Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Overview of Mental Disorders in Children
Assessment and Diagnosis
As with adults, assessment of the mental function of children
has several important goals: to learn the unique functional characteristics of
each individual (sometimes called formulation) and to diagnose signs and
symptoms that suggest the presence of a mental disorder. Case formulation helps
the clinician understand the child in the context of family and community.
Diagnosis helps identify children who may have a mental disorder with an
expected pattern of distress and limitation, course, and recovery. Both
processes are useful in planning for treatment and supportive care. Both are
helpful in developing a treatment plan.
Even with the aid of widely used diagnostic classification systems such as
DSM-IV (see Chapter 2), diagnosis and diagnostic classification present a
greater challenge with children than with adults for several reasons. Children
are often unable to verbalize thoughts and feelings. Clinicians by necessity
become more reliant on parents, teachers, and other professionals, who may be
unable to assess these mental processes in children. Children’s normal
development also presents an ever-changing backdrop that complicates clinical
presentation. As previously noted, some behaviors may be quite normal at one age
but suggest mental illness at another age. Finally, the criteria for diagnosing
most mental disorders in children are derived from those for adults, even though
relatively little research attention has been paid to the validity of these
criteria in children. Expression, manifestation, and course of a disorder in
children might be very different from those in adults. The boundaries between
normal and abnormal are less distinct and those between one diagnosis and
another are fluid.
Thus, the field of childhood mental health historically downplayed diagnosis.
This trend began to change in the 1980s, in part as a result of developing
practice guidelines and tougher reimbursement standards (Lonigan et al., 1998)
and more appropriate diagnostic categories and criteria (DSM III, III-R, and
IV). The body of accumulated research on treatment and services referred to
throughout this chapter reflects the past emphasis on the efficacy of
treatments, sometimes with and sometimes independently of diagnosis.
Most disorders are diagnosed by their manifestations, that is, by symptoms and
signs, as well as functional impairment (see Chapter 2). A diagnosis is made
when the combination and intensity of symptoms and signs meet the criteria for a
disorder listed in DSM-IV. However, diagnosis of childhood mental disorders, as
noted earlier, is rarely an easy task. Many of the symptoms, such as outbursts
of aggression, difficulty in paying attention, fearfulness or shyness,
difficulties in understanding language, food fads, or distress of a child when
habitual behaviors are interfered with, are normal in young children and may
occur sporadically throughout childhood. Well-trained clinicians overcome this
problem by determining whether a given symptom is occurring with an unexpected
frequency, lasting for an unexpected length of time, or is occurring at an
unexpected point in development. Clinicians with less experience may either
overdiagnose normal behavior as a disorder or miss a diagnosis by failing to
recognize abnormal behavior. Inaccurate diagnoses are more likely in children
with mild forms of a disorder.
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