Editorial: beyond diagnosis - taking a 'global' view of research and practice.

There is growing emphasis on multidisciplinary approaches to psychopathology; nevertheless, it is easy to remain blinkered in how we think about maladaptive behaviour. Such conservatism affects the research questions we ask and also the impact of our research on practice. Two papers in the present issue drive this issue home hard: the first highlights a worrying discrepancy between the educational support given to children with a diagnosis of autism spectrum disorder (ASD) and that given to children with equally severe difficulties who are not ‘diagnosed’; the second suggests that physical aggression at an early age is predictive of entry to the criminal justice system but also intimates that physical aggression might itself be the outcome of hidden (and hence undiagnosed) difficulties. In stark contrast, a study in a developing country (Kenya) reports on efforts to identify developmental difficulties at a very early stage. The Avon Longitudinal Study of Parents and Children (ALSPAC) is a longitudinal cohort study of more than 14.000 children. Russell, Ford, Steer, and Golding present a secondary analysis of ALSPAC data assessing the prevalence of ASD in a population representative of the UK. According to medical records, there are 71 cases of children with diagnosed autism spectrum disorder in the ALSPAC cohort, a prevalence of 5 per 1000. ALSPAC includes an array of parent report measures relevant to the assessment of behaviours characterising the autistic triad (social and communication impairments and repetitive behaviours). The authors began by using these data to predict which behavioural traits were associated with a diagnosis of ASD in two sub-groups: classic or atypical autism (diagnosed between 2 and 4 years) and Asperger syndrome (AS) or atypical autism (diagnosed at 5–11 years). Once the predictive traits were established, these were pooled to give composite ‘autism’ traits (weighted with three impairments of social behaviour, two communication impairments and two repetitive behaviours (excluding language delay for AS)). Scores on the composite traits were converted into centile scores across the population: the children with an autism diagnosis scored within the top2% for the autismcomposite and thosewith an AS diagnosis within the top 5% of the AS composite trait. A salutary finding was that there were many undiagnosed children in the population at the same level of severity as those with diagnoses (according to parent ratings). Therewere 135 children in the top 2% of the autism composite, and there were 287 children in the top 5% of the AS composite – in total only 71 of these children had a clinical diagnosis. ALSPAC also contains pupil data from a Schools Census, including a measure of whether children access support services. Relating these data to the above findings raises further cause for concern. Although all pupils with a diagnosis of autism and 89% of those with AS had a Statement of Special Education Needs, the ‘undiagnosed’ children with similarly severe behavioural difficulties were much less likely to be identified as needing special provision in school. Indeed only about half of the ‘undiagnosed’ children were in receipt of educational support; furthermore this was primarily for difficulties with learning and cognition rather than for social or communication difficulties. Russell and colleagues provide vignettes of the typical ‘undiagnosed’ child. For autism ‘an asocial mostly non-verbal child who does not indulge in pretend play, is afraid of unfamiliar things and exhibits repetitive behaviours’. For Asperger Syndrome, ‘a child who lacks social skills and empathy, has difficulty in conversation and often repeats actions that have no obvious function’. If the needs of children such as these are apparently hidden to the professionals who work with them, what chance for children with less pervasive difficulties, such as specific language impairment or dyslexia? According to recent data collected by our group, some 7.6% of children in a nationally representative sample of 1200 children enter secondary school with a reading age below 8 years; yet only 15% of these very poor readers have a Statement of Special Educational Needs. If schools are failing to meet the needs of pupils with developmental disorders of language, learning and communication, it is perhaps unsurprising that such difficulties are common among children who are excluded from school or who number among young offenders (Skuse, 2009). Children whose needs are not met well by school systems often become unhappy, disengaged and ultimately disaffected, though it can be difficult to unravel causal connections. Vazsonyi and Chen report findings on the age of entry into the criminal justice system for a large sample of American youth followed between the ages of 8 and 18. Each individual in the sample had been rated for aggressive behaviours by teachers during the early school years and official records provided data concerning individuals who had A salutary finding was that there were many undiagnosed children . at the same level of severity as those with diagnoses Journal of Child Psychology and Psychiatry 51:6 (2010), pp 641–642 doi:10.1111/j.1469-7610.2010. 02264.x