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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


SPECIFIC DEVELOPMENTAL DISORDERS (SDD) AN OUTDATED DIAGNOSTIC CLASS

Autor: Ştefan Milea

The paper states that the individualization within CIM-10 of the clinical frame called Specific developmental disorders (SDD) is outdated. Among the arguments presented we mention:

  • the fact that in the specialized literature there is no unanimity as to what its form and content are concerned. As well as that, the larger framework that includes it (the 8th class of psychological developmental disorders) is not without significant contradictions.
  • and the most conclusive argument which is the fact that, nowdays, when the close interaction with the developmental processes is admitted for the entire psychical patology of child and adolescent , neither what is the specific for the disorders included in the SDD, nor why only they are considered developmental disorders is explicitly stated.

Their right to autonomy could only be justified if it were mentioned that they are the exclusive expression of the abnormality of the ontogenetical prop underlying the constitutive premises of both abilities.Keywords:

Synonyms – developmental disabilities

 

Introduction

An analysis of what today is called the SDD (Tables: 1-2-3 and 4) reveals that on the one hand, there is no unanimity regarding its content, and on the other hand, terms that describe SDD are not clearly defined.

 

SDD and its present content

The 10th revision of the International Classification of Diseases (ICD-10-1990), currently in use, groups SDD in the 8th class, the „Disorders of psychological development” (F80-F89) which includes four groups of diseases: F80 – F81 – F82 – F83 and F 84 (Table 1). As shown in Tables 2 and 3, they are present in the other important classifications of psychiatric disorders, as „Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revision” (DSM-IV-TRTM – 2000) and the French classification of mental disorders of child and adolescent (CFTMEA R – 2000).

 

Table No.1. The 10th revision of the International Classification of Diseases (ICD-10-1990)

Disorders of psychological development (F80-F89)
1. Specific developmental disorders of speech and language (F80)
2. Specific developmental disorders of scholastic skills (F81)
3. Specific developmental disorder of motor function (F82)
4. Mixed specific developmental disorders (F83)
5. Pervasive developmental disorders (F84)
6. Other disorders of psychological development (F88)
7. Unspecified disorder of psychological development (F89)
1. Specific developmental disorders of speech and language (F80)
ICD-10-1990 Synonyms
Specific speech articulation disorder (F 80.0) Dyslalia; lambdacisms?; Articulation’s functional disorder
Expressive language disorder (F80.1) Motor congenital aphasia; Developmental aphasia, expressive type; audio-mutism
Receptive language disorder (F80.2) Developmental aphasia, Wernicke type; Congenital auditory imperceptions
Acquired aphasia with epilepsy (F 80.3) Landau-Kleffner Syndrome
Other developmental disorders of speech and language (F80.8)
Developmental disorder of speech and language, unspecified (F80.9)
2. Specific developmental disorders of scholastic skills (F81)
ICD-10-1990 Synonyms
Specific reading disorder (F 81.0) Dyslexia; Developmental dyslexia
Specific spelling disorder (F81.1) Dysortographia; Dysgraphia
Specific disorder of arithmetical skills (F81.2) Dyscalculia; Acalculia; Gerstmann Syndrome;

Disorder of arithmetical skills

Mixed disorder of scholastic skills (F81.3)
Developmental disorder of scholastic skills,

unspecified (F81.9)

3. Specific developmental disorder of motor function (F82)
CIM-10 Synonyms
Motor child debility; Developmental dyspraxia
4. Mixed specific developmental disorders (F83)

 

 

Table No. 2. Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TRTM – 2000)

Disorders usually first diagnosed in infancy, childhood or adolescence
DSM-IV-TR Correspondence in ICD-10
Learning disorders F81
Dyslexia F81.0
Dyscalculia F81.2
Dysgraphia F81.1
Learning disorders NOS F81.9
Motor skills disorder F82
Coordination development disorder F82
Communication disorder F80
Expressive language disorder F80.1
Mixed receptive and expressive language disorder
Phonological disorders F80.0
Stuttering F98.5
Communication disorder NOS F80.9

 

 

Table No. 3. The new edition of french classification of Mental Disorders in Children and Adolescents: CFTMEA R – 2000

Specific developmental and instrumental functions’ disorders –Chapter 6
CFTMEA R Correspondence in ICD-10
6.0 Language and speech disorders
6.00 Isolated articulation disorders F80.0
6.01 Language development disorders
6.010 Speech delay F80.1
6.012 Dysphasia F80.2
6.02 Acquired aphasia
6.020 Landau-Kleffner syndrome F80.3
6.028 Other acquired aphasias F80.8
6.03 Mutism F80.1
6.030 Total mutism F98.8
6.031 Selective mutism F94.0
6.04 Stuttering F98.6
6.08 Other language and speech disorders F80.8
6.09 NOS language and speech disorders F80.9
6.1 Cognitive and scholastic skills disorders F81
6.10 Lexicographic disorders
6.100 Isolated dyslexia F81.0
6.101 Orthographic disorders without reading disorders F81.1
6.11 Dyscalculia F81.2
6.12 Cognitive disharmony F88
6.13 Attention disorders without hyperkinesias F88
6.18 Other cognitive and scholastic skills disorders F88
6.19 NOS disorders F89
6.2 Psychomotor disorders
6.20 Psychomotor delay F82
6.21 Tics
6.210 Isolated tics F95.0
6.211 Gilles de la Tourette disorder F83.3
6.28 Other psychomotor disorders F82
6.29 NOS psychomotor disorders F82

 

 

Table No. 4. DSM-III-1980 Disorders usually first diagnosed in infancy, childhood or adolescence

Specific developmental disorders – Axis II
DSM-III-1980 Correspondence in ICD-10
Academic skill disorders
Arithmetic development disorders F81.2
Writing development disorder F81.1
Reading development disorder F81.0
Language and speech disorder
Articulation development disorder F80
Expressive language development disorder F80.1
Receptive language development disorder F80.2
Motor skills disorder
Coordination development disorder F82
Development disorder NOS

 

 

Historic

SDD is relatively new concept appearing for the first time in 1975 in the multi-axial classification of psychiatric disorders of children and it was proposed by Rutter et al. It comprised ADHD, enuresis, encopresis and tics. With a narrower understanding it was used simultaneously by Kaplan and Sadock (1980) and DSM-III (1980) – Table 4 – replacing “Specific learning disorders” from DSM-II (1968). The concept is kept in DSM-III-R (1987). In 1990 it is used by ICD-10 and in 2000 by “Nouvelle édition de la classification française des troubles mentaux de l`enfant et de l`adolescent: la CFTMEA R – 2000”. It is of a great truth that the French label “Specific developmental and instrumental functions’ disorders” (which replaces the one in 1990 “Disorders of instrumental functions” in which SDD was scarcely mentioned as a possible subcategory) is more broad and can cover a larger category as it can be observed from Table 3.

Disorders comprised in SDD were remarked a long time before when some references had been made in numerous classifications of psychological disorders of child mentioning them more or less generally.

We enumerate disorders which we consider suggestive for the name of SDD in a chronological order: Specific reading and educational difficulties (Pearson, 1920); Special writing, reading, calculating disabilities (Miller, 1936); Special mental disabilities (Brown et al., 1937); Limitations of specific intellectual abilities (English and Pearson, 1937); Specific handicap of intellectual development (Cameron, 1955); Special symptoms not otherwise specified (ICD-8, 1965); Specific learning disorders (DSM-II, 1968); Special Symptoms (Kaplan and Sadock, 1975); and Specific development delays (ICD-9, 1975). This phenomenon appeared firstly as a need for delimitating these new alike disorders identified in the cases of mental retardation (global), former oligophrenia.

 

 

Definition

Definitions usually are replaced by a list of the content of this class: diagnosis to which sometimes are added some entries. For example, for Remschmidt and Schulte-Könne (2009) SDD includes “a variety of severe and persistent difficulties in spoken language, reading, writing, arithmetic and motor functions that cannot be justified by an identifiable causal factors”, performance being significantly below age or intellectual level. In the specific literature you may find the following: instrumental deficiencies, developmental delays, special or specific disorders, related to biological maturation, to certain functions or specific areas of development and learning; lack of evolution as a characteristic or as a trait, not part of other disorders; or lack of measurable organic substrate. A systematization of these claims and a serious analysis of the impairments included allow us to consider SDD as regarding to significant ontogenetic endowments with a basic character and lacking evolution of those skills or competencies acquired recently on the evolutionary scale which being useless determine difficulties in knowledge assimilation primarily in the sphere of communication and school requirements and which determine inferiority complexes.

They are based on the dysfunction of the capacity of multi-sensorial integration namely hearing, sight and mioartrokinetic sense and they are characterized by predilection for males and for association as Rutter (1990) underlines. In the case of DSM-IV it is important to have a difference of at least two standard deviations from the QI. We don’t use “from normal level” because these disorders can be present in the global mental deficiencies.

We prefer to speak about ontogenetic underachievement of some skills and not about delays in development or maturity as used generally, to emphasize that they are mostly limited expression of the premises or usual development resources rather than the development of disorders triggered by exogenous factors.

The problem of lacking the organic bases so much emphasized in the past has now become meaningless. This is because, after talking a lot of minimal brain damage and having unsolved the distinction between dysfunction and injury, the focus has shifted to the idea of biochemical injury and dysfunction.

The lack of evolution in disorders does not mean they don’t complicate with other conditions as consequences of inferiority complexes and difficulties in adjustment to requirements, especially in those coming from the school. If in time they do not worsen nor disappear, as often erroneously believed, it is true that there is even spontaneous improvement especially after pedagogical interventions and daily exercise. But once beyond a certain level, difficulties are found in new forms after new requirements and these must be exceeded. For example, after having learned to read, the dyslexic child will find it hard to read fast enough and be efficient in the same time, decrypting the new text.

The above definition allows for recognition of other forms of inability largely ignored. We mean: no musical ear, no voice, the ability to learn foreign languages and to imitate the voice of others, drawing, humor, etc., incapacities which, as mentioned in 1999, are gratuitously ignored.

Comments. A comparative analysis of how SDD are addressed in the three current systematizations of psychiatric disorders allows us to see that they are not in full agreement.

For example:

a. The American classification. It was the first to adopt (in 1980) the SDD concept.

  • But abandoned it in 1994 (DSM-IVTM); option applies to the 2000 version too. The only reference is for “Coordination development disorder” which fails to make clear the specific nature. In this way clinical manifestations constituting the framework of SDD are addressed as independent entities. In addition, this time, they were moved from the second axis, where they were in DSM-III and DSM-III-R, on the first axis.

Independent approach to these disorders is found in major textbooks on child and adolescent psychiatry: Rutter and Hersov (1990), Lebovic et al. (1996), Lewis (1996), Graham et al. (1999), Rutter et al. (2008), Sadock et al. (2009). Exceptions are made by Mircea (2006 and 2008), Gelder et al. (2009), Dobrescu (2010) who separately address the chapter “Specific developmental disorders” and partially Martin and Volkmar (2007) because they delimitate a section entitled “Specific disorders and syndromes” in which they create the chapter “Developmental disorders” which mingle together: Autism and pervasive developmental disorders, Mental delay, Learning disabilities and Communication disorders. In their volume, Rutter and Hersov (1990) emphasize the predilection for associating SDD and the advantage recognizing they are connected.

  • The U.S. classification did not use the broader explanation used in ICD-10 called “Psychological development disorders”. Instead, since 1980 it was introduced a new section – “Disorders usually first diagnosed in infancy, childhood or adolescence” which includes everything ICD-10 includes in SDD, with the exception of acquired aphasia with epilepsy (F80.3) and receptive language disorders (F 80.2). For these two classical names are preferred.

We believe that American options are reasonable. This is because:

– As we shall see, the concept of SDD and psychological developmental disorder are not only without rigorousness but also unnecessary.

– Disclaiming the diagnosis of acquired aphasia with epilepsy and of receptive language disorder is also entitled. This is because the first diagnosis is a condition that belongs more to neurology than psychiatry. Regarding the second diagnosis it is clear that it does not cover a real clinical entity (and practical experience confirms) as receptive language impairment is associated, even if we don’t want it, with impaired expressive language. As such, the mixed form of disorder is the only proposed entity which might be possible.

– Individualization of the group of diseases called “Disorders usually first diagnosed in infancy, childhood or adolescence” is also a good decision. All disorders of the child and adolescent are recognized and not just those in SDD; it is important that these disorders have a connection with the neuropsychological development. Such an option is worth mentioning because it offers a whole identity of the child and adolescent mental illnesses. ICD took over this concept in 1990 which proves this was a good idea, even if they use a narrower formula “Behavior and emotional disorders usually occurring during childhood and adolescence”, codes from F90 to F98. However, SDD were not included in this category, as we believe it would have been natural.

b. The French classification

It includes under a title, as we have seen in the Table, an extended number of disorders obviously higher than in ICD-10. It does not mention explicitly nor what specificity is, or developmental disorders are or what instrumental functions are and neither why only these clinical entities take part from the clinical setting.

c. ICD-10 (reference classification as it is the option of WHO) recognizes the concept of SDD. ICD-10 adopted it in 1990 and offered a distinct place in the eighth class of mental illnesses called “Psychological development disorders” in which it has four positions: F80, F81, F82 and F83. A careful analysis captures a number of drawbacks, which cannot be lightly dismissed. Thus:

– Entitled “Psychological development disorders” of the 8th clinical entities does not fully comply its name. This is because it includes disorders with neurological symptoms like: Rett syndrome (F84.2), acquired aphasia with epilepsy (F80.3), articulated speech acquisition specific disorder (F80.0), specific motor development disorders F 82) and 4 of the fifteen entities it comprised. But the strongest argument in favor of the claim for lack of solidity of the clinical framework called “Psychological development disorders” is that the above entities does not meet the rigorous third characteristic that disorders “have a continuous evolution without remissions and relapses … and that usually diminishes progressively with age (mild deficits may persist into adulthood yet)”.

– Neither the SDD approach and place in the 8th clinical entities together with pervasive development disorders seems fully justified because there are lacking common aspects, for example, with Rett disorder or with the disintegrative disorder

– Nor the concept of SDD or its contents are not fully justified. First, we refer to the inclusion of acquired aphasia with epilepsy (F80.3) which has nothing to do with all that customize other disorders that resembles to, or the impaired expressive and receptive language. Moreover, it is acquired, dominated by epilepsy and worsens progressively. As already mentioned, the delimitation in SDD of receptive language disorder (F80.2) is artificial.

Perhaps the strongest argument to support the lack of consistency of the concept of SDD is that, just as they do and the French classification there is no specification of the manifestation of psychopathology that it includes and why they are the only developmental disorders. Maybe an explanation could be the predilection for males and the statement of Rutter (1990) outlined above, regarding the tendency of association but such features are not characteristics only for SDD. Or today, when it is clearly knows that in children and adolescents, all pathology is marked by the development and maturation of the brain and its functions, separation of developmental disorders without additional emphasis on individualized criteria is free of viable support. In our opinion, it would be justified to have this concept like this only if it is explicitly stated what makes these problems specific or why, of all common mental disorders in children and adolescents, only they are specific or what makes them different from the others. A very long time ago, the idea of specificity was delimited by the similar problems occurring as a consequence of global mental delay which had been a substantial progress. But today these clinical entities have a recognized identity that does not require further emphasis.

It is true that the concept of developmental disorder, which occurred in 1975 with the publication by Achenbach’s volume entitled “Developmental Psychopathology” (Garmezy, 1999), is a complex concept because it is the interface of two processes, the development and mental maturation on the one hand, and the formation and evolution of abnormality on the other. For this reason, it has provided and provides multi-faces, meanings and different angles of analysis, as Garmezy mentioned in his preface “Handbook of Developmental Psychology” edited by Lewis and Miller (1999).

  • The first meaning given to the term mentioned and, in the same time an angle of approach that emphasizes the influence of child and adolescent mental development on psychopathological manifestations, namely on the development process, provides the vulnerability and protective factors, and how Lewis and Miller (1990) express, provides a definition to the field named “predictive study of development of maladaptive behaviors.” Mircea T. (2006 and 2008) it resembles with the making of photography, in time, with age revealing psychopathological manifestations. In this context stands out: the existence of a period of mental development without problems, some predictive factors which make the disease possible, the variations of intensity with age and its evolutionary discontinuities, diversification and improvement of symptoms, and even redirecting development, and of course, the role protective or pathogenic features of age in all these phenomena. It is the most common meaning, the best known together with the recognition that: • mental functions become active with age and can be evaluated only when their quality and hence their potential are in action. That is, for example, the case with SDD; • the mental development implies the existence of protective and psycho-pathogenic factors specific for different stages; • time of onset, clinical presentation and evolution of mental disorders are influenced by age • there are genetic diseases with conditioned onset and expression by age, • the child and adolescent mental pathology differs substantially from that of adults because the first are in the process of development and maturation.
  • A second meaning given to the term “developmental disability”, more properly called a “development disorder”, is about how, how much and the way mental abnormality affects the normal development of the individual. Slowdowns are taking place, stagnations, restructurings and even distortion. For example, it is known that neuropsychological development of children is significantly dependent on the quality of stimulations of the living environment. Or, it is obvious that a child with a mental retardation, because of his deficiency, cannot access, through his own means, what is offered as a stimulation and therefore suffers at all levels including the sensorial
  • A third direction and angle of approach of developing the disorder is the most complete and most complicated because it has the fingerprints of the phenomenon of mutual interaction of the two participants. It revolutionized modern medicine, it has set new dimensions to quality of life, created the name of “pervasive developmental disorder”; it prevented the passage of mental delays from mental disorders among to that of disabilities, etc.
  • You can individualize a fourth direction, which can particularize the concept of developmental disorder. This is, in our opinion, the direction that could validate the term “specific developmental disorders” (see definition above). It covers only the realities of clinical consequences of abnormalities of that premises’ development processes. We consider various deficient skills that according to the genetic program, we expect to emerge and grow to any individual but because of this fact, they prove to have lower quantitative and qualitative functional levels. But in SDD there is no reference to any of these aspects or to others in order to prove their specificity and to recognize their right to autonomy. Until then SDD remains a clinical entity, in our view, of no practical use.

 

 

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Correspondence to:
Stefan Milea, Clinic of Child Psychiatry, no 10-12 Berceni Street, Bucharest, sector 4, cp 041915