European Child & Adolescent Psychiatry
8:225±236 (1999) Ó Steinkop€ Verlag 1999
M. Frisk
Accepted: 28 January 1999
M. Frisk
Department of Child
and Adolescent Psychiatry
University Hospital
SE 750 17 Uppsala
Sweden
ORIGINAL CONTRIBUTION
A complex background in children and
adolescents with psychiatric disorders:
Developmental delay, dyslexia, heredity,
slow cognitive processing and adverse
social factors in a multifactorial entirety
Abstract A consecutive cohort of
112 children, 42 girls and 70 boys,
aged 5±17 years, receiving child
psychiatric inpatient care, was investigated regarding the probability
of a complex background of concomitant biological and social factors. Most of the subjects showed
maladjustment and depressive states,
school problems, problems with
peers, psychosomatic complaints
and anxiety. A very high rate of
factors indicating neurodevelopmental dysfunctions was found particularly in boys, who exhibited
developmental delay, dyslexia, heredity for dyslexia, and a slow complex reaction time (CRT) ±
suggesting slow cognitive processing
± considered an impairment in itself.
Further, many children obtained
errors on the CRT task, indicating
attention de®cit and deterioration
Introduction
Di€erent central nervous disorders and dysfunctions, as
well as adverse social factors, have received much
attention in the etiology of psychiatric problems in
childhood and adolescence. According to Suarez et al.
(47), the child must be seen as a product of a complex
sequence of events, which may depend on a person's
genotype, and on the environment in which the genotype
grows.
Among biological factors in children with psychiatric problems, Hellgren et al. (26, 27) concluded that
de®cits in attention, motor control and perception,
(DAMP), are related to a poor prognosis. In adoles-
during the test, pointing toward
exhaustion. The social background
displayed frequent problems such as
broken homes, care outside the biological home, and disordered and/or
abusing parents. The biological and
social factors created a complex web,
predisposing the child to primary,
secondary and/or comorbidity
problems, and leading to an interactive process reducing the child's
psychosocial capacity and competence. A pattern was developed of an
impaired child, living in an inadequate/insucient family milieu
in a modern society, with increasing
demands on children.
Key words Developmental delay ±
dyslexia ± heredity ± slow cognitive
processing ± exhaustion ± reaction
time aberrations ± adverse family
conditions
cents with psychosocial problems, Frisk et al. (16)
found a complex biological etiology including dyslexia,
heredity and developmental delay. McGee et al. (34)
reported that children with learning disabilities showed
early hyperactivity and poor language skills, and Bax
et al. (3) found that among children with abnormal
neurodevelopmental scoring at school entry there were
higher rates of learning diculties. Baker et al. (2)
reported that speech and language factors could
di€erentiate between emotionally disturbed and control
children. Further, Lerner et al. (32) and Cantwell et al.
(6) concluded that children with speech and language
problems are at risk of developing future psychiatric
disorders.
226
European Child & Adolescent Psychiatry, Vol. 8, No. 3 (1999)
Ó Steinkop€ Verlag 1999
Developmental delay as a background factor, including one or more of the following problems, prolonged
nocturnal enuresis (28), dysmature EEG (29), minimal
brain dysfunction (41), and retarded cognitive development and skeletal age (21), has also received special
attention. Frisk et al. (15) showed that developmental
delay, which was more pronounced among boys, was
common in adolescents with psychosocial problems. In
contrast, early maturity could be a stress factor in some
girls but a protective factor in boys. Gordon et al. (23)
found that children with developmental delay were more
unhappy than their peers and Wol€ (53) observed that
these children were characterized by solitariness, unusual fantasies and special interests. Edelsohn et al. (9) and
Frisk (13, 14) found that developmental delay could
underlie problems such as poor attention and concentration and poor peer relationships.
Reaction time aberrations have also been found to be
related to psychiatric problems (35). Mitchell et al. (36)
noted a prolonged reaction time in hyperactive children.
The impact of poor cognitive functions has been stressed
by Kohen-Raz (30). According to Welford (50), however, a slow reaction time has seldom been considered in
relation to developmental delay. In 260 ordinary school
children in whom a slow complex reaction time (CRT)
was noted at the age of 7 years, Frisk (12) observed early
retardation of motor and language development, often
together with depression, peer problems and low selfcon®dence. Children with early slow CRT, compared
with those with a fast CRT, left school with poor marks
in Swedish, their native language, and many of the boys
also with poor marks in gymnastics and sports as signs
of persistently poor motoricity; further, in these boys
there was a complex background including retarded
language development, poor motoricity and concentration, dyslexia, developmental delay and emotional and
adjustment problems (13). Many of the children with
slow CRT had been in child psychiatric care during
childhood and adolescence, in contrast to the children
with early-fast or normal-fast CRT (14).
In other studies, in which the Frisk CRT method was
used on children with perceptual, motor and attention
de®cits (DAMP), Gillberg et al. (18) found that children
with DAMP displayed an early prolonged CRT compared with normal children. Gillberg IC (19, 20) reported
that this ®nding persisted at the ages of 10 and 13 years,
and Hellgren et al. (26) noted that the boys still showed
prolongation at the age of 15 years. Diculties in the
home and in the social situation have found to be notable
background factors in children with psychiatric problems. Cass et al. (8) reported that early loss of parents and
broken homes were common features in the most
disturbed group of children showing poor relationships.
In light of the above observations it was considered
of interest to make a further study of possible concomitant CNS dysfunctions, including developmental delay,
dyslexia, heredity for dyslexia, CRT aberrations such as
a slow CRT including slow cognitive processing, errors
at the CRT test as signs of attention de®cit, and
exhaustion as a sign of tiring; and also of adverse social
factors such as problems at home, care outside the
biological home, and ill and/or abusing parents, representing a possible multifactorial and complex entirety.
Methods
Subjects
Of a consecutive cohort of 163 patients admitted to a
child psychiatric inpatient unit for investigation and
care, the ®ndings regarding 42 girls and 70 boys are
presented (Table 1). These children, all of normal
intelligence, were referred by child psychiatric outpatient
units, school health services, or child welfare or social
services in the region. A dropout of 51 children was
mainly due to shortcomings in carrying out the total
programme of examinations, and a few children refused
to cooperate. The dropout group did not, however,
di€er from the presented cohort regarding type of
psychosocial problems, special education at school,
early developmental delay, heredity for dyslexia, EEG
®ndings or noted parental ill-health or abuse. The
presented results may, thus, be regarded as representative for the total cohort.
Measures
An extended clinical examination was performed by a
child psychiatric team including child psychiatrists,
psychologists, social workers and special teachers.
Information regarding the early psychophysical development, and problems at school and/or at home, was
provided by the parents, the patients themselves, and/or
by the school or other authorities in contact with the
child and the family.
The child was recorded as having early developmental delay if she or he had shown nocturnal enuresis after
the age of ®ve years and/or retarded motor and language
development, e.g. if the child did not walk before 18
months of age and did not speak words until after the
age of 24 months and sentences until after 36 months.
Risk for CNS damage included previous head injury
with loss of consciousness, meningitis, early convulsions
and prematurity by >4 weeks.
The diagnosis of dyslexia was based on the occurrence of speci®c reading and writing problems ± noted in
special reading and writing tests ± ful®lling the criteria of
the DSM-IV. Heredity for dyslexia implied known
reading and writing diculties in some member of the
family. Slow writing and problems in physical education
6
±
±
6
5
2
6
0
4
3
3
3
5
±
±
0
0
0
0
0
0
0
0
0
0
12±14 years
15±17 years
Maladjustment
Depressed mood
Psychosomatic problems
Anxiety
Psychotic state
Early hyperactivity
Dyslexia
Early and/or current dev. delay
Slow CRT
Problems at home
5±6 years
±
12±14 years
7±11 years
7
8
8
3
3
3
4
9
16
15
±
18
15±17 years
25
10
7
9
6
7
6
6
9
17
18
18
11
±
Maladjustment
22
18
20
12
14
8
14
18
36
39
64
10
24
29
Depressed mood
±
19
16
19
10
13
8
14
18
38
49
47
10
19
19
Psychosomatic problems
0
33
10
7
10
4
6
4
7
20
19
18
18
5
5
8
Anxiety
10
7
6
3
6
1
16
16
9
12
16
3
7
5
1
6
6
5
4
2
9
8
2
2
7
7
4
3
1
0
Psychotic state
1
8
8
10
9
14
35
2
7
11
28
32
3
12
19
1
Early hyperactivity
1
7
7
9
12
42
26
5
10
13
31
39
7
16
19
0
Dyslexia
1
11
10
20
58
39
31
7
15
18
39
53
10
21
26
1
Early and/or current dev. delay
±
8
18
42
39
29
24
4
11
14
32
39
6
19
17
0
Slow CRT
5±6 years
±
±
22
48
31
40
26
26
5
8
10
34
45
4
21
22
1
Problems at home
Girls (n = 42)
±
7±11 years
1
Table 1 Age, sex, and current symptoms related to noted background factors and early hyperactivity
Problems at home
Slow CRT
Early and /or current dev. delay
Dyslexia
Early hyperactivity
Psychotic state
Anxiety
Psychosomatic problems
Depressed mood
Maladjustment
15±17 years
12±14 years
7±11 years
5±6 years
Boys …n ˆ 70†
M. Frisk
A complex background in children and adolescents with psychiatric disorders
227
228
European Child & Adolescent Psychiatry, Vol. 8, No. 3 (1999)
Ó Steinkop€ Verlag 1999
involved disability of the child to perform and cooperate at school at the expected age related level.
EEG ®ndings at rest and during activation with
hyperventilation and photic stimulation, read by a
neurophysiologist, were reported as dysmature if there
was slow alpha/theta activity for age (10). Any paroxysmal/epileptic EEG activity was noted. Skeletal age as
described by Greulich et al. (24) was determined as
retarded if it was >12 months late for age. The reaction
time aberrations were noted by a visually evoked choice
reaction time method, CRT, based on a speci®c
programme designed by this author. Four coloured
squares measuring 5 ´ 5 cm placed two by two in a
quadrangle, and below them four knobs 2 ´ 2 cm whose
colour and placement correspond to the signals, represent the board. During a 20-min test 145 signals are lit
up for 0.25 s each, according to a randomly selected
programme including a maximal response time of 2.4 s
followed by an interval of 4.75, 7.5 or 10.75 s, also
randomly selected. The CRT means, errors and omissions are compared with those found by Frisk (12, 13,
14) in ordinary schoolchildren in the region representing
a control group of the same age and sex. In normal
children the mean CRT (presented in Fig. 1) becomes
faster with age. Also, there are considerable di€erences
in each age group between the fast and slow CRT
children. The children with a fast CRT (0±25%)
comprise the quartile of the fastest and those with a
slow CRT (75±100%) the quartile of the slowest
children. Children outside the 85th percentile are
designated extra-slow (X-slow). The two intermediate
quartiles are noted as normal-fast (25±50%) and normal-slow (50±75%) respectively.
Slow cognitive processing, included in the slow CRT,
was given special attention, since according to Welford
(51), the cognitive processing, i.e. the central decision
time, is the longest part of a choice reaction time. The
possibility that the slow CRT could be caused by mental
retardation was excluded, since the children in the
cohort were of normal intelligence. According to
Nettelbeck (38) an impact on reaction time is found
only when a wide range of measured intelligence is
involved. Social problems as an underlying cause of the
slow CRT seemed to be excluded, since Frisk (12) found
that deviant family factors were equally often present in
di€erent CRT-quartiles in normal children at the age of
7 years and Welford (51) reported that ``RT appears to
be relatively independent of sociocultural in¯uences''.
A recording of many errors in CRT was made if more
errors were found compared with ordinary children at 10
years of age, among whom fast CRT boys made seven or
more and fast CRT girls two or more errors (i.e.
mean + 1 SD) during the test; in contrast, all normal
children with a slow CRT made very few errors.
Omissions, which were very rare in the control group,
were noted if there were more than ®ve nonresponses
during the test. A signi®cant prolongation of CRT/min
during the 20-min test is interpreted as exhaustion, i.e.
an extreme tiring.
Social risk factors noted were broken homes, longlasting physical or mental illness in the parents, alcohol
abuse by the parents and long periods of the child
staying in foster homes or institutions.
Statistical methods
The nonparametric Chi-square test with Yates' correction was used for comparisons. For testing the relationships of CRT means/min, a regression analysis was
performed.
Results
Age distribution
The age distribution of the children (Table 1) showed
that most of the 42 girls were in early or middle
adolescence. Of the 70 boys, who on average were
younger than the girls, most were in pre- or early
puberty, and only 11 in middle adolescence.
Symptoms
The dominating current symptoms (Table 1) were
maladjustment, displayed as truancy, aggressive behaviour and/or petty thefts, and a depressive mood, which
were noted concomitantly in 36 girls and 47 boys.
Maladjustment as a single symptom was seen in some
young boys. Some children, mostly girls, showed
psychosomatic symptoms and anxiety. Psychotic symptoms were observed in nine girls, four with depression,
two with anorexia, and the others with borderline,
organic or reactive psychoses. Eight boys exhibited
psychotic traits, four with depression, the others as
organic psychoses, one of them with temporal epilepsy.
Most psychotic children displayed concomitant maladjustment and depression.
Early hyperactivity had characterized one third of the
girls and half of the boys (Table 1). This early symptomatology was often seen in children with current
maladjustment, depression and school problems. In
their background, developmental delay, dyslexia, a slow
CRT and problems at home were common.
School problems
School problems were common (Table 2). Special education, dyslexia, diculties in physical education and
problems with peers were frequent ®ndings. Girls and
boys di€ered, however, in some respects, the boys
M. Frisk
A complex background in children and adolescents with psychiatric disorders
229
Fig. 1 CRT related to di€erent
background factors compared
with ordinary children
showing higher frequencies of dyslexia (p < 0.001),
slow writing (p < 0.01) and diculties in gymnastics
(p < 0.05). In the background, early hyperactivity and
concomitant biological and social problems were notable. Developmental delay, dyslexia and a slow CRT were
frequent ®ndings, while in contrast a fast CRT was seen
only in some boys, showing many errors at the test.
Frequent adverse social ®ndings correlated to the school
problems were problems at home, care outside the
biological home and broken home; these were especially
often seen in the boys.
Background factors
The background factors made up a complex entirety,
including early and/or current developmental delay,
problems at home, dyslexia, heredity for dyslexia and
CNS risk for brain damage
Heredity for dyslexia
5
3
4
3
4
7
5
0
2
1
0
2
2
1
1
0
0
1
0
0
8
Non-dyslexia
Hyperactivity
Slow writing
Probl. physical education
Special education
Problems with peers
Retarded bone age
Dysmature EEG
Paroxysmal EEG
Dysmature and parox. EEG
Care outside biol. home
Broken home
III mother
III father
Alcohol abuse mother
Alcohol abuse father
Errors in CRT
CRT 0±25
CRT 50±75
CRT 75±100
Early devel. delay
Dyslexia
2
0
1
0
0
0
1
1
2
0
0
2
0
0
2
2
1
1
1
0
3
Dyslexia
0
Non-dyslexia
3
Hyperactivity
0
Slow writing
2
Special education
Early devel. delay
Probl. physical education
CNS risk for brain damage
Problems with peers
8
Retarded bone age
Heredity for dyslexia
Dysmature EEG
2
7
3
7
12
4
4
9
2
5
30
9
8
1
2
3
1
3
4
5
9
2
3
4
2
7
3
2
0
1
0
2
3
5
3
2
3
3
0
13 6
9
5
4
14
2
2
2
1
1
1
2
2
1
4
5
11 8
12 4
2
5
4
2
3
5
8
11 7
0
2
6
3
21 9
11 10 6
8
6
10 9
7
8
15 6
4
2
0
1
0
0
1
1
1
3
1
2
0
1
3
5
4
6
12 19 5
8
4
0
3
2
0
2
1
6
4
0
1
2
2
9
6
13
7
7
7
4
7
4
6
8
4
7
0
0
1
3
0
1
0
0
0
0
10 1
2
4
3
2
4
7
10 0
10 2
1
3
5
2
27
1
5
4
0
0
1
0
2
1
3
1
±
±
9
±
5
1
3
1
0
1
1
1
2
2
2
±
5
1
0
1
0
0
0
0
1
0
1
2
6
3
12 9
2
4
11 12 9
9
10 7
9
5
7
1
4
2
5
5
1
3
3
2
1
3
0
14
7
5
2
7
6
5
6
2
1
2
0
2
3
13
5
3
2
2
5
3
2
4
2
0
3
2
3
8
6
1
5
0
0
2
1
5
4
2
3
4
5
2
5
1
2
2
2
0
1
3
0
5
1
1
0
0
1
2
7
13 3
22 8
28 8
19 2
6
5
9
7
16 22 16 8
13 20 14 5
4
4
10 15 11 7
7
12 17 10 4
15 19 17 9
4
9
11 2
12 ±
19 ±
15 3
54 10 12 11 9
11 13 2
3
1
1
1
0
2
2
4
5
2
2
4
1
8
16
44 38 10 10 10 7
23 17 20 5
22 9
9
11 3
8
35 12 17 25 30 10 8
7
26 15 16 36 39 9
28 9
42 ±
10 ±
9
19
52 35 17 29 17 20 35 44 11 14 11 6
2
4
Paroxysmal EEG
1
Dysmature and parox. EEG
9
Care outside biol. home
9
Broken home
6
III mother
6
III father
9
Alcohol abuse mother
19 12 14 28 27 7
2
0
10 1
7
1
0
17 4
8
5
13 4
9
15 4
8
9
3
2
8
6
2
2
0
4
0
1
5
3
2
2
5
3
4
1
1
4
1
1
1
1
5
±
±
4
11 CNS risk for brain damage
22 Heredity for dyslexia
Boys …No 70†
18 Probl. physical education
19 Slow writing
24 Hyperactivity
13 Non-dyslexia
29 Dyslexia
3
4
2
3
4
6
4
1
2
3
2
9
±
Alcohol abuse father
Alcohol abuse mother
III father
±
18
42 CRT 75±100
CRT 50±75
CRT 0±25
10 Errors in CRT
8
3
7
13 III mother
13 ±
15
Care outside biol. home
Dysmature and parox. EEG
Paroxysmal EEG
19 Broken home
9
9
9
10 Dysmature EEG
12 Retarded bone age
35 Problems with peers
10 29 Special education
4
2
7
5
8
10 34 Early devel. delay
0
6
11 ±
24 9
15 4
6
6
10 7
6
9
3
0
4
2
11 19 8
8
4
5
9
8
7
11 18 6
3
5
Alcohol abuse father
10 1
Errors in CRT
26 29 1
CRT 0±25
11 9
CRT 50±75
30 9
CRT 75±100
Girls (No 42)
Table 2 Concomitant factors in the background of children with psychiatric problems
230
European Child & Adolescent Psychiatry, Vol. 8, No. 3 (1999)
Ó Steinkop€ Verlag 1999
M. Frisk
A complex background in children and adolescents with psychiatric disorders
CRT aberrations (Tables 1 and 2). Early and/or current
developmental delay (Table 1) was noted in a total of 20
girls and 58 boys (p < 0.001). The children with
developmental delay had been in need of special
education. Many of the boys also exhibited slow writing,
poor motoricity at gymnastics and problems with peers
at school.These children (Table 2) often showed early
hyperactivity, dyslexia, heredity for dyslexia, a slow
CRT and social problems seen as care outside the
biological home; among the boys there was also a high
frequency of broken homes, ill parents and alcohol
abuse by the fathers. A current dysmature EEG, a
retarded bone age and a slow CRT, which were more
often seen in the boys, were current signs of persistent
developmental delay at the time of inpatient care.
Dyslexia was signi®cantly more frequent in the boys
(12 girls and 42 boys; p < 0.001) (Tables 1 and 2). A
heredity factor was common. Most children with
dyslexia had displayed early hyperactivity and early
developmental delay. Signs of a persisting developmental delay were especially noted among the boys as a
dysmature EEG and delayed bone age. Risk factors for
CNS damage and paroxysmality at EEG were also seen.
The girls and boys with dyslexia had as groups very slow
CRT compared with ordinary children, with slower
values than the children without dyslexia in the cohort
(Fig. 2); in dyslectic children a fast CRT was rare. Many
errors in the CRT were noted among the dyslectic boys
(Table 2) and most children with dyslexia showed
signi®cant tiring (Fig. 2). Broken homes and care
outside the biological home were frequent concomitant
®ndings and also, especially in the boys, an ill mother
and alcohol abuse by the father.
Heredity for dyslexia was noted in the families of
eight girls and 30 boys (Table 2). Of the children in these
families ®ve girls and 29 boys had current dyslexia. Need
for special education, early hyperactivity and in the boys
a history of early developmental delay, as well as a slow
CRT, were common concomitant ®ndings. Among the
boys with heredity for dyslexia, problems at home were
especially frequent.
A slow CRT including slow cognitive processing was
noted in 18 girls and 42 boys (Tables 1 and 2), of whom
17 girls and 31 boys had X-slow CRT (Fig. 1). The
young boys as a group had a mean CRT about 1.5 years
slower than that of the normal children of the same sex
and age, and the adolescent girls and boys about 3 years
slower (Figs. 1 and 2), but there were great individual
di€erences (Fig. 1). Early hyperactivity and school
problems had been common (Table 2), with need for
special education. Many were slow writers and had
problems in physical education as well as with peers.
Frequent biological ®ndings concomitant with the slow
CRT were developmental delay (Tables 1 and 2) and
dyslexia, which were also noted in some girls with a
normal-slow CRT. In two girls and 11 boys risk factors
231
for brain damage were noted. Problems at home were
most common among the girls. In the girls this was
associated with care outside the biological home, and in
the boys a broken home, care outside the biological
home, an ill mother or father and a father with alcohol
abuse.
A fast CRT was rare (Table 2), and in most cases this
was associated with many errors at the CRT test. Errors
at the test were made by only ®ve girls, distributed
among di€erent CRT-quartiles (Table 2). These girls
often received special education and had problems with
peers. Of the 24 boys with numerous errors, nine had a
fast, and ten a slow CRT; eight of these ten were X-slow.
Early developmental delay, early hyperactivity and
dyslexia were other ®ndings concomitant with a fast
CRT and many of these children had been placed in care
outside their biological home; broken homes and an ill
mother were other frequent ®ndings.
An observation of many omissions was made in only
four girls, three of whom had an X-slow CRT; of these
three, one also made many errors. Of the 11 boys with
omissions, eight had a slow CRT, seven of them X-slow,
and only two had a fast CRT, with many errors.
Dyslexia and developmental delay were common signs
concomitant with omissions.
Exhaustion during the CRT test, i.e. poor persistence
and tiring (Fig. 2) was most pronounced in children with
dyslexia, but this characteristic was also noted in boys,
though not in girls, without dyslexia.
Problems at home (Tables 1 and 2) were noted in 22
girls of whom 14 had been in care outside the biological
home and 13 had a broken home. In many of these
families ill parents and alcohol abuse by the father were
notable. Of the 48 boys with problems at home, 28 had
broken homes and 19 had been in care outside the
biological home. Of their parents, there were 22 ill and
seven abusing mothers and 13 ill and 15 abusing fathers.
Concomitant ®ndings in these children were early
hyperactivity, developmental delay, dyslexia and a slow
CRT.
Discussion
The aim of this study was to investigate the occurrence
of a presumed complex background of adverse biological and social factors among children of normal
intelligence seen in a child psychiatric clinic. The clinical
®ndings reported could be considered to be of good
reliability, but in view of the risk of denial or diculties
in recalling the facts concerning the early psychophysical
development of the child, these ®ndings must be
regarded as approximate data.
There were pronounced sex di€erences in the cohort.
The boys were more numerous and as a group younger
than the girls, pointing towards greater and striking
232
European Child & Adolescent Psychiatry, Vol. 8, No. 3 (1999)
Ó Steinkop€ Verlag 1999
Fig. 2 Tiring in children with
and without dyslexia
problems occurring at an earlier age in boys. The most
common and pronounced current symptoms were
maladjustment and a depressive mood, which very
often occurred simultaneously in girls, but also in boys.
This concomitance has also been reported by McGee
et al. (33). Psychosomatic complaints and anxiety,
more common in adolescent girls, were other current
symptoms. A few children also showed psychotic
behaviour.
Early problems manifested as early hyperactivity and
early developmental delay were common in these
children. Later problems at school were frequent. A
need for special education and, among the boys,
diculties and problems in sports and gymnastics were
notable signs. Problems with peers and mobbing were
also common. The problems at school and with peers
can either be primary or secondary to the problems
noted in the background.
In the background there was complex and multifactorial loading of biological and social risk factors.
Some kinds of CNS dysfunctions were noted in 64% of
the girls and 90% of the boys, and problems at home
in 50% of the girls and 60% of the boys. Most
common background problems were, in order of
frequency, in the girls problems at home, developmental delay, a slow CRT and dyslexia, and in the boys
developmental delay, problems at home, a slow CRT
and dyslexia.
A striking biological ®nding was the frequent occurrence of early and/or current developmental delay,
which was seen in about half of the girls, and twothirds of the boys, in most of them as early signs. Most
prominent current signs were a dysmature EEG and a
retarded boneage, notable ®ndings especially in the
boys, and a slow CRT. The lower rates of current
®ndings of delay among the girls may be a consequence
of their generally earlier physical maturation, as noted
by Noble et al. (40), and their higher age. The children
with developmental delay often displayed maladjustment and a depressive mood, signs that were also
observed in teenage boys by Frisk et al. (15) and in
young boys with severe criminality by Adler et al. (1).
A maturational lag in the frontal lobe system of the
brain noted by Ponitus et al. (44) in young delinquents
strengthens the possibility of an impact of a developmental delay on the psychosocial capability. The
developmental delay may in some children constitute a
long-standing handicap during childhood and adolescence and can be considered an important risk factor,
especially in the boys.
Dyslexia, a handicap noted in 29% of the girls and
60% of the boys, was strongly over represented as
compared with the generally accepted prevalence rates
of 5±10% (43). The occurrence of fewer girls may be
related to their more advanced age, but also to a ®nding
by Frisk et al. (17), that girls showed more subtle writing
problems. The children with dyslexia had often shown
early hyperactivity. Of the concomitant ®ndings delayed
development, heredity for dyslexia and family problems
were common. Many of these children had slow CRT,
several of them X-slow. Some boys, however, showed a
fast CRT including many mistakes. Further, exhaustion,
manifested as poor persistence, observed at the CRT test
was a striking concomitant sign. The children with
dyslexia seemed to be loaded with a complex of CNS
dysfunctions including speci®c and comorbidity signs.
M. Frisk
A complex background in children and adolescents with psychiatric disorders
Dyslexia must, thus, be considered an important distressing and real handicap to the child, causing problems
at school, in the family and in the society of today, with
a risk for serious psychosocial consequences. These
®ndings are in agreement with the conclusion drawn by
Esser et al. (11) that prior learning disabilities and
stressful life events are important factors underlying
psychiatric disorders in schoolage children.Worthy of
special attention was the frequent concomitance of
dyslexia and developmental delay, a concomitance noted
by Frisk et al. (16) with equal frequency in adolescent
girls and boys among whom persisting signs of dysmaturity were found in more than 50%. In accordance with
these observations, Morrison et al. (37) reported that
children with developmental delay often displayed
reading failure at school, and Beitchman et al. (4)
concluded that neurodevelopmental immaturity is a
common underlying antecedent of both linguistic impairment and psychiatric disorders. The very common
concomitant slow CRT, representing slow cognitive
processing, must be seen as an important comorbidity
sign. The developmental delay associated with dyslexia
might constitute a heavy handicap. In some children the
delay may be the main reason for their reading and
writing problems, but in most of them it must be seen as
a comorbidity factor that may aggravate a dyslexia of
genetic or other etiology.
Heredity for dyslexia, which was found in about twothirds of adolescent girls and boys with dyslexia by Frisk
et al. (17) was common. Findings of developmental delay,
current dyslexia and depression concomitant with the
hereditary factor raise the question as to whether in some
children there might be a genetic factor in common. Many
observations strengthen this assumption. Harjan (25)
found that children of parents with a€ective disorders
signi®cantly more often showed delayed psychomotor
development than those of control parents. Rodger (45)
reported that such children often had early enuresis,
speech problems, and Weissman et al. (49) noted that
there was an increased prevalence of depression and
school problems among children of depressed parents.
Moreover, Graham et al. (22) have stressed the importance of genetic factors in the development of behavioural
deviance, especially in boys, and McGee et al. (33)
underlined the relation between depression and antisocial
behaviour in boys. The hypothesis of a possible connection between developmental delay, dyslexia and depression related to chromosome 6 must be considered, since
Cardon et al. (7) found that this chromosome was
involved in reading disability, Pandya et al. (42) in
developmental delay, and Lappalainen et al. (31) in
abnormal brain serotonin function. The heredity in the
complex background might be seen mainly as the cause of
the dyslexia, but also of other problems of the child, and
as a factor that may have been or still is a problem and a
cause of stress also in the family.
233
In the cohort, however, there were also children with
other signs of CNS dysfunction but without current
dyslexia. Some of these girls had shown early developmental delay and displayed a current dysmature EEG
and/or a slow or normal-slow CRT. Some of them had
received special education. Some of the boys also had a
history of developmental delay and heredity for dyslexia
and showed a current dysmature EEG and a slow CRT.
Thus, it seemed possible that some children might have
had earlier reading and writing problems that had
disappeared as a result of adequate training and/or
through a CNS-maturing process, a change also observed in normal children by Frisk (13).
The possibility of brain damage related to observed
CNS dysfunctions must, however be considered. Risk
factors for brain damage were, in particular, noted in
many boys, and in some of them connected with early
developmental delay, dyslexia and heredity for dyslexia
suggesting a possible combination of a constitutional
and an acquired factor in the background of some
children with dyslexia and/or DAMP.
A slow reaction time as a sign of CNS dysfunction
was a striking ®nding and was seen in 43% of the girls
and 60% of the boys; it was noted as X-slow in 38% of
the girls and 54% of the boys, most often in
association with developmental delay, dyslexia and/or
brain damage. Omissions as a sign of a very slow
reaction or a failure to react were also common in the
slow-CRT group and most common in children with
dyslexia or with concomitant dyslexia and developmental delay.
The slow cognitive processing included in the slow
CRT must, thus, be considered as an important
comorbidity problem with impact on the cognitive and
performance speed, causing, for example, slow reading
and writing. Similarly, Nicolson et al. (39) reported that
children with dyslexia showed impairment at an auditive
test, re¯ecting a slower stimulus classi®cation speed.
Byring et al. (5) found that poor spellers showed slow
CNS processing observed as a long auditory evoked
potential latency in the EEG, and Tallal et al. (48)
concluded that temporal processing de®cits which
interfere with the resolution of rapidly presented brief
duration stimuli result in disordered language development. The slow cognitive processing must be seen as a
real handicap per se in the society of today, with rapid
information and demands for fast cognitive abilities and
performance. Furthermore, slow cognitive processing
may make the child prone to shortcomings and limit her
or his possibilities of coping with rapid perceptions,
resulting in a confusing reality, mental chaos and
blocking due to diculties in correctly perceiving and
understanding signals from the inner self or from the
outer world, leading to maladjustment and depression.
The ®ndings of many errors at the CRT test,
especially in boys, could be seen as signs of an attention
234
European Child & Adolescent Psychiatry, Vol. 8, No. 3 (1999)
Ó Steinkop€ Verlag 1999
de®cit. Numerous errors were seen in many children
with early developmental delay and dyslexia, and also
among those with broken homes, care outside the
biological home and an ill mother. These children had
often displayed hyperactivity, and needed special education at school. Contrary to the ®ndings in ordinary
children, many children with a slow CRT made numerous errors, indicating an attention de®cit. Some fast
CRT boys also made many errors as a sign of attention
de®cit, but in others there seemed to be a sensation
seeking, a disinhibition, a strategy to compensate for or
to hide a conscious slowness resulting in errors and a
secondary false fast CRT. The boys with a fast CRT and
numerous errors were often young and maladjusted,
probably with paroxysms of cognitive/mental block or
confusion behind their behaviour problems.
Exhaustion, manifested as poor persistence or tiring
at the CRT test, was a problem especially seen among
boys and most markedly in those with dyslexia. The
poor persistence may reduce the mental capacity and be
a handicap per se, especially at school. The reaction time
aberrations must be considered a notable and reliable
biological ®nding related to di€erent CNS dysfunctions
and must be regarded as primary and/or secondary
comorbidity risk factors for psychiatric and social
problems. The CRT measurement, thus, seems to be a
valuable method in investigating CNS dysfunctions and
disclosing hidden comorbidity signs, and, as pointed out
by Vitiello et al. (52), a method more stable than many
subtle signs.
Problems at home, including care outside the biological home, broken homes and ill and abusing parents
were noted in about 50% of the girls and 70% of the
boys. Care of the child outside the biological home, the
need for which is usually assessed by the social
authorities, was based on indicators of special needs of
the child and/or of severe family problems indicating a
risk for a negative impact on the psychosocial and
mental health of the child, or a risk for or neglect and/or
for lack of support and care of the child. Further, a
broken home as well as loss of one parent, could lead to
lack of security. The adverse family conditions could
partly be related to negative life events of the parents,
but could also be secondary to stress caused by a
``deviant'' child. However, genetic problems and constitutional traits of the parents must be considered as
important primary factors. In relation to the family
situation, problems may arise for the child in the form of
a low sense of security and identity, as well as an
increased risk for a negatively interactive process. Such
associations have also been described by Graham et al.
(22) who found high rates of behavioural deviance
linked to maternal ill-health and parental marriage
problems, and by Schi€ et al. (46) who found that
instability and long-standing physical and/or psychiatric
problems among family members are important risk
factors.
In conclusion, it may be stated that the children
with severe child psychiatric problems showed a
complex symptomatology and a multifactorial entirety
in the background, constituting a complex situation.
The girls, and many boys, often showed depression and
maladjustment. Maladjustment was more striking in
boys, but psychosomatic symptoms and anxiety were
more often noted in the girls. Some children had
psychotic signs. The problems were observed at an
earlier age in the boys than in the girls. School
problems and problems with peers were important
®ndings. In the background, concomitant and probably
interactive adverse biological and social factors were
very common. The biological background included
developmental delay, dyslexia, heredity for dyslexia,
slow cognitive processing, attention de®cit and exhaustion, and the social background care outside the
biological home, broken homes and sick and/or
abusing parents. Most background factors investigated,
primary or comorbidity, were often seen concomitantly
and interacting with one another, creating handicaps
and great psychiatric and social problems not only for
the child but also for the family. The problems of the
child could be either primary or secondary related to a
constitutional or acquired handicap and/or to problems
at home, at school or in the society. The picture was
one of a child at risk in an environment inadequate to
provide the necessary support and security, a child also
stressed by feelings of insuciency, identity problems
and limited future possibilities. The study indicated
that in child psychiatry, in childhood and adolescence,
the total complex background, including central-nervous dysfunctions and stressful life events, must be
considered. Early knowledge of the risk factors loading
a child, but also of the strength of the child, has to
constitute the basis for prevention of secondary disorders and later psychosocial problems and form the
foundation for good habilitation and care. Understanding and knowledge of the problems are important
for the child and for all persons shaping the environment to secure a positive development.
Acknowledgements I sincerely thank the Fredrik and Ingrid
Thuring Foundation for supporting this study ®nancially. I also
thank Kjerstin Hemmingsson, research psychologist, Hans Arinell,
statistician, and my co-workers in the clinical team for valuable
help during the di€erent stages of the study.
M. Frisk
A complex background in children and adolescents with psychiatric disorders
235
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