Chapter 1. Background for the study

In the course of several years’ experience as a teacher in special schools for children (with specific or general developmental disabilities, learning disabilities, emotional disturbances and behavioural disorders), an unambiguous finding was that examination and diagnosis of the children were insufficient in relation to planning remedial programmes. Even when there were medical and psychological assessments available, it was often difficult to see the significance of the examination and test results in relation to planning individual treatment and training programmes. In children with developmental disabilities, medical causal diagnoses such as phenylketonuria and myelomeningocele say little about the child’s function. Children with symptom-related diagnoses such as cerebral palsy or epilepsy may have the same diagnosis but very different levels of function. In child psychiatry, diagnoses are broadly-defined conditions where there is great variation within each diagnosis, for example, in autism and the hyperactivity syndrome. Regardless of type of medical diagnosis, a functional assessment was lacking. Knowledge of the prognosis provides general information regarding expected development (1-6), but few details that are useful for planning therapeutic and educational programmes. In some cases, psychological examination is impossible to perform because of co-operation problems in the test situation or special functional disabilities. In other cases, results of tests have to be interpreted in the light of a medical diagnosis that is often ambiguous as regards function, leading to difficulty in understanding the implications for planning remedial programmes. Far too many of the children under 3-4 years with specific disabilities and those with serious disabilities are assessed as untestable with intelligence tests and other psychological tests. These children have a combination of inattentiveness, restlessness and other behavioural problems, insufficient comprehension of language instructions, motor clumsiness, impulse control problems, and failing motivation in test situations. The lack of tests for these children prevents precise description of function as well as a satisfactory classification system. As a result, professionals trying to educate and treat these children do not receive appropriate help from psychologists, psychiatrists and others who assess the children. Obtaining a baseline in order to study treatment effects is also important in the total management of these children. Basically, research on remedial programmes is not easy. The effect of the programmes becomes specially difficult to study when there are deficiencies in the functional diagnosis and prognostic evaluation. It is then impossible to separate out what is lacking in a programme, and what changes have occurred as a result of spontaneous development, from the the child’s inherent limitations as they affect teaching and development. In recent years attention has been paid to the fact that many children referred to child and adolescent psychiatric clinics show neurocognitive deficits of minor degree (7-11). The increased prevalence of psychiatric disturbances among children with known brain dysfunction is generally ackowledged (1 2-14). There have, however, been few studies of the prevalence of neurocognitive deficit among pre-school children with such problems referred to child psychiatric clinics. Increasingly, authorities in the field of child psychiatry give attention to coping strategies, resilience and protective factors (1 5-17). The children addressed in this study have an increased risk for development of psychopathology, due to their neurocognitive deficits (14, 18). Functional assessment at an early age is one necessary step in limiting the risk for later development of or progression of psychiatric disorder (8). A normative approach to testing is sometimes counterproductive to the intentions of intervention, highlighting the deviations from the norm more than the individual child’s strengths as a basis for remediation planning. In child psychiatry, as well as in special education, age related functional assessment appears to be often based on the clinician’s knowledge of psychomotor and cognitive development rather than on specific tests. If testing is undertaken, the relevance of the results to recommendations for treatment and training is not obvious to the clinicians. Neither does the fact that research on the effects of different treatment approaches is sparse encourage the use of tests. For older children and children with less severe disorders, neuropsychological test batteries have proved their applicability and relevance in planning of treatment and training (19-23). Brain-behaviour relationships are also important for the understanding of developmental disabilities in the youngest or severely disabled children (24-27). There is a need for more formal testing and assessment in clinical work with pre-schoolers. The change in the referred population in child and adolescent psychiatry (CAP) over the last 20-30 years, introducing a more complex picture of developmental disabilities and behavioural disturbances,