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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 18 Bereavement, 299

Preface to the Fourth Edition, xii Dora Black
Preface to the First Edition, xiv 19 Development and Psychopathology, 309
Michael Rutter
20 Child Abuse, 325
Part 1: Clinical Assessment
Robert E. Emery & Lisa Laumann-Billings
1 Classification: Conceptual Issues and Substantive
21 Child Sexual Abuse, 340
Findings, 3
Danya Glaser
Eric Taylor & Michael Rutter
22 Residential and Foster Family Care, 359
2 Clinical Assessment and Diagnostic Formulation, 18
Alan Rushton & Helen Minnis
Michael Rutter & Eric Taylor
23 Adoption, 373
3 Diagnostic Interviews with Parents and Children, 32
Nancy J. Cohen
Adrian Angold
24 History of Child and Adolescent Psychiatry, 382
4 Case Identification in an Epidemiological Context, 52
Michael Neve & Trevor Turner
Eric Fombonne
5 Rating Scales, 70
Frank C. Verhulst & Jan Van der Ende
Part 3: Clinical Syndromes
6 Psychological Testing and Observation, 87
25 Syndromes of Hyperactivity and Attention Deficit, 399
Joseph Sergeant & Eric Taylor
Russell Schachar & Rosemary Tannock
7 Applied Scientific Thinking in Clinical Assessment, 103
26 Conduct and Oppositional Disorders, 419
Michael Rutter & William Yule
Felton Earls & Enrico Mezzacappa
8 Children’s Testimony, 117
27 Substance Use and Abuse: Epidemiology,
Stephen J. Ceci, Livia Gilstrap & Stanka A. Fitneva
Pharmacological Considerations, Identification and
9 Family Interviewing: Issues of Theory and Practice, 128
Suggestions Towards Management, 437
Ivan Eisler
Warren A. Weinberg, Caryn Harper & Roger A.
10 Physical Examination and Medical Investigations, 141
Brumback
Anthony Bailey
28 Substance Use and Abuse: Causal Pathways
11 Clinical Neurophysiology, 161
Considerations, 455
Colin D. Binnie, Steward C. Boyd, Renzo Guerrini &
Michael Rutter
Ronit Pressler
29 Affective Disorders, 463
Richard Harrington
Part 2: Influences on Psychopathology 30 Anxiety Disorders, 486
12 Genetics of Normal and Abnormal Development, 185 Rachel G. Klein & Daniel S. Pine
Peter McGuffin & Michael Rutter 31 Adjustment Disorders, 510
13 Molecular Genetic and Chromosomal Anomalies: Peter Hill
Cognitive and Behavioural Consequences, 205 32 Post-Traumatic Stress Disorders, 520
David H. Skuse & Jonna Kuntsi William Yule
14 Brain Disorders, 241 33 Suicide and Attempted Suicide, 529
Robert Goodman David Shaffer & Jennifer Gutstein
15 Chronic Adversities, 261 34 Anorexia and Bulimia Nervosa, 555
Ruth J. Friedman & P. Lindsay Chase-Lansdale Hans-Christoph Steinhausen
16 Culture, Ethnicity, Society and Psychopathology, 277 35 Obsessive-Compulsive Disorder, 571
Michael Rutter & Anula Nikapota Judith Rapoport & Susan Swedo
17 The Role of Acute Life Stresses, 287 36 Tic Disorders, 593
Seija Sandberg & Michael Rutter James F. Leckman & Donald J. Cohen

v
CONTENTS

37 Schizophrenia and Allied Disorders, 612 55 Problem-solving and Problem-solving Therapies, 938
Chris Hollis Bruce E. Compas, Molly Benson, Margaret Boyer,
38 Autism Spectrum Disorders, 636 Thomas V. Hicks & Brian Konik
Cathy Lord & Anthony Bailey 56 Parent Training Programmes, 949
39 Speech and Language Difficulties, 664 Stephen Scott
Dorothy Bishop 57 Family Therapy, 968
40 Reading and Other Learning Difficulties, 682 Brian W. Jacobs & Joanna Pearse
Margaret J. Snowling 58 Individual and Group Therapy, 983
41 Mental Retardation, 697 Brian W. Jacobs
Fred Volkmar & Elisabeth Dykens 59 Pharmacological and other Physical Treatments, 998
42 Personality and Illness, 711 Isobel Heyman & Paramala Santosh
Janette Moore & Anne Farmer 60 Treatment of Delinquents, 1019
43 Disorders of Personality, 723 Sue Bailey
Jonathan Hill 61 Provision of Intensive Treatment: Inpatient Units, Day
44 Gender Identity Disorder, 737 Units and Intensive Outreach, 1038
Ken J. Zucker Jonathan Green
45 Feeding and Sleep Disorders, 754 62 Paediatric Consultation, 1051
Alan Stein & Jacqueline Barnes Paula Rauch & Michael Jellinek
46 Attachment Disorders of Infancy and Childhood, 776 63 Local Specialist Child and Adolescent Mental Health
Thomas G. O’Connor Services, 1067
47 Wetting and Soiling in Childhood, 793 Peter Hill
Graham Clayden, Eric Taylor, Peter Loader, Malgorzata 64 Practice in Non-medical Settings, 1077
Borzyskowski, Melinda Edwards A. Rory Nicol
48 Psychiatric Aspects of Somatic Disease and Disorders, 810 65 Primary Health Care Psychiatry, 1090
David A. Mrazek M. Elena Garralda
49 Psychiatric Aspects of HIV/AIDS in Childhood and 66 Genetic Counselling, 1101
Adolescence, 828 Emily Simonoff
Jennifer Haven, Claude Ann Mellins & Joyce S. Hunter 67 Services for Children and Adolescents with Severe
50 Psychiatric Aspects of Specific Sensory Impairments, 842 Learning Difficulties (Mental Retardation), 1114
Peter Hindley & Tiejo van Gent Sarah H. Bernard
51 Implications for the Infant of Maternal Puerperal 68 Special Educational Treatment, 1128
Psychiatric Disorders, 858 Patricia Howlin
Maureen Marks, Alison E. Hipwell & the late R. Channi 69 Cultural and Ethnic lssues in Service Provision, 1148
Kumar Anula Nikapota
70 Child Protection, 1158
Part 4: Approaches to Treatment Kevin Browne
52 Prevention, 881 71 The Law Concerning Services for Children with Social and
David Offord & Kathryn J. Bennett Psychological Problems, 1175
53 Behavioural Therapies, 900 Michael Little
Martin Herbert
54 Cognitive-behavioural Approaches to the Treatment of Index, 1189
Depression and Anxiety, 921
David A. Brent, Scott T. Gaynor & V. Robin Weersing

vi
 Contributors

Adrian Angold BSc, MB BS, MRCPsych Dora Black MB, BCh, FRCPsych, FRCPCH, DPM
Associate Professor of Psychiatry and Behavioral Science, Center for Honorary Consultant Child and Adolescent Psychiatrist, Traumatic
Developmental Epidemiology, Box 3454, Duke University Medical Stress Clinic, London WIT 4PL
Center, Durham, NC 27710, USA
Malgorzata Borzyskowski FRCP, FRCPsych
Anthony Bailey BSc, MB BS, MRCPsych, DCH Consultant Neuro-Developmental Paediatrician, Guy’s and St.
MRC Clinical Scientist and Consultant Psychiatrist, Social, Genetic
Thomas’ Trust, Newcomen Centre, Guy’s Hospital, London
and Developmental Psychiatry (SGDP) Research Centre, Institute of
SE1 9RT
Psychiatry, 5 Windsor Walk, London SE5 8BB

Sue Bailey MB, ChB, FRCPsych Stewart G. Boyd MD

Consultant Adolescent Forensic Psychiatrist, Adolescent Forensic Consultant Clinical Neurophysiologist, Department of Clinical
Service, Mental Health Services of Salford NHS Trust, Bury New Road, Neurophysiology, The Hospital for Sick Children, Great Ormond
Prestwich, Manchester M25 3BL Street, London WC1N 9NX

Jacqueline Barnes BSc, MSc, PhD Margaret Boyer BA

Senior Lecturer in Psychology, Leopold Muller Centre for Child and Doctoral Student in Clinical Psychology, Department of Psychology,
Family Mental Health, Paediatrics and Child Health, Royal Free & University of Vermont, Burlington, VT 05405, USA
University College Medical School, University College London,
Rowland Hill Street, London NW3 2PF
David Brent MD, MS Hyg
Academic Chief, Child and Adolescent Psychiatry and Professor of
Kathryn J. Bennett PhD
Psychiatry, Pediatrics and Epidemiology, University of Pittsburgh
Associate Professor, Department of Clinical Epidemiology and
School of Medicine, Western Psychiatric Institute and Clinic, 3811
Biostatistics, Room 3V4D, Canadian Centre for Studies of Children at
O’Hara Street, Suite 112, Pittsburgh, PA 15213, USA
risk, McMaster University, 1200 Main St W, Hamilton, Ontario L8N
3Z5, Canada
Kevin Browne PhD, CPsychol
Molly Benson BA Professor of Forensic & Family Psychology, University of Birmingham,
Doctoral Student in Clinical Psychology, Department of Psychology, Edgbaston, Birmingham B15 2TT and Advisor to the World Health
University of Vermont, Burlington, VT 05405, USA Organisation Regional Office for Europe, Copenhagen

Sarah H. Bernard MD, MRCPsych, DRCOG R. Brumback MD

Consultant Psychiatrist, Learning Disabilities Team, Children’s & Professor and Chairman Department of Pathology, Creighton
Adolescents Department, The Maudsley Hospital, Denmark Hill, University School of Medicine, St Joseph Hospital, 601 N. 30th Street,
London SE5 8AZ Omaha, NE 68131, USA

Colin D. Binnie MD, MA, FRCP

Professor of Clinical Neurophysiology, Department of Clinical Stephen J. Ceci PhD
Neurophysiology, Division of Neurosciences, Guy’s, King’s & St The Helen L. Carr Professor of Developmental Psychology,
Thomas’ School of Medicine, King’s College Hospital, Denmark Hill, Department of Human Development, Cornell University, Ithaca,
London SE5 9RS NY 14853, USA

Dorothy V.M. Bishop MA, DPhil P. Lindsay Chase-Lansdale PhD

Wellcome Principal Research Fellow, and Professor of Developmental Professor of Developmental Psychology, School of Education
Neuropsychology, Oxford Study of Children’s Communication and Social Policy Faculty Fellow, Institute for Policy Research,
Impairments, Department of Experimental Psychology, University of Northwestern University, 2040 Sheridan Road, Evanston,
Oxford, South Parks Road, Oxford OX1 3UD IL 60208-4100, USA

vii
CONTRIBUTORS

Graham Clayden FRCP, FRCPCH Ruth Friedman MA, PhD

Reader and Consultant Paediatrician, St Thomas’ Hospital, Lambeth Legislative Associate, Democratic Staff, House Committee on
Palace Road, London SE1 7EH Education and the Workforce, US House of Representatives,
1107 Longworth House Office Building, Washington,
Donald J. Cohen MD (deceased) D.C. 20515, USA
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
Nancy J. Cohen PhD, CPsych
W2 1PG
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,
Bruce E. Compas PhD
Department of Psychology, 1903 West Michigan Avenue,
Professor of Psychology, Medicine, and Pediatrics, Department
Kalamazoo, MI 49008-5439, USA
of Psychology, University of Vermont, Burlington, VT 05405,
USA
Tiejo van Gent MD
Head of the Department for the Deaf and Hard of Hearing, Academic
Elisabeth Dykens PhD Centre for Child and Adolescent Psychiatry (Curium), Oegstgeest,
Professor of Psychology, University of California Los Angeles,
The Netherlands, and Associate Professor of Child and Adolescent
Neuropsychiatric Institute, 760 Westwood Plaza, Los Angeles,
Psychiatry, University of Leiden, The Netherlands
C A 90024, USA

Livia L. Gilstrap MA
Felton Earls MD Advanced Doctoral Candidate, Department of Human Development,
Professor of Social Medicine, Project on Human Development
Cornell University, Ithaca, NY 14853, USA
in Chicago Neighborhoods, Harvard Medical School, 1430
Massachusetts Avenue, 4th floor, Cambridge, MA 02138, USA
Danya Glaser MB, DCH, FRCPsych
Consultant Child and Adolescent Psychiatrist, Department of
Melinda Edwards BSc, DipClinPsych Psychological Medicine, Great Ormond Street Hospital for Children,
Consultant Clinical Psychologist, Guy’s and St. Thomas’ Trust, London WC1N 3JH
Bloomfield Centre, Guy’s Hospital, London SE1 9RT

Robert Goodman PhD, FRCPsych, MRCP

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

Jonathan Green MB BS, FRCPsych

Robert E. Emery PhD Senior Lecturer and Honorary Consultant in Child and
Professor, Director of Clinical Training, and Director of the Center Adolescent Psychiatry, University of Manchester and Manchester
for Children, Families and the Law, Department of Psychology, Children’s University Hospitals, Academic Department of
Gilmer Hall, Box 400400, University of Virginia, Charlottesville, Child and Adolescent Psychiatry, Booth Hall Children’s Hospital,
VA 22904-4400, USA Blackley, Manchester M9 7AA

Anne Farmer MD, FRCRsych Renzo Guerrini MD

Professor of Psychiatric Nosology, Social, Genetic and Professor of Paediatric Neurology, Department of Neurology,
Developmental Psychiatry (SGDP) Research Centre, Institute of The Hospital for Sick Children, Great Ormond Street,
Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF London WC1N 9NX

Stanka A. Fitneva MA Jennifer Gutstein BA

Advanced Doctoral Candidate, Department of Human 315 College Road, Bronx, NY 10471, USA (formerly
Development, Cornell University, Ithaca, NY 14853, USA Research Assistant, Columbia University, 1051 Riverside Drive,
Unit 78, NY 10032, USA)
Eric Fombonne MD
Professor of Child and Adolescent Psychiatry, McGill University, Caryn Harper MS
and Director of Child and Adolescent Psychiatry, Montreal Faculty Associate, Department of Neurology, University of
Children’s Hospital, 4018 Ste-Catherine West, Montreal, Texas Southwestern Medical Center at Dallas, Exchange Park,
Québec H3Z 1P2, Canada Suite 13350, 6303 Forest Park, Dallas, TX 75390-9119, USA

viii
 CONTRIBUTORS

Richard Harrington MB, ChB, MD, FRCPsych Joyce S. Hunter DSW

Professor of Child and Adolescent Psychiatry, University of Assistant Clinical Professor, Psychiatric Social Work, Department
Manchester, Department of Child & Adolescent Psychiatry, of Psychiatry, College of Physicians & Surgeons, and Assistant
Royal Manchester Children’s Hospital Pendlebury, Professor of Public Health, Sociomedical Sciences, Columbia
Manchester M27 4HA 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,
Jennifer Havens MD
NY 11104, USA
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, Brian W. Jacobs MA, MRCP, DCH, FRCPsych
NY 10032, USA Consultant Child and Adolescent Psychiatrist, Children’s Department,
The Maudsley Hospital, Denmark Hill, London SE5 8AZ

Martin Herbert PhD, FBPS Michael Jellinek MD

Emeritus Professor of Clinical and Community Psychology, Exeter
Professor of Psychiatry and of Pediatrics, Harvard Medical School,
University, School of Psychology, Exeter University, Exeter
and Chief, Child Psychiatry Service, Massachusetts General Hospital,
Bullfinch 351, Fruit St, Boston, MA 02114, USA
Isobel Heyman MB BS, PhD, MRCPsych
Consultant Child Psychiatrist, Department of Child and Adolescent Rachel Klein PhD
Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, Professor of Psychiatry, New York University, Child Study Center,
London SE5 8AF 550 First Avenue, New York, NY 10016, USA

Thomas V. Hicks BA Brian Konik BA

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

R. Channi Kumar MD, PhD, FRCPsych (deceased)

Jonathan Hill BA, MBBChir, MRCP, MRCPsych Professor of Perinatal Psychiatry, Section of Perinatal Psychiatry,
Professor of Child and Developmental Psychiatry, University of
Institute of Psychiatry, De Crespigny Park, Denmark Hill,
Liverpool, University of Child Mental Health, Mulberry House,
London SE5 8AF
Royal Liverpool Children’s Hospital, Alder Hey, Eaton Road,
Liverpool L12 2AP
Jonna Kuntsi BSc, MSc, PhD, CPsychol
Lecturer, Social, Genetic and Developmental Psychiatry (SGDP)
Peter Hill MA, MB, BChir, FRCP, FRCPsych, FRCPCH Research Centre, Institute of Psychiatry, De Crespigny Park,
Professor of Child and Adolescent Psychiatry, Department of Denmark Hill, London SE5 8AF
Psychological Medicine, Great Ormond Street Hospital for Children,
London WC1N 3JH
Lisa Laumann-Billings PhD
Postdoctoral Fellow, Prevention Research Center for Family and
Peter Hindley BSc, MRCPsych, CACDP Stage III Child Health, University of Colorado Health Sciences Center,
Consultant and Senior Lecturer in Child and Adolescent Psychiatry, 1825 Marion Street, Denver, Colorado 80218, USA
Department of Psychiatry, St Georges Hospital Medical School,
Cranmer Terrace, London, SW17 0RE James F. Leckman MD
Neison Harris Professor of Child Psychiatry, Pediatrics and
Psychology, Room I-265 SHM, Child Study Center, Yale University
Alison E. Hipwell BSc, MA, PhD, ClinPsyD
School of Medicine, 230 South Frontage Road, New Haven, CT
Assistant Professor, Pittsburgh Girls Study, Western Psychiatric
06520-7900, USA
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
Chris Hollis MB BS, BSc, PhD, DCH, MRCPsych of Chicago and Researcher, Dartington Social Research Unit,
Professor of Child & Adolescent Psychiatry, Developmental Warren House, Dartington, Totnes TQ9 6EG
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’
Patricia Howlin BA, MSc PhD, FBPS & St. Thomas’ School of Medicine, Honorary Consultant in
Professor of Clinical Psychology, St Georges Hospital Medical Child and Adolescent Psychiatry, South London and Maudsley
School, Psychology Department, Cranmer Terrace, NHS Trust, Department of Child and Adolescent Mental Health,
London SW17 0RE 35 Blackprince Road, London SE11 6JJ

ix
CONTRIBUTORS

Catherine Lord PhD David Offord MDCM, FRCP(C)

Professor and Director of University of Michigan Autism & Director, Canadian Centre for Studies of Children at Risk McMaster
Communicative Disorders Center (UMACC), 1111 Catherine Street, University, & Hamilton Health Sciences Corporation,
Ann Arbor, MI 48109, USA 1200 Main St W, Hamilton, Ontario L8N 3Z5, Canada

Maureen Marks DPhil, CPsychol, AFBPS, MBPAS Joanna Pearse RMN, CQSW, DipFT
Senior Lecturer, Sections of Perinatal Psychiatry and Psychotherapy, Family and Systemic Psychotherapist, The Maudsley Hospital,
Institute of Psychiatry, De Crespigny Park, Denmark Hill, South London and Maudsley NHS Trust, Denmark Hill,
London SE5 8AF London SE5 8AZ

Peter McGuffin MB, PhD, FRCP, FRCPsych, FMedSci Daniel S. Pine MD

Professor of Psychiatric Genetics and Director, Social, Genetic and Chief, Section on Development and Affective Neuroscience, Mood
Developmental Psychiatry (SGDP) Research Centre, Institute of and Anxiety Disorders Program, National Institute of Mental Health,
Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF 9000 Rockville Pike, Building 1, Room B3-10, Bethesda, Maryland
20892, USA
Claude Ann Mellins PhD
Assistant Professor of Clinical Psychology, Department of Psychiatry, Ronit Pressler MD
Columbia University, and Research Scientist, HIV Center for Clinical Chadburn Lecturer in Clinical Neurophysiology, Department of
and Behavioral Studies, New York State Psychiatric Institute, PO Box Clinical Neurophysiology, Division of Neurosciences, Guy’s,
15, 1051 Riverside Drive, New York, NY 10032, USA King’s & St Thomas’ School of Medicine, King’s College Hospital,
Denmark Hill, London SE5 9RS
Enrico Mezzacappa MD
Assistant Professor of Child Psychiatry, Department of Psychiatry, The Judith L. Rapoport MD
Children’s Hospital, Boston, MA, USA Chief, Child Psychiatry Branch, Bldg 10 National Institute of Mental
Health, 10 Center Drive, MSC 1600, Bethesda, MD 29892, USA
Helen Minnis MD, PhD
Specialist Registrar and Research Fellow, Department of Child and Paula K. Rauch MD
Adolescent Psychiatry, Caledonia House, Yorkhill NHS Trust, Director, Child Psychiatry Consultation Service, Massachusetts
Glasgow G3 8SJ General Hospital, 55 Fruit Street, Boston, MA 02114, USA

Janette Moore MSc, MRCPsych Alan Rushton BA, CQSW, PhD

Social, Genetic and Developmental Psychiatry (SGDP) Research Senior Lecturer in Social Work, Section of Social Work and Social Care,
Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, Health Services Research Department, The David Goldberg Centre,
London SE5 8AF Institute of Psychiatry, De Crespigny Park, London SE5 8AF

David A. Mrazek MD, FRCPsych Michael Rutter CBE, MD, FRCP, FRCPsych, FRS, FMedSci
Chair of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Professor of Developmental Psychopathology, Social, Genetic and
Rochester, MN 55905, USA 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 Seija Sandberg MD
the History of Medicine, University College London, Euston House, 24 Consultant and Senior Lecturer, Department of Psychiatry and
Eversholt Street, London NW1 1AD Behavioural Sciences, Royal Free and University College Medical
School, Wolfson Building, 48 Riding House Street,
A. Rory Nicol MPhil, FRCP, FRCPsych, FRCPCH London W1N 8AA
Visiting Professor, WHO Collaborating Centre, Institute of Psychiatry,
De Crespigny Park, Denmark Hill, London, SE5 8AF Paramala Santosh MD, MRCPsych
Lecturer, Department of Child and Adolescent Psychiatry,
Anula Nikapota FRCPsych Institute of Psychiatry, De Crespigny Park, Denmark Hill, London
Honorary Senior Lecturer, Institute of Psychiatry, London, and SE5 8AF
Consultant in Child and Adolescent Psychiatry, Lambeth Child and
Adolescent Community Mental Health Service, South London and Russell Schachar MD, FRCP(C)
Maudsley NHS Trust, 19 Brixton Water Lane, London SW2 1NN Professor, Department of Child Psychiatry, The Hospital for Sick
Children, University of Toronto, Toronto, M5G 1X8, Canada
Thomas G. O’Connor PhD
Senior Lecturer, Department of Child and Adolescent Psychiatry and Stephen Scott BSc, FRCP, MRCPsych
Social, Genetic and Developmental Psychiatry (SGDP) Research Senior Lecturer and Consultant in Child and Adolescent Psychiatry,
Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, Institute of Psychiatry, De Crespigny Park, Denmark Hill,
London SE5 8AF London SE5 8AF

x
 CONTRIBUTORS

Joseph Sergeant PhD Trevor Turner MD FRCPsych

Professor of Clinical Neuropsychology, Department of Clinical Honorary Senior Lecturer at St Bartholomew’s and The Royal
Psychology, Faculty of Psychology, University of Amsterdam, London School of Medicine and Dentistry, Honorary Senior Research
Roetersstraat 15, 1018 WB Amsterdam, The Netherlands Fellow at the Wellcome Trust Centre for the History of Medicine at
UCL, Department of Psychological Medicine, William Harvey House,
David Shaffer MB BS, FRCP, FRCPsych St Bartholomew’s Hospital, London EC1A 7BE
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, Jan Van der Ende MS
New York, NY 10032, USA Research Psychologist, Erasmus Medical Center/Sophia Children’s
Hospital, Rotterdam, The Netherlands
Emily Simonoff MD, MRCPsych
Professor of Child and Adolescent Psychiatry, Department of Child
and Adolescent Psychiatry, Guy’s, Kings’ & St Thomas’ Medical Frank C. Verhulst MD, PhD
Schools, The Munro Centre, Kings College London, 66 Snowsfields, Professor and Director of Child and Adolescent Psychiatry, Erasmus
London SE1 3SS Medical Center/Sophia Children’s Hospital, Rotterdam, The
Netherlands
David H. Skuse MD, FRCP, FRCPsych, FRCPCH
Professor of Behavioural Sciences, Behavioural Sciences Unit,
Institute of Child Health, 30 Guilford Street, London WC1N 1EH
Fred Volkmar MD
Professor of Child Psychiatry, Pediatrics and Psychology, Yale
Margaret J. Snowling PhD, DipClinPsych, FBPsS University School of Medicine, New Haven, CT 06520, USA
Professor of Psychology, Department of Psychology,
University of York, Heslington, York YO10 5DD

Alan Stein MB BChir, FRCPsych V. Robin Weersing PhD

Postdoctoral Fellow, Child Psychiatry, Western Psychiatric Institute
Professor of Child and Adolescent Psychiatry, Section of Child and
Clinic, 3811 O’Hara Street, Suite 112, Pittsburgh, PA 15213, USA
Adolescent Psychiatry, Department of Psychiatry, University of
Oxford, Warneford Hospital, Oxford OX3 7JX

Hans-Christoph Steinhausen MD, Dipl Psych, PhD Warren A. Weinberg MD

Professor and Head of Department of Child and Adolescent Professor of Neurology and Pediatrics, Director of Pediatric
Psychiatry, University of Zurich, Neumuensterallee 9, Behavior Neurology Program, Division of Pediatric Neurology,
Postfach CH-8032 Zurich, Switzerland Department of Neurology, University of Texas Southwestern
Medical Center at Dallas, 6303 Forest Park, Suite 13.350,
Susan E. Swedo MD Dallas, TX 75235-9119, USA
Chief, Pediatrics and Developmental Neuropsychiatry Branch,
MSC 12 Building 10, National Institute of Mental Health,
10 Center Drive, Bethesda, MD 20892, USA William Yule MA, DipPsychol, PhD, FBPsS, C. Psychol
Professor of Applied Child Psychology, Department of Psychology,
Rosemary Tannock PhD Institute of Psychiatry, De Crespigny Park, Denmark Hill, London
Senior Scientist, Brain and Behavior Research Program, SE5 8AF
The Hospital for Sick Children and Associate Professor of Psychiatry,
University of Toronto, Toronto, M5G 1X8, Canada
Kenneth J. Zucker PhD, CPsych
Eric Taylor MA, MB, FRCP, FRCPsych, FMedsci Psychologist-in-Chief, Centre for Addiction and Mental Health, and
Professor of Child and Adolescent Psychiatry, Department of Child Head, Child and Adolescent Gender Identity Clinic, Child Psychiatry
and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, Program–Clarke Division, 250 College St, Toronto, Ontario M5T
Denmark Hill, London SE5 8AF 1R8, Canada

xi
 Preface to the Fourth Edition

The rate of change in child and adolescent mental health has ac- pact of genetic contributions to disorder have been increasingly
celerated in the years between the third and fourth editions of recognized: twin and adoptive studies have clarified both the
this book. Nearly every chapter has had to be completely rewrit- genetic and the environmental influences on the common prob-
ten and reconceptualized to take account of substantial research lems of mental health, and an increasing range of uncommon
and clinical advances; the preparation of this volume has corre- single-gene influences have been identified. The mapping of the
spondingly been an exciting and encouraging (albeit challeng- human genome and the use of molecular chemistry to clarify the
ing) task. In this preface, we pick our some of the main factors modes of expression of genetic variations have added an im-
that are driving this development. mediate relevance to genetic investigations and it seems certain
This edition differs from its predecessors in seven main re- that these will continue. Of course, the application of this
spects. First, it reflects real gains in empirical knowledge and knowledge to the clinic is for the most part confined to the advice
conceptual understanding. These are evident in all chapters and explanations that clinicians provide. Indeed, it is necessary
throughout the book. Second, there is an extended range of to caution against a narrowly deterministic notion of how genes
chapters on measurement issues, a field in which considerable influence psychopathology. Even for the simplest genetic influ-
progress has been made. Third, we have sought to balance ‘aca- ences, their expression is strongly influenced by the actions of
demic’ advances with an equally detailed attention to clinical other genes and by interactions with the environment. The
skills and clinical application. That is evident through the book relationships between genotype and phenotype will need a great
but is also indexed by new chapters on diagnostic formulations deal more understanding, and for the multifactorial disorders
and on the applied science aspects of clinical assessment. Fourth, with which psychiatry usually deals their complexity may baffle
we have endeavoured to introduce a greater developmental ori- our understanding for some time to come.
entation; again, this is reflected both in many individual chap- The rapid development of neuroimaging techniques is also
ters and in a new chapter on this consideration. Fifth, we have full of promise for the future, and the chapter on physical inves-
sought to pay greater attention to sociocultural and ethnic issues tigations has correspondingly been expanded substantially. The
and have added two chapters dealing specifically with these fea- availability of techniques (such as magnetic resonance) that do
tures. Sixth, there is greater attention to genetic findings and not depend upon ionizing radiation has allowed their applica-
their implications, with a detailed discussion of misunderstand- tion to young people, and the psychiatry of childhood has there-
ings about supposed genetic determinism and the possible mis- fore started to be changed by the understanding of the brain that
use of genetics, as well as the huge clinical potential that is likely has informed adult psychiatry for decades. For this, as for genet-
to follow genetic advances. Finally, the trend for an increasing ic advances, the major immediate impact has been intangible: it
international, and interdisciplinary, authorship that has applied has created a climate of opinion in which the disorders of mental
over the first three editions has been further extended. This re- health are seen in the context of neurobiology. The use of psy-
flects not only the wide distribution of centres of excellence in chotropic drugs for young people has increased considerably
the field of mental health but also the increasing cooperation and in most countries over the last ten years. This increase is not
collaboration among such centres. primarily because new and more satisfactory drugs have been
The gains in knowledge over the last few years have been introduced but, rather, it has arisen as a result of an increased
driven both by the accumulation of scientific research and by professional readiness to prescribe, and this in turn may follow
changes in the wider society. One research development with as much from beliefs about causality as from improved knowl-
high impact has been the advance of the methodology of assess- edge of indications. Indeed, there may be a risk of a professional
ment. Reliable instruments for data capture, and agreed criteria and practical division between a biologically oriented psychia-
for disorders, have made knowledge more public. This in turn is try and a group of disciplines focusing on psychosocial influ-
driving both an increase in replicable findings about disorders ences. Any such split would weaken understanding and practice.
and an increase in the practical application of quantitative The authors in this volume come from a wide range of profes-
measures to clinical assessment. Many clinics, for example, sional disciplines, but all have been at pains to bring together
now apply schemes of assessment that were originally worked different perspectives and indicate how different approaches
out for research purposes. can fit together.
Advances in basic scientific knowledge have also provided Developmental psychopathology, still a young science, is mak-
some influential changes in the field. The pervasiveness and im- ing it possible for clinicians to make more informed judgements

xii
 PREFACE TO THE FOURTH EDITION

about the future course of disorder and the influences upon it that lic that are clear, accessible and authoritative. The problem of
need to be assessed. The impact of deprivation and adversity is improving the quality as well as the quantity of public informa-
better understood, and advice to social work agencies and law tion about mental health remains unsolved. The need for author-
courts has changed accordingly. The psychological understand- itative and integrative texts for professionals remains strong.
ing of what is altered in the neurodevelopmental disorders has The changing face of child and adolescent psychiatry is re-
pressed on, and has been one of the agents of change in the ascer- flected in changes of authors for a good number of the chapters,
tainment and treatment of pervasive developmental disorders. and we should like to take this opportunity of expressing our
The increased recognition of depressive disorders in young peo- deep gratitude, not only to the contributors to this edition but to
ple owes a good deal to the clarification of their longitudinal those who created the previous three editions. Most especially,
course. The developmental issues involved in psychopathology we are personally as well as editorially indebted to Lionel Hersov
have received increased attention in this edition, both in disorder- for his wise and supportive editorship over the whole of the ear-
oriented chapters and in a new chapter bringing them together. lier history of this work and for his contribution to its success.
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 Acknowledgements
from a number of small trials with varying methodology. In-
deed, the differences are so substantial that it has not yet been We are most appreciative of the authors’ expertise and effort,
possible to base all treatment recommendations on systematic and of their constructive responsiveness in dealing with the
and quantitative meta-analytic reviews. Rather, authors have many editorial suggestions on possible new material that needed
made critical narrative reviews about the evidence base and their adding, topics that required strengthening, extended interna-
recommendations are based on clinical expertise as well as the tional coverage that was desirable, clarifications that would help
published literature. Nevertheless, it is plain from the chapters readability and integrations across chapters. We note with great
on treatments and services that evaluative research is increas- sadness the premature deaths of Channi Kumar and Donald
ingly the basis of guidelines. Cohen during the course of producing the book. Both were at a
Many of the factors driving change have been social and eco- peak in their careers. The world is much indebted to Channi
nomic rather than scientific. Health care purchasers have Kumar for his pioneering work in developing and championing
become more organized, better informed, and increasingly the field of perinatal psychiatry, and to Donald Cohen for his
concerned to contain the costs of health care. The results, bridging of psychoanalysis and biological research, as well as for
whether in managed care or publicly funded services, includes his international leadership in child and adolescent psychiatry
pressure on providers to follow agreed guidelines and even de- as a whole.
tailed protocols in management regimes. This can have advan- The production of the book has been very much a team effort,
tages: treatment recommendations should of course be explicit and we have been fortunate in having such a good team to work
and challengeable, and there are too many areas noted in this with. Special thanks are due to Rachel Mawhood who exercised
volume where common clinical practices still fall well short of overall administrative responsibility for the complex enterprise
good practice guidelines. But there are dangers if protocols are of checking chapters prior to submission to the publishers, and to
applied mechanically and without sufficient consideration of in- Gill Rangel who had the comparable responsibility for the task of
dividual variability. It remains the case that treatment should be checking and collating proofs (as well as much detailed work on
focused on the individual, not the disorder. Our authors have individual chapters prior to submission). Both stages needed to
correspondingly emphasized the principles underlying assess- run smoothly to a tight timetable and it was crucial to keep an
ment and treatment rather than a set of rules, and they have eagle eye for inconsistencies or inaccuracies. We are also most
borne in mind the great variety of ways in which health care is grateful to Alice Emmott for her efficiency in translating the
organized. Furthermore, protocols that are not based on sound manuscripts into the printed page. Authors will be well aware of
evidence are very likely to be counterproductive, and the chap- the care with which these multiple tasks were undertaken.
ters of this book have striven to indicate the extent to which Thanks also go to Angela Cottingham for her professionalism in
recommendations are based on public and reliable evidence preparing the index. Expert referees who commented on individ-
and therefore the confidence that can be placed in them. ual chapters were very helpful, but must remain anonymous. The
The information revolution has combined with other forms of editorial team also owes much to Jenny Wickham who had the
social change to make a different relationship between the con- main responsibility for dealing with several individual chapters
sumers and the providers of health care. In principle, there is but who also played a full role as a member of a cohesive, effective
everything to welcome in the increasingly active and well-in- administrative team. We would also like to express particular
formed participation of families in treatment decisions. But the thanks to David Shaffer for most helpful guidance and sugges-
heterogeneity and volume of health information available, for tions on authors during the planning stage of the book.
instance on television and the Internet, brings its own problems.
Myths spread as quickly as truths. Our authors have often found Michael Rutter
it hard to recommend sources of health information for the pub- Eric Taylor

xiii
 Preface to the First Edition

These are exciting times for anyone working in the field of child apparent, we do not share any single theoretical viewpoint.
psychiatry. A wider understanding of child development now A variety of theoretical approaches are represented in the
throws a clearer light on deviations from the normal pattern; chapters which also reflect a differing emphasis on biological,
knowledge of the nature and causes of psychiatric disorders in sociocultural, behavioural and psychodynamic aetiologies and
childhood is steadily increasing; new and effective methods of formulations.
treatment are evolving; and clinical and education services for It is also fitting that this book should be based on The Joint
children with mental disorders are growing in scope and sophis- Hospital as it has player such an important part in the develop-
tication. The first academic departments of child psychiatry ment of child psychiatry. Children with psychiatric disorders
in the United Kingdom are now established to meet the needs for were first seen at The Bethlehem Royal Hospital as long ago as
teaching and research and to add to the existing body of knowl- 1800 and Henry Maudsley was unusual among the psychiatrists
edge. A serious concern to raise training standards in the spe- of his day in appreciating the importance of psychiatric disor-
cialty has led to recommendations on the range of content of ders arising in childhood. In his Physiology and Pathology of
training and a national exercise to visit and appraise all training Mind, published in 1867, he included a 34-page chapter on ‘In-
schemes is under way. sanity of early life’. The Maudsley Hospital first opened its doors
For these reasons the time seemed ripe for a new and different just over half a century ago, children have always been included
textbook of child psychiatry. Our aim has been to provide an among its patients and the Children’s Department became
accurate and comprehensive account of the current state of firmly established during those early years. Since then, and
knowledge through the integration of research approaches and especially with the first British academic appointment in child
findings with the understanding that comes from clinical experi- psychiatry at the Institute of Psychiatry in the 1950s, it has
ence and practice. Each chapter scrutinizes existing information trained many child psychiatrists who now practise in all parts of
and emphasizes areas of growth and fresh ideas on a particular the globe.
topic in a rigorous and critical fashion, but also in practical vein The book is organized into five sections. The first eight chap-
to help clinicians meet the needs of individual children and their ters review different influences on psychological development in
families. childhood and are followed by three that discuss the foremost
In planning the book we had to decide how to choose authors developmental theories. A third section describes some of the
of individual chapters. Obviously we wanted colleagues who crucial issues in clinical assessment and the fourth deals system-
had made important contributions in their fields of interest and atically with the various clinical syndromes and their treatment.
who could write with authority and knowledge. We were fortu- The final section comprises six chapters that bring together
nate in our choice and we are deeply indebted to all of them. We knowledge on some of the main therapeutic approaches. We
also decided that it would be appropriate to invite contributions have sought to include most of the topics and issues that are cen-
from those who had worked at The Bethlem Royal and The tral to modern child psychiatry, but there has been no attempt to
Maudsley Hospital or its closely associated postgraduate cover all known syndromes and symptoms. Instead, the focus
medical school, The Institute of Psychiatry. Over the years ‘The has been on concepts and methods with special emphasis on
Maudsley’ has played a major role in training psychiatrists from those areas where development of new ideas or knowledge has
all parts of the world and members of its staff have been among been greatest.
the leaders in both research and clinical practice. The fact that We hope that the book’s contents will be of interest and use to
we have all worked at the same institution has produced some all those professionally concerned with the care, study and treat-
similarities: a firm acceptance of the value of interdisciplinary ment of children with psychiatric disorders. We will be satisfied
collaboration; an intense interest in new ideas and creative if, in the words of Sir Aubrey Lewis, it also helps the psychiatrist
thinking; a commitment to the integration of academic and in training to acquire ‘reasoning and understanding’ and fits him
clinical approaches; a concern for empirical findings; and a be- ‘to combine the scientific and humane temper in his studies as
lief in the benefits that follow from open discussion between the psychiatrist needs to’.
people who hold differing views. As all of us work with children
we have a common concern with developmental theories and M. Rutter
with the process of development. However, as will also be L. Hersov

xiv
PART Clinical Assessment
ONE
 Classification: Conceptual Issues and
1 Substantive Findings
Eric Taylor and Michael Rutter

groups of children that are reasonably homogeneous with re-

Uses and abuses of classification spect to what is being investigated. The replicability of their
A classification is more like a language than a collection of ob- group definitions will affect the use that others can make of their
jects. It supports communication and provides an aid to think- results. They are also likely to be interested in the testable pre-
ing about complex problems. The virtues of a good scientific dictions that derive from a classification. In mature sciences, a
classification are clarity, comprehensiveness, acceptability to classification can itself be a scientific tool, as in cladistics where
users and fidelity to nature; a scheme should change as under- the relations of bodily structure among animals are a means for
standing alters. Each class in the scheme is a concept, not a thing. studying evolutionary descent. This is occasionally the case in
Its value is in relating individual cases to others, and a scientifi- psychopathology, when similarities between obsessions and
cally powerful class will do so in ways that are important to the stereotypies led to trials of a treatment for one condition in the
user and include a good deal of meaning. When a case is assigned other, or similarities between the symptoms of mania and atten-
to a powerful class, many predictions follow. tion deficit hyperactivity disorder (ADHD) led to cross-disorder
Students of mental health face a remarkably broad collection neurochemical studies. For all these purposes, precision and
of phenomena, the sort of classification they need will vary for replicability are the key requirements. Often it will not matter
different purposes, and therefore any one scheme is bound to be very much if many cases are left unclassified, so long as those
a compromise. Early attempts at classifying children’s disorders that are classified are done so accurately but researchers also
were strongly based on psychoanalytic theory (Freud 1965; want their conclusions to guide practice, and therefore they wish
Group for the Advancement of Psychiatry 1966). However, this to choose classes that practitioners will recognize and use.
was theory without strong empirical foundations and it soon be-
came evident that different practitioners used the concepts in
Clinical purposes
rather different ways. The reliability among raters was found to
be very low for diagnoses based on theoretical concepts (Rutter Practitioners need to know how to apply research findings to an
et al. 1969); by contrast, reasonable agreement could be reached individual case, so a widely accepted classification scheme is in-
on the description of what mental problems were actually being dispensable. For them, a scheme leaving many cases unclassified
presented. The overriding need for clarity in communication has serious drawbacks because it cuts the bridge between their
therefore gave rise to a change of approach. Modern schemes, practice and the research that should inform it. Indeed, if re-
which can be taken to date from DSM-III (American Psychiatric search definitions have drifted too far from clinical ones, it may
Association 1980) and ICD-9 (World Health Organization be quite misleading to generalize lessons from strictly defined re-
1977, 1978) are founded mostly, though not exclusively, on de- search groups to broader and vaguer clinical ones. They have
scriptions of patterns of symptomatology. However, they are other needs for classification: for example, in communication
not intended to end there. The classic instance of psychiatric between clinicians, statistical record-keeping and audit, for
classification is Kraepelin’s distinction between schizophrenia which homogeneity of groups in severity and responsiveness to
and manic-depressive psychosis; it was justified by the predic- intervention may be more important than homogeneity with
tion from symptom pattern to developmental course. The justi- respect to cause. In communication with users and carers,
fication of child psychiatric classes is their ability to predict they may use an implicit system of classification that is based
significant aspects of course, causes and response to intervention upon lay as well as scientific concepts; as when the idea of a
(Rutter 1965, 1978). As understanding develops, these aspects minimal brain dysfunction, although discredited scientifically,
are likely to play a stronger part in the definition of concepts of supposedly is still found useful in explanation.
disorder.

Abuses
Classifications, like other useful tools, can be abused. Critics
Research purposes
have attacked the abuses of psychiatric categorization from
Researchers into the psychopathology of young people need various points of view. The critiques are important to heed be-
good diagnostic schemes for several purposes. They often need cause 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 are the units of a scheme of classification and may be categories
the concept. Psychiatric categories may come to be regarded by or dimensions), and in assigning individual cases to the taxons,
long familiarity as things rather than as concepts. This would and some practical issues in the application of their results.
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 Types of classification
difficulty in learning to read were to be denied specific educa-
tional help on the grounds that they did not ‘really’ have a spe-
Categories and dimensions
cific learning disability because there was no evidence of
neurological abnormality. It needs to be kept in mind that psy- The choice of a categorical or a dimensional system of ordering
chiatric diagnoses are usually descriptive, not explanatory. has generated much debate (Sonuga-Barke 1998). A thorough-
‘ADHD’ is a description of the behaviour of a child who is inat- going categorical arrangement is often described, although only
tentive and impulsive, not a disease that explains why the child by its detractors, as a medical model. This is a highly misleading
behaves in that way. view of medicine, which incorporates dimensional as well as cat-
A diagnostic label may also be misleading by lumping unlike egorical approaches. One example would be that of blood
things together. For example, it has been noted several times that pressure, which is a dimension distributed continuously in the
tricyclic antidepressants are very frequently prescribed for chil- population; elevated blood pressure (hypertension) is a diagnos-
dren with major depressive disorders in spite of the evidence tic category, but it is based on the quantitative idea of the degree
base that indicates that they are usually ineffective in depressed of elevation that entails significant risk and at which treatment is
children. The practice seems to be maintained by the use of the justified. Another example is that of anaemia; not only are levels
diagnostic concept derived from adult psychopathology with- of haemoglobin continuously distributed, but the level that is
out sufficient recognition of a crucial age difference with respect judged to be a problem to treat will depend upon other factors,
to tricyclic medications. such as the cause and the society in which it is encountered.
Another adverse effect of diagnosis is the obscuring of as- Nevertheless, it is plain that there are many constraints on
sumptions that are involved. Sonuga-Barke (1998) has re- clinicians’ thinking that favour a set of categories. The output
emphasized the psychopathologist’s fallacy — that because a from many clinical encounters is a set of categorical decisions: a
child has been brought as a patient there must be something child either is, or is not, prescribed a drug; or admitted into a
wrong with him or her. Impulsiveness, for example, is not neces- treatment programme; or taken into care. It is therefore conve-
sarily an organismic dysfunction; it may, under some conditions nient, though obviously not essential, for diagnostic thinking to
of reward, represent an adaptive adjustment to the environ- fall into the same mode. The convenience may be more apparent
ment. Therefore one needs to keep in mind the full range of prob- than real. It invites an immediate abuse, in which the treatment
lems that present; for example, to classify social stressors as well is determined directly and exclusively by the diagnosis. This pos-
as behavioural patterns. sibility becomes all too real in some types of practice. The need
Similarly, a diagnosis may hide heterogeneity. Children with a of busy clinicians for simple rules of thumb, and the wish of
disorder are not all the same. To take just one example of this some purchasers of health care to restrict treatment to mechani-
truism, the intelligence of children with Down syndrome (which cally defined groups and protocols, can lead to a lack of careful
is not usually inherited) still shows strong genetic influences, be- planning of care for the individual case.
cause the differences of intelligence within children who have It is sometimes said that categorical thinking is inherent in the
Down syndrome are marked and are partly determined by the human mind. It arises in the first months of life (Blewitt 1994); in
same factors that determine intelligence in the general popula- adults it is deeply rooted, to the extent that formless sets of
tion. The corresponding caution is that disorders are the subject stimuli are often perceived as consisting of component cate-
of classification, not people. Descriptors, such as ‘the autistic’ or gories, and categorical thinking characterizes the lay theories
‘the brain damaged’, seem to imply that all affected people are through which non-experts perceive psychological abnormality
similar and that the disorder represents all that is important (Schoeeman et al. 1993). Even if this is the natural tendency of
about the individual. This serves to reinforce false overgenerali- the mind, especially when coping with complex information
zation and stereotyping; phrases such as ‘people with autism’ under pressure to make decisions, it is not necessarily the best
are to be preferred. approach. Artificial intelligence can increasingly be used to as-
Other problems in developing classifications, such as cultural sist in handling complex information sets, and need not be con-
dependence, will be considered throughout this chapter. The strained by human infirmity.
recognition of abuses is not a reason to abandon classification. It Categories have other practical advantages (Klein & Riso
would be impossible to do so if we are to maintain the pos- 1996); a single term, if carefully chosen, carries a great deal of
sibility of learning and teaching about disorder. However, it does meaning very conveniently and will be much more tractable in
underline the need to appreciate the strengths and the weakness- communication with parents and teachers than a large set of di-
es of particular classificatory schemes. This chapter describes mensional scores. These advantages have ensured that diagnos-
scientific issues in identifying and arranging the taxons (which tic schemes are mostly categorical; and dimensional ordering is

4
 CLASSIFICATION: CONCEPTUAL ISSUES AND SUBSTANTIVE FINDINGS

for the most part either secondary or rather tentative and specu- tests for mixed distributions is low (Meehl 1995) and even very
lative (e.g. Appendix B of DSM-IV: American Psychiatric Asso- large numbers of cases can fail to give unequivocal answers.
ciation 1994). Random error in the measurement of properties will blur the
Dimensional thinking has been more attractive to contempla- sharpness of any distinctions based upon them. Severity in itself
tive researchers, especially those dealing with graded environ- may not be the grounds for definition of a separate category. For
mental stressors, be they physical or psychosocial. However, example, the identification of a poor-outcome subgroup in early
dimensional liability is also a key feature in genetic thinking, de- onset schizophrenia is based upon a qualitative difference — the
spite the fact that individual alleles are either present or absent presence of neurocognitive changes — rather than on the severity
(see McGuffin & Rutter, Chapter 12). Which type of thinking of ‘schizophrenic symptoms’ (see Hollis, Chapter 37).
maps most helpfully on to the causes of disorder is not obvious, Some investigators have compared the effect size of a continu-
and may well differ for different kinds of psychopathology. Nev- ous measure with a categorical one in predicting an external
ertheless, throughout medicine, even when dealing with cate- association such as outcome. For example, Fergusson &
gorical disease states, dimensional risk factors are the rule rather Horwood (1995) argued on this basis that a dimensional
than the exception. measure of disruptive behaviour in childhood gave a better pre-
The distinctions between categories and dimensions should diction of adolescent outcome than a discrete category of
not be exaggerated. Generally, each can be translated into the childhood disorder. This may say more about the power of alter-
other. A category can be expressed as a set of dimensional scores, native statistical methods than about taxonomy; and it ignores
and a profile of dimensional scores is a category. Indeed, the de- the possibility that a strongly predictive category of antisocial
gree to which an individual case fits a category can itself be a di- behaviour may be present, but one that is based upon the type of
mensional construct, and should perhaps be considered as such problems rather than the severity of disruptiveness. This was,
more often. Sometimes it is preferable to use both ways of think- for example, the conclusion of Bergman & Magnusson (1997)
ing about a single domain. IQ is better conceived as a dimension in another longitudinal study, predicting antisocial outcome,
when the purpose is to predict educational achievement; but low that included a wider range of possible predictors, physiological
IQ (e.g. below 50) is better thought of categorically when the as well as behavioural. Moffitt (1993) also concluded, from
purpose is to consider whether structural disorder of the brain is analysis of the longitudinal course of a population cohort of
likely to be present (see below). Hypertension is conveniently re- boys, that an antisocial outcome in adult life was characteristic,
garded as a diagnostic category when the purpose is to select not so much of the boys who had been the most disruptive ado-
cases for treatment; as a dimension when analysing the physio- lescents, but those who had had the combination of early onset
logical reasons for changes in blood pressure; and as a category and neurodevelopmental impairments.
again when considering the different factors determining varia- Another research strategy has been to examine the distribu-
tions in the most severely affected cases at the top of the range. tion of cases against a measure of presumed aetiology and to
Another conceptual problem arises because an undoubtedly seek a point of discontinuity; for example, in comparing succes-
discrete cause may give rise to a continuum of problems at the sive levels of definition of hyperactivity against measures of neu-
level of behavioural expression. For example, the two genes rodevelopmental delay and reporting that the putative risk
known to give rise to tuberous sclerosis can both be associated factor was more common only in the most severe subgroup of
with a very wide range in the severity and type of the resulting ‘hyperkinetic disorder’ (Taylor et al. 1991). This strategy shares
psychological disorder. This is not strange; their effects in giving the limitations of the first, and entails the further doubt of
rise to physical changes, such as the characteristic malforma- whether the risk factor chosen is truly causative. It may become
tions in the brain, vary greatly between individuals. It would more feasible as more specific causes are discovered — such as
have been quite wrong to conclude from the continuously dis- molecular genetic abnormalities. Other genetic strategies have
tributed range of severity of psychological disorder associated already been elegantly employed in twin designs. Eaves et al.
with tuberous sclerosis that the underlying cause would also be (1993) went beyond the definition on the basis of single cut-off
graded in severity. scores, and applied a latent class analysis to ADHD symptoms in
In spite of the difficulties involved, the testing of assumptions a comparison of monozygotic and dizygotic twins. They succes-
about the nature of the underlying problems is important. For sively fitted models assuming different numbers of classes, and
example, it is likely to guide research strategy in investigating a found the best fit with a model of three separate classes. Gjone et
genetic contribution to disorder (see McGuffin & Rutter, Chap- al. (1996) addressed a similar question by comparing group her-
ter 12). One classic research strategy has been to examine distri- itability with individual heritability of ADHD symptoms in a
butions of cases along a continuum of severity to see if there is a twin study using multiple regression techniques (De Fries &
discontinuity between normality and pathology, such as a bi- Fulker 1988). Their conclusion was different. The extent to
modal distribution. Most rating scales, for example, have indi- which cotwins show a regression to the mean in their scores did
cated that hyperactive behaviour is distributed continuously, not function differently at the extremes of the distribution. This
with progressively fewer cases at successively higher levels of de- was in keeping either with a more dimensional view — with heri-
finition and no sign of a ‘hump on the graph’ (Taylor et al. 1991). tability similar across the whole continuum — or with a single,
This is technically and conceptually problematic. The power of very common category. The issues are not resolved, even for this

5
CHAPTER 1

rather well-studied condition; and indeed the method can re- ly, the extent to which both general and specific learning impair-
quire troublesomely large numbers. But genetic strategies such ments are present.
as these, especially when they can be applied to test hypothesized Multiaxial systems of classification have become the norm in
qualitative distinctions of severity, seem to offer encouraging fu- child/adolescent psychiatry for five main reasons. First, they
ture advances. avoid false dichotomies resulting from having to decide between
In short, the choice of dimensions against categories is com- two diagnoses that do not, in any meaningful sense, constitute
plex, hard to resolve, and likely to be different for different con- alternatives. The example given of autism or mental retardation
ditions. Mixed classification systems are likely to develop, in illustrates the point. The first gives information on the clinical
which some types of problems are subclassified by severity and syndrome whereas the second describes the level of intellectual
others by type. For the moment, there are so many uncertainties impairment. Secondly, because there has to be a coding on each
about whether dimensional or categorical arrangements better and every axis, the classification provides information that is
represent nature that a deeper pathogenetic understanding will both more complete and less ambiguous. Thus, in a multicate-
be needed before the question is resolved. gory 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
Multiaxial classification systems
relevant to the referral problem, or that the diagnosis was
Categorical classifications can be based on allotting cases to the omitted by error. Such an ambiguity could not arise with a mul-
single category they best fit, or on multiple categorization — a tiaxial system. Thirdly, it avoids artefactual unreliability result-
case may be simultaneously classified in several ways. Powerful ing from differing theoretical assumptions. Thus, psychosocial
classifications, such as those of botany, aim for a set of mutually adversity would be coded as present by both the clinician who
exclusive categories that are collectively exhaustive. Every viewed it as the main cause and by the clinician who saw it as
case then falls into one, and only one, class. This would be an only a minor contributor. The same would apply to somatic con-
idealized view of medicine, because in practice multiple diseases ditions such as cerebral palsy or diabetes. Fourthly, it provides a
are often present in the same person — sometimes because one means by which to note systematically, not only the presenting
kind of adversity tends to entail others. It can be a good disci- clinical picture, but also possible causal factors (or factors likely
pline to try to fit multiple problems into a single pattern, but it is to influence prognosis or response to treatment) and degree of
also important to detect a secondary disease even when it is overall psychosocial impairment. Finally, because of these fea-
masked by a more obvious one. tures it represents a style of thinking that is much closer to most
One kind of multiplicity is obviously necessary; different clinician’s preferred style of conceptualization than is the case
domains of problems need different classifications. It makes with a system that forces everything into the Procrustean bed of
no sense to ask whether a child has asthma or intellectual a diagnosis based only on symptom pattern.
retardation. They constitute problems of different types, and
are best considered on separate axes. Field trials of early versions
Handling of comorbidity: single vs.
of the International Classifications of Disease (ICD) (Rutter
multiple category systems
et al. 1969; Tarjan et al. 1972) indicated that many disagree-
ments between clinicians were of this type and, correspondingly, Another kind of multiplicity is provided by the co-occurrence of
that reliability among diagnostic raters could be increased two different types of symptom pattern, such as major depres-
if they were not asked to choose between, say, autism and sion and conduct disorder. The key issue is whether, in reality,
severe intellectual retardation, but were allowed to choose these represent varied manifestations of the same disorder, the
both, one on an axis of psychiatric disorder and the other on simultaneous presence of two conditions that happen to have
one of intellectual ability. This not only increases agreement, arisen in the same individual quite independently, the fact that
but provides a richer conceptualization and an opportunity to the two disorders share some of their risk factors, or some mech-
code and examine the extent to which, in this example, intellec- anism by which one disorder creates a risk for the other (Caron
tual ability modifies the course and treatment response of & Rutter 1991; Rutter 1997). Such comorbidity (meaning the
autism. situation in which two or more separate and independent disor-
A multiaxial system embodies this conceptual refinement; it ders are present in the same person) is almost the rule in the field
differs from a multicategory system in that every axis needs a of psychopathology (Angold et al. 1999). It complicates the di-
coding (even if the coding is of ‘no abnormality’). Axes of psy- agnostic process throughout medicine. On the other hand, the
chiatric syndromes, somatic diseases, psychosocial stressors and reasons for the associations among disorders can also provide
severity of impairment have been incorporated in the multiaxial valuable clues to the understanding of pathogenesis.
version of ICD-10 (WHO 1992, 1993). Specific learning The presentation of several patterns of disturbance by the
disabilities and intellectual impairments are dealt with in rather same person may not be caused only by comorbid disorders; and
different ways by DSM-IV and ICD-10 (in which they are inde- in practice the term ‘comorbidity’ is often applied more broadly,
pendent axes); the important feature is that both, in different to all the possible reasons for apparent associations between dis-
ways, allow the clinician to record, systematically and separate- orders. Comorbidity is less common in epidemiological studies

6
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