An approach to deciding when emotional states and behaviours are abnormal

It is usually helpful for inexperienced clinicians to have a DSM or ICD symptom checklist at hand to ensure that they cover the key items related to each diagnosis. However, it is important to avoid turning such a list into a fixed set of questions. Rather, the aim is to explore an individual's symptomatology with each informant. Allowing individuals to describe problems in their own way is usually the most effective way to begin collecting the necessary information. Closed questions about particular details should be saved, as far as possible, for situations in which open questions fail to elicit all relevant material.

One problem with emotional symptoms is that they are often extremes of normal emotions. In the absence of a detailed epidemiological literature describing how much time the average child spends feeling depressed, or worrying, it is necessary to have some general rules of thumb for deciding what is abnormal as follows.

1. Look for changes in state, or failure to make normal developmental progress.

2. How long do bouts of the symptom last, and how often do they occur? Most people worry or feel depressed sometimes, but these are evanescent phenomena. They are only symptomatic when present for an inordinate amount of time. We lack data on how much worrying is normal, but can determine how much time (average length of bout of worrying times number of bouts per week) has been spent worrying and make a common-sense judgement about whether this is pathological.

3. Is the symptom intrusive into other thoughts and activities? A symptom that disappears as soon as something comes along to distract the individual is unlikely to be of psychopathological import.

4. Is the symptom controllable? If a child can get rid of a symptom by thinking about, or doing, something else, then one can usually be fairly sure that it is not psychopathologically significant.

5. Is the symptom generalized across more than one activity? A 'symptom' that is restricted to a single activity (such as worrying about a mathematics test just before the test, but only then) is usually not a marker for a clinically relevant problem.

An overlapping set of considerations are of primary relevance for behaviour problems. Some undesirable behaviours are normal (such as disobedience or lying) when they occur at low frequency, and should only be regarded as 'symptoms' when they occur often. In such cases, frequency, controllability, and generalization are relevant, but bout duration and intrusiveness are not. However, one should also consider the following.

1. Response to admonition. Some children simply do not do as they are told, while others actively challenge their admonisher (for instance by swearing at a teacher). Here it is very helpful to obtain a specific description of what happens during attempts to assert control over the child's behaviour. Some families are caught in escalating patterns of hostile interchanges around attempts to control child behaviour, and intervention to change these patterns can be helpful. At the other extreme, some parents have given up even trying to keep their children under control, a pattern of response that is probably just as harmful in the long run.

2. With both emotional and behavioural problems it is also important to discover in what situations, and with whom the behaviour occurred. Three general settings can be distinguished: home, school, and elsewhere. For younger children, whose functional lives are not so neatly divided, it still matters with whom, and in what settings, problems are manifested.

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