The articles in the current number fall quite neatly into three sections. The first set of three papers focuses on therapeutics. The Journal of Child Psychology and Psychiatry aims to publish the very best research in areas of current interest and contemporary relevance to the study and practice of child psychology and psychiatry. Previous editorials have highlighted the desire on the part of the Journal to encourage more submissions in areas, such as cognitive and behavioural neuroscience and genetics, that have perhaps been underrepresented in its pages. In fact, special sections of the Journal are planned to emphasise our commitment to these two particular domains of study. I have placed the set of three therapeutics papers at the start of this issue in order to highlight a similar commitment by the JCPP to a third area of activity that has perhaps also been underrepresented in the past: namely, reports of high quality and innovative clinical trials and studies of therapeutic mechanisms and mediators of change.
The specific focus in each of the three papers published here is cognitive behaviour therapy (CBT). Taken together, these papers highlight the way in which CBT offers a broad-based and flexible framework for the treatment of a range of different childhood disorders presented by different types of client. The papers also highlight the potential of CBT to be delivered by different types of therapist. Three different but equally potentially problematic areas of clinical need are discussed. First, as part of their practitioner review Garralda and Chalder introduce readers to a CBT-based approach to the treatment of chronic fatigue syndrome in childhood. The review includes a comprehensive, authoritative and balanced account of this most controversial diagnosis. It highlights, in particular, the potentially damaging impact of the polarisation between those who highlight the organic nature of the condition and those who are content to define it in terms of its psychiatric symptoms and its functional impact on everyday activities. The family-based rehabilitation programme described builds on the concept of graded activity – a treatment approach adapted from similar interventions that have proven useful with adults. Although at present there is only a limited evidence base concerning the efficacy and effectiveness of this approach when used with children and adolescents, there are currently two randomised control trials (RCTs) under way. We wait with great interest the outcome of these studies. The second paper in the series, by Sofronoff and colleagues, highlights the possibility of adapting standard CBT-based treatments for anxiety to children with a primary diagnosis of Asperger syndrome. The authors report a successful RCT in which active treatment led to a reduction in symptoms of anxiety when compared to a wait list control. The fact that the intervention was endorsed as being of value by parents seemed particularly important in this case as the results suggested that the active participation of parents enhanced treatment effects. The third paper, by Leo Wolmer and colleagues, highlights the potential of teachers to act as therapists using CBT-type approaches, and for schools to be the key therapeutic setting for the treatment of post traumatic stress disorder following natural disasters.
The second set of papers focuses on the role of risk factors in relation to the development of psychopathology. In each case the focus is on the issue of factors that mediate and/or moderate the links between risk and disorder. In this way, each paper provides new insights and opens up a number of therapeutically relevant avenues of future study. In the first of these papers Christine Eiser and colleagues highlight the role that parental attitudes and behaviour might play in the adjustment of children at risk through prematurity – especially in relation to a frame of cognitive reference that regards the promotion of developmental goals rather than the prevention of harm as the basis for parenting. Uberto Gatti and colleagues examine the role of gang membership in the emergence and maintenance of delinquency and drug use, concluding that by limiting gang membership one can go some way in reducing levels of antisocial behaviour. In the next paper, Mona El-Sheikh highlights the role of children's physiological reactivity to conflict in the link between exposure to marital conflict and development and adjustment. In the final paper, data from the large-scale Developmental Trends study are used by Burke and colleagues to highlight the multiple pathways between different developmental psychopathologies (ADHD, ODD, CD, anxiety and depression) presented by children (between 7 and 12) and adolescents (18 years). While, as expected, the authors report strong elements of homotypic continuity for each disorder (one disorder in childhood predicting the same disorder later in life), there was also a consistent and meaningful pattern of hetrotypic continuity (one disorder leading to other disorders): ADHD was predicted by no other disorder but exclusively predicted ODD. ODD predicted CD – while ODD predicted anxiety and depression.
The final set of papers each relate to the condition of attention deficit/hyperactivity disorder (ADHD). The issue of whether children with a diagnosis of ADHD, who by definition display behavioural symptoms of poor attention, actually have a deficit in attention when this is measured against performance on objective laboratory tasks has been central to debates about the nature of the core neuropsychological deficit in ADHD. This issue is tackled in different, equally sophisticated, ways in these papers. First, building on recent developments in the basic science of selective attention, Huang-Pollock, Nigg, and Carr report that neither ADHD combined type nor ADHD predominantly inattentive type displayed a selective attention deficit. However, a subset of the inattentive type, identified as having sluggish cognitive tempo, did display abnormalities in early processes. Olga Berwid and colleagues, studying a group of younger children at risk from ADHD, found only small effects in relation to ADHD. These effects they saw as being most likely attributable to generalised response disorganisation or poor state regulation rather than a specific dysfunction in attentional processes. Finally, the paper by Dobler and colleagues refines the notion of attention deficits by linking two phenomena that have been associated with ADHD: left-side attentional neglect and sustained attention. In finding a generalised link between left-sided visual neglect and sustained attention deficits rather than one restricted to ADHD, these authors cast further doubt on the specific role of sustained attention deficits as a primary mediator of this condition. Each of these papers helps in further refining our understanding of attentional deficits in ADHD. They can also be seen as part of a larger, more wide-ranging, ongoing debate about the fundamental nature of ADHD. On one side of this debate we find those who advocate the idea that ADHD results from a core deficit in some underlying neuropsychological process (e.g., selective attention or inhibition) which is common to all children with the condition. On the other side, there are those who have abandoned this search for a core deficit, convinced by the recent evidence that ADHD is not a unitary construct but rather a heterogeneous expression of multiple, more or less distinct but almost certainly overlapping, neuropsychological processes. Implicit in this latter position is that different children with ADHD will have different patterns of underlying pathophysiology. The shift towards this latter position by many in the field bears many of the hallmarks of a classic paradigm shift in the study of ADHD as one model of the fundamental character of the disorder is first challenged and then eventually superseded by another. We are only at the very start of working through the implications for clinical practice of such a shift in scientific perspectives, although in terms of taxonomy, diagnosis and treatment they may be considerable.