The abduction of disorder in psychiatry

The evolutionary cornerstone of J. C. Wakefield's (1999) harmful dysfunction thesis is a faulty assumption of comparability between mental and biological processes that overlooks the unique plasticity and openness of the brain's functioning design. This omission leads Wakefield to an idealized concept of natural mental functions, illusory interpretations of mental disorders as harmful dysfunctions, and exaggerated claims for the validity of his explanatory and stipulative proposals. The authors argue that there are numerous ways in which evolutionarily intact mental and psychological processes, combined with striking discontinuities within and between evolutionary and contemporary social/cultural environments, may cause nondysfunction variants of many widely accepted major mental disorders. These examples undermine many of Wakefield's arguments for adopting a harmful dysfunction concept of mental disorder.

Who's up first? Testing for order effects in structured interviews using a counterbalanced experimental design

A growing body of research suggests that, apart from the wording of specific questions, various aspects of the interview process itself may affect the reliability of information provided by research participants. To examine whether the order of presentation of specific diagnostic modules affects the likelihood of subjects' yes/no responses within the Diagnostic Interview Schedule for Children (DISC), the authors used a counterbalanced design, presenting two DISC diagnostic modules to children and their parents in standard or reversed order. Results indicate that the order of module administration exerts effects on the total numbers of symptoms endorsed, level of impairment, and the likelihood of meeting diagnostic criteria, regardless of whether the information is provided by parent or child respondents. Future child and adult assessment measures should take these difficulties fully into account through novel approaches to instrument design and interview procedures.

The abduction of disorder in psychiatry

The evolutionary cornerstone of J. C. Wakefield's (1999) harmful dysfunction thesis is a faulty assumption of comparability between mental and biological processes that overlooks the unique plasticity and openness of the brain's functioning design. This omission leads Wakefield to an idealized concept of natural mental functions, illusory interpretations of mental disorders as harmful dysfunctions, and exaggerated claims for the validity of his explanatory and stipulative proposals. The authors argue that there are numerous ways in which evolutionarily intact mental and psychological processes, combined with striking discontinuities within and between evolutionary and contemporary social/cultural environments, may cause nondysfunction variants of many widely accepted major mental disorders. These examples undermine many of Wakefield's arguments for adopting a harmful dysfunction concept of mental disorder.

National Institute of Mental Health Collaborative Multimodal Treatment Study of Children with ADHD (the MTA). Design challenges and choices

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first child multisite cooperative agreement treatment study of children conducted by the National Institute of Mental Health, Rockville, Md. It examines the long-term effectiveness of medication vs behavioral treatment vs both for treatment of ADHD and compares state-of-the-art treatment with routine community care. In a parallel-groups design, 576 children (age, 7-9 years) with ADHD (96 at each site) are thoroughly assessed and randomized to 4 conditions: (1) medication alone, (2) psychosocial treatment alone, (3) the combination of both, (4) or community comparison. The first 3 groups are treated for 14 months and all are reassessed periodically for 24 months. Designers met the following challenges: framing clinically relevant primary questions; defining the target population; choice, intensity, and integration and combination of treatments for fair comparisons; combining scientific controls and standardization with clinical flexibility; and implementing a controlled clinical trial in a nonclinical setting (school) controlled by others. Innovative solutions included extensive decision algorithms and manualized adaptations of treatments to specific needs.

The Hubble hypothesis and the developmentalist's dilemma

Developmental psychopathology stands poised at the close of the 20th century on the horns of a major scientific dilemma. The essence of this dilemma lies in the contrast between its heuristically rich open system concepts on the one hand, and the closed system paradigm it adopted from mainstream psychology for investigating those models on the other. Many of the research methods, assessment strategies, and data analytic models of psychology's paradigm are predicated on closed system assumptions and explanatory models. Thus, they are fundamentally inadequate for studying humans, who are unparalleled among open systems in their wide ranging capacities for equifinal and multifinal functioning. Developmental psychopathology faces two challenges in successfully negotiating the developmentalist's dilemma. The first lies in recognizing how the current paradigm encourages research practices that are antithetical to developmental principles, yet continue to flourish. I argue that the developmentalist's dilemma is sustained by long standing, mutually enabling weaknesses in the paradigm's discovery methods and scientific standards. These interdependent weaknesses function like a distorted lens on the research process by variously sustaining the illusion of theoretical progress, obscuring the need for fundamental reforms, and both constraining and misguiding reform efforts. An understanding of how these influences arise and take their toll provides a foundation and rationale for engaging the second challenge. The essence of this challenge will be finding ways to resolve the developmentalist's dilemma outside the constraints of the existing paradigm by developing indigenous research strategies, methods, and standards with fidelity to the complexity of developmental phenomena.

The NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study: background and methodology

OBJECTIVE

A collaborative study was conducted to develop methods for surveys of mental disorder and service utilization in unscreened population-based samples of children and adolescents.

METHOD

Probability household samples of youths 9 through 17 years of age were selected at four sites and interviews were conducted with a total of 1,285 pairs of youths and their adult caretakers in their homes. Lay interviewers administered a computer-assisted version of the NIMH Diagnostic Interview Schedule for Children Version 2.3 and structured interviews to assess demographic variables, functional impairment, risk factors, service utilization, and barriers to service utilization.

RESULTS

More than 7,500 households were enumerated at four sites, with enumeration response rates above 99%. Across sites, 84% of eligible youth-caretaker pairs were interviewed for about 2 hours each. Ninety-five percent of both youths and caretakers found the interview to be acceptable enough to recommend to a friend.

CONCLUSIONS

These findings indicate that large-scale epidemiological surveys of mental disorders and mental health service use involving lengthy interviews in the homes of unscreened population-based samples of youths and their adult caretakers are acceptable to the community and can achieve good response rates. The other reports in this Special Section address the reliability and validity of the various survey instruments and other key findings.

Scales, diagnoses, and child psychopathology: II. Comparing the CBCL and the DISC against external validators

Using a multimethod multistage screening procedure, the authors interviewed 201 parents and their children with the Diagnostic Interview Schedule for Children (DISC 2.1). In addition, parents completed the Child Behavior Checklist (CBCL) and other survey measures, while their children completed self-report scales. Receiver operating characteristic (ROC) analyses were done to determine optimal cutpoints on the CBCL, referenced to DISC diagnostic "caseness." DISC diagnoses, DISC "stem" symptoms, CBCL scores, and CBCL ROC-outpoints were compared against "external validators," in order to determine the comparative advantages of each approach for assessing child psychopathology. Overall findings suggest that the controversies about "best" assessment strategies may be artificial: When both assessment approaches are compared using similar methods, they are reasonably comparable. However, highly specific diagnostic categories may show fewer relationships with external validators and may therefore need more systematic validational studies.

Prevalence of mental disorder in military children and adolescents: findings from a two-stage community survey

OBJECTIVE

Because previous reports have suggested that children of military families are at greater risk for psychopathology, this study examines the levels of psychopathology in an epidemiological community sample of military children all living on a military post.

METHOD

Standardized psychopathology rating scales and a structured diagnostic interview (the Diagnostic Interview Schedule for Children [DISC], version 2.1) were used in a multimethod, multistage survey; 294 six- to seventeen-year-old military children and their parents participated in the study.

RESULTS

Parent- and child-administered structured DSM-III-R DISC interviews indicated that children's levels of psychopathology were at levels consistent with studies of other normal samples. In addition, parents' and children's symptom checklist ratings of children were at national norms, as were parents' ratings of their own symptoms.

CONCLUSIONS

Overall results do not support the notion that levels of psychopathology are greatly increased in military children. Further studies of military families should address the effects of rank and socioeconomic status, housing, and the current impact of life stressors on the parents as well as the children, in order to avoid drawing erroneous conclusions about parts or all of the military community.

Soldier functioning under chronic stress: effects of family member illness

The psychological functioning of soldiers with a handicapped child in the family were compared with that of soldiers without such a child through a survey of 443 soldiers. Self-report questionnaires were utilized to measure depressive symptoms, martial adjustment, social supports, stressful life events, military satisfaction, military performance, and coping. Differences between the 147 soldier-parents with a handicapped child and those without were examined using one-way analyses of variance. The results indicated that soldier-parents with a handicapped child showed significantly higher depressive symptoms, including lower scores on coping, less favorable perception of their military skills and abilities, and more pessimistic attitudes about their long-term military career options, than did the comparison group. Differences in marital satisfaction were not found. Also, perceived social supports played a significantly greater role in buffering the effects of stress on marital adjustment among families with a handicapped child than among those without.

NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale

OBJECTIVE

The National Institute of Mental Health's recently initiated 5-year, multisite, multimodal treatment study of children with attention-deficit hyperactivity disorder (MTA) is the first major clinical trial in its history focused on a childhood mental disorder. This article reviews the major scientific and clinical bases for initiating the MTA.

METHOD

A selective review of the literature is presented in the service of describing the estimated prevalence of ADHD among children and adolescents, its core clinical features, evidence concerning psychopharmacological and psychosocial treatment effects, and related research issues and trends leading to the development of the MTA.

RESULTS

Despite decades of treatment research and clinical practice, there is an insufficient basis for answering the following manifold question: under what circumstances and with what child characteristics (comorbid conditions, gender, family history, home environment, age, nutritional/metabolic status, etc.) do which treatments or combinations of treatment (stimulants, behavior therapy, parent training, school-based intervention) have what impacts (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, neurophysiological, neuropsychological, peer relations, family relations), for how long (short versus long term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)?

CONCLUSIONS

The important scientific, clinical, and public health issues nested within this manifold question provide both the impetus and scaffolding for the MTA.

Child and adolescent psychopathology research: problems and prospects for the 1990s

In November 1990 the National Institute of Mental Health (NIMH) convened a special conference of over 100 scientists and leaders to outline specific strategies and research initiatives that should be developed to implement the recently released National Plan for Research on Child and Adolescent Mental Disorders. Participants included journal editors, educators from psychology and psychiatry, representatives from private foundations, and leaders of research program areas in public funding agencies. Critical knowledge gaps were identified in five areas of child and adolescent psychopathology, including depression, attention deficit hyperactivity disorder, conduct disorder, the anxiety disorders, and the developmental disorders. For each of these areas, special emphasis was placed on developing new ideas and obtaining critical input from other areas of investigation. This report summarizes the identified research gaps and recommends research initiatives to implement the National Plan, as outlined by the conference participants.

Scales, diagnoses, and child psychopathology: I. CBCL and DISC relationships

OBJECTIVE

To clarify the relationship between scales and structured diagnostic interview diagnoses, the authors used a two-stage screening method to study 201 military families with one or more children ages 5 to 17.

METHOD

Parents and children were interviewed with the Diagnostic Interview Schedule for Children (DISC 2.1); parents also completed the Child Behavior Checklist (CBCL) while the children completed other self-report symptom scales.

RESULTS

Results indicate only a modest ability of scales to discriminate among discrete DISC-derived DSM-III-R diagnoses. Inclusion of diagnostic information from both parents and children resulted in more diagnoses than from either informant alone, and the additional diagnoses consisted mostly of internalizing disorders contributed by child-derived DISC information. In general, correlations were larger between scales and diagnoses within the same informant (regardless of diagnostic construct) than across informants (but within the same diagnostic construct). Child self-report measures tended to outperform the CBCL as screeners against the overall "caseness" criterion on the DISC. However, child self-report scales were relatively nonspecific and showed little ability to selectively identify internalizing disorders such as anxiety and/or depression. Compared with single informant diagnoses, combined-informant diagnoses were generally superior in demonstrating broader relationships to both parent and child symptom scales.

CONCLUSIONS

Additional research is needed in order to build careful crosswalks between the various approaches to assessing childhood psychopathology, to decide on optimal rules for combining information to establish diagnoses, and to validate the currently available assessment alternatives.

Community violence and children's development: toward a research agenda for the 1990s

The United States is the most violent country in the industrialized world-particularly for young people. Homicide in the United States ranks as the second leading cause of death among those between 15 and 24 years of age (Earls et al. 1991). Males, especially, are at high risk. As indicated in Figure 1, those between 15 and 24 years of age were more likely to be murdered than their counterparts in all 22 other developed countries for which comparable homicide statistics were available during 1986-1987 (Fingerhut and Kleinman 1990). Young males were 4 times more likely to be murdered than their counterparts in the next highest country, Scotland; 7 times more likely than young males in Canada; 21 times more likely than those in West Germany; and 40 times more likely than same-age males in Japan. Moreover, the U.S. homicide rate for Black males (15 and 24 years) was more than 7 times the homicide rate for White males in this age range. These figures are all the more alarming in light of the fact that homicide rates in major U.S. cities have increased steadily since these data were recorded.

The NIMH community violence project: II. Children's distress symptoms associated with violence exposure

The rising tide of violence in American cities has placed the causes and consequences of violence squarely on the public health agenda. The U.S. Government's Year 2000 National Health Promotion and Disease Prevention Objectives includes a full chapter devoted to violence issues and delineates a number of goals and programs aimed at reducing the number of deaths and injuries associated with violence (Public Health Service 1990). Notably absent from these objectives, however, is attention to the possible adverse psychological consequences of exposure to acute or chronic violence. Nonetheless, in light of numerous media reports of children's exposure to community violence and recent reports documenting high levels of exposure even among very young children (Richters and Martinez 1993), it is reasonable to question whether the risks of exposure extend beyond death and physical injury to psychological well-being.

The NIMH community violence project: I. Children as victims of and witnesses to violence

The 1980s witnessed an extraordinary increase in community violence in most major cities across the United States. In 1990 the homicide rate in Boston increased by 45% over the previous year; in Denver, by 29%; in Chicago, Dallas, and New Orleans, by more than 20%; in Los Angeles, by 16%; in New York, by 11%. In Washington, DC, which has the highest per capita homicide rate in the country, the 1990 murder rate set an all time record in the District's history (Escobar 1991). Across the country, 1 out of 5 teenage and young adult deaths was gun related in 1988 - the first year in which firearm death rates for both Black and White teenagers exceeded the total for all natural causes of death combined. Also in 1988, the firearm homicide rate for young Black males increased by 35%, and Black male teens were 11 times more likely than their White counterparts to be killed by guns (Christofel 1990).

Depressed mothers as informants about their children: a critical review of the evidence for distortion

The claim that depressed mothers have distorted, inflated, perceptions of their children's problems has been made with increasing frequency in recent years. This review explicates the significance of the depression-->distortion controversy, introduces a set of standards for evaluating distortion claims, and uses these standards to evaluate the key characteristics of 22 studies that have published data directly relevant to the distortion question. None of the studies that claimed evidence for a depression-->distortion influence on mothers' ratings of their children met the necessary and sufficient criteria for establishing distortion. This review challenges the empirical foundation for the widely held assumption that depressed mothers have distorted perceptions of their children's problems. Issues that will require reckoning in future efforts to explore the depression-->distortion question are considered.

Allure of self-confirmation: a comment on Swann, Wenzlaff, Krull, and Pelham

Swann, Wenzlaff, Krull, and Pelham (1992) described the results of 4 studies designed to examine the relation of depression and negative feedback seeking. Unfortunately, problems of the characterization of subjects and of constructs, as well as the interpretation of data trends, combine to limit the conclusions that can be drawn from these studies. We provide a brief review of these problems.

Allure of self-confirmation: A comment on Swann, Wenzlaff, Krull, and Pelham

Swann, Wenzlaff, Krull, and Pelham (1992) described the results of 4 studies designed to examine the relation of depression and negative feedback seeking. Unfortunately, problems of the characterization of subjects and of constructs, as well as the interpretation of data trends, combine to limit the conclusions that can be drawn from these studies. We provide a brief review of these problems.

Marital adjustment, parental disagreements about child rearing, and behavior problems in boys: increasing the specificity of the marital assessment

2 studies were conducted to illustrate how measuring a specific aspect of marriage, namely, child-rearing disagreements, provides a better understanding of the link between marriage and boys' behavior. In Study 1, 200 mothers of 3-year-old boys completed unstandardized measures of marital functioning and child behavior. An index of child-rearing disagreements: (1) correlated with a greater variety of behavior problems than nonchild disagreements, and (2) improved upon the prediction of behavior problems after accounting for nonchild disagreements as well as after accounting for boys' exposure to marital conflict. In Study 2, 87 mothers with 4-6-year-old sons completed the index of child-rearing disagreements used in Study 1 as well as standard measures of marital functioning and child behavior. Child-rearing disagreements: (1) predicted a greater variety of behavior problems than global marital adjustment, and (2) improved upon the prediction of internalizing problems after controlling for global marital adjustment as well as after controlling for boys' exposure to marital conflict.

Alternative measures of expressed emotion: A methodological and cautionary note

Undergraduate raters listened to Camberwell Family Interviews that had been conducted with the spouses of depressed patients and then rated each relative with a rating-scale assessment of expressed emotion (EE). Students' ratings of relatives' criticism, hostility, emotional overinvolvement, and warmth were significantly correlated with trained raters' EE assessments obtained in the conventional manner. Despite this correspondence, further analyses revealed that undergraduates' assessments of relatives did not predict 9-month relapse rates in patients. These results highlight the importance of establishing both the concurrent and predictive validity of any alternative measure of EE. They also emphasize the dangers of assuming that significant correlates of EE are necessarily significant predictors of relapse.

Alternative measures of expressed emotion: a methodological and cautionary note

Undergraduate raters listened to Camberwell Family Interviews that had been conducted with the spouses of depressed patients and then rated each relative with a rating-scale assessment of expressed emotion (EE). Students' ratings of relatives' criticism, hostility, emotional overinvolvement, and warmth were significantly correlated with trained raters' EE assessments obtained in the conventional manner. Despite this correspondence, further analyses revealed that undergraduates' assessments of relatives did not predict 9-month relapse rates in patients. These results highlight the importance of establishing both the concurrent and predictive validity of any alternative measure of EE. They also emphasize the dangers of assuming that significant correlates of EE are necessarily significant predictors of relapse.

Empirical classification of infant-mother relationships from interactive behavior and crying during reunion

Multiple discriminant function analysis (MDFA) was conducted with data from 255 Strange Situations conducted and scored by Ainsworth and her colleagues. Cross-validated discriminant functions and classification weights were obtained, allowing attachment classifications (A, B, C) to be assigned directly from scores on interactive behavior and crying during reunion episodes. In the past, classification agreement within laboratories has often been used as a training criterion. Unfortunately, this does not insure that classification criteria agreed upon within a laboratory are comparable across laboratories, nor does it insure that agreed upon criteria will yield the same classifications that would have been assigned by the researchers who developed the scoring system. The present results enable researchers who have mastered the scoring systems for reunion behavior and crying to obtain attachment classifications directly from scores on these variables. Alternatively, this procedure may be used to guide the training of, and validate classification decisions by, local judges.