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Explore why disorders manifest differently in children, major classes of psychiatric disorders, prevalence rates, diagnostic challenges, and specific disorders like anxiety, depression, and ADHD. Learn about separation anxiety and potential comorbid conditions.
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Child and Adolescent Psychopathology Tomàs, J.
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
Why disorders may appear differently in children? • Neurodevelopmental factors (certain neurocircuits not fully developed yet; synaptic pruning) • Cognitive maturity • Social Context
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
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%
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
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
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
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)
Attention-Deficit Hyperactivity Disorder (ADHD) • Hyperactivity • Inattention/Distractibility • Impulsivity
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
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
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
ADHD - Impulsivity • Blurts out answers • Interrupts others • Intrudes on activities of others • Difficulty waiting turn • Can be verbal or physical
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%)
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
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
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
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
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
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
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
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)
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
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
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)
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)
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
Tourette’s – Associated Symptoms • Attention Deficit Hyperactivity Disorder and other behavior disorders • Obsessive-Compulsive Disorder • Depression • Substance Abuse