A classification system can benefit disturbed children enormously by bringing to bear a wealth of... more A classification system can benefit disturbed children enormously by bringing to bear a wealth of knowledge and experience. This can make all the difference between an inadequate consultation and a precise formulation of the nature and extent of a child's difficulties, their cause, the likely outcome and a realistic treatment plan. However, inappropriate application of a diagnostic label that has little validity could do more harm than good, and classification systems can be misused. This paper discusses, with examples, issues particular to childhood and adolescence that diagnostic systems need to address if they are to be useful. It considers different solutions applied by the two most widely used schemes, theInternational Classification of Diseases(ICD–10; World Heath Organization, 1992) and theDiagnostic and Statistical Manual of Mental Disorders(DSM–IV; American Psychiatric Association, 1994). Finally, the types of criteria used to validate categories are discussed.
Matthew Constantinou (m.constantinou@ucl.ac.uk), Elizabeth Simes (e.simes@ucl.ac.uk), Rachel Elli... more Matthew Constantinou (m.constantinou@ucl.ac.uk), Elizabeth Simes (e.simes@ucl.ac.uk), Rachel Ellison (rachelmaryellison@gmail.com), Dr Elizabeth Allison (e.allison@ucl.ac.uk), Professor Stephen Pilling (s.pilling@ucl.ac.uk), and Professor Peter Fonagy (p.fonagy@ucl.ac.uk) are from the Research Department of Clinical, Educational and Health Psychology, Division of Psychology and Language Sciences, University College London, London, UK.
Children and adolescents with callous-unemotional (CU) traits have been distinguished as a subset... more Children and adolescents with callous-unemotional (CU) traits have been distinguished as a subset of individuals with disruptive behavioral disorders who may be less sensitive to parenting influence; we test this hypothesis using multiple methods and assessment paradigms. Two hundred seventy-one adolescents (mean age = 12.6 years) from 3 samples at elevated risk for disruptive behavior disorders were studied. Symptoms of CU behavior were derived from standard questionnaire; assessments of behavioral adjustment were derived from clinical interview with parent, and parent-report, teacher-report, and self-report questionnaire. Parent-child relationship quality was based on observational assessments in which adolescent and parent behaviors were rated in 3 interaction tasks: (a) low conflict planning task; (b) problem-solving conflict task; (c) puzzle challenge task; parent interview and parent-report and child-report questionnaires of parenting were also assessed. Results indicated that...
We previously hypothesised that the early development of psychopathy is associated with a failure... more We previously hypothesised that the early development of psychopathy is associated with a failure to attend to the eyes of attachment figures, and we have presented preliminary data from a parent-child 'love' scenario in support of this. Here, we confirm the association in a larger sample and test mechanisms of impaired eye contact during expressions of love in control and behaviourally disturbed children. Oppositional defiant disorder children, assessed for callous-unemotional (CU) traits, and controls, were observed in a brief interaction task where the mother was asked to show love to her child. Eye contact and affection were measured for each dyad. As predicted, there were no group differences in affection and eye contact expressed by mothers; levels of CU traits predicted low levels of eye contact towards their mothers across all groups of children. As expected, low eye contact was correlated with psychopathic fearlessness in their fathers, and maternal reports of negative feelings towards the child. Independent observations showed that child's behaviour largely drives the low eye contact associated with CU traits, and low eye contact was not associated with independent observations of the quality of attachment-related behaviours in mothers. Impaired eye contact is a unique characteristic of children with CU traits; these impairments are largely independent of maternal behaviour, but associated with psychopathic traits in the fathers. These impairments should be tested for functional significance and amenability to change in longitudinal and treatment studies.
Inhibitory and attention deficits have been suggested to be shared problems of disruptive behavio... more Inhibitory and attention deficits have been suggested to be shared problems of disruptive behaviour disorders. Patients with attention deficit hyperactivity disorder (ADHD) and patients with conduct disorder (CD) show deficits in tasks of attention allocation and interference inhibition. However, functional magnetic resonance imaging (fMRI) of inhibitory and attention control has only been investigated in patients with ADHD, including comorbidity with CD, finding fronto-striatal and temporo-parietal dysfunction. This study investigates differences and commonalities in functional neural networks mediating interference inhibition and attention allocation between medication-naïve children and adolescents with pure CD and those with pure ADHD. Event-related fMRI was used to compare brain activation of 13 boys with non-comorbid CD, 20 boys with non-comorbid ADHD and 20 healthy comparison boys during a Simon task that measures interference inhibition and controls for attention allocation, thus tapping into interference inhibition and selective attention networks. During interference inhibition, both patient groups shared reduced activation compared to controls in right superior temporal lobe and in predominantly right precuneus. During the oddball condition, both patient groups showed reduced activation compared to healthy control children in right medial prefrontal lobe. However, only ADHD patients showed a disorder-specific under-activation compared to the other two groups in an extensive activation cluster in left inferior prefrontal cortex. This study shows shared dysfunction in both patients groups in right hemispheric temporal and parietal brain regions during interference inhibition and in right dorsolateral prefrontal cortex during attention allocation. Ventrolateral prefrontal dysfunction, however, was specific to ADHD and not observed in patients with CD in the context of attention allocation. The findings suggest that the typically reduced functional activation in patients with ADHD in ventrolateral prefrontal cortex may be specific to the disorder, at least when compared to patients with CD.
A classification system can benefit disturbed children enormously by bringing to bear a wealth of... more A classification system can benefit disturbed children enormously by bringing to bear a wealth of knowledge and experience. This can make all the difference between an inadequate consultation and a precise formulation of the nature and extent of a child's difficulties, their cause, the likely outcome and a realistic treatment plan. However, inappropriate application of a diagnostic label that has little validity could do more harm than good, and classification systems can be misused. This paper discusses, with examples, issues particular to childhood and adolescence that diagnostic systems need to address if they are to be useful. It considers different solutions applied by the two most widely used schemes, theInternational Classification of Diseases(ICD–10; World Heath Organization, 1992) and theDiagnostic and Statistical Manual of Mental Disorders(DSM–IV; American Psychiatric Association, 1994). Finally, the types of criteria used to validate categories are discussed.
Matthew Constantinou (m.constantinou@ucl.ac.uk), Elizabeth Simes (e.simes@ucl.ac.uk), Rachel Elli... more Matthew Constantinou (m.constantinou@ucl.ac.uk), Elizabeth Simes (e.simes@ucl.ac.uk), Rachel Ellison (rachelmaryellison@gmail.com), Dr Elizabeth Allison (e.allison@ucl.ac.uk), Professor Stephen Pilling (s.pilling@ucl.ac.uk), and Professor Peter Fonagy (p.fonagy@ucl.ac.uk) are from the Research Department of Clinical, Educational and Health Psychology, Division of Psychology and Language Sciences, University College London, London, UK.
Children and adolescents with callous-unemotional (CU) traits have been distinguished as a subset... more Children and adolescents with callous-unemotional (CU) traits have been distinguished as a subset of individuals with disruptive behavioral disorders who may be less sensitive to parenting influence; we test this hypothesis using multiple methods and assessment paradigms. Two hundred seventy-one adolescents (mean age = 12.6 years) from 3 samples at elevated risk for disruptive behavior disorders were studied. Symptoms of CU behavior were derived from standard questionnaire; assessments of behavioral adjustment were derived from clinical interview with parent, and parent-report, teacher-report, and self-report questionnaire. Parent-child relationship quality was based on observational assessments in which adolescent and parent behaviors were rated in 3 interaction tasks: (a) low conflict planning task; (b) problem-solving conflict task; (c) puzzle challenge task; parent interview and parent-report and child-report questionnaires of parenting were also assessed. Results indicated that...
We previously hypothesised that the early development of psychopathy is associated with a failure... more We previously hypothesised that the early development of psychopathy is associated with a failure to attend to the eyes of attachment figures, and we have presented preliminary data from a parent-child 'love' scenario in support of this. Here, we confirm the association in a larger sample and test mechanisms of impaired eye contact during expressions of love in control and behaviourally disturbed children. Oppositional defiant disorder children, assessed for callous-unemotional (CU) traits, and controls, were observed in a brief interaction task where the mother was asked to show love to her child. Eye contact and affection were measured for each dyad. As predicted, there were no group differences in affection and eye contact expressed by mothers; levels of CU traits predicted low levels of eye contact towards their mothers across all groups of children. As expected, low eye contact was correlated with psychopathic fearlessness in their fathers, and maternal reports of negative feelings towards the child. Independent observations showed that child's behaviour largely drives the low eye contact associated with CU traits, and low eye contact was not associated with independent observations of the quality of attachment-related behaviours in mothers. Impaired eye contact is a unique characteristic of children with CU traits; these impairments are largely independent of maternal behaviour, but associated with psychopathic traits in the fathers. These impairments should be tested for functional significance and amenability to change in longitudinal and treatment studies.
Inhibitory and attention deficits have been suggested to be shared problems of disruptive behavio... more Inhibitory and attention deficits have been suggested to be shared problems of disruptive behaviour disorders. Patients with attention deficit hyperactivity disorder (ADHD) and patients with conduct disorder (CD) show deficits in tasks of attention allocation and interference inhibition. However, functional magnetic resonance imaging (fMRI) of inhibitory and attention control has only been investigated in patients with ADHD, including comorbidity with CD, finding fronto-striatal and temporo-parietal dysfunction. This study investigates differences and commonalities in functional neural networks mediating interference inhibition and attention allocation between medication-naïve children and adolescents with pure CD and those with pure ADHD. Event-related fMRI was used to compare brain activation of 13 boys with non-comorbid CD, 20 boys with non-comorbid ADHD and 20 healthy comparison boys during a Simon task that measures interference inhibition and controls for attention allocation, thus tapping into interference inhibition and selective attention networks. During interference inhibition, both patient groups shared reduced activation compared to controls in right superior temporal lobe and in predominantly right precuneus. During the oddball condition, both patient groups showed reduced activation compared to healthy control children in right medial prefrontal lobe. However, only ADHD patients showed a disorder-specific under-activation compared to the other two groups in an extensive activation cluster in left inferior prefrontal cortex. This study shows shared dysfunction in both patients groups in right hemispheric temporal and parietal brain regions during interference inhibition and in right dorsolateral prefrontal cortex during attention allocation. Ventrolateral prefrontal dysfunction, however, was specific to ADHD and not observed in patients with CD in the context of attention allocation. The findings suggest that the typically reduced functional activation in patients with ADHD in ventrolateral prefrontal cortex may be specific to the disorder, at least when compared to patients with CD.
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