ADJUSTMENT VERSUS PSYCHIATRIC DIAGNOSIS

It is important to recognize the distinction between psychiatric disturbance and adjustment problems as conversant concepts in assessment for a pediatric reha­bilitation population.

A wide body of literature addresses the adjustment of children with chronic physical conditions. This group was twice as likely to have adjustment problems as healthy children in a meta-analysis of 87 articles by Lavigne and Faier-Routman (9). Though the specific prevalence rates were higher yet among these chil­dren, only a minority showed maladjustment. Such children, then, are more vulnerable than those who are healthy. Newer assessment instruments have been developed that utilize the concept of quality of life (10) and will be discussed here in the section “Population­Specific Assessments.” With this approach, the nature of a child's or teen's adjustment and the reflection of the uncontrollable factors in his or her situation are captured for a wider rubric than the inadequate dichot­omy of normal versus abnormal.

However, the use of psychiatric diagnoses can be appropriate in both this population and those with neurodevelopmental disabilities. The latter group showed a rate six times that of the general popula­tion for significant emotional and behavioral problems (drawn from an outpatient clinic population) (11). The identified problems run the gamut, encompassing a breadth of disorders, and are more likely to persist into adulthood. There is the primary impairment of the neurologic disorder and a secondary impairment of psychosocial support problems (4). With the primary disturbance in the brain, these findings are not sur­prising. Other factors exist as well to either exacerbate or ameliorate the brain's abnormality, but the overall picture is one of significant neurologic and psycholog­ical morbidity, with the source of disability either con­genital or traumatic.

The most common disabling injury of childhood is, in fact, traumatic brain injury (12), which carries a substantial risk for long-term cognitive disability as well as behavioral deficits (13). Expressed differ­ently, incidence figures are such that by the tenth grade, 1 in 30 students would have had a traumatic brain injury (across severity ranges). This popula­tion will be a substantial part of a pediatric rehabili­tation medicine practice. The causative link between cognitive and behavioral functioning represents the juncture of thinking and adaptive behavior that can be devastating to the ongoing development of a child survivor (14). There is a particular danger in the misattribution that easily occurs. Behavioral deficits are attributed to more common etiologies, as opposed to the organic brain disorder from the injury. With mis­attribution comes inappropriate treatment. Cognitive limitations are not accounted for in treatment efforts, or the wrong premise (for example, antecedent versus contingent programming) used, and failure occurs or even exacerbation of the original problems. Awareness and consideration of the brain damage from an injury means assessment must encompass a wide focus. Neuropsychological testing is the centerpiece in these children and teens, representing a subtype of general psychological assessment that will be an important aspect of many rehabilitation cases.