Increasingly, pediatricians are asked to evaluate and treat not only physical ailments but also disturbances of behavior, a field they may share with pediatrie psychologists and psychiatrists. This field has undergone an explosion of knowledge during the past few decades, with advances in areas of diagnostic nosology, phenomenology, and treatment, as well as a reconceptualization of models used to explain misconduct.
In the past generation, the dominant model to explain childhood misconduct was the psychodynamic model. Misconduct was considered a final common pathway, representing a failure to resolve unconscious conflicts. The obvious remedy was to resolve these conflicts, usually through long-term psychotherapy, so the patient could gain insight. This model, based on "soft" Freudian psychology, gradually fell out of favor and was replaced by more rigorous, scientifically based models.
Initially, scientists found it difficult to study childhood misconduct because there was an inadequate nosology of childhood disorders of misconduct. In the earlier editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the criteria for conduct disorders were neither reliable nor valid. Therefore, it was never clear if the scientist was studying a patient with conduct disorder or an imposter. It was not until 1980, when DSM-IlI was published, that pediatrie psychologists and psychiatrists had diagnostic criteria that were reliable and thus provided a basis for scientific enquiry.
The past 25 years have seen much research on conduct disorders (all reliably defined using the strict criteria of the latest DSM, now the DSM-IV-TR). However, even though these diagnostic criteria do show good reliability - doctors using these criteria tend to agree on the diagnosis - it is not clear that they show good validity. Do the criteria for conduct disorder define conduct disorder or disordered conduct? The next challenge for the nosologist will be to better separate "conduct disorder," which is a mental disorder, from disordered conduct, such as child and adolescent antisocial behavior and juvenile delinquency. Child and adolescent antisocial behavior is not a mental disorder but a mental condition, and juvenile delinquency is neither a mental disorder nor a mental condition.
IN THIS ISSUE
One of the most exciting findings in pediatrie forensic psychiatry has been the emergence of a biological theory of criminality, reviewed by Scarpa and Raine in their article, "The Psychophysiology of Child Misconduct." If biological deficits predispose people to antisocial behaviors, how can society hold such persons responsible? The question is further complicated if the antisocial person is a child. We have not discussed all of these complex issues in this issue of Pediatrie Annals. However, if biological deficits play a role in misconduct, then perhaps we should seek remedy in biological interventions.
Drs Steven Ruths and Hans Steiner review some of these interventions in their article, "Psychopharmacologic Treatment of Aggression in Children and Adolescents." They note there is now a vast range of medications for the potential treatment of aggression available. Pediatrians should have knowledge not only of psychopharmacology but also of the various subtypes of aggression to better match the particular subtype with the appropriate agent.
Aggression (or any type of misconduct) is not a unitary phenomenon but represents a variety of behaviors with varying causes and characteristics. The aggressive act, or the misconduct, should be viewed as a symptom, requiring analysis and exploration so the actual disease (or lack of disease) may be identified properly. Pediatricians may use a psychiatric model of analysis, as suggested by Haroun in "Evaluating Wickedness in Children." This model should be supported by psychological testing based on the recommendations of Ahmad, Titus, and Saunders in their article, "Neuropsychological Characteristics of Juvenile Delinquency." This article reviews the characteristics of juvenile delinquency in contrast to its causes.
ARE THE CAUSES OF MISCONDUCT IGNORED?
Juvenile misconduct may present to a legal agency (the juvenile court system), a medical agency (pediatricians), or both. "Cause" has different meanings in law and medicine, which may be confusing. In law, cause is usually assessed using the "but for" test. If the juvenile would not have committed the misconduct but for his alcohol intoxication, then the law may reason that the alcohol caused the misconduct. In medicine, cause is analyzed through examining factors that may be necessary or sufficient. For example, because trisomy 21 is both necessary and sufficient for the development of Down syndrome, pediatricians would agree that this trisomy causes the syndrome. Does smoking cause cancer? We tell our children it does, but smoking is neither necessary nor sufficient for the development of cancer, so strictly speaking, it does not - using the language of medical logic - cause cancer, although it is a risk factor for cancer.
Using this model, we have no known "cause" for childhood misconduct, although we have knowledge of many risk factors, reviewed in many of the articles in this issue.
Knowing the cause of a phenomenon may be intellectually satisfying but it is not necessary for purposes of intervention. Pediatricians who know of potential biomedical, psychological, and sociocultural risk factors for any particular misconduct are uniquely qualified to assess patients and manage those risk factors.
Addressing childhood misconduct will contribute to reducing misery at the individual patient level, and also at the broader societal level. This is surely one of the most worthwhile tasks for pediatricians.