Child and Adolescent Psychiatry

Classification 27

are more likely to be referring to similar conditions when they use a par-
ticular diagnostic label. There are disadvantages, however. The DSM and
ICD criteria can come to seem like Holy Writ, making it easy to forget that
the criteria are often built on very shaky foundations. They have become
a straitjacket as well as an aid for clinicians and researchers. Furthermore,
many children and adolescents who clearly do have psychiatric disorders
(since they have symptoms that result in substantial distress, disruption
or social impairment) fail to meet the full criteria for an operationalised
diagnosis and have to be given one of the ‘not otherwise specified’ labels.
Most of these individuals havesub-thresholdorundifferentiatedsyndromes.
Individuals with sub-threshold syndromes have some of the features of op-
erationalised disorders, but not enough to reach the diagnostic threshold.
For example, many children have pronounced autistic features, but fall
short of the full criteria for autism. Undifferentiated syndromes involve a
mixture of symptoms from different operationalised disorders but do not
meet the full criteria for any one of them. For instance, children with a
mixture of worries, fears, misery and somatic complaints may clearly have
some sort of emotional disorder even though they do not meet all the
criteria for generalised anxiety disorder, specific phobia, major depression
or any other operationalised diagnosis. Yet other children fall between the
cracks of the current schemes, having constellations of problems that have
not yet been recognised; the mapping of child and adolescent psychiatric
disorders still has a long way to go.

The main diagnostic groupings
Three broad diagnostic groupings are particularly relevant to child and
adolescent psychiatrists (see Table 2.1). Theemotional disordersare also
sometimes described as internalising disorders, dating back to the notion
that ‘stresses’ could be turned inwards (internalised), leading to worries,
fears, misery, stomach-aches, etc.Externalising disorderslikewise derive
their name from the notion that ‘stresses’ can alternatively be turned
outwards (externalised), resulting in disruptive, defiant, aggressive or
antisocial behaviours that impinge on others. Thedevelopmental disorders
are a heterogeneous group characterised by delays or abnormalities in the
development of functions that normally unfold in a predictable sequence

Table 2.1The three main diagnostic groupings

Emotional disorders Externalising disorders Developmental disorders

Anxiety disorders Conduct disorder Speech/language delay
Phobias Oppositional-defiant disorder Reading delay
Depression Attention-deficit/hyperactivity
disorder (ADHD)

Autistic disorders

Obsessive-compulsive disorder Intellectual disability
Some somatisation Enuresis and encopresis