an age (or cultural) difference as of overlooking a real difference. The arbitration has to lie in empirical studies, most of which are still waiting to be undertaken.

Computerized assessments
Modern technology has allowed many assessment procedures to be computerized. For example, Berg et al. (1992) compared the reliability, concurrent and criterion validity of two standard and computer-assisted procedures to collect data using two common psychopathology scales, the Rutter A2 scale and the CBCL. Psychometric properties were similar with the two procedures, suggesting that computer-assisted technologies might be used more extensively in routine practice. There are numerous advantages to computerization: it eliminates observer bias; it ensures that all respondents receive precisely the same instructions and questions; by having a voice read aloud the questions it avoids illiteracy problems; it allows more complex and ﬂexible skip and branching patterns than possible with paper-and-pencil procedures; immediate checking of the consistency and range of responses is possible; and it provides error-free computation of scores with or without reference to existing norms. Data are readily stored in a format that allows for further analysis and computer storage also makes the data collection procedure less vulnerable to errors such as accidental loss of data, theft, or inadvertent disclosure of conﬁdential materials. Several structured diagnostic interviews already have computerized versions. The role of the computer does, however, vary considerably. Computers are sometimes used to assist interviewers in their task of conducting the interview. In this instance, the interviewer still performs a face-to-face interview and records the answers of the respondent on a (usually laptop) computer as the interview proceeds. This procedure has both the advantage and disadvantage of allowing some degree of interviewer judgement. Fully computerized diagnostic interviews tend to be highly structured, with restricted response options. Computer-aided administration is particularly useful in helping the interviewer to follow complex skip rules and to track respondent’s answers that require follow-up questions in the course of the interview. The Diagnostic Interview Schedule for Children (NIMH DISCIV; Shaffer et al. 2000) is typical of such interviews devised for large-scale epidemiological surveys. The Development and Well-Being Assessment (DAWBA; Goodman et al. 2000), used in the UK National Survey of Child Mental Health (Meltzer et al. 2000) provides another example, with the additional feature that space is allocated to record respondents’ descriptions verbatim as well, so allowing a subsequent overarching clinical interpretation of all structured data and the addition of open-ended commentaries. However, this procedure detracts somewhat from the greater efﬁciency of the computerized interviews — a major ‘selling’ point. In other developments, computers are used to replace interviewers fully. Some sound versions of diagnostic interviews have now been developed for full selfadministration, using headphones or speakers. The Voice DISC

CASE IDENTIFICATION IN AN EPIDEMIOLOGICAL CONTEXT Appendix 1 Selecting an instrument. Interview Purpose Main use Reliability Validity Coverage/content Method Response format Screening/diagnosis Epidemiological/clinical Test–retest Interrater Content, discriminant, concurrent, predictive Cross-cultural Diagnostic categories Number of disorders Face-to-face interview Yes/No (respondent-based) All informants’ descriptions (investigator-based) Long (hours) Subject Parent Other Current (last 3 or 6 months) Last year Lifetime Depends on informant and content Required: detailed for investigator-based limited for respondent-based Availability of training packages Availability of manual Paper-and-pencil Computer-assisted Computer administered Laborious (unless computerized) Diagnostic algorithms High Modularity of the interview Scale scores available Personal and family details, impairment, burden, etc. Adult diagnostic interviews Companion observational schedule Availability in other languages Validity in different populations Questionnaire Screening/assessment Epidemiological/clinical Test–retest Split-half, internal consistency Content, discriminant, concurrent, predictive Factorial/construct validity Cross-cultural Psychopathological constructs Number of items Self-report (usually) or other informant (parent, teacher, clinician) Interval Likert scaling Visual analogue Brief (minutes) Subject (over 10 years) Parent, teacher Clinician, interviewer, other Current, last week Last 3–12 months Depends on informant and content None (self-administered) or minimal (interviewer-assisted) Literacy requirement Availability of manual Paper-and-pencil Computer administered Easy (optical forms) Norms, centiles, cut-offs Low Easy, demonstrated sensitivity to change

Completion time Informant

Time frame

Age assessed Training

Version

Data entry Scoring Costs Repeat assessments Extra features Other domains Suitability for longitudinal studies Observational assessments Cultural context

Personal and family details, scholastic achievement, etc. Parallel adult forms Parallel observational scale Availability in other languages Validity in different populations

(Shaffer et al. 2000) and a substance abuse module of the Child and Adolescent Psychiatric Assessment (CAPA; Angold & Costello 2000) are examples of such developments, which totally eliminate interviewer costs. Investigator-based interviews have been, for obvious reasons, less amenable to computerization, although some attempts have been made, such as with the Diagnostic Interview Schedule for Children and Adolescents (DICA; Reich 2000). One diagnostic interview relying on displays of pictures or cartoons to elicit symptomatic data has been released in computerized form

(Interactive Dominic Questionnaire; Valla et al. 2000) but data are still needed on its basic properties. Computerized interviewing does not usually decrease the time needed to administer the interview, but it can lead to substantial savings in terms of interviewer time (and costs) by eliminating that used for coding and interpretation. Successful use has been achieved in recent epidemiological surveys (Patton et al. 1999; Meltzer et al. 2000). It is possible, too, that computerized interviews may be better at eliciting potentially embarrassing personal information 63

CHAPTER 4

because it eliminates the interpersonal context. Reich et al. (1995) found that children enjoyed the computerized DICA-R interview, preferring it over a personal interview and said that they would tell things to the computer that they would not tell to a person. Survey research has shown that rates of at-risk behaviours involving sexual contacts and use of addictive substances were three times higher when questions were asked via audiocomputerized methods than when asked face-to-face (Turner et al. 1998). Similar results have been found regarding suicidal behaviours (Reich et al. 1995). It is too early to draw ﬁrm conclusions on the merits and demerits of computerized interviews. Clearly, they have very important advantages for some purposes and there is no doubt that they will be used more in the future. However, for some purposes their chief advantage of eliminating the need for interviewers may be a disadvantage just because it eliminates personal contact. The structural format, too, will be limiting in relation to the eliciting of important unexpected information (see Rutter & Taylor, Chapter 2).

recognition of these needs and of the usefulness of these databases will help mental health professionals to inﬂuence these information systems in a way that might be more clinically relevant and useful for their own research and practice.

Appendix 2
Hypothetical data from a screening study. Cases D Test positive (T+) Test negative (T–) a c a+c ¯ Normal D b d b+d a+b c+d a+b+c+d=N

Multiaxial systems and recording clinical data
Epidemiological investigations have contributed much to our knowledge and the use of standardized methods has played an important role in ensuring their success, as has attention to the measurement and sampling issues discussed in this chapter. However, many of the same principles also apply to databases used for clinical monitoring and clinical research (World Health Organization 1996). A good example of such a clinical data recording system is the Item Sheet that has been in place at the Maudsley Hospital for over half a century and which records diagnoses, symptoms, demographic details, psychosocial features, test ﬁndings, details of referral and rating of clinical outcome. As a result, a large computerized database has been available to facilitate clinical research. Examples of its use are the study of speciﬁc problem behaviours (Thorley 1987; Wannan & Fombonne 1998; Moore & Fombonne 1999); the sampling of subjects for long-term follow-up studies (Harrington et al. 1990; Fombonne et al., 2001); patient comparisons between centres in different countries (Duyx & van Engeland 1993); the investigation of trends over time in speciﬁc behavioural problems and of their causes (Fombonne 1998a); and the study of comorbid patterns (Simic & Fombonne, 2001). More streamlined data recording systems could easily achieve the same goals if a core set of variables was deﬁned. Also, centres could decide to add on, for speciﬁc groups of patients of interest, or for deﬁned periods of time, more exhaustive data recording procedures, because databases can easily be managed on modularity principles. Progress in information technology has made it easy and cheap to set up such databases and to exchange data when appropriate. Indeed, the need to audit services and to be accountable of services activity for the health service will make such systems increasingly mandatory in most countries. Timely 64

¯, non-diseased. D, diseased; D True positives, TP = a; True negatives, TN = d; False negatives, FN = c; False positives, FP = b. Sensitivity (or rate of true positives, RTP): Se = a/a + c = p (T+/D). ¯). Speciﬁcity (or rate of true negatives, RTN): Sp = d/b + d = p (T–/D Rate of false negatives: RFN = c/a + c = p (T–/D). ¯). Rate of false positives: RFP = b/b + d = p (T+/D Prevalence: P = a + c/N = p(D). Positive predictive value: PPV = a/a + b = p(D/T+). – Negative predictive value: NPV = d/c + d = p( D/T–).

This table provides the results of a hypothetical screening study (see also Fig. 4.2). Several proportions are used to summarize the data: sensitivity (proportion of cases above the threshold); and speciﬁcity (proportion of non-cases below the threshold). These two proportions can be regarded as indices of the criterion of validity of the instrument. Both proportions vary inversely and changes in the proposed cut-off to improve sensitivity would normally result in decreased speciﬁcity, and vice versa. Another proportion of importance is the positive predictive value which expresses the probability that a subject with a positive screening has a disorder. The proportion varies as a function of the sensitivity and the speciﬁcity of the instrument, but also with the prevalence of the disease in the population: PPV = (P ¥ Se) / (P ¥ Se) + [(1 – P) + (1 – Sp)]. It can be shown that the PPV associated with an excellent instrument (sensitivity = speciﬁcity = 90%) is very good (79%) if the prevalence of the disorder is high (P = 0.3), but poor (8%) when the prevalence falls to a low value of 1%. This reminds us that intrinsically good instruments might have poor performances, depending on the context of their use.

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Rutter, M., Shaffer, D. & Shepherd, M. (1975) An Evaluation of a Proposal for a Multiaxial Classiﬁcation of Child Psychiatric Disorders. World Health Organization Monograph. World Health Organization, Geneva. Rutter, M., Tizard, J., Yule, W., Graham, P. & Whitmore, K. (1976) Research report: Isle of Wight studies, 1964–74. Psychological Medicine, 6, 313–332. Rutter, M., Tuma, A. & Lann, I., eds (1988) Assessment and Diagnosis in Child Psychopathology. David Fulton, London. Rutter, M., Silberg, J., O’Connor, T. & Simonoff, E. (1999) Genetics and child psychiatry. I. Advances in quantitative and molecular genetics. Journal of Child Psychology and Psychiatry, 40, 3–18. Rutter, M., Pickles, A., Murray, R. & Eaves, L. (2001) Testing hypotheses on speciﬁc environmental causal effects on behavior. Psychological Bulletin, 127, 291–324. Sanford, M.N., Offord, D.R., Boyle, M.H., Peace, A. & Racine, Y.A. (1992) Ontario Child Health Study: social and school impairments in children age 6–16 years. 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(2000) NIMH Diagnostic Interview Schedule for Children, Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 28–38. Shepherd, M., Oppenheim, B. & Mitchell, S. (1971) Childhood Behaviour and Mental Health. University of London Press, London. Simic, M. & Fombonne, E. (2001) Depressive conduct disorder: symptom patterns and correlates in referred children and adolescents. Journal of Affective Disorders, 62, 175–185. Simon, G. & Von Korff, M. (1992) Re-evaluation of secular trends in depression rates. American Journal of Epidemiology, 135, 1411– 1422. Simonoff, E., Pickles, A., Meyer, J.M. et al. (1997) The Virginia Twin Study of Adolescent Behavioral Development: inﬂuences of age, sex, and impairment on rates of disorder. Archives of General Psychiatry, 54, 801–808. Simonoff, E., Pickles, A., Hervas, A., Silberg, J.L., Rutter, M. & Eaves, L. 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CASE IDENTIFICATION IN AN EPIDEMIOLOGICAL CONTEXT deﬁcit and impulsiveness. Development and Psychopathology, 11, 607–628. Taylor, E., Chadwick, O., Heptinstall, E. & Danckaerts, M. (1996) Hyperactivity and conduct problems as risk factors for adolescent development. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1213–1226. Thorley, G. (1987) Factor study of a psychiatric child rating scale: based on ratings made by clinicians on child and adolescent clinic attenders. British Journal of Psychiatry, 150, 49–59. Turner, C., Ku, L., Rogers, S., Lindberg, L., Pleck, J. & Sonenstein, F. (1998) Adolescent sexual behavior, drug use, and violence: increased reporting with computer survey technology. Science, 280, 867–873. Valla, J., Bergeron, L. & Smolla, N. (2000) The Dominic-R: a pictorial interview for 6- to 11-year-old children. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 85–93. Verhulst, F.C. & Achenbach, T.M. (1995) Empirically based assessment and taxonomy of psychopathology: cross-cultural applications — a review. European Child and Adolescent Psychiatry, 4, 61–76. Verhulst, F. & Koot, H. (1992) Child psychiatric epidemiology: concepts, methods and ﬁndings. In: Developmental Clinical Psychology and Psychiatry Series (ed. A. Kazdin). Sage Publications, Newbury Park, CA. Verhulst, F. & Koot, H. (1995) The Epidemiology of Child and Adolescent Psychopathology. Oxford University Press, Oxford. Verhulst, F. & Van Der Ende, J. (1997) Factors associated with child mental health service use in the community. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 901–909. Verhulst, F., van der Ende, J., Ferdinand, R. & Kasius, M. (1997) The prevalence of DSM-III-R diagnosis in a national sample of Dutch adolescents. Archives of General Psychiatry, 54, 329–336. Vikan, A. (1985) Psychiatric epidemiology in a sample of 1510 10-yearold children. I. Prevalence. 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5
Introduction

Rating Scales
Frank C. Verhulst and Jan Van der Ende

Issues speciﬁc to scales for child psychopathology
Age-relatedness
Many problem behaviours, such as temper tantrums or separation anxiety, are common and therefore statistically normal at a young age, but much less frequent and more likely to indicate psychopathology at older ages. Clinical signiﬁcance has to take into account the child’s developmental level. For young people within the normal range for cognitive and physical development, comparisons with normative samples of children of the same age (and sex) provide guidelines for evaluating behaviours. If the ages of children to be studied differ substantially from those in the standardization sample for the scale, valid comparisons are not possible. Some rating scales employ the same version for different age groups. This has the considerable advantage that scores obtained for children at one age can be compared directly with scores obtained for the same children at a later age. Provided that there are age-standardized norms, comparisons can also be made on the relative levels of problems at different ages. Other scales use different versions for different age groups. These have the advantage that behaviours relevant for one age group but not for another are included only in the age-relevant version. For example, alcohol and drug use, truancy or vandalism are applicable in adolescence but not in the preschool period. However, a disadvantage is that in the transition from one age group to another, there is loss of continuity of item and scale scores. This is especially problematic for longitudinal studies.

Over the last 30 years or so, many rating scales have been developed to assess general child/adolescent psychopathology. Their number and variety creates a potential problem because of the uncertainties about generalizing ﬁndings from one study to another if different instruments have been used. In this chapter we consider the purposes for which such rating scales may be used, discuss their psychometric properties, note their similarities and differences, and outline the criteria by which to judge which instrument best suits a particular purpose. The evaluation of rating scales does not result in a static conclusion. Many of the scales have developed over time in terms of content, age span covered, the production of parallel versions for parents, teachers and adolescents themselves, the means of administration and scoring, and the availability of standardized data. Speciﬁc rating scales are referred to in the text by their abbreviations. Table 5.1 and Appendix 1 give the full name, author(s) and relevant information for each scale. Our focus is exclusively on scales to measure general psychopathology; those for speciﬁc disorders/behaviours and for psychosocial features are considered in the relevant chapter elsewhere in the book. Our evaluation of general scales is based on four key assumptions: 1 that diagnoses are hypothesized latent constructs, the validity of which need empirical testing (see also Fombonne, Chapter 4; Taylor & Rutter, Chapter 1); 2 as follows from the ﬁrst assumption, we do not regard agreement with a clinical diagnosis as the ultimate test of the validity of a rating scale; 3 that no single measure is ever a perfect index of the construct that it aims to tap (see Fombonne, Chapter 4); and 4 that the value of any rating scale needs to be considered in relation to the purposes to which it is to be put. It is most unlikely that any one scale will be optimal for all purposes. To give an obvious example, the type of measure needed to examine changes over a short time (such as in a trial of treatment) is scarcely likely to be the same as that needed to assess continuing liability (as in a genetic study).

Informant and situational speciﬁcity
For both statistical and clinical reasons, it is necessary to obtain information from different informants that cover behaviour in different settings, such as home and school (see Fombonne, Chapter 4; Rutter & Taylor, Chapter 2). Instead of viewing low agreement among different informants (the usual picture — Achenbach et al. 1987) as a nuisance, or systematically discarding one source of information, it is important to regard each informant as a potentially valid source of information. Each informant has their own unique, and potentially valid, contribution to the formation of an overall picture of the child’s functioning (Verhulst et al. 1994, 1997; Van der Valk

RATING SCALES

et al. in press). Even disagreement among informants can be valuable (Jensen et al. 1999). An example of the potential value of information from different sources is the ﬁnding that children who are hyperactive at home and at school have a poorer prognosis than children who are hyperactive only at home or at school (Schachar et al. 1981). Most rating scales for the assessment of child/adolescent psychopathology have parallel versions for parents and teachers. Some rating scales have versions for adolescents’ selfreports, although sometimes the self-report version is not parallel to the parent and teacher versions and may tap other domains, such as personality (e.g. Behavioral Assessment System for Children (BASC); Millon Adolescent Clinical Inventory (MACI); Minnesota Multiphasic Personality Inventory (MMPI)). The advantage of rating scales with parallel parent, teacher and self-report versions is that the scores across the different informants can be compared. The Achenbach System of Empirically Based Assessment (ASEBA; Achenbach & Rescorla 1999) is an example of a rating scale with versions for parents, teachers and self-reports that yield scale scores that can be compared.

include error (see Fombonne, Chapter 4). By focusing on the consistency of answers across many items, measurement error is reduced (Streiner & Norman 1998). The reliability of dimensional measures therefore tends to be greater than that for categories (Shaffer et al. 1999a). Nevertheless, if needed for decision-making purposes, it is a straightforward matter to transform dimensions into categories (see Fombonne, Chapter 4). Conversely, for most diagnostic categories, it is usual to bring in dimensional considerations (e.g. symptom severity or degree of impairment).

Overview of generic rating scales
We searched the literature for psychometrically sound rating scales for the assessment of general child/adolescent psychopathology (excluding those designed for very limited purposes such as the Achenbach, Conners, Quay questionnaire, ACQ; Achenbach et al. 1991). We contacted the authors and/or publishers and requested information on the format, administration, scoring and interpretation of questionnaires. Where appropriate, we sought feedback from the authors and/or publishers to detect any errors in the factual information we provided in the text. Detailed information on individual questionnaires is available elsewhere (Maruish 1999; Shaffer et al. 1999b). Accordingly, we focus on the principles and quality criteria to be employed in the valuation of any rating scale. Table 5.1 provides an overview of the scales considered and Appendix 1 gives a more comprehensive description of each.

Dimensional nature of child/adolescent problem behaviours
The construction of rating scales is usually based on psychometric principles. The basic premise is that most problem behaviours in children and adolescents constitute quantitative variations rather than present/absent categories. To identify quantitative gradations, multiple items are rated by the respondent using standardized procedures. The items of rating scales are then usually aggregated into subscales. Thus, items can be grouped to derive scale scores for domains such as ‘hyperactivity’, ‘anxiety’, or ‘oppositional’ behaviour. This quantitative approach allows assessment of the degree to which one child’s behaviour differs from that of comparable children of the same age and sex in the normative samples. The quality of normative samples used varies considerably. Some scales have large representative standardization samples from the general population [e.g. ASEBA; Conners’ Rating Scales– Revised (CRS-R); Devereaux Scales of Mental Disorder (DSMD); MACI); others use samples of convenience [e.g. Revised Behavior Problem Checklist (RBPC); Paediatric Symptom Checklist (PSC); Strengths and Difﬁculties Questionnaire (SDQ)]. The advantage of using quantitative scores is that they contain more statistical information than categories (Streiner & Norman 1998; Goldberg 2000). This is because they use data across the whole range and not just around a particular cut-off point and because they avoid the major problems of classiﬁcation error for scores just above and below that point. Thus, if a categorical diagnosis is made if a score is above, say, 10, scores of 10 and 11 are treated as radically different although the difference between them is as likely to be caused by measurement error as to the presence/absence of a disorder. All measures

Item content
The content of an instrument is chosen on the basis of what it is intended to measure. Generic instruments seek to tap a broad range of psychopathology, using items likely to be relevant for all common types of mental disorder and giving priority to those that apply to several disorders and not just one. For scales that have been developed over many years through successive revisions, empirical information obtained from earlier versions (for instance on content coverage or on the discriminative validity of speciﬁc items) is incorporated into the newer versions. Examples are the ASEBA (Achenbach & Rescorla 1999) and the CRS-R (Conners 1997). In CRS-R, Conners included items that were modelled on the DSM-IV criteria (American Psychiatric Association 1994).

Item response scaling
Most scales have items that can be scored on a 3-point scale (0, 1 and 2), but some use 4-point scaling (0, 1, 2 and 3), and a few use a 2-point ‘true/false’ scoring approach such as the MMPI-A (Butcher et al. 1992). From a psychometric point of view, some argue that the higher the number of scoring categories within the range of 2–10, the better the reliability will be (Streiner & 71

72
Current authors T.M. Achenbach L.A. Rescorla Teacher Self C.R. Reynolds R.W. Kamphaus Teacher Parent 21/2–5 6–11 12–18 21/2–5 6–11 12–18 105 138 126 109 148 138 10–15 0–3 0–1 Normal Clinical A priori 10–20 0–3 Normal Clinical Empirical Parent 2–3 4–18 2–5 5–18 11–18 100 140 100 136 137 20 0–2 Normal Clinical Empirical Informants Age range Norms Scales† Activities, Social, School, Total competence Score Withdrawn, Somatic Complaints, Anxious/ Depressed, Social Problems, Thought Problems, Attention Problems, Delinquent Behaviour, Aggressive Behaviour, Internalizing, Externalizing, Total Problem Score Aggression, Hyperactivity, Conduct Problems, Anxiety, Depression, Somatization, Attention Problems, Atypicality, Withdrawal, Adaptability, Leadership, Social Skills, Externalizing Problems, Internalizing Problems, Adaptive Skills, Behavioural Symptoms Index Number of items Time in minutes Item scaling Derivation of scales K.D. Gadow J. Sprafkin Teacher Parent Self 3–5 6–12 13–18 3–5 6–12 13–18 12–18 108 97 120 87 77 79 120 ADHD-inattentive type, ADHD-hyperactiveimpulsive type, ADHD-combined type, Oppositional/Deﬁant Disorder, Conduct Disorder, Generalized Anxiety Disorder, Social Phobia, Separation Anxiety, Speciﬁc Phobia, ObsessiveCompulsive Disorder, Post-traumatic Stress Disorder, Motor Tic Disorder, Vocal Tic Disorder, Tourette’s Disorder, Major Depressive Disorder, Dysthymic Disorder, Autistic Disorder, Asperger’s Disorder, PDD not otherwise speciﬁed, Schizophrenia, enuresis, encopresis 15–20 0–3 Normal Empirical Oppositional, Cognitive Problems/Inattention, Hyperactivity, Anxious–Shy, Perfectionism, Social Problems, Psychosomatic, Conners’ Global Index, Restless–Impulsive, Emotional Lability, ADHD Index, DSM-IV Symptoms subscales, DSM-IV Inattentive, DSM-IV Hyperactive-Impulsive 15 0–5 Normal Clinical Empirical C.K. Conners Parent Teacher Self 3–17 3–17 12–17 80 59 87 J.A. Naglieri et al. Teacher Parent 5–12 13–18 5–12 13–18 111 110 111 110 Conduct, Attention, Anxiety, Depression, Autism, Acute Problems, Internalizing, Externalizing, Critical Pathology

CHAPTER 5

Table 5.1 Overview of generic rating scales for the assessment of psychopathology.

Instrument

Acronym

Achenbach System of Empirically Based Assessment

ASEBA*

Behavioral Assessment System for Children

BASC*‡

Child Symptom Inventories

CSI

Conners’ Rating Scales–Revised

CRS-R

Devereux Scales of Mental Disorders

DSMD

ECBI

S.M. Eyberg

Parent Teacher

2–16 2–16

36 36

0–6 0–1

Normal

A priori

Total Intensity Score, Total Problem Score

Eyberg Child Behavior Inventory Sutter–Eyberg Student Behavior Inventory–Revised T. Millon Self 13–19 160 30 0–1 Clinical A priori

SESBI-R

Millon Adolescent Clinical Inventory

MACI§

Eating Dysfunctions, Academic Non-compliance, Alcohol Predilection, Drug Proneness, Delinquent Disposition, Impulsive Propensity, Anxious Feelings, Depressive Affect, Suicidal Ideation (only Clinical Indices) Hypochondriasis, Depression, Hysteria, Psychopathic Deviate, Masculinity–Femininity, Paranoia, Psychasthenia, Schizophrenia, Mania, Social Introversion

Minnesota Multiphasic Personality Inventory– Adolescent M.S. Jellinek J.M. Murphy H.C. Quay D.R. Peterson M. Rutter Teacher R. Goodman Parent Teacher Self 4–16 4–16 11–16 25 25 25 Parent 3–5 6–16 3–5 6–16 43 50 41 59 6 Parent Teacher 5–18 5–18 89 89 20 0–2 Parent Self 2–16 11–16 35 35 5 0–2 –

MMPI-Ad J.N. Butcher et al. Self 14–18 478 60 0–1 Normal

A priori

Pediatric Symptom Checklist

PSC

A priori

Total Problem Score

Revised Behavior Problem Checklist

RBPC

Normal Clinical 0–2 –

Empirical

Conduct Disorder, Socialized Aggression, Attention Problems–Immaturity, Anxiety–Withdrawal, Psychotic Behaviour, Motor Tension–Excess A priori Emotional Difﬁculties, Conduct Difﬁculties, Hyperactivity/Inattention, Prosocial, Total Difﬁculties

Revised Rutter Scales

Rutter

Strengths and Difﬁculties Questionnaire

SDQ

0–2

–

A priori

Conduct Problems, Emotional Symptoms, Hyperactivity, Peer Problems, Prosocial Behaviour

* For ASEBA and BASC adaptive behaviour are listed in addition to problem scales. † If scales differ by informant, only parent scales indicated; if scales differ by age, only scales for broadest age range; see Appendix 1 for more complete information. ‡ The BASC includes a self-report personality inventory, which is not listed in this overview. § The MACI and MMPI-A include personality scales, which are not listed in this overview.

RATING SCALES

CHAPTER 5

Norman 1998). However, with untrained raters (such as parents) and with relative phenomena (such as degree of misery or overactivity) raters tend to use scores only in the middle range. For example, Achenbach, Conners and Quay (Achenbach et al. 1991) developed a new scale (ACQ) which included items that originated from the three authors’ original scales, choosing a 4point item scoring format. However, it was found that the ACQ items that had counterparts on the Child Behaviour Checklist (CBCL; Achenbach 1991a) discriminated less well between clinically referred and non-referred children than the original CBCL items which have a 3-point scoring format. Whatever the theoretical psychometric advantages of many scoring points, 3-point scales are usually to be preferred. The psychometric advantages are better obtained through many items rather than through many scoring points.

Composition of scales
Empirical vs. a priori approaches
Two main approaches, the empirical and the a priori, may be used to select and group items. Empirical approaches employ multivariate statistical techniques, such as factor analysis or principal components analysis, to identify sets of problems that tend to occur together, and thereby make up syndromes. Each syndrome can be quantiﬁed by summing the scores of the items that compose the syndrome. This ‘from the ground up’ approach starts with empirical data derived from informants, without any assumptions about whether the syndrome reﬂects predetermined diagnostic categories. The empirical-quantitative approach forms the basis of most of the rating scales listed in Table 5.1. It is not always clear from the description of the derivation of scales whether the authors used general population samples or clinical samples to compute their syndrome scales. For the construction of the scales for the ASEBA (Achenbach & Rescorla 1999) and the RBPC (Quay & Peterson 1996), scores derived from large clinical samples were used. It remains a matter of controversy what kind of samples are needed to create the scales. Achenbach (1991b) has been a strong proponent of the use of clinical samples as the data source for multivariate analyses, because they yield items with frequencies high enough to be retained in reliable factor analyses or principal component analyses. Also, the use of clinical samples will result in scales that relate to aggregations of problems as encountered in clinical practice. Others, especially those who use rating scales in general population samples, argue that syndrome scales should be based on data derived from general population samples, because the factor structure should reﬂect the underlying structure of problems in the samples to be studied. Before using a factor structure in samples that are essentially different from the ones from which the factor structure was derived, it is important to test the applicability of the factor structure (De Groot et al. 1994, 1996; Koot et al. 1997). The second approach is to take the diagnostic categories of 74

one of the two international classiﬁcation systems as the basis for the syndromes to be scored with the rating scales. This a priori or consensus approach is a ‘from the top down’ method because it starts with experts’ assumptions about which disorders exist and which symptoms are relevant for them. The a priori approach formed the basis of the Child Symptom Inventories (CSI; Gadow & Sprafkin 1998). Like the DSM categories, the CSI syndromes can be scored as present vs. absent by using cutpoints that are based on DSM criteria. For computing the so-called Symptom Criterion score, the authors transformed the original 0–3 item scale into a 2-point present-vs.-absent category by combining the scores 0 and 1 indicating the absence of the symptom, and the scores 2 and 3 indicating the presence of the symptom. Unlike DSM, the syndromes can also be scored as dimensions using the so-called Symptom Severity scoring by retaining the original 4-point item scoring format. The advantage of the empirical approach is that it does not start from unvalidated assumptions about the disorders; yet it can help to improve existing knowledge about nosology. Because the empirical approach starts with data derived from representative samples, its intrinsic validity is appealing. However, a disadvantage is that the empirically based syndrome scales vary as a function of the item content, the number of items, the statistical technique that was used to compute the syndromes, and the samples used to derive the data. As a consequence, the content and the number of scales differ across the different instruments. An advantage of the a priori approach is that despite the lack of validity of most DSM and ICD (World Health Organization 1992) diagnostic categories, they represent a system that is widely accepted. This facilitates communication across researchers and clinicians. Although the empirical and a priori approaches converge, they do not converge to a degree that one approach can replace the other (Edelbrock & Costello 1988; Jensen et al. 1993; Kasius et al. 1997). Both approaches are needed and can be combined. For example, the revision of the CBCL (Achenbach & Rescorla 2001), will make it possible to score the items on two sets of scales. One involves empirically derived scales, and the other scales related to DSM categories. Both sets can be scored quantitatively and categorically by imposing cutpoints to each scale (Achenbach & Rescorla 2000).

Overall index of psychopathology
If the main purpose is to decide only whether an individual has some form of psychopathology, syndrome scales may not be needed. The sum of the scores for all items (the total problem score) usually serves as a general indicator of the overall level of psychopathology. Most scales have this option in addition to syndrome scores. One, the 35-item PSC (Jellinek et al. 1986), designed for primary care settings, can only yield a total problem score.

RATING SCALES

Externalizing and internalizing scales
For some purposes, a level of precision that is intermediate between the ﬁne-grained syndrome level and the crude total problem score may be desirable. For those purposes, a number of instruments use two broad band groupings: ‘externalizing’ and ‘internalizing’. Externalizing reﬂects interpersonal and societal norm conﬂicts, whereas internalizing reﬂects internal distress. These groupings are usually determined through second-order factor analyses of the correlations among the syndrome scale scores. Some rating scales, such as the CBCL (Achenbach 1991a), the DSMD (Naglieri et al. 1994) and the BASC (Reynolds & Kamphaus 1992), can be scored in this way.

Weighting of items
It might be thought that simple summation of all items will lose valuable information, because some items are more important than others and should be weighted accordingly. Differential weighting using weights derived from factor analyses or regression analyses may yield greater precision in that sample. However, applying weights to new samples does not usually increase precision (Wainer 1976). Because the use of differential weighting contributes relatively little, except added complexity, all rating scales considered here use non-weighted summation scoring.

percentile. The advantage of both percentiles and T-scores is that they allow us to determine where an individual’s score stands in relation to scores of individuals of the same sex and age. The utility of both percentiles and T-scores depends on the size and the representativeness of the reference samples. Most instruments listed in Table 5.1 have data on reference samples and provide T-scores, including the ASEBA, BASC, CRS-R, DSMD, MMPI-A and the RBPC. Some instruments provide T-scores based on representative clinical samples in addition to T-scores based on normative samples. This is true for the ASEBA and the RBPC. T-scores based on clinical samples enable us to determine where an individual’s score stands in relation to scores of individuals of the same sex and age who are referred for mental health services. The MACI (Millon 1993) uses what the authors call ‘base rate’ scores that (arbitrarily) take account of the base rates of certain disorders in clinical samples.

Psychometric qualities of rating scales
Reliability
Any measurement is affected by both random and systematic error. The ratio of variability among subjects (true score variation) to the total measurement variability (the sum of subject variability, random error and systematic error) is called reliability. In practice, reliability refers to the replicability of measurement. It is important to know the degree to which the same informants provide similar results on different occasions (see also Fombonne, Chapter 4). The time intervals used for assessing the test–retest reliability should be short enough to expect that the subject’s behaviour will not have changed. In case of teachers as informants it is possible to assess the level of agreement between scores obtained from two teachers — interrater reliability. Because parents are such a central source of information on their child’s functioning, it is also helpful to know the degree of agreement between scores from fathers and mothers. Because reliability involves variation in assessments of the same phenomena, interparent agreement should not be treated as a reliability measure. Because ratings by mothers and fathers are based on somewhat different samples of the child’s behaviour, interparent agreement is not expected to be as high as test– retest or interinterviewer reliability. Scores obtained through repeated measurements can be affected both by their rank ordering and by differences in level so it is important that reliability measures reﬂect both. Pearson correlation coefﬁcients are often used as reliability measures but they are affected only by differences in rank ordering of the correlated scores, whereas t-tests are affected only by differences in mean scores (level of the trait). A measure that is affected both by differences in the rank ordering and mean scores is the intraclass correlation coefﬁcient (ICC; Shrout & Fleiss 1979). When evaluating the psychometric qualities of an instrument, it is 75

Percentiles and T-scores
The various subscales of the same instrument have different mean scores in normative samples because of differences in the number of items of each scale, and resulting differences in mean scores. Because each scale is scored on a different metric, comparisons across syndrome scales are difﬁcult. How can a score of 20 on a syndrome scale (e.g. of aggression) with a scoring range between 0 and 40, be compared with a score of 10 on a syndrome scale (e.g. of depression) with a scoring range between 0 and 20? They are measured on different yardsticks so any comparison would require transforming the raw scores into scores that have a similar metric. One approach is the use of percentiles. A percentile is the percentage of individuals who score below a certain value. The height and weight charts used to assess the physical development of children provide a well-known example. Percentiles can be computed on the basis of questionnaire scores for a representative normative sample of children whose scores are ranked from the highest to the lowest. The advantage of percentiles is that they are easy to interpret. For instance, if a boy received a score on the aggression scale corresponding with the 90th percentile, this means that only 10% of normal boys of the same age obtain higher aggression scores. A second approach to transforming scores into ones that can be compared across scales with different metrics is the use of T-scores. A T-score is a score with a mean of 50 and a standard deviation of 10. A T-score of 50 will correspond with the 50th

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important to be aware of the kind of reliability measure that is reported. Reliability is often wrongly treated as an intrinsic characteristic of a measure. Reliability is highly linked to the population to which the measure is applied, and to the procedure with which the reliability was tested. For most scales listed in Table 5.1, data on test–retest reliability are reported and, where appropriate, data on interrater reliability or interparent agreement. Reliability measures for these instruments are usually favourable for broad measures such as total problem scores. For some individual syndrome scales, reliability may be lower, and in fact problematic in some instances. A somewhat different measure, also referred to as reliability, is the instrument’s index of internal consistency, often presented as coefﬁcient alpha, or Cronbach’s alpha (Schmitt 1996). Alpha is a function of the interrelatedness of the items in a test. Internal consistency does not tell us anything about the degree to which an instrument will give us the same results over different occasions, such as the reliability measures discussed so far. There is yet another problem with internal consistency in those instances where the scales are derived through principal components analysis. Because principal components analysis aims at arriving at scales with intercorrelated items, it is not surprising that measures of internal consistency for such scales are very high. In fact, measures of internal consistency for such scales are redundant as they do not give much new information. In most instances it is found that the shorter the scale, the lower the internal consistency.

Validity
Validity refers to the degree to which an instrument measures what it is designed to measure (see also Fombonne, Chapter 4). The most basic form of validity is content validity, meaning that the items tap the behaviours thought to be relevant because they map onto prevailing diagnostic concepts or because empirically they differentiate between clinically referred and non-referred children (if that is the purpose of the scale). The latter criterion may result in the conclusion on the scale of some rarely occurring, but usefully discriminatory, items. Thus, the CBCL has items dealing with self-harm, pica and faecal soiling. Construct validity refers to the extent to which scores are related to external validating criteria, such as aetiology, outcome or response to treatment. Construct validation is an ongoing process of interrelated procedures through which we try to learn more about the construct. In this way, each new study can strengthen what Cronbach & Meehl (1955) called the ‘nomological network’ of interrelated procedures intended to reﬂect the underlying construct. Instruments used in many studies, such as the CRS (Wainwright 1996) and the CBCL (Vignoe et al. 1999), thereby have an advantage. Concurrent validity concerns the associations (or correlations) between the scores on one instrument with those on other instruments designed to measure similar constructs. Why this should be carried out; if a good measure already exists, why 76

bother to test another one? It is usually performed because the instrument used as the criterion is too long or expensive. This may be the case when a brief and inexpensive rating scale is compared with a more time-consuming and expensive clinical interview. For example, the Youth Self-Report (YSR; Achenbach 1991d), an inexpensive and easy to administer self-report questionnaire, was correlated with the Semistructured Clinical Interview for Children and Adolescents (SCICA; McConaughy and Achenbach 1994), an interview that has to be given by a trained clinician (Kasius 1997). The intercorrelation between the two was 0.62, comparable to the mean correlation of 0.60 found for pairs of similar informants using the same scale (Achenbach et al. 1987). Criterion-related validity refers to the relationship of a measure to another measure that is regarded as the ‘gold standard’. For brief rating scales, this type of validity can be called predictive validity. The external reference criterion usually takes the form of a comprehensive deﬁnitive clinical diagnostic evaluation, but it is very dubious whether this should be viewed as a ‘gold standard’ in view of the uncertainties over the validity of such assessments. Questionnaire scores have been tested against DSM diagnoses derived from standardized interviews (e.g. Grayson & Carlson 1991; Kasius et al. 1997; Gadow & Sprafkin 1998), or with DSM diagnoses derived through unstandardized clinical procedures (Naglieri & Pfeiffer 1999). Because of doubts about the superiority of one approach over others, these studies are really testing concurrent validity. This view is supported by Boyle et al. (1997) who compared the associations with external validators of a rating scale (the Ontario Child Health Study scales) and a psychiatric interview (the revised version of the Diagnostic Interview for Children and Adolescents; DICA). They concluded that validity differences between the two procedures were small and, where present, showed a somewhat better performance for the rating scales than the interview. Referral status is used for many rating scales to test the criterion-related validity by testing the ability of an instrument to discriminate between children and adolescents who are referred for mental health services and those who are non-referred (ASEBA, CRS-R, RBPC, DSMD, Rutter, SDQ, CSI). Referral status is not an infallible morbidity criterion either, because some children and adolescents are referred for reasons other than being truly disordered. Equally, it is known that many disordered children and adolescents in the general population do not receive professional help for their problems. When an instrument is tested against referral status as the criterion, this may result in an underestimate of its ability to discriminate between disordered and normal children or adolescents.

Other validity issues
Measuring change
Because rating scales may be used to test changes over time, it is important that they are sensitive to such changes. Few tests of

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this feature have been undertaken with most scales. The CRS-R and earlier versions of the CRS have been shown to be sensitive to the effects of drug treatment of hyperactive children, supporting the validity of the hyperactivity construct (Conners 1999). The CBCL was found to be sensitive to change and to be useful for evaluating the clinical signiﬁcance of therapeutic intervention (Kendall et al. 1999). The manual of the CBCL and related instruments (Achenbach 1991a–d) and a number of studies with the CBCL (Crijnen et al. 1997, 1999; Stanger et al. 1997) showed that the CBCL captures age differences in scores in cross-sectional as well as in longitudinal studies. However, these usually span longer time periods than used in trials of interventions.

Drop in scores on re-administration
A well-known, but poorly understood, phenomenon is that re-administration of a rating scale usually results in a decrease in scores (see Fombonne, Chapter 4). By testing differences in mean scores over time in test–retest analyses, the magnitude of differences in mean scores on re-administration can be determined; however, such information is available for very few scales. For the original version, as well as for the Dutch translation of the CBCL, it was found that for some scales readministration resulted in a small but signiﬁcant decrease in scores across intervals of 1–2 weeks (Achenbach 1991a; Verhulst et al. 1996). In a separate study, a decrease in CBCL scores was found over a 2-year period but this was not maintained at a 4-year follow-up (Verhulst & Althaus 1988; Verhulst et al. 1990). This decrease in levels of problems has also been reported for standardized interviews, both for adult and child psychiatric disorders (Edelbrock et al. 1985; Helzer et al. 1985). The reason for this decline in scores on re-assessment is not known, so it is not clear how it should be dealt with. Case– control intervention comparisons should be robust to this bias because the decline should affect both, provided measures are taken at the same time intervals. The bias is more problematic in simple group longitudinal studies. Although not done routinely, it may be advisable to ask each respondent who completes a rating scale to indicate whether the same rating scale had been completed earlier.

the PSC only provide an overall measure of dysfunctioning, whereas the other rating scales allow more differentiation and can be scored on syndrome scales. The CRS-R has abbreviated versions in addition to the longer standard forms. The short parent form is approximately onethird of the length of the long form, and covers only four scales instead of the 14 scales in the long form. Although the correlations among the four scales of the short form and the corresponding scales of the long form are reported to be very high, there are no comparisons between the short and the long versions with respect to validation against external measures (Conners 1997). Also, it is clear that the short form gives a much less differentiated picture of the child’s problems. There are few studies that directly compare short vs. long rating scales. One study compared the short SDQ with the much longer CBCL (Goodman & Scott 1999). Scores from the SDQ and CBCL were equally able to discriminate psychiatric from non-psychiatric comparison children. As judged against a semistructured parent interview, the SDQ was better than the CBCL at detecting inattention and hyperactivity, and did equally well at detecting internalizing and externalizing problems. For measuring psychopathology in adults, the General Health Questionnaire (GHQ; Goldberg & Williams 1988) is used with different numbers of items varying from the full 60 to 12. The shorter versions perform rather well in discriminating between psychiatric cases and normal individuals (Goldberg et al. 1997), and some even advocate the use of only four items of the GHQ to detect cases (Jacobsen et al. 1995). The use of extremely brief rating scales with only a few items, questions the rationale for using a rating scale at all. Why not just pose two questions to parents: ‘Do you think your child has a problem?’, and ‘Do you or other people have a problem with your child?’ The fact that very short rating scales do not perform much worse than the longer versions in detecting psychiatric cases also reﬂects the lack of speciﬁcity of psychopathology, and casts doubt on the usefulness of mass screening if the initial screening is not followed by more extensive evaluation.

Measures of accuracy of a rating scale
Rating scales applied to populations not known to have psychiatric conditions can be regarded as screening tests, whereas the same rating scales applied to populations known to have symptoms can be termed diagnostic tests (Weiss 1998). The underlying rationale for the use of a test is identical for both screening and diagnostic tests. The rationale is that among individuals to whom the test is administered, the monetary, physical and psychological costs of the condition along with the cost of the test and the errors that arise when the test does not classify individuals accurately, will be exceeded by the costs of the condition had the test not been carried out.

Short vs. long rating scales
Most rating scales take between 10 and 20 min to complete. For screening and early assessment procedures in which a global impression of the child’s functioning is needed, to be followed by more extensive assessment in a later phase for those who have elevated problem scores, a very brief rating scale is sometimes desirable. Another situation in which there is often a need for a very brief rating scale is when one teacher has to complete rating scales for many children in one classroom. A number of rating scales in their standard format are relatively brief, such as the Eyberg Child Behaviour Inventory (ECBI), PSC, Revised Rutter Scales, and the SDQ. The ECBI and

CHAPTER 5

Sensitivity, speciﬁcity and predictive value
The usefulness of a test depends on its accuracy. This can be assessed in several different ways: by sensitivity, speciﬁcity, positive and negative prediction. The meaning of these terms, and how to measure them is described by Fombonne (Chapter 4). As he points out, sensitivity and speciﬁcity do not reﬂect an intrinsic quality of a test; they will vary with the samples on which they were based and with the critical values chosen. Robins (1985) showed how the sensitivity of a test for the presence of a psychiatric disorder was higher in a patient sample than in a general population sample (such tests usually detect severe cases more readily than mild ones), but speciﬁcity will be higher in general population than in patient samples. Cutpoints are chosen by making compromises among several considerations. Any cutpoint chosen is a trade-off between sensitivity and speciﬁcity. The relationship between sensitivity and speciﬁcity can also be expressed by a Receiver Operating Characteristic (ROC) curve. The ROC curve is constructed by plotting the sensitivity on the vertical axis, against the false positive rate (100speciﬁcity) on the horizontal axis. The use of ROC curves has two advantages. The curve readily shows the trade-off between sensitivity and speciﬁcity, and so indicates the optimal scoring range for choosing the cutpoint that provides the best match with the aims of the user. The area under the curve (AUC) can be computed and used as an index for the criterion-related validity of a test. The AUC can be conceptualized as the probability of correctly identifying a randomly chosen pair of individuals (one who has the disorder, one who does not have the disorder). The AUC ranges between 0.5, which indicates that the test does not add to the chance probability of correctly classifying individuals, and 1.0 which would indicate a perfect test. The AUC enables us to compare the discriminative power of different rating scales (Kresanov et al. 1998). We can also express the accuracy of a test as the extent to which being categorized as ‘test positive’ or ‘test negative’ actually predicts the presence of the disorder. This may be an important method by which to determine the probability that an individual has a certain disorder, given the results of a test. Predictive value is much inﬂuenced by prevalence. In a sample with relatively few disordered individuals, the positive predictive value (PV+) of even a very speciﬁc test will be low, meaning that a ‘positive’ result will yield many false positives. If the same test was used in a sample with a much higher prevalence, the PV+ would be much higher. This makes screening for very rare disorders, such as autism, using rating scales in community settings unattractive. Although the problem of low base rates for predicting rare conditions, even with highly valid tests, was observed long ago (Meehl & Rosen 1955), Clark & Harrington (1999) showed that few child mental health professionals who regularly use questionnaires to screen for mental disorders were aware of this problem. A technique that can be used to overcome low base rates problems is sequential screening (Derogatis & Lynn 1999; see epidemiological applications below). 78

For some rating scales in Table 5.1, the authors specify the sensitivity and speciﬁcity (ASEBA, Rutter, SDQ, PSC, CSI); they are usually satisfactory and in the same range as rating scales for adult psychiatric disorders. However, the relative nature of these measures makes it imperative for the potential user to judge these values against the background of the speciﬁc purpose for which the rating scales is intended.

Scoring procedures and interpretation
The scoring procedures and the interpretation of the results of a rating scale should be easy to follow and understandable. Most rating scales have scoring forms or graphic displays that describe the scores relative to the norms. Computerized scoring and proﬁle printouts in graphic form have many advantages. The majority of rating scales listed in Table 5.1 have the option of using computerized scoring, including the ASEBA, CRS-R, BASC, DSMD, CSI, MMPI-A and the MACI. Rating scales are developed to assist in determining the likelihood that the subject does or does not have the speciﬁc problem the instrument is designed to identify. Use for any other purpose (e.g. assigning a diagnosis based solely on the instrument’s results) only serves to undermine the integrity of the instrument (Maruish 1999, p. 16).

Translation
There is a growing need for translations of psychometrically sound rating scales, mostly from English into other languages. This comes from researchers and clinicians in various countries, but also from researchers and clinicians who work in major metropolitan areas with their multiethnic multilanguage character. There are no generally accepted guidelines for gauging the adequacy of translation, although there is an increasing awareness of the many difﬁculties in the faithful translation of instruments (Weisz & Eastman 1995; Streiner & Norman 1998; Canino & Bravo 1999; see also Fombonne, Chapter 4). To ensure optimal accuracy in translations, some authors advise repetition of the translation-back-translation procedure (Weisz & Eastman 1995), whereas others emphasize the importance of ﬁeld testing (Canino & Bravo 1999). However, even very accurate translations may result in linguistic nuances that need explicit reporting. The CBCL (Achenbach 1991a), the CSI (Gadow & Sprafkin 1998), the CRS-R (Conners 1997), the DSMD (Naglieri et al. 1994) and the Revised Rutter Scales have all been translated into multiple languages. Accurate translation is the ﬁrst step towards using an existing instrument in different cultural settings. The second step is the testing of the instrument’s psychometric properties in these other contexts, including the reliability and validity. In particular, the determination of the factorial structure needs to be determined in case empirically derived syndromes are used. The third

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step is the derivation of reference scores, both in representative normative and clinical samples. The last step is the testing of the generalizability of the results by comparing population norms (Crijnen et al. 1997, 1999), and by comparing the factor structure across different cultural settings.

Advantages and disadvantages of rating scales
One of the great advantages of rating scales over clinical interviews is that they can be applied in a ﬂexible, easy to administer and economic way. Administration time is usually modest — some 10–20 min. Rating scales are also characterized by great ﬂexibility in the way they can be administered: in person, by telephone or by mail. Administration can be facilitated by using computer-assisted client entry programs. Some rating scales, such as the ASEBA, CRS-R, and the BASC have a computerassisted client entry program. Rating scales need not be administered by expensive clinically trained professionals. This means that they can be routinely administered in (mental) health settings at intake, or can be used in large-scale epidemiological surveys. Thanks to their practicality, many rating scales also have good data on reliability and validity. Rating scales also have a number of disadvantages, some of which are shared by other measurement procedures. They are limited to the informant’s perspective. Characteristics of the informant and the tendency toward response biases are sources of variation in ratings (Briggs-Gowan et al. 1996; Fergusson 1997; Sawyer et al. 1998). Scales are limited to the structured scores for standardized items. Information that may be relevant but that is not covered by the items of the scale will be missed. It is not possible to explore the informant’s responses and subjective experiences, nor is it possible to observe behaviour directly. Misunderstandings and ambiguous answers that may be clariﬁed in a clinical interview are missed when using questionnaires. Slight changes in the wording of instructions, or the wording of the items themselves, may have large effects that limit comparability (Woodward et al. 1989). Despite these limitations, one study that directly compared the validity of a rating scale against a structured interview in the ability to predict external criteria did not ﬁnd the rating scale to be less valid (Boyle et al. 1997). Many of these problems can be prevented by unambiguous wording of items and instructions. For instance, before having a respondent complete a screening questionnaire, we must have an indication of the respondent’s reading skills.

poses. The medical meaning of screening refers to the examination of asymptomatic or non-referred people in order to classify them as likely or unlikely to have the disease that is the object of screening (Morrison 1998). People who appear likely to have the disease are investigated further to arrive at a ﬁnal diagnosis. Those people who are then found to have the disease are treated. When the application of early diagnosis and treatment is organized within large groups, this is described as mass screening or population screening. It is not readily evident that psychiatric conditions meet all the criteria for being subjected to screening programmes (Derogatis & Lynn 1998). First, screening is a method originally developed for detecting highly speciﬁc medical target conditions that are either present or absent, such as phenylketonuria or breast cancer or HIV. Medical screening usually has a narrow focus, and is able to use a single test with a high degree of diagnostic precision. In contrast, psychiatric disorders lack speciﬁcity and do not have a highly accurate diagnostic test. The second concern is that most child and adolescent psychiatric disorders are not characterized by an asymptomatic or benign period in which detection can be reliably and validly performed. Moreover, most conditions lack a clear-cut welldelineated onset (see Sandberg & Rutter, Chapter 17). If subthreshold psychopathology is accepted as a risk factor for the persistence or recurrence of psychopathology, then the early detection of problems could be advantageous. The moderate to strong continuity of problem behaviour from childhood or adolescence into young adulthood supports this view (Ferdinand et al. 1995; Verhulst & Van der Ende 1995; Hofstra et al. 2000). It has been found that high levels of parent reported problem behaviours in non-referred children from the general population were not only predictive of referral for mental health services as recorded in a psychiatric case register in the year following the assessment, but they were almost equally strong predictors of referral for up to 5 years later (Laitinen-Krispijn et al. 1999). Earlier detection and subsequent treatment may improve the prognosis or reduce the period of suffering. The third factor that makes it not readily evident that mass screening is helpful is that is has not been deﬁnitively demonstrated that treatment or prevention of child and adolescent disorders at the stage before disorder is manifest is beneﬁcial (see Brent, Chapter 54). We do not advocate the use of rating scales, or any other assessment procedure, in mass population screening to detect whether or not a certain psychiatric condition is present. However, if precision in individual diagnosis is not required, as in epidemiological studies in which the error can be taken into account, or if early assessment is just one component in decision making, then there is a place for the use of rating scales.

Use of rating scales as screening instruments
Because rating scales are relatively inexpensive and easy to administer, they are often thought of as handy tools for screening large populations both for research and community health pur79

CHAPTER 5

Application of rating scales in screening procedures and early assessment
Epidemiological application of screening procedures
Epidemiology, with its emphasis on large-scale measurements, has an evident need for assessment procedures that are accurate, practical and economical. When the ﬁrst child psychiatric epidemiological studies were planned, the lack of such assessment procedures was the driving force for developing the ﬁrst generation of brief rating scales. The ﬁrst version of the Rutter scales proved their value in the Isle of Wight study (Rutter et al. 1970).

Speciﬁc questionnaires, generic questionnaires, or both?
When information about only one disorder (such as depression) is sought, it is possible to use a brief questionnaire in stage 1 that is focused only on the condition of interest. However, if a speciﬁc selection strategy in stage 1 is chosen, it is important that the stage 2 assessments cover a much broader range of psychopathology otherwise problems that are associated with depression (such as conduct problems or substance abuse; see Rutter, Chapter 28) will be missed. A question that may arise is whether it is better to use one generic rating scale or multiple speciﬁc rating scales at the initial stage of assessment. Most generic rating scales have the option of using the total problem score, the speciﬁc syndrome scales, or both, to score each individual. A disadvantage of using multiple instruments that only assess one area (such as depression, anxiety, or hyperactivity) is that each instrument has its own metric and norms, making comparisons difﬁcult, and there may be considerable overlap in the items across the various instruments. Accordingly, we do not advocate the general use of multiple focused scales for sceening purposes. An exception when this might be a preferred option is when it is important to detect disorders not well encompassed by syndrome scores and which might not be picked up by a high total score. This might apply, for example, to obsessive-compulsive disorders, Tourette syndrome and anorexia nervosa.

Multistage/multimethod sampling
Epidemiological measures for large-scale descriptive or aetiological studies need to be brief and inexpensive. Especially when investigating conditions with low base rates, it is problematic to assess many individuals who do not have a disorder with elaborate procedures. Therefore, it is advantageous to use a multistage sampling approach (Dohrenwend & Dohrendwend 1982; Verhulst & Koot 1992; Derogatis & Lynn 1998). In stage 1, a rating scale is applied to the total sample in which the base rate of a disorder is relatively low. Individuals with high problem scores are designated cases or ‘screen positives’. All others are designated non-cases or ‘screen negatives’. The advantage here is that although a low base rate has a bad effect on positive predictions, its impact on negative predictions is far less. In stage 2, all ‘screen positives’ (thereby an enriched sample with a higher prevalence rate, so avoiding the problematic effect of low base rates) and a random sample of the ‘screen negatives’ from stage 1, are assessed using more elaborate procedures, such as a clinical interview. The results of the interviews will conﬁrm or disconﬁrm ‘caseness’ as determined in stage 1. For some purposes this two-stage approach may be sufﬁcient. However, if greater precision is desirable, a third assessment procedure can be introduced, preferably using other indices of malfunctioning. This may be a measure of social impairment or some alternative method, such as the use of records. Either total problem scores or speciﬁc syndrome scale scores can be used in these ways. Some individuals who score above the cutpoint of a speciﬁc syndrome scale may score below the cutpoint for the total problem score and vice versa. Because selection of individuals based solely on one strategy may miss cases that would have been identiﬁed by the other strategy, it may be advantageous to combine both approaches. By doing so not only will the number of cases identiﬁed by the procedure be raised (a higher sensitivity), but the number of normal individuals misclassiﬁed as disordered will also be raised (lower speciﬁcity). This need not be a problem if a higher speciﬁcity in the stage 2 assessment is achieved.

Combining information from multiple informants
For all the reasons discussed here and by Fombonne (Chapter 4) all stages of epidemiological assessment need to be based on multiple informants. The key issue is how best to combine this information. Each strategy for combining the results from multiple informants has its consequences for the sensitivity and speciﬁcity of the assessment procedure. If any positive result is accepted, the sensitivity of the procedure will be higher than when all tests need to be positive. The more restrictive the criterion, the lower the sensitivity will be, and the more disturbed the individuals who are selected (Verhulst et al. 1994). There is another way to combine information from different informants by treating the data from rating scales as continuous scores. The problem that different scores will have different metrics can be overcome by transforming the scores for each version into standard scores (z-scores) with a mean of 0 and a standard deviation of 1. It is now possible to compute each individual’s mean z-score across the different informant versions of rating scales. By applying a cutpoint to the frequency distribution of this mean score, we can determine the individuals who score above this cutpoint and who may be selected for further evaluation (Verhulst et al. 1997).

Clinical applications of rating scales
The application of rating scales need not to be conﬁned to community samples, but can also be applied in routine clinical prac-

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tice to assist in decision-making. Many countries have ﬁnancial or other constraints on the services that can be provided to children and adolescents with mental health problems. Rating scales can help in ensuring that professionals’ valuable time is used in the most efﬁcient and productive way. At the time of referral, decisions are needed on whether assessment at this particular clinic is the most appropriate way of proceeding; if it is, what sort of diagnostic assessment should be undertaken, what type of treatment should be provided for how long, what type and degree of improvement should be expected with intervention, and what should be done after treatment? Clinical practice can beneﬁt from a standardized approach to these various decisions. When decisions are based on explicit rules and procedures, we may improve our ways of helping young people. The series of steps that need to be taken from ﬁrst contact with the clinic to the time of case closure should be based on an adequate database, and at each point decisions need to be taken on what is needed for that purpose. Clearly, it would not be feasible for everyone to have the fullest evaluation from the most experienced clinicians at all stages. Rather, some sort of ﬁlter, or process of triage, is needed to decide which cases need the most extensive and specialized assessments and treatments. Rating scales can have a useful role in this process. For example, they may be mailed to parents, teachers or the adolescents themselves before ﬁrst attendance. Many clinicians combine this contact with a request to the family to outline their main concerns and questions that they want addressed. This combination of standardized measurement and open-ended enquiry can be useful in guiding the form of the initial (fuller) evaluation, and it may also assist decisions on which part of the clinical service should be involved. Once a comprehensive formulation has been made (questionnaires can never provide that), rating scale data can aid in the selection of the key targets for intervention. It has been found that interventions that are effective under research conditions are often much less so under typical clinical conditions (Weisz et al. 1992). If standardized assessments are used systematically to identify the target problems that should be matched with the most appropriate treatment, it may be possible to improve the efﬁcacy of interventions in routine practice. Similarly, by monitoring the effects of interventions, it should be possible to decide whether the treatment is being effective or whether a change needs to be considered. Rating scales can have a valuable role in this monitoring because they are quantiﬁed and provide measures that are comparable from case to case. The same advantages apply to the assessment of outcome.

prehensive way. However, there are some differences that may be relevant for some purposes. Answers to a series of questions may help in making a choice of which scale to use. 1 Do I need multiple informants? The ASEBA, CSI, CRS-R and the SDQ have versions for parents, teachers and self-report on problems. 2 Do I need a rating scale for early assessment/screening, or do I need one for more extensive evaluation, and will the instrument be completed for one individual or for many individuals by the same informant? Most scales take 10–20 min to complete. The ECBI, PSC, Revised Rutter Scales and the SDQ are much shorter. However, only the Revised Rutter Scales and the SDQ can be scored on speciﬁc syndrome scales and not only on a global index of malfunctioning. The CRS-R has both short and long forms. 3 Do I need to assess problems only, or do I need to assess competence as well? The ASEBA, BASC, the Revised Rutter Scales and the SDQ have scales for adaptive functioning. 4 Do I want to obtain ratings that can be scored on DSMorientated scales, on empirically derived scales, or both? Five instruments have empirically derived scales (ASEBA, BASC, CRS-R, DSMD, RBPC), whereas the other seven have a priori derived scales. The new version of the ASEBA will have both options: the same rating scale can be scored on empirically derived scales as well as on DSM-orientated scales. 5 Are translations of the instrument available in the languages I need? The most widely used scales (ASEBA, CRS-R, Revised Rutter Scales) have the advantage that they are translated in different languages. This is not only an advantage for crosscultural research but also for the assessment of children from different cultures living in our present day pluriform societies. 6 Are there local norms available for the instrument or not? The ASEBA is probably the instrument with the largest number of normative data from different countries. 7 Do I want to compare my ﬁndings with those from others? The most widely used instruments (ASEBA, CRS-R, Revised Rutter Scales) have the most well-documented and published ﬁndings with which new ﬁndings can be compared.

Challenges and prospects for the future
It is hard to imagine that any future rating scale would be much better than the ones that already exist, or that this new instrument would solve the problems that are probably inherent in the assessment of child psychopathology. Rather than designing new instruments, the challenge for the future lies in the improvement of the construction and, especially, the use of scales. This may come from the application of modern statistical techniques (such as structural equation modelling) and from genetic studies that aim at constructing phenotypes that are more genetically informative. Also, the development of parallel scoring of the same instrument on both empirical and DSM-orientated scales may be a step towards more informative diagnostic information. There is an increasing need for more standardized assessment 81

How to select a rating scale
In our review of generic rating scales we were more impressed by the similarities among the various scales than we were with their differences. Most cover a roughly similar content, although their extensiveness varies, most have evidence of reliability and validity, most are user-friendly and most can be scored in a com-

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of child psychiatric conditions and for evaluation of treatment. Rating scales can be valuable in clinical practice where research standards are increasingly adopted. Future directions then include the development of methodologies, including the use of rating scales, that will enhance clinical decision making.

Appendix 1
Description of generic screening questionnaires
Achenbach System of Empirically Based Assessment (ASEBA)
The ASEBA (Achenbach 1991a–d, 1992, 1999; McConaughy & Achenbach 1994; Achenbach & Rescorla 1999) are rating scales for assessing psychopathology, social competence and adaptive behaviours. There are separate forms for different ages and for parents, teachers and self-reports. The forms for parents are: the Child Behavior Checklist/2–3 (CBCL/2–3) for ages 2–3 years; and the Child Behavior Checklist/4–18 (CBCL/ 4–18) for ages 4–18 years. The forms for teachers are: the Caregiver–Teacher Report Form (C-TRF) for ages 2–5 years; and the Teacher’s Report Form (TRF) for ages 5–18 years. The self-report form, the Youth Self-Report (YSR), is for ages 11–18 years. The items for assessing psychopathology are rated on a 3point scale ranging from ‘Not true’ to ‘Very true or often true’. The items of the CBCL/4–18, TRF and YSR are scored on the eight scales listed in Table 5.1 for ages 4–11 and 12–18 years, although the number of items per scale varies slightly across informants. The items of the CBCL/2–3 and C-TRF are scored on separate scales. For the CBCL/2–3 these scales are Anxious/ Depressed, Withdrawn, Sleep Problems, Somatic Complaints, Aggressive Behaviour and Destructive Behaviour. For the C-TRF these scales are Anxious/Obsessive, Depressed/ Withdrawn, Fears, Somatic Problems, Immature, Aggressive Behaviour, and Attention Problems. The CBCL/4–18, TRF, YSR, CBCL/2–3 and C-TRF can be scored on the composite scales of Internalizing, Externalizing and Total Problems. CBCL/4–18, TRF and YSR norms for different gender and age groups 4–11 and 12–18 years are based on a representative sample of children who were not referred for mental health services or did not attend special classes in the year prior to data collection. Rating scales can be scored using hand scoring proﬁles or computer scoring proﬁles. The computer scoring proﬁles also gives the level of agreement between informants. Computer software for administering the rating scales is available. The CBCL is translated into nearly 60 languages. The bibliography of published studies using ASEBA (Vignoe et al. 1999) lists over 3000 studies.

chopathology, self-perceptions and personality. There are separate forms for different ages and for parents, teachers and selfreports (only for perceptions and personality). The Parent Rating Scale (PRS) forms are for ages 21/2–5, 6–11 and 12–18 years. The Teacher Rating Scale (TRS) forms are for ages 21/2–5, 6–11 and 12–18 years. The self-report forms, the Self-Report of Personality (SRP), are for ages 8–11 and 12–18 years (not listed in Table 5.1). The items of the PRS and TRS are rated on a 4point scale ranging from ‘Never’ to ‘Almost always’. The items are scored on the scales listed in Table 5.1, with scales and number of items per scale varying slightly across ages and informants. The PRS cannot be scored on the scales Learning Problems, Study Skills, and on the composite scale School Problems. The SRP assesses personality traits; therefore they are not listed here (Reynolds & Kamphaus 1992). Norms for different gender and age groups are based on a representative sample, except for the SRP which was based on convenience samples. Rating scales can be scored using hand scoring proﬁles or computer scoring proﬁles. Computer software for administering the rating scales is available.

Child Symptom Inventories (CSI)
The CSI (Gadow & Sprafkin 1996, 1997a,b, 1998, 1999) are rating scales for assessing psychopathology. There are separate forms for different ages and for parents, teachers and selfreports. The forms for parents and teachers are: the Early Childhood Inventory-4 (ECI) for ages 3–5 years, the Child Symptom Inventory-4 (CSI) for ages 6–11 years, the Adolescent Symptom Inventory-4 (ASI) for ages 12–18 years. The self-report form is the Youth’s Inventory-4 (YI) for ages 12–18 years. Most items are rated on a 4-point scale ranging from ‘Never’ to ‘Very often’. Some items are rated with only ‘No’ or ‘Yes’. The items of the CSI are scored on scales representing DSM-IV categories (see Table 5.1). Scales and number of items per scale vary slightly across ages and informants. Norms for different gender and age groups 3–5, 6–11 and 12–18 years are based on samples of children who did not receive special education services. Rating scales can be scored using hand scoring proﬁles or computer scoring proﬁles.

Conners’ Rating Scales–Revised (CRS-R)
The CRS-R (Conners 1997; Conners et al. 1997, 1998a,b) are rating scales for assessing psychopathology. There are separate forms for different ages and for parents, teachers and selfreports. The form for parents is the Conners’ Parent Rating Scale (CPRS-R:L) for ages 3–17 years. The form for teachers is the Conners’ Teacher Rating Scale (CTRS-R:L) for ages 3–17 years. The self-report form is the Conners/Wells Adolescent SelfReport of Symptoms (CASS:L) for ages 12–17 years. These forms also exist in short versions for parents (CPRS-R:S), teachers (CTRS-R:S) and self-report (CASS:S). The items are rated on a 4-point scale ranging from ‘Not true at all’ to ‘Very much true’. The items of the CRS-R are scored on the scales in Table 5.1,

Behavioral Assessment System for Children (BASC)
The BASC (Reynolds & Kamphaus 1992; Kamphaus et al. 1997; Kamphaus et al. 1999) are rating scales for assessing psy82

RATING SCALES

although scales and number of items per scale vary slightly across ages and informants. The CTRS-R:L does not have a Psychosomatic scale. The items of the CASS:L are scored on different scales than the scales of the CPRS-R:L and the CTRSR:L. The items of the CASS:L are scored on Family Problems, Emotional Problems, Conduct Problems, Cognitive Problems/ Inattention, Anger Control Problems, Hyperactivity, ADHD Index, DSM-IV Symptoms, DSM-IV Inattentive, and DSM-IV Hyperactive-Impulsive. Norms for different gender and age groups 3–5, 6–8, 9–11, 12–14 and 15–17 years are based on representative samples. Rating scales can be scored using hand scoring proﬁles or computer scoring proﬁles. Computer software for administering the CRS-R is available. An annotated bibliography (Wainwright 1996) lists over 450 studies.

Minnesota Multiphasic Personality Inventory–Adolescent (MMPI-A)
The MMPI-A (Butcher et al. 1992) is a rating scale for assessing personality and psychopathology. There is only a self-report for ages 14–18 years. The items are rated on ‘True’ or ‘False’ answering categories. The items of the MMPI-A are scored on scales indicating personality traits and scales indicating psychopathology. Only the psychopathology scales are listed in Table 5.1. Norms for different gender groups are based on a representative sample. Rating scales can be scored using hand scoring proﬁles.

Paediatric Symptom Checklist (PSC)
The PSC (Jellinek et al. 1979, 1986; Jellinek & Murphy 1988; Pagano et al., 2000) are rating scales for assessing psychopathology. There are separate versions for different parents and self-reports. The form for parents is for ages 2–16 years. The self-report form is for ages 11–16 years. The items are rated on a 3-point scale ranging from ‘Never’ to ‘Often’. The items of the PSC can only be scored on a Total Problem scale. The rating scale is hand scored. A form for teachers is currently being tested.

Devereux Scales of Mental Disorders (DSMD)
The DSMD (Naglieri et al. 1994) are rating scales for assessing psychopathology. There are separate versions for different ages and for parent and teachers. The parent and teacher forms are for ages 5–12 and 13–18 years. The items are rated on a 5-point scale ranging from ‘Never’ to ‘Very frequently’. The rating scales are scored on the scales in Table 5.1, although scales and number of items per scale vary slightly across ages and informants. The scale Attention is for ages 5–12 years only, and the scale Delinquency is for ages 13–18 years only. Norms for different gender and age groups 5–11 and 12–18 years are based on a representative sample of children who did not receive special education services. Rating scales can be scored using hand scoring proﬁles and computer scoring proﬁles.

Revised Behaviour Problem Checklist (RBPC)
The RBPC (Quay & Peterson 1996) is a rating scale for assessing psychopathology. There is a single form for both parents and teachers for ages 5–18 years. The items are rated on a 3-point scale ranging from ‘Not a problem’ to ‘Severe problem’. The items of the RBPC are scored on the scales in Table 5.1. Norms for different gender and age groups 5–8, 9–11 and 12–13 years are based on samples of children who did not receive special education services. Rating scales can be scored using hand scoring proﬁles.

Eyberg Child Behaviour Inventory (ECBI) and Sutter–Eyberg Student Behaviour Inventory–Revised (SESBI-R)
The ECBI and SESBI-R (Eyberg & Pincus 1999) are rating scales for assessing disruptive behaviours. There are separate forms for different informants. The form for parents is the ECBI for ages 2–16 years. The form for teachers is the SESBI-R for ages 2–16 years. The items are rated on a 7-point Intensity scale, and on a Problem scale with ‘True’ or ‘False’ answering categories. Norms for different gender groups are based on a representative sample. The rating scale is hand scored.

Revised Rutter Scales (Rutter)
The Revised Rutter Scales (Rutter et al. 1970; Rutter 1976; Elander & Rutter 1996a,b; Hogg et al. 1998) are rating scales for assessing psychopathology and prosocial behaviour. There are separate versions for ages 3–5 and 6–16 years, and for parents and teachers. The items are rated on a 3-point scale ranging from ‘Does not apply’ to ‘Certainly applies’. The items of the Revised Rutter Scales are scored on the scales in Table 5.1. Rating scales can be scored using hand scoring sheets.

Millon Adolescent Clinical Inventory (MACI)
The MACI (Millon 1993) is a rating scale for assessing personality and psychopathology. There is only a self-report for ages 13–19 years. The items are rated with ‘True’ or ‘False’ answering categories. The items of the MACI are scored on scales indicating personality traits and scales indicating psychopathology. Only the psychopathology scales are listed in Table 5.1. Norms for different gender and age groups 13–15 and 16–19 years are based on a representative sample. Rating scales can be scored using hand scoring proﬁles.

Strengths and Difﬁculties Questionnaire (SDQ)
The SDQ (Goodman 1997; Goodman et al. 1998; Goodman & Scott 1999) are rating scales for assessing psychopathology and prosocial behaviour. There are separate forms for parents and teachers for ages 4–16 years. The self-report form is for ages 11–16 years. The items are rated on a 3-point scale ranging from 83

CHAPTER 5

‘Not true’ to ‘Certainly true’. The items of the SDQ are scored on the scales in Table 5.1. Cutpoints for discriminating between normal and clinical cases based on community and clinical samples are available. Rating scales can be scored using hand scoring sheets.

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(1979) Intraclass correlations: uses in assessing rater reliability. Psychological Bulletin, 86, 420–428. Stanger, C., Achenbach, T.M. & Verhulst, F.C. (1997) Accelerated longitudinal comparisons of aggressive versus delinquent syndromes. Development and Psychopathology, 9, 43–58. Streiner, D.L. & Norman, G.R. (1998) Health Measurement Scales: a Practical Guide to Their Development and Use. Oxford University Press, Oxford. Van der Valk, J., Van den Oord, E., Verhulst, F.C. & Boomsma, D. (2001) Using parental ratings to study the etiology of 3-year-old twins’ problem behaviours: different views or rater bias? Journal of Child Psychology and Psychiatry, 42, 921–931. Verhulst, F.C. & Althaus, M. (1988) Peristence and change in behavioral/emotional problems reported by parents of children aged 4–14: an epidemiological study. Acta Psychiatrica Scandinavica, 77 (Suppl. 339), 1–28. Verhulst, F.C. & Koot, H.M. (1992) Child Psychiatric Epidemiology. Sage Publications, Newbury Park. Verhulst, F.C. & Van der Ende, J. (1995) The eight year stability of problem behavior in an epidemiologic sample. Pediatric Research, 38, 612–617. Verhulst, F.C., Koot, H.M. & Berden, G.F.M.G. (1990) Four-year follow-up of an epidemiological sample. Journal of the American Child and Adolescent Psychiatry, 29, 440–448. Verhulst, F.C., Koot, H.M. & Van der Ende, J. (1994) Differential predictive value of parents’ and teachers’ reports of children’s problem behaviors: a longitudinal study. Journal of Abnormal Child Psychology, 22, 531–546. Verhulst, F.C., Van der Ende, J. & Koot, H.M. (1996) Handleiding voor de CBCL/4–18 (Manual for the CBCL/4–18). Afdeling Kinder-en Jeugdpsychiatrie, Sophia Kinderziekenhuis/Academisch Ziekenhuis Rotterdam. Erasmus University, Rotterdam, The Netherlands. Verhulst, F.C., Dekker, M. & Van der Ende, J. (1997) Parent, teacher and self-reports as predictors of signs of disturbance in adolescents: whose information carries the most weight? Acta Psychiatrica Scandinavica, 96, 75–81. Verhulst, F.C., Van der Ende, J., Ferdinand, R.F. & Kasius, M.C. (1997) The prevalence of DSM-III-R diagnoses in a national sample of Dutch adolescents. Archives of General Psychiatry, 54, 329–336. Vignoe, D., Bérubé, D.L. & Achenbach, T.M. (1999) Bibliography of Published Studies Using the Child Behavior Checklist and Related Materials: 1999 Edition. Department of Psychiatry, University of Vermont, Burlington, VT. Wainer, H. (1976) Estimating coefﬁcients in linear models: it don’t make no nevermind. Psychological Bulletin, 83, 231–217. Wainwright, A. (1996) Conners’ Rating Scales: Over 25 Years of Research — an Annotated Bibliography. Multi-Health Systems, Toronto. Weiss, N. (1998) Clinical epidemiology. In: Modern Epidemiology (eds K.J. Rothman & S. Greenland), pp. 519–528. Lippincott-Raven, PA. Weisz, J.R. & Eastman, K.L. (1995) Cross-national research on child and adolescent psychopathology. In: The Epidemiology of Child and Adolescent Psychopathology (eds F.C. Verhulst & H.M. Koot), pp. 42–65. Oxford Medical Publications, Oxford. Weisz, J.R., Weiss, B. & Donenberg, G.R. (1992) The lab versus the clinic: effects of child and adolescent psychotherapy. American Psychologist, 47, 1578–1585. Woodward, C.A., Thomas, H.B., Boyle, M.H., Links, P.S. & Offord, D.R. (1989) Methodologic note for child epidemiological surveys: the efforts of instructions on estimates of behavior prevalence. Journal of Child Psychology and Psychiatry, 30, 919–924. World Health Organization (1992) Mental disorders. Glossary and Guide to Their Classiﬁcation in Accordance with the Tenth Revision of International Classiﬁcation of Diseases, 10th edn. World Health Organization, Geneva.

6
Introduction

Psychological Testing and Observation
Joseph Sergeant and Eric Taylor

The approach of a psychologist to assessing a case is that of an investigator. The ﬁrst step is to understand and clarify the problem being presented, and from then on the process of assessment is a succession of formulating hypotheses about the nature of the problem, testing them, and modifying the formulation and the intervention plan accordingly. From this perspective, a ‘test’ is any systematic and quantiﬁed way of describing behaviour. It may be as highly standardized as an IQ test, or it may be developed and used for the unique problems of an individual case. The rating scale and interview approaches described by Verhulst & Van der Ende (see Chapter 5) and Angold (see Chapter 3) are tests in this sense; so are psychophysiological measures and naturalistic observations. It is important for the assessor to think broadly and creatively about the process of assessment, and to bring together different sources of evidence (see Rutter & Yule, Chapter 7). The more narrow and traditional deﬁnitions of psychological tests concentrate on those procedures and instruments that have been standardized through psychometric reﬁnement, have demonstrated satisfactory reliability, and are known to be valid in giving descriptions of an individual child in relation to the rest of the population or in predicting a speciﬁed criterion. Such tests can bring power to clinical inferences, because they allow one to know the accuracy with which a test can be generalized to other circumstances — whether, for instance, it will give the same result if administered again. Some clinical problems lend themselves very well to the use of such batteries: for example, whether a child who is failing to make school progress has an impairment of intellectual function. IQ scales then include a good (but not complete) description of a range of functions. Even then, the essential rationale remains that of testing a falsiﬁable hypothesis. However, many clinical problems require one to go beyond the boundaries of standardized tests. The assessor will then consult the research literature for suitable measures as well as compendia of established tests (Sattler 2001). This volume describes many clinical uses of psychological tests and systematic observational schemes. They include contributing to psychiatric diagnosis, as of disorders in the autism spectrum (see Lord & Bailey, Chapter 38); to neurological diagnosis, as in the early stages of dementing disorders (see Goodman, Chapter 14); resolving differences when there are discrepant accounts of a child’s competence or problems, as in the case of hyperactivity (see Schachar & Tannock, Chapter 25);

and differentiating between the various possible causes of a clinical problem, such as reading (see Snowling, Chapter 40). They contribute strongly to decisions outside the mental health services, for instance in helping to determine special needs in education (see Howlin, Chapter 68). Most of them give rise to one or more of a key set of objectives for the assessment process: describing a child’s behaviour or cognitive performance relative to that of other children; predicting the future; determining proﬁles of performance to indicate whether one ability is out of keeping with others; analysing the reasons for discrepancy between different reports; explaining a behaviour change or cognitive alteration by reference to another level of description; and tracking changes over time. The development of psychological testing and observation has been a process of making mental assessments more reliable and closer to what they seek to measure. Test developers start from concepts of the mental function they wish to assess. They seek to make the assessments quantitative, so that individuals can be ordered according to level of function they show; standard, so that the ways assessments are made are constant; referenced, so that children can be ordered with respect to the population they come from; and explicit — for example, in interrater reliability and stability — so that the strengths and limitations of inferences based upon them can be known. All these are aspirations of other types of assessment too. Investigators developing rating scales (see Verhulst & Van der Ende, Chapter 5) and standardized interviews (see Angold, Chapter 3) have also made explicit their reliability and validity and established normative values. The characteristic quality of tests is that they are also operational. That is to say, they seek to obtain more objective data than can be obtained through the ﬁlter of descriptions made by people who are already in a relationship with the child. They specify what procedures are to be carried out — for example, what task the child is asked to do — and provide explicit ways of scoring the child’s responses. Observational methods are not usually so well operationalized (although they can be) and they may be conducted in naturalistic as well as in controlled settings. However, they do provide either control or careful description of the stimulus setting, they substitute a professional observer of known reliability for the involved parent or teacher, and correspondingly they are able to record behaviour more accurately and more precisely. Further, they may be necessary to interpret the validity of test results. 87

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Tests of cognition
Descriptions of individual differences
The key concept in the minds of early developers of cognitive tests was ‘intelligence’ (Binet 1905). There were already many and varying deﬁnitions even by that time; but the main notions were the capacity to learn from experience and the ability to adapt successfully to changing environmental demands. More recently, Gregory (1981) has succinctly described intelligence as the creation and understanding of successful novelty. The tests that were developed therefore used problems that would be novel to a child being tested. They were intended at ﬁrst for educational purposes. If one knows only that a child is failing in school, there is no way of distinguishing ability from motivation or previous learning experiences. The use of an IQ scale aims to control for previous learning by giving quite unfamiliar and culture-fair problems, and for motivation by providing a standard setting with distractions minimized. If this is successful — and the extent to which it is successful is an empirical question — then a poor score suggests low aptitude. The study of individual differences in test scores proved to be very productive. Scores were stable over time (see below) and predicted quite well to real-world measures such as examination grades. In turn, the technology of IQ testing altered concepts of intelligence. Long familiarity with IQ scores has led most clinicians tacitly to accept that intelligence is what an IQ score measures, and that it is an important aspect of mental function. This is in some contrast to developing theories of cognitive functioning, which largely reject a uniﬁed intellectual capacity, and propose a variety of independent (but cooperating) systems for processing information, or a hierarchy of competencies (Sternberg & Kaufman 1988). Furthermore, the advent of cognitive paradigms in experimental psychology in the 1960s generated a different approach to information processing. This work was theory driven (Broadbent 1971) and could predict human performance in relation to task demands, stimuli, temporal characteristics and the effect of higher order control systems (Sanders 1983). In contrast to the psychometric approach in IQ development (where norms and standardization are key issues), cognitive psychologists showed that task performance on tests and paradigms depended upon whether the task demands were continuously varying or held constant (Shriffrin & Schneider 1977). From this emerged the concept of controlled and automatic processing, whereby attentional allocation and resource deployment depended upon whether the task was new or old. Later work showed that cognitive resources not only depended upon this distinction but also upon whether in a double task, the child was required to perform attentional switches (Allport & Styles 1997). The tension between ‘cognitive’ and ‘IQ’ approaches is pervasive. It is one of the reasons that some practitioners have abandoned intellectual testing in their work with children. Yet the practical value of tests is substantial. IQ tests have evolved 88

through several generations since the original work of Binet and Simon to the modern test batteries described below. The most inﬂuential consist of a range of different, short puzzles that require a variety of intellectual operations to solve them. They are given on a one-to-one basis, the child sitting with the examiner in a quiet and distraction-free room. The examiner takes care to establish a rapport with the child, explains what will happen and allays worries about the situation. This usually entails going through the same process with the parent, and explaining why the child is being seen separately from them. General encouragement to performance is given, but not feedback about whether individual answers are correct. Standardized scores for each subtest are calculated on the basis of the child’s performance and age. The scores show a Gaussian distribution in the population, not because this reﬂects a fundamental truth about the population but because the tests have been developed in order to give such a distribution. Statistical methods of taxonomy — especially, factor analysis — have been applied to them so that the results from the variety of items can be reduced to a small number of factor scores, and ultimately to a single score, the IQ. The standardization of the tests ensures that these scaled scores will have a mean of 100 and a standard deviation of 15. The IQ score therefore gives an estimate of the individual’s deviation from the population mean. The main such test ‘batteries’ are described below. It is also possible to use the individual subtests as measures of more speciﬁc processes, though caution is needed in this. The reliability of an individual subtest is considerably less than that of the scales based on several subtests. Correspondingly, there needs to be a large difference between one subtest score and what is expected from other scores before one can conclude that poor performance on what that subtest measures is a robust description of the child’s ability. Even scale scores can be inﬂuenced by many factors, and a trained psychologist’s judgement is needed to interpret them.

Stability of individual differences
Early in the development of IQ tests, longitudinal studies followed individuals with regular testing from infancy into adult life: after the age of about 6 years there were high correlations between test scores at different times, typically of the order 0.8 over 5-year periods (Bayley 1949). The prediction is substantial but incomplete, and individuals can show considerable difference between successive administrations. Nevertheless, Mofﬁtt et al. (1993) have analysed trajectories of intellectual development in a longitudinal study of a birth cohort, and have stressed that continuity of individual differences is the rule. When a child has departed from the previous trajectory at a testing point, then he or she is likely to return to the previous level at subsequent testing points. Most change over time is unpredictable and seldom shows evidence of systematic increase or decline. At the individual level, it is not possible to regard IQ as a ﬁxed capacity. As most change is random, then a child who is far removed from the mean when ﬁrst tested is likely to be closer to

PSYCHOLOGICAL TESTING AND OBSERVATION

the mean on subsequent testing. This can be quantiﬁed for the group — for instance, if the correlation between two age points is 0.7, then children will regress almost half the distance towards the mean at subsequent testing. This cannot be taken to the individual level, and clinicians should remember that there is change as well as continuity in test scores. When decisions have to be based upon IQ tests (e.g. recommendations about suitable schools) the psychologist should retest and not base judgements on outdated information. Test scores also predict other qualities of children. Some of these are important only at the extremes of the range. An IQ less than 50, for example, predicts quite strongly that there will be structural abnormalities of the brain, that there will be a much higher prevalence than normal of known medical causes of intellectual retardation, that independent life will not be reached in adulthood, that fertility will be reduced, and so on. For reasons such as these, the categories of intellectual handicap are an important classiﬁcation of clinical cases and constitute one of the axes of the ICD-10 diagnostic scheme.

Analysis of impaired function
Psychological testing is also used in a more explanatory way. The aim then is to clarify a known problem by reference to a more fundamental level of description. An example would be the testing of a child with poor reading. Not only can the severity of the reading problem be quantiﬁed and its severity be shown to be out of proportion to general cognitive development, but it can also be shown to be associated with a ﬁnding of speciﬁc problems in phonological processing or word recognition (see Snowling, Chapter 40). The process of understanding a dysfunction often takes the investigator to the research literature, selecting tests from experimental psychology that may not have much normative data. Caution is needed when applying tests, whose validity is known only at the group level, to individuals. This is all the more true when a test is given repeatedly with systematic variation in the way it is given. Experimental control of one aspect of a test is, in theory, a powerful way of analysing a deﬁcit. For example, it might be highly relevant to know that a child had poor performance on a continuous performance test (CPT) of attention when given without incentives, yet a normal performance when correct responses were rapidly rewarded. Experimental tests are often set up in this way for comparing groups. For assessing individuals, the reliability between two administrations of the test should ideally be known. Without this knowledge, test results should be seen as aids to making a clinical formulation, not as direct providers of diagnostic information. Nevertheless, the suggestions made from analysing problems in this way are often illuminating, and can be tested by the consequences of actions based on them.

Proﬁle analysis
It can be of great help in assessing a case to know that different abilities are out of keeping with one another. For instance, for a child who is failing in school and scoring poorly on IQ tests, it may be very illuminating to know that all the depression of the scores can be accounted for by one factor, such as processing speed. A speciﬁc rather than a global impairment is suggested. It helps the child and family to understand the problem, and it suggests strategies to teachers: in this instance, perhaps to relax time pressure. The distinction of global and speciﬁc delays is not exclusive. A child with global delay may still have an extra problem in one type of function, such as language (see Bishop, Chapter 39). Detecting a speciﬁc problem in the presence of a global one would be very difﬁcult in the absence of quantiﬁed tests for a range of functions. It is important to remember that this practical value does not depend on acceptance of any one theory. Even those who reject the idea of a uniﬁed concept of intelligence, and prefer to think of a number of speciﬁc intelligences, will ﬁnd it valuable to describe children in terms of their strengths and weaknesses. An investigator who is trying to establish whether a particular function is impaired will need to establish whether it is impaired by comparison with other functions. IQ is convenient as a summary description of some of those functions. Its value therefore does not depend upon supposing that it indexes an underlying entity. Indeed, judgement is often needed in deciding exactly what one is controlling for, and therefore on the exact tests to be used. If the aim is to measure short-term memory, then one would want to say that it is (or is not) disproportionate to scores on IQ tests that do not place much load on memory. One is controlling for other aspects of test performance. If memory tests were included in the IQ measure that is used as a control, one would be in danger of controlling out the main subject of study.

Descriptions of outcome
Clinicians often wish to quantify change over time — both the natural course of disorder and the response to treatment. Accurate quantiﬁcation helps not only in detecting subtle differences (e.g. whether attention has improved during a course of stimulant medication) but also in allowing for the fact that the child is maturing over the period of observation. Cognitive tests standardized for different ages are therefore very valuable. They can, however, be confounded by the effects on test scores of repeating the test. ‘Practice’ effects are of various kinds. First, and simplest, the child may remember from one administration to another what the answers were, so that memory rather than problem-solving is being tested on the second occasion. This kind of practice effect is perhaps the easiest for the clinician to manage. Some tests have alternative forms available, so that the second presentation can be of different material but of comparable difﬁculty. For a well-standardized scale, such as the Wechsler, the effects of repeated testing are known and can be allowed for, both by specifying the minimum time between administrations for them to be valid and by providing tables for the probable limits of practice effects. For less well-standardized tests, even the simple effects of practice may be unknown. 89

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A second kind of practice effect is more fundamental: the child has acquired an insight into how to do tests of this type. For instance, an effective strategy for coding one set of symbols into another may only have been worked out by the end of the ﬁrst test administration, but is available right from the start of a second. This is best detected by the observation of the alert examiner, who will be noting the way that the child is carrying out the test as well as recording the score. A third kind of practice effect, particularly affecting attentional performance, is a shift from automatic to controlled processing in the same test. Some tests evoke both automatic and controlled processing, so that the effects of repetition are complex. For example, the Stroop test (see Executive Function, below) is based upon an interference effect between an overlearned and automatic process — reading words such as red, blue, green and yellow — and the controlled process of inhibiting the reading and naming the colour in which they are printed. With repetition the inhibition may become automatic. The converse of the Stroop effect is the phenomenon that controlled attention is independent of past learning and depends upon the child being able to meet changing relations within the task. For example, in one version of the CPT, the letter that has to be identiﬁed as a target changes from trial to trial. This places demands upon the child that are different from the version of the CPT in which the target remains constant over the entire series of trials. In the ﬁrst case there is clearly demanded controlled attention. In the second case the child may learn the target–non-target relations and become swifter in performance as the task progresses. If sufﬁcient trials are given in the constant target condition, a relatively automatic process of detection will develop, which is called an automatic attention response. Thus analysis of the task demands of what is apparently the same test, the CPT, can involve quite different attentional processes, each of which are of interest in themselves. These subtle differences may point to quite different types of deﬁcits in attention, and may vary in different ways over time. For all these reasons, one should record in detail the previous testing history of the child. Even when carrying out an initial assessment, it is important to ﬁnd out whether the child has had any previous exposure to the test so that possible practice effects can be allowed for.

tive function that have come from experimental psychology. Many cognitive tests are available, and we mention only a few: they are chosen to indicate the range of purposes and methods, and the considerations that enter into the choice of test. To go more deeply into the existing tests, the reader may consult a recent review (e.g. Sparrow & Davis 2000) or text book (e.g. Sattler 2001).

Intellectual functions
The Wechsler Intelligence Scales are the most popular of all the comprehensive and general-purpose test batteries. The Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) (Wechsler 1989) is standardized for ages 3–7 years; the Wechsler Intelligence Scale for Children-Third Edition (WISC-III) (Wechsler 1991) for ages 6–16 years; and the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III) (Wechsler 1997) for ages 16–74 years. The extensive data available about them, their translation into a number of languages, and the existence of norms for some countries outside the USA (e.g. for Wechsler 1992a) are all substantial advantages. Each subtest is standardized to a mean of 10 and standard deviation of 3 and has a range of 3 standard deviations on either side of the mean. The two subscales — verbal and performance IQ — and the full scale IQ have means of 100 and standard deviations of 15. The standardization allows quantitative inferences to be made about the signiﬁcance of discrepancies between the scales and the reliability of differences between two administrations. Figures for judging the reliability of subtest scores on items such as memory have also been published (Ryan et al. 2000). These are, of course, statistical considerations. A ‘signiﬁcant’ discrepancy means that it is likely to be a reliable description of that child’s performance but it does not in itself imply a pathological cause. Further, a ‘verbal-performance’ distinction is about the type of information that is being presented, not the way it is being handled. Many practitioners prefer to base their interpretations on a four-factor solution: verbal comprehension, perceptual organization, freedom from distractibility and processing speed. These roughly correspond to some clinical distinctions, e.g. groups of children with attention deﬁcit hyperactivity disorder (ADHD) tend to have low scores on ‘freedom from distractibility’, and children with language disabilities tend to score poorly on ‘verbal comprehension’ (Wechsler 1991). However, the match cannot be pushed too far; there is considerable overlap between groups, and individual diagnosis on this basis should not be attempted. The Wechsler scales have been criticized on various grounds — most pervasively, for lacking a clear theoretical rationale (some perceive this as a strength). Individual items have been criticized for including emotionally laden material, information derived from education, and language-driven instructions. These could reduce its fairness to children from adverse backgrounds or whose native language is different from that of the tester. The corresponding advantage is that it does include important aspects of linguistic and social intelligence for use in groups to

Cognitive tests and test batteries
Tests differ in the psychological functions measured and the cognitive theories that underlie them. For example, the Wechsler scales (see below) derive from a psychometric approach. Subscales are derived from factor analysis, and items are chosen partly for the strength of their loadings on speciﬁc factors. The aim is to give an economical description of a range of performance scores, and the scales are not necessarily to be reiﬁed into speciﬁc mental modules. By contrast, more recent scales such as the Kaufman (see below) were developed to reﬂect more explicitly the theoretical distinctions between different types of cogni90

PSYCHOLOGICAL TESTING AND OBSERVATION

whom they are appropriate. The 3-standard deviation range (either side of the mean) makes it somewhat insensitive to differences at the extremes of the range. Other tests are also available, some of which avoid some of the disadvantages and are preferred in some situations. The Stanford-Binet Test, Fourth Edition (SB-IV) (Thorndike et al. 1986) has the longest pedigree of any test. The norms are good, and extend from age 2 years to adulthood. It shares many of the limitations of the Wechsler, and the linguistic demands of test presentation are considerable. It does have a potential advantage in assessing differences at the top end of the IQ range, and is sometimes used by those assessing gifted children. A version has also been developed for children with visual impairment (Perkins-Binet Test of Intelligence for the Blind; Davis 1980). The Leiter International Performance Scale-Revised (Roid & Miller 1997) avoids much of the dependence upon language to understand tests — which are presented with pantomime and simple practice items. Its norms extend from age 2 to 20 years and it yields standard scores on scales of reasoning, visualization, attention and memory. It is therefore popular in assessing children with communication problems. Raven’s Progressive Matrices (PM) (Court & Raven 1995) are suitable from age 5 years to adult life. Like the Leiter, the tests can be presented with virtually no spoken language; like the Leiter, they are untimed. PM testing is quicker, but less comprehensive, than most other tests of intellectual function. Both these tests are useful in assessing children with hearing impairment. The Hiskey–Nebraska Test of Learning Aptitude (Hiskey 1966) is particularly intended for hearing-impaired children and has been standardized for them (ages 3–17 years). The Kaufman Assessment Battery for Children (Kaufman & Kaufman 1983) is ﬁrmly based on cognitive theory, and especially on the distinction between sequential processing (involved in processing information that is ordered in time or space) and simultaneous processing (in which several pieces of information are integrated and processed as a whole) (Luria 1980). In practice most ‘simultaneous’ tasks are visuoperceptual, and most ‘sequential’ tasks are verbal or motor; so the theoretical distinctions may be confounded in practice. Other items are derived from Piagetian theory and from Luria’s notions of high-level planning ability (especially decision-making and hypothesis evaluation). The test was standardized on 2000 children in the USA. It covers ages 2–12 years (and the Kaufman Adult and Adolescent Intelligence Test extends the range to adult life). It has been translated into several languages, though not yet standardized for other cultures. Its exclusion of verbal abilities and speciﬁc knowledge has made it of particular interest to those working with children with communication disorders. It gives not only Sequential Processing and Simultaneous Processing scales but also a Mental Processing Composite that is equivalent to an IQ score. The Cognitive Assessment Scale (Naglieri & Das 1997) is another attempt to combine psychometric credibility with satisfying psychological theory, and yields subscales of planning, attention, simultaneous and successive processes, as well as

a Full Scale. It was standardized on 2200 children in the USA, and its validity was tested in several criterion groups. It is too early to assess its full value, and especially the extent to which it will prove culture-fair. The British Ability Scales (Cook 1988) also include items that are based on current cognitive theories of attention, information processing and memory. The test battery was standardized on 1700 children in the UK, which has made it popular in this country. It covers ages 2–6 years in one form, and 6–18 years in another. It yields scales of verbal (often interpreted as ‘crystallized’) and non-verbal (often interpreted as ‘ﬂuid’) reasoning and spatial ability; there is a general conceptual ability scale (corresponding to IQ) and another general measure from which verbal test scores have been excluded (‘special non-verbal composite’).

Neuropsychological tests
Neuropsychological test batteries base their component tests on theories rather different from those informing IQ tests — those of brain–behaviour relationships (Korkman 1999). Their emphasis in the past has been on those tests that are similar to the adult neuropsychological tests that have shown themselves sensitive to localized neurological disorders, e.g. the Halstead–Reitan battery (Reitan & Wolfson 1993) and Luria Nebraska (Golden 1987). Scepticism has often been expressed about the extent to which this localization is relevant to the problems shown by children with brain abnormalities, for whom the psychological consequences are characterized by plasticity and compensation and by global rather than speciﬁc outcomes (Taylor 1991). More recent development of neuropsychological batteries aim to give a broader description of the strengths and weaknesses of cognitive function. The NEPSY (Korkman et al. 1997), for example, includes scores for language and communication, sensorimotor functions, visuospatial abilities, learning and memory, and executive functions such as attention and planning. It therefore represents something of a compromise between the psychometrically based tests such as the Wechsler (with their advantage of comprehensiveness) and the more experimental neuropsychological tests (with their advantage of close and detailed analysis of a speciﬁc function). The study of brain–behaviour relationships in cognition is currently undergoing a rapid and exciting change. The correlation of psychological test performance with underlying alterations of the brain has been thrown into revolution by the advent of modern neuroimaging (see Bailey, Chapter 10). Some tests have shown surprisingly strong associations, e.g. tests of attention with size of frontal structures and basal ganglia (Castellanos 1997). It is too soon to know how far this process will go, but it seems to give promise of understanding which functions are carried out in a modular way by particular brain structures, and which (and how) are served by the cooperative working of several brain structures. Such tests are likely to play 91

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an increasingly large part in the future of assessing children psychologically. The most common neuropsychological functions assessed are the following.

Language
The verbal IQ of the Wechsler can give a general guide. More detailed analyses of language function are available, such as the Clinical Evaluation of Language Fundamentals–Third Edition (CELF-3; Semel et al. 1995). Language assessments can make distinctions about types of language impairment, e.g. comprehension, expression and pragmatic use, and quantify the degree of any impairment (see Bishop, Chapter 39).

Sonneville et al. 1999) and executive functioning (Robbins et al. 1998). Attention is a behavioural as well as a cognitive construct. Observation of children’s behaviour during testing (see below) is probably the main source of evidence on which judgements about attention are based.

Executive functioning
Since the 1970s, cognitive neuroscientists have stressed study of the active, planning and evaluative systems of cognitive performance (Broadbent 1971; Posner 1978; Shallice 1982; Sanders 1983). Various tests are intended to measure the high-level functions of planning, inhibiting immediate or inappropriate reactions, decision-making and organization. For the most part their standardization is weak. They include the Stroop Colour–Word Test (Stroop 1935), in which a conﬂict of information is set up (e.g. the word ‘blue’ being printed in red colours), so that successful completion of the test requires one to suppress an ‘obvious’ but wrong response. Like many neuropsychological tests, it is dependent upon a wide variety of processes. Colour perception and reading ability inﬂuence performance (SemrudClickeman et al. 2000; Tannock et al. 2000). The interference score derived from the Stroop may not simply reﬂect a sole process, such as inhibition. Unlike many neuropsychological tests, the Stroop controls for some of the processes: it contains separate information on colour naming and reading. Other ‘executive function’ tests are intended to test aspects of problem-solving, e.g. the Trail Making and Wisconsin Card Sort Tests (WCST; Berg 1948), especially when an abstract element of thinking before response is required, e.g. Tower of London (TOL; Shallice 1982). A set of tests of this type is available as the CANTAB (Cambridge Neuropsychological Test Automated Battery; Lowe & Rabbitt 1998; Robbins et al. 1998; Luciana & Nelson 2000). These computerized tests include set-shifting, working memory, pattern recognition, inhibition and planning. There are developmental trends on these tasks, which have been followed (for example) from age 4–8 years by Luciano & Nelson (1998), but they do not yet have the kind of standardization that would allow for secure inferences about individual children. Tests of planning and organization are embodied in tests such as the Behavioural Assessment of Dysexecutive Syndrome (BADS; Wilson et al. 1996), which have been applied essentially to adults with disorders such as schizophrenia but have a face validity for neurodevelopmental disturbances in childhood. (Evans et al. 1997; Krabbendam et al. 1999). Tests of inhibition are operationalized as ‘stop’ tests, in which a response to a stimulus has to be interrupted after another stimulus has indicated that one should not respond; ‘go–no go’ tests, in which standard signals call for a response but others require the response to be withheld; and ‘delay’ tests, in which a stimulus calls for a response to be emitted only after a period of a few seconds has elapsed (Rubia et al. 1999). Some of these tests are very prone to the practice effect mentioned above. For instance, a child’s performance on the

Memory
Brief tests stressing memory are found in the Wechsler Memory Scales, Binet Short-Term Memory, and the Kaufman tests. More detailed assessment, with some normative data, are provided by the Rivermead Behavioural Memory Test (Wilson et al. 1985) which includes useful tests of new learning with non-verbal and motor as well as verbal components; the California Verbal Learning Test–Children’s Version (Delis et al. 1993; Elwood 1995) and the Wide Range Attention and Memory and Learning Test (Sheslow & Adams 1990).

Visuospatial skills
Visuospatial processing is included in all the main test batteries. Speciﬁc tests are available, but usually add rather little by way of superior standardization or making ﬁner distinctions. However, a motor-free visual perception test may be useful in assessing perceptual processes more speciﬁcally (Aliotti & Rajabiun 1991) and the Bender–Gestalt Test (Piotrowski 1995) offers a complementary emphasis on visuomotor integration — though its initial purpose of detecting brain damage would no longer be seen as a valid rationale.

Attention
A large experimental literature has not yet translated itself into well-standardized tests (Sergeant et al. 1999). It has been conceptually and practically difﬁcult to distinguish between attention on a test and ability at the test when the only measure available is test performance. Experimental tests are usually presented under strict timing control (usually with a computer) and with manipulation of experimental parameters. Standard automated versions of the CPT are available with age norms (Conners 2000). Simple counts of number of errors will reﬂect processes other than attention, but analysis of different patterns of error is feasible and may give clues to the presence of such ‘attentional’ problems as overrapid and impulsive responding (see Schachar & Tannock, Chapter 25). Computer batteries exist for tests of attention (de 92

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TOL requires careful clinical observation. In the beginning of such a task, the child has to ‘catch on’ to the sort of planning that is required, so thoughtful reﬂection is needed before carrying out a sequence of permissible moves. As time passes, the child learns which moves are required or, in the WCST, learns when hearing ‘no’ that the principle for sorting cards has been changed. Once the child has caught on to what ‘the trick’ is, the test no longer measures planning or control over perseveration in the same way. If one repeats the TOL or WCST with the same child, reliability will be found to be low, because the child is often able to recall ‘the trick’. Hence in clinical practice, careful inspection of the performance of the child over time is required to assess at what point planning may have been measured and at what point the trick has been applied. Scores on such tests may over- or underestimate the child’s planning ability. Executive function tasks are sometimes supposed to draw on a common working memory (Baddeley & Hitch 1974). This assumption has been modiﬁed: there may be speciﬁc and distinguishable working memory domains (Baddeley 1990). Indeed, Kimberg & Farrach (1993) have argued that performance on the TOL, Stroop and WCST may be managed by separate working memory systems. If this proves to be correct, it would emphasize that the terms ‘executive functioning’ and ‘working memory’ are not homogeneous. This being the case, practical neuropsychological assessment must examine different features of these concepts (Pennington & Ozonoff 1996). A ﬂexible rather than a ﬁxed test battery approach would seem more appropriate to answer issues such as which type of working memory is deﬁcient in children with learning disabilities. If one does not apply sufﬁciently comprehensive testing with sufﬁcient ﬂexibility to meet the case at hand, one may be replacing one ‘wastepaper basket’ term with another. In summary, choosing a ‘working memory’ task may result in greater heterogeneity than one might expect, but may still validly reﬂect cognitiveneuropsychological processing. Clinicians should not be surprised when the apparent cross-reliability between tests is not found to be high.

Quantiﬁed motor tests have a particular place in the assessment of the development of younger children, for whom tasks involving complex communication and symbolic understanding are not appropriate. The Grifﬁths Scales of Mental Development (Grifﬁths 1970) contain a range of tasks requiring motor skills, and locomotor development constitutes some of the scales of the Revised Denver Developmental Screening Test (Frankenburg & Dodds 1967; Frankenburg et al. 1986) Grifﬁths and Denver scales also include items that relate to self-care and independence skills. Quantifying these kinds of ‘adaptive function’ are important in assessing the needs of children with global learning disabilities (see Bernard, Chapter 67). The Vineland Adaptive Behaviour Scales (Sparrow et al. 1984) are widely used for this purpose, and have a practical advantage in that information can be acquired by parental report as well as by direct examination of the child’s abilities.

Achievement tests
It is often useful to quantify the level of academic achievement — for instance, in reading or mathematics — that a child has attained. Schools do so for many purposes — to assess pupils, teachers and whole school systems — and the methods vary with the aims. The most common aim in clinical practice is diagnostic — to determine whether the degree of difﬁculty in (say) reading is above and beyond that which can be attributed to any global cognitive impairment. If there is a speciﬁc problem, then detecting it helps in giving advice to young people and their families, and (in many school systems) leads to administrative decisions about provision of special help and placement in special units. For this purpose, the tester is seeking evidence of a discrepancy between achieved scores and those predicted from the age and IQ of the child. In order to do this, one should not rely on impressionistic statements that the child is below expectation, or that the child is so many years behind his or her peers (because the signiﬁcance of, say, a 2-year discrepancy will be very different at the age of 8 to that of 14 years), or arbitrary statistics such as the ratio of reading age to mental age. These fail to achieve the precision that is the point of quantifying. Regression formulae or expectancy tables should be used to predict the expected level of attainment from age and IQ (Yule 1967) and identify those with an extreme difference between that and the observed level, such as 2 standard errors of prediction below expectation (see Snowling, Chapter 40). The best scales to use for this purpose will be those that have been developed and standardized alongside IQ scales. A tester using the Wechsler Intelligence Scales will usually choose the Wechsler Objective Reading and Numerical Dimensions (Wechsler 1992b, 1996); one using the Kauffman will opt for the Kaufman Test of Educational Achievement (Kaufman & Kaufman 1985). In educational practice, simple achievement tests are helpful in screening to detect children whose progress is untypical. This is a part of routine good practice in schools, but nationally standardized tests are also valuable as reference points. For this 93

Motor abilities and adaptive function
The organization and coordination of motor tasks is a difﬁculty for children referred with problems related to dyspraxia. Clinical neurological examination is usually the key tool for assessment. It aims to uncover patterns of incoordination (such as cerebellar ataxia, motor overﬂow or ideomotor apraxia) as well as underlying causes (such as mild cerebral palsy). Standardized tests of various kinds are available, and are used when the level of incoordination needs to be quantiﬁed more precisely (when a test battery of a wide range of ﬁne and gross motor coordination, such as the Henderson & Sugden (1992) Movement ABC, based on the Lincoln Oseretsky, is suitable); or when a speciﬁc problem is detected (as by the Fogs tests; Szatmari & Taylor 1984, concentrating on the observation of associated and redundant movements during speciﬁed effortful motor tasks).

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purpose, the prime consideration will be to choose a test with the best national standardization. The Wide Range Achievement Test (Jastak & Wilkinson 1984) is extensively used and provides both a brief screen and a more comprehensive version analysing types of errors in reading decoding, reading comprehension, mathematics applications, mathematics computation, and spelling. The Neale tests of reading (Neale 1997) are reasonably quick to administer and widely used. Teachers are often disappointed with the results of psychological testing because they are hoping for a prescriptive approach to guide curriculum and classroom practice for the individual child. There is still a considerable gap between the description of abilities that comes from testing and the decisions about the most helpful remedial approaches. For this reason, many educationists emphasize the approach of curriculum-based assessment (Tucker 1985). This is criterion-based rather than based on what is average for the population; the aim is simply to describe whether or not a young person has mastered what they are expected to learn. The test items should be drawn directly from the curriculum, and assessment is closely bound up with teaching. Such tests are indicative of the level reached rather than diagnostic of the reasons for any impairment.

used as the key operational manipulation in several experimental means of eliciting responses. For example, ‘communication deviance’ can be scored from responses to Thematic Apperception Test material, and was predictive of breakdown in young people at risk for schizophrenia (Doane et al. 1981). A speciﬁed scoring system for the Rorschach has been introduced (Exner & Weiner 1994), although even the most recent evaluations (Jorgensen et al. 2000; Wood et al. 2000) have had to conclude that the test is unsuitable for scientiﬁcally based assessment. However, the principle that has survived the individual tests is that of providing a standard set of stimuli to elicit the behaviours for professional observation — a principle taken up under ‘Observational approaches’, below.

Cognitive testing in very young children
Several test batteries describe the cognitive abilities of very young and preverbal children: the most commonly used are probably the Bayley Scales of Infant Development, now in their second edition (Bayley 1993). Other tests, such as the Merrill Palmer (Stutsman 1931), are sometimes used but have less satisfactory normative data. The same tests are used to describe the competencies of older children with severe mental retardation. The two uses, however, raise rather different issues. There are at present serious limitations to the predictive value of cognitive testing when one tries to predict from infancy to later childhood. This can be a pressing clinical issue, because it would often be very useful to know whether a baby with a risk factor for later cognitive development (such as a very low birth weight) is in fact speciﬁcally vulnerable. Remedial education could then be started very early for the high-risk group in the hope of preventing the later sequelae. The hope has not yet been translated into reality, partly because of a lack of strong predictors from infancy to cognitive abilities in later childhood. The difﬁculty does not arise from lack of measures for infant development, nor from lack of reliability in those tests (Bayley 1993). Indeed, there is a respectable measure of agreement between different types of developmental assessment when carried out in children aged 1 year (Raggio et al. 1994). Rather, the problem seems to be that the abilities that are assessed in early development (such as sensorimotor coordination) have rather little to do with the symbolic cognitive operations that are assessed in later childhood. The situation is improving with further research. More recently developed measures for infants, such as those of visual information processing and means-ends problem-solving show signiﬁcant correlations with IQ in later childhood (Slater 1995). They have clariﬁed some of the reason for poor predictiveness of traditional tests. For example, habituation to sensory stimuli at the age of 4–8 months is not a stable trait. It does not predict similar measures taken at the age of 3 years. It does, however, predict developmental quotients at the age of 3 years quite well (McCall & Carriger 1993). The apparent paradox — that an unstable test can have predictive validity — emphasizes that a test

Social and emotional understanding
Standardized self-reports are valuable tools in an assessment of social and emotional function (see Angold, Chapter 3). Further questions often arise as to how far an abnormality of social behaviour is based on a failure to understand social situations and the expectations of others. Research approaches to this issue can be adapted to the assessment of individuals. ‘Theory of mind’ tests describe the extent to which individuals can understand situations involving the motives and understanding of other people — the extent, for instance, to which they appreciate what will embarrass other people or how they will understand deception. Carefully constructed false-belief tasks have been found to show good test–retest reliability and internal consistency (Hughes et al. 2000). They are therefore suitable for individual assessment. The recognition of faux pas has also been assessed with a test showing predictive validity in distinguishing groups of people with and without Asperger disorder (Baron-Cohen et al. 1999). Heavey et al. (2000) have presented an Awkward Moments Test: an advanced theory of mind task, developed to approximate the demands of real-life mentalizing in able individuals with autism. Excerpts of ﬁlms showing characters in social situations are presented, with participants required to answer questions on characters’ mental states and on control, non-social questions. Projective tests are still widely used, in spite of having fared poorly against empirical tests of reliability and validity. The lack of structure, and the difﬁculty of making quantitative sense out of the enormous number of possible responses, has worked against their utility. When clear and explicit rules for administration and scoring have been applied, then progress can be made. The presentation of projective test materials has been 94

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such as habituation indexes different psychological functions at different ages. The new generation of tests in infancy may well come to be applicable on a routine clinical basis, though at present it is difﬁcult to achieve robust and reliable descriptions of individuals because of marked ﬂuctuations in scores depending on the state of the infant. Nevertheless, the prediction of later impairment is still rather too weak to be a basis for selecting children for intervention. Practically, the best predictors of cognitive outcome in very high-risk groups remain neurological signs, or neuroimaging tests of the extent to which the physical structure of the brain has been altered by perinatal hazards (Stewart et al. 1999). The assessment of older children at very low levels of function raises different issues. Nearly all such children have diffuse structural abnormalities of the brain, and the cognitive consequences are complex. The tests are highly predictive of later cognitive functioning at this extreme of the range. However, individual tests have rather little in common. Gould (1977), for example, found very little association between measures of social maturity, visuospatial skills not involving symbolic concepts, and level of language comprehension in an epidemiological study of young people with severe disability. The discrepancies probably reﬂect the true situation of the children, and underline the importance of understanding the range of strengths and weaknesses that they present.

is designed to be fair to children with sensory impairments — and therefore covers a narrower range of intellectual skills. Children with severe motor disability may need to be helped to a signalling system before their cognitive strengths and weaknesses can be fairly assessed, and reliance may have to be placed on tests (such as Raven’s Matrices) where the answer is a choice from a limited range of alternatives and can be indicated through many different kinds of motor response. Clumsy children may obtain low scores on tests where speed of reaction is being assessed, merely because their motor responses take longer, and it may be wise to discount such tests in making the overall cognitive assessment. Very shy children, or those with selective mutism, may need to write down their responses or whisper them without eye contact with the tester. Care must be taken to indicate the limits of conﬁdence that there may be in non-standard testing; but creative use of cognitive test materials has sometimes been able to show the presence of high ability in children whose sensory or motor impairments have previously prevented the abilities from being shown, and this rightly guides formulation of their special needs in education.

Observational approaches
As already indicated, observation of behaviour is always an important part of psychological testing. Observation can also be applied in many situations where testing is not feasible, and its reliability and validity need be no less. The most explicit schemes of observation provide an experimental control of the environment and give standard stimuli to evoke informative behaviour. In a clinic or laboratory setting, speciﬁc tasks are imposed on the child and deﬁned types of response are elicited. For example, Ainsworth’s Strange Situation Test (see O’Connor, Chapter 46) has been the foundation of attachment research. In clinics it is seldom appropriate for it to be used in its exact experimental form, but observations of children reacting to a contrived separation and reunion are used extensively to inform judgements about the nature of the children’s attachment to their parents. The Autism Diagnostic Observational Schedule (ADOS; Lord et al. 2000; see Lord & Bailey, Chapter 38) is a good example of an observational scheme that is based on speciﬁed operations by the examiner (for example, providing a variety of standard stimuli and social presses) and explicit descriptions of the behavioural responses that are to be made. It was originally introduced for research purposes, and its high interrater and test–retest reliability, and its ability to discriminate well between autistic people and people with different diagnoses, have led to its adoption in clinical practice. Kagan (1997) has reviewed an extensive series of studies based on the direct observation of young children’s behavioural reaction to the standardized presentation of unfamiliar stimuli. Four-month-old infants who show a low threshold for becoming distressed and motorically aroused to unfamiliar stimuli are more likely than others to become fearful and subdued during 95

Special testing situations
Every child needs individual consideration; the tests and observations to be used will need to reﬂect not only the presenting problems, but the effect that testing is having on the children, their developmental level and ability to understand test expectations, and their willingness to comply with them. The length and difﬁculty of tests need to be taken into account: if difﬁcult items are presented too early in the course of an assessment, or if children are asked to persist for too long at test items that are too hard for them, then they may become demotivated. The extent to which tests are giving a valid description of the individual needs always to be considered; the issues involved in doing so are described by Rutter & Yule (Chapter 7). The clinician is often confronted with situations where for one reason or another the standard approach to testing needs to be modiﬁed considerably. For example, sensory or motor impairments can have their own inﬂuence on cognitive tests. At the simplest, the professional making the assessment needs to check that children do indeed have the spectacles or hearing aids that they may need for adequate performance; and to be alert throughout the assessment for signs that a superﬁcially cognitive difﬁculty (for example, of detecting ﬁne differences between pictures) may be caused by a sensory impairment (in this instance, diminished visual acuity). Sometimes, more meaningful scores may be obtained by special procedures. For example, inability to follow spoken instructions may be bypassed by the choice of a test (such as Raven’s Progressive Matrices) where very little such instruction is needed, or by a test battery (such as the Leiter) that

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early childhood; whereas infants who show a high arousal threshold are more likely to become bold and sociable. Observed inhibition in this method has made predictions to later anxiety, even though only a small proportion of children maintain a consistently inhibited or uninhibited phenotype through their childhood (Kagan et al. 1998). Clinical application so far has been limited by the variability that individual children show over time on the measure. Several observational schemes for inattentive and overactive behaviours have been presented; they have been reviewed by Luk (1985). In general, they have made rather less use of careful control of what social presses are imposed by the examiner, but specify the expectations that are on the child (e.g. by observation during psychological testing). The schemes have mostly been used in research, e.g. to describe the alteration in spontaneous activities of children in classrooms (Schachar et al. 1986), playroom and testing situations (Luk et al. 1987), controlled settings with parents (Kalverboer 1971) and interview with a psychiatrist (Dienske et al. 1985). In these studies they discriminate well between children with ADHD and healthy controls, and predict to questionnaire and interview measures. They gain something in ‘ecological validity’ by being based on naturally occurring events, but correspondingly lose the clarity of interpretation that comes from experiment. Attempts to combine both sets of virtues have involved the careful description of a limited set of frequently occurring events (e.g. mother giving an instruction to child) so that the child’s reactions to those events can be clearly speciﬁed (Dunn & Kendrick 1980; Bates et al. 1985). Very large amounts of data are sometimes generated, so that analysis may become very complex. The techniques have therefore been limited to research applications, but the conclusions about process may well give good ideas to clinicians about what to look for; e.g. when interviewing and observing families, to note especially sequences in which the child has been asked to do something and has in fact done it, so as to record the consequence of compliance. Most of these clinical applications of observational techniques are based on ratings that take into account the function and purpose of the behaviour. These qualitative ratings can be very reliable, but usually require training of the raters to make them so. They are needed because molecular descriptions of acts are usually rather unilluminating without their context. It is not only the speed of an action that determines whether it is impulsive, but whether it is too rapid to allow appraisal of the situation; therefore it depends on the amount of uncertainty in what response should be made. It is not just whether a child points at an object that is important in his or her appraisal of it; it is also whether that pointing includes the social function of indicating it to somebody else. In some situations, however, systematic observation is trying to quantify a rather simple act. The frequency of tics may be important to note, so as to gauge the impact of a treatment; or the number of times a child strikes him- or herself may be an important dependent variable for understanding how different contingencies affect the self-injury. There is then a choice of 96

techniques: recording during a set interval how often the behaviour has happened, or sampling brief periods over a session to record whether or not it has occurred at each point. The decision will depend on the properties of the behaviour. If it ﬂuctuates considerably over time (as tics may) then the counting of events during one time period may be seriously unrepresentative, and short intervals scattered throughout a longer period may be substantially more reliable. If the behaviour is infrequent then a succession of very short samples may not elicit enough events for a reliable estimate.

Clinical applications of observational analysis
Clarifying rater and source effects
In clinical practice, observation is sometimes used as the gold standard when there is discrepancy between sources of information. For example, a parent may say that a child is well-behaved but cannot concentrate, while a teacher says that the same child is able to concentrate but chooses not to; so the clinician decides to go to the classroom to decide for him- or herself. The simple question of ‘who is correct?’ often underestimates the complexity of what the professional observer strives to do. In the ﬁrst place, the method has important limitations as well as strengths. It may be based on a very atypical period of observation; the observer may alter the behaviour unknowingly, and allowance needs to be made for this. In the second place, the observer is not only trying to establish who is right but the reasons for the discrepancy. It will probably be very useful for the observer to check with the real life rater whether they are giving different meanings to the same behaviour, or referring to different behaviours shown on different occasions by the same child. In the above example, both parent and teacher may be observing the same thing — a high level of off-task activity; whether it is construed as disability or choice may stem from the signiﬁcance attached to the observations. The raters’ accounts might be strongly coloured by their own personal circumstances or their relationship with the child. It may then be useful to explore what different actions would result from the theoretical expectations — how, for example, parents might provide incentives to test the idea that motivation would alter performance; or how the teacher might test the idea of a disability by presenting materials to be learned in a simpliﬁed and clearer way. The third and most fundamental reason for regarding ‘who is correct?’ as an oversimpliﬁed question is that different accounts by different observers can reﬂect important situational inﬂuences. The reasons underlying situational differences in behaviour can be crucial clues to the nature of a child’s problems. For example, a child may be referred because of a massive recent deterioration in school performance; no emotional problems are apparent, and the ﬁrst working hypothesis, of cognitive impairment, is provisionally disconﬁrmed by good performance at

PSYCHOLOGICAL TESTING AND OBSERVATION

the clinic on tests of intellectual aptitude and executive dysfunction. This does not mean that there is ‘no real problem’. The next set of hypotheses should then relate to the reasons for the discrepancy: is it associated with the kind of test that is performed, the place it is carried out in, or the contingencies attending the way it is carried out? In one such example, the next step was to arrange for academic tasks (solving mathematics problems) and an attentional task (deleting the ‘e’s from a prose passage) to be performed in three settings: the clinic; the regular classroom; and the same classroom during a visit from the clinic psychologist. Both tasks were performed much less well in the classroom than the clinic, but the performance at school was as good as in the clinic when the psychologist was seen to be present. The discrepancy between school and clinic appeared not to lie in the precise nature of the tests used in the different settings, nor in the generic qualities of the settings, but in the degree to which the child received the attention of an adult. The provisional recommendation was therefore for enhanced monitoring in the classroom, and indeed intermittent individual attention from an aide quickly led to a resumption of good academic progress. The ﬁnding also led to another set of hypotheses about why performance should have been selectively affected — whether adult attention was providing monitoring or safety or warmth of interest — and therefore to reinvestigation of psychosocial stresses (in this case, a neighbourhood feud had spilled into the school setting). The general point is that the interactions between child traits and environments can often be understood from the effects of contrasting environmental circumstances. A functional analysis of a behaviour problem — which is often the purpose of making observations in natural settings — requires speciﬁcation of the antecedents and consequences of the behaviour in the environment (see Herbert, Chapter 53). It follows that the observations carried out at a school or home visit should not only focus on the child but also on the qualities of the environment. At school, one should note not only the child’s scholastic behaviour and relationships with peers and teacher but also the organization of the classroom. In elementary class, can the child see a record of their achievement (such as a points system), and are examples of their good work on display? Do they know the activity to engage in, and are they in a position where their activity can readily be monitored by the teacher? Is the atmosphere of class and school one of safety and constructive activity? At home, is there a cognitively stimulating environment with toys or books? Are there rules for conduct and can caregivers tell what children are doing? What is the affective tone in exchanges between parents and children and between siblings? Naturalistic observations can be distorted by the accidents of what salient events happen to take place during the visit, and it can be hard to be sure of the sequence of events in an escalating situation: did the child protest at an instruction about behaviour or was the instruction in response to the beginning of rebellion? It is therefore helpful, when possible, to give particular notice to how the child reacts to contrived or independent events. For

example, transitions between activities in the classroom are a high-risk point for disruptive behaviour, so in investigating this problem the teacher can be asked to introduce an activity change. Similarly, at home, the parent would be asked to introduce a press for an unwelcome activity (such as ‘tidy up your toys now’) so that the nature and consequences of compliance can be seen. As ever, it is necessary to check whether the sequence of behaviours that has been observed has been typical of what would normally occur in that situation. Observational analyses of some clinical problems extend to a quasi-experimental use of speciﬁed procedures. A closely speciﬁed challenge can be inserted into a period of naturalistic observation. For example, intellectually impaired children who show challenging behaviours may have learned them in diverse ways (see Volkmar & Dykens, Chapter 41). Some may have learned to continue injuring themselves because the behaviour has been rewarded by the attention of others, some because self-injury serves to help them escape from unwelcome tasks, and some because the self-stimulation involved is inherently rewarding to them. It may not be obvious which of these apply in a particular situation, and the consequences matter a good deal. If a behavioural programme involves withdrawing contingent attention through a time-out procedure (see Herbert, Chapter 53) and if the true rewarder in the situation is escaping from school work, then the time-out may be a strong reward and perpetuate the problem. Accordingly, it is possible to introduce escape or contingent attention as consequences of self-injury during an extended period of observation and examine the effects (Sturmey et al. 1988). The method is laborious because of the need for repetition of observations, and it is not always possible to be certain that these ‘analogue observations’ are representative of real life; but it can be a helpful guide to practice in difﬁcult and refractory situations.

Clarifying discrepancies between test scores
Discrepancies between performance scores on tests may be illuminating in clarifying the nature of a problem — for instance, in detecting speciﬁc learning disorders. However, interpretation is often uncertain because of the imperfect reliability in test scores and the corresponding uncertainties about how far apparent differences are clinically meaningful. Observation is then a useful means of helping to determine the validity of test scores. For example, it may be apparent that a poor score on one subtest was associated with an uninterested and uncooperative attitude towards it. The tester may then do much more than usual by way of coaxing a good performance, or repeating it on another occasion — with, of course, the note that it was obtained in nonstandard ways; and may interpret the difference as secondary to motivational factors. Observation may suggest new functions to be tested. For example, a boy was referred for assessment some years after an episode of severe encephalitis. Even after apparent neurological recovery, he was quite unable to cope with the classwork in his academically orientated school. Extensive testing of intellectual 97

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function showed no deﬁcit: although premorbid testing was not available, he tested in the superior or very superior range on all tests given. The possibility of a breakdown in his conﬁdence was entertained, but incidental observation and the description of his family both emphasized how muddled and disorganized he could be in simple everyday tasks, such as getting his outdoor clothes to go home — even though all tests relating to dyspraxia, attention and memory had shown better than average scores. He was therefore observed while carrying out several simple tasks simultaneously; and there was a marked disability in doing this that was not present when he was asked to carry them out successively. It appeared that he had an executive type of dysfunction in which the allocation of effort to tasks was uncontrolled. Statistical signiﬁcance on this would have been hard to obtain, in that it would have required larger number of observations than could be obtained feasibly. Accordingly, the testing of the hypothesis was by the response to intervention. The result was in a sense encouraging, because careful breaking down of academic tasks into components helped performance of them substantially. But the disability remained, the burden of the intervention on teachers in a mainstream school was unsustainable, and specialist education was sought.

Examining relationships between functions
Systematic observation may assist in disentangling the relationships between different psychological processes, especially when they are hard to detect by rating scales and interviews. For example, an adolescent with Tourette disorder was referred because of recurrent transient episodes of great distress, but found it hard to describe the changes of his mood and the reasons for them, and the relationship between them and his tics was correspondingly difﬁcult to formulate. Psychophysiological recordings of skin conductance and heart rate were carried out simultaneously with event recording of tics, and showed consistent marked increases immediately after bouts of tics — interpreted (in discussion with him) as indicating increased emotionality (associated with a distressed feeling that he had failed to control them and would be in trouble). This is not a usual pattern; more commonly, in our experience, children report a sense of tension as they strive to suppress the tics and even a sense of relief after a bout is ﬁnished. For him, it suggested an approach to treatment in which he practised coping skills while watching videos of himself during tics and was praised by parents for his courage in ignoring adverse comments by others. Although the tics continued a poorly controlled and ﬂuctuating course, he described himself as less distressed and better able to cope with perceived teasing.

their own controls. Observation is particularly helpful when rating scales do not give the ﬁneness of discrimination that is sometimes required. For example, rating scales made by teachers and parents for a boy of 6 years who had started on stimulant medication indicated that he was quieter and possibly more withdrawn in social situations. The question therefore arose of whether this was an adverse effect or an acceptable part of the package of drug action. It was possible that the behavioural descriptions described a more clinging and dependent style of interaction, or a lack of spontaneous interactions. Attachment behaviour was therefore observed by ratings during separation and reunion, analogous to the Strange Situation Test, and peer behaviour in a playroom situation with neighbourhood friends; both were recorded on and off medication by a clinical student who was blind to the treatment condition. Attachment measures did not show a change. Observations of approaches to peers and shared play with peers indicated that they were actually higher during medication. The description of quietness was conﬁrmed, but it related to a diminution of loudness of speech and disinhibited behaviour, rather than to a lack of spontaneity. The conclusion was that the social change was unlikely to be harmful and did not constitute an indication for stopping medication. Conversely, clinical observation that a medicated child is socially unspontaneous, or perseverative in attention, may be crucial in detecting an adverse effect that is not apparent in everyday monitoring at school, where perseverativeness may be confused with enhanced attention.

Inferences from tests and observations
In the course of this chapter we have described tests and observational methods that can provide incremental knowledge by which a clinician can conclude that working hypotheses about the nature of children’s problems are supported or rejected. This is an approach, not a diagnostic protocol. The way in which a clinician should organize tests to come to evidence-based decisions is guided by judgement and a clear sense of the questions that need to be answered. In other areas of medicine, there has been a considerable body of research on how clinicians gather and evaluate information. This knowledge base has not been applied systematically to child mental health issues, so this section brieﬂy mentions some of the cognitive heuristics that are useful to bear in mind. One common cognitive heuristic is representativeness. By this is meant that incoming information is processed primarily on the similarity it has with a particular class of information. For example, the clinician seeks to place incoming data (such as symptoms and signs) into a limited number of classes (syndromes). Psychiatrists and clinical psychologists are trained to detect symptoms that could be part of a prototype (Genero & Cantor 1987). A bias can arise if symptom variance is underestimated. Clinicians may overestimate the extent to which the symptoms agree with the prototype or syndrome, seeking conﬁrmatory instances and not disproof. For training purposes, the

Description of outcome
Observed behaviour is often less vulnerable than cognitive tests to repeated administration. A lack of standardization may not be a serious problem for this purpose, because children act as 98

PSYCHOLOGICAL TESTING AND OBSERVATION

use of distinctive prototypes is a good starting point, but needs to be varied to show the full range of cases involved in the syndrome (Horowitz et al. 1979). The clinician then learns to make sure that the assessment is comprehensive, and has not stopped at the recognition of a prototype but has gone on to understand what is out of keeping with the prototype and what further problems are present. Once a ﬁrst impression has been formed, it can be hard to change it. ‘Anchoring’ refers to the potential problem that perceptions can become rigid as a result of the initial impression that one has made of a client. Friedlander & Stockman (1983) found that pathology that appeared late in a series of interviews had much less impact on diagnostic decisions than when it appeared early in the series. In short, we need to stay alert to new information that should force us to revise and review the case. Prior conceptions have been shown to inﬂuence the interpretation which diagnosticians place on test results. An illusory association is constructed between a test result and a diagnosis, which can be hard to change. A study that neatly illustrates the problem of erroneous diagnostic observation was conducted over 30 years ago by Chapman & Chapman (1967). Novices tried to match responses on a projective test (Draw-a-Person) with a set of contrived symptoms. In one sense, they were successful, in that they produced the same associations between responses and symptoms as the experts, but in the experimental design the symptoms had been contrived so as to have no actual association with the responses at all. Apparent reliability between raters was achieved, but the validity of their ratings was zero. Similarly, Golding & Rorer (1972) repeatedly presented to subjects an individual Rorschach response and asked them to predict what symptom was associated with the response. They were given immediate feedback on their decision and informed of the actual symptoms of the patient — which of course did not necessarily correspond. Despite this there persisted a strong illusion of an association between the Rorschach response and the actual symptoms of the patient. The remedy for the clinician is to remain open to the empirical reality of the case in spite of the temptations to theoretical overconﬁdence. Fischoff & Lichtenstein (1978) discussed how prediction of events was inﬂuenced by the knowledge that the event had occurred. This effect has been conﬁrmed by Arkes et al. (1981). They showed that trained physicians, when required to diagnose one of four possible illnesses, were just as susceptible to hindsight bias as had been found by Fischoff when using students. Those who knew the actual diagnosis overestimated the likelihood that they would have been able to predict the correct diagnosis had they been asked to do so beforehand. Even experienced clinicians have also been shown to suffer from this bias when dealing with patients who later commit suicide (Goggin & Range 1985). Systematic evaluation of one’s practice is an essential way of counteracting misleading subjective impressions. Another important consideration in the interpretation of tests

is the application of understanding about base rates (see Rutter & Yule, Chapter 7). The signiﬁcance that clinicians attach to an abnormal test result can be inﬂuenced by a variety of factors, one being the frequency with which they encounter it. Most clinicians work on the basis of the frequency with which they see the combination of a clinical problem and an abnormal test result, rather than the relative frequencies of an abnormal test in the presence or absence of the problem. For example, if clinicians are asked to judge the likelihood of pneumonia from an X-ray, a preliminary diagnosis can be given. When they are further provided with information on the sensitivity and speciﬁcity of the test and the prevalence of the disease and asked to estimate the predictive value (positive and negative), the prevalence tends to be ignored in their estimations (Casscells et al. 1978). Clinicians generally use frequency as a major principle guiding retrieval of information, so it is important that they school themselves to base their judgements about the signiﬁcance of a test on the relative frequency. Another important cognitive heuristic is comprehensiveness. This is intended to overcome one of the common errors in judgement — to focus too narrowly on one aspect of a complex case. Problem behaviour does not come packed in neat parcels. Comorbidity, correlated dimensions, and associated features have become much better recognized over the last 15 years and are dealt with by Fombonne (see Chapter 4), Verhulst & Van der Ende (see Chapter 5), Rutter (see Chapter 19) and Taylor & Rutter (see Chapter 1). This development implies that the assessment procedure must be sufﬁciently comprehensive in order to detect correlated dimensional problems, at the least, and to be aware that exceptions can occur that require probing for noncorrelated conditions. For example, the clinician can use a standardized diagnostic interview that covers at least the most common presenting problems. Comprehensive problem deﬁnition implies that the clinical problem as presented needs to be assessed at a variety of levels, including clinical syndrome; severity of impairment; somatic condition; personality; cognitive performance; social skills; and emotional processing (to name but a few). The problem then arises of how to square comprehensiveness with the costs of assessment? It is obvious that choices will have to be made. One policy (not recommended here) is to assess only that which is necessary for a particular treatment. One conﬁrms a hypothesis, but rejects none of the alternatives and misses fundamental explanatory factors. Part of this issue can be solved by using ‘screeners’ for covering a wide range of pathology and psychological dysfunctioning. The cognitive heuristics discussed above clearly spell out the message that empirical support for one’s hunches is required. They also have a second message: searching only to conﬁrm a hunch exposes one to ﬁnding only what one expects. For most of the possible biases mentioned above, the remedy is the adoption of an investigative and hypothesis-testing approach, with a critical willingness to revise hypotheses about the nature of a problem that do not ﬁt the data (see Rutter & Yule, Chapter 7). 99

CHAPTER 6

Conclusions
In this chapter we have attempted to indicate the use of tests, tasks and observation in the diagnostic process. Further, we have touched on the cognitive biases which operate in the interpretation of the psychological assessment. We note that one of the major differences between classical psychometric tests and cognitive tasks is that the latter are theory driven. From the neuropsychological perspective, cognitive tests are linked to complex brain networks and not speciﬁc brain loci. While cognitive heuristics have their dangers, when conditions are met and they are applied, these heuristics can be effective tools in clinical work. It seems likely that the future will bring an increase in their clinical use, especially as neurodevelopmental disorders are seen to depend strongly upon alterations of cognitive processing. However, their very strength can lead to their application in inappropriate conditions. It is this last point where the expert can excel the novice in detecting whether the cognitive heuristics are producing answers that are acceptable. This in turn is determined by the theoretical position, model or hypotheses being generated. Tests and observations are simply means to assess whether the assumptions and hypotheses about a case are being met. This requires insight into when or when not to use a test or task for a particular purpose and under which state they may or may not be applied. Consequently, child psychiatrist and psychologist need to work hand in hand in developing the rules and criteria for which tests can be applied to test speciﬁc aims. Standardized batteries depend for their application not on a slavish philosophy of assessment but on a critical deﬁnition of purpose, conditions, intervening variables and criteria. This places clinical diagnostics into the realm where it belongs: of critical cognitive processing.

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102

Applied Scientiﬁc Thinking in Clinical Assessment
Michael Rutter and William Yule

Concepts of applied science
Both clinical psychology and clinical psychiatry (together with the rest of medicine) aspire to being applied sciences (Shapiro 1957; Kennedy & Llewelyn 2001; Rutter 1975; Yule 1989; see also Taylor & Rutter, Chapter 1). This does not mean that clinical practice only involves the use of scientiﬁc methods and scientiﬁc knowledge; interpersonal skills, and social sensitivity, are also crucially important. Intuition and experience constitute key elements in assessment, as well as in the planning and undertaking of treatment. Moreover, there are many points during the clinical process when either ethical considerations or value judgements have to be made. The current debate on whether tricyclic medication or selective serotonin uptake inhibitors should be the drug of ﬁrst choice in treating depression in adults well illustrates the considerations that have to go into the interpretation of empirical ﬁndings (Barbui & Hotopf 2001; Thompson 2001). Findings on efﬁcacy are fundamental but the choice of drug needs to be inﬂuenced also by side-effects, patient acceptability, and cost. The concept of an applied science does not mean that practice has to be based just on ‘facts’. It is a common misunderstanding that science is an enterprise deﬁned by its production of factual knowledge. Rather, science constitutes a way of thinking and a set of approaches that is concerned with solving problems — with formulating hypotheses, putting these together in an integrated and cohesive notion of how nature might operate (a theory) and in ﬁnding ways of putting those ideas to the test. Scientiﬁc study does provide immensely useful ﬁndings but knowledge is always partial. It has been said that of the ‘facts’ learned during training, a third will prove to be true, a third will subsequently be shown to be wrong, and a further third will be found to be irrelevant. More importantly, scientiﬁc advances mean that during the course of a professional lifetime, clinical practice will change, and will need to change, as a result of the understanding and clinical opportunities that derive from research (Rutter 1998, 1999, 2000). First and foremost, clinical training has to involve the acquisition of a large amount of factual knowledge because of the basic requirement that clinicians must function in ways that are both safe and effective. However, there are two other needs that are almost as important. First, training involves a considerable focus on experimental psychology, neurophysiology, neuroscience and biology. In addition, psychiatric training includes

systematic learning about pharmacology, neurology and internal medicine as they impinge on the workings of the brain and the functioning of the mind. This is not primarily because such knowledge is of immediate clinical importance: indeed, rather little is. Rather, it is because it provides a rich source of ideas about the ways in which nature operates and which might apply to clinical problems. It is likely, if not actually certain, that much of this knowledge will lead to clinical advances during the course of people’s working years. Secondly, in the course of their clinical lifetime, people will need to practise on the basis of new knowledge derived from research since they completed their formal training. They will have to cope with a ﬂood of claims and counterclaims and an essential part of training is to enable people to understand enough about research for them to evaluate research evidence and its clinical implications — not just on the basis of the hyperbole of the evangelists, but on the basis of their own assessment of the quality of the evidence and of how it might, or should, alter what they do clinically. This applies, not just to psychologists and psychiatrists, but to nurses, social workers and psychotherapists; indeed to all clinicians. These broad issues pervade the whole of this book. In this chapter, we concentrate on the narrower issue of how the concept of clinical psychology and psychiatry as applied sciences impinges on clinical assessment as applied to children and adolescents. We argue that the key deﬁning feature is the use of experimental concepts and stratagems in the planning and undertaking of clinical assessment. The starting point has to be some type of clinical question. That is so whether the assessment is designed to lead to diagnosis, to the design of treatments, or to their evaluation (Mash & Terdal 1981). Psychiatrists are irritated by referrals that simply say, ‘This is John Brown. Please see and advise.’ Psychologists, equally, take exception to requests that just state that the referral is for ‘IQ testing’ or ‘tests of language’. That is not to say that there is not a place for screening assessments of various kinds. Some form of medical screening is desirable in all clinical referrals, and some medical investigations should be undertaken as a routine (see Bailey, Chapter 10). For example, assessments of hearing and vision, and screening for chromosomal abnormalities, should be part of the routine in the case of all children referred for serious developmental disorders. In the same way, the high frequency with which psychopathology is associated with scholastic retardation and/or cognitive deﬁcits means that screening for them should be a routine matter in clinical assessment. 103

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This may be carried out through obtaining information from schools, or clinics may choose to undertake some form of screening testing. Nevertheless, a clinical question should constitute the starting point for most referrals for clinical assessment — either psychological or psychiatric. An applied scientiﬁc approach, we suggest, involves several key elements. First, there is a need to identify the key clinical issues. Those may be implicit or explicit in the clinical question posed but the starting point, nevertheless, needs to be a reconsideration and reconceptualization of those clinical issues. The second, and most basic step, constitutes the translation of the clinical issues into testable questions. These necessarily involve a consideration of alternative hypotheses and a decision on how one hypothesis may be pitted against another (Rutter et al., 2001). Naturally, that requires a knowledge of the range of possible stratagems that may be employed for this purpose. This is the essence of experimental thinking. For this testing to be undertaken satisfactorily, the clinician needs to consider how to ensure that the testing will be based on high-quality data that are relevant to this individual and which have the appropriate meaning in relation to the clinical issues being considered. Some of the key technical issues that concern psychometric testing, the development of diagnostic interviews, the construction of questionnaires, and the use of medical testing and investigations, are considered in other chapters and will not be discussed further here (see Sergeant & Taylor, Chapter 6; Angold, Chapter 3; Verhulst & Van der Ende, Chapter 5; Bailey, Chapter 10). The main principles apply to clinical work with all age groups but the assessment of children involves, in addition, the need to adopt a developmental perspective. This requires a good understanding of developmental psychology (Rutter & Rutter 1993) and of developmental psychopathology (Rutter & Sroufe 2000). Fombonne (see Chapter 4) discusses how all of these need to be put together for case identiﬁcation and Rutter & Taylor (see Chapter 2) consider how this ﬁts into an overall approach to clinical assessment and diagnostic formulations. Here we focus more narrowly on the special considerations with respect to data quality as they apply to experimental or applied scientiﬁc approaches in clinical evaluation. Hypothesis testing almost always requires some form of quantiﬁcation. That is because the essence of an experiment lies in the manipulation of one variable, under controlled conditions, to determine if, in a systematic and regular fashion (as shown across a range of varying conditions) this causes another variable to ‘move’. This can only be carried out if there is a way of determining that the initial ‘manipulation’ truly involves a substantial change in the ﬁrst variable and if the predicted change in the second variable is robust to the extent that it exceeds the variations that may be expected by chance. Occasionally, this may involve some qualitative categorical alteration, rather than a quantiﬁed dimensional change but, either way, quantiﬁcation (of the presence/absence variety or of a point on a continuum variety) has occurred. 104

In both psychology and psychiatry, there has been much debate in recent years with respect to the merits and demerits of quantitative and qualitative approaches (Rutter, 2001). This is a false dichotomy and the polarization between the two research approaches has been unhelpful. Qualitative researchers have rightly been critical of the mindless application of quantitative methods before determination of the meaning of the phenomena to be assessed. Some form of qualitative analysis will almost always need to proceed the application of quantitative methods (see Rutter & Nikapota, Chapter 16, for a consideration of this issue in relation to social group comparisons). On the other hand, hypothesis testing requires quantitative research. The main reason that this is so derives from epidemiological considerations. First, because almost all psychopathology is multifactorial in origin, even in relation to a single case, it is crucial to be able to test whether a particular effect is a consequence of one factor rather than another (see below). For obvious reasons, that can only be done if there is adequate quantitative measurement of both the risk factors and the psychopathology. Secondly, all human groups (whether they involve members of the general population or patient samples) are very heterogeneous. For good reason, qualitative studies (which tend to be quite intensive) need to use relatively small samples. That is perfectly acceptable for the purpose of gaining a better understanding of what is happening, such understanding being used to generate testable hypotheses. On the other hand, it is not acceptable for testing hypotheses, because small heterogeneous samples inevitably mean uncertainty as to whether the ﬁndings refer to the psychopathological deﬁning feature of the sample or to some other source of heterogeneity. Most research questions require a combination of qualitative and quantitative methods and the same applies to the assessment of individual cases. They have a different mix of strengths and limitations and both approaches are required. In considering clinical assessment, we turn ﬁrst to diagnosis. Apart from the applied scientiﬁc methods we advocate, four other approaches to diagnosis are possible and we need to consider whether their use now means that experimental methods are no longer needed in diagnosis, even if they are needed in other aspects of clinical work. First, there are the algorithmic approaches based on standardized diagnostic instruments. Thus, both DSM-IV (American Psychiatric Association 1994) and the research version of ICD-10 (World Health Organization 1993) have formulae that generate diagnoses once the speciﬁed set of criteria have been met. Moreover, computer programs have been written to enable people to do this entirely through computer software without the need for the manual counting of numbers of particular sorts of symptoms, duration and other inclusionary and exclusionary speciﬁcations. Undoubtedly, this has been a most useful advance but two basic problems remain. There is the key question of the validity of the data that are read into the algorithm. The agreement among different instruments and among different algorithms has been found to be only moderate (Volkmar et al. 1992; Farmer et al. 1993; McGufﬁn & Farmer, in press ). As we discuss

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below, experimental approaches can be helpful in testing the validity of the basic data. Very few psychiatric diagnoses have an unambiguous external validating criterion and, hence, it is most unlikely that the precise algorithmic criteria will ultimately prove to be fully valid (see Taylor & Rutter, Chapter 1). Secondly, diagnoses may be determined by pattern recognition. The late Jack Tizard, a most important mentor for both of us, often remarked that he saw this approach as the one that was most different between medicine and clinical psychology. He expressed amazement at the surprising ability of good medics to recognize rare and unusual syndromes that they had seen only once before some 30 years ago or indeed may never have seen, relying only on textbook descriptions. It is certainly true that this constitutes a key part of medical training and, at its very best, works well. Moreover, this human skill is one in which the top level minds can often defeat supercomputers despite the immensely greater capacity of the computer to test vast numbers of possibilities very swiftly. It was this pattern recognition skill that enabled chess masters to defeat supercomputers at chess for a long time. The skill, it is true, does not involve experimental thinking at all in the ordinary sense. However, it would be a grave error to think that this is how most medical diagnoses are made (let alone psychiatric ones). Rather, diagnosis consists of putting together very complex sets of data, weighting different elements appropriately, and considering possible interactions among risk and protective factors. There is no question that computers are usually very considerably better at this than are human minds. That is why computer diagnoses have come to have an increasingly important role in medical diagnoses. For them to work really satisfactorily, of course, there must be some external diagnostic criterion and, when that comes in the ﬁeld of psychopathology, computers are likely to play an increasing part there as well. On the other hand, as we discuss below, ending up with the ‘correct’ diagnosis is not all that clinical assessment is about and hypothesis-testing approaches are likely to continue to be important for a long time to come. A third approach is provided by quantiﬁed diagnostic methods that are based on the well-justiﬁed assumption that many disorders (in medicine as a whole and not just in psychopathology) represent extremes on some continuously distributed liability dimension. Thus, just as hypertension may be diagnosed on the basis of a blood pressure above a certain predetermined and speciﬁed level, so mental retardation may be diagnosed by an IQ score below some particular criterion point. Similarly, depressive disorder may be diagnosed by a depression symptom score above a certain threshold on some standardized measure. Unquestionably, this approach has considerable utility but very few diagnoses can be made on the basis of a single dimension. It is usual to need to consider patterns of symptoms and to assess functional consequences. At a more basic level, however, it is essential to determine whether the test score (whatever the test may be) has the meaning that is required for its use in diagnosis. Just as it is necessary to check whether a high blood pressure may reﬂect excessive alcohol consumption, smoking, exercise or anxiety, so it is crucial to test whether a low IQ score reﬂects a

limited cognitive capacity rather than a lack of engagement in the task, negativism, the distorting effect of psychopathology or situational features. That is where experimental thinking needs to come in. Finally, diagnoses may rest on some qualitative abnormality that is a necessary requirement for the diagnosis, even though it may not be a sufﬁcient one. There are examples among mental disorders where a particular abnormality is both a necessary and sufﬁcient feature. For example, this applies to chromosome abnormalities (as with Down syndrome) and with other entirely genetic disorders (such as the fragile X anomaly or Huntington disease). However, these account for a tiny proportion of mental disorders. The situation is quite different with multifactorial disorders. Nevertheless, even with them, it may possibly turn out that one or more genetic mutations are a necessary basis for the diagnosis, even though they are not a sufﬁcient one (because the disorder requires the operation of other genetic or environmental risk factors). Certainly, molecular genetics has the potential to deliver diagnostic tests of this kind (see McGufﬁn & Rutter, Chapter 12) but it is most uncertain whether genetic factors will operate in this way (as a necessary risk factor) for most forms of psychopathology. Also, it needs to be appreciated that many diagnostic tests in internal medicine involve a crucial experimental element. Most diagnoses are based on an abnormal pathophysiology that relates to function, rather than to a ﬁxed feature that is independent of circumstances. Thus, the glucose tolerance test for diabetes, the exercise tolerance test for cardiac function, the various sensitivity tests for allergies and tests of respiratory function, all involve determining changes of some kind in response to a particular stimulus, but not to other stimuli. As we discuss below, this is similarly true of most psychological tests. In short, an experimental way of thinking is likely to continue to have a central role in clinical assessment for many years to come. Its operation is central to the whole of biology and medicine and not something that is peculiar to mental disorders or psychopathology. Moreover, it is a need that applies to both clinical psychology and clinical psychiatry. It was for that reason that the authorship of this chapter combines disciplines. In the remainder of this chapter, we consider various different applications of applied scientiﬁc thinking in clinical assessment. The examples we use span both psychometric testing and psychiatric diagnostic methods because we wish to emphasize the generality of the application of the concepts we discuss. However, we have deliberately chosen more examples from psychology than psychiatry because, quite mistakenly, it is often assumed that, with well-established psychological tests, experimental thinking is not needed. Nothing could be further from the reality. It should be added that the current trend to encourage the use of well-designed assessment and treatment protocols in order to ensure high standards in service delivery will not obviate the need for an applied scientiﬁc approach. There is much to be said for the use of standardized approaches but, as Kanner (1958) emphasized years ago, the problems that children present at the clinic do not adhere to textbook descriptions. The systematic standardized protocols provide an excellent starting point, but 105

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clinicians need to appreciate the extent and importance of individual differences. This will often require the undertaking of individually tailored scientiﬁcally based assessments of the kind we describe here.

Obtaining valid psychometric test scores
Psychological tests vary considerably in the extent to which standardization data on appropriate populations have shown them to have adequately high reliability and validity. Other things being equal, a clinician will want to use instruments for which there is the best data demonstrating high reliability and validity. However, a differentiation needs to be made between a reliable and valid instrument and a reliable and valid assessment (Berger & Yule 1972). The latter concerns the qualities of the testing of a particular child under particular circumstances. Although written 30 years ago, Berger & Yule’s (1972) suggestions with respect to the testing of young disabled children with a possible language disorder are relevant. They argued that motivation is important in all testing and the tests constructed for use with children need to incorporate items that will arouse and maintain their interest. This is particularly the case with disabled children who may have experienced frequent failure and may therefore be unwilling to participate in, and persist with, items that they perceive as difﬁcult. The clinician may choose to deviate somewhat from the prescribed order of testing procedures, and to intersperse simpler items among those likely to tax the child. It is usually wise to begin testing at a point much below the level at which a child is thought to be capable in order to provide the child with sufﬁcient successes to encourage him or her to attempt more difﬁcult tasks. Clark & Rutter (1979) showed that this was particularly important with some autistic children who tended to move into a stereotyped pattern of responses if they encountered a series of items that they could not deal with. Also, if the child appears to enjoy a particular task and is unwilling to attempt others, it is often a good idea to allow the child to work at what they like on condition that they attempt other tasks later. Similarly, it may, in some circumstances, be appropriate to allow the child to respond in a non-standardized way that provides the same information. Thus, Clark & Rutter (1979) described an example of a ‘negativistic’ child who became amenable to testing when allowed to say what the answer was, rather than to point to the correct solution. Board forms of Raven’s Coloured Progressive Matrices (Raven et al. 1990) have also been devised to allow disabled children to demonstrate their choice by picking up the piece that provides the correct answer, rather than to use pointing (which some autistic individuals do not do well). Comparable adaptations of tests have also been devised for children with severe impairments of hearing or vision (see Hindley & van Gent, Chapter 50). Sometimes, it is appropriate for parents to be present during the assessment in order to allow the child to be more at ease and also to help as a translator of instructions and responses. This is a two-edged sword, however, and it is most important that par106

ents appreciate the importance of allowing the tester to obtain the child’s response without parental help. Certain items on cognitive tests require the child to complete the task correctly within prescribed time limits, and some give bonus points for rapid solutions. Particular care needs to be exercised when using these timed items with disabled children. Those with motor coordination problems, or those who are highly distractable, are most likely to be penalized with timed tests. Special considerations also apply to the testing of children who lack speech, or whose understanding of speech is limited. It is essential to differentiate between items failed because the child could not perform the task and items ‘failed’ because the child did not know what task it was they were supposed to perform. When this is in doubt, instructions should be given in some form (such as mime or demonstration) that avoids the use of spoken language. These principles played a major part in Stutsman’s (1948) development of the Merrill–Palmer scales many years ago. It was appreciated that young and disabled children often get tired, distracted or oppositional. That is why the test was devised to take account of circumstances in which items are refused or have to be omitted for some reason. Standardization of the test is now out of date and lacks qualities that are now regarded as essential. Nevertheless, the approach has many advantages and it may well be that modern day test construction pays inadequate attention to the realities of young children’s engagement and interest and lacks adequate steps for dealing with items refused. Clinicians need to be very sensitive to the fact that the more that they depart from standard test administration procedures, the more cautious they must be in the interpretation of test ﬁndings. Nevertheless, for reasons discussed below, adequate psychometric testing requires determination of the tasks that the child can perform as well as those leading to failure. The meaning of the test score is crucially dependent on this mixture of passes and failures and on the ability to determine the features that go along with each. When we started in clinical practice, some four decades ago, it was very common for psychologists to report that disabled children (especially those with autism) were ‘untestable’. As Berger & Yule (1972) commented, this is simply a statement that the psychologist has failed in his or her endeavour and it says nothing about the child except that he or she was difﬁcult to test. The challenge with such difﬁcult children is to use the reports of others, and the psychologist’s own observations, to think of ways in which the child may be induced to be engaged in the relevant tasks and to persist at them. It will readily be appreciated that ﬁnding how to do this will provide invaluable information on the features that affect the child’s behaviour as well as bringing about a means for obtaining a valid test assessment. One particular concern that occupies a major place in the literature on cognitive testing is the desire to develop and use culture-free or culture-fair psychological tests. There are both good and bad aspects of this concern. The positive side is that it is appropriate, indeed essential, to use forms of assessment that are not biased because of an individual’s particular experiences

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or lack of experiences — in exactly the same way that it is essential to use tests that are not biased by a person’s disabilities in vision, hearing or language. The negative side is that the concept seems to presuppose that it would be possible to devise a pure measure of innate cognitive capacity that is not open to the inﬂuence of experience. Theoretically, this is nonsense. Intelligence, just like other psychological qualities, is multifactorially determined and its development will be inﬂuenced by experiences as well as by genetic background. The concept is also misleading because, in so far as constitutional features are strongly operative, they set a reaction range and not a particular level of performance. Also, psychological tests are measures of performance and not of some hypothesized internal quality as it might be if the child’s experiences had been different. That does not mean that the issue of the effects of culture on test performance can be ignored: on the contrary. However, what it does mean is that it may be more appropriate to examine the positive effects of culture directly rather than try to devise tests that are free of them. The example of the Brazilian street vendors mentioned by Rutter & Nikapota (see Chapter 16) is illuminating. What was important in studying their mathematical skills was to devise ways of testing that were relevant to the particular circumstances in which they had to function in real life. A highly unusual clinical example was provided by a young man seen by one of us some 40 years ago. He originated from an isolated rural community in one of the smaller Caribbean islands and on coming to London encountered a form of life that was entirely different to anything he had ever experienced before. He lacked family ties and emotionally he rather ‘fell apart’, ultimately being admitted to hospital with what seemed a psychoticlike disorder. Formal psychological testing gave rise to a score in the mentally retarded range but this seemed out of keeping with his behaviour as observed on the ward. It was appreciated that he was virtually unschooled and that the test tasks might well have a quite different meaning for him than for other people in the standardization sample. He was a ﬁsherman by trade and, after some discussion with staff in the occupational therapy department, it was decided to give him the run of the materials in that department with a request that he construct the type of ﬁshing basket that he used in the Caribbean. The result was spectacular. To begin with, he came into his own emotionally and became highly engaged in the task. From our point of view, we observed with awe his skill in using an unfamiliar set of materials to make a complicated basket involving a sleeve that went into its interior. The rationale was that the ﬁsh swam down this sleeve that had a very large opening and swam out of the narrower end into the middle of the basket and was thereby caught, because it was much more difﬁcult for the ﬁsh to ﬁnd the entrance to the interior end of the sleeve. It rapidly became obvious that, although this task could not give rise to a cognitive ‘score’, he clearly was not mentally retarded. The circumstance was a highly unusual one, but the general principle has a wider application. That is, as with the Brazilian street vendors, it may be worthwhile to make positive use of the cultural variations (rather than avoid them) and to seek ways of tapping skills,

rather than ﬁnding failures, although, as always, it is the pattern of the two that is most informative. Two other issues warrant mention. First, it is necessary to differentiate between the use of psychological assessment to consider performance in a person from a quite different background who is going to return to that background, and the rather different issues with respect to someone from a very different culture who is going to need to live in an industrialized country with all the usual expectations about schooling, jobs and the like. The former case might, for example, be relevant with respect to a clinical referral from abroad in relation to a child living in circumstances quite different from those of London (where we practise). The second point is that when there has been a very major change in life circumstances, test ﬁndings may have a quite different meaning with respect to their predictions for future performance. For example, in the children adopted into UK families from Romanian orphanages, the shift from profound deprivation to somewhat above-average family environment was followed by major cognitive gains (Rutter et al. 1998a; O’Connor et al. 2000).

Determining the validity of a test score
There are three main ways in which the validity of a score may be assessed in an individual case. First, use may be made of the psychologist’s own observations of the child’s motivation and persistent engagement in the tasks involved in the test. It is not always easy to differentiate between task failure and a lack of adequate engagement but careful observation of the child’s performance, together with information from parents and teachers on the child’s response to tasks, will usually provide an adequate lead. Other things being equal, if task failure occurs on tasks that obviously interest the child and attract adequate engagement, it is much more likely that the failure reﬂects lack of competence than if a child has only made a half-hearted attempt to do what was required. The second approach is provided by an internal analysis of the pattern of task passes and fails. The basic assumption, or hypothesis, underlying the test is that success or failure reﬂects task difﬁculty rather than extraneous features such as distraction, anxiety or motivation. Accordingly, it is necessary to examine the pattern of item responses to determine if there is a reasonably consistent hierarchy with successes on easier items and failures on more difﬁcult ones. Some tests, such as Raven’s Progressive Matrices (Court & Raven 1995), build this in to the test construction so that there is a systematic progression from easy items to more difﬁcult ones, back to easy ones and on to more difﬁcult ones, and so forth. This is not usual in other tests but, nevertheless, there is a means of assessing the association with the task difﬁculty by going across subtests. There should always be caution about the validity of an overall score that is made up of a mixture of passes and failures on both more difﬁcult and easier items. This will usually require further testing in order to determine what explains the pattern. Consistency across differ107

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ent tests or across separate testing occasions can also be helpful. When the test ﬁndings do not show a consistent pattern of response to task difﬁculty, an experimental approach will be needed in order to pit against each other alternative hypotheses about the reasons for these discrepancies. The third approach is provided by examining the consistency between the test ﬁndings and other assessments of performance that derived from observations by the clinician or reports from parents or teachers. From a psychiatric perspective, it has been our practice always to use observations and reports in order to come up with a clinical expectation of test performance level (whether this be in relation to general intelligence or language or scholastic attainment) before hearing about test ﬁndings. It is only by having some sort of quantiﬁed other assessment that it is possible to determine whether there is a discrepancy to be explained. However, in doing this it is essential not to be content with some overall impression but rather to have thought through carefully what it is in the observations or reports that give rise to the expectation. This may be, for example, reports or observations of problem-solving skills outside the test situation, or it may involve the child’s level of curiosity and organized exploration of the environment, or it may involve the style of approach to problem-solving (e.g. whether it is random trial and error or systematic and organized). The observations may involve the extent to which the child attempts, and succeeds, in ﬁnding out how toys and how sold objects ‘work’ or it may involve complexity in play (Rutter 1985a). As Berger & Yule (1972) emphasize, it is never acceptable to leave discrepancies between test ﬁndings and parental reports unexplained; their existence is always an indication for a critical hypothesis-testing study of possible reasons for the discrepancy. The reasons may lie in the nature of the task (e.g. the child having more cues at home than in the controlled test situation), or in the parent’s or teacher’s interpretation (or misinterpretation) of the child’s behaviour, or in the nature of the cognitive skills being assessed. If the parental report suggests marked skills or deﬁcits on clinically important abilities that have not been tapped by standardized tests, other tests should be used to sample the additional functions. In cases where the child seems able to perform the task at a higher level at home than he or she does in the clinic, and when no reasons in the nature of the task seem to explain this discrepancy, the psychologist should seek to repeat observations in the home (or in the school if that is relevant) in order to determine the explanation for the discrepancy. Psychological assessment is complete only when this has been accomplished and when it has given rise to an explanation for the discrepancy. An example of this kind arose with respect to a clinical referral of a boy who had suffered a very severe head injury. The school that the boy had attended both before and after the injury had concluded that the boy, of previously superior intelligence, had been left mentally retarded by the injury. To everyone’s surprise, standardized testing, by contrast, showed that his overall IQ was still well above the population mean (although not as high as it is likely to have been before the injury). Observations in the classroom and of the boy coping with work at home 108

seemed to indicate that he was indeed performing poorly. One possibility was that the successful test performance was a function of the tasks being very short. Accordingly, a different set of tasks was constructed that required more prolonged persistence. The boy performed equally well on these and that explanation could be ruled out. It was similarly possible to rule out the possibility that his failures reﬂected undue distraction by extraneous stimuli. Eventually, it appeared that the key feature involved the requirement for initiative and individual decision-making in more open-ended tasks. This provided important clues as to how he might be helped to improve his school learning. A very different example was provided by a young girl who had been referred because of puzzlingly variable uncooperative behaviour. Her school record made it clear that she was of above average intelligence and therefore it was a surprise to ﬁnd that on standardized cognitive testing her score was only about 80. However, the psychologist also reported that although the girl had been cooperative throughout the testing, had spoken appropriately and seemed to be engaged in the tasks, her behaviour did not seem normal in that she appeared not quite ‘with it’. This contrasted with her style of interaction when seen by the psychiatrist and a discussion of possibilities led to an arrangement whereby the next time that the child seemed to be behaving in the reported somewhat unusual fashion, an EEG was to be performed instantly. Interestingly, when this was carried out, it showed that she was in petit mal status. At ﬁrst sight, it seemed impossible that she could be functioning as well as she was (albeit below her best) while having a continuous set of minor epileptic seizures. However, a careful examination of the EEG record showed that there were very brief breaks and apparently these were enough to enable her to function. Subsequent cognitive testing both within and outside periods of petit mal status conﬁrmed the low average functioning in the one and the superior functioning in the other. A further example is provided by a girl referred because of acquired aphasia with epilepsy (see Bishop, Chapter 39). Standardized testing showed that her understanding of spoken language was negligible but her parents reported that, despite her virtually complete loss of use of spoken language, she seemed to understand surprisingly well what was said to her. Both our observations in the clinic and parental reporting suggested that this might be because of her use of non-language information to guess correctly what was being communicated. Systematic observation, using situations that varied according to the level of possible other information that was available to the girl, conﬁrmed that this was indeed the case. Once more, the resolution of the discrepancy provided an important lead as to how best to help her. A more structured experimental design was needed to investigate several cases of supposed ‘facilitated communication’ in autistic individuals, seen at a time before this concept became fashionable. Although the details were slightly different in each case, what they had in common was that in all ordinary circumstances the young people were performing at an extremely low

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level, whether assessed on the basis of standardized test performance or spontaneous behaviour at home or at school. By contrast, when cognitive performance was assessed by any means involving the mediation of a facilitator (in two cases a parent but in the third case a therapist) a surprisingly high level of knowledge or understanding was shown. In each case, it was necessary for the child to rest their hand on the arm of the facilitator (or vice versa) and to use a system of pointing to letters or spelling out words on a kind of simpliﬁed typewriter. Observations conﬁrmed that the reports of performance using this type of facilitation were indeed correct and there was every reason to suppose that the facilitator was not consciously manipulating what the child was doing. It quickly became apparent that the challenge was to account for the successes with facilitation, rather than the failures without it. Furthermore, it was clear that nothing would be gained by structuring the circumstances so that there could be failure with the facilitated task. That was because it would be easy to account for such failure on the basis of motivational inﬂuences. Instead, it was decided that the way ahead lay in tackling head-on the two main alternatives — that the correct answers derived from the facilitator or that they derived from the child. This led to the stratagem of so organizing the task that one or other of them would have to give the right answers to the wrong questions. The need to undertake this testing was fully explained but the precise details of how this was to be carried out were not revealed in advance (by agreement with those concerned). The child and the facilitator were each given the same set of questions but they were in a different order, without this being obvious to either of them. In all three cases, replicated testing showed that the answers reﬂected the questions as evident to the facilitator and not those evident to the child. Subsequent systematic studies of small groups of young people showing facilitated communication used a broadly comparable strategy with much the same results (Montee et al. 1995; Bebko et al. 1996). These four rather different examples illustrate the range of ways in which an experimental, or quasi-experimental, approach to hypothesis testing in relation to the validity of a test score may be undertaken. The facilitated communication example approximates to a single case research investigation (Yule & Hemsley 1977); the epilepsy example involved the use of testing outside the psychological domain; and the other two examples required only variations in a more ‘ordinary’ exploratory clinical approach. In all four cases, however, it was necessary to ask questions about the validity of the test ﬁndings, to pose alternative explanations, and to devise means of differentiating among these alternatives.

Exploring reasons for situational variation in behaviour
It is a commonplace in both research and clinical practice to ﬁnd that children’s behaviour in one situation is not the same as that in another, or that their behaviour with one person differs from that with another. It is necessary in both research and clinical

practice to develop hypotheses with respect to possible causes of the variation, and to devise means to test which explanation or explanations are valid. Apart from the usual need to consider how hypothesis testing may be undertaken, there is clearly a requirement to have adequate measures of both the child’s behaviour and the situational or interpersonal circumstances. In addition, it is necessary to check that the apparent situational variation is real. The alternative is that the behaviour is actually similar across situations but that it is being perceived differently by different people. Again, the approach may be illustrated by giving a few varied examples. The ﬁrst example concerned a request from a particular school in relation to an apparent ‘epidemic’ of hysterical attacks in the classroom (McEvedy et al. 1966; Moss & McEvedy 1966; Benaim et al. 1973). This was a new phenomenon in an otherwise well-functioning school and it was also noteworthy that this was only occurring in some lessons and with some teachers. Observations showed that the behaviour of one girl constituted the usual initiator of similar behaviour in others. Also, it became apparent that the ways in which different teachers responded to what was happening made quite a difference to whether it spread. The details in both cases provided the lead on how the school might deal with the situation and the limited ‘epidemic’ soon came to an end. Another quite different circumstance in which explanations of situational variation are needed concerns reports that a child’s behaviour is inﬂuenced by diet. Thus, it is relatively common to have reports that, for example, children are more hyperactive when they have ingested foods that contain additives or when they have eaten particular foods, such as chocolate. The approach needed is reasonably straightforward in principle, although often very difﬁcult in practice. The ﬁrst need is to consider alternative hypotheses for the apparent variation in behaviour. In most cases, the two chief contenders are chance variations and the inﬂuence of other features. Thus, the clinician needs to consider whether the variation might be caused by the fact that at the times when behaviour is worse the child is in a different situation, or is tired or excited for reasons unconnected with the content of the food. Sometimes, careful history-taking makes it evident that the supposed connection with foods is so inconstant and weak that it is most unlikely to represent a causal effect. However, quite often, it is necessary to go on to some more systematic documenting of temporal relationships. In most cases, a key step is to identify speciﬁc time-limited behaviours that can serve as an index of the behavioural disturbance that is at issue. The parents may then be asked to keep a careful daily diary of the occurrence of such behaviours, together with possible circumstances or precipitants (other than food) that might be relevant. It is only when procedures of this kind provide evidence that indicates a strong case for an association with particular foods that it is justiﬁed to undertake the more searching experimental testing of the hypothesis. Basically, this requires going to a very simple diet and then experimentally adding, one by one, in blind fashion, different types of food substance (Egger et al. 1985; Carter et al. 1993). Single case studies 109

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of this kind are arduous and demanding and are not to be engaged in lightly. Nevertheless, they do have a place and the results have shown that, although most claims that speciﬁc foods have a predictable worsening effect on behaviour cannot be substantiated, they have proved valid in some instances and have led to effective and worthwhile therapeutic interventions. Similar issues may arise in relation to parental responses to a ‘problem’ behaviour. For example, some years ago, one of us saw a young mother who was at her wits’ end because her toddler would not sleep through the night. She had received conﬂicting advice from family and friends. One big issue was whether she should allow the child to have a nap in the middle of the day. Some people advised her to ensure that he did not have a nap; she should keep him awake so that he was sufﬁciently tired at the end of the day to go to sleep promptly. Others urged her to let the child have a nap when he wanted, on the grounds that to prevent it would merely make him irritable and oppositional. The mother was asked to keep a systematic sleep diary over a period of several weeks. A simple statistical test showed that on days when he was kept awake he would not settle at night, whereas on days when he had a nap, he slept through the night. This had seemed counterintuitive but data settled the issue. Another example of the same kind was provided by a child who had been placed in a residential unit after a series of foster and adoptive placements had broken down. The unit had a good reputation for preparing children to move on to new families but, in this case, they were faced with what seemed to be unpredictable aggression. The main concern was over infrequent severe outbursts, but minor episodes were more common. On the principle that low-frequency high-amplitude behaviours can often be understood by looking at high-frequency lowamplitude equivalents, all episodes of aggression were systematically charted. The next step was to examine the temporal pattern in order to relate it to possible precipitants. It quickly became apparent that aggression was particularly likely to follow his sessions with the art therapist who was undertaking ‘life story work’ with him. It appeared that he was not yet ready to face the pain of his past, and a different approach proved more effective with him. Individual differences, as ever, are crucial. Very comparable issues arise with respect to the possibility that mood disturbances are a function of phases in the menstrual cycle or that a marked change in a child’s behaviour represents some fundamental alteration in their physical condition. For example, a consultation was sought by a residential institution for young people with autism in relation to a particular child who had shown a marked escalation in quite dangerous aggressive and destructive behaviours. They were concerned that it might reﬂect some unusual form of epileptic disturbance or some neurological deterioration. Again, careful history-taking from staff at the institution and from parents led to several alternative possibilities that needed to be considered. There had been marked changes of staff, the young person was now primarily looked after by someone new, and there had been possibly important changes in schedule and expectations. The problem required, again, selecting the key behaviours that gave the prime 110

cause for concern with respect to the changes and a recording system was instigated, being planned jointly with staff, to test out the various possibilities. In this particular case, the evidence showed that the variations were related fairly systematically to changes in the institution and that when these were modiﬁed in ways that seemed likely to be helpful, there was a substantial reduction (although not elimination) of the aggressive and destructive behaviour. In another somewhat similar referral, the approach taken was similar but the answer was rather different. In the second case, the variations in behaviour seemed likely to be a function of a cyclical mood disturbance. This is not easy to gauge in non-verbal autistic individuals but appropriate medication proved helpful. It is often said that, if you want to understand a behaviour, introduce experimental changes to alter it. Hypothesis testing in assessment has a two-way relationship with therapeutic intervention: each can inform the other. Sometimes the need is to check the validity of the referrer’s perception of the problem. When working with teachers on part of a school-based clinical intervention project, concern was expressed over an apparently highly intelligent 6-year-old who ‘never settled to do any work’. The teacher was helped to deﬁne and operationalize what she meant by ‘work’, and then to undertake a simple binary on/off task observation every ﬁfth minute for 1 hour each morning. The results showed that the boy was on-task 60% of the time. This led to a redeﬁnition of the problem and a focus on reinforcing his on-task behaviour, which was plentiful. Soon he was working at a level above the average for the class. Reports that a child’s behaviour is much worse at school than at home, or vice versa, are extremely common and clinicians need to decide whether systematic investigation is indicated or whether the evidence from research, together with the particular ﬁndings in this case, provide enough leads to indicate some of the likely features and therefore some of the elements that might constitute a focus for intervention. The hypothesis generation requires a knowledge of what might be relevant in the school environment as judged from studies of school effectiveness (Maughan 1994; Mortimore 1995, 1998), together with psychopathological evidence of the possible importance of features such as structure, group instruction, task demands and so forth. Similarly, hypotheses about relevant features in the family and in the home need to be guided by evidence from observational studies that have systematically investigated different features (Patterson 1982). It is usually helpful when focusing on situational variation to try to identify situations and circumstances that have comparabilities across the settings showing variation. It may then be most appropriate to move to a functional analysis of the behaviours in that situation (see below).

Functional analysis of behaviour
Systematic approaches to functional analysis of behaviour developed as an intrinsic element of the development of behavioural methods of treatment (see Herbert, Chapter 53).

APPLIED SCIENTIFIC THINKING IN CLINICAL ASSESSMENT

However, in a more general sense, they are inherent in all forms of clinical assessment. In seeking to understand the nature of disturbed behaviour that has constituted the basis for referral, it is necessary to develop and test hypotheses about alternative explanations. For example, with respect to faecal soiling, it may have arisen because the child has failed to gain control of bowel function that ordinarily arises in childhood, or it may arise because the bowel has become blocked through impaction and there is seepage of faecal material around the blockage, or the child may have no blockage, have full control of bowel function, but for psychological reasons is depositing faeces in inappropriate places (Rutter 1975; see also Clayden et al., Chapter 47). Various predictions follow from these alternatives. Thus, the form and consistency of the bowel motions is likely to be normal in the ﬁrst and third alternatives but abnormal in the second. Also, the spatial deposition of faeces is likely to be relatively haphazard in the ﬁrst two possibilities but systematic and psychologically meaningful in the third. Of course, there may be a combination of features and there are also other possibilities. The basic point, however, is that the clinician needs to adopt an experimental approach to the development and testing of clinical hypotheses. Similar issues arose with respect to school non-attendance in which the main alternatives lie between avoidance of school as part of truancy associated with an antisocial propensity and avoidance of school for emotional reasons associated either with separation anxiety in relation to the family or fear of some aspect of the school situation (Hersov 1960a,b; Eysenck & Rachman 1965). In the same sort of way, these alternatives give rise to predictions about the details of the function of school non-attendance. Functional analysis needs to be applied to the somewhat different issue of predisposing circumstances and immediate provoking stimuli or controlling contingencies. It can be important to determine the extent to which disruptive behaviours or emotional disturbance are most likely to arise when children are tired or hungry, when they are being required to do things that they do not want to do, when they are unable to communicate their needs or wishes (a particular issue in relation to autism, see Rutter 1985b; Howlin & Rutter 1987), or when maternal depression is associated with increased family discord or impaired parenting, or when father goes away from home on work, or when it is an anniversary of some particularly stressful situation. The analysis with these issues is broadly comparable to those already considered in relation to situational variations. The more detailed ‘blow-by-blow’ sequential analysis of the circumstances most likely to provoke a particular behaviour or cut it short requires a careful systematic attention to particular episodes of behaviour. The well-based assumption is that, although there are major individual differences in children’s liability to show different forms of psychopathology, there are also important situational inﬂuences on whether such psychopathology is manifest and how long it continues. The issues are well illustrated in the pathways involved in substance use and abuse (see Rutter, Chapter 28) or suicidal behaviour (see Shaffer &

Gutstein, Chapter 33) or antisocial behaviour (Rutter et al. 1998b; see also Earls & Mezzacappa, Chapter 26). Such a behavioural analysis needs to be guided by both what research has shown as likely features to inﬂuence behaviour and what seems to be happening with this particular individual. A hypothesistesting approach is obviously the way to proceed. However, an important caveat is that the most important feature may not be what parents or teachers do after a particular behaviour has occurred but, rather, what they do to avoid it happening in the ﬁrst instance. Thus, skilled parenting may have less to do with efﬁcient disciplinary methods or social problemsolving strategies or coping techniques than with an accurate picking up of social cues and an appropriate use of diversionary tactics. This was well illustrated in one study of children’s and parents’ behaviour negotiating a supermarket (Holden 1983) and in other studies of parenting strategies (Gardner et al. 1999). Ordinarily, functional analysis of behaviour tends to be thought of in terms of the features in the immediate situation that inﬂuence the occurrence of behaviours. However, precisely the same issues and approaches are relevant in relation to the possibility that the key inﬂuences on behaviour derive from meaningful connections with some past experiences. At one time, psychoanalytic psychotherapies were largely predicated on this basis; that the origins of mental disorders lay in internal thought processes in relation to past experiences, real or imagined. These approaches have become outmoded, at least as applied in their original form, because theoretical assumptions have not proved valid, because it became obvious that there was a need to take the immediate life situation into account, and because therapeutic methods lacked efﬁcacy as compared with other forms of intervention. Nevertheless, the general notion that past experiences may have contemporary relevance is valid as shown, for example, by the persistence of post-traumatic stress disorder symptoms in some cases (see Yule, Chapter 32), by the long-term sequelae of sexual abuse in some circumstances (see Glaser, Chapter 21), or by the ways in which the experience of past relationships inﬂuences people’s approach to current ones (Cassidy & Shaver 1999). However, if these possible connections with past experiences are to be used in clinical assessment (as they should be) it is important that ways be found of translating the notion into some form of testable hypothesis to which experimental thinking may be applied in putting the hypothesis to test.

Analysing test score discrepancies
Throughout the history of psychological testing, there has been an interest in the inferences that may be drawn from discrepancies between scores on two different tests or subtests. Thus, there has been a wish to draw conclusions about brain function when large differences have been found between verbal and performance subscores on the Wechsler scales, or from instances when performance on some skill such as language or reading is markedly lower than that expected of the child’s age and overall 111

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level of intelligence. Three rather different issues have to be considered in relation to the topic of score discrepancies (Yule 1989). First, there is a need to appreciate the relatively wide conﬁdence limits that surround most subtest scores. That is to say, it is very common for a child to obtain some particular score on one testing occasion and a somewhat higher, or lower, score on a subsequent occasion. The method of dealing with this is a straightforward statistical one requiring no hypothesis testing. With many tests (such as the Wechsler scales) tables are provided on the reliability (the likelihood that the same pattern would be found consistently over repeated testing) of different sized discrepancies. These data indicate whether the pattern is truly characteristic of the child, but they do not indicate whether it is statistically unusual. The answer to this second, although closely related, question requires data on frequency of discrepancies in the general population of different sizes. Again, statistical tables are available for many tests and the ﬁndings generally show that discrepancies have to be quite large for them to be regarded as statistically rare. The third question concerns the clinical meaning to be attached to a statistically unusual discrepancy. This immediately raises a base rate problem when trying to use a relatively common ﬁnding (a large discrepancy) to predict a rare phenomenon (such as brain damage) (Yule 1989). The key consideration is that differences between groups may provide a misleading expectation of the meaning of a ﬁnding in an individual case, unless attention is paid to base rates (Meehl & Rosen 1955). Thus, in the Isle of Wight survey (Rutter et al. 1970) verbal performance discrepancies of 25 points or greater on the Wechsler Intelligence Scale for Children (WISC) were twice as common in children with neurological disorders as in controls (14 vs. 7.5%). However, when the base rate of neurological disorders (6.4 per 1000) was taken into account, this translated into a chance of only 1 in 60 that a child with a large V–P discrepancy would have a neurological disorder (Yule 1989). The practical point is that even when there is a very strong association between features (one of which is rare), false positive predictions will be usual simply because normality is much more common than the abnormal disorder being predicted. Some assistance is provided by paying attention to patterns made up of several different indices. For example, longitudinal studies have shown that various social abnormalities, developmental delays and attentional deﬁcits all predict the later development of schizophrenia (Rutter & Garmezy 1983). Each of these is relatively common in the general population and of very little use for individual prediction. However, the combination of all three is much rarer, but is fairly common in the abnormal group. The ﬁndings in this instance are still, even in combination, not sufﬁciently distinctive to be of value in individual diagnosis, but the principle is one of utility. It is always worthwhile to consider whether there are several different indices that could be put together in this way and, if there are, whether data are available on the frequency of particular pattern occurrences. 112

A further problem concerns the supposed purity of the function being tapped by a particular test or subtest. Research ﬁndings are clear-cut in indicating that most tests reﬂect a wider range of skills than might be anticipated from the name or description of the test. Thus, most of the so-called non-verbal tests on the Wechsler Scales actually are inﬂuenced to some extent by language and language-related skills. Accordingly, care needs to be taken before assuming that an unusually high or low score is indeed measuring what it purports to measure. In many instances, a full understanding of this is not crucial in the clinical assessment of an individual case. Nevertheless, occasionally it is important, and the appropriate single case design means to investigate the meaning of unusual talents or deﬁcits, as illustrated by studies of idiot savants (Hermelin 2001). These are individuals who have highly precocious skills in one narrow area that enable them to perform at levels well above those achieved by most people in the general population, despite the fact that their own level of overall intelligence is in the retarded range. A high proportion of such individuals show autism. One of the questions that needs to be addressed is whether their unusually high level of performance in their special talent constitutes some trick of rote learning or whether it is based on the same sorts of cognitive processes employed by more generally talented individuals. The style of investigation has involved setting the tasks in ways that allow, or prevent, different rule-based strategies, or different sources of information, to be used. Very similar strategies are relevant for the investigation of particular severe deﬁcits. A further issue concerns the clinical implications of marked discrepancies (giving rise to either skills or deﬁcits). There has often been a wish to jump from test ﬁndings to inferences about brain lesions. Thus, for example, tests may be labelled as ‘left hemisphere’ or ‘right hemisphere’ tests (Prior 1979) or tests of frontal lobe function (Prior & Hoffman 1990). Sergeant & Taylor (see Chapter 6) point to the many problems involved in such inferences. So far as childhood is concerned, a crucial consideration is that lateralized or localized lesions incurred in early life do not lead to the same patterns of psychological functions that they do when the lesion has been incurred in adult life (see Goodman, Chapter 14; Vargha-Khadem et al. 1992; Rutter 1993). Particular genetic conditions can and do give rise to relatively distinctive psychological proﬁles in some instances (see Skuse & Kuntsi, Chapter 13) but there is rather less speciﬁcity to the supposed cognitive and behavioural phenotypes than sometimes claimed. They are real, and clinically important, but attention needs to be paid to individual variability as well as to syndrome speciﬁcity. A rather different clinical implication has been that the identiﬁcation of particular test score patterns may indicate which form of intervention is likely to be most effective in this child — giving rise to so-called ‘prescriptive teaching’. The intention is clearly laudable and, in the future, it may prove possible to use test ﬁndings in this way (Sternberg 1997; Sternberg et al. 1998). However, this remains a ﬁeld in which claims rather outstrip accomplishments and caution is needed in moving from test ﬁndings to the planning of intervention strategies. On the other

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hand, if a hypothesis-testing single case approach is followed (Berger 1994) it can be clinically worthwhile. The difﬁculty remains as to whether it is better to build on areas of strength, or concentrate attention to countering areas of weakness, or of ﬁnding ways to circumvent the difﬁculties.

Designing assessments to elicit speciﬁc psychological features
For many years projective tests used to comprise a major part of the psychological assessment in many clinics. The basic idea was that by presenting people with ambiguous visual stimuli, such as inkblots, as in the Rorschach test, or pictures, as in the Thematic Apperception Test, the meaning that individuals read into these ambiguous stimuli could be used to tap their innermost thoughts, of which they might not even be aware. Furthermore, it was thought that responses could lead to relatively strong diagnostic inferences. Such tests have now largely fallen out of regular usage because empirical ﬁndings have shown that the tests have many problems in interpretation and do not give rise to reliable diagnoses as assessed in other ways (Klein 1986). Nevertheless, the basic strategy of using tasks or situations to tap particular realms of behaviour, rather than to rely simply on their occurrence in unstructured situations, or to rely on reporting, remains clinically useful. The well-established clinical assessment tools of this kind are not projective in quite the same sense as the ambiguous pictures. Several different examples may serve to illustrate the approach. In each case, research ﬁndings were used to hypothesize the sorts of tasks or settings that might be expected to elicit the relevant behaviours and the tests were constructed in ways designed to isolate the speciﬁc psychological features of interest. Ainsworth’s ‘Strange Situation procedure’ is an example (Ainsworth 1967; Ainsworth et al. 1978). It was designed to use very brief separation and reunion episodes to tap qualities of security or insecurity in selective dyadic attachments (see O’Connor, Chapter 46). It was originally developed in Uganda, then further tested and developed in the USA and subsequently used in many different countries. Although it is not without its critics (Lamb et al. 1984), it has proved a remarkably robust measure of certain important attachment qualities. It has been important, however, that studies of abnormal groups of various kinds indicated the need to modify the scoring procedures in order to pick up qualities that were not captured by the original scoring system (Main & Solomon 1990; van Ijzendoorn et al. 1995). It does not pick up so clearly some of the key unusual features associated with attachment disorders in institutionally deprived children (see O’Connor, Chapter 46) and because of that, and because of the very limited age range to which it is applicable, it is not a tool that can be recommended for ordinary clinical use. Nevertheless, the principles are applicable and it may be that further developments using methods that are more appropriate to tapping variations in attachment behaviour in older children (Waters et al. 1995; Cassidy & Shaver 1999) may give rise

to tools that could be used for individual clinical assessment, although that point has not yet been reached. The Autism Diagnostic Observation Schedule (ADOS) (Lord et al. 2000) provides a rather different example. It arose out of an appreciation that it was not particularly informative simply to observe possibly autistic individuals in an unstructured fashion and, at least with younger children, it was not possible to interview them in the ordinary way. Accordingly, various situations providing ‘presses’ for various forms of social initiatory, socially responsive behaviours, types of play or types of communication, were devised. Empirical research ﬁndings showed that it was not particularly useful to score whether or not the children performed particular actions in relation to these situations but the ﬁndings also indicated that standardized ratings of social and communicative behaviour were possible. Settings tapped a rich variety of behaviour, the ratings were reasonably reliable, and they had reasonable diagnostic differential validity. The half an hour or so period of observation is not sufﬁcient on its own to give rise to a diagnosis, but the evidence does show that it contributes in a most valuable way to diagnosis when combined with parental reports as also obtained using standardized interviews such as the Autism Diagnostic Interview (Lord et al. 1994). Training is required for the use of this assessment but it has come increasingly to be used as part of ordinary clinical assessments in tertiary care clinics that see a large number of children with possible autism spectrum disorders. It has been a universal experience that the kind of structured diagnostic interviews that are appropriate for older children do not work so well with very young children. Accordingly, a variety of interview techniques, using pictures and play stimuli, have been developed (see Angold, Chapter 3). Similarly, in an attempt to avoid direct, possibly leading, questions about experiences of sexual abuse, there has been the development of play-based interviews using anatomically explicit dolls (see Glaser, Chapter 21). In each case, it seems likely that the ‘props’ have been useful in getting the children engaged and in stimulating them to talk about relevant experiences. On the other hand, there is the twin risk that the props themselves may bias the information given because of the particular leads they provide. The remedy does not lie in either an uncritical acceptance of these approaches or an equally uncritical dismissal of their use. Rather, it is necessary to approach their use in an empirical way. In so doing, it will not be appropriate to rely on any overall statistic of reliability or validity. Rather, in relation to the situations in which they are used, it will be important to consider rates of false positives and false negatives and also to consider which of these is the more important in the circumstance in which they are to be used (see Fombonne, Chapter 4). A range of psychometric tests to assess different functions have been devised (see Sergeant & Taylor, Chapter 6) and some of these include the element of response to particular stimuli; e.g. the continuous performance test, in which one of the key aims is to assess children’s task performance in circumstances that have, or do not have, distracting stimuli (Rosvold et al. 1956; Conners 113

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2000). Portable galvanic skin response (GSR) measures are also available to provide biofeedback to anxious children when they face feared situations. Assessment approaches, of a quasi-experimental kind, have also been developed to assess both patterns of family interaction and patterns of social cue perception. For example, Goldstein et al. (Goldstein 1995) developed a method in which different family members were interviewed separately, differences among them in their perceptions of joint behaviour were identiﬁed, and the family was then brought together for a videotaped session in order to discuss these revealed differences. The idea was to provide a standardized stimulus that provided a potential for conﬂict in order to see how the family dealt with disagreements and differences. Video clips have also been developed to tap people’s ability to identify different social cues and to assess the extent to which their interpretations of behaviour (as, for example, in relation to hostility or anxiety) were consonant with those of other people (Roeyers et al. 2001). Brown & Rutter (1966) (Rutter & Brown 1966) used parental interviews to tap the emotions expressed when parents talked about their children in response to neutral questions. This gave rise to a measure that came to be called ‘expressed emotion’ and subsequently to modiﬁcations based on a 5-min speech sample (Magaña et al. 1986) either in response to a request that parents simply talk unprompted about their children or talk in response to a series of neutral questions about their qualities (Sandberg et al. 1993). In each case, the development is hypothesis-based in the sense that standardized stimuli have been devised in order to elicit particular forms of behaviour in ways that are meant to be unbiased. In each case, in addition to the usual matters of standardization, reliability and the like, there is the key question of the extent to which the behaviour in these standard situations is or is not representative of behaviours shown in the more ordinary circumstances of life. It is clear from numerous studies that these approaches have real value, but equally they also have important limitations. For the most part, the procedures are ones largely conﬁned to research use at the moment, although at least some of them have the potential for development into procedures that might be applied in ordinary clinical assessment.

ways in which psychology and psychiatry differ but they agree in showing the need for, and value of, a style of applied scientiﬁc thinking in approaching clinical assessment. Deliberately, we have referred to applied scientiﬁc thinking, rather than experimental designs, because the range of applications is so broad, extending from something that is little more than thoughtful questioning clinical enquiry, to a scientiﬁc investigation that approximates to a piece of research that can be applied to individual cases. This is not the whole of clinical assessment, as we have striven to emphasize, but it is an important, we would argue, essential, part of what is involved and it is an aspect that draws as heavily on the clinicians’ creative and innovative skills as on their academic knowledge.

References
Ainsworth, M.D.S. (1967) Infancy in Uganda: Infant Care and the Growth of Love. Johns Hopkins University Press, Baltimore, MD. Ainsworth, M.D.S., Blehar, M.C., Waters, E. & Wall, S. (1978) Patterns of Attachment: A Psychological Study of the Strange Situation. Erlbaum, Hillsdale, NJ. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (DSM-1V), 4th edn. American Psychiatric Association, Washington, D.C. Barbui, C. & Hotopf, M. (2001) Amitriptyline vs. the rest: still the leading antidepressant after 40 years of randomised controlled trials. British Journal of Psychiatry, 178, 129–144. Bebko, J.M., Perry, A. & Bryson, S. (1996) Multiple method validation study of facilitated communication. II. Individual differences and subgroup results. Journal of Autism and Developmental Disorders, 26, 19–42. Benaim, S., Horder, J. & Anderson, J. (1973) Hysterical epidemic in a classroom. Psychological Medicine, 3, 366–373. Berger, M. (1994) Psychological tests and assessment. In: Child and Adolescent Psychiatry, Modern Approaches (eds M. Rutter, E. Taylor & L. Hersov), 3rd edn, pp. 94–109. Blackwell Science, Oxford. Berger, M. & Yule, W. (1972) Cognitive assessment in young children with language delay. In: The Child with Delayed Speech (eds M. Rutter & J.A.M. Martin), pp. 120–135. Spastics International Medical Publications, London. Brown, G.W. & Rutter, M. (1966) The measurement of family activities and relationships: A methodological study. Human Relations, 19, 241–263. Carter, C.M., Urbanowicz, M., Hemsley, R. et al. (1993) Effects of a few food diet in attention deﬁcit disorder. Archives of Disease in Childhood, 69, 564–568. Cassidy, J. & Shaver, P.R. (1999) Handbook of Attachment: Theory, Research and Clinical Applications. Guilford Press, New York. Clark, P. & Rutter, M. (1979) Task difﬁculty and task performance in autistic children. Journal of Child Psychology and Psychiatry, 20, 271–285. Conners, C.K. (2000) Conners’ Continuous Performance Test II Computer Program for Windows. International Psychology Services, Hurstpierpoint, UK. Court, J.H. & Raven, J. (1995) Manual for Raven’s Progressive Matrices and Vocabulary Scales. Oxford Psychologists Press, Oxford. Egger, J., Carter, C.M., Graham, P.J., Gumley, D. & Soothill, J.F. (1985) Controlled trial of oligoantigenic treatment in the hyperkinetic syndrome. Lancet, 1, 540–545.

Conclusions
Throughout the last century, clinical psychology has paralleled clinical medicine in its aspiration that clinicians should be ‘scientist-practitioners’; such a concept has had its critics but it is interesting that a recent British survey showed a continuing general endorsement of the evidence-based scientistpractitioner model (Kennedy & Llewelyn 2001). These authors emphasized, as we have done, the range of diverse approaches to scientiﬁc enquiry and the importance of a critical pragmatic approach to the integration of research into practice, as well as the need for a high degree of responsiveness to the cultural and institutional contexts of practice. We agree. There are important 114

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Introduction

Children’s Testimony
Stephen J. Ceci, Livia L. Gilstrap and Stanka A. Fitneva

Every day courts, social services, mental health professionals and law enforcement personnel are faced with the difﬁcult job of deciding whether to believe a child’s report of abuse or neglect. It can be devilishly difﬁcult to sort out the truth in such cases, and it is becoming increasingly common for courts to look to the ﬁeld of developmental psychology for help. The relationship between research, practice and the law is complicated (see Little, Chapter 71). Consider the following case, which illustrates some unfortunately typical ingredients in such cases, and by implication suggests some areas of need that developmental psychologists might address.

Children’s testimonial behaviour in the real world
Case of State of New Jersey v. D.G.
In the State of New Jersey v. D.G., the defendant was an enlisted man in the US Navy. He married a woman who had two children previously. One of her children, Michelle, was four and a half years old at the time of the alleged abuse. Michelle claims that her stepfather asked her to accompany him on an errand one day, and during it he took her to an empty house that the family was planning to move into. ‘Michelle stated that the defendant . . . laid down next to her and proceeded to place his hands under her shirt. Defendant touched and squeezed her breasts, fondled her vagina, and kissed her on the mouth. He then pulled off her shirt and pants, removed his own pants and climbed on top of her. Michelle testiﬁed that the defendant put his ‘dinky’ into her and then that he cleaned up the ‘wet stuff’ on the bed with a towel. He then told her to clean herself up and get dressed. The pair then proceeded to a pizza place and then returned to the great-grandmother’s house.’ (State of NJ v. D.G. 1999, WL 64702) Three weeks later, while Michelle was playing with two girls, her ‘Aunt Sandy’ found her lying on the bed with these girls who had their pants down to their knees and one of them had her hand down Michelle’s pants. Aunt Sandy testiﬁed that she ‘freaked out’ and called the girls bad names. She ordered Michelle to sit alone and told her she was very upset with her.

Aunt Sandy testiﬁed that she took her daughters to the bathroom, washed them, and attempted, in her word, to ‘deprogram’ them. One of these girls told Aunt Sandy that Michelle wanted to ‘lick her pee-pee’. Forty-ﬁve minutes after being scolded and isolated, Aunt Sandy returned to Michelle and questioned her. Although she purported to have calmed down by then, she said that Michelle still seemed nervous. At ﬁrst, Michelle allegedly blamed the behaviour on Aunt Sandy’s two daughters; however, after more questioning she stated that her stepfather did those things to her. Michelle testiﬁed that Aunt Sandy asked her: ‘What made you do this? Did anybody ever do anything like this to you to make you do this?’ Michelle replied that her stepfather stuck his ‘thing’ in her and then ‘peed on the bed’, wiping it up with a towel. Michelle begged Aunt Sandy not to tell her mother. (Michelle’s mother testiﬁed for the prosecution that the stepfather was ‘a fanatic about towelling himself off after intercourse even after ejaculating inside her’.) Several days after the incident with the two daughters of Aunt Sandy, Michelle was interviewed by a female detective trained to conduct sex abuse investigations. Her Aunt Sandy accompanied her to this interview. During this interview, however, Michelle failed to make a disclosure about her stepfather, saying only that he touched her ‘boobies’. After frequent failed attempts to get Michelle to talk, the detective sensed that she was scared and was holding back. She stopped the videotaped interview because Michelle’s nose began to bleed and brought her to a bathroom to stop the bleeding. Then the detective asked Aunt Sandy to reassure Michelle about talking to her. Aunt Sandy put Michelle on her lap and told her to tell the detective the truth. Approximately 7 minutes later, the videotape was turned back on and the interview proceeded. Now on video Michelle proceeded to claim the stepfather had put his penis into her vagina. The following week, Michelle was examined by a paediatrician who specialized in sexual abuse. Although he found no physical evidence that was diagnostic of sexual trauma to Michelle’s genitalia (not unusual, even in cases of known sexual penetration), this paediatrician did report that Michelle demonstrated with an anatomically detailed doll that she had been raped, plus she told him that the stepfather had rubbed his penis against her ‘private’. Based on Michelle’s doll use and her oral description of events, the paediatrician concluded there was a ‘high likelihood that sexual abuse had occurred’. Michelle alleged that her mother beat her in an attempt to get 117

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her to recant her allegations. She was sent to live out of state with her biological father. When Michelle returned from his home, however, she accused him of raping her in a similar manner (e.g. including the wiping off with a towel). When examined again by the paediatrician, Michelle recanted her allegation against her stepfather but made three different allegations of sexual abuse against her biological father. In the following 6 months, Michelle told her Aunt Sandy, a social worker and an investigator that she had been lying about her stepfather. To confuse matters even more, Michelle recanted her recantations at various times. Just before the case came to court, Michelle met with the prosecutor and detective and told them her stepfather did not rape her, but after further questioning she told them that her mother had urged her to deny the rape. During the trial, Michelle’s testimony changed somewhat from her prior statements. A child abuse expert testiﬁed that it is not unusual for abused children to change their statements, especially when they believe that others will not believe them or will criticize them. The jury convicted the stepfather; he was sentenced to a 7-year term of imprisonment. The case of State of New Jersey v. D.G. illustrates many of the challenges facing those who must interview alleged child victims. Should we believe Michelle’s claims of abuse, or her recantations, or her recantations of her prior recantations? And was Michelle’s behaviour with anatomical dolls diagnostic of abuse? These are a few of the questions that courts turn to developmental psychology for answers. In this chapter we will brieﬂy review the relevant scientiﬁc research from the ﬁeld of children’s testimonial competence. We will address each of the following six topics: historical research on suggestibility; recent trends in suggestibility research; whether statement consistency is diagnostic of an accurate report; the use of anatomical dolls in interviewing; boundary conditions beyond which children are hypothesized not to be suggestible; and conclude with the application of suggestibility ﬁndings for forensic interviewers.

Historical research on suggestibility
Scientiﬁc researchers have examined the question of children’s testimonial competence for more than a century, since a study by W.S. Small (1896). Small ﬁrst asked several students to come to the front of the classroom and smell a clear liquid in a bottle that was an essence familiar to children of that era. After these children announced their answers (claiming it was a familiar fragrance), Small asked the rest of the class to raise their hands if and when they could smell the same fragrance when he sprayed it into the air in front of their classroom. In actuality, the bottle he sprayed contained only distilled water, yet many children claimed to smell its fragrance after seeing classmates’ hands raised. Small repeated this practice with sounds, sights (apparent movement of a toy), and other stimuli, and he tested children both in classroom groups as well as individually. He concluded that young children were highly suggestible, particularly when they were in groups. We will return to this claim below as it con118

nects historical research with both more modern research and with actual testimonial situations of past and present. From the beginning, the dominant view among researchers has been that young children are suggestible — more so than older children and adults. With a few notable exceptions, early scientiﬁc studies reported that young children are vulnerable to a variety of suggestive techniques and pressures, such as leading questions, peer pressure, repeated questioning, the tendency to perceive conditions as conforming to expectancies created by adults, and the need to comply with adults’ wishes. One of the earliest scientiﬁc researchers of children’s suggestibility was Alfred Binet, the French psychologist best known as the father of the modern IQ test. Binet’s (1900) book on suggestibility continues to have a role in modern discussions of the topic. Indeed, although Binet’s experimental methods may now appear relatively primitive, he reached several conclusions that have continued to be echoed by later research. First, Binet concluded that young children were highly suggestible. Like others after him (Lipmann 1911; Dale et al. 1978), Binet argued that suggestibility reﬂects the operation of two different factors: cognitive and social. The ﬁrst factor, which he called ‘auto-suggestion’, develops within the child without outside inﬂuence because it fulﬁls his or her expectation of what it supposed to happen. In one of Binet’s experiments, ﬁve lines of increasing length were presented to children of ages 7–14, followed by a series of ‘target’ lines that were of the same length as the longest (ﬁnal) line of the series. Children tended to be inﬂuenced by the expectation of ever-increasing lines; their reproductions of the target line were systematically too long because they expected that it would be longer than the line that had preceded it. Binet questioned the children after the study and found that many knew that the lines they had drawn were incorrect; they were able to redraw them more accurately on demand. Binet claimed that this demonstrated that children could escape the inﬂuence of auto-suggestions. Binet’s second factor was the desire to conform to the expectations or pressures of an interviewer, and thus reﬂected a form of mental obedience to another. For example, Binet showed that children sometimes asserted that they witnessed non-existent events that they were led to expect. Binet reported that one of the external forces that could affect children’s responses was the examiner’s language. In one of his studies, he showed children between the ages of 7 and 14 years a poster that contained six everyday items. He asked children a series of questions, some of which were misleading (e.g. implying that a button was afﬁxed to a poster with thread rather than glue). He found that these children often went along with the erroneous suggestion (e.g. claiming to have seen the thread). Some children were asked for their free recall — to write down everything they observed, without being aided by speciﬁc questions. These children were the most accurate, although they recalled very little. Other children were asked direct questions about the objects (e.g. ‘How is the button attached to the board?’) These children, although not as accurate as children in free recall, were signiﬁcantly more accurate than children who were asked leading questions that sug-

CHILDREN’S TESTIMONY

gested an inaccurate answer (e.g. ‘Wasn’t the button attached by a thread?’) who in turn were more accurate than children asked highly misleading and suggestive questions that assumed factually incorrect information (e.g. ‘What was the colour of the thread that attached the button to the board?’). Binet did not test questions that were correctly leading (e.g. ‘Wasn’t the button glued?’). Subsequent research has demonstrated that such questions are answered with the highest degree of accuracy. All modern commentators agree on this relationship between the nature of questioning and accuracy: free recall is the most accurate (although yielding the sparsest recollections); followed by responses to direct non-leading questions; then by responses to leading questions suggesting an inaccurate answer; and ﬁnally by misleading questions (Cunningham 1988; Ceci & Bruck 1993; Ceci & Friedman 2000). Binet also noted that children’s answers to questions are often characterized by exactness and conﬁdence, regardless of their accuracy level. Even among adults, there is low correlation between an eyewitness’s conﬁdence and accuracy (Bothwell et al. 1987). When the children in Binet’s study were later asked if they had made any mistakes, they did not correct their inaccurate responses to misleading questions. Binet concluded that the children’s erroneous responses and subsequent high conﬁdence reﬂected gaps in their memories, which they attempted to ﬁll in order to please the experimenter. Once an erroneous response was given, Binet surmised that it became incorporated into their memory. This assumption on his part was based on the fact that, in contrast to the auto-suggestion study, in which children could later re-draw the line correctly, children in this study were unable later to correct their wrong answers. Finally, Binet concluded that children are more suggestible in groups than when alone. When a group of three children was shown the same six everyday objects, asked a series of misleading questions, and told to call out the answer to each question as quickly as possible, children who responded second and third were more likely to give the same answer as the ﬁrst respondent — even if that answer was inaccurate. The late seventeenth century Swedish witch trials present an interesting analogue to Binet’s ﬁnding of group conformity effects. Sjoberg (1995) analysed the statements given to parish priests by 809 children and reported that they were more likely to claim to have witnessed celestial apparitions, witches ﬂying on brooms, and so forth, if they gave their testimony to the parish priest after waiting in line with other witnesses outside the rectory to attend prayer meetings. Sjoberg believes this was because they were inﬂuenced by other witnesses who also were waiting in line. ‘Only 59% of the children testifying at other places than prayer meetings were sure about the real life quality of their experiences of the witches’ sabbath whereas as many as 91% were sure about it after standing in line with others at prayer meetings. The differences were signiﬁcant.’ Other early twentieth century researchers reached results consonant with Binet’s, and drew further conclusions that continue to ﬁnd support. The Belgian psychologist J. Varendonck, a contemporary of Binet’s, conducted a number of experiments on

children’s suggestibility with the speciﬁc intent of demonstrating the unreliability of children’s testimony and so enabling him to provide expert testimony in a murder case (Varendonck 1911). In one study, 7-year-old children were asked about the colour of a teacher’s beard. Sixteen of 18 children provided a response, whereas only two said they did not know. The teacher in question did not have a beard. In another demonstration, a teacher from an adjoining classroom came into Varendonck’s classroom and, without removing his hat, talked in an agitated fashion for approximately 5 minutes. (Keeping one’s hat on when entering a room was uncommon then because it was considered a sign of rudeness in that society.) After this teacher had left the classroom, the children were then asked in which hand that teacher had held his hat. Only 3 of the 27 students claimed that the hat was not in his hand. Varendonck, as well as other researchers in this early period, emphasized one of the points found by Binet, that questioning by inﬂuential adults could lead children to make false statements. According to the German psychologist William Stern, children viewed such suggestive questions as imperatives (Stern 1910). Further, both Varendonck and Stern provided early support for the proposition that repeat questioning can have a particularly powerful effect. Stern concluded that a child was likely to remember his or her answers to earlier questions better than the underlying events themselves. Research by Lipmann (1911) and colleagues (e.g. Piaget 1986) in the same period, also suggested that very young children often have difﬁculty distinguishing fantasy from reality. More generally, researchers in the 1920s and 1930s consistently found that younger children were more suggestible than older ones (Otis 1924; Messerschmidt 1933; Burtt 1948). At the same time, scientists also recognized that even adults can be suggestible to a signiﬁcant degree (for details, see Loftus 1979). For several reasons, this early research is of limited usefulness in analysing issues of forensic signiﬁcance. Most obviously, although some of the early researchers, including Binet and Varendonck, had forensic use in mind, the subject matter of the questions they posed bore little resemblance to the subject matter of statements that children give in actual cases. In the early experiments, children were often asked leading questions about details that they likely regarded as peripheral and of little signiﬁcance, such as the colour of a strange man’s beard in one of Varendonck’s (1911) studies, which of several lines was longer in Binet’s (1900) study, or whether they smelled a non-existent fragrance when a liquid was sprayed in front of the classroom that in reality was distilled water in Small’s (1896) study. ‘ . . . . Most research on children as eyewitnesses has relied on situations that are very different from the personal involvement and trauma of sexual abuse. Researchers have used brief stories, ﬁlms, videotapes, or slides to simulate a witnessed event. A few have used actual staged events, but these events — for example, a man tending plants — are also qualitatively different from incidents of child abuse. The children are typically bystanders to the events, there is no 119

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bodily contact between the child and adult, and it is seldom even known whether the events hold much interest for the children. Of even more importance, the questions the children are asked often focus on peripheral details of the incident like what the confederate was wearing, rather than on the main actions that occurred, or more to the point, whether sexual actions were committed.’ (Goodman & ClarkeStewart 1991) In contrast to laboratory research, in actual forensic investigations — most of which involve abuse of the child herself — the child is usually questioned about central, bodily actions, often experienced rather than merely witnessed, and frequently associated with embarrassment, fear and pain. Thus, whatever the early experiments might show about the reliability of children under the conditions of the experiments, they lack external or ecological validity for the context of principal contemporary signiﬁcance. That is, they cannot be relied on with conﬁdence to show how suggestible children are in the realworld context of interest — when a child makes an allegation of abuse. Nevertheless, this brief historical review indicates that recent research ﬁndings on the suggestibility of children is not a modern departure from earlier understandings; on the contrary, it ﬁts in squarely with what has been the dominant view for a full century.

imply that suggestibility can result from the provision of information either before (e.g. in the form of expectations or stereotypes) or after an event. Thus, this broader conceptualization of suggestibility accords with both the legal and everyday uses of the term, to connote how easily one is inﬂuenced by subtle suggestions, expectations, stereotypes and leading questions that can unconsciously alter memories, as well as by explicit bribes, threats and other forms of social inducement that can lead to the conscious alteration of reports without affecting the underlying memory.

Recent trends in suggestibility research
Beginning in the late 1970s, there was a resurgence of interest in the area of children’s suggestibility, which has continued to the present. This virtual explosion of research was fuelled by various factors: a dramatic increase of reports of child abuse and increasing recognition of the commonness of abuse; greater receptivity by courts to expert psychological testimony; increased focus of social scientists on socially relevant issues; and increasing interest in the study of eyewitness testimony of adults (Ceci & Bruck 1993). Thus, researchers became increasingly concerned by the frequency with which children failed to report abuse, by the fact that when they did allege abuse the reports were met with scepticism and also, later, by the possibilities for contamination of their reports. Although virtually all researchers agree that these two possibilities exist, they disagree about the likelihood of each occurring. Additionally, there is vigorous disagreement in interpretation of the recent studies, with some seeing them as supporting the view that children are highly suggestible, and others seeing these studies as evidence for children’s resistance to suggestions. Lyon (1999) has termed the group of researchers who emphasize children’s suggestibility the ‘New Wave’. In contrast to the so-called New Wave research, those who focus on children’s testimonial strengths have reported studies showing that, in the absence of strongly suggestive questioning techniques, preschool-age children are capable of providing courts with highly accurate recollections. In response to this claim, researchers have provided evidence that actual front-line interviewers routinely employ highly suggestive techniques when questioning young children, leading to the expectation that potential suggestibility errors may occur (Ceci & Friedman 2000). Below, we brieﬂy review some of the studies that are used by each of these camps to bolster their competing claims. Rather than attempt a full summary of modern research on suggestibility, we begin by discussing four illustrative studies conducted by Goodman et al. We have chosen Goodman because she is the scholar most favoured by child advocates and critics of the so-called New Wave research. Yet, her studies provide strong evidence that children, especially young children, are suggestible to a signiﬁcant degree — even about abuse-related questions.

Deﬁning suggestibility
Traditionally, suggestibility has been deﬁned as ‘the extent to which individuals come to accept and subsequently incorporate postevent information into their memory recollections’ (Gudjonsson & Clark 1986; see also Powers et al. 1979). This deﬁnition implies that: 1 suggestibility is an unconscious process; 2 suggestibility results from information that was supplied after an event; and 3 suggestibility is thought to inﬂuence reports via incorporation into the memory system, not through social pressure to lie or conform to expectations. This traditional conceptualization and demonstration of suggestibility is too restrictive to aid in understanding real case studies like that presented at the beginning of this chapter. Therefore, many researchers have broadened the deﬁnition of suggestibility to encompass what is usually connoted by its lay usage. Suggestibility is deﬁned as the degree to which the encoding, storage, retrieval and reporting of events can be inﬂuenced by a range of internal and external factors. By adding ‘reporting’ to the deﬁnition, we broaden the deﬁnition of suggestibility to include false reporting. False reporting implies that it is possible to accept information while fully conscious of its divergence from the originally perceived event, as in the case of acquiescence to social demands, lying or efforts to please loved ones. This broadened deﬁnition of suggestibility does not necessarily involve the alteration of the underlying memory; a child may still remember what actually occurred but choose not to report it for motivational reasons. By removing ‘postevent’ from the deﬁnition, we 120

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Paediatric examination study
In a study by Saywitz et al. (1991), girls whose genitalia and anus were touched during a paediatric examination were much more likely to report that touching in response to doll-aided directed questioning than in response to open-ended questions. In fact many studies have found that young children provide little information to open-ended questions although the information they do provide tends to be highly accurate. This highlights the potential beneﬁts of directed questioning. However, in the Saywitz et al. study, although the vast majority of girls whose genitalia had not been touched during the exam correctly denied a genital touch, during directed questioning one out of 35 (2.86%) did answer afﬁrmatively when asked about a genital touch, and two out of 36 girls (5.56%) answered afﬁrmatively when asked about an anal touch. Thus, directed questioning can also lead to false allegations of touching. A common ﬁnding in the literature is that directed questioning elicits both more accurate details and more inaccurate details (Ceci & Friedman 2000). We could conclude, as Saywitz et al. did, that ‘although there is a risk of increased error with dollaided direct questions, there is an even greater risk that not asking about vaginal and anal touch leaves the majority of such touch unreported’ (Saywitz et al. 1991, emphasis added). However, the data on young children’s suggestibility in the face of directed questioning suggest a more conservative approach to its use that acknowledges both the potential beneﬁts and the potential risks.

other, helped her dress in a clown’s costume, lifted her onto a desk, and took two photographs of her. Each child was asked various types of questions 10–12 days later, some of which involved actions that might be of special concern in child abuse investigations, such as, ‘How many times did he spank you?’ and ‘Did he put anything into your mouth?’ Rudy & Goodman reported that the 7-year-olds ‘did not make a single commission error to the speciﬁc abuse questions’. The authors concluded that 4-year-old participants made very few commission errors (3%), while the 4-year-old bystanders evidenced a slightly higher, but still low, error rate (7%) (Rudy & Goodman 1991).

Mount Sinai study
Eisen et al. (1998) conducted an experiment involving 108 children between the ages 3 and 15 who were examined as part of a 5-day assessment period for children with suspected histories of abuse at Chicago’s Mount Sinai Hospital. The important focus of this experiment was of increasing ecological validity by studying children who were actually involved in abuse investigations. The authors expressed the view that, because of various problems that they suffered, this group could be more suggestible than the children typically involved in suggestibility studies. ‘It is also possible’, they wrote, ‘that abused children are hypervigilant regarding abusive actions or abuse suggestions and, as a result, would be more resistant to such questioning than non-abused children’ (Eisen et al. 1998). On the ﬁrst day of their stay, children received a medical check-up. On the second day, the children were given an anogenital examination, and swabbed for culture. On the ﬁfth day, the children were interviewed, and the interview included misleading or other suggestive questions. Eisen et al. concluded: ‘Despite performing more poorly than their older counterparts, the 3–5-year-olds still demonstrated relatively good resistance to misleading information in answering abuse-related questions. When presented with misleading questions related to abusive or inappropriate behaviour by the doctor and/or nurse (e.g. ‘How many times did the doctor kiss you?’), 3–5-year-olds answered 79% of the questions without making commission errors.’ (Eisen et al. 1998, emphasis added.) The unstated implication is that this group made commission errors in answering 21% of misleading abuse-related questions. Furthermore, the authors pointed out that ‘approximately 40% of the errors made by the 3–5-year-olds in response to misleading abuse-related questions were produced by only 6 of the 29 children in this group.’ Thus, although the group’s proportion of commission errors to misleading abuse-related questions was relatively low on average, some children were more suggestible than others. ‘If such children were interviewed in an abuse investigation’, the authors acknowledged, ‘a false accusation could potentially result’ (Eisen et al. 1998). Children in the older groups did substantially better, but still answered a fairly sizeable percentage of the misleading abuse-related questions incorrectly, 16% for the 6–10-year-olds and 9% for the 11–15-year-olds. 121

Delayed inquiry study
Goodman et al. (1989) asked 3–6-year-olds to play a game with a strange man for approximately 5 minutes. During this time, the man did not engage in any behaviours that were sexually provocative. Four years later, 15 of these same children, now between 7 and 10 years old, were re-interviewed and asked what they could recall of their prior experience with the strange man. To create an ‘atmosphere of accusation’, the interviewers said such things as: ‘Are you afraid to tell? You’ll feel better once you’ve told.’ Goodman & Clarke-Stewart wrote that ‘the children were more resistant to abuse-related than to non-abuserelated suggestions’. Nevertheless, these children were quite susceptible to abuse-related questioning: ﬁve of the 15 children agreed with the interviewer’s false suggestion that the stranger had kissed them or hugged them, two out of the 15 agreed that they had their photo taken by the stranger, and one child even agreed she had been given a bath by him. Goodman & ClarkeStewart acknowledged that some of these errors ‘might lead to suspicion of abuse’ (Goodman et al. 1989).

Trailer study
Rudy & Goodman (1991) conducted a study in which pairs of 4- and 7-year-olds were left in a trailer with a strange adult. One child watched while the adult played games with the

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These studies by Goodman et al. are each important for understanding children’s intellectual development and in revealing the underlying mechanisms of suggestibility and memory. As we have shown, it has been understood since the time of Binet (1900) that a child’s free recall tends to be more accurate than his or her responses to suggestive questioning. However, free recall also tends to be extremely sparse. When asked for free recall, children usually give correct but very brief answers, and they often omit important details. This is especially so for very young children, and it is especially true in the abuse context because of the possibility of embarrassment and threats from the alleged perpetrator. One response of researchers such as Goodman has been to emphasize the potential value of suggestive or other directed questioning in securing disclosure of abuse. Abuse investigators have used more directive and focused approaches, including leading and repeated questions, in an attempt to secure useful information from the child and some modern research highlights the potential value of these techniques. Consider the study by Saywitz et al. (1991), discussed above. When girls whose paediatric examinations had included an exterior vaginal and anal examination were asked for their free recall, only 8 of 36 (22%) correctly mentioned the vaginal touch and only 4 of 36 (11%) mentioned the anal touch. Directed questioning with the aid of anatomically correct dolls raised these numbers to 31 (86%) and 25 (68%), respectively. Thus, directed questioning will often be more effective than requests for free recall in prompting disclosures of abuse. On the other hand, there is risk of creating false positives by suggestive questioning. Although the four studies we reviewed used suggestive questions (‘Did the doctor touch you there?’ ‘How many times did he spank you?’ ‘Did he put anything into your mouth?’ ‘How many times did the doctor kiss you?’), they did not use highly suggestive techniques, such as repeating the suggestive questioning over time (Poole & White 1993, 1995), coercion or peer pressure. This is a point that the authors recognized. In three of the four studies, the suggestive techniques employed were embedded in neutral or supportive interviews. These studies therefore provide weak tests of young children’s vulnerability to suggestion. Even in this research, however, the evidence shows that error rates for false claims range between 3 and 40%. They do not indicate how high these error rates might go in the presence of a web of motives, strong suggestions, threats and inducements. As we will now show, such highly suggestive techniques can produce much higher error rates.

Impact of highly suggestive techniques
As we have indicated, the studies described above may underestimate the susceptibility of young children when confronted with stronger suggestions. To test this hypothesis, a number of attempts have been made to design and conduct studies that incorporate stronger forms of suggestions — including suggestive techniques that have been used by investigators in some wellpublicized child abuse cases (see Ceci & Bruck 1995 for review 122

of several well-publicized cases). Among these stronger forms of suggestion that research has shown to be detrimental are repetition of question within the same interview (Poole & White 1993), stereotype inducement (Leichtman & Ceci 1995), guided imagery (Ceci et al. 1994), peer pressure and selective reinforcement. Numerous studies have shown that when exposed to these forms of suggestion the error rates of children can be very high, sometimes exceeding 50%. Moreover, this phenomenon holds true even when the questions concern events that supposedly affect the child him- or herself as opposed to events to which he or she was supposedly a bystander; even when the questions are central, rather than peripheral to the supposed event; and even when the questions concern abuse-related matters. For the sake of brevity and symmetry with the research we have already reviewed, we will present below only a subset of evidence that falls into this category. Garven et al. (1998) used strong suggestions (e.g. reinforcing answers that were consistent with interviewers’ hunches and invoking pressure to conform) based on tactics used in the McMartin daycare sexual abuse case. These researchers found a 57% false claim rate as to various behaviours in which an adult had supposedly engaged, vs. only a 17% error rate when weaker suggestions were used. In a follow-up publication (Garven et al. 2000), these researchers found between 35 and 52% false claims — including statements that the adult had tickled the child’s tummy or had kissed the child on the nose — in response to strong suggestions, vs. 13–15% when these were not used. The following exchange in their study is an example of a combination of conformity pressure with positive reinforcement: I: The other kids say that Paco took them to a farm. Did Paco take you to a farm? C: Yes. I: Great. You’re doing excellent now. Other researchers who have used these stronger suggestive techniques also have reported high error rates for claiming a strange man ‘put something yucky into their mouths’ during a visit to a science exhibit (Poole & Lindsay 1996), took off their clothes and kissed them (Lepore & Sesco 1994), or touched them inappropriately (Rawls 1996). Studies focusing on repeated questions include a study by Bruck et al. (1995) in which 3-year-olds were repeatedly asked strongly suggestive questions about a doctor touching their anogenital regions (e.g. ‘Can you show how Dr Emmett touched your vagina?’). Among children whom the doctor did not touch, fully 50% falsely claimed the doctor had inserted objects into their anogenital cavities. After a third exposure in a period of a week to an anatomically correct doll, one 3-year-old child reported that her paediatrician had tried to strangle her with a rope, insert a stick into her vagina and hammer an earscope into her anus. Similarly, Steward et al. (1996) interviewed children aged 3–6 years three times after a paediatric clinic visit. With each interview, children’s false reports of anal touching increased; by the ﬁnal interview, which took place 6 months after the initial visit, more than one-third of the children in this study falsely reported anal touching.

CHILDREN’S TESTIMONY

Poole & White (1991) interviewed 4-, 6- and 8-year-olds and adults immediately and 1 week following a staged encounter with a man. Another group of subjects were interviewed only once, after a delay of 1 week. Some of the repeated questions were open-ended ones (e.g. ‘What did the man look like?’), whereas others were closed or yes/no ones (e.g. ‘Did the man hurt Melanie?’). Poole & White reported that the ‘repeatinterview’ 4-year-olds were signiﬁcantly more likely than the ‘single-delayed’ ones to give a false afﬁrmative answer to the closed question while the repetition of the open-ended questions did not result in more errors. Collapsing across age and gender of subjects, those in the repeat condition were signiﬁcantly more likely to report that the man hurt Melanie (60%) than were those in the single interview condition (33%). Finally, in a study by Rawls (1996), 30 5-year-olds and seven 4-year-olds participated in a series of benign play events with a male adult. Over the course of four interviews, the children were asked both open-ended questions such as ‘Where were you with X?’ and ‘What sort of things did you do with him?’, and closed questions such as ‘Do you know why he touched that part of your body?’ Rawls reported that nearly one-quarter of her sample falsely claimed the man inappropriately touched them, with three of the children (10%) falsely reporting genital touching, two (7%) falsely reporting anal touching, and two additional children reporting mutual adult–child touching (e.g. claiming the adult pretended to rub cream into their bodies). The authors stated that ‘reports of mutual undressing without touching were also common, although this often reﬂected a confusion between dress-up items and ordinary clothes.’ Similarly, in the so-called Monkey Thief study, Bruck et al. (1997) found that over half of the youngest children made false claims of witnessing a theft of food in their daycare facility when they were exposed to repeated suggestions and pressures. (For additional examples of false claims — involving bodily touching or witnessing a bicycle theft — see Cassel & Bjorklund 1996; Ornstein et al. 1997). Taken together, the above studies indicate that if very young children are subjected to questioning techniques that are highly suggestive, their rates of making false claims, even on abuserelated questions, may be very high. However, these studies are of limited utility for forensic purposes unless children are in fact exposed to these techniques in the real world of abuse investigation. Elsewhere, we have provided evidence that front-line interviewers use, on average, 8–10 suggestive utterances per interview (questions such as ‘He forced you to do that, didn’t he?’ (Lamb et al. 1996; see Ceci & Friedman 2000 for review of this evidence). Since this article has been in draft, Warren et al. (2000) have presented a paper, based on interview transcripts with child protective service workers in a southern state of the USA, that in their view provides some support for the contention that the most egregiously suggestive practices are used only rarely by front-line interviewers of children. The interviews they analysed contained far fewer egregious practices than the studies we listed above. But their data revealed that some particularly sugges-

tive techniques, although usually constituting a small part of the interaction in any given interview, are quite common in that they appear in most interviews at least once. Even a single occurrence of such a technique is capable of derailing the entire interview. Perhaps most strikingly, the interviewers in Warren et al.’s analysis invoked negative consequences such as telling the child, ‘You haven’t told us anything’ in 28 of the 42 (67%) interviews. In 40 (95%) of the interviews, the interviewer repeated a question, in an attempt to elicit a new answer, even though the child had unambiguously answered the question in the immediately preceding portion of the interview. In ﬁve (12%) of the interviews the interviewer told the child about information received from another person. In 37 (88%) of the interviews the interviewer invoked positive consequences on at least one occasion for an answer, although the researchers report that this occurred mainly in the context of the early rapportbuilding part of the interview. In 14 (33%) of the interviews the interviewer invited the child to speculate about past events or to use imagination or solve a mystery. Taken together, the data on practices employed by front-line interviewers indicates that highly suggestive techniques are very common.

Is statement consistency diagnostic?
Consistency of a child’s report is often one of the most important criteria used by professionals in evaluating the reliability of children’s allegations of abuse (Conte et al. 1991), whereas inconsistency in young children’s reports lowers their credibility in the eyes of mock jurors (Ross et al. 1990; Leippe et al. 1992). Several studies have found that when preschool-age children are interviewed twice about an event, about 30% of the information they recall is consistent across interviews, and it tends to be highly accurate (Fivush & Schwarzmueller 1998; Fivush & Shukat 1995). However, accuracy rates when suggestive questioning is used may differ from those of Fivush et al. in which there was no suggestive questioning. Perhaps repeated opportunities to reminisce are an advantage if the interviewer avoids using suggestive questioning. We turn to this possibility next. Based on two ﬁndings from a recent study by Bruck et al. (in press) that: (i) the length of children’s narratives remained the same with repeated interviews; and (ii) the number of their new reminiscences during each new interview were greater for false than true narratives, one would predict that the same details are more likely to be repeated in true compared to false narratives. This was tested directly in analyses that included spontaneous as well as prompted utterances. We examined how frequently children reported an event in one interview that had been reported in a previous interview. Thus, we examined consistency of utterances beginning at the third interview (because the ﬁrst interview was a baseline interview that was of necessity not included, so the ﬁrst comparison was between the second and third interviews), asking whether these details had been mentioned in any previous 123

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interview. Similarly, we examined how many utterances in the fourth interview had been mentioned in previous interviews, and how many in the ﬁfth interview had been mentioned in any of the previous interviews. Numerators were then divided by the total number of utterances in each interview. This measure reﬂects the proportion of details in each interview that had already been provided by the child in previous interviews. It was discovered that the true reports were more consistent than the false reports. Summing over the third, fourth and ﬁfth interviews, consistency rates were 67% for true reports about negative events, 50% for true reports about positive events, 30% for false reports about negative events, and 25% for false reports about positive events. The consistency in narratives increased between the third (35%) and fourth interviews (47%), with no change between the fourth and ﬁfth interview (47%). In summary, repeated suggestive questioning takes a toll on children’s accuracy, with increasing errors over time and the consistency of false reports exceeding that of true reports.

Is intercourse positioning with anatomic dolls diagnostic?
Anatomically detailed dolls are frequently used by professionals when they interview young children about suspected sexual abuse. It is thought that the dolls facilitate disclosure by providing props that help young children describe complex and embarrassing events as well as providing them with the appropriate non-verbal cues to facilitate memory retrieval (Boat & Everson 1996). These techniques, which have been especially designed to overcome language, memory and motivational (e.g. embarrassment) problems when interviewing children about sexual abuse, may be potentially suggestive. However, existing data indicate that the dolls do not facilitate accurate reporting (Goodman & Aman 1990) and it also appears that the use of dolls increases errors for younger children (3- and 4-year-olds) when asked to demonstrate certain events that never happened (Gordon et al. 1993) or when they are asked to use the dolls to act out an experienced medical procedure (Goodman et al. 1997). Recent studies by Bruck et al. (1995, 1997) give examples of the potential suggestion inherent in doll use when interviewing about genital touch. Three- and 4-year-old children had a medical examination, with some of the children receiving a routine genital examination. The children were then interviewed about the examination. During the interview they were given an anatomical doll and told, ‘Show me on the doll how the doctor touched your genitals.’ A signiﬁcant proportion of the children who had not been touched (particularly the girls) showed touching on the doll. Furthermore, when children who had received a genital examination were asked the same question, a number of children (particularly the girls) incorrectly showed that the doctor had inserted a ﬁnger into their genitals; the paediatrician did not do this. Next, when the children were given a stethoscope and a spoon and asked to show what the doctor did or might do with these instruments, some children incorrectly showed that 124

he used the stethoscope to examine their genitals and some children inserted the spoon into the genital or anal openings or hit the doll’s genitals; none of these actions occurred. We concluded that these false actions were the result of implicit suggestions (communicated through a number of requests that the child use the dolls to show and talk about touching of the genitals and buttocks) that it is permissible to show sexualized behaviours. Also, because of the novelty of the dolls, children were drawn to insert ﬁngers and other objects into their cavities. A number of recent studies have raised concerns about the use of dolls with young children, who generally have difﬁculty with symbolic representations. Deloache et al. have argued that because young children exhibit general problems in symbolreferent relations, they therefore may have difﬁculty in using dolls as symbols of self and colleagues. Some of Deloache’s work conﬁrms this prediction. In these studies (Deloache & Marzolf 1995; Uttal et al. 1995), a sticker was ﬁrst placed on a child or on a researcher, then the child was asked to use a doll to show where the sticker was placed. Children between the ages of 2.5 and 3.5 years made many errors when they used a doll to show where the sticker was placed on their own body. However, they were much more accurate when asked to represent one doll with another doll or when the sticker was placed on the research assistant and the child showed on his or her own body where the sticker had been placed. From these ﬁndings, Deloache concluded that children do poorly when they have to use dolls as a symbol of a person. Although there is concern about the use of dolls with 3-yearold children, the results of a study by Saywitz et al. (1991) suggest that these concerns do not extend to 5- and 7-year-old girls. In their study, half of the children had received a genital examination and the other half had received a scoliosis examination in which the child’s genitals were not touched by the doctor. When questioned several weeks later, most of the children in this study who had received a genital examination made omission errors (they failed to report genital or buttock touching when they were asked for a verbal report of their examination, or they failed to show on the dolls what had actually happened). However, when the experimenter pointed to either the genitalia or buttocks of the doll and asked a direct question, ‘Did the doctor touch you here?’, a substantial majority of the children now correctly assented to buttock or genital touching, thus reversing their earlier omission error. In contrast to the Bruck et al. ﬁndings, children who received the scoliosis examination (with no genital touching) never made false reports of genital touching (errors of commission) in either the verbal free recall or the doll enactment conditions. For this group, errors of commission were very low when the experimenter pointed to the genital or anal region of the doll and asked, ‘Did the doctor touch you here?’ In summary, the dolls in the Saywitz et al. study of older children did not promote false reports of touching, and when used in a very directive manner, they reduced children’s resistance to talk about anogenital touching, and reversed their former false denials.

CHILDREN’S TESTIMONY

Are there boundaries beyond which children are not suggestible?
There is still some controversy regarding the boundary conditions for younger children’s greater suggestibility. Some argue that suggestibility is diminished or even non-existent when the act in question concerns a signiﬁcant action, or when the child is a participant as opposed to a bystander, or when the report is a free narrative (Goodman et al. 1990; Fivush 1993). The strongest claim of this sort is that children are not suggestible about personally experienced central actions, especially those that involve their own bodies. While it is probably true that children are somewhat less prone to false suggestions about actions to their own bodies as opposed to neutral non-bodily acts, the literature clearly does not support the strong view that bodily acts are impervious to suggestion. There are numerous demonstrations of how suggestive interviewing procedures can lead children to make inaccurate reports about events involving their own bodies and at times these reports have been tinged with sexual connotations. As noted earlier, young children have made false claims about ‘silly events’ that involved body contact (e.g. Did the nurse lick your knee? Did she blow in your ear?), and these false claims persisted in repeated interviewing over a 3-month period (Ornstein et al. 1992). Young children falsely reported that a man put something yuckie in their mouths (Poole & Lindsay 1995). Threeyear-olds falsely alleged that their paediatrician had inserted a ﬁnger or a stick into their genitals (Bruck et al. 1995). Preschoolage children falsely alleged that some man touched their friends, kissed their friends on the lips and removed some of the children’s clothes (Lepore & Sesco 1994). Studies of children who have undergone a radiological procedure (a voiding cystourethrogram) accord with this claim (Goodman et al. 1997). These children have their bladders pumped with ﬂuid and are encouraged to urinate on the table in front of the medical staff. Later, they are asked suggestive questions about whether they were kissed during the procedure, etc., and the results indicate that children are suggestible about such matters. Additional examples are provided by research by Goodman et al. In one study, 3-year-olds gave false answers 32% of the time to questions such as, ‘Did he touch your private parts?’, whereas 5-year-olds gave false answers 24% of the time (Goodman et al. 1990). In response to questions such as, ‘How many times did he spank you?’, 3-year-olds gave false answers 24% of the time, while 5-year-olds gave false answers only 3% of the time (Goodman & Aman 1990). When 3–4-year-olds were interviewed about events surrounding an inoculation, there was an error rate of 23% on questions such as, ‘How many times did she kiss you?’ and ‘She touched your bottom didn’t she?’. Many of these children replied ‘yes’ even though these events did not occur. Taken together, one can safely conclude that, compared to older children, young children, and speciﬁcally preschool-age children, are at a greater risk for suggestion about a wide variety of topics, including those containing sexual themes.

Conclusions
Notwithstanding the above conclusion, it is clear that children — even preschool-age children — are capable of accurately recalling much that is forensically relevant. For example, in many of our own studies, children in the control group conditions recalled events ﬂawlessly. This indicates that the absence of suggestive techniques allows even very young preschool-age children to provide highly accurate reports, although they may be sparse in the number of details. There are a number of other studies that highlight the strengths of young children’s memories (see Goodman et al. 1992; Fivush 1993 for a review). What characterizes many such studies is the neutral tone of the interviewer, the limited use of misleading questions (for the most part, if suggestions are used, they are limited to a single occasion) and the absence of the induction of any motive or stereotype for the child to make a false report. When such conditions are satisﬁed, it is a common (although not universal) ﬁnding that children are relatively immune to isolated suggestive inﬂuences, particularly about sexual details. An important implication of the studies that focus on the strength of children’s reports is that although children are generally accurate when they are interviewed by a neutral experimenter, who asks few leading questions, and when they are not given any motivation to produce distorted reports, there are occasionally a few children who do give bizarre or sexualized answers to some leading questions. For example, in the Saywitz et al. (1991) study of children’s reports of their medical examinations, one child, who never had a genital exam, falsely reported that the paediatrician had touched her buttocks and on further questioning claimed that it tickled and that the doctor used a long stick. In a study of children’s recollection of their visit to a laboratory (Rudy & Goodman 1991), one young child claimed that he had seen bones and blood in the research trailer (see Goodman et al. 1992 for additional examples). Thus, young children occasionally make spontaneous, strange and unfounded allegations, and the individual difference factors that may contribute to these bizarre narratives are unknown. However, as Goodman et al. point out, many of these allegations can be understood by sensibly questioning the child and parents further. Still, interviewers must be especially cautious when dealing with younger children because they are disproportionately suggestible to deviation from the ideal neutral interview. This leaves three important questions. 1 What is it about younger children that makes them more susceptible than older children? 2 Why do some children provide spontaneous elaborate false reports? 3 What do these ﬁndings tell us about who should interview and what types of training interviewers should be given?

Why younger children may be more susceptible to suggestive interviewing
Not a great deal is known about factors that lead some children 125

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to create embellished false narratives and colleagues to resist this tendency. Despite vigorous research activity on this issue, there is much that we know does not account for variation among children. For example, differences in intelligence (above the borderline retarded threshold level) do not appear to discriminate between children who develop false narratives and those who do not; nor do a variety of personality attributes, such as need for compliance, need for closure, and dissociation. The few factors that have been found to be associated with false narratives are source monitoring ability (keeping track of the source of memories) and memory strength. In general, younger children lack well-developed source monitoring skills, and this may be a major reason why they produce more false narratives than older children and adults. If a child learns about an event from a story read to them, or even through a dream, they are more likely to later believe that they learned of it through actual participation. Similarly, younger children’s memories are weaker and fade quicker than older children’s memory traces, and this, too, may be a reason they create more false narratives. In studies of individual differences among children of the same age, these same factors appear to be associated with differences in false narratives. Children who have stronger memories are more resistant to suggestions about those memories.

Interviewer training and selection
There is not a great deal of data on who should interview, although people prone to emphasizing their own authority or who have an ingrained bias or expectation as to the outcome of an interview which cannot be dissuaded by training are probably not ideal candidates. Some data on the effectiveness of speciﬁc interviewer training programmes has emerged (Warren et al. 1999), but more research needs to be carried out in this area. The types of interviewer behaviours that should be encouraged, however, have received attention and we have discussed many of those: open-ended questioning; the use of directed questioning with caution and only in the most neutral manner; avoiding any stereotype induction; minimizing motivation to provide speciﬁc answers; and not introducing information or preferences to the child. It is important to note that both areas of research have contributed to a growing body of knowledge that is beginning to inﬂuence the training of forensic interviewers. These ﬁndings have resulted in texts that provide interviewers with clear realworld recommendations on interviewing (Ceci & Bruck 1995; Poole & Lamb 1998). Changes in interviewer behaviour to more open-ended questioning helps both victims of child abuse and victims of false accusations.

References
Binet, A. (1900) La Suggestibilité. Schleicher Frères, Paris. Boat, B.W. & Everson, M.D. (1996) Concerning practices of interviewers when using anatomical dolls in child protective services investigations. Child Maltreatment, 1(2), 96–104.

Bothwell, R.K., Deffenbacker, K.A. & Brigham, J.C. (1987) Correlation of eyewitness accuracy and conﬁdence: optimality hypothesis revisited. Journal of Applied Psychology, 72, 691–695. Bruck, M., Ceci, S.J., Francoeur, E. & Renick, A. (1995) Anatomically detailed dolls do not facilitate preschoolers’ reports of a pediatric examination involving genital touching. Journal of Experimental Psychology: Applied, 1, 95–109. Bruck, M., Hembrooke, H. & Ceci, S. (1997) Children’s reports of pleasant and unpleasant events. In: Recollections of trauma: Scientiﬁc evidence and clinical practice, (eds J.D. Read & D.S. Lindsay), pp. 199–219. Plenum Press, New York. Bruck, M., Ceci, S.J., & Hembrooke, H. (in press) The nature of children’s true and false narratives. Developmental Review. Burtt, H.E. (1948) Applied Psychology. Prentice Hall, Englewood Cliffs, NJ. Cassel, W. & Bjorklund, D. (1996) Developmental patterns of eyewitness memory, forgetting, and suggestibility: an ecologically based short term longitudinal study. Law and Human Behavior, 19, 507–532. Ceci, S.J. & Bruck, M. (1993) The suggestibility of the child witness: a historical review and synthesis. Psychological Bulletin, 113, 401–432. Ceci, S.J. & Bruck, M. (1995) Jeopardy in the Courtroom: a Scientiﬁc Analysis of Children’s Testimony. American Psychological Association, Washington, D.C. Ceci, S.J. & Friedman, R.D. (2000) The suggestibility of children: scientiﬁc research and legal implications. Cornell Law Review, 86, 101–182. Ceci, S.J., Loftus, E.F., Leichtman, M.D. & Bruck, M. (1994) The role of source misattributions in the creation of false beliefs among preschoolers. International Journal of Clinical and Experimental Hypnosis, 62, 304–320. Conte, J.R., Sorenson, E., Fogarty, L. & Rosa, J.D. (1991) Evaluating children’s reports of sexual abuse: Results from a survey of professionals. American Journal of Orthopsychiatry, 61(3), 428– 437 Cunningham, J.L. (1988) Contribution to the history of psychology. XLVL. The pioneer work of Alfred Binet on children as eyewitnesses. Psychological Reports, 62, 272–283. Dale, P.S., Loftus, E.F. & Rathburn, L. (1978) The inﬂuence of the form of the question on eyewitness testimony of preschool children. Journal of Psycholinguistic Research, 7, 269–277. DeLoache, J.S. & Marzolf, D.P. (1995) The use of dolls to interview young children: Issues of symbolic representation. Journal of Experimental Child Psychology, 60, 155–173. Eisen, M.L., Goodman, G.S., Qin, J. & Davis, S.L. (1998) Memory and suggestibility in maltreated children: new research relevant to evaluating allegations of abuse. In: Truth in Memory (eds S. Lynn & K. McConkey), pp. 163–188. Guilford Press, New York. Fivush, R. (1993) Developmental perspectives on autobiographical recall. In: Child victims, child witnesses: Understanding and improving testimony (eds G.S. Goodman & B.L. Bottoms), pp. 1–24. Guilford Press, New York. Fivush, R. & Schwarzmueller, A. (1998) Children remember childhood: Implications for childhood amnesia. Applied Cognitive Psychology, 12, 455–473. Fivush, R. & Shukat, J. (1995) Content, consistency, and coherence of early autobiograhical recall. In: Memory and testimony in the child witness (eds M.S. Zaragoza, J.R. Graham, G.C.N. Hall, R. Hirschman & Y.S. Ben-Porath), pp. 5–23. Thousand Oaks, CA: Sage. Garven, S., Wood, J.M., Malpass, R.S. & Shaw, J.S., III. (1998) More than suggestion: the effect of interviewing techniques from the

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CHILDREN’S TESTIMONY McMartin Preschool case. Journal of Applied Psychology, 83(3), 347–359. Garven, S., Wood, J.M. & Malpass, R.S. (2000) Allegations of wrongdoing: the effects of reinforcement on children’s mundane and fantastic claims. Journal of Applied Psychology, 85(1), 38–49. Goodman, G.S. & Aman, C. (1990) Children’s use of anatomically detailed dolls to recount an event. Child Development, 61(6), 1859–1871. Goodman, G.S. & Clarke-Stewart, A. (1991) Suggestibility in children’s testimony: implications for child sexual abuse investigations. In: Suggestibility of Children’s Recollections (ed. J.L. Doris), pp. 92–105. American Psychological Association, Washington, D.C. Goodman, G., Wilson, M.E., Hazan, C. & Reed, R.S. (1989) Children’s testimony nearly four years after an event. Paper presented at the annual meeting of the Eastern Psychological Association, Boston MA. Goodman, G.S., Rudy, L., Bottoms, B. & Aman. C. (1990) Children’s concerns and memory: issues of ecological validity in the study of children’s eyewitness testimony. In: Knowing and Remembering in Young Children (eds R. Fivush & J. Hudson), pp. 249–284. Cambridge University Press, New York. Goodman, G.S., Batterman-Faunce, J.M. & Kenney, R. (1992) Optimizing children’s testimony: Research and social policy issues concerning allegations of child sexual abuse. In: Child abuse, child development and social policy (eds D. Cicchetti & S. Toth). Ablex, Norwood, NJ. Goodman, G.S., Quas, J.A., Batterman-Faunce, J.M., Riddlesberger, M.M. & Kuhn, G. (1997) Children’s reactions to and memory for a stressful event: inﬂuences of age, anatomical dolls, knowledge, and parental attachment. Applied Developmental Science, 1, 54–75. Gordon, B.N., Ornstein, P.A., Nida, R.E., Follmer, A. et al. (1993) Does the use of dolls facilitate children’s memory of visits to the doctor? Applied Cognitive Psychology, 7(6), 459–474. Gudjonsson, G.H. & Clark, N.K. (1986) Suggestibility in police interrogation: A social psychological model. Social Behaviour, 1, 83–104. Lamb, M.E., Hershkowitz, I., Sternberg, K.J. et al. (1996) Effects of investigative utterance types on Israeli children’s responses. International Journal of Behavioral Development, 19, 627–637. Leichtman, M.D. & Ceci, S.J. (1995) The effects of stereotypes and suggestions on preschoolers’ reports. Developmental Psychology, 31, 568–578. Leippe, M.R., Manion, A.P. & Romanczyk, A. (1992) Eyewitness persuasion: How and how well do fact ﬁnders judge the accuracy of adults’ and children’s memory reports? Journal of Personality and Social Psychology, 63(2), 181–197. Lepore, S.J. & Sesco, B. (1994) Distorting children’s reports and interpretations. Applied Psychology, 79, 108–120. Lipmann, O. (1911) Pedagogical psychology of report. Journal of Educational Psychology, 2, 253–260. Loftus, E.F. (1979) Eyewitness Testimony. Harvard University Press, Cambridge, MA. Lyon, T.D. (1999) The New Wave in Children’s Suggestibility Research: A Critique. Cornell Law Review, 84, 1001–1081. Messerschmidt, R. (1933) The suggestibility of boys and girls between the ages of six and sixteen. Journal of Genetic Psychology, 43, 422–437. Ornstein, P.A., Gordon, B.N. & Larus, D.M. (1992) Children’s memory for a personally experienced event: Implications for testimony. Applied Cognitive Psychology, 6, 49–60. Ornstein, P.A., Shapiro, L., Clubb, P. & Follmer, A. (1997) The inﬂuence of prior knowledge on children’s memory for salient medical experiences. In: Memory for Everyday and Emotional Events (eds N. Stein, P.A. Ornstein, T. Trabasso & C. Brainerd), pp. 83–112. Erlbaum, Mahwah, NJ. Otis, M. (1924) A study of suggestibility in children. Archives of Psychology, 11, 5–108. Piaget, J. (1986) Judgment and Reasoning in the Child. Harcourt Brace & Co., New York. Poole, D.A. & Lamb, M.E. (1998) Investigative interviews of children: a guide for helping professionals. American Psychological Association, Washington, D.C. Poole, D.A. & Lindsay, D.S. (1995) Interviewing preschoolers: Effects of nonsuggestive techniques, parental coaching, and leading questions on reports of nonexperienced events. Journal of Experimental Child Psychology, 60, 129–154. Poole, D.A. & Lindsay, D.S. (1996) Interviewing preschoolers: effects of nonsuggestive techniques, parental coaching, and leading questions. Journal of Experimental Child Psychology, 60, 129–154. Poole, D.A. & White, L.T. (1991) Effects of question repetition on the eyewitness testimony of children and adults. Developmental Psychology, 27, 975–986. Poole, D.A. & White, L.T. (1993) Two years later: effects of question repetition and retention interval on the eyewitness testimony of children and adults. Developmental Psychology, 29, 844–853. Poole, D.A. & White, LT.. (1995) Tell me again and again: stability and change in the repeated testimonies of children and adults. In: Memory and Testimony in the Child Witness (eds M.S. Zaragoza, J.R. Graham, C.N. Gordon, R. Hirschman & Y. Ben-Porath), pp. 24–43. Sage Publications, Thousand Oaks, CA. Powers, P., Andriks, J.L. & Loftus, E.F. (1979) Eyewitness accounts of females and males. Journal of Applied Psychology, 64, 339–347. Rawls, J.M. (1996) How question form and body-parts diagrams can affect the content of young children’s disclosures. Paper presented at the NATO Advanced Study Institute, Recollections of trauma: Scientiﬁc research and clinical practice. Port de Bourgenay, France. Lawtalk, April 1996, pp. 28–29. Ross, D.F., Dunning, D., Toglia, M. & Ceci, S.J. (1990) The child in the eyes of the jury. Law & Human Behavior, 14, 5–23. Rudy, L. & &. Goodman, G.S. (1991) Effects of participation on children’s reports: implications for children’s testimony. Developmental Psychology, 27, 527–538. Saywitz, K.J., Goodman, G.S., Nicholas, E. & Moan, S.F. (1991) Children’s memories of a physical examination involving genital touch: implications for reports of child sexual abuse. Journal of Consulting and Clinical Psychology, 59(5), 682–691. Sjoberg, R. (1995) Child testimonies during an outbreak of witch hysteria, Sweden 1670–71. Journal of Child Psychology and Psychiatry, 36, 1039–1051. Small, W.S. (1896) Suggestibility of Children. 13 Pedagogical Seminar. Stern, W. (1910) Abstracts of lectures on the psychology of testimony and on the study of individuality. American Journal of Psychology, 21, 270–282. Steward, M., Steward, D.S., Farquahar L. et al. (1996) Interviewing young children about body touch and handling. Monographs of the Society of for Research in Child Development, 61, (4–5: Serial no. 248). Uttal, D., Schreiber, J.C. & DeLoache, J.S. (1995) Waiting to use a symbol: The effects of delay on children’s use of models. Child Development, 66(6), 1875–1889. Varendonck, J. (1911) Les témoignages d’enfants dans un procès retentissant. Archives de Psychologie, 11, 129–171. Warren, A.R., Woodall, C.E., Thomas, M. et al. (1999) Assessing the effectiveness of a training program for interviewing child witnesses. Applied Developmental Science, 3, 128–135. Warren, A., Garven, S., Walker, N., Woodall, E. (2000) Setting the record straight. Paper presented at the Biennial Meeting of the American Psychology-Law Society, New Orleans, LA.

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9
Introduction

Family Interviewing: Issues of Theory and Practice
Ivan Eisler

Conjoint family interviews, whether as part of assessment or treatment, have become a standard part of child psychiatric practice. A well-conducted family interview will provide the clinician with an important source of information about the family and opportunities for intervention that are not available when family members are seen on their own. Like other clinical interviews, the family interview will generally have a mixture of objectives — making an engagement with the members of the family, obtaining information and observing family process for purposes of assessment and making therapeutic interventions. The family interview has a number of distinct features in comparison with an individual interview, which gives it both strengths as well as certain weaknesses. It offers the opportunity to observe family members in direct interaction, which can give unique insights into the way the family is currently functioning and the way it is organized around the presenting problem. The family interview is also well suited to explore the perceptions and meanings that different family members hold about the problem, which can lead to new understandings of the part it might be playing in their lives. If the family members experience the clinician as someone who has a real interest in their different points of view and takes each of them seriously, the opening up of different perspectives in this way can be an important starting point for the process of therapeutic change. On the other hand, as Cox (1994) has argued, the family interview is not ideally suited for the gathering of historical data about the individual (or family) and its ‘public’ nature may make it more difﬁcult, and sometimes inappropriate, to discuss issues that family members may feel are private or awkward to talk about in the family context. A useful framework for thinking about the family interview (both in terms of understanding the observed family process and also as a way of framing some of the speciﬁc techniques and interventions that may be used by the clinician when seeing the family) is provided by family systems theory. Before outlining this theoretical framework, an important caveat needs to be made. Clinicians sometimes assume that the principal reason for a family assessment is to identify dysfunctional patterns of family functioning, which may be the underlying cause of the child’s problem and which need to be corrected if the child is to be helped. Over the years a variety of theoretical family models (see Jacobs & Pearse, Chapter 57) have been put forward to explain 128

the development of a range of disorders from schizophrenia (Bateson et al. 1956; Lidz et al. 1957), through anorexia nervosa (Palazzoli 1974; Minuchin et al. 1975) to conduct disorder (Patterson 1982). These models, based on careful clinical observations, are often very persuasive and have been highly inﬂuential, leading to important developments in family therapy (Dare et al. 1995). Paradoxically, alongside the growing evidence for the effectiveness of family interventions for most child and adolescent disorders (Alexander & Parsons 1973; Patterson et al. 1982; Russell et al. 1987; Henggeler & Borduin 1991; Joanning et al. 1992; Kazdin et al. 1992; Borduin et al. 1995; Webster-Stratton & Hammond 1997; Eisler et al. 1997, 2000; see also reviews by Carr 2000a,b), there is also increasing evidence that many of the theoretical models, such as Bateson’s double-blind theory (Bateson et al. 1956) or Minuchin’s model of the Psychosomatic Family (Minuchin et al. 1978) are ﬂawed (Olson 1972; Kog et al. 1985; Eisler 1995a). While it is undoubtedly true that relationships within the family, the emotional climate and the patterns of family interaction are an important part of the complex matrix that contributes to the development and/or maintenance of individual psychopathology, the evidence that speciﬁc family factors or particular forms of family organization are directly associated with certain disorders is not very persuasive. Poor family functioning, family discord, inadequate parenting or neglect are generally higher in clinical samples than in control groups (Sawyer et al. 1988; Friedman et al. 1997; Beavers & Hampson 2000) but this is likely to be a reﬂection of a complex interaction over time between the effect of the family environment, personality and temperamental characteristics of the child, the impact of the developing disorder on the family, resilience factors as well as mediating genetic factors (Fergusson & Lynskey 1996; Rutter 1999). This is highlighted by behavioural genetic research showing the differential impact of the family environment on children within the same family (Dunn & Plomin 1990; Reiss et al. 1995; Rutter et al. 1999). When observing a family in the clinic setting it is all too easy to forget the complexity of the interaction that has led to the current situation and to jump to the conclusion that the observed pattern of family functioning can provide the explanation of why the child has problems. Such a conclusion is not only diagnostically simplistic but also therapeutically unhelpful as it reinforces feelings of guilt and blame which family members, and parents in particular, are likely to experience (Reimers & Treacher 1995). The clinician needs to be sensitive to the fact

FAMILY INTERVIEWING: ISSUES OF THEORY AND PRACTICE

that inviting the whole family to attend together may be interpreted by them as an indication that the family is seen as the source of their child’s problem.

Family systems theory
The idea that the family can be thought of as a system may seem at one level self-evident, as clearly the family is an entity that is more than just a collection of individuals. Members of a family are intimately connected, they have a shared history, they may share certain beliefs and values, they take on particular roles and they ﬁnd themselves responding to one another in predictable ways. The connectedness of the elements of the system and the notion that what happens in one part of the system has an effect on the rest of the system ﬁts well with our notion of the family, but accords less well with how we think of individuals. It seems to take away from the value that we attach to individuals, their individual feelings, beliefs and their ability to make choices about individual actions. A similar tension arises when we consider individual development as being part of an evolving family system. If children as well as parents are considered ‘merely’ as elements in the system, how do we account, for instance, for the differences in power between parents and children to inﬂuence the evolving system? Even though we may readily accept that parents and children inﬂuence each other mutually, we still want to emphasize that it is primarily parents who socialize their children, and not vice versa. While at a theoretical level it may be possible to integrate the essentially linear notions of individual development and growth with the systems notion of circular causality (Minuchin 1988), in practice there is always likely to be a tension between the two perspectives. There is a danger therefore that we either concentrate on the individual without taking sufﬁcient account of the family context, or that we focus on the family to the extent that we lose sight of the needs of individual members and, in particular, the child (Strickland-Clark et al. 2000). It is beyond the scope of this chapter to discuss family systems theory in detail but the following are the key features (for more detailed accounts see Gorell Barnes 1985; Eisler 1993; Dallos & Draper 1999).

anxious child may complain of feeling sick before going to school, which may evoke a worried response from the child’s mother which in turn may reinforce the child’s anxiety. Mother’s response will have been determined not only by her perception of the situation but also by her anticipation of how others (father, school, etc.) are likely to respond. If father perceives the child’s behaviour as manipulative and/or views mother’s worried response as something that is fuelling the anxiety in the child, he may try to play down the urgency of the situation. Mother may see this as father’s lack of understanding (or lack of concern) and she may respond by highlighting the seriousness of the situation, which will have an effect on both the father’s and the child’s further response. Each of the behaviours is only fully comprehended when both the preceding behaviours and anticipated responses are taken into account. In fact, without knowing the social context, it is difﬁcult to know what meaning to attach to a particular behaviour.

Patterns of interactions in families
Over time families develop a set of patterns of interactions which become relatively stable. These patterns are connected to the beliefs, perceptions and expectations that different members of the family have, some of which may be shared and may also become relatively ﬁxed (Byng-Hall 1986; Papp & Imber-Black 1996). Some patterns are related to the structure or the hierarchical organization of the family and the different roles that the family members take on, reﬂecting family beliefs, often strongly inﬂuenced by cultural or speciﬁc family traditions, about the nature of family life, gender roles, parenting tasks, etc. Subtler patterns of family process, of which family members themselves may not be always aware, can be observed in the moment-tomoment interaction in the family. When a family discussion is observed, relatively stable patterns can be observed of whospeaks-to-whom, turn-taking, interruptions, etc. (Lennard & Bernstein 1969). More complex patterns, e.g. in the way that a family handles disagreement or conﬂict, will also be characteristic of a particular family (Minuchin et al. 1978; Street & Foot 1984); so that, for instance, when a teenage daughter and her father start having a disagreement, mother will step in and diffuse the argument. In families with an ill child, the symptomatic behaviour will often take on a central role in the process of family transactions to the point where much of what happens seems to revolve around the symptomatic behaviour in a way that may both reinforce the symptom and in turn be maintained by it.

The social context of behaviour
Individual behaviour and individual personal characteristics need to be viewed in the social context in which they occur. It is a familiar observation that individuals will behave differently in the different contexts in which they ﬁnd themselves. At the simplest level, every behaviour is both a response to the previous behaviour and, at the same time, a stimulus for the next element of behaviour in the sequence (such sequences often being recursive, so that behaviours may be mutually reinforcing). The way in which even a simple sequence of behaviours evolves is complex, as it depends on the meaning attached to the observed behaviour as well as the anticipation of future response(s). For instance, an

Stability and change in families
The family system evolves through alternating periods of stability and periods of change in response to the changing developmental needs of its members and/or external pressures. The stability and predictability of the family environment is an important aspect of family life, as it provides the context in which the individual developmental needs of its members are met. For 129

CHAPTER 9

instance, the child’s need for dependence and attachment require a degree of stability and constancy in the family but, as the child develops, the family must ﬁnd ways of meeting his or her needs for independence and separation as well (Langmeier & Matˇ ejˇ cek 1975; Byng-Hall 1991; Eisler 1993). Thus, as the family evolves through the predictable stages of the family life cycle (Carter & McGoldrick 1989), it needs to be able to adapt and change its habitual style of functioning. These transitional points in the family life cycle (whether in response to developmental changes or to unpredictable events, such as bereavement or family break-up, migration, major societal change, etc.) create pressure on individual family members and may lead to increased psychological morbidity (Hetherington 1989; Sartorius 1996; Gorell Barnes et al. 1998; Ritsner & Ponizovsky 1999). The way the family adapts may be a crucial factor in determining the extent of individual vulnerability to such pressures (Walsh 1997). Current systems theory (von Foerster 1981; Hoffman 1990; Dallos & Draper 1999) emphasizes that the clinician, in exploring the family system, is never a passive detached observer looking in on the system, but has an active role observing him- or herself in interaction with the family. This has important implications for thinking about the way family interviews are conducted and how descriptions of interaction are made, which will be discussed later on in the chapter. It is best illustrated by an example. Clinical accounts of families often include descriptions of ‘overprotective’ parental behaviour (Levy 1939; Minuchin et al. 1978). Such a label is limited, in that it does not take into account the interaction between the parent’s protective behaviour and the child’s dependent behaviour and often ignores the context in which it occurs (e.g. a serious illness in the child). Equally importantly, it assumes that the clinician is a detached observer who is simply describing a behaviour and is not inﬂuenced by his or her own relationship with the family. However, the parent who is described as ‘overprotective’ is probably also being experienced by the clinician as someone who is reluctant to heed the advice to give the child more independence, thereby frustrating the well-meant efforts of the clinician. The description of overprotectiveness therefore has to be seen both as a reﬂection of the observed parent–child relationship and also of the relationship between the clinician and the family.

and our expectations of the effect that these might have on the family (Lau 1984; Hodes 1985; Messent 1992; Wieselberg 1992; Gorell Barnes 1994, 1998). The other aspect of the wider social context that the clinician needs to keep in mind is the family’s position in relation to other professionals or agencies. Often there is a network of helpers within health, education or social services, with whom the family has an ongoing relationship. These relationships have an important bearing on what the family expects of us, how the family members present themselves and how they experience our interventions. At times the network of professional relationships can become quite disabling, creating a sense of neediness and helplessness, which is met with further provisions of support, making any resources that the family itself has more and more invisible (Cooklin et al. 1983; Imber-Black 1988; BoydFranklin 1989). Exploring the relationship that the family has with the professional network can therefore be an important part of understanding how the family is functioning.

Practical aspects of family interviewing
How and when clinicians use family interviews in their clinical practice varies considerably. This is largely determined by theoretical preferences, although factors such as the age of the child, the nature of the presenting problem or other factors, such as research or training needs, may also have a role. Different considerations may also apply, depending on whether one is thinking of the family interview as part of engagement, assessment or treatment, although clearly the distinction between the three is somewhat arbitrary. An assessment interview is a starting point for the development of a treatment alliance but, at the same time, enquiring sympathetically about the problem, clarifying its nature and asking how it affects different family members is also a very powerful therapeutic intervention in its own right. By the same token, however thorough the initial diagnostic assessment interview has been, during the process of treatment new information and new connections will emerge, adding to or changing the initial conclusions that were reached during the assessment stage. For the purposes of this discussion the distinction between engagement, assessment and treatment is useful, because it may help to clarify some of the ideas of when and how it may be useful to include family interviews in clinical practice.

Social and cultural context of the family
Earlier family therapy texts tended to treat the family as a normative entity and took little account of the enormous diversity of family life and the role of the wider social and cultural context in which the family is placed. These issues are noted also in Jacobs & Pearse (Chapter 57) and will not be discussed in detail here. However, it is important to stress that awareness and sensitivity to cultural and social diversity of families is a crucial factor in how we as clinicians relate to families, the language that we use, the meanings that we attach to our observations of family interaction, as well as the choice of therapeutic interventions 130

The family interview as a context for engagement in treatment
For the systemically orientated clinician, the family interview is both the principal assessment instrument as well as the main context for therapeutic interventions. Most family therapy texts therefore assume that a family interview will also be where the engagement and the negotiation of the treatment contract takes place. Not all clinicians use the family interview to this extent, seeing it perhaps primarily as just one of the components of a comprehensive assessment and would not necessarily think of

FAMILY INTERVIEWING: ISSUES OF THEORY AND PRACTICE

inviting the whole family to the ﬁrst meeting. However, there will be many instances when it is useful to start by seeing the family together. Children and adolescents seldom seek psychiatric help for themselves and how they are to be engaged in the treatment process has to be considered alongside of how one engages the parents. For young children, being seen together with the parents, at least initially, may feel less threatening than being seen on their own. There may also be advantages, as will be discussed later, in seeing a reluctant child or adolescent in the context of a family meeting, as it may be possible to engage them even without them taking a particularly active part. Whether the family is initially seen in a conjoint interview or separately may make a difference to their expectation of future treatment and perhaps also to their perception of why they are being asked to attend as a family. In a randomized study in which a conjoint family assessment was compared with separate parent and child assessments, Cox et al. (1995) found that there was a signiﬁcantly higher failure rate of attendance for subsequent appointments if the mode of contact (conjoint or separate) was changed after the initial assessment. There is also evidence that families in which both parents attend the ﬁrst interview are more likely to continue in treatment than when only the mother attends (LeFave 1980). Engaging the whole family may be more difﬁcult where there is hostility, criticism or generally poorer family functioning (Szmukler et al. 1985; Dare et al. 1990; Hampson & Beaver 1996a), particularly if the style of treatment does not provide sufﬁcient structure and containment (Hampson & Beaver 1996b).

The family interview as part of assessment
In one sense the case for including conjoint family interviews in a comprehensive assessment is the most obvious. The family interview certainly provides an ideal opportunity to assess the patterns of relationships, the emotional climate of the family and a chance to see the way in which the family has become organized around the symptomatic behaviour of the child. However, to argue that such information can only be obtained by seeing the family together would be to overstate the case. A number of studies have shown that, when global measures of family functioning are used (family or marital satisfaction, family competence, family health, etc.), self-report measures correlate highly with clinical ratings of observed interaction in both clinical (Miller et al. 1994; Hayden et al. 1998; Beavers & Hampson 2000) and non-clinical samples (Stevenson-Hinde & Akister 1995). Ratings on individual subscales showed moderate but signiﬁcant correlations both between individual family members’ self-reports and between self-report and observer rating, with the exception of ratings of affective expressiveness and behavioural control (Miller et al. 1994; Stevenson-Hinde & Akister 1995). Comparisons have also been made of ratings of Expressed Emotion (one of the most widely used measures of family atmosphere) from individual and family interviews (Szmukler et al. 1987; Hodes et al. 1999) showing a moderate to strong correlation of ratings between the two settings.

The above studies suggest that while conjoint family interviews may provide a richer and, in some cases, more meaningful picture of family functioning, if the principal aim is to assess the overall level of family functioning, individual interviews should provide a reasonably accurate picture. Indeed, in some instances, individuals may be more willing to report negative aspects of family functioning when they are interviewed on their own (Haynes et al. 1981). The question of whether to include conjoint family interviewing in an overall assessment cannot be answered simply on the basis of comparing the quality of information obtained from individual or family interviews but must also depend on the context and the purpose for which the assessment is made and how the information is to be used. Where the primary aim is to provide a detailed considered assessment on which important decisions about the child might be made (e.g. for a Court report), a combination of family and individual interviews would be advisable. In such cases an open-ended unstructured family interview could be usefully supplemented by one of several available structured family interviews and clinical rating scales that have been developed based on well-deﬁned theoretical models of family functioning: the McMaster Model of Family Functioning (Epstein et al. 1978; Bishop et al. 1980; Miller et al. 2000); the Beavers Systems Model of Family Functioning (Beavers & Hampson 1990, 2000); or the Olson Circumplex model (Olson et al. 1989; Olson 1990, 2000). These measures are well researched and have satisfactory psychometric properties (see also Grotevant & Carlson 1989; Kerig & Lindahl 2001 for reviews of family assessment measures). Research and/or training needs might be additional factors weighing in support of the use of such measures. The potential disadvantage of such an approach is that the assessment of family functioning can easily become a search for family dysfunction. All too often there is at least an implicit assumption that the primary aim of family assessment is to uncover areas of poor functioning, that can be corrected by providing treatment for the family. The evidence that well-functioning families beneﬁt more from family therapy than poorly functioning families (Hampson & Beavers 1996a) suggests that correcting family dysfunction may not be a necessary ingredient of effective family interventions. The above points highlight the importance for family assessment to focus at least as much on family strengths, family resources and family competencies as on areas of poor functioning. While assessing strengths and resources is an important aspect of any comprehensive diagnosis, it is particularly important if the aim is to engage the family in treatment. A family assessment that is a prelude to (or perhaps more accurately the initial phase of) family treatment is above all a way of answering questions of how best to work with the family; questions about whether or how the family might need to change should come second. The manner in which we engage the family in this process and the nature of the evolving therapeutic relationship is probably more important than whether the family is seen together or separately. 131

CHAPTER 9

The family interview as part of treatment
The different ways in which family interviews are used in the context of treatment are discussed in detail in Jacobs & Pearse (Chapter 57) so only some general points will be made here. If one assumes that the impact of a clinical interview experience is directly related to how ‘new’ the experience is, then clearly the family interview, in exploring a multiplicity of perspectives, always has the potential of having a signiﬁcant impact on the family and, as Tomm (1987a) pointed out, affords considerably more therapeutic opportunities than clinicians sometimes realize. Positive results have been reported following single session interventions with the family (Boyhan 1996; Campbell 1999; Hampson et al. 1999). Because one of the aims of the family interview is to gain access to the different perceptions of individual family members, there are always opportunities for new meanings and new perspectives to emerge. Not all family members will have the same knowledge and understanding of the problem and some may be involved for the ﬁrst time in discussing the problem openly. Some connections, particularly ones that are linked with the non-verbal processes occurring in families, may have been outside of the awareness of all the family members. The fact that the family interview is an experience shared with other family members means that sometimes even seemingly trivial things occurring during the interview can have quite a powerful effect. One should not automatically assume that these effects are necessarily always experienced as positive by the family. The process of bringing out unspoken or hidden meanings into the open may sometimes be quite painful for them (Gorell Barnes 1998). This may be particularly true if the family feels judged or criticized, or if the interview itself becomes acrimonious or hostile and is dominated by mutual criticisms among family members. Some of these issues will be addressed in more detail later in the chapter. How the family is most effectively involved in the treatment process varies depending on the type of problem (Carr 2000b), although there is also evidence that how families respond to treatment may be dependent on an interaction between type of family organization and therapeutic style. Hampson & Beavers (1996b) found that families rated as high on general family functioning responded best to an open collaborative therapeutic style, whereas disorganized families, with unclear internal boundaries, were more likely to do well when the therapist adopted a less open and more directive style. This was particularly true for families where there was open conﬂict and hostility.

ferent family members might be affected (e.g. a ‘non-problem’ sibling who may be sidelined by the amount of attention that is demanded by the ‘problem’ child in the family) but, more importantly, the presence of siblings often makes it easier to see some of the family strengths and resources that would otherwise remain hidden. While one ought not to be rigid about who should come to the family meeting, it is important not to accept too readily that certain members of the family should be excluded, either because the family feels it would not be appropriate for them to attend, or because there is a view that they would refuse anyhow. Often the apparent unwillingness or inability to attend, e.g. because of work commitments on the part of father, turns out to be more to do with his sense that he would not be able to help anyhow and when the clinician stresses his or her belief that father has an important part to play in helping the child, the initial reluctance is usually readily overcome. If a family is being seen as part of ongoing treatment it can sometimes be helpful to see different subgroupings of the family (parents, siblings) on different occasions as this may allow different perspectives to emerge (Eisler 1995b; Gustafsson et al. 1995). Who should be seen when divorced or step-families are involved may be more difﬁcult to decide. It is usually best to start, as one does with intact families, by inviting the existing household. Inviting divorced parents to subsequent meetings may be useful, although care needs to be taken that this is not interpreted as signalling to the children that the aim of such a meeting is to re-create the old family (Robinson 1990). Where the parents have new partners, and where there may be complex step-family arrangements, it is important to take care not only in who is being invited but also in the way in which the invitation is made. Asking the family to help clarify who has what role in relationship to the children (for the purpose of knowing who should be coming to the family meetings) is often useful in helping to clarify boundaries and in exploring where the family is in the process of its life cycle transition. Such clariﬁcation can help to provide a greater sense of coherence for the children affected by the family break-up and this in itself may be an important part of helping them to adjust to the transition (Gorell Barnes et al. 1998).

Engaging the family and observing family process
It is important at the start of the initial meeting with the family to engage all family members in an age-appropriate way. This requires relating to all family members in a way that makes it clear that their different viewpoints are valued and that the reason they have been asked to come as a family is because they are seen as a resource for helping to deal with the problem, rather than being seen as its cause. It is useful to start by asking relatively low-key social questions about schools, jobs, interests that the children might have, how far the family had to travel for the appointment and so on. This phase of the interview should generally be unhurried and relaxed, making sure that all the family members are included in the interchanges in a way that is appro-

Who should be included in the family interview?
To some extent this will depend on the speciﬁc aim of the particular interview and the subsequent plans for how the family should be involved in treatment. In general, it is useful to start by inviting all members of the family living in the household. This provides the fullest picture of the family, both in the way that dif132

FAMILY INTERVIEWING: ISSUES OF THEORY AND PRACTICE

priate for their age. Although the primary goal during this phase is to allow the family to feel more at ease and to get a sense that they are being taken seriously, it also provides the therapist with an opportunity to make initial observations about patterns of interaction and the structure of the family. Who speaks to whom, how family members respond to one another, who is attended to, who ﬁnds it easy or difﬁcult to join in the conversation, how disagreements or conﬂicts are handled, how the children are helped to settle down, etc., will all provide important initial impressions about the family. If the family is being interviewed in a room with a one-way screen or video cameras it is important, during this initial phase, to point these out to the family and explain the role of the observing team, stressing issues of conﬁdentiality. While much of the initial family interview is likely to be concerned with obtaining information about the nature and history of the problem, the ways in which the family has tried to tackle the problem, and so on, the presence of the whole family makes this a different kind of exercise from individual historytaking. Asking the views of different family members requires the family to reﬂect on the problem and on their relationship to the problem in new ways, especially if the questions are formulated in a relational manner (as will be described in the following section). Thus, although the focus remains primarily on the presenting problem, the clinician is beginning to collect information about the way the family may be organized in relationship to the problem. The clinician may develop certain hypotheses about the nature of these links which will lead to further questions and the response to these will provide further evidence about the usefulness or otherwise of such hypotheses. This information comes both in the form of the verbal response to the question but also from the non-verbal responses of the different family members.

the problem but also often connects with feelings of helplessness, guilt, blame and resentment. This preferred ‘story’ may be shared by some, though not necessarily all, family members. Tomm (1988) argued that lineal questions, particularly if they are the only type of questions asked, may invoke defensiveness and guilt or lead to criticism among family members.

Circular questions
These differ from lineal questions not only in form but also in their underlying assumption. They are questions that make the assumption that individual problems are connected or embedded in patterns of relationships, and the aim of these questions is therefore to illuminate or make visible what these patterns are. So for instance, instead of simply asking ‘What is the problem?’, one might ask ‘How would different people in the family describe your problem?’, ‘Who worries about it?’, ‘Who else worries?’, ‘When people get worried about how unhappy you are, does it make you more or less depressed?’ Other questions might require family members to describe what they make of behaviours that they observe, or speculate about thoughts and feelings of other family members. For instance, instead of asking just about the duration of the problem, the therapist might ask, ‘When did your family ﬁrst notice that you had a problem?’ or ‘What effect did it have on you when your parents started talking about the problem?’ Additional questions might be asked about the way different people in the family responded to the problem and what interactions this might lead to; ‘When your mother shows her worry, what does your father do?’ Asking circular questions around the problem often starts to provide a basis for describing the problem in a more contextual way and also allows for alternative descriptions to be heard. For instance, the family might explain that ‘Mum is the one that worries most, because she’s at home much more, whereas dad is always at work and doesn’t really know what’s going on’, implying that the father, perhaps, cares less than the mother does about the child. Asking the question ‘How much time does your father spend worrying about you when he is at work?’, ‘What is the difference between the way he shows his worry and the way your mother shows hers?’ may elicit an alternative description, namely that father feels quite isolated and excluded but prefers not to show this because he fears that he will be told once more that he does not really understand. The unexpected nature of these questions and the sometimes surprising responses may provide both the clinician and the family with alternative ways of viewing the problem, or may bring out a new aspect of behaviour that had not been part of the family’s awareness. This can open up new options for the family to act on in search of new solutions.

Speciﬁc interview techniques
It is beyond the scope of this chapter to cover in depth the variety of techniques that have been developed for interviewing families (Palazzoli et al. 1980; Penn 1982; Tomm 1987a,b, 1988; Burnham 1986; Dallos & Draper 1990; l’Abate 1994). The following provides a brief outline of some of the different styles of questioning that have proved useful in family interviews. Tomm (1988) suggests the following classiﬁcation.

Lineal questions
These are questions that are asked to orientate the clinician in determining what the problem is, what the family sees as the nature or the cause of the problem, etc. All interviews will include some questions of this type: ‘What is the problem that you have come with?’, ‘How long has it been going on for?’, etc. The disadvantage of lineal questions is that they tend to elicit a rather automatic response. Families tend to have a preferred, and often well-rehearsed, way of presenting their problem which may be quite ﬁxed and expresses not only their belief about the nature of

Strategic questions
These are questions that are used with the primary aim of inﬂuencing the family in a particular way rather than to obtain information and are analogous to giving instructions but, because 133

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they are formulated as a question, this may not always be immediately apparent. ‘Why do you let your mother speak for you?’ is as much a statement which implies that it would be better for the adolescent to speak for him- or herself, as a question asking for an explanation. Challenging interventions of this kind can be useful at times but should be used sparingly, as they can induce feelings of guilt and they may also undermine the therapeutic relationship with the family (Tomm 1988).

Reﬂexive questions
These are questions that are also intended to inﬂuence the family but are less directive, instead requiring family members to reﬂect on how things might be different under changed circumstances, or if they took a different course of action: ‘What would happen if you were able to hide your worry when your daughter got depressed?’, ‘If your mother didn’t try to help next time you have a row with your father which one of you would be more likely to ﬁnd a way of ending the argument; who would be the one to suggest a compromise solution?’ Reﬂexive questions will typically introduce an alternative way of framing a particular behaviour, opening up new possibilities and challenging the assumptions that may underlie a particular pattern of behaviour. They may address an emotion or an aspect of behaviour that is not being expressed overtly and may only be guessed at. They may include an implicit assumption: ‘What will you argue about with your mother when you are no longer bulimic?’ — implying both that there will be change and that arguments between adolescents and parents are normal. Reﬂexive questions, like circular questions, assume that behaviours and the meanings that we attach to them are part of the relational context of the family and that there may be more than one meaning that might be attached to a particular behaviour. The aim is for the family to reﬂect on this context and to explore the way in which thoughts, feelings and behaviours of different family members connect and how they might change. The following example provides an illustration. During an interview with a family with a daughter suffering from bulimia the therapist noted the critical tone of mother’s voice when she described the bulimic behaviour of her daughter. The daughter would mostly turn away from her mother but occasionally would snap back, which would evoke a very defensive response from her mother. After this happened several times the therapist turned to the daughter: ‘When your mother talks about your bulimia are you more aware of her irritation or of her worry about you?’ to which the daughter replied, ‘I know she’s very worried but her irritation drowns that out.’ At which point mother joined in: ‘I know I sound terribly critical but I’m so worried and I can’t stop myself.’ Acknowledging mother’s anxiety made it possible to also talk about her being critical without it sounding as if the therapist was criticizing her for being critical. The pattern of criticism–irritation–defensiveness–criticism was broadened to include mother’s anxiety and both mother’s and daughter’s sense of guilt. It is important for the clinician to be able to use a range of 134

interview styles with families and to have a repertoire of different types of questions. Circular questions, for instance, can be extremely useful in illuminating patterns of relationships in the family and this in itself may be an important and powerful part of the therapeutic process. However, such questions are most usefully applied when the interviewer has a clear hypothesis about the nature of the family relationships and the part played by the symptomatic behaviour in the family organization (Burnham 1986). When the interviewer has a clear focus, one question will naturally lead to the next one, helping to conﬁrm or disconﬁrm the particular hypothesis. If, however, such questions are used without a clear focus they are more likely to create confusion and a sense of alienation (Reimers 1999; Strickland-Clark et al. 2000).

Using genograms
Constructing a family tree is a useful way of enquiring about family history, family beliefs, patterns of relationship over time but also to assess some of the strengths and resources that the family might have, which they themselves may have lost sight of (for detailed discussions of the use of genograms see McGoldrick & Gerson 1985; Bloch et al. 1994). This is best performed when an opportunity presents itself, arising spontaneously from a conversation with the family, e.g. about the extended family or a piece of family history that the family themselves have mentioned. ‘I need to have a clear picture of who ﬁts where, perhaps you could help me draw a family tree so that I can see this’, could be a way of introducing the idea. It is important that the way in which the discussion about the family is conducted highlights that one is enquiring about the family primarily because one is interested in having a better understanding of the wider family context and in particular of the family strengths, resources and resilience, rather than because one is searching for family pathology. One should enquire not only about individuals and events from the family history but also about the nature of the relationships, looking for patterns across generations in dealing with relevant life cycle transitions, identifying important beliefs and values that the family holds, etc. Enquiring about differences between traditions and beliefs on the mother’s and father’s side of the family, and which of these and how they have been incorporated into their own family, can provide a useful starting point for a discussion amongst family members. If there are younger children in the family they can be asked to help in drawing the family tree and encouraged to ask questions about the details of the families of their parents of which they are unsure. When techniques such as genograms are used during family interviews a degree of caution is needed. It is all too easy to read into a genogram far more than is actually warranted and relatively trivial matters may be included and interpreted as giving the ‘true’ picture of the family. It is therefore particularly important not to try and interpret the meaning of such patterns too readily and it is generally more useful to ask the family what they themselves make of the patterns that they have identiﬁed.

FAMILY INTERVIEWING: ISSUES OF THEORY AND PRACTICE

Tracking and responding to the interaction process
Awareness and sensitivity to the processes within the family are important, not only as ways of assessing the nature of the relationships within the family, but also as an important part of the process of joining the family and introducing change (Minuchin & Fishman 1981). For instance, if one notices that questions directed towards an adolescent are repeatedly answered by one or other of the parents, one might want to check out how readily such a pattern might change. This might be done non-verbally, by ﬁxing the adolescent’s gaze more intently next time one asks a question, or leaning forward so that it is more difﬁcult for someone else to join in the conversation. Alternatively, one could ask a question or comment in a way that draws attention to what is happening; ‘I have noticed that you often let your mother speak for you; it is as if you thought she has better answers than you do.’ When commenting on family process it is always important to recognize that the same phenomenon can be described in a number of ways: ranging from neutral (questions addressed to the daughter are more likely to be answered by the mother than by the daughter herself); through ascribing agency to one or other participant in the interaction (mother speaks for daughter; daughter lets mother speak for her); to overtly critical (mother behaves in an intrusive way; daughter cannot be bothered to answer any questions). Even quite neutral comments may appear critical to family members and the clinician therefore has to be careful in choosing an appropriate style of comment or question. Andersen (1987) recommended that reﬂections of this kind are best done in a tentative way rather than being pronouncements or authoritative interpretations that are likely to come across as being judgemental.

Interviewing families with young children
All too often when a family with young children is seen, the children become passive participants of a discussion between the adults. Even very young children can be effectively included in family interviews, provided they are engaged in an ageappropriate way. This can be aided through providing toys, drawing materials, etc., and using creative and play techniques in a similar way that they would be used in individual interviews with a child. Engaging a child effectively is often very reassuring for parents, who may feel unsure whether bringing the child to a psychiatric setting is the right thing to do. The choice of language in talking to parents about their child’s problems is also important with young children present as it may be difﬁcult for the child to understand what is being said. Often it is better to ask the parents to explain things to the child, rather than the clinician doing this directly as this may be both less threatening for the child and also reinforces the sense that the parents are the experts in their own child. With very lively active children the ﬁrst task is to create a working environment in which what family members have to say can be attended to. This is best achieved by actively collabo-

rating with the parents. Asking the parents for advice on how best to occupy young children ‘so that we can also talk’ will both reinforce the parents’ sense that they are being taken seriously and also may make it easier for the child to join in spontaneously at some point during the interview. Little is gained from trying to talk to the parents until one has assisted them to help the children settle down and play in a way that both the parents and the clinician are comfortable with. Children are often reluctant attendees in a psychiatric setting and may not be too keen to take part in discussions at ﬁrst. Making it clear at the start of the session that everyone in the room will have an opportunity to have their say, while stressing that it is also ﬁne to sit and listen, is important for some children, to avoid making them feel that they are being put on the spot. When the pressure on them to join in is removed, children will often join in spontaneously. Joining with a child in creative play or talking about a drawing he or she has made can also provide an opportunity for the child to have his or her voice heard in the session (see also Dare & Lindsey 1979; Larner 1996; Wilson 1998). A similar situation can sometimes arise with an adolescent who may be reluctant to talk, while the parents may have an expectation that the ‘experts’ will succeed where they themselves have been unable to get through. While sometimes such an adolescent may be more willing to talk when seen individually this is, by no means, always the case. The advantage of a family interview is that even a reluctant or unwilling participant can be included in an interview through indirect means. Making it clear that the therapist respects the adolescent’s right not to speak can avoid an unhelpful battle. This can be done in a way that respects the adolescent’s autonomy while at the same time making sure that he or she is not being simply ignored. One might say: ‘I often ﬁnd that young people, when they come here, feel that its best for them not to say too much at ﬁrst, which is ﬁne, but if you want to say how things are from your point of view I would obviously be interested to know. I do need to know your parents’ views about things as well but I want to make sure that we don’t simply ignore you, so I will check from time to time whether you want to add something.’

Problems and pitfalls of family interviews
Personal and intimate issues
There will always be areas and topics that are either too difﬁcult or inappropriate to raise in the context of a family interview. The distinction between difﬁcult and inappropriate may sometimes be obvious (e.g. discussing the sexual relationship of the parents in the presence of their children) but more often than not the two tend to get blurred. Often the reluctance to talk about certain topics in the presence of the whole family is either to protect other family members from painful feelings or to avoid the reopening of a disagreement or a confrontation. The appropriateness or otherwise of discussing speciﬁc topics will vary from family to family, which will be determined partly by their social, 135

CHAPTER 9

cultural and religious background, but may also be idiosyncratically connected to speciﬁc aspects of their own family history and beliefs. Sometimes the uncertainty that the interviewer feels about whether or how to raise a particular topic may be as much to do with his or her own feelings and attitudes on the subject as they are to do with the family themselves. It is important that it is always made clear to the family that they have a choice about what is to be discussed. Asking questions that help to clarify what the family ﬁnd appropriate, or asking for permission to talk about a certain subject, will often make it possible to talk about the issue without the discomfort that would otherwise accompany it or prevent the discussion altogether. As clinicians we are sometimes driven by a quest for ‘complete’ information in order to make sure that we have not missed anything important. This may be justiﬁed from an assessment perspective, but clinically it is sometimes more important to respect that families maintain control over the ﬂow of information. It is also important to recognize that the fact that a particular area has not been addressed directly does not automatically mean that the clinical interventions are less effective. In a study that compared two forms of family intervention in anorexia nervosa — conjoint family therapy and a separated family therapy in which the parents were seen as a couple, and the adolescent was seen separately by the same therapist — it was found (Eisler et al. 2000) that the conjoint family therapy produced more individual psychological change than did the separated therapy. This was in spite of the fact that some of the areas for which this was true (e.g. psychosexual adjustment) the topics were seldom addressed directly in the conjoint family interviews.

Critical or hostile interactions may be difﬁcult to contain
Interviewing families where there is open conﬂict, hostility or frequent criticism is particularly difﬁcult. Studies of family therapy have shown that such families are more likely to drop out of treatment (Szmukler et al. 1985) and are less likely to beneﬁt from conjoint family therapy (Hampson & Beavers 1996a; Eisler et al. 2000). There is some evidence that with this type of family a relatively structured directive style of interviewing may lead to a better therapeutic outcome than when a more open collaborative interview style is used, whereas the reverse seems to be the case with other types of families (Hampson & Beavers 1996b). Criticism and hostility are often accompanied by feelings of guilt and self-blame (Besharat et al. 2001) and conjoint family interviews that are unable to provide sufﬁcient containment may reinforce such feelings. In such cases it is sometimes better not to see the whole family together, or at least to postpone conjoint meetings to a time when the family is well engaged and some of the painful feelings have been addressed in separate sessions. It has been a recurrent theme in this chapter that one of the risks of inviting the whole family for conjoint family interviews is that it will be understood by the family as suggesting that they are the cause of the problem. Even when it has been made clear that the purpose of seeing the family is to help them rediscover their own resources as a family, feelings of guilt and blame are very easily re-ignited. A number of studies have shown that even when family interventions are effective they may be perceived as blaming by the family (Squire-Dehouck 1993; Reimers & Treacher 1995).

Unequal relationships with family members
With some families the clinician may ﬁnd it difﬁcult to maintain an equal relationship with all family members. This is particularly true with families where there is an open dispute between family members and where simply being sympathetic to an account from one person may give the impression that one is taking sides. For instance, the parents may have a disagreement as to how best to respond to the difﬁcult behaviour of their child. The clinician may feel more sympathetic to one or the other of the parents, not necessarily because of believing that that parent’s approach is better or more effective but more because of the way he or she perceives the parents overall. Strictly speaking, it is never possible to be entirely neutral, as any act implies that one has taken a certain position and even the overt expression of neutrality itself implies that one is preferring the status quo and does not take into account that different family members (children, adults, men, women) are not in equal positions with respect of being able to bring about change. A recognition of this is of particular importance when working with families where there is abuse or violence (Goldner et al. 1990; Glaser & Frosh 1993).

Conﬁdentiality, boundaries and family secrets
As mentioned earlier, when interviewing families, issues arise around conﬁdentiality and boundaries that are different, to some extent, from individual interviews with patients or parents. Family interviews, by deﬁnition, are more ‘public’ than individual interviews. This is not only because of the presence of more people in the room but also because family interviews are often conducted with other people observing through one-way screens or using a video link. This is partly to do with the history of the development of family therapy, which places strong emphasis on the importance of the observing team providing an outside perspective (Palazzoli et al. 1978; Hoffman 1981; Boscolo et al. 1987), partly with the development of a variety of intervention techniques that make use of the different views held within the team (Papp 1980; Andersen 1987), and also with the way in which family therapy training has developed through trainees being supervised ‘live’ (Liddle et al. 1988). There is some empirical evidence that the input of the observing team enhances the efﬁcacy of family interventions (Green & Herget 1989a,b) but it is also clear that families often ﬁnd the

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FAMILY INTERVIEWING: ISSUES OF THEORY AND PRACTICE

experience unpleasant or at least uncomfortable, particularly if not enough thought has been given to how such devices should be introduced to the family (Howe 1989; Reimers & Treacher 1995). Reimers & Treacher (1995) found that much of the negative effect on the family of having an invisible team behind the screen could be mitigated by introducing the team members to the family at the beginning of the ﬁrst session. Getting informed consent for having an observing team or using a video is part of good practice but it is also a useful way of emphasizing that we respect the family’s boundaries and their right to act as gatekeepers to the amount of intrusion that they will allow as part of the clinical process. Demystifying the process by introducing the members of the team to the family and perhaps showing the children how the camera works, can also help in making the family feel more at ease and facilitate the engagement process. Respecting boundaries within the family is no less important. There are a number of contexts where the clinician needs to be particularly aware of conﬁdentiality issues when seeing families. One is when interviewing a family with an adolescent who may quite appropriately feel that there are aspects of his or her life that he or she does not want to talk about in front of parents. The difﬁculty arises when the issues of privacy and conﬁdentiality concern behaviours that are potentially risky or dangerous (e.g. self-harm), or symptoms that are clearly of clinical signiﬁcance and may need to be discussed with others. The clinician will need to be both sensitive to the internal family boundary issues while at the same time making it clear that in some cases issues of safety or health might override issues of conﬁdentiality. For instance, an adolescent girl suffering from anorexia may be reluctant to talk about the absence of her periods in front of her father or brother but at the same time this may be part of the general picture of her trying to hide the seriousness of her illness from the family. The clinician may therefore agree to discuss this in an individual meeting, while making it also clear that her parents need to know the extent of her illness in order to be able to help her. If the adolescent is seen on her own it is important to restate the conﬁdentiality of the individual interview as well as its limits. It is sometimes assumed that there is an advantage in seeing adolescents on their own as a way of promoting the process of individuation/separation from the family. While it is possible to use individual sessions to address such issues, there is always the danger that the therapist gets co-opted into a parental role and the adolescent’s independence may become largely illusory (e.g. as would be the case of the adolescent who is always brought by a parent who then sits in the waiting room while the adolescent is seen individually). If, instead, the individual sessions are combined with, or replaced by, family meetings in which one regularly checks on the appropriateness of what is being discussed in the family context, the issue of separateness/independence is addressed much more directly. Another type of situation sometimes arises, particularly with families with younger children, when sensitive issues for the family or family secrets are touched on. While one should not as-

sume that anything that is difﬁcult for the family to talk about should be avoided, one also has to respect that when and how a family talk about such issues may determine whether it has been a useful experience for them or not (Karpel 1980). This is particularly important to bear in mind with families with quite young children, as the clinician can sometimes be too ‘skilful’ in helping the children to talk about things that they actually would rather not say, with the child then perhaps feeling disloyal to the family. It is therefore important that one emphasizes that as clinicians we have to be free to ask even the most awkward questions but the family always has the right not to discuss any particular issues if they feel that the time, the place or the constellation of people in the room is not right.

Conclusions
The conjoint family interview is undoubtedly a valuable part of clinical practice in child psychiatry, regardless of the theoretical orientation that the clinician adopts. Seeing the whole family together provides valuable information that would otherwise be inaccessible to the clinician, about patterns of interaction and family function which the family may not necessarily be always aware of and therefore not always be able, or willing, to provide information on. The aim of this chapter has been to emphasize, both in the account of the theoretical framework and in the account of some of the interviewing techniques, the interactive nature of the task. The clinician interviewing the family is not a neutral detached observer but is an active participant entering into a relationship with the family which inevitably contributes to the picture that he or she forms about the family. This has implications not only for the way that the clinician conducts family interviews and the judgements drawn from them, but also for the effect that the interview is likely to have on the family.

References
l’Abate, L. (1994) Family Evaluation: A Psychological Approach. Sage, Thousand Oaks, CA. Alexander, R. & Parsons, B. (1973) Short-term behavioural interventions with delinquent families: impact on family process and recidivism. Journal of Abnormal Psychology, 81, 219–225. Andersen, T. (1987) The reﬂecting team: dialogue and metadialogue in clinical work. Family Process, 26, 415–428. Bateson, G., Jackson, D.D., Haley, J. & Weakland, J.H. (1956) Towards a theory of schizophrenia. Behavioural Science, 1, 251–265. Beavers, R. & Hampson, R.B. (1990) Successful Families: Assessment and Intervention. W.W. Norton, New York. Beavers, R. & Hampson, R.B. (2000) The Beavers systems model of family functioning. Journal of Family Therapy, 22, 128–143. Besharat, M.A., Eisler, I. & Dare, C. (2001) The self- and other-blame scale (SOBS): the development and reliability of an observational measure of guilt and blame in families. Journal of Family Therapy, 23, 208–223. Bishop, D., Epstein, N., Keitner, G., Miller, I. & Zlotnick, C. (1980) The McMaster Structured Interview for Family Functioning. Brown University Family Research Program, Providence, RI.

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FAMILY INTERVIEWING: ISSUES OF THEORY AND PRACTICE Multisystemic Approach to Treating Behavior Problems of Children and Adolescents. Brooks Cole, Paciﬁc Grove, CA. Hetherington, M.E. (1989) Coping with family transitions: winners, losers and survivors. Child Development, 60, 1–14. Hodes, M. (1985) Family therapy and the problem of cultural relativism. Journal of Family Therapy, 7, 261–272. Hodes, M., Dare, C., Dodge, E. & Eisler, I. (1999) The assessment of expressed emotion in a standardised family interview. Journal of Child Psychology and Psychiatry, 40, 617–625. Hoffman, L. (1981) Foundations of Family Therapy: a Conceptual Framework for Systems Change. Basic Books, New York. Hoffman, L. (1990) Constructing realities: an art of lenses. Family Process, 29, 1–12. Howe, D. (1989) Client experience of counselling and treatment interventions: a qualitative study of family views of family therapy. British Journal of Guidance and Counselling, 24, 367–375. Imber-Black, E. 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10
Introduction

Physical Examination and Medical Investigations
Anthony Bailey

The presenting problems seen by individual clinicians vary considerably, reﬂecting differences in disease prevalence, the organization of psychiatric and paediatric services and the particular interests and expertise of practitioners. The relative importance of the medical history, physical examination and investigations naturally also varies from patient to patient. Some readers may anticipate that this chapter will be irrelevant to their daily practice, whereas neuropsychiatrists may bemoan a lack of detail. In charting a course between Scylla and Charybdis, the overarching objectives are to remind practitioners of the importance of assessing and treating the whole patient, of the need consciously to question the signiﬁcance of historical information and any physical ﬁndings, and to highlight some of the recent developments in investigations, particularly in genetics and neuroimaging. One of the initial goals is to identify any biological factors that may underlie the referral disorder, as well as to assess growth, nutritional status and general health. In many general child psychiatry outpatient services, identiﬁable biological factors may be infrequent. However, worldwide these factors are as relevant now as ever, both because of the increasing impact of environmental (particularly infectious) agents on children’s health, and because of the advances in identifying genetic inﬂuences on developmental and psychiatric disorders, with the associated implications for diagnosis and management. Thus, in the last 5–10 years, HIV and tuberculosis have had a devastating effect upon children in the developing world. Recent wars, political upheavals and changed attitudes have also coincided with an increased incidence of sexually transmitted diseases (with the associated risk of vertical transmission), substantial transnational movement of refugees and a growth in international adoption — all trends that require continuing vigilance for infectious diseases. In parallel there has been a worldwide increase in the non-medicinal use of drugs by the young, with all the attendant psychiatric, social and physical risks. Previous chapters deal with assessment of psychopathology and the family environment and the measurement of cognitive deﬁcits and developmental delays. Nevertheless, this information will often not be adequate to identify somatic (‘organic’) aetiologies. This is an important goal because identiﬁcation of causal inﬂuences is necessary to provide optimal treatment, speciﬁc advice on prognosis and likely complications and, occasionally, genetic counselling or screening of at-risk relatives. In

ordinary outpatient practice, the amount of detail that it is necessary to obtain from the history, physical examination and investigations will vary according to the nature of the presenting complaint and local circumstances. Thus, this chapter is structured according to the nature of the presenting difﬁculties and the level of examination and investigation that they require. By necessity, this approach is illustrative rather than exhaustive; the goal is to encourage clinicians to go through a problem-solving approach with each case that they assess. The strategy outlined here is not intended for tertiary services dealing with unusual cases, or for research.

General child psychiatry cases
In most individuals presenting with one of the common disorders of behaviour or emotions, there are unlikely to be aetiological somatic conditions. The starting point is for clinicians ﬁrst to satisfy themselves that the disorder is what it seems; in other words, are the history and symptomatology typical, the age and nature of onset in keeping with the provisional diagnosis, as well as the clinical course and response to treatment. Usually the clinical picture will be straightforward, but clinicians need to be alert to mention of any physical abnormalities (particularly neurological symptoms such as gait disturbance, clumsiness, or visual changes), an unusual or partial clinical picture, or impairments that seem disproportionate to the degree of symptomatology. These aspects of the history may require clariﬁcation to establish if they signify a somatic disorder. On the rare occasion that suspicions are aroused, bodily systems should be reviewed as this will usually provide some of the most obvious pointers to neurological dysfunction or systemic disease (see Edgeworth et al. 1996). Next, the clinician needs to consider whether there is any history suggestive of cognitive impairments in the form of mental retardation, speciﬁc developmental delays, chronic difﬁculties with school work or deteriorating school performance. Again, cognitive difﬁculties indicate the need for a much more probing history and thorough physical examination (see below). It is not uncommon for mild mental retardation to go undetected until middle childhood and many children ﬁrst come to attention because of behavioural problems, often associated with poor school performance. Consequently, when patients do not have routine psychometric assessment, the clinician will need to take sufﬁcient history to exclude cognitive difﬁculties. 141

CHAPTER 10

A further step is to enquire about any pertinent environmental aetiological factors; drug and alcohol abuse are particularly relevant. Children at increased risk for substance abuse include those with parents who abuse drugs or alcohol, who are in dysfunctional or divorced families, who are subject to abuse and who are under- or overcontrolled by their parents (Belcher & Shinitzky 1998; Milberger et al. 1999). It is important always to enquire directly about drug and alcohol abuse, especially in those who smoke. That is because young people who use drugs or alcohol often do not seek help for these problems but are seen because of associated difﬁculties, such as school underachievement, delinquency, teenage pregnancy and depression (Belcher & Shinitzky 1998). Indeed, alcohol abuse is one of the few factors associated with eventual suicide in adolescents who self-harm (Hawton et al. 1993). Identifying drug and alcohol abuse can require clinical acumen, knowledge of familial and individual risk factors, as well as familiarity with the locality. The clinician will also want to establish whether there is any possibility that the child has been subject to abuse; if so, a full physical examination is indicated to search for signs of old and fresh injuries, malnourishment and general neglect. A detailed examination to determine if there is any evidence of sexual abuse should be performed by clinicians (usually paediatricians or police surgeons) with the relevant training and experience. Before proceeding to the physical examination, the clinician needs to consider several further issues. First, are there any medical conditions relevant to the psychiatric disorder? For instance, behavioural problems are not uncommon amongst children and adolescents with chronic conditions such as diabetes (see Mrazek, Chapter 48), and some drug treatments, such as high-dose steroids, can lead directly to mental state changes. Secondly, in areas of the world where serious infectious diseases are endemic the clinician should enquire directly about relevant symptomatology. That is not because these diseases are common causes of behavioural difﬁculties (although they are occasionally implicated), but because the physician’s concern is with the health of the whole individual, and ensuring that a child receives treatment for tuberculosis, malaria or other serious diseases is a crucial aspect of clinical management. Thirdly, the clinician needs to consider whether the young person’s behaviour may itself lead to medical complications. Thus, the drugusing adolescent is at increased risk for contracting a variety of infectious diseases, as well as for criminal behaviour. HIV and hepatitis B may be acquired from contaminated needles and individuals may also be exposing themselves to sexually transmitted infections. The earlier adolescents initiate sexual activity the less likely they are to use a condom and the more likely they are to have unprotected sex with multiple partners; the risks are not trivial because one in every eight adolescents aged between 13 and 19 in the USA has had a sexually transmitted disease (Rome 1999). Part of overall management is to ensure that at-risk individuals are subsequently screened for sexually transmitted and other infectious diseases. Finally, it may be relevant to enquire about medical problems in other family members; e.g. a family 142

history of thyroid disease may be linked to an adolescent onset of anxiety disorder. A psychiatric diagnostic assessment should always include a physical examination, albeit sometimes limited in scope. Often an appropriate examination will have been undertaken by referrers, and repetition will not advance the diagnostic process. Nevertheless, if the history suggests an unexpected somatic condition, clinicians should search speciﬁcally for the relevant signs. In some settings, not all children will be seen initially by medical staff and the need then is to ensure that an appropriate physical examination has either already been undertaken or can be arranged in a timely manner. It is also helpful to ensure that nonmedical staff have some basic training in the features of the history and mental state that indicate a possible organic aetiology and are able routinely to measure height, weight and head circumference. Clinicians usually begin the physical examination as soon as they meet a patient, whether or not this is performed consciously. An abnormal facial appearance is often most obvious when ﬁrst seen. Similarly, the patient’s language or speech may raise the possibility of neurological or cognitive impairments, and abnormal movements may be noted in the waiting area that the patient is later able to suppress. How the patient rises from a chair, their gait, and possibly stair climbing, can all be observed en route to the interview or examination room. Whether the patient looks well or ill, obese or malnourished, well cared for or unkempt should also guide the extent of the subsequent examination. It is worth paying some attention to the environment for the physical examination proper. If this is to be satisfactory then the room needs to be warm, well lit (but able to be blacked out) and private. In addition to the usual medical equipment, a ﬁxed rule for measuring height, accurate weighing scales, a nonstretchable tape measure, a vision testing chart and a Wood light should be available. A parent or chaperone should usually accompany children and adolescents. When there is no suspicion from the history or mental state that the child has a somatic condition, when there is no evidence of cognitive deﬁcits and when the patient’s appearance has not caused concern, what should be the minimum physical examination? All patients should have height, weight and head circumference measured and these percentiles plotted. One reason for measuring growth is to identify any deviations from normal which in combination with behavioural difﬁculties, cognitive deﬁcits or physical signs raise the possibility of an underlying syndrome. Another reason is to detect suboptimal development associated with systemic disease or malnutrition. Unless cooperation is limited, growth should usually be measured at the beginning of the examination because some abnormalities may not be apparent until charted, and these should always prompt a search for recognized associations. Clinicians should also be aware that there have been signiﬁcant upward secular trends in height, weight and head circumference in the developed world over the last century, but there are considerable vagaries in the extent to which growth charts are based on up-to-date data.

PHYSICAL EXAMINATION AND MEDICAL INVESTIGATIONS

If growth parameters are abnormal, the clinician needs to consider the possible underlying causes and also whether the combination of particular behaviours and abnormal growth may signify a syndrome. Short stature and/or microcephaly should both prompt the clinician to review whether there is clear evidence that intelligence is in the normal range; when there is doubt, consideration should be given to psychometric testing. Abnormal growth parameters should also lead to a full physical examination. In the absence of mental retardation or cognitive difﬁculties, the usual causes of suboptimal growth in developing and developed regions are quite different. In developed countries short stature is usually constitutional, and chronic illness is a much more frequent cause of short stature than are hormonal abnormalities. An appropriate history should already have alerted the clinician to impaired growth as a consequence of feeding difﬁculties (see Stein & Barnes, Chapter 45). Worldwide, malnutrition is the most common cause of growth retardation and is frequently compounded by parasitic infections; these infect over 3.5 billion people (Albonico et al. 1999), and intestinal helminths are the main disease burden in children aged 5–14 years (World Bank 1993). The other major cause of impaired growth or weight loss in the developing world is tuberculosis, which is the leading cause of death as a result of infectious disease: a problem exacerbated by the HIV pandemic and drug resistance (Zumla et al. 1999). Clinicians working in areas where parasitic and other infectious diseases are endemic will usually be familiar with their presentation, but a high index of suspicion is also required by those working with exposed immigrant communities, refugees and international adoptees. Tall stature is usually either constitutional or linked with obesity. However, it is also a feature of several syndromes associated with behavioural disturbance and/or learning difﬁculties. By and large, clinicians are less aware of the signiﬁcance of increased as opposed to decreased growth and several syndromes that are not uncommon can easily be missed, especially if they are not associated with obvious cognitive difﬁculties. Thus, if the diagnosis of Klinefelter syndrome, which affects approximately 1 in 800 males, is not made prenatally, it is very unlikely to be made at all during the ﬁrst decade (Abramsky & Chapple 1997). Affected males show increased growth and weight associated with eunuchoid proportions, delayed or incomplete puberty and small testes and penis; most individuals are eventually karyotyped for hypogonadism or infertility. Klinefelter syndrome is associated with an increased rate of learning disabilities, poor impulse control and a range of psychiatric disorders (Rovet et al. 1996; Smyth & Bremner 1998). 47XYY syndrome affects approximately 1 in 1000 males, about half of whom are diagnosed because of developmental delay or behavioural problems (Abramsky & Chapple 1997; see also Skuse & Kuntsi, Chapter 13). The additional Y chromosome causes increased growth, and body, head and craniofacial dimensions are greater than in control and male relatives (Grön et al. 1997). Children with Sotos syndrome show prenatal onset of excessive size with signiﬁcantly increased growth in infancy. They have a relatively large span and large hands and feet as well as macrocephaly.

Obesity is usually a consequence of excess calorie intake and insufﬁcient exercise, and often it becomes a problem during adolescence. Much less frequently it signiﬁes a congenital or acquired syndrome. Because many of these disorders are characterized by hypogonadism and delayed puberty, obesity should always prompt a full physical examination. Some of the congenital syndromes include major malformations that should already have aided their identiﬁcation. Small head size may be a familial or ethnic trait, and may be proportionate to height. Similarly macrocephaly may also be a normal variant and often has a familial basis (Lorber & Priestley 1981). An estimate of pubertal status can usually be obtained from the history from parents and/or the young person. There is considerable variation in the timing of normal puberty, but the physical changes are considered delayed if not evident before 13 years in girls or 14 years in boys, and precocious when seen before 8 years in girls or 9 years in boys. If the history raises the possibility of abnormal timing then the patient should have a full physical examination. The differential diagnosis of disorders of pubertal timing is complex, although some causes are linked with psychiatric and/or cognitive difﬁculties. In patients for whom there is no a priori reason (from the history, mental state examination, cognitive testing and measurement of growth) to suspect a concomitant somatic disorder, it is difﬁcult to justify a full physical examination that includes complete undressing. What should the physician do? First, the clinician should check the patient’s face and hands for any evidence of obvious dysmorphic features that may signify a perturbation in development. Secondly, there needs to be an examination to identify any signs of drug use. The arms should be examined for evidence of intravenous or subcutaneous drug injection in the form of needle tracks, abscesses, areas of hyperpigmentation, or scar tissue from healed abscesses. Long-term stigmata of oral or nasal ingestion of drugs are minimal, with the exception of inhalation of solvents from a bag which may produce a circumoral rash. Pupillary constriction or dilatation and tachycardia may be seen acutely with many drugs. The clinician should then ensure as a minimum that there are no localizing neurological abnormalities, no evidence of gait abnormalities (an early sign in most progressive neurological disorders) or signiﬁcant coordination problems, and no visual impairments detectable with a testing chart or hearing difﬁculties to whispered voice. When young people are assessed who have not had routine developmental surveillance or access to medical services, the physical examination should include undressing and examination of all bodily systems. Sometimes patients will refuse an examination or be extremely unco-operative. A ﬂexible discussion with the patient and their family, the co-opting of doctors with whom the patient has a rapport, or an attempt at a different time or in a different place will usually be successful. Neither should the utility of repeating an examination be overlooked. That situation is most likely to arise if the diagnosis remains uncertain, the clinical picture deteriorates or the disorder is unusually resistant to appropriate treatment. In these circumstances, signs may be detected that 143

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were previously overlooked or whose signiﬁcance was not appreciated initially. There is currently no evidence to suggest that routine medical investigation of all child psychiatry patients makes clinical or economic sense. In the absence of symptoms or signs, are there any other indications for routine screening investigations? First, depending on local circumstances, clinicians will want to consider whether a urine screen for drugs should be routine in newly presenting adolescents or only in those with identiﬁable risk factors (see Weinberg et al., Chapter 27). Urinalysis should not be restricted to any reported drug of abuse because multiple drug abuse is common. Some drugs, such as cannabis, may appear in the urine for several weeks after consumption, the psychostimulant methylenedioxymethamphetamine (MDMA) or ‘ecstasy’ disappears within 24 h whereas hallucinogens — such as lysergic acid diethylamide (LSD) — will not be detected by urinalysis at all. Secondly, international adoptees are at especial risk of infectious diseases and if they have not had an infection screen at time of entry into the country (Hostetter 1999), the clinician should consider which infectious agents should be excluded. Thirdly, if it is planned to administer psychotropic medication, renal and liver function should be checked (also thyroid function if lithium is to be administered) and, if administration of drugs with cardiac effects is anticipated, then a baseline electrocardiogram (ECG) should be obtained (see Heyman & Santosh, Chapter 59).

Individuals with disorders that involve speciﬁc cognitive deﬁcits or developmental delays
In neurodevelopmental disorders, such as attention deﬁcit disorder (ADHD), some form of abnormal brain function is likely to be present, but the association with identiﬁable medical conditions is much weaker than in individuals with mental retardation. Parents will sometimes wonder whether obstetric or neonatal difﬁculties were a factor in aetiology, and clinicians will occasionally be faced with the need to differentiate between possible obstetric causes of psychopathology and a suboptimal obstetric history that is a consequence of a genetic susceptibility. The ﬁrst task is to clarify whether these difﬁculties are manifestations of a more pervasive abnormality. Thus, it is essential that a comprehensive developmental history is obtained in all areas of functioning to establish whether the child has a general or speciﬁc cognitive difﬁculty or evidence of motor dysfunction. Also, language delay and symptoms of inattention and overactivity are common in children with pervasive developmental disorders. There should be no diagnostic confusion with cases of clear-cut autism, but it is not unusual for children with milder variants of pervasive developmental disorders (such as Asperger syndrome) to receive an initial diagnosis of ADHD, ‘communication disorder’ or dyspraxia. Thus, the clinician needs to obtain an adequate history of social development. Secondly, these difﬁculties are usually developmental in origin and the clinician 144

should be particularly alert to symptoms that arise later in childhood in case they are the initial manifestations of either progressive neurological disorders or abuse. The next task is to obtain a detailed obstetric and neonatal history. Illegal drug use during pregnancy is now a considerable problem in some communities and should be enquired about in at-risk groups. Drug use is linked with suboptimal pregnancy outcome (Loebstein & Koren 1997), an increased risk for perinatal acquisition of HIV (Belcher & Shinitzky 1998) and subsequent child abuse (Jaudes et al. 1995). Similarly, fetal alcohol syndrome now affects at least 2.8 in 1000 live births (Sampson et al. 1997) and an alcohol history should be obtained routinely in these cases. It has been suggested that even in the absence of a suggestive pattern of craniofacial dysmorphism (see below), symptoms such as hyperactivity and language delay may be consequences of alcohol use during pregnancy; so-called fetal alcohol effects (Weinberg 1997). When alcohol use was not obviously excessive, the clinician needs to be cautious about assuming an aetiological role when genetic vulnerability may be more relevant. It should also not be forgotten that parental alcohol abuse is an ongoing risk factor for injury, poisonings and medical hospitalizations. Language difﬁculties are more common amongst twins than singletons and the rate of multiple births in the developed world has increased signiﬁcantly over the last two decades, in part because of infertility treatment (D’Souza et al. 1997). Currently, there is no clear evidence of an increased risk of psychopathology associated with assisted reproduction. Nevertheless, conception by subzonal injection of spermatozoa appears to have been associated with a skewed sex ratio and a slightly elevated rate of major malformations (Patrat et al. 1999) and twins conceived by in vitro fertilization are at signiﬁcantly higher risk for prematurity and associated neonatal morbitity and mortality than spontaneously conceived twins (Moise et al. 1998). Indeed twins and other multiples are a vulnerable group, as twinning is associated with prematurity, low birth weight and increased perinatal mortality, as well as an elevated rate of congenital anomalies (Myrianthopoulos 1976). The rate of cerebral palsy is also increased, particularly when a comultiple suffers a fetal or neonatal death (Petterson et al. 1998). Thus, when assessing twins (or singleton survivors) clinicians need to obtain a thorough history of the obstetric course and neonatal period. Quite how one interprets a history of obstetric adversity that is not a clear cause of brain damage is problematic in both singletons and twins. Clinicians may need to reassure parents that mild obstetric difﬁculties are not likely to be aetiological factors. The role of genetic inﬂuences in the causation of ADHD and speciﬁc developmental delays has been increasingly recognized (see McGufﬁn & Rutter, Chapter 12; Schachar & Tannock, Chapter 25), and the clinician should enquire directly about whether other family members are affected by similar difﬁculties, although the absence of a family history does not preclude genetic inﬂuences in complex disorders. Rarely, postnatal environmental aetiologies may need to be considered in the genesis of these difﬁculties. Thus, paediatric autoimmune neuropsychi-

PHYSICAL EXAMINATION AND MEDICAL INVESTIGATIONS

atric disorders associated with streptococcal infection (PANDAS) have been suggested to represent a distinct clinical entity from rheumatic fever (Garvey et al. 1998; see also Rapoport & Swedo, Chapter 35). Affected children show motor hyperactivity, new problems with attention and impulsivity, clumsiness, choreiform movements and emotional lability. The validity of the syndrome as a separate entity remains somewhat uncertain (Garvey et al. 1998) and the streptococcal-induced disease remain largely a clinical diagnosis because investigations provide only ancillary evidence (Thatai & Turi 1999). Interpreting the signiﬁcance of symptoms of inattention and overactivity and developmental delay depends on knowledge about the child’s overall level of cognitive functioning. Accurate diagnosis and optimal management requires comprehensive psychometric assessment and ideally the clinician should be aware of the ﬁndings before conducting a physical examination. In practice, this will often not be possible and if evidence of mental retardation subsequently becomes available the clinician should consider whether further examination is warranted. In terms of the physical examination, several causes of abnormal growth associated with learning difﬁculties are noted above. The full fetal alcohol syndrome is associated with preand/or postnatal growth deﬁciency (and usually mental retardation). Short stature is also a minor disease manifestation of neuroﬁbromatosis 1 (NF1) — the most common single gene disorder to affect the nervous system — with about one-third of patients having a height at or below the third percentile (North 1998). The rate of mental retardation in NF1 patients is only slightly elevated, but speciﬁc learning disabilities affect between 30 and 60% of children. Head circumference is also increased. In patients with a neurodevelopmental disorder a more thorough physical examination should be conducted that includes undressing, attention to dysmorphic features and examination of all bodily systems. Most children dislike undressing in front of strangers and only the area to be examined should be exposed at any one time, unless there is a concern about disproportion. The examiner should also be able to make full use of humour and any available props. The major skin and eye manifestations of NF1 to look out for include café au lait spots, axillary freckling, cutaneous neuroﬁbromas and iris hamartomas (Lisch nodules). Particular attention should be paid to the neurological examination and handedness noted; language delays are sometimes early manifestations of neuromuscular disorders and the clinician is quite likely to identify neurological soft signs. These refer to a heterogeneous collection of motor delays and problems with coordination that do not indicate a localized abnormality in the central nervous system. When the age of onset and clinical picture is typical, there is no evidence of mental retardation, and growth parameters and the physical examination are unremarkable, there are no indications for routine blood or urine tests. When the history is atypical, cognitive difﬁculties are more widespread than anticipated

or there are dysmorphic features or other physical signs, a highresolution karyotype should be obtained and any suspected single gene or other disorders tested for speciﬁcally. Occasionally, the assessment will reveal that the child has mental retardation or a progressive disorder. Although there is some evidence that at a population level an allele of the dopamine D4 receptor gene (LaHoste et al. 1996) and a variant of the dopamine transporter gene (Cook et al. 1995) may confer a modest increased risk for ADHD, testing for these alleles is not currently useful at an individual level. Similarly, a potential susceptibility locus for language disorder has been localized to chromosome 7 (Fisher et al. 1998; Lai et al. 2000) and there is evidence for a susceptibility locus for reading difﬁculties on chromosome 6p (Cardon et al. 1994; Grigorenko et al. 1997; Fisher et al. 1999), but the potential clinical application of these ﬁndings awaits further study. Although there has been much research interest in the use of structural and functional neuroimaging in elucidating the brain basis of language and reading disorders, these investigations are not currently indicated in straightforward cases. The clinician should ensure, however, that children with developmental language delay have their hearing tested by a trained audiologist. If treatment with stimulant medication is planned it is important that baseline growth parameters, blood pressure and full blood count are obtained and regularly monitored.

Mental retardation and autism
Both types of disorder are dealt with in this section because autism is frequently accompanied by mental retardation (although identiﬁable aetiological factors are much more common in mentally retarded individuals who do not have autism). Whether child psychiatrists assess children with severe mental retardation will depend on individual working practices and expertise, but all clinicians can expect to see mildly retarded individuals, although their cognitive difﬁculties may not have been identiﬁed previously. The approach of the clinician, at least with respect to mentalretardation, is somewhat different from that outlined above. That is because the starting assumption is that an identiﬁable cause for general cognitive impairment can be found in roughly half of all cases of mental retardation. The overall approach to these disorders is to obtain a systematic history of potential aetiological factors, to conduct a careful and comprehensive physical examination in order to identify physical signs that might suggest speciﬁc causes or syndromes, and to choose investigations judiciously, based either on available evidence or what is known about the probability of individual factors. It is difﬁcult to acquire this range of skills — particularly in physical examination — from reading alone and the training of child psychiatrists should include the opportunity to gain paediatric experience, particularly in developmental surveillance and genetic clinics. Often a speciﬁc aetiology will not be identiﬁable in individual cases, but an understanding of the most likely cause may be sufﬁcient to answer the family’s questions. Several studies suggest that a 145

CHAPTER 10

diagnosis or cause of mental retardation can be identiﬁed in 40–60% of cases (Curry et al. 1997) and with advances in molecular and cytogenetics and in neuroimaging this rate is likely to increase. Nevertheless, common and distinctive syndromes, such as trisomy 21, will have been identiﬁed at birth or shortly thereafter, and the rate of identiﬁable aetiologies in cases presenting to most child psychiatrists is likely to be somewhat lower. The history will often indicate probable aetiological factors and consequently needs to be particularly thorough, especially when there are no initial clues as to the most likely aetiology. Exposure to drugs, toxins and radiation during pregnancy must be asked about directly. Maternal infections should also be recorded and, even if there was no signiﬁcant history during pregnancy, congenital infection should be suspected if there was intrauterine growth retardation, prematurity or a history of neonatal jaundice, hepatosplenomegaly, purpura or rashes. Congenital malformations should be noted. Medical advances over the last decade have led to improved survival rates for extremely premature and very low birth weight babies, but there has been little change in their neurodevelopmental outcome (Hack & Fanaroff 1999). These infants are at particular risk for cerebral palsy, mental retardation and visual impairments (Lorenz et al. 1998). With respect to the aetiology of cerebral palsy, the current consensus is that in most cases the critical events occur in the fetus before the onset of labour or in the newborn after delivery (MacLennan 1999 for the International Cerebral Palsy Task Force). Spastic quadriplegia and, less commonly, dyskinetic cerebral palsy, are the only subtypes that appear to be associated with acute hypoxic intrapartum events. If the clinician suspects that a developmental disorder is linked to prior perinatal difﬁculties, reviewing the obstetric and paediatric notes may be informative, but the possibility that obstetric difﬁculties are a consequence of abnormal development should not be overlooked. When children are adopted or fostered it may be difﬁcult to obtain details of pregnancy and early development, but this information will occasionally be relevant. Some internationally adopted children will have come from countries where there is an increased risk for vertical transmission of HIV and syphilis (as well as for infection with HIV by unscreened blood and its products) and in these circumstances more thorough screening investigations are warranted. With respect to infancy and early childhood, the physician needs to obtain a detailed developmental history and not forget to enquire about signs that may have resolved, such as hypotonia (an early sign of Prader–Willi syndrome) and mild paresis. Severe postnatal infections, such as meningitis and encephalitis, seizures and any associated cognitive decline should also be documented. Children with disabilities are also at risk of secondary complications from their behaviour and any history of pica (potentially leading to lead exposure) and severe self-injury should be noted. The family history is particularly important in identifying genetic causes of mental retardation. Relatives with psychiatric or medical disorders linked to the patient’s condition should be 146

identiﬁed, as well as individuals who might beneﬁt from examination, testing or possibly genetic counselling. The usual starting point is a three-generation pedigree of family members, including an enquiry about consanguinity. Attention should be paid to the presence of learning difﬁculties, developmental delays and mental retardation, psychiatric disorders and neurological and other medical disorders. Identifying whether the mother has had any miscarriages, stillbirths or neonatal deaths may also be pertinent, as many genetic syndromes show quite variable phenotypic expression and a congenital abnormality in another pregnancy may be related to a milder phenotype in the index child — the holoprosencephaly spectrum providing a clear example (Gorlin et al. 1990). Occasionally, the physical examination may be challenging because of limited co-operation, potentially necessitating a piecemeal or opportunistic approach. With respect to measurement of growth, the association of many mental retardation syndromes with short stature has already been noted. Prader–Willi syndrome (Khan & Wood 1999) is the most common genetic mental retardation syndrome associated with obesity and physical signs include infantile hypotonia, short stature, severe obesity, hypogonadism, and small hands and feet. Microcephaly arising on the basis of in utero infection may also be accompanied by eye signs such as retinopathy, cataracts, corneal scarring and micopthalmia and by hearing impairment and cerebral palsy. Otherwise, obtaining newborn and postnatal head circumference measurements may help to differentiate a prenatal from postnatal (e.g. HIV, Rett syndrome) onset of microcephaly. Increased head circumference is found in some individuals with fragile X syndrome (De Vries et al. 1998), autism (Kanner 1943; Bailey et al. 1993; Woodhouse et al. 1996) and is characteristic of Sotos syndrome. Increased head circumference may also be secondary to much rarer conditions, such as the mucopolysaccharidoses. Delayed or incomplete puberty is a feature of Klinefelter, Prader–Willi and Turner syndromes, whereas precocious puberty is sometimes seen in children with neuroﬁbromatosis, tuberous sclerosis, and occasionally as a sequelae of meningitis or encephalitis. A comprehensive head-to-toe examination of individuals with mental retardation is always necessary, particularly to identify minor anomalies that might lead to speciﬁc syndrome diagnosis, or help to date the onset of a developmental problem (Curry et al. 1997; Battaglia et al. 1999). In this section, the dysmorphic features that the examiner should search for are covered in detail, as most psychiatrists have no particular training in their identiﬁcation and usually they are not brought together in standard texts. There is a deliberate focus on abnormal facial structures as these provide the most frequent clues to speciﬁc syndrome diagnosis. Photographs of dysmorphic features are available in standard texts (Gorlin et al. 1990; Jones 1997) and computerized databases (Winter & Baraitser 2000). The skin should be examined for evidence of phakomatoses. The earliest skin lesion in tuberous sclerosis is the depigmented, ash leaf shaped macule, which is most easily seen under a Wood ultraviolet light. Fibroangiomatous naevi occur princi-

PHYSICAL EXAMINATION AND MEDICAL INVESTIGATIONS

pally in the nasolabial folds and on the cheeks but these may not be apparent until 4–7 years of age. The skin should also be examined for hypo- or hyperpigmentation and naevi, looseness or oedema, absent or excessive facial or body hair, telangiectases and haemangiomas. A malar ﬂush is usually seen in homocystinuria and a photosensitive eruption is common in Hartnup disease. The shape of the skull should be noted and the forehead inspected for prominent supraorbital ridges or frontal bossing. The examiner should consider whether the face is particularly round, broad, triangular or ﬂat and note any excessive subcutaneous tissue or coarseness. Facial structure should be examined to establish whether the jaw is unusually prominent or receding and whether there is malar or maxillary hypoplasia. The ears should be inspected for signs of malformation, abnormal vertical position or posterior rotation. Inspection of the hair may reveal displacement of the parietal whorl, unusual hair loss, or altered form or brittleness of the hairs. The examiner should assess whether the nose is particularly short, small or unusually prominent and also note whether the nostrils are properly formed, or are hypoplastic or anteverted. Whether the nasal bridge is unusually low, high or prominent should be considered as well as whether the nasal bridge and nasal root are unusually broad. The overall size and shape of the mouth, lips and philtrum should be assessed and the possibility of hypotonia considered. The size of the tongue and any irregularities in its shape and the presence of frenula should be observed. The height and width of the palate can also be assessed and the alveolar ridges examined for hypertrophy and lead lines. The examiner should consider whether the right number of teeth are present in the right position and whether their form or size is abnormal. Eye abnormalities are found in association with all the major chromosomal aberrations, with many inborn errors of metabolism and with congenital infections. During embryonic development the eyes move medially; many syndromes and diseases are associated with an increased distance between the orbits (hyperteleorism) or, less commonly, a decreased distance (hypoteleorism). Many facial features may produce the appearance of hyperteleorism and when the abnormality is suspected interpupillary distance can be measured and compared with published norms (Hall et al. 1989; Jones 1997). The slant and length of the palpebral ﬁssures should be assessed, any prominence or retraction of the eyeballs noted, and the eyes examined for congenital ptosis. Whether the medial canthi are laterally displaced should be considered and any epicanthal folds noted. The sclera should be inspected for abnormal pigmentation and the cornea for abnormal size, clouding, opacity or deposits. Defects, unusual patterning or colouration of the iris may also be noted. Brushﬁeld spots may be seen in both Klinefelter and Down syndrome; and Lisch nodules, pigmented hamartomas of the iris, are seen in the majority of patients with neuroﬁbromatosis. A thorough fundoscopic examination of the eye requires pupillary dilatation. Whether this is a worthwhile procedure must be decided on the basis of the fundal ﬁndings without my-

driasis, and the abnormalities detected in the remainder of the examination. A darkened room will normally ensure a reasonable view. Cataracts and lens dislocation may be noted and the retina should be examined for abnormal pigmentation, chorioretinitis and the macular changes seen in storage diseases, such as a cherry red spot or grey colouration. The optic nerve should be examined for atrophy. The length of the neck should be noted and any abnormal formation of the thorax, such as pectus excavatum or carinatum. The spine should be examined for evidence of scoliosis, kyphosis, vertebral defects and sacral dimples. The examiner should consider whether the limbs are in proportion to body size and look for ﬁxed deformities of the joints; any joint hyperextensibility should also be recorded. The hands and feet should be carefully examined, paying attention to their overall size, absence or duplication of any ﬁngers or toes or their partial fusion. The examiner may also assess whether the ﬁngers or thumb are unusually long or short and whether there is metacarpal or metatarsal hypoplasia. The thumb and big toe should be inspected to determine if they are unusually broad, and the examiner should determine if any digits are either bent or permanently ﬂexed. The pattern of creases on the ﬁngers, palms and soles should be checked and the nails examined for unusual formation, in particular hypoplasia or hyperconvexity. A thorough examination of the bodily systems is always necessary and particular attention paid to the presence of heart murmurs, hepatosplenomegaly and anomalies or hyper- or hypoplasia of the external genitalia. Mental retardation is frequently accompanied by sensory impairments and all affected individuals should have audiometry and a thorough assessment of visual acuity. Sometimes the physical examination will reveal structural abnormalities of uncertain signiﬁcance and then the next steps are to refer to appropriate atlases and texts and measure possible minor anomalies with reference to population norms (Hall et al. 1989). Consultation with clinical genetics colleagues may also be necessary; indeed many clinical genetics laboratories will not order expensive speciﬁc cytogenetic investigations unless a clinical geneticist has reviewed the child. The approach to the investigation of a child with developmental delay varies considerably. A recent survey of consultant community paediatricians found that the typical number of investigations ordered varied from 0 to 15 (Gringras 1998) with the associated costs ranged from £0–1181. At the level of tertiary neurology/developmental paediatric services a comprehensive set of investigations may be routine (Majnemer & Shevell 1995; Battaglia et al. 1999) with considerable costs, particularly for neuroimaging and neurophysiological investigations. The current consensus (Curry et al. 1997) is that the choice of investigations should be based on the information available from the history and physical examination. Several different types of abnormality illustrate the general approach. Children with a history or signs of prenatal infection can be tested for immunological evidence of the common aetiological agents: toxoplasmosis, rubella, cytomegalovirus, herpes 147

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simplex and syphilis — the so-called TORCHES screen. These tests are usually most informative when conducted early in life, prior to postnatal infection or vaccination. Some individuals with congenital infections will be asymptomatic at birth, with mental retardation or neurological abnormalities, such as seizures, sensorineural hearing loss, microcephaly or motor problems, appearing at a later age. Although a TORCHES screen is still relevant in older individuals, the interpretation of positive ﬁndings is not straightforward. Unlike many causes of mental retardation, the relative importance of infectious aetiologies is subject to secular trends. There has been a recent dramatic increase in the prevalence of sexually transmitted diseases amongst young women in some countries, with the attendant risk of congenital infection. For instance, the rate of syphilis amongst girls age 15–17 years increased 126-fold in the Russian Federation between 1988 and 1996 (Tichonova et al. 1997). In high-risk areas a search should be made for Hutchinson teeth, interstitial keratitis, eighth nerve deafness, Clutton joints and rhagades. There is also an argument for routine screening for syphilis in children with mental retardation in endemic areas. The venereal disease reference laboratory test (VDRL) and the rapid plasma reagin ﬂocculation test (RPR) are indirect antigen tests which are sensitive, inexpensive and easy to perform, but false positives occur in 1–2% of the general population. Accordingly, positive ﬁndings should be followed by a sensitive and speciﬁc test for treponemal antigen, such as the ﬂuorescent treponemal antibody absorption test (FTA-ABS) and the microhaemagglutination assay for antibody to Treponema pallidum (MHA-TP). Similar issues with respect to screening arise when clinicians know that there has been a recent upsurge in one of the other infectious aetiologies. Because detailed local knowledge is not usually available when children are internationally adopted, children with mental retardation should routinely have a comprehensive infection screen (Hostetter 1999). Severe kernicterus is another relatively easily identiﬁed cause of mental retardation. Rhesus incompatibility will usually have been investigated in the postnatal period, but if this was excluded the possibility of glucose-6-phosphate dehydrogenase (G6PD) deﬁciency should be considered, especially as further episodes of haemolysis may be precipitated by a variety of chemicals and drugs. Prolonged jaundice accompanied by feeding difﬁculties, a hoarse cry and subsequent hypotonia strongly suggests congenital hypothyroidism and the face should be examined for myxoedema and a protruding tongue. Affected infants will occasionally have escaped detection by newborn screening. Some children may have dysmorphic features that suggest a syndrome that can be tested for speciﬁcally, or are strongly suggestive of a chromosomal abnormality: • fragile X syndrome is characterized by a long face, prominent jaw, thickening of the nasal bridge and large ears; • Prader–Willi syndrome by a narrow bifrontal diameter, almond-shaped palpebral ﬁssures, narrow nasal bridge and a downturned mouth; • velocardiofacial syndrome by palatal anomalies, a long nar148

row face, narrow palpable ﬁssures, ﬂat cheeks, prominent nose, small ears and mouth and a retruded chin; • Sotos syndrome by increased head circumference, frontal bossing, antimongoloid slant and a prominent jaw; and • fetal alcohol syndrome by microcephaly, short palpebral ﬁssures, a long smooth philtrum, a thin vermilion border, epicanthal folds and a ﬂat midface. However, these physical phenotypes often change with development, further complicating recognition: • the typical fragile X faces may not be apparent until after childhood; • the face in Sotos syndrome becomes longer in adolescence with disproportionate prominence of the chin; and • fetal alcohol syndrome is difﬁcult to recognize at birth and may also become less obvious after puberty. Developmental changes in physical and behavioural phenotypes are one of the key reasons for comprehensive serial evaluations of individuals, as this increases the likelihood of a speciﬁc diagnosis being made. Regular photographic records of patients may be particularly helpful in aiding recognition of an emerging physical phenotype. Children may show clinical features, such as encephalopathic or acidotic states, unusual odours, poor growth or dysmorphic features, that will suggest the need for targeted metabolic investigation (Curry et al. 1997). Neuroimaging is indicated in patients with micro- or macrocephaly or unusual skull shape, and when there are seizures, neurological signs or loss of psychomotor skills. Magnetic resonance imaging (MRI) is now the procedure of choice except when it is necessary to visualize intracranial calciﬁcation (e.g. in congenital toxoplasma or tuberous sclerosis) or visualization of the skull is required (as in the various craniosynostosis syndromes). There will be many children, however, who are not dysmorphic, show no growth abnormalities, and do not have features suggesting either a metabolic abnormality or the likelihood of a central nervous system problem visualizable with neuroimaging. Traditionally, many of these children would have had a comprehensive screen for mental retardation. The current consensus (Curry et al. 1997) has been to move away from a routine screen, when there are no clinical indicators of particular disorders, to a more restricted approach. In part that consensus derives from the very low detection rate associated with routine administration of tests such as plasma amino acid chromatography (Curry et al. 1997). The current view is that, in the absence of pointers to speciﬁc disorders, children with developmental delay should routinely have a karyotype at the 500 band level. That is because chromosomal abnormalities are the single most common known cause of mental retardation and, increasingly, it has been appreciated that they may not always be associated with obvious dysmorphology (Curry et al. 1996). Knight et al. (1999) have recently reported that 7% of children with unexplained moderate to severe mental retardation and normal routine karyotypes have subtelemeric chromosomal rearrangements detectable using a multiprobe ﬂuorescent in situ hybridization (FISH) protocol. If these ﬁndings are replicated by

PHYSICAL EXAMINATION AND MEDICAL INVESTIGATIONS

others, screening for submicroscopic telomeric chromosomal rearrangements should probably also become routine. Because the fragile X syndrome is such a common cause of unexplained mental retardation, laboratory testing is relatively inexpensive and the diagnosis has implications for patient management and genetic advice, FMR1 testing should also be considered in most patients with unexplained mental retardation (Curry et al. 1997). The advice to move to a limited screen in the absence of pointers to disease is geared towards clinicians with expertise in the assessment of children with mental retardation, who are expected to recognize indications for speciﬁc tests. Clinicians who do not consider themselves expert must decide whether to refer on for a more expert assessment or, in situations where this is impractical, to conduct a traditional screen. In addition to a TORCHES screen and karyotyping this would typically include a routine urine examination for unusual colour, odour or sediment; tests for protein, glucose, ketones and occult blood and measurement of speciﬁc gravity and pH. The urine should also be examined for metachromatic granules and tested for the presence of mucopolysaccharides (if the Lesch–Nyhan syndrome is suspected in boys, uric acid should also be measured) and the amino acid, organic acid and sugar composition of the sample determined. Haematological investigations include a full blood count with red cell indices, and microscopic examination of a blood ﬁlm for vacuolated lymphocytes and metachromatic inclusions. Biochemical investigations on blood includes measurement of thyroxine (T4), thyroid-stimulating hormone (TSH), calcium and phosphate; and plasma amino acid chromatography. In those areas where lead remains an environmental hazard, serum levels should routinely be estimated. If the course of the disorder is progressive, or there is clinical evidence of a particular disorder but screening tests are negative, then further investigation should be conducted by a centre with expertise in inborn errors of metabolism and progressive neurological disorders. If an aetiology for mental retardation is eventually identiﬁed, then optimal care will be provided if the child is seen by a doctor with experience in the underlying disorder. As new aetiologies are recognized and diagnostic testing improves, clinicians should also consider re-examination and testing for young people under their care. This is especially important when disorders are genetically determined because of the potential implications for relatives. A rather similar approach applies to the assessment of children with autism. A variety of studies suggest that an identiﬁable medical disorder of aetiological signiﬁcance occurs in only a small minority of patients (Rutter et al. 1994; Barton & Volkmar 1998; Skjeldal et al. 1998; Fombonne 1999); chromosomal abnormalities, fragile X and tuberous sclerosis being the most frequently identiﬁed disorders. As with mental retardation, a thorough history and comprehensive head-to-toe examination of all cases — including a search for depigmented lesions with a Wood light — is necessary to identify any pointers to identiﬁable aetiologies. When the history and physical examination are unremarkable, routine investigation should be conﬁned to kary-

otyping and FMR1 testing. If there are clinical indications of seizure activity an electroencephalogram (EEG) should also be performed. Because macrocephaly is found in a minority of individuals with idiopathic autism, the ﬁnding in isolation is not an indication for neuroimaging.

Loss of skills
The extent to which children who lose skills present to child psychiatrists depends upon their age, which skills are lost and the nature of any associated symptomatology. In early childhood, development may ﬁrst slow or reach a plateau before there is frank loss of skills but this pattern will only be recognized if a detailed developmental history is taken. Establishing the child’s developmental trajectory may require repeat assessments of psychological and physical development. Infants and toddlers with metabolic disorders will usually present to paediatricians with poor feeding or acute illnesses. Girls with Rett syndrome may occasionally be seen initially by child psychiatrists when there is a presumption of autism, although that confusion should now be much less common (see Lord & Bailey, Chapter 38). Some parents of children with autism are worried about their development from shortly after birth, but most are identiﬁed as showing abnormalities or delays in the second year of life. About one-quarter to one-third of children with autism lose speech in the ﬁrst years of life (Rogers & DiLalla 1990) often accompanied by or preceded by changes in social behaviour. The history of uninterrupted motor development and the previous acquisition of only a very small vocabulary are important in differentiating autism from disintegrative psychosis, which usually has an onset after age 2 and involves the loss, not just of language, but also of motor and self-help skills and bowel/bladder control. The ﬁnal outcome is usually indistinguishable from profound mental retardation and autism (Hill & Rosenbloom 1986), although deterioration can continue with more severe motor dysfunction and the development of seizures and localized neurological signs (Corbett et al. 1977). The age of onset and the usual lack of an association with seizures are also important features differentiating autism from Landau–Kleffner syndrome (see Bishop, Chapter 39), which affects previously healthy children who lose language comprehension and expression over a period of weeks or months, usually (but not always) accompanied by epileptic seizures. The peak age of onset occurs at 3–8 years. Geography and the family and social history will usually indicate the likelihood of HIV encephalopathy rather than the other causes of early developmental slowing and loss seen by neuropsychiatrists. The pandemic of HIV has now made progressive neurological disorder a very signiﬁcant presenting problem in Sub-Saharan Africa and Southeast Asia (Oleske & Czarniecki 1999). Infants acquire HIV from their mothers during pregnancy or delivery, or postnatally through breastfeeding (Giaquinto et al. 1998). Children with HIV-associated progressive encephalopathy usually develop neurological symptoms in the 149

CHAPTER 10

ﬁrst 2–3 years of life (see Havens et al., Chapter 49). There is loss of developmental milestones or cognitive abilities and progressive symmetric motor deﬁcits; sometimes loss or impairment of language and social adaptation skills may be the ﬁrst signs of encephalopathy. Some children have a more insidious illness, with non-progressive cognitive and motor deﬁcits and slowed developmental progression. In children with early loss of skills the physical examination needs to be particularly comprehensive, both with respect to a search for dysmorphic features and the neurological examination. In terms of growth parameters, an important clinical sign differentiating Rett syndrome from idiopathic autism is the deceleration in head growth leading eventually to acquired microcephaly. When Rett syndrome is suspected clinically it is possible to test directly for mutations in the MECP2 gene (Amir et al. 1999), which are found in 75% to 90% of sporadic cases and 50% of familial cases (Shahbazian & Zoghbi 2001) as well as in male relatives with profound mental retardation (Orrico et al. 2000). Childhood disintegrative disorder has been linked to cerebral lipidoses, mucopolysaccharidoses, leukodystrophies and other neurological conditions (see below). These children should usually be investigated by a paediatric neurologist as screening tests may be negative and more focused speciﬁc testing indicated. Landau–Kleffner syndrome is associated with spike and wave discharges originating in auditory cortex; these abnormalities may sometimes only be seen during slow wave sleep. Often MRI will not reveal structural abnormalities. In older children with progressive neurological disorders, loss of skills may not be the presenting complaint; rather, individuals may be seen because relatively non-speciﬁc psychiatric symptomatology or psychosis are the ﬁrst signs of dementia. The early identiﬁcation of affected individuals will usually rely on obtaining a detailed history of school performance, and this should be a routine part of the psychiatric history. Any decline should prompt a detailed enquiry about those neurological difﬁculties that may not be volunteered, particularly gait, co-ordination and visual difﬁculties. The extreme psychological consequences of physical or sexual abuse will occasionally need to be differentiated from somatic conditions, and this requires a thorough history and a high index of suspicion. Often observation in an inpatient setting may help to differentiate such psychological reactions from somatic disorders. Abuse may also constitute a risk factor for brain injury or infection. Location and disorders in other relatives will often provide clues to the most likely aetiological factors underlying progressive disorders; a number of different aetiologies are outlined that illustrate some general principals. AIDS is now the leading cause of presenile dementia, characterized by cognitive impairment ranging in intensity from memory dysfunction to global dementia, motor disabilities, involuntary and slowed movements and behavioural abnormalities such as psychosis and depression. Outside endemic areas, drug-abusing adolescents, sexually abused children (Hammerschlag 1998) and individuals who may have been exposed to unscreened blood products are at most risk. 150

Wilson disease (Bacon & Schilsky 1999; Schaefer & Gitlin 1999) is an autosomal recessive disorder of copper metabolism for which an effective therapy is available; consequently the challenge is to make the diagnosis before end organ damage and to identify potentially at-risk siblings. Wilson disease is usually symptomatic in adolescents and young adults and the majority of patients show neurological/psychiatric disorders (Cuthbert 1998). Common psychiatric manifestations include abnormal behaviour, personality change, a schizoaffective picture, depression and cognitive impairment. Huntington disease is an autosomal dominant disorder and so the presence of other affected family members substantially narrows the diagnostic possibilities, although psychological disturbance may be a consequence of an abnormal family environment. Juvenile onset occurs in about 5% of cases, usually via paternal inheritance. Affected individuals may ﬁrst become withdrawn or show emotional disturbances or changes in personality. X-linked adrenoleukodystrophy is a peroxisomal disorder associated with abnormal accumulation of very long chain fatty acids (VLCFA) (Smith et al. 1999). The commonly recognized form affects boys between 4 and 8 years of age and begins with signs and symptoms of ADHD followed by intellectual, behavioural and neurological deterioration; progression is slower with an adolescent presentation. Juvenile onset metachromatic leukodystrophy may also present with emotional or schooling difﬁculties. When progressive neurological disorders are suspected, examination of the motor system is particularly critical and early gait ataxia may be detected during tandem walk. Thus, the early neurological ﬁndings in AIDS include gait ataxia (which may be mild), hyperreﬂexia and weakness of the lower limbs. In Wilson disease, four types of movement disorder are seen: parkinsonian, pseudosclerotic, dystonic and choreic (Cuthbert 1998). Copper is deposited in the cornea and the basal ganglia at the same time and a slit lamp examination of the cornea should be undertaken for Kayser–Fleischer rings (a brown–green discolouration in the limbic area of the cornea). Hepatomegaly or splenomegaly may also be found. The abnormal movements in Huntington disease also include chorea, akinesia and rigidity. In X-linked adrenoleukodystrophy the disease process targets the white matter of the central nervous system, the adrenal cortex and the gonads. In patients with adrenal failure increased skin pigmentation may be noted in skin folds, in addition to pyramidal and extrapyramidal signs. In metachromatic leukodystrophy the examiner may detect nystagmus, hypertonia and intention tremor as well as ataxia. Speciﬁc investigations are available to detect these diverse disorders. In endemic areas, testing for HIV should be routine in the assessment of children with onset of cognitive difﬁculties, depression or psychosis. Available tests either measure antibodies to HIV-1 or HIV-2 or detect the virus directly. Enzyme-linked immunosorbent assay (ELISA) to detect antibody is readily available and cheap, but this test will not detect antibodies within 3 months of infection and is not useful in children less than 24

PHYSICAL EXAMINATION AND MEDICAL INVESTIGATIONS

months of age. HIV DNA can be screened by polymerase chain reaction (PCR) and culture; but the growth characteristics of viral strains from different countries may differ and laboratories should be alerted to the country of origin of the child (Hostetter 1999). In parallel with the worldwide spread of HIV, the prevalence of other sexually transmitted diseases has increased and infected children should also be tested for syphilis. When available, baseline neuroimaging studies are usually performed as screening for encephalopathy and to detect secondary neurological complications. HIV is rapidly becoming the most common cause of basal ganglia calciﬁcations in children (States et al. 1997) and is unique to vertically infected children, thus computed tomography (CT) is the imaging modality of choice for evaluating the symptomatic HIV-infected child. Both CT and MRI will reveal atrophy in 57–86% of children (States et al. 1997). In Wilson disease hepatic copper is not incorporated into ceruloplasmin or excreted into bile and accumulates in the hepatocyte cytoplasm, eventually resulting in cellular necrosis and leakage of copper into plasma. A 24-h urine collection to detect elevated urinary copper levels is the most cost-effective screen. The level of ceruloplasmin-bound copper and total copper are decreased, as is ceruloplasmin oxidase activity. Serum ceruloplasmin levels are also decreased, as non-copper-containing ceruloplasmin has a shorter half-life. Measurement of hepatic copper by biopsy, together with the other tests, allows a deﬁnitive diagnosis. Molecular genetic studies enable early diagnosis of affected presymptomatic siblings and treatment with zinc salts to reduce copper absorption. Nevertheless, this is complicated because more than 60 mutations and polymorphisms in the gene have been identiﬁed (Bacon & Schilsky 1999) and many patients have different mutations in each copy of their gene: compound heterozygotes (Gasser 1997). Particular mutations are frequently found in members of a speciﬁc population or ethnic group and screening of family members by haplotype analysis is possible (Cuthbert 1998). In Huntington disease (Huntington’s Disease Collaborative Research Group 1993) a CAG expansion in a protein-coding region of the gene results in an abnormal protein. Repeat length explains about 50–60% of the variance in age at onset, with lengths of > 60 or 70 CAG triplets frequently resulting in juvenile onset (Trottier et al. 1994). Deﬁnitive diagnosis is by detection of the expanded triplet repeat using PCR. Neuroimaging may demonstrate caudate atrophy and hypometabolism. There is also the possibility of presymptomatic genetic testing (see Simonoff, Chapter 66). In the cerebral form of leukodystrophy, cerebral demyelinating lesions usually start in the spleenium of the corpus callosum and show a slow progression; symmetrical demyelinating lesions in the parieto-occipital regions can be detected by MRI. A total of 200 genetic mutations have been reported with the majority of kindreds having private mutations (Smith et al. 1999). There is still much uncertainty about the scale of the problem presented by new variant Creutzfeldt–Jakob prion disease (Collinge 1999). These brain diseases are associated with accumulation of an abnormal isoform of a host encoded glycopro-

tein known as prion protein. A new variant prion protein that can be passed from cattle infected with bovine spongiform encephalitis (BSE) — mainly acquired through the consumption of feed containing animal products — to humans and other animals has been recognized since 1986, initially in the UK, but now also in mainland Europe. Infection probably occurs via the food chain and infected individuals probably also have a high innate sensitivity to BSE. In the early stages the disorder predominantly presents with psychiatric symptoms. These include particularly depression, and also anxiety, withdrawal, aggression/ irritability, ﬁrst rank symptoms, hallucinations, delusions, forgetfulness and suicidal ideation. There is also pain in the limbs or joints, or painful or unpleasant paraesthesia or dysaesthesia (Will et al. 1999). Obvious neurological symptoms subsequently develop, including gait and motor disturbance and dementia. Diagnosis usually awaits the onset of these neurological abnormalities. The prion protein can be detected in tonsils and other lymphoreticular tissue, and other tests include immunoassay for 14-3-3 protein (Will et al. 2000). So far all identiﬁed cases have been associated with homozygosity for methionine at codon 129 of the prion protein gene, highlighting the role of genetic inﬂuences on susceptibility. Because of the long incubation period of the prion diseases (mean of 12 years in kuru), it is unclear whether the number of cases will ever reach epidemic proportions.

Psychosis and acute behavioural change
Many children present to child psychiatrists with acute changes in their behaviour. When not obvious, an organic aetiology will need to be considered if the symptomatology is atypical, there are no psychological stressors or relevant family history or the disorder is subsequently refractory to adequate treatment. Additionally, these young people may be at increased risk for acquiring other diseases because of their behaviour. A comprehensive history is the most important part of the assessment and should establish the time course and severity of symptoms, as well as highlighting unusual features and possible aetiological factors. Depression, mania and schizophrenia are rare before puberty and a marked behavioural change in a prepubertal child should raise the possibility of a somatic condition or physical or sexual abuse. In addition to eliciting psychiatric symptoms, the physician will also need to gather information about the individual’s overall level of functioning, including school reports and any deterioration in self-help skills. The most puzzling cases will often require admission and in these circumstances planned investigations, particularly to identify progressive neurological impairments, should usually be discussed with neurological colleagues. Young people with an acute brain syndrome (Lishman 1998) with impairments in consciousness, thinking and memory and disturbances of perception, emotion and motor behaviour will usually be seen by paediatricians, or in the emergency department. When there are hallucinations or irrational behaviour, 151

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however, patients may be sent initially to psychiatric services. Consequently, the mental state examination must include a cognitive assessment, and any evidence of an acute organic syndrome should lead to a focused search for underlying causes (including use of drugs). Ideally, this should be in a paediatric setting where there are the appropriate resources for rapid investigation and resuscitation. A preliminary physical examination will need to establish whether the child is acutely unwell or pyrexial, detect any neurological impairments (which are often evident in progressive disorders) or evidence of an underlying disease process. In the absence of pyrexia and obvious pointers to underlying aetiology, a routine screen for a severe change in behaviour or psychosis should include: • a full blood count and erythrocyte sedimentation rate (ESR); • urea, electrolytes and glucose; • calcium and phosphate; • alkaline phosphatase, aspartate transaminase and albumin; • T4 and TSH; and • a routine urinalysis (including porphyrins and metachromatic granules) and a urine toxicology screen. Many clinicians will now undertake an MRI scan routinely following the ﬁrst episode of psychosis. An EEG should also be performed if there is a suspicion of epilepsy. Subsequent tests should be guided by the clinical course, but clinicians should also consider the possibility of conditions such as cerebral systemic lupus erythematosis as well as the progressive disorders outlined above. Worldwide cerebral infections may present with behavioural change or cognitive decline, and clinicians in the relevant areas will need to be alert to the key features of these disorders. A change in temperament of a child with a primary tuberculosis complex should arouse suspicion of tuberculous meningitis. Many parasitic organisms invade the central nervous system producing focal seizures, signs of space-occupying lesions, encephalopathies or behavioural change; these include: hydatid cyst disease, malaria, schistosomiasis, tapeworms, toxocariasis and trichinosis. Where measles remains endemic, the virus can also cause a progressive central nervous system disorder (subacute sclerosing panencephalitis) that begins several years after measles infection (Roos 1998).

childhood sexual abuse (Friedrich & Schafer 1995; Kinzl et al. 1995). Pain and neurological symptoms do not ﬁt with any local anatomical or physiological process, whereas fatigue is usually present to a pathological degree and can rarely be objectively conﬁrmed (Jordan et al. 1998). The initial goal is to rule out diagnosable medical disease. The history is particularly important in differentiating physical disease from somatic symptoms and requires an accurate description of the nature and timing of the problem, direct questioning about associated symptoms that might suggest an organic condition and a wide-ranging search for precipitating or maintaining factors. The clinician should then attempt to elicit physical signs and note whether growth and pubertal status are appropriate for the child’s age. The investigation of individual disorders should be undertaken by a physician with the relevant expertise, in order that any underlying pathology is not missed. The psychiatrist must search for diagnosable psychiatric disorders, particularly depression and panic disorder. All the involved professionals need to establish a collaborative therapeutic alliance with the patient, making symptom palliation, coping and rehabilitation the focus of the clinical enterprise (Barsky & Borus 1999).

Anorexia and bulimia
Anorexia and bulimia are disorders in which abnormal behaviours adversely affect the patient’s physical health (see Steinhausen, Chapter 34). The history should include the patient’s view about their weight and shape, details of their diet, the frequency and severity of any vomiting and purging, the amount of exercise they take, the chronology of weight change and, in females, the pattern of menstruation. The physical examination has several purposes. The patient’s current weight and height should be measured and the percentage of expected body weight or body mass index (BMI; Wt/H2) calculated. The extent of emaciation in patients with weight loss should be noted, pubertal status assessed and a search made for the complications of malnutrition, vomiting, purging and medication abuse (Becker et al. 1999). Measuring endocrine and metabolic disturbances provides a means of monitoring the course of the disorder and the ﬁndings can be explained to patients and parents, who may doubt the severity of the condition. Serum potassium may be decreased and bicarbonate elevated from vomiting or diuretic abuse, whereas a non-anion gap acidosis is associated with laxative use. Decreased sodium is usually a consequence of excess water intake or inappropriate antidiuretic hormone secretion. A full blood count may reveal leucopenia, neutropenia, anaemia and thrombocytopenia. Amenorrhoea is a consequence of decreased pulsatility of gonadotrophin-releasing hormone which leads to low oestradiol/testosterone levels. Bone loss can be assessed by bone densitometry. If tricyclic antidepressants are being contemplated, an ECG should be performed as prolongation of the QT interval is a contraindication to their use.

Somatizing disorders
The tendency to experience and communicate somatic distress and symptoms in the absence of organic pathology is common in childhood. Symptoms undergo a developmental sequence and are usually monosymptomatic initially. Recurrent abdominal pain and, less frequently, headaches are the most prominent complaints prepubertally, whereas limb pain or aching muscles, fatigue and neurological symptoms increase with age (Fritz et al. 1997). The disorders are more common in girls and in nonWestern clinical settings (Chandrasekaran et al. 1994; see also Rutter & Nikapota, Chapter 16). They are also associated with 152

PHYSICAL EXAMINATION AND MEDICAL INVESTIGATIONS

Investigations
There have been remarkable advances in the investigation of neuropsychiatric disorders since the last edition of this textbook. Genetic testing and structural and functional neuroimaging deserve especial mention, both because of the progress to date and the potential for substantial future developments. Chromosomal abnormalities constitute the largest identiﬁable cause of mental retardation syndromes and are even more common in aborted fetuses and preimplantation embryos (Delhanty et al. 1997; Munne et al. 1999). There is now improved detection of some of the subtle chromosomal abnormalities linked with developmental difﬁculties, as typiﬁed by the microdeletion syndromes. The physical and behavioural phenotypes and the underlying genetic basis of Prader–Willi and Angleman syndromes (Khan & Wood 1999), 22q deletion syndrome (Basset & Chow 1999) — which encompasses velocardiofacial syndrome and DiGeorge syndromes — and Williams syndrome (Bellugi et al. 1999) nicely illustrate the complex pathways between genetic predisposition and phenotypic expression, including the role of genetic imprinting (see Skuse & Kuntsi, Chapter 13). Improved detection of these syndromes and other chromosomal abnormalities has depended upon recent advances in cytogenetics. FISH combines molecular genetic and conventional karyotype banding approaches. It involves the binding of speciﬁc DNA probes to denatured chromosomes, hybridization being detected using ﬂuorescently labelled molecules linked to the probes. FISH can detect deletions, duplications and translocations of speciﬁc chromosomal regions with sufﬁcient sensitivity to detect intragenic rearrangements (Ekong & Wolfe 1998). Speciﬁc probes are now available to detect Prader–Willi, Angelman, velocardiofacial, Williams, Smith–Magenis and Dieker syndrome microdeletions, but the requesting clinician must still specify the syndrome/chromosomal region. Another important development is a multiprobe FISH protocol to detect subtelomeric microdeletions when there is no knowledge about which chromosome might be affected (Knight et al. 1997). A further advance is spectral karyotyping (SKY; Schröck et al. 1997): the colour differentiation of all chromosomes based on the simultaneous hybridization of 24 chromosome-speciﬁc painting probes. This research tool can identify subtle translocations and those that involve regions with similar traditional banding patterns. In terms of psychopathology linked with single gene disorders, identiﬁcation of the unusual patterns of inheritance associated with expansion of trinucleotide repeats represents a signiﬁcant advance (Margolis et al. 1999). Of most relevance to child psychiatry are the mechanisms underlying the fragile X syndrome (and related conditions); an X-linked condition that is the most common genetic cause of severe cognitive deﬁcit (De Vries et al. 1998; Kaufmann & Reiss 1999). The disorder arises from an expansion of a long CGG repeat in the FMR1 gene, leading to hypermethylation of an adjacent genomic region and consequent loss of gene transcription. The CGG repeat expan-

sion can be detected by either Southern blotting or PCR. The FMR1 protein is absent in males with a fully methylated mutation and an antibody test is a rapid and cheap means of screening in mentally retarded males and male neonates, although it will not differentiate between normal and premutation alleles (De Vries et al. 1998). Recent progress in identifying genes for relevant Mendelian disorders includes tuberous sclerosis 1 (van Slegtenhorst et al. 1997), most cases of Rett syndrome (Amir et al. 1999) and Wilson disease (Bull et al. 1993; Tanzi et al. 1993; Petrukhin et al. 1994). Testing individuals for mutations in such disorders can be useful when symptoms or signs are equivocal, or to detect at-risk relatives when effective treatments are available. Often, however, de novo analysis for speciﬁc mutations is difﬁcult if either the gene is large or there are many different mutations. In these situations, knowledge about the most frequent mutations in a particular population may be helpful, or family members can be screened using haplotype analysis (Bacon & Schilsky 1999). In the future, methodologies that screen the entire coding system of genes may make it practical to consider direct molecular genetic testing (Saugier-Veber et al. 1998). For many childhood psychiatric disorders, however, a complex genetic predisposition is thought to be relevant (Rutter et al. 1999). Although there are promising developments in this area, none so far is useful at the individual level. In autism there is overlap in the linkage ﬁndings from several whole genome scans (see Lamb et al. 2000; Maestrini et al. 2000 for reviews), particularly on chromosome 7 (IMGSAC 1998). There has also been progress in respect to ADHD and language-related disorders (see above). The extent to which testing for individual susceptibility genes will be clinically relevant in the future will depend upon the magnitude of the gene’s effect, the degree of genetic heterogeneity (whether an identiﬁed gene is implicated in a particular family), whether there is epistasis (interactions between genes), and how phenotypic expression relates to particular loci (Turner et al. 2000). Paradoxically, as knowledge about susceptibility loci increases, the recognition that complex genetic inﬂuences are not implicated in individual cases may indicate the need for further investigation. Keeping abreast of the rapid developments in genetic testing can be problematical and HTTP://www.genetests.org provides a regularly updated list of available investigations.

Neuroimaging
Over the last decade there have been considerable advances in the ability to visualize brain structure and function. The main clinical use of neuroimaging is in the detection and investigation of neurological disorders, but in the future clinical applications may extend to idiopathic childhood psychiatric disorders. The detail of the physics and practical aspects of neuroimaging are beyond the scope of this chapter and interested readers are referred to several excellent books (Orrison et al. 1995; Lewis & Higgins 1996; Frackowiak et al. 1997; Ernst & Rumsey 2000). 153

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A brief summary of the main methodologies is included in Appendix 1. The detailed ﬁndings in child psychiatry have been frequently reviewed (Bailey & Cox 1996; Filipek 1999; Santosh 2000; Overmeyer & Taylor, in press) and the ﬁndings in individual disorders are also covered in the relevant chapters. Neuroimaging has had most clinical impact in epileptology, investigation of mental retardation and assessment of progressive neurological disorders. The imaging of intractable epilepsy nicely illustrates the potential of multiple imaging approaches when there are neurodevelopmental and metabolic abnormalities as well as secondary pathology. Structural MRI is clinically useful in the investigation of temporal lobe epilepsy, demonstrating hippocampal sclerosis and atrophy in intractable complex partial seizures, often removing the need for invasive or expensive presurgical investigations (Cross et al. 1993; Cook 1994). Magnetic resonance spectroscopy (MRS) can also detect pathology by measuring the changes in N-acetylaspartate : creatinine + choline ratios associated with neuronal loss or damage (Gadian et al. 1994; Cross et al. 1997). In many cases of intractable epilepsy, ictal technetium-99 HMPAO single photon emission CT (SPECT) will demonstrate areas of hyperperfusion predictive of the seizure focus, whereas interictal studies can show unilateral hypoperfusion (Cross et al. 1997), which is also visualized using FDG-PET (Gaillard et al. 1995). Metabolic abnormalities may also be detectable when there are no focal cerebral structural abnormalities and ligands to benzodiazepine receptors are claimed to further increase the sensitivity of positron emission tomography (PET) studies (Muzik et al. 2000). Structural MRI has also been invaluable in identifying areas of cortical dysgenesis in patients with intractable partial seizures, particularly those associated with mental retardation (Palmini et al. 1991; Brodtkorb et al. 1992; Wolf et al. 1995). The dysplastic lesions can be intrinsically epileptogenic, as demonstrated by electrocorticography, magnetoencephalography (MEG) and the results of surgery (Palmini et al. 1995; Morioka et al. 1999), but surgical outcome studies also indicate that structural abnormalities may extend beyond the visualized boundaries of cortical dysplasia (Palmini et al. 1994). Immunocytochemical studies of surgically resected tissue suggest that the epileptogenicity of these dysplastic lesions is in part a consequence of decreased numbers of gamma-aminobutyric acid (GABA) -ergic neurones (Spreaﬁco et al. 1998) and recent advances in MRS editing techniques now allow non-invasive measurement of brain GABA, glutamate and glutamine levels, with some evidence that seizure frequency in patients with complex partial seizures is inversely related to brain GABA levels (Petroff et al. 1999). Analyses of quantitative relationships between cortical surface areas and volumes in cerebral dysgenesis (Sisodiya & Free 1997) offers another approach to identiﬁcation of presumed abnormal connectivity in the absence of visual abnormalities. Severe and intractable cases of epilepsy sometimes beneﬁt from surgery, but this requires establishing whether eloquent cortex is affected and clarifying language lateralization. Increas154

ingly functional MRI (fMRI) is being used for presurgical mapping of cortical function and language laterality (Stapleton et al. 1997; Bookheimer et al. 1999), with a reduced risk of morbidity and mortality compared to traditional methods. The excellent temporal and good spatial resolution of MEG is also useful in the presurgical evaluation of Landau–Kleffner syndrome: an acquired aphasia secondary to a focal epileptogenic lesion affecting speech cortex. MRI (and CT) are typically normal (Sobel et al. 2000). Spike and spike-wave discharges originate in intraperisylvian regions (Paetau et al. 1999; Sobel et al. 2000) and may be triggered by environmental sounds (Paetau et al. 1999). Multiple subpial transection is claimed to be an effective treatment in unilateral cases (Morrell et al. 1995) and MEG can identify sources precisely, and also those individuals with a unique unilateral pacemaker and spread to the opposite hemisphere (Paetau et al. 1999). Structural brain abnormalities are found in a signiﬁcant proportion of individuals with mental retardation (Curry et al. 1997). These patients often have epilepsy (see above) and MRI has revealed the full range of neuronal migration disorders and dysgenetic lesions, as well as other gross developmental abnormalities visualizable by CT. MRI is also the modality of choice for detecting lesions associated with cerebral palsy: that applies to common (Truwit et al. 1992) and rare (Kuzniecky et al. 1993) migration disorders; vascular lesions, such as periventricular leukomalacia; localized cortical necrosis; multicystic encephalomalacia; and basal ganglia injury (Krägeloh-Mann et al. 1995). There are some contradictory results in the ﬁelds of epileptology and mental retardation, but the convergence of ﬁndings is impressive. This contrasts with the discrepant ﬁndings from many neuroimaging studies of childhood psychiatric disorders (see Lord & Bailey, Chapter 38). As the ﬁeld matures, current methodological difﬁculties are likely to be overcome, but it is too soon to gauge the future role of neuroimaging in routine clinical practice. One of the aims of this work is to identify the impaired neural systems underlying complex neurodevelopmental disorders. The obstacles are the weaknesses of current explanatory models (which are largely derived from animal work and lesion studies in adults) and the limited availability of histopathological and post-mortem neurochemistry data. These ﬁndings are necessary to link genetic and molecular biology ﬁndings with the macroscopic phenomena visualized by structural and functional imaging. Findings from several disorders illustrate the range of conceptual problems. Measuring the size of brain structures in vivo has a long history. Recently, for instance, the caudate nucleus has been the subject of scrutiny in ADHD (Filipek 1999; Overmeyer & Taylor, in press). Nevertheless, there are no post-mortem studies against which to judge these ﬁndings, and although these abnormal frontostriatal interactions are considered to partly underlie some behavioural abnormalities in ADHD, there is no clear consensus about whether the effects lateralize, and if so to which side. Measures of planum temporale asymmetry in individuals with speciﬁc reading difﬁculties are similarly contra-

PHYSICAL EXAMINATION AND MEDICAL INVESTIGATIONS

dictory (Bailey & Cox 1996; Filipek 1999) and the rationale underlying this measure is uncertain when nearly 40% of the general population do not show the supposedly ‘normal’ pattern of asymmetry. Even in autism (for which there is some limited post-mortem data), contradictions abound. Thus, claims of speciﬁc hypoplasia of cerebellar vermal lobules VI and VII (Courchesne et al. 1988) have not been consistently replicated (reviewed by Filipek 1999). Also the predicted macroscopic correlates of increased cell packing density in the hippocampus and related structures (Kemper & Bauman 1998) are unclear, which complicates the interpretation of unchanged (Filipek et al. 1992; Piven et al. 1998), decreased (Aylward et al. 1999) and increased (Abell et al. 1999; Howard et al. 2000) measures of medial temporal structures. Although establishing age-appropriate norms for human brain development (Giedd et al. 1996) should aid interpretation, the underlying conceptual problem will persist: there is not a universal relationship between size of a structure and either pathology or function. In the longer term, functional imaging is likely to transform our understanding of the brain basis of developmental psychopathology. There may also be scope for clinical applications: e.g. in complex cases in which symptomatology is compatible with several different diagnoses; when there are also severe psychosocial stressors; in clinically mild cases who may pass standard cognitive tests using alternative neural pathways; and in monitoring treatment response. For disorders such as hyperactivity, in which there are strong psychopharmacological effects, it is already possible to visualize differential responses to medication during functional imaging (Vaidya et al. 1998). However, it seems probable that most psychiatric disorders arise on the basis of several cognitive (and emotional) deﬁcits, and clinically speciﬁc diagnostic approaches will likely require a heterogeneous functional test battery. Clinical utility will also demand considerable standardization of tasks, stimulus presentation parameters and data analysis. There are also conceptual challenges in the interpretation of functional imaging data. Cognitive studies using PET and fMRI rely upon subtraction paradigms in which brain activity generated by a control task is subtracted from that evoked by the task of interest. The resulting image is a difference image, not a response to a physically presented stimulus. If the underlying disorder involves the use of qualitatively different processing strategies (Rubia et al. 1999), unusual processing of control stimuli will be most evident if there is also a baseline task in addition to control and probe tasks. Subtraction approaches also assume that cognition is serial and non-interactive. Cognitive processes that are interactive or which are similar in their anatomical distribution but differ in their order or time course will not be properly differentiated using subtraction methodology (see Sergent et al. 1992, for a fuller discussion of this issue). Consequently, complementary methods with adequate temporal resolution, such as EEG or MEG, are also necessary. However, all of these approaches assess function at the level of large populations of neurones which ultimately constrains the

neurophysiological models that can be tested. A ﬁnal challenge is to understand the developmental processes that lead to abnormal localization of activation in older children and adolescents. Whereas such abnormalities may represent localized dysfunction, they may also be a consequence of abnormal input, possibly earlier in development, and while appropriate tasks may identify current input abnormalities, identifying developmental precursors will ultimately require studies of infants and young children.

Appendix 1
Computerized tomography (CT)
Computerized tomography is an X-ray technique that isolates a plane of interest in the subject by blurring out adjacent planes. It produces a series of sectional images, usually transverse to the long axis of the subject, which reﬂect the radiographic density of tissues in the plane of sectioning. The technique was a major innovation in modern imaging and, although now largely superseded by MRI, it remains the modality of choice for visualizing calciﬁcation and the skull.

Positron emission tomography (PET) and single photon emission computed tomography (SPECT)
Positron emission tomography and single photon emission computed tomography are techniques in which radioactive isotopes linked to tracers cross the blood–brain barrier and emit gamma radiation while decaying. PET uses isotopes of carbon, nitrogen, oxygen and ﬂuorine which emit a positron when they decay. After travelling a few millimetres the positron collides with an electron, producing two high energy photons which travel in opposite directions. By detecting both photons outside the head their origin can be pinpointed to a within slice resolution of 5–6 mm. Depending on the property of the tracer to which the isotope is attached, it is possible to calculate increases in absolute regional cerebral blood ﬂow or glucose metabolism associated with neuronal activity, or image neurotransmitter synthesis, the distribution and occupancy of receptors and the density of neurotransmitter transporters. The various isotopes have short half-lives necessitating manufacture on-site using expensive cyclotron or particle accelerators. The short half-life of the isotopes enables several activation studies to be conducted during one scanning session, with the administration of a series of cognitive tasks and the ‘subtraction’ of one image from another to identify statistically signiﬁcant brain activity associated with cognitive components. A variety of statistical techniques are available for analysing data produced by brain activation studies, but statistical parametric mapping (SPM) using the general linear model (Friston et al. 1995) is particularly widely used. In order to compare groups of subjects, regions of interest can be delineated, or the functional images can be co-registered with structural images 155

CHAPTER 10

or plastically transformed (Friston et al. 1995) onto a standard brain shape (Talairach et al. 1967). SPECT uses radioactive isotopes such as iodine and technetium, which have a comparatively long half-life (thus not requiring expensive on-site generation) and hence involve greater radiation exposure. They decay with emission of a single photon that has relatively low energy and thus the technique is less sensitive than PET. Although only relative blood ﬂow and semiquantitative indices of receptor binding can be calculated, these will be adequate for many purposes. The exposure to ionizing radiation largely precludes the use of PET and SPECT in children for research into the brain correlates of cognition.

available. fMRI data can be combined with structural MRI images to provide excellent localization of activation and fMRI data analysis techniques have built upon those developed to analyse PET data. Regardless of imaging sequence, the main practical problems are minimizing subject movement during the experiment and correction for any movements during statistical analysis. The lag between neuronal activity and haemodynamic response ultimately constrains the time resolution of fMRI approaches, but this is a rapidly developing ﬁeld with continuing improvements in temporal resolution and quantiﬁcation of data.

Magnetic resonance spectroscopy (MRS)
Magnetic resonance spectroscopy is a method for detecting the presence and amount of different molecules in tissue, either in vivo or in vitro. The technique detects differences in how atoms with an odd number of protons (e.g. hydrogen, carbon, ﬂuorine, sodium, potassium, phosphorus) resonate in a magnetic resonance scanner. The resonant frequency is affected by the local magnetic ﬁeld surrounding the nucleus (the chemical shift) and thus the same atom in different chemical compounds produces a distinctive peak in a frequency spectrum. In child psychiatry most interest has focused on the study of membrane phospholipids and the levels of N-acetylaspartate (NAA), a compound largely found in neurones.

Magnetic resonance imaging (MRI)
Magnetic resonance imaging is based on the capacity of organic tissue placed in a magnetic ﬁeld to absorb energy from radio waves and then re-emit this energy in proportion to the mobile hydrogen ion concentration (Wolbarst 1993). The magnetic resonance image is a map of signal strengths across a deﬁned section of tissue and the signals are inﬂuenced by the tissue environment in which the protons are situated. The technique does not involve ionizing radiation and there is a very wide choice in scanning parameters, which can emphasize the contrast between different tissue types, with new approaches being developed continuously. Diffusion tensor imaging also has the potential to identify the direction and conﬂuence of white matter tracts (Jones et al. 1999). Unlike CT, MR images can be generated in any plane and spatial resolution is excellent.

Electroencephalopathy (EEG) and magnetoencephalography (MEG)
Electroencephalopathy and magnetoencephalography are the only currently available techniques that directly detect the activity of populations of neurones with millisecond time resolution. The primary source of signals are postsynaptic potentials in activated cortical dendrites that are generally orthogonal to the cortical surface. EEG detects the induced extracellular volume currents, regardless of their orientation, which spread passively throughout the head. MEG detects the minute magnetic ﬁelds that wrap around the currents ﬂowing along dendrites, but only neurones in sulci (or whose dendritic ﬁelds are parallel to the skull) produce a magnetic ﬁeld detectable outside the head. The chief advantages of MEG over EEG are the lack of signal distortion by the skull and scalp and the ability to model the underlying current source. In addition to ‘resting’ brain activity, the potentials induced by physical stimuli or cognitive tasks can be recorded to permit computation of the underlying neural sources with no requirement for subtraction methods. The data from EEG and MEG can be combined with anatomical data from structural MRI to constraint calculations of underlying neural generators.

Functional magnetic resonance imaging (fMRI)
Functional MRI refers to a fast imaging method for indirectly visualizing regional changes in brain activity by detecting local haemodynamic changes. Following brain activation there is a disproportionate increase in blood ﬂow resulting in increased oxygenation of venous blood compared with the resting state. The increased MRI signal from oxygenated blood compared to the inactive state can be visualized by appropriate choice of pulse sequence (blood oxygen level dependent effect, BOLD; Kwong et al. 1992; Ogawa et al. 1992). Signal intensity is measured in arbitrary units and it is usually necessary to compare two activation states with each other. The haemodynamic response lags behind brain activity and this delay is taken into account in data analysis. Most published studies have presented alternating blocks of contrasting stimuli and correlated measured signal intensity from each point (voxel) in the image with the time course of stimulus presentation to detect statistically signiﬁcant differences in activation between the two stimulus types. It is now possible to interleave different types of stimuli and analyse the correlation between single trials and blood ﬂow changes (eventrelated fMRI; Buckner et al. 1996) allowing new classes of behavioural paradigms to be tested. Other methods of visualizing haemodynamic changes are also 156

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