Toward a New Diagnostic System for Child Psychopathology: Moving Beyond the DSM

Drs. Peter Jensen, Penny Knapp, and David Mrazek co-authored a remarkable book that should be read and re-read by child psychiatry fellows, practicing child psychiatrists, and members of the DSM-V working groups. Child psychiatrists have long complained that the existing DSM-IV is a static document and fails to take into account the developmental nature of children. For example, as children mature their relationships change with all family members and to their peers. As relationships change they may also improve or deteriorate. There is no satisfactory code in DSM-IV to account for changed relationships as a developmental issue in children and adolescents.

The authors have also taken advantage of the new discoveries reported in the “decade of the brain.” The first chapters of the book have integrated research findings from multiple new disciplines recognized during this decade. For example, they elaborate on the research advances made by evolutionary contemporary molecular biologists, geneticists, and the new brain imaging techniques. They discuss the theoretical model proposed in evolutionary biology and ask this fundamental question, “What is the function of any given structure or organ?” Then they suggest that the brain’s major functions (thoughts, feelings, behaviors) are shaped by the evolutionary selective processes and conclude that the human brain has adapted and evolved over time to meet modern issues and contemporary needs.

The authors posit that psychiatric disorders (or brain malfunctions) are the result of both environment and biology and that psychiatric disorders are the result of the progressive development of the brain as it unfolds within the constraints of the genomic map, general environmental circumstances, and the unique environmental context of a given organism. They explain the presence and persistence of psychopathology in the gene pool by both genetic drift and its consequences (a maladaptive genetic trait is correlated with some other genetic trait that is adaptive), environmental change (a trait that was adaptive in our ancestral environment is no longer adaptive because of environmental change), and natural selection without adaptation (a maladaptive trait is correlated with increased fecundity). They emphasize that although natural selection in evolution is important, it is not the be all and end all and is just one factor that needs to be considered.

Several chapters discuss specific mental, emotional, and cognitive disorders from a developmental and evolutionary perspective. The disorders, described in depth, include, anxiety disorders, childhood depression, attention-deficit/hyperactivity disorder, conduct disorder, stress disorder, autism, and other pervasive developmental disorders. Each of the chapters is authored by an expert in the disorder.

In the final chapters of this slim but important theoretical book, the authors discuss implications for evaluation and treatment using the conceptual approach they champion. The authors comment that they have been enlightened, amused, skeptical, and astounded as they considered the implications of re-thinking the diagnostic terminology from an evolutionary and adaptational perspective. Their radical re-thinking of childhood disorders has implications for research in the areas of etiology, prevention, and intervention of childhood disorders. They have advanced fresh new ideas about the conceptual basis of psychiatric diagnosis. Their theoretical concepts have evolved from the reality they face in dealing clinically with children and the diagnostic system designed for adults, which child psychiatrists live with and complain about. They have stimulated my thinking in regard to the importance of developing a new diagnostic system that is more user-friendly and more reality-based for those working with children and adolescents daily in clinical practice. I hope that the multiple groups working to develop DSM-V pay attention to concepts developed in this book as they struggle to satisfy the needs and wishes of the many interest groups who look forward to a developmental and evolutionary change in our diagnostic system. The new ideas springing from evolutionary biology and developmental psychology are critical to incorporate in the next diagnostic system.