RDC-PA: A Major Step Forward and Some Issues

Abstract

Mental health clinicians working with young children will be extremely grateful for the focused results that are presented by the task force concerning research diagnostic criteria as reported in the Journal. This commentary will provide a frame for the importance of the effort in the midst of its challenges. It will also provide a critical discussion of some issues that arise because of the assumptions and focus of the group. Importance of Classification and the New Criteria Diagnosis is a process that consists of the assessment of individuals and the classification of disorder. The latter is important for communication among clinicians, linking to existing knowledge about etiology, prognosis, and treatment, and it is also important for a linking to services and clinical decision-making (e.g., whether to treat or not). Classification of mental disorder in the early years of life, as acknowledged by the task group, is an especially challenging task. This is so for a number of reasons. Among these are the difficulties in evaluating the role of rapid developmental changes; the overlap of individual differences in normal development with what can be usefully considered disorder; the fact that behavioral and physiological dysregulation is apt to be pervasive and multiply expressed across systems; the fact that adaptation is embedded in caregiving interactions; and the fact that the child’s verbal expression is likely to be limited or absent. Still, there are urgent needs for diagnostic classification in the early years. The field of infant mental health and related clinical activity with preschool children is an extremely active one, responding to widespread needs of children and families, as multiple publications and related professional organizations document (Emde and Wide, 2003; Guendeney and Maestro, 2003; Osofsky and Fitzgerald, 2000; Zeanah, 2000). Mental health clinicians are involved daily with early interventions. Such interventions are aimed at relieving current suffering and patterns of maladaptive behavior as well as preventing additional later developmental dysfunction. This has been true even though standard classification systems in DSM and ICD have contained limited specification of syndromes and disorders that take into account the features of early development. Correspondingly, communication, as well as links to knowledge and services, has often been constrained. Mental health clinicians working with young children will therefore welcome the classification system that results from the systematic efforts of the task group in clarifying and expanding criteria for the syndromes of this age period. The task group has focused its efforts on classification, without considerations of assessment, and it has emphasized the assembling of criteria for classification that are developmentally appropriate, based on clinical evidence and considerations of usefulness for promoting research in clinical trials and epidemiologic surveys—hence the designation of “research diagnostic criteria.” Insofar as possible, they have kept continuity with the classification categories of DSM-IV, have avoided inferring internal states, and have not included parental behaviors that could cause child symptoms. While these self-imposed constraints were undoubtedly useful in making the task group’s job a manageable one, and while the results of the work should indeed facilitate research efforts, the constraints do raise questions about other limitations that will be discussed below as “issues.” The RDC-PA seems most useful in revising DSM criteria for anxiety disorders, posttraumatic stress disorder, sleep disorder, and feeding disorders. These now have clear criteria added that are developmentally based, and they should be useful for improving reliability assessments. The new criteria also have connections with evidence-based reports in the literature (although the revisions of feeding disorders are based on the reports of a single investigator). The