Child and Adolescent Psychopathology

1. Child and Adolescent Psychopathology Tomàs, J.

2. Child vs. Adult Psychopathology • Disorders that occur or have onset primarily in childhood • Disorders that can occur at all ages; kids have same symptoms but manifest in developmental context • Disorders that occur in all ages but symptoms/presentation is different in kids

3. Why disorders may appear differently in children? • Neurodevelopmental factors (certain neurocircuits not fully developed yet; synaptic pruning) • Cognitive maturity • Social Context

4. Major classes of childhood psychiatric disorders • Developmental Disorders • Autism; Pervasive Developmental Disorders • Language and Learning Disorders • Disruptive Behavior Disorders (“externalizing”) • Attention Deficit Hyperactivity Disorder • Oppositional Defiant Disorder; Conduct Disorder • Affective Disorders (“internalizing”) • Anxiety Disorders • Depression; Bipolar Disorder • Other disorders • Tourette’s Disorder; Eating Disorders; Substance Use D/O’s

5. Epidemiology • Overall Prevalence (over 3-6 month period) of 15-20% of children & adolescents • Comorbidity frequent (20 – 50%) • Anxiety: 3 - 8% (child > adol.) • Depression: 2 - 6% (adol. > child) • Disruptive Disorders: 5 – 15%

6. Issues in Making Psychiatric Diagnoses in Kids • Must rely on parents/caretakers/teachers for much of the data – especially for externalizing disorders • Though cognitive/language make interviewing kids more difficult, it is important to do – internalizing d/o’s, rule out abuse • Need to evaluate whether symptoms are inappropriate for developmental level, and whether they cause functional impairment or clinically significant distress

7. Anxiety Disorders • What is developmentally normal vs. pathological • Generalized anxiety disorder, Post-traumatic stress disorder, Obsessive-compulsive disorder, social phobia, specific phobia can all occur • Panic disorder – can occur, but rare • Separation Anxiety Disorder – prototypical childhood anxiety disorder • Kids frequently have more than one • Most kids improve; may develop depression when older

8. Separation Anxiety Disorder • Prevalence of about 2% • Children aged 5 to 8 most commonly report unrealistic worry about harm to parents or attachment figures and school refusal. • Children aged 9 to 12 usually manifest excessive distress at times of separation, whereas adolescents most commonly manifest somatic complaints and school refusal. • Boys and girls manifest similar symptoms of separation anxiety disorder. • 75% of children with separation anxiety disorder manifest school refusal

9. Depression • Irritability is often the primary symptom • Suicidality increases substantially after age 10 • Kids often brighten temporarily when in positive environment or with friends • School performance often drops (amotivation, poor concentration)

10. Attention-Deficit Hyperactivity Disorder (ADHD) • Hyperactivity • Inattention/Distractibility • Impulsivity

11. ADHD - Epidemiology • Prevalence rates vary among studies from 3 – 8% of school-age children • Ratio of male to female generally ranges from 3:1 to 8:1. • Age of onset prior to age seven • Slightly more prevalent in lower socioeconomic groups

12. Manifestations of Hyperactivity • Unable to sit still in seat in the classroom represents gross motor hyperactivity, particularly in pre-pubertal children. • In post-pubertal children, usually more subtle fidgetiness • Always on the go – “driven by a motor” • Talks excessively

13. ADHD - Inattention • Cannot sustain attention compared to peers, esp. at long, boring, or monotonous tasks • Disorganized; often loses things • Distractible • Cannot follow through on instructions • Doesn’t seem to be listening when spoken to

14. ADHD - Impulsivity • Blurts out answers • Interrupts others • Intrudes on activities of others • Difficulty waiting turn • Can be verbal or physical

15. ADHD – Associated Symptoms • Difficulty getting along with others • Increase in behavioral problems due to impulsivity • Difficulty learning due to inattention • Poor self-esteem – can lead to depression • Frequent Co-morbid Conditions (50-60%) • Oppositional-Defiant Disorder (40%) • Conduct Disorder (30%) • Anxiety (15-20%) or Depression (15-20%)

16. ADHD – Clinical Course • About 30% improve in adolescence • 1/3 have symptoms as adults, but not substantial impairment • 1/3 still very symptomatic into adulthood • Sequelae include substance use, school failure, antisocial behavior

17. Other disruptive behavior disorders • More akin to syndromes or symptom clusters • Oppositional Defiant Disorder • Conduct Disorder (child vs. adolescent onset) • Cruelty to animals • Fighting; assaulting others • Stealing, conning • Property Destruction • Many progress to antisocial behavior as adults

18. Pervasive Developmental Disorders (PDD) • Autism • Impairment in Language • Deficits in social functioning • Abnormally restricted activities and interests • Likely a “spectrum” of PDD’s • Profound autism to milder PDD NOS or Asperger’s syndrome

19. Autism - Epidemiology • Prevalence rate 1-2 in 1000 (may be rising) • Age of onset before age 3 in 94% cases • Ratio of male: female = 4 - 5:1 • Evenly distributed across socioeconomic and ethnic groups

20. Autism – Impairment of Social Interactions • Limited awareness of the existence of others or the feelings of others (lack of “theory of mind”) • Absent or abnormal seeking of comfort at times of distress • Absence of sharing experiences with others (“bring to show”) • Absent or abnormal social play • Gross impairment in ability to make peer friendships

21. Impairment of Communication/Language Abnormalities • May have no mode of verbal communication • Markedly abnormal non-verbal communication • Absence of playacting, fantasy life, etc. • Abnormalities in the production of speech • Echolalia, or idiosyncratic use of words or phrases • Impairment in ability to sustain a conversation with others

22. Impaired Repertoire of Activities/Interests • Stereotyped body movements • Persistent preoccupation with parts of objects • Marked distress over changes in trivial aspects of environment • Unreasonable insistence on following routines in precise detail • Markedly restricted range of interests

23. Autism – Associated symptoms • 75-80% have mental retardation • Higher incidence of abnormal EEG and seizures • Self-injurious behavior • Unusual posturing and other motor behaviors (repetitive, non-functional movements)

24. Other Pervasive Developmental Disorders • Asperger’s Disorder • Normal early language development and intelligence • Impairment in social functioning and restriction in interests like autism • PDD NOS • Most common (1 in 200-500) • Meets some but not all criteria for autism

25. Tourette’s Syndrome • Motor and vocal tics, lasting at least one year in duration • Tics: sudden, • Tics vs. compulsions • Tic = repetitive, purposeless, non-goal directed, involuntary, partially suppressible • Compulsion = repetitive, with purpose (to relieve anxiety), goal-directed, quasivoluntary, partially suppressible

26. Tourette’s - Epidemiology • Prevalence rate at least 0.09% • Ratio of male:female = 3:1 • Median age of onset is 6 years (range 1-17)

27. Tics • Motor Tics • Simple motor tics (single muscle group) – e.g.: eye blinking • Complex motor tics (multiple muscle groups) – e.g.: kicking • Vocal Tics • Simple vocal tics (noises) e.g. clicking • Complex vocal tics (words, phrases, or sentences) • Coprolalia (complex vocal tics made up of swear words or other socially unacceptable words/phrases, such as racial slurs)

28. Tourette’s – Clinical Course • Waxes and wanes, may fluctuate with "stress" • Tics are migratory (i.e. may change type, location over time) • Usually symptoms stop worsening after puberty, but are generally life-long

29. Tourette’s – Associated Symptoms • Attention Deficit Hyperactivity Disorder and other behavior disorders • Obsessive-Compulsive Disorder • Depression • Substance Abuse