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Disorders of Childhood and Adolescence
Many disorders seen in adults can occur in children.
However, there is a group of disorders usually first diagnosed in children. Table 7-1 lists these disorders according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). This chapter reviews only the more common disorders.
Disorders of Childhood and Adolescence
Child psychiatric assessment requires attention to details of a child's stage of development, family structure and dynamics, and normative age-appropriate behavior. Consulting with parents and obtaining information from schools, teachers, and other involved parties (e.g., Department of Social Services/Youth Services) are essential to proper assessment.
Children, especially young children, usually express emotion in a more concrete (less abstract) way than adults. Consequently, child interviews require more concrete queries (Do you feel like crying? instead of Are you sad?). Playing games, taking turns telling stories, and imaginative play are often used to gain insight into the child's emotional and interpersonal life. During play, observations are also made regarding activity level, motor skills, and verbal expression. Children are much more Likely than adults to have comorbid mental disorders, making diagnosis and treatment more complicated.
The complexities of diagnosis in child psychiatry often require the use of psychological testing. Tests of general intelligence include the Stanford-Binet Intelligence Scale (one of the first intelligence tests developed and often used in young children) and the Wechsler Intelligence Scale for Children-Revised (WISC-R). The WISC-R is the most widely used intelligence test for assessing school-age children. It yields a verbal score, a performance score, and a fullscale score (both verbal and performance) or intelligence quotient (IQ).
Prevalence Of Child And Adolescent Mental Disorders
Four million children and adolescents in this country suffer from a serious mental disorder that causes significant functional impairments at home, at school and with peers. Of children ages 9 to 17, 21 percent have a diagnosable mental or addictive disorder that causes at least minimal impairment.
Half of all lifetime cases of mental disorders begin by age 14. Despite effective treatments, there are long delays, sometimes decades, between the first onset of symptoms and when people seek and receive treatment. An untreated mental disorder can lead to a more severe, more difficult to treat illness and to the development of co-occurring mental illnesses.
In any given year, only 20 percent of children with mental disorders are identified and receive mental health services.
U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
U.S. Public Health Service, Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. Washington, DC: Department of Health and Human Services, 2000.
National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, 2001.
Schizophrenia
A common and serious mental disorder characterized by loss of contact with reality (psychosis), hallucinations (false perceptions), delusions (false beliefs), abnormal thinking
There are many other tests and objective rating scales designed to measure behavior (e.g., impulsiveness, physical activity), perceptual-motor skills (by drawing people, placing pegs in appropriately shaped holes), and personality style (by describing what is happening in an ambiguous scene).
Autistic Disorder
It is characterized by the triad of impaired social interactions, impaired ability to communicate, and restricted repertoire of activities and interests.
Anxiety disorders in youth
During the past decade, the results of international epidemiologic surveys have revealed that anxiety disorders are the most, prevalent, class of mental disorders in adults. Similar to community studies of adults, anxiety disorders are also quite prevalent in the general population of children and adolescents. The median prevalence rate of all anxiety disorders in a recent review was 8% with an extremely wide range of estimates (eg, 2% to 24%). Current, or 12-month rates of anxiety disorders range from 2.2% in North Carolina youth to 9.5% in Puerto Rico. Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD) are the two most prevalence disorders in youth. In contrast, panic disorder and obsessive-compulsive disorder (OCD) are both quite rare in children under 12.
Similar to the gender ratio for adults, girls tend to have more of all subtypes of anxiety disorders, irrespective of the age composition of the sample. However, it has also been reported that, despite the greater rates of anxiety in girls across all ages, there is no significant difference between boys and girls in the average age at onset of anxiety.
Comorbidity between anxiety disorders and other mental disorders is already apparent in childhood and adolescence. Anxiety disorders are associated with all of the other major classes of disorders, including mood disorders, disruptive behaviors, eating disorders, and substance use disorders. The co-occurrence of anxiety disorders and mood disorders is so common that there is emerging evidence that anxiety disorders may be part of the developmental sequence in which anxiety is expressed early in life followed by depression in adulthood.
Autistic disorder is familial. Genetic studies demonstrate incomplete penetrance (36% concordance rate in monozygotic twins), although a specific genetic defect has not been discovered. A small percentage of those with autistic disorder have a fragile X chromosome, and a high rate of autism exists with tuberous sclerosis.
Kids can get depressed and disorders ranging from major depression to bipolar disorder are increasingly diagnosed in children, whose symptoms are especially likely to include irritability. Psychotherapy is often highly effective, although drug treatment may also be needed.
Attention-Deficit/ Hyperactivity Disorder (ADHD)
ADHD is characterized by a persistent and dysfunctional pattern of overactivity, impulsiveness, inattention, and distractibility.
The disorder runs in families and cosegregates with mood disorders, substance use disorders, learning disorders, and antisocial personality disorder.
Families with a child diagnosed with ADHD are more likely than those without ADHD offspring to have family members with the above-mentioned disorders.
Learning Disorders
Learning disorders are characterized by performance in a specific area of learning (e.g., reading, writing, arithmetic) substantially below the expectation of a child's chronologic age, measured intelligence, and age-appropriate education. The (DSM-IV) identifies three learning disorders: reading disorder, mathematics disorder, and disorder of written expression.
Specific learning disorders often occur in families. They are presumed to result from focal cerebral injury or from a neurodevelopmental defect.
Mental health disorders in children and adolescents are caused by biology, environment, or a mix of both. Examples of biological factors are genetics, chemical imbalances in the body, and damage to the central nervous system, such as a head injury. Many factors in a young person's environment can affect his or her mental health, such as exposure to violence, extreme stress, and loss of an important person. Caring families and communities working together can help children and adolescents with mental disorders. A broad range of services often is necessary to meet the needs of these young people and families.
Types of Disorders
Following are descriptions of some of the mental, emotional, and behavior problems that can occur during childhood and adolescence. All of these disorders can have a serious impact on a child's overall health.
Some disorders are more common than others, and conditions can range from mild to severe. Often, a child has more than one disorder.
Anxiety disorders are the most common of childhood disorders. They affect an estimated 8 to 10 of every 100 children and adolescents. These young people experience excessive fear, worry, or uneasiness that interferes with their daily lives. Anxiety disorders include:
Depressive disorders, which include major depressive disorder (unipolar depression), dysthymic disorder (chronic, mild depression), and bipolar disorder (manic-depression), can have far-reaching effects on the functioning and adjustment of young people.
Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. An episode of major depression may occur only once in a person's lifetime, but more often, it recurs throughout a person's life. Dysthymia involves long-term (two years or longer) but less severe symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives. Bipolar disorder is not nearly as prevalent as other forms of depressive disorders and is characterized by mood changes: severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of a depressive disorder. When in the manic cycle, the individual may be overactive, overly talkative, and have a great deal of energy. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment.
Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include: Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions. Seasonal affective disorder (SAD) is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer.
- Phobia - an unrealistic and overwhelming fear of some abject or situation;
- Generalized anxiety disorder - a pattern of excessive, unrealistic worry not attributable to any recent experience.
- Panic disorder - terrifying panic attacks that include physical symptoms such as rapid heartbeat and dizziness;
- Obsessive compulsive disorder - being trapped in a pattern of repeated thoughts and behaviors such as counting or hand washing; and
- Post-traumatic stress disorder - a pattern of flashbacks and other symptoms that occurs in children who have experienced a psychologically distressing event such as physical or sexual abuse, being a victim or witness of violence, or exposure to some other traumatic event such as a bombing or hurricane.
Major depression is recognized more and more in young people. Years ago, many people believed that major depression did not occur in childhood. But we now know that the disorder can occur at any age. Studies show that up to 6 out of every 100 children may have depression. Some adolescents or even elementary school children with depression may not place any value on their own lives, which may lead to suicide. The disorder is marked by changes in:
- Emotion - the child often feels sad, cries, looks tearful, feels worthless;
- Motivation - schoolwork declines, the child shows no interest in play;
- Physical well-being - there may be changes in appetite or sleep patterns and vague physical complaints; and
- Thoughts - the child believes that he or she is ugly, that he or she is unable to do anything right, or that the world or life is hopeless.
Bipolar disorder (manic-depressive illness) in children and adolescents is marked by exaggerated mood swings between extreme lows(depression) and highs (excited ness or manic phases). Periods of moderate mood occur in between. During a manic phase, the child or adolescent may talk nonstop, need very little sleep, and show unusually poor judgment. Bipolar mood swings can recur throughout life. Adults with bipolar disorder, as common as 1 in 100 adults, often experienced their first symptoms during teenage years.
Attention-deficit/hyperactivity disorder occurs in up to 5 of every 100 children. A young person with attention-deficit/hyperactivity disorder is unable to focus attention and is often impulsive and easily distracted. Most children with this disorder have great difficulty remaining still, taking turns, and keeping quiet. Symptoms must be evident in at least two settings(for instance, at home and at school) for attention-deficit/hyperactivity disorder to be diagnosed.
Learning disorders affect the ability of children and adolescents to receive or express information. These problems can show up as difficulties with spoken and written language, coordination, attention, or self-control. Such difficulties can make it harder for a child to learn to read, write, or do math. Approximately 5 of every 100 children in public schools are identified as having a learning disorder.
Conduct disorder causes children and adolescents to act out their feelings or impulses toward others in destructive ways. Young people with conduct disorder repeatedly violate the basic rights of others and the rules of society. The offenses that these children and adolescents commit often get more serious over time. Examples include lying, theft, aggression, truancy, fire setting, and vandalism. Children and adolescents with conduct disorder usually have little care or concern for others. Current research has yielded varying estimates of the number of young people with this disorder; most estimates range from 4 to 10 of every 100 children and adolescents.
Eating disorders can be life threatening. A young person with anorexia nervosa, for example, cannot be persuaded to maintain a minimally normal body weight. This child or adolescent is intensely afraid of gaining weight and doesn't believe that he or she is underweight. Anorexia affects 1 in every 100 to adolescent girls and a much smaller number of boys.
Youngsters with bulimia nervosa feel compelled to binge (eat huge amounts of food at a time). Afterward, to prevent weight gain, they rid their bodies of the food by vomiting, abusing laxatives, taking enemas, or exercising obsessively. Reported rates vary from 1 to 3 out of 100 young people.
Autism spectrum disorder or autism appears before a child's third birthday. Children with autism have problems interacting and communicating with others. They behave inappropriately, often repeating behaviors over long periods. For example, some children bang thier heads, rock, or spin objects. The impairments range from mild to severe. Children with autistic disorder may have a very limited awareness of others and are at increased risk for other mental disorders. Studies suggest that autism spectrum disorder affects 7 to 14 of every 10,000 children.
Schizophrenia can be a devastating mental disorder can be a devastating mental disorder. Young people with schizophrenia have psychotic periods when they may have hallucinations (sense things that do not exist, such as hearing voices), withdraw from others, and lose contact with reality. Other symptoms include delusional or disordered thoughts and an inability to experience pleasure. Schizophrenia is even more rare than autism in children under 12, but occurs in about 3 out of every 1000 adolescents.
