Objective: Classification systems and their practical implications have become increasingly important in child and adolescent psychiatry. This paper presents the evolution and practical applications of a multiaxial classification system for children and adolescents presenting to mental health services. Included are some worked examples demonstrating both the complexity of many presentations and how broadening the use of the multiaxial system can help in identifying appropriate interventions. Conclusions: Classification systems in child and adolescent psychiatry have largely remained uniaxial in nature. A multiaxial system encapsulates the broader biopsychosocial aspects of the presenting child or adolescent, and orders complex data in a concise manner. This approach can be used to concisely communicate with other treating clinicians, and assist with case reviews, formulation and teaching.
In child and adolescent psychiatry, the multiaxial classification approach has been developed over some decades and remains very relevant as it encapsulates the biopsychosocial approach, an approach which is also central to paediatric practice. There is considerable overlap between developmental-behavioural paediatrics and child and adolescent mental health, including presenting clinical problems, diagnoses, multidisciplinary and holistic approach to assessment and management, and similar use of pharmacological agents and psychosocial interventions. Multiaxial classification can be of use to paediatricians in a variety of ways, both in clinical practice and for teaching purposes. It can improve communication between the two disciplines and promotes a more holistic diagnostic representation in a structured and consistent format. Presented here are a number of practical ways in which the multiaxial biopsychosocial framework can be used, including case description, formulation, timeline and interventions, training and teaching.
Background This paper describes pseudo-seizure as an atypical presentation of attention-deficit hyperactivity disorder (ADHD) in an adolescent female in the context of psychosocial difficulties. We present the case, which explains the clinical dilemma in such situations, along with selective literature review. Case Presentation An adolescent female, who is an academic high achiever, living with parents, presented with unresponsive spells which were initially treated with antiepileptics by the paediatrician without any significant improvement. Later, after further assessments and revision of her diagnosis to conversion disorder, she was referred to the child and youth mental health service team. Further evaluation revealed her symptoms to be a result of multiple psychosocial stressors in the context of her having undiagnosed ADHD. Individual therapy, treatment with stimulant, resulted in significant improvement in her school and home adjustments. Conclusions This case demonstrates the diagnostic challenges that high-functioning girls with ADHD coloured by psychosocial stressors can pose and raises the need for reviewing our diagnostic approaches in these situations.
SUMMARY
Multiaxial classification system development (organising important and relevant clinical factors under multiple headings or ‘axes’) has a long history stretching back to the 1940s. The World Health Organization supported the development of a multiaxial system of classification for children from the 1960s and in the 1990s produced a comprehensive multiaxial system which could be used with ICD-10. Using the multiaxial approach provides for an atheoretical framework that can integrate factors from within the child and the environmental influences on the child. This article presents a variety of ways in which the ICD-10 multiaxial framework can be extended from its classic usage to provide clinicians with valuable tools to assist in a biopsychosocial clinical assessment. Using the multiaxial system in an extended format allows a more comprehensive diagnosis and planning of treatments and is helpful in the training and teaching of juniors. It is also useful in evaluating responses to medication when it is combined with a chronological analysis and can provide other useful ways of integrating information relevant to understanding clinical cases.
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