66 Chapter 6
Psychiatric labelling and social control
Should children and adolescents be given a psychiatric label simply be-
cause their behaviour is unacceptable to people in authority? Totalitarian
regimes have used similar rationales in order to justify the incarceration of
dissidents in psychiatric hospitals. Partly for this reason, some psychiatrists
will only make a diagnosis of a disruptive behavioural disorder if a further
criterion is met, namely that the disruptive behaviour results in impair-
ment in everyday functioning (for example, in interpersonal relations or
schoolwork). This impairment criterion is included in DSM-IV, but not in
ICD-10.
Dimension or category?
It is, arguably more appropriate to think of disruptive behaviour as a
dimension than as an all-or-nothing category. In medicine, cut-offs are
often imposed on continuous variables in order to distinguish between
normality and abnormality. In psychology, the thinking is much more
likely to be in dimensional terms, retaining the continuous variable and
investigating the extent to which increasingly abnormal scores have in-
creasingly maladaptive outcomes. In the case of disruptive behaviour, both
dimensions and categories have advantages and disadvantages.
Advantages of a dimension
As the variety and severity of disruptive behaviour increase, so the progno-
sis progressively worsens. There is not a relatively sudden transition from
a good prognosis for children and adolescents just below the threshold
for a disruptive behavioural disorder to a bad prognosis for those above
the threshold (although it does seem to be the case that individuals with
disruptive behaviour confined to just one area, such as aggression, do have
a relatively good prognosis). An advantage of seeing disruptive behaviour
as a dimension and hence an exaggeration of normal behaviour is that the
environmental determinants causing or exacerbating the behaviour may
be more thoroughly examined, and hopefully put right.
Disadvantages of a dimension
Coexisting difficulties may be missed because they are not part of the same
dimension, for example, reading problems, ADHD.
Advantages of a category
It is simpler and focuses on the most severely affected individuals; they are
particularly relevant clinically and most studies of causation and treatment
have been based on this group. An advantage of giving a diagnosis is that
it implies the need to look for known associated features outside the core
phenomenology (for example, poor parenting, ADHD, reading delay, poor