Child & Adolescent Disorders

Behavior Disorders:

Attention-Deficit/Hyperactivity

Conduct Disorder

Diagnosis in C & A Problems

"Disorders usually first evident in infancy, childhood, or adolescence"

Psychologists less enthusiastic about DSM for children because it is more difficult to identify syndromes in child problems

Two main classes of disorders: developmental, behavioral

Many childhood problems not included under DSM-IV

Types of Behavior Disorders

Disruptive

Attention-Deficit/Hyperactivity Disorder

Conduct disorder

Oppositional

Types of BDs (cont)

Anxiety

Separation

Avoidant

Overanxious

Types of BDs (cont)

Eating disorders

Anorexia

Bulimia

Pica

Rumination disorder of infancy

Types of BDs (cont)

Gender identity disorder

Tic disorders, e.g. Tourette's

Elimination disorders: enuresis, encopresis

Speech disorders: cluttering, stuttering; elective mutism

Reactive detachment disorder

Stereotypy/habit disorder

Attention-Deficit/Hyperactivity Disorder

Symptoms of AD/HD

Inattention: (six or more symptoms) and/or hyperactivity-impulsivity (six or more symptoms) for at least 6 months

Problems must be cause social academic or occupational problems and be inconsistent with developmental level

Some symptoms that caused impairment were present before age 7 years.

Symptoms of AD/HD (cont)

Some impairment from the symptoms is present in two or more settings (e.g., at school and at home).

The symptoms do not occur exclusively during the course of a Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder).

Symptoms of AD/HD (cont)

Types:

Predominantly Inattentive Type: Attention problems but not Hyperactive/Impulsive for the past 6 months

Predominantly Hyperactive-Impulsive: Hyperactivity/Impulsivity but no Attention problems for the past 6 months

Combined Type: Both are present for the past 6 months

In Partial Remission

Symptoms of AD/HD (cont)

Inattention

poor attention to detail, careless mistakes

difficulty sustaining attention/easily distracted

does not seem to listen when spoken to

often does not follow through on instructions

has difficulty organizing tasks and activities

avoids or dislikes tasks that require sustained mental effort (such as schoolwork)

often loses things or is forgetful

Symptoms of AD/HD (cont)

Hyperactivity

fidgets with hands or feet or squirms in seat

leaves seat in classroom or in other situations

runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults feelings of restlessness)

has difficulty engaging in leisure act quietly

"on the go" or acts as if "driven by a motor"

talks excessively

Symptoms of AD/HD (cont)

Impulsivity

blurts out answers before questions have been completed

has difficulty awaiting turn

interrupts or intrudes on others (e.g., butts into conversations or games)

Epidemiology of AD/HD

Prevalence 3-5% in school age children, frequency unclear in adolescents/adults

Occurs in various cultures, with variations in reported prevalence among Western countries probably arising from different diagnostic practices

More frequent in males than in females, with male-to-female ratios ranging from 4:1 to 9:1, depending on the setting

Epidemiology (cont)

In most individuals, symptoms attenuate during late adolescence and adulthood

AD/HD is more common in first-degree biological relatives of children with AD/HD

Family members of individuals with AD/HD have a higher prevalence of Mood and Anxiety Disorders, Learning Disorders, Substance-Related Disorders, and Antisocial Personality Disorder

Causes of AD/HD

Biological: hypoactivity in areas of the brain that control attention, e.g parietal lobes

Psychosocial: High levels of stress and family dysfunction are noted, but these may be effects rather than causes

Medications for AD/HD: Stimulants

Advantages

immediate improvement (1st day) except Cylert (1-4 weeks)

Disadvantages

Can’t ed in children with seizure disorders or a family history of Tourette’s

Side effects can include irritability, temporarly changes in growth rate, decreased appetite, initial sleep problems, mild HR/BP changes; side effects different with Cylert as compared to other stimulants

Some potential for abuse, especially in extended high doses (except Cylert)

Stimulants for AD/HD (cont)

Examples

pemoline (Cylert)

Duration: 12-18 hrs.

Must start or stop gradually

methylphenidate (Ritalin)

Duration: 3-4 hrs, tablet.; 6-8 hrs, liquid

Advantage: more flexibility in use (skip weekends)

dextroamphetamine (Dexedrine)

Duration: 4-6 hrs.(elixir, tablet): 8-12 hrs. (spansule)

Advantage: less cost and more forms than Ritalin

Medications for AD/HD: Antidepressants

Advantages

alleviates other problems like bedwetting, mood, sleep & anxiety disorders;

good for children suffering from Tourette's syndrome & ADD/ ADHD

potential for abuse: none

Medications for AD/HD: Antidepressants

Disadvantages

adverse effects if mixed with antihistamines, pain killers, or alcohol; overdose can be lethal

first improvement: 1-5 weeks

possible side effects: constipation, dry mouth, blurred vision, tiredness, bad breath, nausea, sweating

Antidepressants for AD/HD: Antidepressants (cont)

Examples: 1st generation antidepressants

Imipramine (Tofranil)

Nortriptyline (Pamelor)

Amitriptyline (Elavil)

Desipramine (Norpramin, Pertofrane)

Medications for AD/HD: Other

Lithium (mood stabalizer)

Used if other meds don’t work or mood disorder present

Disadvantages: narrow therapeutic range; causes fetal malformations; not recommended for individual with serious medical illness; adversely reacts with other medications

Possible side effects: drowsiness; increased thirst, weight, urination, and diarrhea; increases acne; kidney or thyroid problems

Symptoms of Conduct Disorder

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated

Three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

Causes clinically significant impairment in social, academic, or work functioning

Symptoms of CD (cont)

Aggression or cruelty to people and animals, including bullying, fighting, mugging,, forcing sexual activity

Destruction of property or fire setting

Deceitfulness or theft

Serious violations of rules, e.g. running away or truancy before age 13

Symptoms of CD (cont)

Severity:

Mild: few if any conduct problems in excess of those required to make the diag and conduct probs cause only minor harm

Moderate: number of problems and effect on others intermediate between mild and severe

Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others

Epidemiology of CD

Much more common in males

Prevalence of Conduct Disorder appears to have increased over the last decades and may be higher in urban than in rural settings

Rates vary widely depending on the nature of the population sampled and methods of ascertainment

males under age 18, 6%-16%

females under age 18, 2%-9%

Epidemiology of CD (cont)

Male-female differences in symptoms

CD Males frequently exhibit fighting, stealing, vandalism, and school discipline problems, while females are more likely to exhibit lying, truancy, running away, substance use, and prostitution

Confrontational aggression is more often displayed by males, females tend to use more nonconfrontational behaviors.

Epidemiology of CD (cont)

Risk for Conduct Disorder is increased in children with

a biological or adoptive parent with Antisocial Personality Disorder or

a sibling with Conduct Disorder

biological parents with Alcohol Dependence, Mood Disorders, or Schizophrenia

biological parents who have a history of AD/HD or Conduct Disorder

Types of Conduct Disorder

Childhood-Onset Type

Onset of at least one criterion of Conduct Disorder prior to age 10 years.

Usually male, frequently display physical aggression, have disturbed peer relationships, may have had Oppositional Defiant Disorder during early childhood, and usually meet full criteria for Conduct Disorder prior to puberty.

More likely to have persistent Conduct Disorder and develop Antisocial Personality

Types of CD (cont)

Adolescent-Onset Type.

Absence of any criteria characteristic of Conduct Disorder prior to age 10 years

Less aggressive, tend to have more normative peer relationships (although they often display conduct problems in the company of others)

Less likely to have persistent Conduct Disorder or to develop adult Antisocial Personality

Ratio of males to females with Conduct Disorder is lower

Causes of Conduct Disorder

Estimates from twin and adoption studies show that Conduct Disorder has both genetic and environmental components

Most common: poor parent-child relationships, family conflict and hostility

Also sociocultural factors like drug abuse and poverty