Psychiatric Diagnosis and Classification - ResearchGate

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236 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION improvement than a question about symptom severity. Disability assessment has another advantage: it acts as a qualifier on complaints of symptoms. That is, a person who complains of many and varied symptoms, but who is not disabled, is probably in need of less treatment than their symptoms would indicate. Conversely, a person who says stoically ``I'm just a bit down and find it hard to get started'', has no other symptoms but has missed days at work and has had to cut down on most other days in the past month, is certainly in need of treatment. SPECIAL GROUPS Children and Adolescents Children and adolescents do have emotional and behavioral disorders that should be recognized and treated. The recognition of the externalizing or acting out youth requires little skill, the parents or school will complain about the behavior, but the recognition of the internalized anxious or depressed child is difficult. Epidemiological surveys in many countries have shown that one in five children and adolescents will have experienced significant emotional problems in the previous sixmonths. At any point in time, one in ten children will meet criteria for a mental disorder and warrant treatment if education and vocational choice is not to be impaired by what may well be a chronic mental disorder. Thus, the task for the clinician is to decide whether the symptoms being reported by the parent or complained of by the older child are evidence of normal variation, are problems related to intercurrent stressors, or are evidence of an ICD-10 or DSM-IV-PC defined mental disorder. There are well established risk factors that should raise the indexof suspicion in clinicians that the child is at risk of developing a mental disorder. Mental disorders are more frequent in children of low intelligence, and in children with chronic physical disease, especially if that disease involves the central nervous system, e.g. epilepsy. Temperament, evident from infancy, is another good predictor. Easy children tend to be happy, regular in feeding and sleeping patterns, and they adapt easily to new situations. Difficult children are irritable, unhappy, intense, and have difficulty adjusting to change. Children with difficult temperaments are at higher risk of developing emotional and behavioral problems. Children are very sensitive to their direct family environment and, while the preceding factors are intrinsic to the child, poor family environments are not. Clinicians must be alert to families that are characterized by lack of affection, parental conflict, overprotection, inconsistent rules and discipline, families in which there is parental mental illness such as depression or
PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION IN PRIMARY CARE 237 substance use disorders, and above all to families in which physical or sexual abuse of the child is a possibility. When the indexof suspicion is high, clinicians should attempt to obtain information from several informants: the child, the parents and sometimes the teachers or other family members. The following is a checklist of areas that should be covered, differentiating between symptoms and behaviors that are within normal variation, or consistent with problems that are likely to remit, or indicative of mental disorder [40]: . Achievement of developmental milestones . Fears, phobias and obsessions . Depressive symptoms, including suicidal thoughts . Inattention, impulsivity, excessive activity . Aggressive, delinquent and rule breaking conduct . Problems with learning, hearing, seeing . Bizarre or strange ideas or behavior . Use of alcohol or drugs . Difficult relationships with parents, siblings or peers. Studies indicate that less than 30% of children with substantial dysfunction are recognized by primary care physicians. Recognition of conduct or attention problems is reasonably good because of the clarity of the parental complaint or school report, but recognition of the anxiety and depressive syndromes or of physical or sexual abuse is poor. There is a 35 item Pediatric Symptom Checklist PSC) that has demonstrated reliability and validity as a screening instrument for use with cooperative parents. According to the author [41], it can be given to parents in the waiting room and completed in a few minutes before seeing the doctor. The scale is reproduced in Table 9.5. The PSC is scored by assigning two points for every ``often'' response, one point for every ``sometimes'' response and no points to the ``never'' answers. Adding the points yields the total score. If the PSC score is 28 or above, there is a 70% likelihood that the child has a significant problem. If the score is below this, then there is a 95% likelihood that the child does not have serious difficulties. Interested clinicians should consult the original articles or access the website www.healthcare.partners. org/psc). Diagnosis in the Elderly Across all ages, common mental disorders are much more likely to present in primary care than in specialist clinics. Among the elderly, primary care accounts for an even greater proportion of mental health care [42]. Even in
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PREFACE xi world who are interested
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IMPLICATIONS OF COMORBIDITY 81 Fina
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Table 4.2 Matrix of levels and subl
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THE ROLE OF PHENOMENOLOGY IN PSYCHI
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288 INDEX India contd) Unani/Arabic
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