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On This Day … 23 June

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People (Births)

Ellyn Kaschak

Ellyn Kaschak (born 23 June 1943), is an American clinical psychologisy, Professor of Psychology at San Jose State University. She is one of the founders of the field of feminist psychology, which she has practiced and taught since 1972.

Her many publications, including Engendered Lives: A New Psychology of Women’s Experience (Kaschak, 1993), and Sight Unseen: Gender and Race through Blind Eyes (Kaschak, 2015), have helped define the field. She was the editor of the academic journal, Women & Therapy, for twenty years.

What is Behavioural Neurology?

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Introduction

Behavioural neurology is a subspecialty of neurology that studies the impact of neurological damage and disease upon behaviour, memory, and cognition, and the treatment thereof.

Refer to Behavioural Neuroscience.

Background

Two fields associated with behavioural neurology are neuropsychiatry and neuropsychology. In the United States, ‘Behavioural Neurology & Neuropsychiatry’ has been recognised as a single subspecialty by the United Council for Neurologic Subspecialties (UCNS) since 2004.

Symptoms

Syndromes and diseases commonly studied by behavioural neurology include:

  • Agraphia.
  • Agnosias.
  • Agraphesthesia.
  • Alexia (acquired dyslexia).
  • Amnesias.
  • Anosognosia.
  • Aphasias.
  • Apraxias.
  • Aprosodias.
  • Attention deficit hyperactivity disorder (ADHD).
  • Autism.
  • Dementia.
  • Dyslexia.
  • Epilepsy.
  • Hemispatial Neglect.
  • Psychosis.
  • Stroke.
  • Traumatic brain injury.

Brief History

While descriptions of behavioural syndromes go back to the ancient Greeks and Egyptians, it was during the 19th century that behavioural neurology began to arise, first with the primitive localisation theories of Franz Gall, followed in the mid 19th century by the first localisations in aphasias by Paul Broca and then Carl Wernicke. Localisationist neurology and clinical descriptions reached a peak in the late 19th and early 20th century, with work extending into the clinical descriptions of dementias by Alois Alzheimer and Arnold Pick. The work of Karl Lashley in rats for a time in the early to mid 20th century put a damper on localisation theory and lesion models of behavioural function.

In the United States, the work of Norman Geschwind led to a renaissance of behavioural neurology. He is famous for his work on disconnection syndromes, aphasia, and behavioural syndromes of limbic epilepsy, also called Geschwind syndrome. Having trained generations of behavioural neurologists (e.g. Antonio Damasio), Geschwind is considered the father of behavioural neurology.

The advent of in vivo neuroimaging starting in the 1980s led to a further strengthening of interest in the cognitive neurosciences and provided a tool that allowed for lesion, structural, and functional correlations with behavioural dysfunction in living people.

What is the Biopsychiatry Controversy?

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Introduction

The biopsychiatry controversy is a dispute over which viewpoint should predominate and form a basis of psychiatric theory and practice.

The debate is a criticism of a claimed strict biological view of psychiatric thinking. Its critics include disparate groups such as the antipsychiatry movement and some academics.

Overview of Opposition to Biopsychiatry

Biological psychiatry or biopsychiatry aims to investigate determinants of mental disorders devising remedial measures of a primarily somatic nature.

This has been criticised by Alvin Pam for being a “stilted, unidimensional, and mechanistic world-view”, so that subsequent “research in psychiatry has been geared toward discovering which aberrant genetic or neurophysiological factors underlie and cause social deviance”. According to Pam the “blame the body” approach, which typically offers medication for mental distress, shifts the focus from disturbed behaviour in the family to putative biochemical imbalances.

Research Issues

2003 Status in Biopsychiatric Research

Biopsychiatric research has produced reproducible abnormalities of brain structure and function, and a strong genetic component for a number of psychiatric disorders (although the latter has never been shown to be causative, merely correlative). It has also elucidated some of the mechanisms of action of medications that are effective in treating some of these disorders. Still, by their own admission, this research has not progressed to the stage that they can identify clear biomarkers of these disorders.

Research has shown that serious neurobiological disorders such as schizophrenia reveal reproducible abnormalities of brain structure (such as ventricular enlargement) and function. Compelling evidence exists that disorders including schizophrenia, bipolar disorder, and autism to name a few have a strong genetic component. Still, brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group. Ultimately, no gross anatomical lesion such as a tumour may ever be found; rather, mental disorders will likely be proven to represent disorders of intercellular communication; or of disrupted neural circuitry. Research already has elucidated some of the mechanisms of action of medications that are effective for depression, schizophrenia, anxiety, attention deficit, and cognitive disorders such as Alzheimer’s disease. These medications clearly exert influence on specific neurotransmitters, naturally occurring brain chemicals that effect, or regulate, communication between neurons in regions of the brain that control mood, complex reasoning, anxiety, and cognition. In 1970, The Nobel Prize was awarded to Julius Axelrod, Ph.D., of the National Institute of Mental Health, for his discovery of how anti-depressant medications regulate the availability of neurotransmitters such as norepinephrine in the synapses, or gaps, between nerve cells. (American Psychiatric Association, Statement on Diagnosis and Treatment of Mental Disorders, 26 September 2003).

Focus on Genetic Factors

Researchers have proposed that most common psychiatric and drug abuse disorders can be traced to a small number of dimensions of genetic risk and reports show significant associations between specific genomic regions and psychiatric disorders. Though, to date only a few genetic lesions have been demonstrated to be mechanistically responsible for psychiatric conditions. For example, one reported finding suggests that in persons diagnosed as schizophrenic as well as in their relatives with chronic psychiatric illnesses, the gene that encodes phosphodiesterase 4B (PDE4B) is disrupted by a balanced translocation.

The reasons for the relative lack of genetic understanding is because the links between genes and mental states defined as abnormal appear highly complex, involve extensive environmental influences and can be mediated in numerous different ways, for example by personality, temperament or life events. Therefore, while twin studies and other research suggests that personality is heritable to some extent, finding the genetic basis for particular personality or temperament traits, and their links to mental health problems, is “at least as hard as the search for genes involved in other complex disorders.” Theodore Lidz and The Gene Illusion argue that biopsychiatrists use genetic terminology in an unscientific way to reinforce their approach. Joseph maintains that biopsychiatrists disproportionately focus on understanding the genetics of those individuals with mental health problems at the expense of addressing the problems of the living in the environments of some extremely abusive families or societies.

Focus on Biochemical Factors

The chemical imbalance hypothesis states that a chemical imbalance within the brain is the main cause of psychiatric conditions and that these conditions can be improved with medication which corrects this imbalance. In that, emotions within a “normal” spectrum reflect a proper balance of neurotransmitter function, but abnormally extreme emotions which are severe enough to impact the daily functioning of patients (as seen in schizophrenia) reflect a profound imbalance. It is the goal of psychiatric intervention, therefore, to regain the homeostasis (via psychopharmacological approaches) that existed prior to the onset of disease.

This conceptual framework has been debated within the scientific community, although no other demonstrably superior hypothesis has emerged. Recently, the biopsychosocial approach to mental illness has been shown to be the most comprehensive and applicable theory in understanding psychiatric disorders. However, there is still much to be discovered in this area of inquiry. As a prime example – while great strides have been made in the field of understanding certain psychiatric disorders (such as schizophrenia) others (such as major depressive disorder) operate via multiple different neurotransmitters and interact in a complex array of systems which are (as yet) not completely understood.

Reductionism

Niall McLaren emphasizes in his books Humanizing Madness and Humanizing Psychiatry that the major problem with psychiatry is that it lacks a unified model of the mind and has become entrapped in a biological reductionist paradigm. The reasons for this biological shift are intuitive as reductionism has been very effective in other fields of science and medicine. However, despite reductionism’s efficacy in explaining the smallest parts of the brain this does not explain the mind, which is where he contends the majority of psychopathology stems from. An example would be that every aspect of a computer can be understood scientifically down to the last atom; however, this does not reveal the program that drives this hardware. He also argues that the widespread acceptance of the reductionist paradigm leads to a lack of openness to self-criticism and therefore halts the very engine of scientific progress. He has proposed his own natural dualist model of the mind, the biocognitive model, which is rooted in the theories of David Chalmers and Alan Turing and does not fall into the dualist’s trap of spiritualism.

Economic Influences on Psychiatric Practice

American Psychiatric Association president Steven S. Sharfstein, M.D. has stated that when the profit motive of pharmaceutical companies and human good are aligned, the results are mutually beneficial for all. In that, “Pharmaceutical companies have developed and brought to market medications that have transformed the lives of millions of psychiatric patients. The proven effectiveness of antidepressant, mood-stabilising, and antipsychotic medications has helped sensitize the public to the reality of mental illness and taught them that treatment works[citation needed]. In this way, Big Pharma has helped reduce stigma associated with psychiatric treatment and with psychiatrists.” However, Sharfstein acknowledged that the goals of individual physicians who deliver direct patient care can be different from the pharmaceutical and medical device industry. Conflicts arising from this disparity raise natural concerns in this regard including:

  • A “broken health care system” that allows “many patients [to be] prescribed the wrong drugs or drugs they don’t need”;
  • “medical education opportunities sponsored by pharmaceutical companies [that] are often biased toward one product or another”;
  • “[d]irect marketing to consumers [that] also leads to increased demand for medications and inflates expectations about the benefits of medications”;
  • “drug companies [paying] physicians to allow company reps to sit in on patient sessions to learn more about care for patients.”

Nevertheless, Sharfstein acknowledged that without pharmaceutical companies developing and producing modern medicines – virtually every medical specialty would have few (if any) treatments for the patients that they care for.

Pharmaceutical Industry Influences in Psychiatry

Studies have shown that promotional marketing by pharmaceutical and other companies has the potential to influence physician decision making. Pharmaceutical manufacturers (and other advocates) would argue that in today’s modern world – physicians simply do not have the time to continually update their knowledge base on the status of the latest research and that by providing educational materials for both physicians and patients, they are providing an educational perspective and that it is up to the individual physician to decide what treatment is best for their patients. The idea of pure promotion (e.g. lavish dinners) is a remnant of bygone era. It has been replaced by educationally-based activities that became the basis for the legal and industry reforms involving physician gifts, influence in graduate medical education, physician disclosure of conflicts of interest, and other promotional activities.

In an essay on the effect of advertisements for marketed anti-depressants there is some evidence that both patients and physicians can be influenced by media advertisements and this has the possibility of increasing the frequency of certain medicines being prescribed over others.

What is the Body Attitudes Questionnaire?

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Introduction

The Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) is a 44 item self-report questionnaire divided into six subscales that measures a woman’s attitude towards their own body.

The BAQ is used in the assessment of eating disorders. It was devised by D.I. Ben-Tovim and M.K. Walker in 1991.

Refer to the Body Attitudes Test.

Sub-Scales

The six subscales measured by the BAQ are:

  • Overall fatness.
  • Self disparagement.
  • Strength.
  • Salience of weight.
  • Feelings of attractiveness.
  • Consciousness of lower body fat.
  • Foreign-language versions.

Portuguese Version

The BAQ was the first body attitudes scale to be translated into Portuguese. The validity of the Portuguese language version was proven in a test conducted on a cohort of Brazilian women who speak Portuguese as their native language. The test-retest reliability was 0.57 and 0.85 after a one-month interval. The test was conducted by Scagliusi et al.

Japanese Version

The BAQ was translated into Japanese and tested on 68 males and 139 females in Japan and 68 Japanese males living in Australia (Kagawa et al.) The scores were assessed against 72 Australian men using the English-language version as well as scores from previous female Australian participants. There was a significant difference between the Japanese and Australian groups (p,0.05). The BAQ was deemed adequate for use in both Japanese males and females.

References

Ben-Tovim, D.I. & Walker, M.K. (1991) The development of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure of women’s attitudes towards their own bodies. Psychological Medicine. 21(3), pp.775-784. doi:10.1017/S0033291700022406.

Kagawa, M., Uchida, H., Uenishi, K., Binns, C.W. & Hills, A.P. (2007) Applicability of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) and the Attention to Body Shape scale (ABS) in Japanese males and females (PDF). Eating Behaviors. 8(3), pp.2772-284. doi:10.1016/j.eatbeh.2006.11.002.

Scagliusi, F.B., Polacow, V.O., Cordas, T.A., Coelho, D., Alvarenga, M., Philippi, S.T. & Lancha Jr, A.H. (2005) Psychometric testing and applications of the Body Attitudes Questionnaire translated into Portuguese. Perceptual and Motor Skills. 101(1), pp.25-41. doi:10.2466/PMS.101.5.25-41.

What is the Body Attitudes Test?

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Introduction

The Body Attitudes Test (BAT) was developed by Probst and colleagues in 1995.

Refer to Body Attitudes Questionnaire.

Background

It was designed for the assessment of eating disorders in women. The BAT measures an individual’s subjective body experience and attitudes towards one’s own body it differentiates between clinical and non-clinical subjects and between anorexics and bulimics. It is composed of twenty items which yield four factors:

  1. Negative appreciation of body size.
  2. Lack of familiarity with one’s own body.
  3. General body dissatisfaction.
  4. A rest factor.

Reference

Probst, M. Van Coppenolle, H. & Vandereycken, W. (1997) Further experience with the Body Attitude Test. Eating and Weight Disorders. 2(2), pp.100104. doi:10.1007/bf03339956.

On This Day … 22 June

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People (Births)

  • 1871 – William McDougall, English psychologist and polymath (d. 1938).
  • 1891 – Franz Alexander, Hungarian psychoanalyst and physician (d. 1964).
  • 1919 – Henri Tajfel, Polish social psychologist (d. 1982).
  • 1940 – Joan Busfield, English sociologist, psychologist, and academic.
  • 1946 – Sheila Hollins, Baroness Hollins, English psychiatrist and academic.

People (Deaths)

  • 2008 – Natalia Bekhtereva, Russian neuroscientist and psychologist (b. 1924).

William McDougall

William McDougall FRS (22 June 1871 to 28 November 1938) was an early 20th century psychologist who spent the first part of his career in the United Kingdom and the latter part in the United States. He wrote a number of influential textbooks, and was important in the development of the theory of instinct and of social psychology in the English-speaking world.

McDougall was an opponent of behaviourism and stands somewhat outside the mainstream of the development of Anglo-American psychological thought in the first half of the 20th century; but his work was known and respected among lay people.

Psychical Research

McDougall was a strong advocate of the scientific method and academic professionalisation in psychical research. He was instrumental in establishing parapsychology as a university discipline in the US in the early 1930s. The traditional historiography of psychical research, dominated by the ‘winners’ of the race for ‘the science of the soul’, reveals fascinating epistemological incommensurabilities and a complex set of interplays between scientific and metaphysical presuppositions in the making and keeping alive of the scientific status of psychology. Thus, revised histories of psychical research and its relationship to psychology with a critical thrust not limited to that which has been viewed with suspicion anyway, offer both a challenge and a promise to historians, the discussion of which the present article hopes to stimulate (Sommer, 2012). In 1920, McDougall served as president of the Society for Psychical Research, and in the subsequent year of its US counterpart, the American Society for Psychical Research.

McDougall worked to enlist a number of scientific, religious, ethical, political and philosophical issues and causes into a wide “actor-network” which finally pushed through the institutionalization and professionalisation of parapsychology. He was also a member of the Scientific American committee that investigated the medium Mina Crandon. He attended séances with the medium and was sceptical about her “ectoplasmic hand”. He suspected that it was part of an animal, artificially manipulated to resemble a hand. McDougall’s suspicion was confirmed by independent experts who had examined photographs of the hand.

McDougall was critical of spiritualism, he believed that some of its proponents such as Arthur Conan Doyle misunderstood psychical research and “devote themselves to propaganda”. In 1926, McDougall concluded “I have taken part in a considerable number of investigations of alleged supernormal phenomena; but hitherto have failed to find convincing evidence in any case, but have found rather much evidence of fraud and trickery.”

McDougall, however, continued to encourage scientific research on psychic phenomena and in 1937 was a founding co-editor (with Joseph Banks Rhine) of the peer-reviewed Journal of Parapsychology, which continues to be published. Because he was the first to formulate a theory of human instinctual behaviour, he influenced the development of the new field of social psychology.

Franz Alexander

Franz Gabriel Alexander (22 January 1891 to 0 8 March 1964) was a Hungarian-American psychoanalyst and physician, who is considered one of the founders of psychosomatic medicine and psychoanalytic criminology.

Life

Franz Gabriel Alexander, in Hungarian Alexander Ferenc Gábor, was born into a Jewish family in Budapest in 1891, his father was Bernhard Alexander, a philosopher and literary critic, his nephew was Alfréd Rényi, a Hungarian mathematician who made contributions in combinatorics, graph theory, number theory but mostly in probability theory. Alexander studied in Berlin; there he was part of an influential group of German analysts mentored by Karl Abraham, including Karen Horney and Helene Deutsch, and gathered around the Berlin Psychoanalytic Institute. ‘In the early 1920s, Oliver Freud was in analysis with Franz Alexander’ there — Sigmund Freud’s son — while ‘Charles Odier, one of the first among French psychoanalysts, was analysed in Berlin by Franz Alexander’ as well.

In 1930 he was invited by Robert Hutchins, then President of the University of Chicago, to become its Visiting Professor of Psychoanalysis. Alexander worked there at the Chicago Institute for Psychoanalysis, where Paul Rosenfels was one of his students. End 1950s he was among the first members of the Society for General Systems Research.

Franz Alexander died in Palm Springs, California in 1964.

Early Writings (1923-1943)

Alexander was a prolific writer. Between ‘The Castration Complex in the Formation of Character [1923] … [&] Fundamental Concepts of Psychosomatic Research [1943]’ he published nearly twenty other articles, contributing on a wide variety of subjects to the work of the “second psychoanalytic generation”.

‘Alexander in his “vector analysis”… measured the relative participation of the three basic directions in which an organism’s tendencies towards the external world may be effective: reception, elimination, and retention’. In this he may have been a forerunner to Erik H. Erikson’s later exploration of ‘Zones, Modes, and Modalities’.

He also explored the ‘morality demanded by the archaic superego … an automatized pseudo morality, characterized by Alexander as the corruptibility of the superego’.

Notable too was his exploration of acting out in real life, ‘in which the patient’s entire life consists of actions not adapted to reality but rather aimed at relieving unconscious tensions. It was this type of neurosis that was first described by Alexander under the name of neurotic character’.

Psychosomatic Work and Short-Term Psychotherapy

Franz Alexander led the movement looking for the dynamic interrelation between mind and body. Sigmund Freud pursued a deep interest in psychosomatic illnesses following his correspondence with Georg Groddeck who was, at the time, researching the possibility of treating physical disorders through psychological processes.

Together with Freud and Sándor Ferenczi, Alexander developed the concept of autoplastic adaptation. They proposed that when an individual was presented with a stressful situation, he could react in one of two ways:

  • Autoplastic adaptation: The subject tries to change himself, i.e. the internal environment.
  • Alloplastic adaptation: The subject tries to change the situation, i.e. the external environment.

From the 1930s through the 1950s, numerous analysts were engaged with the question of how to shorten the course of therapy but still achieve therapeutic effectiveness. These included Alexander, Ferenczi, and Wilhelm Reich. Alexander found that the patients who tended to benefit the most greatly from therapy were those who could rapidly engage, could describe a specific therapeutic focus, and could quickly move to an experience of their previously warded-off feelings. These also happened to represent those patients who were the healthiest to begin with and therefore had the least need for the therapy being offered. Clinical research revealed that these patients were able to benefit because they were the least resistant. They were the least resistant because they were the least traumatised and therefore had the smallest burden of repressed emotion. However, among the patients coming to the clinic for various problems, the rapid responders represented only a small minority. What could be offered to those who represented the vast bulk of patients coming for treatment? See further Intensive short-term dynamic psychotherapy.

Henri Tajfel

Henri Tajfel (born Hersz Mordche; 22 June 1919 to 03 May 1982) was a Polish social psychologist, best known for his pioneering work on the cognitive aspects of prejudice and social identity theory, as well as being one of the founders of the European Association of Experimental Social Psychology.

Early Research

Tajfel’s early research at University of Durham and University of Oxford involved examining the processes of social judgement. He believed that the cognitive processes of categorisation contributed strongly to the psychological dimensions of prejudice, which went against the prevailing views of the time. Many psychologists assumed that extreme prejudice was the result of personality factors, such as authoritarianism. According to this perspective, only those with personalities that predisposed them to prejudice were likely to become bigots. Tajfel believed this was mistaken. He had seen how large numbers of Germans – not just those with particular personalities – had given their support to Nazism and had held extreme views about Jews. Nazism would not have been successful without the support of “ordinary” Germans. Tajfel sought to discover whether the roots of prejudice might be found in “ordinary” processes of thinking, rather than in “extraordinary” personality types.

He conducted a series of experiments, investigating the role of categorization. One of his most notable experiments looked at the way that people judged the length of lines. He found that the imposition of a category directly affected judgements. If the lines, which were presented individually, were shown without any category label, then errors of judgement tended to be random. If the longest lines were each labelled A, and the shortest were labelled B, then the errors followed a pattern. Perceivers would tend to judge the lines of each category (whether A or B) as being more similar to each other than they were; and perceivers would judge the differences between categories as greater than they were (i.e., the differences between the longest B line and the shortest ‘A’ line). These findings have continued to influence subsequent work on categorisation and have been replicated subsequently.

Tajfel viewed these investigations into social judgement as being directly related to the issue of prejudice. Imposing category distinctions on lines (A and B) was like dividing the social world into different groups of people (e.g., French, Germans, British). The results of his experiments showed how cognitively deep-seated it was for perceivers to assume that all members of a certain nationality-based category (for instance, all the French or all the British) were more similar to each other than they actually were, and to assume that the members of different categories differed more than they did (for instance, to exaggerate the differences between the French and the British). In this respect, the judging of lines was similar to making stereotyped judgements about social groups. Tajfel also argued that if the categories were of value to the perceiver, then these processes of exaggeration were likely to be enhanced.

The implications of this position were profound. It meant that some of the basic psychological roots of prejudice lay not in particular personality types, but in general, “ordinary” processes of thinking, especially processes of categorising. Tajfel outlined these ideas in his article, “Cognitive Aspects of Prejudice”, which was first published in 1969 and has been republished subsequently. For this article, Tajfel was awarded the first annual Gordon Allport Intergroup Relations Prize by the Society for the Psychological Study of Social Issues.

Intergroup Relations

Having moved to Bristol University, Tajfel began his work on intergroup relations and conducted the renowned minimal groups experiments. In these studies, test subjects were divided arbitrarily into two groups, based on a trivial and almost completely irrelevant basis. Participants did not know other members of the group, did not even know who they were, and had no reason to expect that they would interact with them in the future. Still, members of both groups allocated resources in such a way that showed favouritism for members of their own group in a way that maximized their own group’s outcomes in comparison to the alternate group, even at the expense of maximum gains for their own group. Even “on the basis of a coin toss…simple categorization into groups seems to be sufficient reason for people to dispense valued rewards in ways that favor in-group members over those who are ‘different'”.

Social Identity Theory

Subsequently, Tajfel and his student John Turner developed the theory of social identity. They proposed that people have an inbuilt tendency to categorise themselves into one or more “ingroups”, building a part of their identity on the basis of membership of that group and enforcing boundaries with other groups.

Social identity theory suggests that people identify with groups in such a way as to maximise positive distinctiveness. Groups offer both identity (they tell us who we are) and self-esteem (they make us feel good about ourselves). The theory of social identity has had a very substantial impact on many areas of social psychology, including group dynamics, intergroup relations, prejudice and stereotyping, and organizational psychology.

Tajfel’s Influence

Henri Tajfel’s influence on social psychology, especially in Britain and Europe, continues to be significant. His influence has reached beyond his particular views on social identity and social judgement, as he had a wide vision of creating a social psychology that was genuinely social and was engaged with broader issues. Too much social psychology was, in his view, trivial and based on what he called “experiments in a vacuum”. Tajfel thought that social psychologists should seek to address serious social problems by examining how psychological dimensions interact with historical, ideological, and cultural factors.

The influence of his general vision can be seen in the book Social Groups and Identities. This book was a posthumous tribute to Tajfel, containing chapters written by many of his former students. Some of his students went on to develop his theories of social identity and some continued his early work on social judgement. There were also chapters from former students who developed very different sorts of social psychology. However, both those who continued Tajfel’s work directly and those who moved in other directions were united in paying tribute to the force of Tajfel’s vision for a broad-based, politically important social psychology.

Joan Busfield

Joan Busfield (born 22 June 1940), is a British sociologist and psychologist, Professor of Sociology at the University of Essex and former President of the British Sociological Association (2003-2005). Her research focuses on psychiatry and mental disorder.

She originally trained as a clinical psychologist at the Tavistock Clinic, and holds an MA from St Andrews, and an MA and a PhD from Essex.

Sheila Hollins

Sheila Clare Hollins, Baroness Hollins, (born 22 June 1946) is a professor of the psychiatry of learning disability at St George’s, University of London, and was created a crossbench life peer in the House of Lords on 15 November 2010 taking the title Baroness Hollins, of Wimbledon in the London Borough of Merton and of Grenoside in the County of South Yorkshire.

She was President of the Royal College of Psychiatrists from 2005 to 2008, succeeded by Dinesh Bhugra. From 2012 to 2013 she was president of the British Medical Association (BMA) and was formerly chair of the BMA Board of Science. In 2014 Pope Francis appointed her a member of the newly created Pontifical Commission for the Protection of Minors. The Baroness is also a member of the Scientific Advisory Board of the Centre for Child Protection and is President of the Royal Medical Benevolent Fund.

Natalia Bekhtereva

Natalia Petrovna Bekhtereva (07 July 1924 to 22 June 2008) was a Soviet and Russian neuroscientist and psychologist who developed neurophysiological approaches to psychology, such as measuring the impulse activity of human neurons. She was a participant in the documentary films The Call of the Abyss (Russian: Зов бездны) and Storm of Consciousness (Russian: Штурм сознания), which aroused wide public interest. Candidate of Biological Sciences, Doctor of Medicine, Full Professor.

She is Vladimir Bekhterev’s granddaughter. She was brought up with her brother in an orphanage. She graduated from the First Pavlov State Medical University of St. Petersburg (1941-1947) and graduate school of the Pavlov Institute of Physiology. In the summer of 1941, more than 700 students entered the University; by the end of the training, only 4 graduates survived. The rest perished from war and hunger. She survived the Siege of Leningrad.

She worked as a junior research fellow at the Institute of Experimental Medicine, USSR Academy of Medical Sciences (1950-1954). After working her way up from a senior research fellow to the head of the laboratory and Deputy Director, she worked at the Research Neurosurgical Institute named after Professor Andrey L. Polenov of the USSR Ministry of Health (1954-1962). In 1959 she became a Doctor of Medicine. Since 1962 – at the Institute of Institute of Experimental Medicine, USSR Academy of Medical Sciences (the head of the Department of human neurophysiology; the Deputy Director for Research; from 1970 to 1990 – the Director).

In 1975, she became an academician of the USSR Academy of Medical Sciences (subsequently Russian Academy of Medical Sciences). In 1981, she became an academician of the Academy of Sciences of the Soviet Union. Starting in 1990, she was the scientific director of the Centre “Brain” of the Academy of Sciences of the Soviet Union. In 1992 she became the head of the scientific group of the neurophysiology of thinking, creativity and consciousness of the Institute for Human Brain of the RAS.

She was Vice President of the International Union of Physiological Sciences (1974-1980) and Vice President of the International Organization for Psychophysiology (1982-1994).

She worked as editor-in-chief of the academic journals Human Physiology (1975-1987) and International Journal of Psychophysiology (1984-1994).

Deputy of the Supreme Soviet of the Soviet Union of the 8th convocation (1970-1974) and People’s Deputy of the Soviet Union (1989-1991).

What is Clinical Neuroscience?

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Introduction

Clinical neuroscience is a branch of neuroscience that focuses on the scientific study of fundamental mechanisms that underlie diseases and disorders of the brain and central nervous system.

It seeks to develop new ways of conceptualising and diagnosing such disorders and ultimately of developing novel treatments.

A clinical neuroscientist is a scientist who has specialised knowledge in the field. Not all clinicians are clinical neuroscientists. Clinicians and scientists – including psychiatrists, neurologists, clinical psychologists, neuroscientists, and other specialists – use basic research findings from neuroscience in general and clinical neuroscience in particular to develop diagnostic methods and ways to prevent and treat neurobiological disorders. Such disorders include addiction, Alzheimer’s disease, amyotrophic lateral sclerosis, anxiety disorders, attention deficit hyperactivity disorder, autism, bipolar disorder, brain tumours, depression, Down syndrome, dyslexia, epilepsy, Huntington’s disease, multiple sclerosis, neurological AIDS, neurological trauma, pain, obsessive-compulsive disorder, Parkinson’s disease, schizophrenia, sleep disorders, stroke and Tourette syndrome.

While neurology, neurosurgery and psychiatry are the main medical specialties that use neuroscientific information, other specialties such as cognitive neuroscience, neuroradiology, neuropathology, ophthalmology, otorhinolaryngology, anaesthesiology and rehabilitation medicine can contribute to the discipline. Integration of the neuroscience perspective alongside other traditions like psychotherapy, social psychiatry or social psychology will become increasingly important.

One Mind for Research

The “One Mind for Research” forum was a convention held in Boston, Massachusetts on 23 to 25 May 2011 that produced the blueprint document A Ten-Year Plan for Neuroscience: From Molecules to Brain Health. Leading neuroscience researchers and practitioners in the United States contributed to the creation of this document, in which 17 key areas of opportunities are listed under the Clinical Neuroscience section. These include the following:

  • Rethinking curricula to break down intellectual silos.
  • Training translational neuroscientists and clinical investigators.
  • Investigating biomarkers.
  • Improving psychiatric diagnosis.
  • Developing a “Framingham Study of Brain Disorders” (i.e. longitudinal cohort for central nervous system disease).
  • Identifying developmental risk factors and producing effective interventions.
  • Discovering new treatments for pain, including neuropathic pain.
  • Treating disorders of neural signalling and pathological synchrony.
  • Treating disorders of immunity or inflammation.
  • Treating metabolic and mitochondrial disorders.
  • Developing new treatments for depression.
  • Treating addictive disorders.
  • Improving treatment of schizophrenia.
  • Preventing and treating cerebrovascular disease.
  • Achieving personalized medicine.
  • Understanding shared mechanisms of neurodegeneration.
  • Advancing anaesthesia.

In particular, it advocates for better integrated and scientifically driven curricula for practitioners, and it recommends that such curricula be shared among neurologists, psychiatrists, psychologists, neurosurgeons and neuroradiologists.

Given the various ethical, legal and societal implications for healthcare practitioners arising from advances in neuroscience, the University of Pennsylvania inaugurated the Penn Conference on Clinical Neuroscience and Society in July 2011.

What is Clinical Neuropsychology?

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Introduction

Clinical neuropsychology is a sub-field of psychology concerned with the applied science of brain-behaviour relationships.

Clinical neuropsychologists use this knowledge in the assessment, diagnosis, treatment, and or rehabilitation of patients across the lifespan with neurological, medical, neurodevelopmental and psychiatric conditions, as well as other cognitive and learning disorders. The branch of neuropsychology associated with children and young people is paediatric neuropsychology.

Clinical neuropsychology is a specialised form of clinical psychology. Strict rules are in place to maintain evidence as a focal point of treatment and research within clinical neuropsychology. The assessment and rehabilitation of neuropsychopathologies is the focus for a clinical neuropsychologist. A clinical neuropsychologist must be able to determine whether a symptom(s) may be caused by an injury to the head through interviewing a patient in order to determine what actions should be taken to best help the patient. Another duty of a clinical neuropsychologist is to find cerebral abnormalities and possible correlations. Evidence based practice in both research and treatment is paramount to appropriate clinical neuropsychological practice.

Assessment is primarily by way of neuropsychological tests, but also includes patient history, qualitative observation and may draw on findings from neuroimaging and other diagnostic medical procedures. Clinical neuropsychology requires an in-depth knowledge of: neuroanatomy, neurobiology, psychopharmacology and neuropathology.

Brief History

During the late 1800s, brain-behaviour relationships were interpreted by European physicians who observed and identified behavioural syndromes that were related with focal brain dysfunction.

Clinical neuropsychology is a fairly new practice in comparison to other specialty fields in psychology with history going back to the 1960s. The specialty focus of clinical neuropsychology evolved slowly into a more defined whole as interest grew. Threads from neurology, clinical psychology, psychiatry, cognitive psychology, and psychometrics all have been woven together to create the intricate tapestry of clinical neuropsychology, a practice which is very much so still evolving. The history of clinical neuropsychology is long and complicated due to its ties to so many older practices. Researchers like Thomas Willis (1621-1675) who has been credited with creating neurology, John Hughlings Jackson (1835-1911) who theorised that cognitive processes occurred in specific parts of the brain, Paul Broca (1824-1880) and Karl Wernicke (1848-1905) who studied the human brain in relation to psychopathology, Jean Martin Charcot (1825-1893) who apprenticed Sigmund Freud (1856-1939) who created the psychoanalytic theory all contributed to clinical medicine which later contributed to clinical neuropsychology. The field of psychometrics contributed to clinical neuropsychology through individuals such as Francis Galton (1822-1911) who collected quantitative data on physical and sensory characteristics, Karl Pearson (1857-1936) who established the statistics which psychology now relies on, Wilhelm Wundt (1832-1920) who created the first psychology lab, his student Charles Spearman (1863-1945) who furthered statistics through discoveries like factor analysis, Alfred Binet (1857-1911) and his apprentice Theodore Simon (1872-1961) who together made the Binet-Simon scale of intellectual development, and Jean Piaget (1896-1980) who studied child development. Studies in intelligence testing made by Lewis Terman (1877-1956) who updated the Binet-Simon scale to the Stanford-Binet intelligence scale, Henry Goddard (1866-1957) who developed different classification scales, and Robert Yerkes (1876-1956) who was in charge of the Army Alpha and Beta tests also all contributed to where clinical neuropsychology is today.

Clinical neuropsychology focuses on the brain and goes back to the beginning of the 20th century. As a clinician a clinical neuropsychologist offers their services by addressing three steps: assessment, diagnosis, and treatment. The term clinical neuropsychologist was first made by Sir William Osler on 16 April 1913. While clinical neuropsychology was not a focus until the 20th century evidence of brain and behaviour treatment and studies are seen as far back as the neolithic area when trephination, a crude surgery in which a piece of the skull is removed, has been observed in skulls. As a profession, clinical neuropsychology is a subspecialty beneath clinical psychology. During World War I (1914-1918) the early term shell shock was first observed in soldiers who survived the war. This was the beginning of efforts to understand traumatic events and how they affected people. During the Great Depression (1929-1941) further stressors caused shell shock like symptoms to emerge. In World War II (1939-1945) the term shell shock was changed to battle fatigue and clinical neuropsychology became even more involved with attempting to solve the puzzle of peoples’ continued signs of trauma and distress. The Veterans Administration or VA was created in 1930 which increased the call for clinical neuropsychologists and by extension the need for training. The Korean War (1950-1953) and Vietnam War (1960-1973) further solidified the need for treatment by trained clinical neuropsychologists. In 1985 the term post-traumatic stress disorder or PTSD was coined and the understanding that traumatic events of all kinds could cause PTSD started to evolve.

The relationship between human behaviour and the brain is the focus of clinical neuropsychology as defined by Meir in 1974. There are two subdivisions of clinical neuropsychology which draw much focus; organic and environmental natures. Ralph M. Reitan, Arthur L. Benton, and A.R. Luria are all past neuropsychologists whom believed and studied the organic nature of clinical neuropsychology. Alexander Luria is the Russian neuropsychologist responsible for the origination of clinical psychoneurological assessment after WWII. Building upon his original contribution connecting the voluntary and involuntary functions influencing behaviour, Luria further conjoins the methodical structures and associations of neurological processes in the brain. Luria developed the ‘combined motor method’ to measure thought processes based on the reaction times when three simultaneous tasks are appointed that require a verbal response. On the other side, environmental nature of clinical neuropsychology did not appear until more recently and is characterised by treatments such as behaviour therapy. The relationship between physical brain abnormalities and the presentation of psychopathology is not completely understood, but this is one of the questions which clinical neuropsychologists hope to answer in time. In 1861 the debate over human potentiality versus localisation began. The two sides argued over how human behaviour presented in the brain. Paul Broca postulated that cognitive problems could be caused by physical damage to specific parts of the brain based on a case study of his in which he found a lesion on the brain of a deceased patient who had presented the symptom of being unable to speak, that portion of the brain is now known as Broca’s Area. In 1874 Carl Wernicke also made a similar observation in a case study involving a patient with a brain lesion whom was unable to comprehend speech, the part of the brain with the lesion is now deemed Wernicke’s Area. Both Broca and Wernicke believed and studied the theory of localisation. On the other hand, equal potentiality theorists believed that brain function was not based on a single piece of the brain but rather on the brain as a whole. Marie J.P Flourens conducted animal studies in which he found that the amount of brain tissue damaged directly affected the amount that behaviour ability was altered or damaged. Kurt Goldstein observed the same idea as Flourens except in veterans who had fought in World War I. In the end, despite all of the disagreement, neither theory completely explains the human brains complexity. Thomas Hughlings Jackson created a theory which was thought to be a possible solution. Jackson believed that both potentiality and localisation were in part correct and that behaviour was made by multiple parts of the brain working collectively to cause behaviours, and Luria (1966-1973) furthered Jackson’s theory.

The Role

When considering where a clinical neuropsychologist works, hospitals are a common place for practitioners to end up. There are three main variations in which a clinical neuropsychologist may work at a hospital; as an employee, consultant, or independent practitioner. As a clinical neuropsychologist working as an employee of a hospital the individual may receive a salary, benefits, and sign a contract for employment. In the case of an employee of a hospital the hospital is in charge of legal and financial responsibilities. The second option of working as a consultant implies that the clinical neuropsychologist is part of a private practice or is a member of a physicians group. In this scenario, the clinical neuropsychologist may work in the hospital like the employee of the hospital but all financial and legal responsibilities go through the group which the clinical neuropsychologist is a part of. The third option is an independent practitioner whom works alone and may even have their office outside of the hospital or rent a room in the hospital. In the third case, the clinical neuropsychologist is completely on their own and in charge of their own financial and legal responsibilities.

Assessment

Assessments are used in clinical neuropsychology to find brain psychopathologies of the cognitive, behavioural, and emotional variety. Physical evidence is not always readily visible so clinical neuropsychologists must rely on assessments to tell them the extent of the damage. The cognitive strengths and weaknesses of the patient are assessed to help narrow down the possible causes of the brain pathology. A clinical neuropsychologist is expected to help educate the patient on what is happening to them so that the patient can understand how to work with their own cognitive deficits and strengths. An assessment should accomplish many goals such as; gage consequences of impairments to quality of life, compile symptoms and the change in symptoms over time, and assess cognitive strengths and weaknesses. Accumulation of the knowledge earned from the assessment is then dedicated to developing a treatment plan based on the patient’s individual needs. An assessment can also help the clinical neuropsychologist gauge the impact of medications and neurosurgery on a patient. Behavioural neurology and neuropsychology tools can be standardised or psychometric tests and observational data collected on the patient to help build an understanding of the patient and what is happening with them. There are essential prerequisites which must be present in a patient in order for the assessment to be effective; concentration, comprehension, and motivation and effort.

Lezak lists six primary reasons neuropsychological assessments are carried out: diagnosis, patient care and its planning, treatment planning, treatment evaluation, research and forensic neuropsychology. To conduct a comprehensive assessment will typically take several hours and may need to be conducted over more than a single visit. Even the use of a screening battery covering several cognitive domains may take 1.5-2 hours. At the commencement of the assessment it is important to establish a good rapport with the patient and ensure they understand the nature and aims of the assessment.

Neuropsychological assessment can be carried out from two basic perspectives, depending on the purpose of assessment. These methods are normative or individual. Normative assessment, involves the comparison of the patient’s performance against a representative population. This method may be appropriate in investigation of an adult onset brain insult such as traumatic brain injury or stroke. Individual assessment may involve serial assessment, to establish whether declines beyond those which are expected to occur with normal aging, as with dementia or another neurodegenerative condition.

Assessment can be further subdivided into sub-sections:

History Taking

Neuropsychological assessments usually commence with a clinical interview as a means of collecting a history, which is relevant to the interpretation of any later neuropsychological tests. In addition, this interview provides qualitative information about the patient’s ability to act in a socially apt manner, organise and communicate information effectively and provide an indication as to the patient’s mood, insight and motivation. It is only within the context of a patient’s history that an accurate interpretation of their test data and thus a diagnosis can be made. The clinical interview should take place in a quiet area free from distractions. Important elements of a history include demographic information, description of presenting problem, medical history (including any childhood or developmental problems, psychiatric and psychological history), educational and occupational history (and if any legal history and military history).

Selection of Neuropsychological Tests

It is not uncommon for patients to be anxious about being tested; explaining that tests are designed so that they will challenge everyone and that no one is expected to answer all questions correctly may be helpful. An important consideration of any neuropsychological assessment is a basic coverage of all major cognitive functions. The most efficient way to achieve this is the administration of a battery of tests covering: attention, visual perception and reasoning, learning and memory, verbal function, construction, concept formation, executive function, motor abilities and emotional status. Beyond this basic battery, choices of neuropsychological tests to be administered are mainly made on the basis of which cognitive functions need to be evaluated in order to fulfil the assessment objectives.

Report Writing

Following a neuropsychological assessment it is important to complete a comprehensive report based on the assessment conducted. The report is for other clinicians, as well as the patient and their family so it is important to avoid jargon or the use of language which has different clinical and lay meanings (e.g. intellectually disabled as the correct clinical term for an IQ below 70, but offensive in lay language). The report should cover background to the referral, relevant history, reasons for assessment, neuropsychologists observations of patient’s behaviour, test administered and results for cognitive domains tested, any additional findings (e.g. questionnaires for mood) and finish the report with a summary and recommendations. In the summary it is important to comment on what the profile of results indicates regarding the referral question. The recommendations section contains practical information to assist the patient and family, or improve the management of the patient’s condition.

Educational Requirements of Different Countries

The educational requirements for becoming a clinical neuropsychologist differ between countries. In some countries it may be necessary to complete a clinical psychology degree, before specialising with further studies in clinical neuropsychology. While some countries offer clinical neuropsychology courses to students who have completed 4 years of psychology studies. All clinical neuropsychologists require a postgraduate qualification, whether it be a Masters or Doctorate (Ph.D, Psy.D. or D.Psych).

Australia

To become a clinical neuropsychologist in Australia requires the completion of a 3-year Australian Psychology Accreditation Council (APAC) approved undergraduate degree in psychology, a 1-year psychology honours, followed by a 2-year Masters or 3-year Doctorate of Psychology (D.Psych) in clinical neuropsychology. These courses involve coursework (lectures, tutorials, practicals etc.), supervised practice placements and the completion of a research thesis. Masters and D.Psych courses involve the same amount of coursework units, but differ in the amount of supervised placements undertaken and length of research thesis. Masters courses require a minimum of 1,000 hours (125 days) and D.Psych courses require a minimum of 1,500 hours (200 days), it is mandatory that these placements expose students to acute neurology/neurosurgery, rehabilitation, psychiatric, geriatric and paediatric populations.

Canada

To become a clinical neuropsychologist in Canada requires the completion of a 4-year honours degree in psychology and a 4-year doctoral degree in clinical neuropsychology. Often a 2-year master’s degree is required before commencing the doctoral degree. The doctoral degree involves coursework and practical experience (practicum and internship). Practicum is between 600 and 1,000 hours of practical application of skills acquired in the programme. At least 300 hours must be supervised, face-to-face client contact. The practicum is intended to prepare students for the internship/residency. Internships/residencies are a year long experience in which the student functions as a neuropsychologist, under supervision. Currently, there are 3 CPA-accredited Clinical Neuropsychology internships/residencies in Canada, although other unaccredited ones exist. Prior to commencing the internship students must have completed all doctoral coursework, received approval for their thesis proposal (if not completed the thesis) and the 600 hours of practicum.

United Kingdom

To become a clinical neuropsychologist in the UK, requires prior qualification as a clinical or educational psychologist as recognised by the Health Professions Council, followed by further postgraduate study in clinical neuropsychology. In its entirety, education to become a clinical neuropsychologist in the UK consists of the completion of a 3-year British Psychological Society accredited undergraduate degree in psychology, 3-year Doctorate in clinical (usually D.Clin.Psy.) or educational psychology (D.Ed.Psy.), followed by a 1-year Masters (MSc) or 9-month Postgraduate Diploma (PgDip) in Clinical Neuropsychology. The British Psychological Division of Counselling Psychology are also currently offering training to its members in order to ensure that they can apply to be registered Neuropsychologists also.

United States

In order to become a clinical neuropsychologist in the US and be compliant with Houston Conference Guidelines, the completion of a 4-year undergraduate degree in psychology and a 4 to 5-year doctoral degree (Psy.D. or Ph.D.) must be completed. After the completion of the doctoral coursework, training and dissertation, students must complete a 1-year internship, followed by an additional 2 years of supervised residency. The doctoral degree, internship and residency must all be undertaken at American Psychological Association approved institutions. After the completion of all training, students must apply to become licensed in their state to practice psychology. The American Board of Clinical Neuropsychology, The American Board of Professional Neuropsychology, and The American Board of Paediatric Neuropsychology all award board certification to neuropsychologists that demonstrate competency in specific areas of neuropsychology, by reviewing the neuropsychologist’s training, experience, submitted case samples, and successfully completing both written and oral examinations. Although these requirements are standard according to Houston Conference Guidelines, even these guidelines have stated that the completion of all of these requirements is still aspirational, and other ways of achieving clinical neuropsychologist status are possible.

What is the Diagnostic Classification of Mental Health and Developmental Disorder of Infancy and Early Childhood?

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Introduction

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC) is a developmentally based diagnostic manual that provides clinical criteria for categorising mental health and developmental disorders in infants and toddlers.

It is organised into a five-part axis system. The book has been translated into several languages and its model is widely adopted for the assessment of children of up to five years in age.

The DC 0-3R is meant to complement, but not replace, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) of the World Health Organisation (WHO). It is intended to enhance the understanding of young children by making it possible to assess, diagnose, and treat mental health problems in infants and toddlers by allowing for the identification of disorders not addressed in other classification systems.

The DC is organised around three primary principles:

  1. That children’s psychological functioning unfolds in the context of relationships;
  2. That individual differences in temperament and constitutional strengths and vulnerabilities play a major role in how children experience and process events; and
  3. That the family’s cultural context is important for the understanding of the child’s developmental course.

Brief History

Originally published in 1994, ZERO TO THREE’s Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:03) was the first developmentally based system for diagnosing mental health and developmental disorders of infants and toddlers (i.e. 0 to 3).

The revised DC:03, published in 2005 (DC:03R) drew on empirical research and clinical practice that had occurred worldwide since the 1994 publication and extended the depth and criteria of the original DC:03.

DC:05 captures new findings relevant to diagnosis in young children and addresses unresolved issues in the field since DC:03R was published in 2005.

DC:05 is designed to help mental health and other professionals: recognize mental health and developmental challenges in infants and young children, through 5 years old; understand that relationships and psychosocial stressors contribute to mental health and developmental disorders and incorporate contextual factors into the diagnostic process; use diagnostic criteria effectively for classification, case formulation, and intervention; and facilitate research on mental health disorders in infants and young children. DC:05 enhances the professional’s ability to prevent, diagnose, and treat mental health problems in the earliest years by identifying and describing disorders not addressed in other classification systems and by pointing the way to effective intervention approaches. Individuals across disciplines, mental health clinicians, counsellors, physicians, nurses, early interventionists, social workers, and researchers will find DC:05 to be an essential guide to evaluation and treatment planning with infants, young children, and their families in a wide range of settings.

The Diagnostic Process

The diagnostic process is one that is ongoing and done over a period of time. The process includes gathering a series of information regarding the child’s behaviour and presenting problems. The information is collected by a clinician and pertains to the child’s adaptation and development across different occasions and contexts.

According to the DC, the diagnostic process consists of two aspects:

  1. The classification of disorders; and
  2. The assessment of individuals.

One of the primary reasons for the classification of disorders is to facilitate communication between professionals. Once a diagnosis has been made, a clinician can then make associations between their clients’ symptoms and previously existing knowledge regarding the disorders’ aetiology, pathogenesis, treatment, and prognosis. Furthermore, using the classification of disorders can facilitate the process of finding existing services and mental health systems that are appropriate for the particular needs of the affected child. The assessment of children thus becomes a pivotal process that is undertaken by clinicians in order to grant access to treatment and intervention services related to specified disorders.

Clinical assessment and diagnosis involves making observations and gathering information from multiple sources relating to the child’s life in conjunction with a general diagnostic scheme. Both the DSM and ICD classification systems have evolved to use a multiaxial scheme, thus, clinicians have been using them not only for the classification of disorder but also as a guide for assessment and diagnosis. The first three axes of the DSM and ICD relate to the classification of disorder, and the fourth and fifth relate to the assessment of the individual within their personal environment. Similarly, the DC also follows a multiaxial scheme.

Classification

The DC 0-3R provides a provisional diagnosis system, focusing on multi-axial classification. The system is a provisional system because it recognises the fluidity and change that may occur with more knowledge in the field. This classification system is not entirely synonymous with the DSM-IV and the ICD-10, because it concentrates on developmental issues. There is also an emphasis placed on dynamic processes, relationships, and adaptive patterns within a developmental framework. The use of this classification system imparts knowledge about the diagnostic profile of a child, and the various contextual factors that may contribute to difficulties.

The DC functions as a reference for the earlier manifestations of problems in infants and children, which can be connected to later problems in functioning. Secondly, the categorisation focuses on types of difficulties in young children that are not addressed in other classification models.

The diagnostic categories vary in description, with more familiar categories described less. Categories that are more specific to young childhood and infancy, and newly based on clinical approaches are described in more detail. Furthermore, some categories may have subtypes to promote research, clinical awareness, and intervention planning, whereas others do not. This is important information to keep in mind when reading the DC.

The Multi-Axial System

Axis I: Clinical Disorders

Axis 1 of the DC provides diagnostic classifications for the most primary symptoms of the presenting difficulties. These diagnoses focus on the infant or child’s functioning. The primary diagnoses include:

  1. Posttraumatic Stress Disorder:
    • This refers to children who may be experiencing or have experienced a single traumatic event (e.g. an earthquake), a series of traumatic events (e.g. air raids), or chronic stress (e.g. abuse).
    • Furthermore, the nature of the trauma and its effect on the child must be understood in the context of the child. Specifically, attention must be paid to factors such as social context, personality factors, and the caregivers’ ability to assist with coping.
  2. Disorders of Affect:
    • This classification of disorders is related to the infant or child’s affective and behavioural experiences.
    • This group of disorders includes mood disorders and deprivation/maltreatment disorder.
    • This classification focuses on the infant or child’s functioning in its entirety rather than a specific event or situation (refer to Affective spectrum).
  3. Adjustment Disorder:
    • When considering a diagnosis of adjustment disorder, one has to examine the situational factors to determine if it is a mild disruption in the child’s usual functioning (e.g. switching schools).
    • These difficulties must also not meet the criteria for other disorders included in the categories.
  4. Regulation Disorders of Sensory Processing:
    1. The child manifests difficulties in regulating behavioural, motor, attention, physiological, sensory, and affective processes.
    2. These difficulties can affect the child’s daily functioning and relationships (refer to Sensory processing disorder).
  5. Sleep Behaviour Disorder:
    • To diagnose a sleep disorder, the child should be showing a sleep disturbance and not be demonstrating sensory reactive or processing difficulties.
    • This diagnosis should not be used when sleep problems are related to issues of anxiety or traumatic events.
  6. Eating Behaviour Disorder:
    • This diagnosis may become evident in infancy and young childhood as the child may show difficulties in regular eating patterns.
    • The child may not be regulating feeding with physiological reactions of hunger. This diagnosis is a primary diagnosis in the absence of traumatic, affective, and regulatory difficulties (refer to eating disorder).
  7. Disorders of Relating and Communicating:
    • These disorders involve difficulties in communication, in conjunction with difficulties in regulation of physiological, motor, cognitive, and many other processes.

Axis II: Relationship Classification

Axis II focuses on children and infants developing in the context of emotional relationships. Specifically, the quality of caregiving can have a strong impact in nurturance and steering a child on a particular developmental course, either adaptive or maladaptive. This particular axis concentrates on the diagnosis of a clinical issue in the relationship between the child and the caregiver. The presence of a disorder indicates difficulties in relationships. These disorders include various patterns that highlight behaviour, affective, and psychological factors between the child and the caregiver.

  • Overinvolved.
  • Underinvolved.
  • Anxious/Tense.
  • Angry/Hostile.
  • Mixed Relationship Disorder.
  • Abusive.

Axis III: Medical and Developmental Disorders and Conditions

Axis III focuses on physical, mental, or developmental classification using other diagnosis methods. These disorders and conditions are not treated as a single diagnosis, but as a problem that may co-exist with others, as it may involve developmental difficulties.

Axis IV: Psychosocial Stressors

This axis allows clinicians to focus on the intensity of psychosocial stress, which may act as influencing agents in infant and childhood difficulties/disorders. Psychosocial stress can have direct and indirect influences on infants and children, and depends on various factors.

Axis V: Emotional and Social Functioning

Emotional and social functioning capacities can be assessed using observations of the child with primary caregivers. The essential domains of functioning can be used in these observations on a 5-point scale, that describes overall functional emotional level.

Rating Scales and Checklists

The DC contains four forms that aid clinicians in identifying disorders in infants and toddlers, in examining the extent of problem behaviours, and in determining the nature of external factors influencing the child.

  • Functional Rating Scale for Emotional and Social Functioning Capacities: to evaluate the child’s communication skills and expressions of thoughts and feelings.
  • The Parent-Infant Relationship Global Assessment Scale (PIR-GAS; from Axis II): to evaluate the quality of a caregiver-child relationship and identify relationship disorders.
  • Relationship Problems Checklist (RPCL; from Axis II): allows the clinician to identify the extent to which a caregiver-child relationship can be described by a number of criterion-based qualities.
  • Psychosocial and Environmental Stressors Checklist (from Axis IV): to provide information on the stressors experienced by the child in various contexts.

The Future of DC

Important questions remain to be answered, in spite of the revisions made in the DC. Such questions include the following:

  • How can the functional adaptation of infants and children be evaluated and described independent of diagnosis?
  • How can disruptive behaviours of typical development in infants and children be distinguished from disordered behaviours that lead to atypical development?
  • Should Excessive Crying Disorder be considered as a functional regulatory disorder? Other functional regulatory disorders include Sleeping Behaviour and Feeding Behaviour Disorders.
  • Should future editions of the DC include a Family Axis containing information about family history of mental illness, family structure and available supports, and family culture? These aspects are all central to assessment and treatment planning.

What is Child Psychopathology?

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Introduction

Child psychopathology refers to the scientific study of mental disorders in children and adolescents.

Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Mental health providers who work with children and adolescents are informed by research in developmental psychology, clinical child psychology, and family systems. Lists of child and adult mental disorders can be found in the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), published by the World Health Organisation (WHO) and in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA). In addition, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC) is used in assessing mental health and developmental disorders in children up to age five.

Causes

The aetiology of child psychopathology has many explanations which differ from case to case. Many psychopathological disorders in children involve genetic and physiological mechanisms, though there are still many without any physical grounds. It is absolutely imperative that multiple sources of data be gathered. Diagnosing the psychopathology of children is daunting. It is influenced by development and contest, in addition to the traditional sources. Interviews with parents about school, etc., are inadequate. Either reports from teachers or direct observation by the professional are critical. (author, Robert B. Bloom, Ph.D.) The disorders with physical or biological mechanisms are easier to diagnose in children and are often diagnosed earlier in childhood. However, there are some disorders, no matter the mechanisms, that are not identified until adulthood. There is also reason to believe that there is co-morbidity of disorders, in that if one disorder is present, there is often another.

Stress

Emotional stress or trauma in the parent-child relationship tends to be a cause of child psychopathology. First seen in infants, separation anxiety in root of parental-child stress may lay the foundations for future disorders in children. There is a direct correlation between maternal stress and child stress that is factored in both throughout adolescent development. In a situation where the mother is absent, any primary caregiver to the child could be seen as the “maternal” relationship. Essentially, the child would bond with the primary caregiver, and may exude some personality traits of the caregiver.

In studies of child in two age groups of pregnancy to five years, and fifteen years and twenty years, Raposa and colleagues (2011) studied the impact of psychopathology in the child-maternal relationship and how not only the mothers stress affected the child, but the child’s stress affected the mother. Historically, it was believed that mothers who suffered from post partum depression might be the reason their child suffers from mental disorders both earlier and later in development. However this correlation was found to not only reflect maternal depression on child psychopathology, but also child psychopathology could reflect on maternal depression.

Children with a predisposition to psychopathology may cause higher stress in the relationship with their mother, and mothers who suffer from psychopathology may also cause higher stress in the relationship with their child. Child psychopathology creates stress in parenting which may increase the severity of the psychopathology within the child. Together, these factors push and pull the relationship thus causing higher levels of depression, ADHD, defiant disorder, learning disabilities, and pervasive developmental disorder in both the mother and the child. The outline and summary of this study is found below:

In looking at child-related stress, the number of past child mental health diagnoses significantly predicted a higher number of acute stressors for mothers as well as more chronic stress in the mother-child relationship at age 15. These increased levels of maternal stress and mother-child relationship stress at age 15 then predicted higher levels of maternal depression when the youth were 20 years old.

Looking more closely at the data, the authors found that it was the chronic stress in the mother-child relationship and the child-related acute stressors that were the linchpins between child psychopathology and maternal depression. The stress is what fuelled the fires between mother and child mental health. Going one step further, the researchers found that youth with a history of more than one diagnosis as well as youth that had externalizing disorders (e.g. conduct disorder) had the highest number of child-related stressors and the highest levels of mother-child stress. Again, all of the findings held up when other potentially stressful variables, such as economic worries and past maternal depression, were controlled for.

Additionally, siblings- both older and younger and of both genders, can be factored into the aetiology and development of child psychopathology. In a longitudinal study of maternal depression and older male child depression and antisocial behaviours on younger siblings adolescent mental health outcome. The study factored in ineffective parenting and sibling conflicts such as sibling rivalry. Younger female siblings were more directly affected by maternal depression and older brother depression and anti social behaviours when the indirect effects were not place, in comparison to younger male siblings who showed no such comparison. However, if an older brother were anti-social, the younger child – female or male would exude higher anti-social behaviours. In the presence of a sibling conflict, anti social behaviour was more influential on younger male children than younger female children. Female children were more sensitive to pathological familial environments, thus showing that in a high-stress environment with both maternal depression and older- male sibling depression and anti social behaviour, there is a higher risk of female children developing psychopathological disorders. This was a small study, and more research needs to be done especially with older female children, paternal relationships, maternal-paternal-child stress relationships, and/or caregiver-child stress relationships if the child is orphaned or not being raised by the biological child to reach a conclusive child-parent stress model on the effects of familial and environmental pathology on the child’s development.

Temperament

The child-parent stress and development is only one hypothesis for the aetiology of child psychopathology. Other experts believe that child temperament is a large factor in the development of child psychopathology. High susceptibility to child psychopathology is marked by low levels of effortful control and high levels of emotionality and neuroticism. Parental divorce is often a large factor in childhood depression and other psychopathological disorders. This is more so when the divorce involves a long-drawn separation and one parent bad-mouthing the other. That is not to say that divorce will lead to psychopathological disorders, there are also other factors such as temperament, trauma, and other negative life events (e.g. death, sudden moving of home, physical or sexual abuse), genetics, environment, and nurture that correlate to the onset of a disorder. Research has also shown that child maltreatment may increase risk for various forms of psychopathology as it increases threat sensitivity, decreases responsivity to reward, and causes deficits in emotion recognition and understanding.

Found in “The Role of Temperament in the Etiology of Child Psychopathology”, a model for the aetiology of child psychopathology by Vasey and Dadds (2001) proposed that the four things that are important to the development of psychopathological disorders is:

  1. Biological factors: hormones, genetics, and neurotransmitters;
  2. Psychological: self-esteem, coping skills, and cognitive issues;
  3. Social factors: family rearing, negative learning experiences, and stress; and
  4. Child’s temperament.

Using an array of neurological scans and exams, psychological evaluations, family medical history, and observing the child in daily factors can help the physician find the aetiology of the psychopathological disorder to help release the child of the symptoms through therapy, medication use, social skills training, and life style changes.

Child psychopathology can cause separation anxiety from parents, attention deficit disorders in children, sleep disorders in children, aggression with both peers and adults, night terrors, extreme anxiety, anti social behaviour, depression symptoms, aloof attitude, sensitive emotions, and rebellious behaviour that are not in line of typical childhood development. Aggression is found to manifest in children before five years of age, and early stress and aggression in the parental-child relationship correlates with the manifestation of aggression. Aggression in children causes problematic peer relationships, difficulty adjusting, and coping problems. Children who fail to overcome acceptable ways of coping and emotion expression are put on tract for psychopathological disorders and violent and anti social behaviours into adolescence and adulthood. There is a higher rate of substance abuse in these children with coping and aggression issues, and causes a cycle of emotional instability and manifestation psychopathological disorders.

Neurology and Aetiology

Borderline personality disorder (BPD) is one of many psychopathology disorders a child can suffer from. In the neurobiological scheme, borderline personality disorder may have effects on the left amygdala. In a 2003 study of BPD patients versus control patients, when faced with expressions that were happy, sad, or fearful BPD patients showed significantly more activation versus control patients. In neutral faces, BPD patients attributed negative qualities to these faces. As stated by Gabbard, an experimenter in this study:

“A hyperactive amygdala may be involved in the predisposition to be hyper vigilant and over reactive to relatively benign emotional expressions. Misreading neutral faces is clearly related to transference misreadings that occur in psychotherapy and the creation of bad object experiences linked with projective identification.”

Also linked to BPD, is the presence of serotonin transporter (5-HTT) in a short allele demonstrated larger amygdala neuronal activity when presented with fearful stimuli as in comparison to individuals with a long allele of 5-HTT. As found in the Dunedin Longitudinal Study a short allele of 5-HTT predisposes the person to have hyperactivity in the amygdala in response to trauma, and thus moderated the impact of stressful life events leading to a higher risk of depression and suicidal idealities. These same qualities were not observed in individuals with long alleles of 5-HTT. However, the environment the child is in can change in impact of this gene, proving that correct treatment, intensive social support, and a healthy and nurturing environment can modify genetic vulnerability.

Possibly the most studied or documented of the child psychopathologies is attention deficit hyperactivity disorder (ADHD) which is marked with learning disabilities, mood disorders, and/or aggression. Though believed to be over diagnosed, ADHD is highly comorbid for other disorders such as depression and obsessive compulsive disorder. In studies of the prefrontal cortex in ADHD children, which is responsible for the regulation of behaviour, cognition, and attention; and in the dopamine system there has been identified a hidden genetic polymorphisms. More specific, the 7-repeat allele of the dopamine D4 receptor gene, responsible for inhibited prefrontal cortex cognition and less efficient receptors, causes more externalised behaviours such as aggression since the child has trouble “thinking through” seemingly ordinary and at level childhood tasks.

Agenesis of the Corpus Callosum and Aetiology

Agenesis of the corpus callosum (ACC) is used to determine the frequency of social and behavioural problems in children with a prevalence rate of about 2-3%. ACC is described as a defect in the brain where the 200 million axons that make the corpus collosum are either completely absent, or partially gone. In many cases, the anterior commissure is still present to allow for the passing of information from one cerebral hemisphere to the other. The children are of normal intelligence level. For younger children, ages two to five, Agenesis of the corpus callosum causes problems in sleep. Sleep is critical for development in children, and lack of sleep can set the grounds for a manifestation of psychopathological disorders. In children ages six to eleven, ACC showed manifestation in problems with social function, thought, attention, and somatic grievances. In comparison, of children with autism, children with ACC showed less impairment on almost all scales such as anxiety and depression, attention, abnormal thoughts, and social function versus autistic children. However, a small percentage of children with ACC showed traits that may lead to the diagnosis of autism in the areas of social communications and social interactions but do not show the same symptoms of autism in the repetitive and restricted behaviours category. The difficulties from ACC may lead to the aetiology of child psychopathological disorders, such as depression or ADHD and manifest many autistic-like disorders that can cause future psychological disorders in later adolescence. The aetiology of child psychopathology is a multi-factor path. A slew of factors must be taken into account before diagnosis of a disorder.

The child’s genetics, environment, temperament, past medical history, family medical history, prevalence of symptoms and neuro-anatomical structures are all factors that should be considered when diagnosing a child with a psychopathological disorder. Thousands of children each year are misdiagnosed and put on the wrong treatment, which may result in the manifestation of other disorders the child would have not have gotten else wise. There are hundreds of causes of psychopathological disorders, and each one manifests at different ages and stages in child development and can come out due to trauma and stress. Some disorders may “disappear” and reappear in the presence of a trauma, depression, or stress similar to the one that brought the disorder out in the child in the beginning.

Treatment

It is estimated that 5% of children under the age of eight suffer from a psychopathology disorder. Girls more frequently manifested disorders than boys in similar situations. By age sixteen about thirty percent of children will have fit the criteria for at least one psychopathology disorder. Only a small number of these children receive treatment for their disorder. Anxiety and depression disorders in children- whether noted or un-noted, are found to be a precursor for similar episodes in adulthood. Usually a large stressor similar to the one the person experienced in childhood brings out the anxiety or depression in adulthood.

Multifinality refers to the idea that two children can react to same stressful event quite differently, and may display divergent types of problem behaviour. Psychopathological disorders are extremely situational- having to take into account the child, the genetics, the environment, the stressor, and many other factors to tailor the best type of treatment to relieve the child of the psychopathology symptoms.

Many child psychopathology disorders are treated with control medications prescribed by a paediatrician or psychiatrist. After extensive evaluation of the child through school visits, by psychologists and physicians, a medication can be prescribed. A patient may need to go through several trials of medicines to find the best fit, as many cause uncomfortable and undesired side effects – such as dry mouth or suicidal thoughts can occur. There are many classes of drugs a physician can choose from and they are: psychostimulants, beta blockers, atypical antipsychotics, lithium, alpha-2 agonists, traditional antipsychotics, SSRIs, and anticonvulsant mood- stabilisers. Given the multifinality of psychopathological disorders, two children may be on the same medication for two completely different disorders, or have the same disorder and be taking two completely different medications.

ADHD is the most successfully treated disorder of child psychopathology, and the medications used have a high- abuse rate especially among college-aged students. Psycho stimulants such as Ritalin, amphetamine- related stimulant drugs: e.g. Adderall, and antidepressants such as Wellbutrin have been successfully used to treat ADHD with a 78% success rate. Many of these drug treatment options are paired with behavioural treatment such as therapy or social skills lessons.

Lithium has shown to be extremely effective in treating ADHD and bipolar disorder. Lithium treats both mania and depression and helps prevent relapse. The mechanism of lithium include the inhibition of GSK-3, it is a glutamate antagonism at NMDA receptors that together make lithium a neuroprotective medicine. The drug relieves bipolar symptoms, aggressiveness and irritability. Lithium has many, many side effects and requires weekly blood tests to tests for toxicity of the drug.

Medications that act on cell membrane ion channels, are GABA inhibitory neurotransmission, and also inhibit excitatory glutamate transmission have shown to be extremely effective in treating an array of child psychopathological disorders. Pharmaceutical companies are in the process of creating new drugs and improving those on the market to help avoid negative and possibly life altering short term and long term side effects, making drugs more safe to use in younger children and over long periods of time during adolescent development.

Psychotherapy Treatments for Common Psychological Disorders in Children

Some psychological disorders commonly found in children include depression, anxiety, and conduct disorder. For adolescents with depression, a combination of antidepressants and cognitive-behavioural or interpersonal psychotherapy is recommended, in contrast there is not much evidence for the efficacy of antidepressants in children under 12 years of age, therefore a combination of parent training and cognitive-behavioural psychotherapy is recommended. For children and adolescents suffering from anxiety disorders, cognitive-behavioural therapy in combination with exposure-based techniques is a highly recommended and evidence-based treatment. Research suggests that children and adolescents with conduct disorder or disruptive behaviour may benefit from psychotherapy that includes both a behavioural component and parental involvement.

Future of Child Psychopathology

The future of child psychopathology-aetiology and treatment has a two-way path. While many professionals agree that many children who suffer from a disorder do not receive proper treatment, at the rate of 5-15% that receive treatment leaving many children in the dark. In the same boat are the physicians who also say that not only do more of these disorders need to be recognised in children and treated properly, but also even those children who show some qualifying symptoms of a disorder but not to the degree of diagnosis should also receive treatment and therapy to avoid the manifestation of the disorder. By treating children even with slight degrees of a psychopathological disorder, children can show improvements in their relationships with peers, family, and teachers and also improvements in school, mental health, and personal development. Many physicians believe the best prevention and help starts in the home and the school of the child, before physicians and psychologists are contacted.

So while there is more awareness of child psychopathological disorders and more research to prevent and effectively treat these disorders to maintain healthy emotional health in children, there is also a negative factor in that parents, schools, and psychologists may be more sensitive and therefore over-diagnose children with these disorders. Mental health professionals and pharmaceutical marketing companies need to be cautious of making disorders too readily diagnosed and treated with medications.

Child psychopathology is a real thing that thousands of children suffer from. While hundreds of children are diagnosed with a new disorder daily, researchers are developing new strategies to beat these disorders in children to allow all children the right to a happy and healthy childhood. With further education on the symptoms and implications of child psychopathology, psychologists and physicians will improve their accuracy in diagnosing children – giving the right diagnosis and discovering the most helpful treatment and therapies for children.

The current trend in the US is to understand child psychopathology from a systems based perspective called developmental psychopathology. Recent emphasis has also been on understanding psychological disorders from a relational perspective with attention also given to neurobiology. Practitioners who follow attachment theory believe that early attachment experiences of children can promote adaptive strategies or lay the groundwork for maladaptive ways of coping which can later lead to mental health disorders.

Research and clinical work on child psychopathology tends to fall under several main areas: aetiology, epidemiology, diagnosis, assessment, and treatment.

Parents are considered a reliable source of information because they spend more time with children than any other adult. A child’s psychopathology can be connected to parental behaviours. Clinicians and researchers have experienced problems with children’s self-reports and rely on adults to provide the information.