Introduction to the Study of Child & Adolescent Psychopathology

1. Introduction to the Study of Child & Adolescent Psychopathology Jess P. Shatkin, MD, MPH Vice Chair for Education NYU Child Study Center, Department of Child & Adolescent Psychiatry New York University School of Medicine

2. “When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much he had learned in seven years.” --Mark Twain (1835 – 1910)

3. Learning Objectives Residents will be able to: 1. Describe the relative neglect that child and adolescent mental health has historically suffered as a field. 2. Identify various theories of normal child development, risk factors for child mental illness, and sex and socio-cultural differences responsible for mental wellness and illness. 3. Explain the health paradox of adolescence.

4. Why study child & adolescent psychopathology? • High prevalence of mental health problems among adolescents and young adults; estimated at 20% by Surgeon General’s Report of 1999. • Is this due to better diagnosis, an actual increase in prevalence, or both? • Half of all lifetime cases of mental illness are now recognized to begin by age 14 and three-quarters by age 24 (Kessler et al, 2005). • The median number of years from the time a child first experiences psychiatric disturbance and receives treatment is 9 years (2 years for psychotic illnesses); Kessler et al, 2005 • Despite effective treatments, however, there are typically long delays, sometimes decades, between when individuals first experience clinically significant symptoms and when they first seek and receive treatment.

5. What kind of numbers are we talking? • Severe, disabling depression affects approximately 17% of adolescents and young adults nationally (Kashani & Sherman, 1988; Fleming & Offord, 1990; Lewinsohn et al, 1993 & 1994; Kessler & Walters, 1998) • Anxiety in its many forms results in significant impairment in approximately 13% of children and adolescents (Shaffer et al, 1996). • Attention Deficit-Hyperactivity Disorder (with a prevalence of 3 – 7%) and Bipolar Mood Disorder (with a prevalence of over 1%), and others affect smaller numbers but are ubiquitous

6. What kind of numbers are we talking? (2) • Despite the fact that federal government spending on anti-drug measures has increased over ten-fold in the last 15 years, over 50% of high school seniors have experimented with an illicit drug, 23% have used an illicit drug within the past 30 days, and over 30% have been drunk within the past 30 days (Johnston et al, 2005). • Suicide, the most feared and tragic outcome of mental illness, is the third most common cause of death among adolescents and young adults, preceded only by accidents and homicide (Anderson and Smith, 2003).

7. Who gets help? • The population of children and adolescents under age 20 is projected to grow by about 33 percent in the next 40 years from about 84 million to 112 million by 2050 (U.S. Bureau of the Census, 2010). • Fifteen million children in the U.S. have diagnosable psychiatric or learning disorders but nearly 70% don't receive the help they need • Who receives services? • 1 in 3 Caucasian kids • 1 in 5 African American kids • 1 in 7 Latino kids • Fewer than 10% of the 80,000 public schools in the U.S. have comprehensive mental health services

8. What do we know about these problems? • Epidemiology is important but etiology is vital • Basic research and clinical investigation are needed to understand the neurobiological basis of mental illness • The tragedy is that we most often do not know the “best” treatment and for whom various treatments will be most accurately provided • The growth in evidence-based treatments, including medications and psychotherapies, increasingly allows us to treat specific symptoms in a replicable fashion

9. Who does this work? • Mental health practitioners who treat children and adolescents are in short supply. • The United States’ Federal Bureau of Health Professions has named Child and Adolescent Psychiatry as the most underserved of all medical subspecialties. The current workforce consists of approximately 6300 Child and Adolescents psychiatrists (Thomas and Holzer, 2006), whereas the need has been estimated to be as high as 32,000 (AACAP, 2001). • Child and Adolescent Psychiatrists are not alone, however, as the national need for child and adolescent social workers, educational specialists, and psychologists is equally as great.

10. Present Supply of Child and Adolescent Psychiatrists • There are currently about 7,000 child and adolescent psychiatrists practicing in the U.S. (AMA, 2010). • Severe maldistribution of child psychiatric services in the U.S., with children in rural areas and areas of low SES having significantly reduced access. • The ratio of child and adolescent psychiatrists per 100,000 youth ranges from 3.1 in Alaska to 21.3 in Massachusetts with an average of 8.7 (Thomas & Holzer, 2006). • The number of child and adolescent psychiatrists will increase by about 30 percent to 8,312 by 2020. This is far less than the estimated 12,624 needed to meet demand.

12. So, who really does this work? • The vast majority of child and adolescent mental health services worldwide are provided by primary care practitioners, psychologists, and all manner of therapists, ranging from masters level social workers to marriage and family therapists. • Nearly 85% of all psychotropic medications prescribed to children, including stimulants, antipsychotics, antidepressants, anxiolytics, and mood stabilizers, for example, are written by primary care practitioners (Goodwin et al, 2001). • Yet these individuals generally receive no formal training in child and adolescent mental health (ACGME(b), 2007).

13. What does a child/adolescent psychiatrist do for a living? • Works with children, adolescents, and families who have problems with their: • Emotions • Behavior • Cognition/thinking

14. Books

15. Historical Perspective • Valuing children in their own right has not been a priority of earlier societies • “Childhood” itself is really an invention of the Victorian Age (mid-1800s onward) • Prior to the 18th century, children’s mental health problems (unlike those of adults) were rarely mentioned in professional texts and communications • During this time, virtually all etiologies for disordered behavior in children were based upon religious explanations (and magic to a lesser degree) • The separation between medicine, science, religion, and magic was virtually nonexistent

17. Humoral Theory • Until the mid-1880s, the predominant theory used to explain all health problems • Based upon the tradition of Galen, a 2nd century Greek physician • Disease followed an excess in the production of any one of the four humors: Blood, yellow bile, black bile, & phlegm • Physiologic imbalances that resulted were treated by non- specific therapies (e.g., bleeding and purging)

18. “Official” Child Maltreatment • During the 17th – 18th centuries, as many as 2/3 of children died before their 5th birthday • Many children were also subjected to harsh treatment or indifference by their parents • Children were essentially the property of their parents • Massachusetts’ Stubborn Child Act of 1654 permitted parents to put “stubborn” children to death for noncompliance • Until the mid-1800s, the law allowed children with severe developmental disabilities to be kept in cellars and cages

19. The Emergence of Social Conscience • In the West, this process began in the 17th century when both a philosophy of humane care and institutions for social protection began to take root (following on industrialization) • John Locke (1632 – 1704), an English philosopher, believed in individual rights and expressed the novel opinion that children should be raised with thought and care rather than indifference and harsh treatment

20. Victor: The Wild Boy of Aveyron • One of the first documented efforts to work with a special child was undertaken by Jean-Marc Itard (1775 – 1838) • Victor was discovered by hunters in the woods of France at 11 – 12 years of age, having presumably lived alone all his life (or at least since age 2-3) • He was nonverbal, inattentive, and insensitive to basic sensations (hot & cold) • Itard believed that environmental stimulation could “humanize” Victor, but he was never fully socialized

21. The father of French psychiatry Discarded the long held notion of mental illness being due to demoniacal possession Began to classify his observations of the mentally ill Developed “moral treatment” and the first efforts at psychotherapy Physician to Napoleon Philippe Pinel1745 - 1826

23. Benjamin Rush(1746 – 1813) • Physician, educator, writer, humanitarian • B&R in Philadelphia, his practice was aimed at providing care for the poor • He advocated for the abolition of slavery and signed the constitution • His greatest contributions to medical science were the reforms he instituted in the care of the mentally ill during his thirty years of service as a senior physician at the Pennsylvania Hospital; he was more compassionate than was typical and replaced routine reliance on archaic procedures with careful clinical observation and study • The year before he died, he published Medical Inquiries and Observations upon the Diseases of the Mind, the first American textbook on psychiatry

24. Dorothea Dix(1802 – 1887) • A teacher and social reformer for the treatment of the mentally ill. She established 32 humane mental hospitals for the treatment of troubled youth previously relegated to cellars and cages. • She is somewhat neglected in the history books because she did not contribute to our understanding of the nature of mental disorders

25. The Brief Emergence of a Biological Paradigm • Successful treatment of infectious diseases strengthened the emerging belief that illness and disease (including mental illness) were biological processes • Although the mental effects of some “biological” diseases came to be recognized (e.g., syphilis, Huntington’s, etc.), still little could be done to help those with mental illness and early attempts at biological explanations of mental illness were still biased in locating the cause of the illness within the individual • Consequently, once again attitudes toward those with mental illness turned from cautious optimism to dire pessimism, hostility, fear and disdain • During this time (the late 19th and early 20th centuries), emerging ideas around public health and medicine were essentially used against the mentally ill, including eugenics (sterilization) and segregation (institutionalization) to prevent the “insane” from interacting with the rest of society

26. Psychoanalytic Theory • In Freud’s day (the beginning of the 20th century) child psychiatrists and psychologists had become pessimistic about their ability to treat children’s mental disorders in a fashion other than palliative or custodial • Although he believed in innate drives and predisposition (or that the origin of most mental illness was biological), he also believed in the importance of experience in the shaping of psychopathology; he was the first to give meaning to mental disorders by linking them to childhood experiences • For the first time, the course of mental disorders was not seen as inevitable

27. Structural Theories of Development • Postulate a genetically determined capacity for the development of patterns, or systems, of behavior in which the child acts on the environment from the very beginning • Major examples include psychoanalysis (Freud), psychosocial development (Erikson), and cognitive development (Piaget) • The clinical implication of such structural theories is that some kind of reorganization within the child is required (e.g., resolution of an intrapsychic conflict, alteration of the family homeostasis, and acquisition of a new schema) to develop

28. Freud’s Drive Theory • Aggressive and sexual “drives” are the primary motivating forces in our quest for pleasure • The end goal of development is sexual maturity; five stages are defined: • Oral Phase (Infancy, birth to 18 months) • Anal Phase (aka: Sadistic Phase, 18 – 36 months) • Phallic-Oedipal Phase (3 – 6 years) • Latency Phase (6 – 12 years) • Puberty and Adolescence

29. Mahler’s Separation/Individuation • Mahler’s intent was not to add new theory but to systematically observe and detail the unfolding of object relations in children and infants • Objective Relations is a more “modern” adaptation of psychoanalytic theory that places less emphasis on the drives of aggression and sexuality as motivational forces and more emphasis on human relationships as the primary motivational force in life; in other words, we seek relationships rather than pleasure (as Freud suggested). • Six stages of development lead to normal object relations, predicated upon a recognition of “separateness”: • Normal Autism (birth to 2 months) • Symbiosis (2 – 5 months) • Differentiation (5 – 10 months) • Practicing Sub-Phase (10 – 18 months) • Rapprochement (18 – 24 months) • Object Constancy (2 – 5 years)

30. Erikson’s Psychosocial Development A psychoanalytic theory comprising 8 stages, where “normal” development hinges upon successfully traversing 8 dichotomies: • Basic Trust vs. Mistrust (Birth to 1 year) • Autonomy vs. Shame and Doubt (1 – 3 years) • Initiative vs. Guilt (3 – 5 years) • Industry vs. Inferiority (6 – 11 years) • Identity vs. Role Diffusion (11 years – end of adolescence) • Intimacy vs. Isolation (21 – 40 years) • Generativity vs. Stagnation (40 –65 years) • Integrity vs. Despair (over 65 years)

31. Bringing Analytic Theory to Children • Anna Freud (1895 – 1984) was particularly important in expanding Freud’s ideas to children • Melanie Klein (1882 – 1960) argued that children’s play could be interpreted in terms of unconscious fantasy • Their combined work led to the development of child psychoanalysis and a recognition of the importance of nonverbal communication (e.g,. play, drawings, etc.)

32. Piaget and Cognitive Development Piaget identified 4 major stages of cognitive development: • Sensorimotor Stage (birth to 2 years) • Preoperational Stage (2 to 7 years) • Concrete Operational Stage (7 years to adolescence) • Formal Operational Stage (adolescence)

34. The Emergence of Behavioral Theory • The development of “evidence based” treatments in mental health is traced to behavioral theory • Early investigators’ (e.g., Pavlov, Skinner, and Watson) experimental research established the foundations of conditioning • As evidence mounted, current treatments were questioned, including the use of orphanages. The increasing data for behavioral treatments led to increasing acceptance of these treatments, which by the 1970s had become (and remain) more the norm than the exception

35. What is normal? • Is it the converse of abnormal? • When does an “issue” become a problem? • Why do some children struggle more than others with the same symptoms or diagnosis? • What accounts for the waxing and waning of symptoms over time? • How can you help an abnormal child become normal?

36. “All happy families are happy alike, all unhappy families are unhappy in their own way.” --Leo Tolstoy Anna Karenina 1877

37. Defining Psychological Disorders • A pattern of behavioral, cognitive, emotional, and/or physical symptoms shown by an individual • Characteristics must include: • Distress • Disability • Risk of further suffering or harm

38. Developmental Pathways • Multifinality: Various outcomes may stem from similar beginnings • Equifinality: Similar outcomes may follow from different early experiences

40. Risk Factors • A variable that precedes a negative outcome and increases the chance of that outcome occurring • Primary risk factors for child psychopathology include: poverty, inconsistent care giving, parental mental illness, death of a parent, homelessness, family break up, early pregnancy, neonatal complications, etc.

41. Resilience Factors • A variable that increases one’s ability to avoid negative outcomes despite a risk for psychopathology • A much more difficult factor to categorize and may change over time depending upon the child and the environment; individual, family, and social factors will all have an impact

42. How Are Children Faring Today? • 1 in 6 children live in poverty in the U.S. and Canada • 1 in 3 children will be “poor” at some point during childhood • Low income is correlated with other disadvantages: • Less education, lower paying jobs, inadequate healthcare, singe-parent status, limited resources, poor nutrition, greater likelihood of exposure to violence

43. Maltreatment & Non-Accidental Trauma • Nearly 1 million verified cases of child abuse occur in the U.S. each year and 60,000 in Canada • U.S. phone surveys of children 10 – 16 y/o estimate that over 1/3 (6 million) have experienced physical and/or sexual assaults during these years; not only by family members but also by people they may know from their communities and schools

44. The Effect of Poverty • Children from poor and disadvantaged backgrounds show 3x the rate of Conduct Disorder, 2x the rate of chronic illness, and >2x as many school problems (including hyperactivity and emotional disorders) • The worse the poverty, the higher the incidence of childhood violence (3x greater in girls, 5x greater in boys)

45. Sex Differences • Girls • More internalizing problems: • anxiety, depression, somatization, withdrawal • Girls who display resilience come from households that combine risk taking and independence with support from a female caregiver (e.g., mother, sister, grandmother, etc.)

46. Sex Differences • Boys • More externalizing problems: • aggression, delinquency • Boys who display resilience come from households in which there is a positive male role model (e.g., father, older brother, grandfather, etc.) along with structure, rules, and some encouragement of emotional expression

48. Sex Brain Differences • Men tend to use 7,000 words on average per day and women tend to use 20,000 words on average per day • Beginning in the teen years, females may get a larger dopamine “rush” from talking (and gossiping) than males (likened to an orgasm?) • By 8 weeks in utero, testosterone produced by the testes begins to lead to enlargement of the amygdala where aggression behaviors appear to be housed

49. Sex Brain Differences (2) • Female babies are more interested in faces and boys more interested in objects • Female babies increase their visual interest in faces by 400% in the first 3 months of life; whereas males demonstrate no change by 3 months • Girls’ brains mature about 20% faster than boys’ until the mid-teen years (e.g., girls tend to develop language quicker, toilet train earlier, etc.) • Brizendine, 2006

50. Race and Culture • Minority children are overrepresented in some disorders (e.g., SUDS, delinquency, teen suicide); but once SES, gender, age, and referral status are controlled for, very few differences in the rate of children’s psychological disorder emerge • Certainly the barriers to receiving and accessing care are greater among racial minorities and some cultures • Racial and ethnic minorities are also neglected in studies; and most research into childhood psychopathology is not based upon diverse populations