Guest Editorial: Classification in Child Psychiatry

As far back as 1959, Wooten warned about the dangers of “premature hardening of the categories” referring to how, inevitably, refinements of classification become incorporated into social practice with disproportionate speed, surpassing the careful data collection and hypothesis testing still necessary to validate categories. Sound familiar? And these were the pre-internet days!

As I researched the history of classification I came across a wonderful two volume collection on “Issues of Classification of Children: A Sourcebook on Categories, Labels and their Consequences” by Nicholas Hobbs dating back to 1976. It was a thoughtful discussion about classifying and its effects, penned by psychiatrists, educators, parents and yes, even children, the often passive recipients of our musings. It was after the appearance of the Diagnostic and Statistical Manuals I and II (DSM-I and II) and the “DSM approach” was one of many models competing for the attention of child and youth clinicians and researchers in search of a more satisfying and practical approach to classification. The Group for the Advancement of Psychiatry (GAP) child committee proposed a preliminary classification incorporating “normality”, “developmental deviations” and descriptive operational definitions of clinical categories (GAP, 1966) but Robert Spitzer’s (the chairman of DSM III) categorical approach with its multi-axial framework found more universal appeal as well as a clean break from the past. We have undoubtedly made huge strides and advances since those days As this theme issue will demonstrate, though, the same classification challenges to proper contextualize the child that bedevilled thoughtful clinicians in pre-DSM III days, are still hotly debated now; how can a classification for children and families be valid and reliable but still include relevant developmental, social, cultural and contextual (individual and situation specific) factors?

The contributors to this theme issue are clinicians and researchers who have struggled with finding a balance between recognizing the need for valid and reliable categories but conserving as well the shadings and gray areas inherent in dealing with distress and suffering in developing children and their families. Carrey and Gregson review historical factors as well as shortcomings of the current adult centered universal and categorical approach as applied to children. Rousseau and colleagues provide the provisos and caveats necessary when dealing with other cultures but also how the assessor needs to situate him or herself as “person in culture”. Cameron takes a broad view, reminding us of the multiple interactions affecting development and the attendant implications for assessment and diagnosis. Finally Greenspan and Weider have taken on the daunting task of filling the existing DSM void in classifying infants and toddlers.

What then is the proper attitude to take towards classification? Instead of throwing out the baby with the bathwater, by either becoming too reductionistic or too critical, the use of classification as both a research and clinical tool can be enhanced by recognition of the inherent limitations of classification (the trade-offs involved) and the socio-cultural processes underlying the discourse. There will never be a perfect or comprehensive diagnostic system despite the sheen of objective reality as portrayed in the newest coding manuals. These “graspings at the elephant” always remain tentative in nature, a work in progress.