36 - 31 Child Psychiatry

01 - 31.1 Introduction Infant, Child, and Adolesce
31.1 Introduction: Infant, Child, and Adolescent Development
Child Psychiatry
31.1 Introduction: Infant, Child, and Adolescent
Development
The transactional nature of development in infancy, childhood, and adolescence,
consisting
of
a
continuous
interplay
between
biological
predisposition
and
environmental experiences, forms the basis of current conceptualizations of
development. There is much evidence that observed developmental outcomes evolve
from interactions between particular biological substrates and specific environmental
events. For example, the serotonin transporter gene sensitizes a child with early adverse
experiences of abuse or neglect to increased risk for later development of a depressive
disorder. In addition, the degree of resilience and adaptation, that is, the ability to
withstand adversity without negative effects, is likely to be mediated by endogenous
glucocorticoids, cytokines, and neurotrophins. Thus, allostasis, the process of achieving
stability in the face of adverse environmental events, results from interactions between
specific environmental challenges and particular genetic backgrounds that combine to
result in a response. It is widely accepted that adverse childhood experiences (ACEs) are
likely to alter the trajectory of development in a given individual, and that during early
development the brain is especially vulnerable to injury. Future studies may uncover
windows of plasticity in older children and adolescents that affect vulnerability as well.
Changes in both white matter and gray matter in the brains of adolescents are linked to
increased acquisition of subtle social skills. Adolescents’ keen abilities, competencies,
and interests in a host of technological advances—including the Internet, social media
sites such as Facebook, Twitter, and Instagram, and smart phones, to name a few—shed
some light on their potential to adapt to new and challenging demands.
PRENATAL, INFANT, AND CHILD
The phases of development described in this section are defined as follows: prenatal is
the time frame from conception to 8 weeks; the fetus, from 8 weeks to birth; infancy,
from birth to 15 months; the toddler period, from 15 months to 2½ years; the preschool
period, from 2½ years to 6 years; and the middle years, from 6 to 12 years.
PRENATAL
Historically, the analysis of human development began with birth. The influence of
endogenous and exogenous in utero factors, however, now requires that developmental
schemes take intrauterine events into consideration. The infant is not a tabula rasa, a
smooth slate upon which outside influences etch patterns. To the contrary, the newborn
has already been influenced by myriad factors that have occurred in the safety of the
womb, the result of which has produced wide individual differences among infants. For
example, the studies of Stella Chess and Alexander Thomas (described later) have
demonstrated a wide range of temperamental differences among newborns. Maternal
stress, through the production of adrenal hormones, also influences behavioral
characteristics of newborns.
The time frame in which the development of the embryo and fetus occurs is known as
the prenatal period. After implantation, the egg begins to divide and is known as an
embryo. Growth and development occur at a rapid pace; by the end of 8 weeks, the
shape is recognizably human, and the embryo has become a fetus. Figure 31.1-1
illustrates a sonogram of a 9-week and 15-week fetus in utero.
FIGURE 31.1-1
A. Sonogram of fetus at 9 weeks. B. Same fetus at 15 weeks. (Courtesy K.C. Attwell,
M.D.)
The fetus maintains an internal equilibrium that, with variable effects, interacts
continuously with the intrauterine environment. In general, most disorders that occur
are multifactorial—the result of a combination of effects, some of which can be additive.
Damage at the fetal stage usually has a more global impact than damage after birth,
because rapidly growing organs are the most vulnerable. Boys are more vulnerable to
developmental damage than girls are; geneticists recognize that in humans and animals,
female fetuses show a propensity for greater biological vigor than male fetuses, possibly
because of the second X chromosome in the female.
Prenatal Life
Much biological activity occurs in utero. A fetus is involved in a variety of behaviors
that are necessary for adaptation outside the womb. For example, a fetus sucks on
thumb and fingers; folds and unfolds its body, and eventually assumes a position in
which its occiput is in an anterior vertex position, which is the position in which fetuses
usually exit the uterus.
Behavior.
Pregnant women are extraordinarily sensitive to prenatal movements.
They describe their unborn babies as active or passive, as kicking vigorously or rolling
around, as quiet when the mothers are active, but as kicking as soon as the mothers try
to rest.
Women usually detect fetal movements 16 to 20 weeks into the pregnancy; the fetus
can be artificially set into total body motion by in utero stimulation of its ventral skin
surfaces by the 14th week. The fetus may be able to hear by the 18th week, and it
responds to loud noises with muscle contractions, movements, and an increased heart
rate. Bright light flashed on the abdominal wall of the 20-week pregnant woman causes
changes in fetal heart rate and position. The retinal structures begin to function at that
time. Eyelids open at 7 months. Smell and taste are also developed at this time, and the
fetus responds to substances that may be injected into the amniotic sac, such as contrast
medium. Some reflexes present at birth exist in utero: the grasp reflex, which appears at
17 weeks; the Moro (startle) reflex, which appears at 25 weeks; and the sucking reflex,
which appears at about 28 weeks.
Nervous System.
The nervous system arises from the neural plate, which is a
dorsal ectodermal thickening that appears on about day 16 of gestation. By the sixth
week, part of the neural tube becomes the cerebral vesicle, which later becomes the
cerebral hemispheres (Fig. 31.1-2).
FIGURE 31.1-2
Formation of the neural tube and neural crest. These schematic illustrations follow the
early development of the nervous system in the embryo. The drawings above are dorsal
views of the embryo; those below are cross sections. A. The primitive embryonic central
nervous system (CNS) begins as a thin sheet of ectoderm. B. The first important step in
the development of the nervous system is the formation of the neural groove. C. The
walls of the groove, called neural folds, come together and fuse, forming the neural
tube. D. The bits of neural ectoderm that are pinched off when the tube rolls up are
called the neural crest, from which the peripheral nervous system (PNS) will develop.
The somites are mesoderm that will give rise to much of the skeletal system and the
muscles. (Reprinted from Bear MF, Conners BW, Paradiso MA, eds. Neuroscience:
Exploring the Brain. 2nd ed. Philadelphia: Lippincott Williams & Wilkins. 2001:179, with
permission.)
The cerebral cortex begins to develop by the 10th week, but layers do not appear until
the sixth month of pregnancy; the sensory cortex and the motor cortex are formed
before the association cortex. Some brain function has been detected in utero by fetal
encephalographic responses to sound. The human brain weighs about 350 g at birth and
1,450 g at full adult development, a fourfold increase, mainly in the neocortex. This
increase is almost entirely because of the growth in the number and branching of
dendrites establishing new connections. After birth, the number of new neurons is
negligible. Uterine contractions can contribute to fetal neural development by causing
the developing neural network to receive and transmit sensory impulses.
Pruning
Pruning refers to the programmed elimination during development of neurons,
synapses, axons, and other brain structures from the original number, present at birth,
to a lesser number. Thus, the developing brain contains structures and cellular elements
that are absent in the older brain. The fetal brain generates more neurons than it will
need for adult life. For example, in the visual cortex, neurons increase in number from
birth to 3 years of age, at which point they diminish in number. Another example is that
the adult brain contains fewer neural connections than were present during the early
and middle years of childhood. Approximately twice as many synapses are present in
certain parts of the cerebral cortex during early postnatal life than during adulthood.
Pruning occurs to rid the nervous system of cells that have served their function in the
development of the brain. Some neurons, for example, exist to produce neurotrophic or
growth factors and are programmed to die—a process called apoptosis—when that
function is fulfilled.
The implication of these observations is that the immature brain can be vulnerable in
locations that lack sensitivity to injury later on. The developing white matter of the
human brain before 32 weeks of gestation is especially sensitive to damage from
hypoxic and ischemic injury and metabolic insults. Neurotransmitter receptors located
on synaptic terminals are subject to injury from excessive stimulation by excitatory
amino acids, (e.g., glutamate, aspartate), a process referred to as excitotoxicity.
Research is proceeding on the implications of such events in the etiology of child and
adult neuropsychiatric disorders such as schizophrenia.
Maternal Stress
Maternal stress correlates with high levels of stress hormones (epinephrine,
norepinephrine, and adrenocorticotropic hormone) in the fetal bloodstream, which act
directly on the fetal neuronal network to increase blood pressure, heart rate, and
activity level. Mothers with high levels of anxiety are more likely to have babies who
are hyperactive, irritable, and of low birth weight, and who have problems feeding and
sleeping than are mothers with low anxiety levels. A fever in the mother causes the
fetus’s temperature to rise.
Genetic Disorders
In many cases, genetic counseling depends on prenatal diagnosis. The diagnostic
techniques used include amniocentesis (transabdominal aspiration of fluid from the
amniotic sac), ultrasound examinations, x-ray studies, fetoscopy (direct visualization of
the fetus), fetal blood and skin sampling, chorionic villus sampling, and α-fetoprotein
screening. In about 2 percent of women tested, the results are positive for some
abnormality, including X-linked disorders, neural tube defects (detected by high levels of
α-fetoprotein), chromosomal disorders (e.g., trisomy 21), and various inborn errors of
metabolism (e.g., Tay-Sachs disease and lipoidoses). Figure 31.1-3 illustrates
hypertelorism of the eyes.
FIGURE 31.1-3
Hypertelorism. Note the wide distance between the eyes, flat nasal bridge, and external
strabismus. (Courtesy of Michael Malone, M.D. Children’s Hospital, Washington, D.C.)
Some diagnostic tests carry a risk; for instance, about 5 percent of women who
undergo fetoscopy miscarry. Amniocentesis, which is usually performed between the
14th and 16th weeks of pregnancy, causes fetal damage or miscarriage in less than 1
percent of women tested. Fully 98 percent of all prenatal tests in pregnant women
reveal no abnormality in the fetus. Prenatal testing is recommended for women older
than 35 years of age and for those with a family history of a congenital defect.
Parental reactions to birth defects can include feelings of guilt, anxiety, or anger as
their worst fears during the pregnancy are realized. Some degree of depression over the
loss of the fantasized perfect child may be observed before the parents develop more
active coping strategies. Termination of a pregnancy because of a known or suspected
birth defect is an option chosen by some women.
Maternal Drug Use
Alcohol.
Alcohol use in pregnancy is a major cause of serious physical and mental
birth defects in children. Each year, up to 40,000 babies are born with some degree of
alcohol-related damage. The National Institute on Drug Abuse (NIDA) reports that 19
percent of pregnant women used alcohol during their pregnancy, the highest rate being
among white women.
Fetal alcohol syndrome (Fig. 31.1-4) affects about one third of all infants born to
alcoholic women. The syndrome is characterized by growth retardation of prenatal
origin (height, weight); minor anomalies, including microphthalmia (small eyeballs),
short palpebral fissures, midface hypoplasia (underdevelopment), a smooth or short
philtrum, and a thin upper lip; and central nervous system (CNS) manifestations,
including microcephaly (head circumference below the third percentile), a history of
delayed development, hyperactivity, attention deficits, learning disabilities, intellectual
deficits, and seizures. The incidence of infants born with fetal alcohol syndrome is about
0.5 per 1,000 live births.
FIGURE 31.1-4
Photographs of children with “fetal-alcohol syndrome.” A. Severe case. B. Slightly
affected child. Note in both children the short palpebral fissures and hypoplasia of the
maxilla. Usually, the defect includes other craniofacial abnormalities. Cardiovascular
defects and limb deformities are also common symptoms of the fetal alcohol syndrome.
(From Langman J. Medical Embryology. 7th ed. Philadelphia: Williams & Wilkins;
1995:108, with permission.)
Some studies suggest that alcohol use during pregnancy may contribute to attentiondeficit/hyperactivity disorder (ADHD). Animal experiments have shown that alcohol
reduces the number of active dopamine neurons in the midbrain area, and ADHD is
associated with reduced dopaminergic activity in the brain.
Smoking.
Smoking during pregnancy is associated with both premature births and
below-average infant birth weight. Some reports have associated sudden infant death
syndrome (SIDS) with mothers who smoke.
Other Substances.
Marijuana (used by 3 percent of all pregnant women) and
cocaine (used by 1 percent) are the two most commonly abused illegal drugs, followed
by heroin. Chronic marijuana use is associated with low infant birth weight,
prematurity, and withdrawal-like symptoms, including excessive crying, tremors, and
hyperemesis (severe and chronic vomiting). Crack cocaine use by women during
pregnancy has been correlated with behavioral abnormalities such as increased
irritability and crying and decreased desire for human contact. Infants born to mothers
dependent on narcotics go through a withdrawal syndrome at birth.
Prenatal exposure to various prescribed medications can also result in abnormalities.
Common
drugs
with
teratogenic
effects
include
antibiotics
(tetracyclines),
anticonvulsants
(valproate
[Depakene],
carbamazepine
[Tegretol],
phenytoin
[Dilantin]), progesterone-estrogens, lithium (Eskalith), and warfarin (Coumadin). Table
31.1-1 outlines the etiologies of malformations that may emerge during the first year of
life.
Table 31.1-1
Causes of Human Malformations Observed During the First Year of Life
INFANCY
The delivery of the fetus marks the start of infancy. The average newborn weighs about
3,400 g (7.5 lb.). Small fetuses, defined as those with a birth weight below the 10th
percentile for their gestational age, occur in about 7 percent of all pregnancies. At the
26th to the 28th week of gestation, the prematurely born fetus has a good chance of
survival. Arnold Gesell described developmental landmarks that are widely used in both
pediatrics and child psychiatry. These landmarks outline the sequence of children’s
motor, adaptive, and personal–social behavior from birth to 6 years (Table 31.1-2).
Table 31.1-2
Landmarks of Normal Behavioral Development
Premature infants are defined as those with a gestation of less than 34 weeks or a
birth weight less than 2,500 g (5.5 lb.). Such infants are at increased risk for learning
disabilities, such as dyslexia, emotional and behavioral problems, mental retardation,
and child abuse. With each 100 g increment of weight, beginning at about 1,000 g (2.2
lb.), infants have a progressively better chance of survival. A 36-week-old fetus has less
chance of survival than a 3,000 g (6.6 lb) fetus born close to term. The differences
between full-term and infants born prematurely are shown in Figure 31.1-5.
FIGURE 31.1-5
Contrast between full-term (A and B) and premature (C and D) infants. Note the limp
sprawl of the baby in C and the difficulty in raising the head to clear the nose and
mouth in D. (Reprinted from Stone LJ, Church J. Childhood and Adolescence. 4th ed. New
York: Random House; 1979:7, with permission.)
Postmature infants are defined as infants born 2 weeks or more beyond the expected
date of birth. Because pregnancy at term is calculated as extending 40 weeks from the
last menstrual period and the exact time of fertilization varies, the incidence of
postmaturity is high if based on menstrual history alone. The postmature baby typically
has long nails, scanty lanugo, more scalp hair than usual, and increased alertness.
Developmental Milestones in Infants
Reflexes and Survival Systems at Birth.
Reflexes are present at birth. They
include the rooting reflex (puckering of the lips in response to perioral stimulation), the
grasp reflex, the plantar (Babinski) reflex, the knee reflex, the abdominal reflexes, the
startle (Moro) reflex (Fig. 31.1-6), and the tonic neck reflex. In normal children, the
grasp reflex, the startle reflex, and the tonic neck reflex disappear by the fourth month.
The Babinski reflex usually disappears by the 12th month.
FIGURE 31.1-6
Moro reflex. (Reprinted with permission from Stone LJ, Church J. Childhood and
Adolescence. 4th ed. New York: Random House 1979:14 with permission.)
Survival systems—breathing, sucking, swallowing, and circulatory and temperature
homeostasis—are relatively functional at birth, but the sensory organs are incompletely
developed. Further differentiation of neurophysiological functions depends on an active
process of stimulatory reinforcement from the external environment, such as persons
touching and stroking the infant. The newborn infant is awake for only a short period
each day; rapid eye movement (REM) and non-REM sleep are present at birth. Other
spontaneous behaviors include crying, smiling, and penile erection in males. Infants 1
day old can detect the smell of their mother’s milk, and those 3 days old distinguish their
mother’s voice.
Language and Cognitive Development.
At birth, infants can make noises, such
as crying, but they do not vocalize until about 8 weeks. At that time, guttural or
babbling sounds occur spontaneously, especially in response to the mother. The
persistence and further evolution of children’s vocalizations depend on parental
reinforcement. Language development occurs in well-delineated stages as outlined in
Table 31.1-3.
Table 31.1-3
Language Development
By the end of infancy (about 2 years), infants have transformed reflexes into
voluntary actions that are the building blocks of cognition. They begin to interact with
the environment, to experience feedback from their own bodies, and to become
intentional in their actions. By the end of the second year of life, children begin to use
symbolic play and language.
Jean Piaget (1896–1980), a Swiss psychologist, observed the growing capacity of
young children (including his own) to think and to reason. An outline of the Piaget’s
stages of cognitive development is presented in Table 31.1-4.
Table 31.1-4
Piaget’s Stages of Cognitive Development
Emotional and Social Development.
By the age of 3 weeks, infants imitate the
facial movements of adult caregivers. They open their mouths and thrust out their
tongues in response to adults who do the same. By the third and fourth months of life,
these behaviors are easily elicited. These imitative behaviors are believed to be the
precursors of the infant’s emotional life. The smiling response occurs in two phases: the
first phase is endogenous smiling, which occurs spontaneously within the first 2 months
and is unrelated to external stimulation; the second phase is exogenous smiling, which is
stimulated from the outside, usually by the mother, and occurs by the 16th week.
The stages of emotional development parallel those of cognitive development. Indeed,
the caregiving person provides the major stimulus for both aspects of mental growth.
Human infants depend totally on adults for survival. Through warm and predictable
interactions, an infant’s social and emotional repertoire expands with the interplay of
caregivers’ social responses (Table 31.1-5).
Table 31.1-5
Emotional Development
In the first year, infants’ moods are highly variable and intimately related to internal
states such as hunger. Toward the second two thirds of the first year, infants’ moods
grow increasingly related to external social cues; a parent can get even a hungry infant
to smile. When the infant is internally comfortable, a sense of interest and pleasure in
the world and in its primary caregivers should prevail. Prolonged separation from the
mother (or other primary caregiver) during the second 6 months of life can lead to
depression that may persist into adulthood as part of an individual’s character.
Temperamental Differences
There are strong suggestions of inborn differences and wide variability in autonomic
reactivity and temperament among individual infants. Chess and Thomas identified nine
behavioral dimensions, in which reliable differences among infants can be observed
(Table 31.1-6).
Table 31.1-6
Temperament—Newborn to 6 Years
Most temperamental dimensions of individual children showed considerable stability
over a 25-year follow-up period, but some temperamental traits did not persist. This
finding was attributed to genetic and environmental effects on personality. A complex
interplay exists among the initial characteristics of infants, the mode of parental
interactions, and children’s subsequent behavior. Observations of the stability and
plasticity of certain temperamental traits support the importance of interactions
between genetic endowment (nature) and environmental experience (nurture) in
behavior.
Attachment
Bonding is the term used to describe the intense emotional and psychological
relationship a mother develops for her baby. Attachment is the relationship the baby
develops with its caregivers. Infants in the first months after birth become attuned to
social and interpersonal interaction. They show a rapidly increasing responsivity to the
external environment and an ability to form a special relationship with significant
primary caregivers—that is, to form an attachment. Table 31.1-7 lists the commonly
observed attachment styles.
Table 31.1-7
Types of Attachment
Harry Harlow.
Harry Harlow studied social learning and the effects of social
isolation in monkeys. Harlow placed newborn rhesus monkeys with two types of
surrogate mothers—one a wire-mesh surrogate with a feeding bottle and the other a
wire-mesh surrogate covered with terry cloth. The monkeys preferred the terry-cloth
surrogates, which provided contact and comfort, to the feeding surrogate. (When
hungry, the infant monkeys would go to the feeding bottle but then would quickly
return to the terry-cloth surrogate.) When frightened, monkeys raised with terry-cloth
surrogates showed intense clinging behavior and appeared to be comforted, whereas
those raised with wire-mesh surrogates gained no comfort and appeared to be
disorganized. The results of Harlow’s experiments were widely interpreted as indicating
that infant attachment is not simply the result of feeding.
Both types of surrogate-reared monkeys were subsequently unable to adjust to life in a
monkey colony and had extraordinary difficulty learning to mate. When impregnated,
the female monkeys failed to mother their young. These behavioral peculiarities were
attributed to the isolates’ lack of mothering in infancy.
John Bowlby.
John Bowlby studied the attachment of infants to mothers and
concluded that early separation of infants from their mothers had severe negative
effects on children’s emotional and intellectual development. He described attachment
behavior, which develops during the first year of life, as the maintenance of physical
contact between the mother and child when the child is hungry, frightened, or in
distress.
Mary Ainsworth.
Mary Ainsworth expanded on Bowlby’s observations and found
that the interaction between mother and baby during the attachment period influences
the baby’s current and future behavior significantly. Many observers believe that
patterns of infant attachment affect future adult emotional relationships. Patterns of
attachment vary among babies; for example, some babies signal or cry less than others.
Sensitive responsiveness to infant signals, such as cuddling the baby when it cries,
causes infants to cry less in later months. Close bodily contact with the mother when the
baby signals for her is also associated with the growth of self-reliance, rather than
clinging dependence, as the baby grows older. Unresponsive mothers produce anxious
babies.
Ainsworth also confirmed that attachment serves to reduce anxiety. What she called
the secured base effect enables a child to move away from the attachment figure and
explore the environment. Inanimate objects, such as a teddy bear or a blanket (called
the transitional object by Donald Winnicott), also serve as a secure base, one that often
accompanies children as they investigate the world. A growing body of literature
derived from direct observation of mother–infant interactions and longitudinal studies
has expanded on, and refined, Ainsworth’s original descriptions. Maternal sensitivity
and responsiveness are the main determinants of secure attachment. But when the
attachment is insecure, the type of insecurity (avoidant, anxious, or ambivalent) is
determined by infant temperament. Overall, male infants are less likely to have secure
attachments and are more vulnerable to changes in maternal sensitivity than are female
infants.
The attachment of the firstborn child is decreased by the birth of a second, but it is
decreased much more when the firstborn is 2 to 5 years of age when the younger sibling
is born than when the firstborn is younger than 24 months. Not surprisingly, the extent
of the decrease also depends on the mother’s own sense of security, confidence, and
mental health.
Social Deprivation Syndromes and Maternal Neglect.
Investigators,
especially René Spitz, have long documented the severe developmental retardation that
accompanies maternal rejection and neglect. Infants in institutions characterized by low
staff-to-infant ratios and frequent turnover of personnel tend to display marked
developmental retardation, even with adequate physical care and freedom from
infection. The same infants, placed in adequate foster or adoptive care, exhibit marked
acceleration in development.
Fathers and Attachment.
Babies become attached to fathers as well as to
mothers, but the attachment is different. Generally, mothers hold babies for caregiving,
and fathers hold babies for purposes of play. Given a choice of either parent after
separation, infants usually go to the mother, but if the mother is unavailable they turn
to the father for comfort. Babies raised in extended families or with multiple caregivers
are able to establish many attachments.
Stranger Anxiety.
A developmentally expected fear of strangers is first noted in
infants at about 26 weeks of age, and more fully developed by 32 weeks (8 months). At
the approach of a stranger, infants cry and cling to their mothers. Babies exposed to
only one caregiver are more likely to have stranger anxiety than babies exposed to a
variety of caregivers. Stranger anxiety is believed to result from a baby’s growing ability
to distinguish caregivers from all other persons.
Separation anxiety, which occurs between 10 and 18 months of age, is related to
stranger anxiety but is not identical to it. Separation from the person to whom the
infant is attached precipitates separation anxiety. Stranger anxiety, however, occurs
even when the infant is in the mother’s arms. The infant learns to separate as it starts to
crawl and move away from the mother, but the infant constantly looks back and
frequently returns to the mother for reassurance.
Margaret Mahler (1897–1985) proposed a theory to describe how young children
acquire a sense of identity separate from that of their mothers’. Her theory of
separation–individuation was based on observations of the interactions of children and
their mothers. Mahler’s stages of separation–individuation are outlined in Table 31.1-8.
Table 31.1-8
Stages of Separation-Individuation Proposed by Mahler
Infant Care
Clinicians are now beginning to view infants as important actors in the family drama,
ones who partly determine its course. Infants’ behavior controls mothers’ behavior, just
as mothers’ behavior modulates infants’ behavior. A calm, smiling, predictable infant is
a powerful reward for tender maternal care. A jittery, irregular, irritable infant tries a
mother’s patience. When a mother’s capacity for giving is marginal, such infant traits
may cause her to turn away from her child and thus complicate the child’s alreadytroubled beginnings.
Parental Fit
Parental fit describes how well the mother or father relates to the newborn or
developing infant; the idea takes into account temperamental characteristics of both
parent and child. Each newborn has innate psychophysiological characteristics, which
are known collectively as temperament. Chess and Thomas identified a range of normal
temperamental patterns, from the difficult child at one end of the spectrum to the easy
child at the other end.
Difficult children, who make up 10 percent of all children, have a hyperalert
physiological makeup. They react intensely to stimuli (cry easily at loud noises), sleep
poorly, eat at unpredictable times, and are difficult to comfort. Easy children, who make
up 40 percent of all children, are regular in eating, eliminating, and sleeping; they are
flexible, can adapt to change and new stimuli with a minimum of distress, and are easily
comforted when they cry. The other 50 percent of children are mixtures of these two
types. The difficult child is harder to raise and places greater demands on the parent
than the easy child. Chess and Thomas used the term goodness of fit to characterize the
harmonious and consonant interaction between a mother and a child in their
motivations, capacities, and styles of behavior. Poor fit is likely to lead to distorted
development and maladaptive functioning. A difficult child must be recognized, because
parents of such infants often have feelings of inadequacy and believe that they are
doing something wrong to account for the child’s difficulty in sleeping and eating and
their problems comforting the child. In addition, most difficult children have emotional
disturbances later in life.
Good-Enough Mothering.
Winnicott believed that infants begin life in a state of
nonintegration, with unconnected and diffuse experiences, and that mothers provide the
relationship that enables infants’ incipient selves to emerge. Mothers supply a holding
environment in which infants are contained and experienced. During the last trimester
of pregnancy and for the first few months of a baby’s life, the mother is in a state of
primary maternal preoccupation, absorbed in fantasies about, and experiences with, her
baby. The mother need not be perfect, but she must provide good-enough mothering.
She plays a vital role in bringing the world to the child and offering empathic
anticipation of the infant’s needs. If the mother can resonate with the infant’s needs, the
baby can become attuned to its own bodily functions and drives that are the basis for
the gradually evolving sense of self.
TODDLER PERIOD
The second year of life is marked by accelerated motor and intellectual development.
The ability to walk gives toddlers some control over their own actions; this mobility
enables children to determine when to approach and when to withdraw. The acquisition
of speech profoundly extends their horizons. Typically, children learn to say “no” before
they learn to say “yes.” Toddlers’ negativism is vital to the development of
independence, but if it persists, oppositional behavior connotes a problem.
Learning language is a crucial task in the toddler period. Vocalizations become
distinct, and toddlers can name a few objects and make needs known in one or two
words. Near the end of the second year and into the third year, toddlers sometimes use
short sentences. The pace of language development varies considerably from child to
child, and although a small number of children are truly late developers, most child
experts recommend a hearing test if the child is not making two-word sentences by age
2.
Developmental Milestones in Toddlers
Language and Cognitive Development.
Toddlers begin to listen to
explanations that can help them tolerate delay. They create new behaviors from old
ones (originality) and engage in symbolic activities, for instance, using words and
playing with dolls when the dolls represent something, such as a feeding sequence.
Toddlers have varied capacities for concentration and self-regulation.
Emotional and Social Development.
In the second year, pleasure and
displeasure become further differentiated. Social referencing is often apparent at this
age; the child looks to parents and others for emotional cues about how to respond to
novel events. Toddlers show exploratory excitement, assertive pleasure, and pleasure in
discovery and in developing new behavior (e.g., new games), including teasing and
surprising or fooling the parent (e.g., hiding). The toddler has capacities for an
organized demonstration of love, as when the toddler runs up and hugs, smiles, and
kisses the parent at the same time, and of protest when the toddler turns away, cries,
bangs, bites, hits, yells, and kicks. Comfort with family and apprehension with strangers
may increase. Anxiety appears to be related to disapproval and the loss of a loved
caregiver and can be disorganizing.
Sexual Development.
Sexual differentiation is evident from birth, when parents
start dressing and treating infants differently because of the expectations evoked by sex
typing. Through imitation, reward, and coercion, children assume the behaviors that
their cultures define as appropriate for their sexual roles. Children exhibit curiosity
about anatomical sex. When their curiosity is recognized as healthy and is met with
honest, age-appropriate replies, children acquire a sense of the wonder of life and are
comfortable with their own roles. If the subject of sex is taboo and children’s questions
are rebuffed, shame and discomfort may result.
Gender identity, the conviction of being male or female, begins to manifest at 18
months of age and is often fixed by 24 to 30 months. It was once widely believed that
gender identity was primarily a function of social learning. John Money reported on
children with ambiguous or damaged external genitalia who were raised as the sex
opposite to their chromosomal sex. Long-term follow-up of those individuals suggests
that the major part of gender identity is innate and that rearing may not affect the
genetic diathesis.
Gender role describes the behavior that society deems appropriate for one sex or
another, and it is not surprising that significant cultural differences exist. There may be
different expectations for boys and girls in what and with whom they play, their tone of
voice, the expression of emotions, and how they dress. Nevertheless, some
generalizations are possible. Boys are more likely than girls to engage in rough and
tumble play. Mothers talk more to girls than to boys, and by the time the child is 2 years
of age, fathers generally pay more attention to boys. Many educated, middle-class
parents determined to raise nonsexist children are startled to see their children’s
determined preference for sex-stereotyped toys: girls want to play with dolls, and boys
with guns.
Toilet Training.
The second year of life is a period of increasing social demands on
children. Toilet training serves as a paradigm of the family’s general training practices;
that is, the parent who is overly severe in the area of toilet training is likely to be
punitive and restrictive in other areas also. Control of daytime urination is usually
complete by the age of 2½, and control of nighttime urination is usually complete by
the age of 4 years, when bowel control is usually accomplished. Since 1900, the
pendulum has swung between extremes of permissiveness and control in toilet training.
The trend in the United States has been toward delayed training, but in the last few
years this trend appears to be shifting back to early training.
Toddlers may have sleep difficulties related to fear of the dark, which can often be
managed by using a nightlight. Most toddlers generally sleep about 12 hours a day,
including a 2-hour nap. Parents must be aware that children of this age may need
reassurance before going to bed and that the average 2-year-old takes about 30 minutes
to fall asleep.
Parenting Challenges.
In infancy, the major responsibility for parents is to meet
the infant’s needs in a sensitive and consistent fashion. The parental task in the toddler
stage requires firmness about the boundaries of acceptable behavior and encouragement
of the child’s progressive emancipation. Parents must be careful not to be too
authoritarian at this stage; children must be allowed to operate for themselves and to
learn from their mistakes and must be protected and assisted when challenges are
beyond their abilities.
During the toddler period, children are likely to struggle for the exclusive affection
and attention of their parents. This struggle includes rivalry, both with siblings and with
one or another parent for the star role in the family. Although children are beginning to
be able to share, they do so reluctantly. When the demands for exclusive possession are
not resolved effectively, the result is likely to be jealous competitiveness in relationships
with peers and lovers. The fantasies aroused by the struggle lead to fear of retaliation
and to displacement of fear onto external objects. In an equitable, loving family a child
elaborates a moral system of ethical rights. Parents need to balance between
punishment and permissiveness and set realistic limits on a toddler’s behavior.
PRESCHOOL PERIOD
The preschool period is characterized by marked physical and emotional growth.
Generally, between 2 and 3 years of age, children reach half their adult height. The 20
baby teeth are in place at the beginning of the stage, and by the end they begin to fall
out. Children are ready to enter school by the time the stage ends at age 5 or 6. They
have mastered the tasks of primary socialization—to control their bowels and urine, to
dress and feed themselves, and to control their tears and temper outbursts, at least most
of the time.
The term preschool for the age group of 2½ to 6 years may be a misnomer; many
children are already in school-like settings, such as preschool nurseries and day care
centers, where working mothers must often place their children. Preschool education can
be valuable, but stressing academic advancement too far beyond a child’s capabilities
can be counterproductive.
Developmental Milestones in Preschoolers
Language and Cognitive Development.
In the preschool period, children’s use
of language expands, and they use sentences. Individual words have regular and
consistent meanings at the beginning of the period, and children begin to think
symbolically. In general, however, their thinking is egocentric; they cannot place
themselves in the position of another child and are incapable of empathy. Children
think intuitively and prelogically and do not understand causal relations.
Emotional and Social Behavior.
At the start of the preschool period, children
can express such complex emotions as love, unhappiness, jealousy, and envy, both
preverbally and verbally. Their emotions are still easily influenced by somatic events,
such as tiredness and hunger. Although they still think mostly egocentrically, children’s
capacity for cooperation and sharing is emerging. Anxiety is related to loss of a person
who was loved and depended on and to loss of approval and acceptance. Although still
potentially disorganizing, anxiety can be tolerated better than in the past. Four-yearolds are learning to share and to have concern for others. Feelings of tenderness are
sometimes expressed. Anxiety over bodily injury and the loss of a loved person’s
approval is sometimes disruptive.
By the end of the preschool period, children have many relatively stable emotions.
Expansiveness, curiosity, pride, and gleeful excitement related to the self and the family
are balanced with coyness, shyness, fearfulness, jealousy, and envy. Shame and
humiliation are evident. Capacities for empathy and love are developed but are fragile
and easily lost if competitive or jealous strivings intervene. Anxiety and fears are
related to bodily injury and loss of respect, love, and emerging self-esteem. Guilt
feelings are possible.
Children between the ages of 3 and 6 years are aware of their bodies, and of
differences between the sexes. In their play, doctor–nurse games allow children to act
out their sexual fantasies. Their awareness of their bodies extends beyond the genitalia;
they show a preoccupation with illness or injury, so much so that the period has been
called “the Band-Aid phase.” Every injury must be examined and taken care of by a
parent.
Children develop a division between what they want and what they are told to do.
The division increases until a gap grows between their set of expanded desires, their
exuberance at unlimited growth, and their parents’ restrictions; they gradually turn
parental values into self-obedience, self-guidance, and self-punishment.
At the end of the preschool stage, the child’s conscience is evolving. The development
of a conscience sets the tone for the moral sense of “right and wrong.” Until about 7
years of age, children typically experience rules as “absolute” and as existing for their
own sake. They do not understand that more than one point of view on a moral issue
may exist; a violation of the rules calls for absolute retribution—that is, children have
the notion of immanent justice.
SIBLING RIVALRY. In the preschool period, children relate to others in new ways. The
birth of a sibling (a common occurrence during this time) tests a preschool child’s
capacity for further cooperation and sharing but may also evoke sibling rivalry, which is
most likely to occur at this time. Sibling rivalry depends on child-rearing practice.
Favoritism for any reason commonly aggravates such rivalry. Children who get special
treatment because they are gifted, are defective in some way, or have a preferred
gender are likely to receive angry feelings from their siblings. Experiences with siblings
can influence growing children’s relationships with peers and authority; for example, a
problem may result if the needs of a new baby prevent the mother from attending to a
firstborn child’s needs. If not handled properly, the displacement of the firstborn can be
a traumatic event.
PLAY. In the preschool years, children begin to distinguish reality from fantasy, and
play reflects this growing awareness. Pretend games are popular and help test real-life
situations in a playful manner. Dramatic play in which children act out a role, such as a
housewife or a truck driver, is common. One-to-one play relationships advance to
complicated patterns with rivalries, secrets, and two-against-one intrigues. Children’s
play behavior reflects their level of social development.
Between 2½ and 3 years, children commonly engage in parallel play, solitary play
alongside another child with no interaction between them. By age 3, play is often
associative, that is, playing with the same toys in pairs or in small groups, but still with
no real interaction among them. By age 4, children are usually able to share and engage
in cooperative play. Real interactions and taking turns become possible.
Between 3 and 6 years of age, growth can be traced through drawings. A child’s first
drawing of a human being is a circular line with marks for the mouth, nose, and eyes;
ears and hair are added later; arms and stick-like fingers appear next; and then legs
appear. Last to appear is a torso in proportion to the rest of the body. Intelligent
children can deal with details in their art. Drawings express creativity throughout a
child’s development: They are representational and formal in early childhood, make use
of perspective in middle childhood, and become abstract and affect-laden in
adolescence. Drawings also reflect children’s body image concepts and sexual and
aggressive impulses.
IMAGINARY COMPANIONS. Imaginary companions most often appear during preschool
years, usually in children with above-average intelligence and usually in the form of
persons. Imaginary companions may also be things, such as toys that are
anthropomorphized. Some studies indicate that up to 50 percent of children between the
ages of 3 and 10 years have imaginary companions at one time or another. Their
significance is not clear, but these figures are usually friendly, relieve loneliness, and
reduce anxiety. In most instances, imaginary companions disappear by age 12, but they
can occasionally persist into adulthood.
MIDDLE YEARS
The period between age 6 and puberty is often called the middle years. During this time,
children enter elementary school. The formal demands for academic learning and
accomplishment become major determinants of further personality development.
Developmental Milestones in School-age Children
Language and Cognitive Development.
In the middle years, language
expresses complex ideas with relations among several elements. Logical exploration
tends to dominate fantasy, and children show an increased interest in rules and
orderliness and an increased capacity for self-regulation. During this period, children’s
conceptual skills develop, and thinking becomes organized and logical. The ability to
concentrate is well established by age 9 or 10, and by the end of the period, children
begin to think in abstract terms. Improved gross motor coordination and muscle
strength enable children to write fluently and draw artistically. They are also capable of
complex motor tasks and activities, such as tennis, gymnastics, golf, baseball, and
skateboarding.
Recent evidence has shown that changes in thinking and reasoning during the middle
years result from maturational changes in the brain. Children are now capable of
increased independence, learning, and socialization. Theorists consider moral
development a gradual, stepwise process spanning childhood, adolescence, and young
adulthood.
In the middle years, both girls and boys make new identifications with other adults,
such as teachers and counselors. These identifications may so influence girls that their
goals of wanting to marry and have babies, as their mothers did, may be combined with
a desire for a career or may be postponed or abandoned entirely.
Girls who cannot identify with their mothers or whose fathers are overly attached may
become fixated at about a 6-year-old level; as a result, they may fear men or women or
both or become seductively close to them. In either case, such girls may not be seen as
normal during the school-age years. A similar situation can occur in boys who have been
unable to identify successfully with fathers who were aloof, brutal, or absent. Perhaps
his mother prevented a boy from identifying with his father by being overprotective or
by binding the son too closely to her. As a result, boys may enter this period with a
variety of problems. They may be fearful of men, unsure of their sense of masculinity, or
unwilling to leave their mothers (sometimes manifested by a school phobia); they may
lack initiative and be unable to master school tasks, thus incurring academic problems.
The school-age period is a time when peer interaction assumes major importance.
Interest in relationships outside the family takes precedence over those within the
family. Nevertheless, a special relationship exists with the same-sex parent, with whom
children identify and who is now an ideal and a role model.
Empathy and concern for others begin to emerge early in the middle years; by the
time children are 9 or 10, they have well-developed capacities for love, compassion, and
sharing. They have a capacity for long-term, stable relationships with family, peers, and
friends, including best friends. Emotions about sexual differences begin to emerge as
either excitement or shyness with the opposite sex. School-age children prefer to interact
with children of the same sex. Although the middle years have sometimes been referred
to as a latency period—a moratorium on psychosexual exploration and play until the
eruption of sexual impulses with puberty—it is now recognized that a considerable
amount of sexual interest continues through these years. Sex play and curiosity are
common, especially among boys, but also among girls. Boys compare genitals and
sometimes engage in group or mutual masturbation. An interest in anal humor and
toilet jokes is often seen. Children this age often start using sexual and excretory words
as expletives.
BEST FRIEND. Harry Stack Sullivan postulated that a buddy, or best friend, is an
important phenomenon during the school years. By about 10 years of age, children
develop a close same-sex relationship, which Sullivan believed is necessary for further
healthy psychological growth. Moreover, Sullivan believed that the absence of a chum
during the middle years of childhood is an early harbinger of schizophrenia.
SCHOOL REFUSAL. Some children refuse to go to school at this time, generally because of
separation anxiety. A fearful mother may transmit her own fear of separation to a child,
or a child who has not resolved dependence needs panics at the idea of separation.
School refusal is usually not an isolated problem; children with the problem typically
avoid many other social situations.
Sex Role Development
Persons’ sex roles are similar to their gender identity; persons see themselves as male or
female. The sex role also involves identification with culturally acceptable masculine or
feminine ways of behaving; but changing expectations in society (particularly in the
United States) of what constitutes masculine and feminine behavior can create
ambiguity.
Parents react differently to their male and female children. Independence, physical
play, and aggressiveness are encouraged in boys; dependence, verbalization, and
physical intimacy are encouraged in girls. Nowadays, however, boys are encouraged to
verbalize their feelings and to pursue interests traditionally associated with girls,
whereas girls are encouraged to pursue careers traditionally dominated by men and to
participate in competitive sports. As society grows more tolerant in its expectations of
the sexes, roles become less rigid, and opportunities for boys and girls enlarge and
broaden.
Biologically, boys are more physically aggressive than girls; and parental
expectations, particularly the expectations of fathers, reinforce this trait. Differences
also exist between boys and girls in the influence of persons outside the family. Girls
tend to respond to the expectations and opinions of girls and of teachers of either sex,
but to ignore boys. Boys, on the other hand, tend to respond to other boys, but to ignore
girls and teachers.
Dreams and Sleep
Children’s dreams can have a profound effect on behavior. During the first year of life,
when reality and fantasy are not yet fully differentiated, dreams may be experienced as
if they were, or could be, true. At age 3, many children believe dreams are shared
directly by more than one person, but most 4-year-olds understand that dreams are
unique to each person. Children view dreams either with pleasure or, as is most often
reported, with fear. The dream content should be seen in connection with children’s life
experience, developmental stage, mechanisms used during dreaming, and sex.
Disturbing dreams peak when children are 3, 6, and 10 years of age. Two-year-old
children may dream about being bitten or chased; at the age of 4, they may have many
animal dreams and also dream of persons who either protect or destroy. At age 5 or 6,
dreams of being killed or injured, of flying and being in cars, and of ghosts become
prominent; the role of conscience, moral values, and increasing conflicts are concerned
with these themes. In early childhood, aggressive dreams rarely seem to occur; instead,
dreamers are in danger, a state that perhaps reflects children’s dependent position. By
about the age of 5, children realize that their dreams are not real; before then, they
believed them to be real events. By age 7, children know that they create their dreams
themselves.
Between the ages of 3 and 6 years, children normally want to keep their bedroom
door open or to have a nightlight, so that they can either maintain contact with their
parents or view the room in a realistic, nonfearful way. At times, children resist going to
sleep to avoid dreaming. Disorders associated with falling asleep, therefore, are often
connected with dreaming. Children often create rituals to protect themselves in the
withdrawal from the world of reality into the world of sleep. Parasomnias, such as
sleepwalking, sleep talking, enuresis (bed-wetting), and night terrors, are common at
this age. They usually occur during stage 4 sleep when dreaming is minimal, and they
do not indicate emotional trouble or underlying psychopathology. Most children grow
out of parasomnias by adolescence.
Periods of REM occur about 60 percent of the time during the first few weeks of life, a
period when infants sleep two thirds of the time. Premature babies sleep even longer
than full-term babies, and a greater proportion of their sleep is REM sleep. The sleep–
wake cycle of newborns is about 3 hours long. Among adults, the dream-to-sleep ratio is
stable: 20 percent of sleeping time is spent dreaming. Even newborns have brain
activity similar to that of the dreaming state.
Birth Spacing
For women in the United States, 10 percent of conceptions that lead to live births are
considered unwanted, and 20 percent are wanted but considered ill timed.
Children born close together have higher rates of premature or underweight births,
and malnutrition; they develop more slowly and are at increased risk of contracting and
dying from childhood infectious diseases. Studies have shown when a child is born 3 to 5
years after a previous birth, health risks are reduced for both mother and child.
Compared with 24- to 29-month intervals, children born in 36- to 41-month intervals are
associated with a 28 percent reduction in stunting and a 29 percent reduction of low
birth weight. Women who have children at 27- to 32-month intervals are 1.3 times more
likely to avoid anemia, 1.7 times more likely to avoid third-trimester bleeding, and 2.5
times more likely to survive childbirth.
Birth Order
The effects of birth order vary. Firstborn children are often more highly valued and
given more attention than subsequent children. Firstborn children appear to be more
achievement oriented and motivated to please their parents than subsequent children
born to the same parents. Some studies show that people in certain competitive
occupational areas, such as architecture, accounting, and engineering, tend to be
firstborn children.
Second and third children have the advantage of their parents’ previous experience.
Younger children also learn from their older siblings. For example, they may show more
sophisticated use of pronouns at an earlier age than firstborns did. When children are
spaced too closely, however, there may not be enough time for each child. The arrival of
new children in the family affects not only the parents but also the siblings. Firstborn
children may resent the birth of a new sibling, who threatens their sole claim on
parental attention. In some cases, regressive behavior, such as enuresis or thumbsucking, occurs.
According to Frank Sulloway, firstborn children tend to be conservative and
conformists; by contrast, youngest children tend to be independent and rebellious in
regard to family and cultural norms. Sulloway found that a high proportion of
prominent persons were lastborn children. He ascribes these differences to birth order
and suggests that each child develops personality traits to fit an unfilled slot in the
family. His findings need to be replicated.
Children and Divorce
Many children live in homes in which divorce has occurred. Approximately 30 to 50
percent of all children in the United States live in homes in which one parent (usually
the mother) is the sole head of the household, and 61 percent of all children born in any
given year can expect to live with only one parent before they reach the age of 18
years. A child’s age at the time of the parents’ divorce affects the child’s reaction to the
divorce. Immediately after a divorce, an increase in behavioral and emotional disorders
appears in all age groups. Infants do not understand anything about separation or
divorce; however, they do notice changes in their parents’ responses to them and may
experience changes in their eating or sleeping patterns; have bowel problems; and seem
more fretful, fearful, or anxious. Children 3- to 6-years of age may not understand what
is happening, and those who do understand often assume that they are somehow
responsible for the divorce. Older children, especially adolescents, comprehend the
situation and may believe that they could have prevented the divorce had they
intervened in some way, but they are still hurt, angry, and critical of their parents’
behavior.
Some children harbor the fantasy that their parents will be reunited in the future. Such
children may show animosity toward a parent’s real or potential new mate because they
are faced with the reality that reconciliation between their parents is not taking place.
Adaptation to the effects of divorce in children typically takes several years; however,
up to about one third of children from divorced homes may have lasting psychological
trauma. Among boys, physical aggression is a common sign of distress. Adolescents tend
to spend more time away from the parental home after the divorce. Children who adapt
best to divorce are typically in a situation in which both parents make genuine efforts to
spend time and relate to the child despite the child’s potential anger about the divorce.
To facilitate adaptation in children, a divorced couple who are amicable, and avoid
arguing with one another is most likely to succeed. Table 31.1-9 lists potential
psychological effects of divorce on children.
Table 31.1-9
Effects of Divorce on Children
Stepparents.
Although there are many different scenarios that may occur after a
divorce and remarriage, several potential scenarios have been outlined in Table 31.1-10.
These include: (1) Neo-traditional, (2) Romantic, and (3) Matriarchal. When remarriage
occurs, children must learn to adapt to the stepparent and to the “blended” family.
Adaptation is often challenging, especially when a child feels that a stepparent is
nonsupportive, resents the stepchild, or favors his or her own natural children. Of stepfamilies, 25 percent tend to dissolve within the first 2 years, whereas 75 percent grow to
find a new balance in their blended family. A biological child born to a new couple with
a stepchild already in the home may receive more attention than the stepchild, leading
to of sibling rivalry. After 5 years, about 20 percent of adolescents in step-families
suggest that they move out and try living with their other biological parent.
Table 31.1-10
Types of Step-Families
Family Factors in Child Development
Family Stability.
Parents and children living under the same roof in harmonious
interaction is the expected cultural norm in Western society. Within this framework,
childhood development presumably proceeds most expeditiously. Deviations from the
norm, such as divorced- and single-parent families, are associated with a broad range of
problems in children, including low self-esteem, increased risk of child abuse, and
increased incidence of divorce when they eventually marry, and increased incidence of
mental disorders, particularly depressive disorders and antisocial personality disorder as
adults. Why some children from unstable homes are less affected than others (or even
immune to these deleterious effects) is of great interest. Michael Rutter has postulated
that vulnerability is influenced by sex (boys are more affected than girls), age (older
children are less vulnerable than younger ones), and inborn personality characteristics.
For example, children who have a placid temperament are less likely to be victims of
abuse within a family than are hyperactive children; by virtue of their placidity, they
may be less affected by the emotional turmoil surrounding them.
Adverse Events.
It is now well known that significant adverse events, especially in
early childhood such as sexual and physical abuse, neglect, or loss of a parent, interact
with genetic background in a given child and influences the trajectory of development.
For example, as mentioned earlier early severe maltreatment such as sexual abuse
increases the risk of multiple psychosocial difficulties and emergence of many
psychiatric disorders. Among young maltreated children, those with particular genetics,
that is, who have the “short” variant of the serotonin transporter gene (short 5-HTTLPR
polymorphism) are significantly more vulnerable to chronic depression in adulthood.
This example of specific gene–environment interaction plays an important role in a
child’s development as well as in the risk for future psychopathology. Current
investigations are also seeking insight into what factors lead to resilience in youth who
have been exposed to adverse events, yet maintain allostasis, that is, stability in the face
of stressful events. Hormones of the adrenal glands, thyroid, gonads, as well as
metabolic hormones play a role on the brain’s ability to maintain stability upon
exposure to stress, and the prefrontal cortex, hippocampus, and amygdala play critical
roles in regulating emotionality, aggression, and resilience.
Day Care Centers.
The role of day care centers for children is under continuous
investigation, and various studies have produced different results. One study found that
children placed in day care centers before the age of 5 are less assertive and less
effectively toilet trained than home-reared children. Another study found children in day
care to be more advanced in social and cognitive development than children who were
not in day care. The National Institute of Child Health and Human Development
reported that 4½ year olds who had spent more than 30 hours a week in child care were
more demanding, more aggressive, and more noncompliant than those raised at home
and showed higher cognitive skills, particularly in math and reading. These same
children who were tracked through the third grade continued to score higher in math
and reading skills but had poorer work habits and social skills. The researchers were
careful to note that this behavior was within the normal range, however.
All studies of day care must take into account the quality of both the day care center
and the homes from which children come. For example, a child from a disadvantaged
home may be better off at a day care center than a child from an advantaged home.
Similarly, a woman who wishes to leave the home to work for financial or other reasons
and cannot do so may resent being forced to remain in the home in a child-rearing role,
which may adversely affect the child.
Parenting Styles.
The ways in which children are raised vary considerably
between and within cultures. Rutter has clustered the diversity into four general styles.
Subsequent research has confirmed that certain styles tend to correlate with certain
behavior in the children, although the outcomes are by no means absolute. The
authoritarian style, characterized by strict, inflexible rules, can lead to low self-esteem,
unhappiness, and social withdrawal. The indulgent-permissive style, which includes
little or no limit setting coupled with unpredictable parental harshness, can lead to low
self-reliance, poor impulse control, and aggression. The indulgent-neglectful style, one
of noninvolvement in the child’s life and rearing, puts the child at risk for low selfesteem, impaired self-control, and increased aggression. The authoritative-reciprocal
style, marked by firm rules and shared decision-making in a warm, loving environment,
is believed to be the style most likely to result in self-reliance, self-esteem, and a sense
of social responsibility.
Development and Expression of Psychopathology
The expression of psychopathology in children can be related to both age and
developmental level. Specific developmental disorders, particularly developmental
language disorders, often are diagnosed in the preschool years. Delayed development of
language is a common parental concern. Children who do not use words by 18 months
or phrases by 2½ to 3 years may need assessment, particularly if they do not appear to
understand normal verbal cues or much language at all. Mild mental retardation or
specific learning problems often are not diagnosed until after the child begins
elementary school. Disruptive behavior disorder will become apparent at that time as
the child begins to interact with peers. Similarly, attention-deficit disorders are only
diagnosed when the demands for sustained attention are made in school. Other
conditions, particularly schizophrenia and bipolar disorder, are rare in preschool and
school-aged children.
ADOLESCENCE
Adolescence, marked by the physiological signs and surging sexual hormones of puberty,
is the period of maturation between childhood and adulthood. Adolescence is a
transitional period in which peer relationships deepen, autonomy in decision-making
grows, and intellectual pursuits and social belonging are sought. Adolescence is largely
a time of exploration and making choices, a gradual process of working toward an
integrated concept of self. Adolescents can best be described as “works in progress,”
characterized by increasing ability for mastery over complex challenges of academic,
interpersonal, and emotional tasks, while searching for new interests, talents, and social
identities. A body of growing literature of the specific mechanisms of brain development
in adolescence has increased our understanding of broadening social skills in
adolescents, in addition to the three expected developmental changes in adolescence:
increased risk taking, increased sexual behavior, and a move toward peer affiliation
rather than primary family attachment. The total cortical gray matter is at its peak at
about age 11 years in girls and 13 years in boys, which enhances the ability to
understand subtle social situations, control impulses, make long range plans, and think
ahead. White matter volume increases throughout childhood and adolescence, which
may allow for increased “connectivity,” thereby enhancing the abilities of adolescents to
acquire new competencies, such as those needed to master today’s technology.
What is Normal Adolescence?
The concept of normality in adolescent development refers to the degree of
psychological adaptation that is achieved while navigating the hurdles and meeting the
milestones characteristic of this period of growth. For up to approximately 75 percent of
youth, adolescence is a period of successful adaptation to physical, cognitive, and
emotional changes, largely continuous with their previous functioning. Psychological
maladjustment, self-loathing, disturbance of conduct, substance abuse, affective
disorders, and other impairing psychiatric disorders emerge in approximately 20 percent
of the adolescent population.
Adolescent adjustment is continuous with previous psychological function; thus,
psychologically disturbed children are at greater risk for psychiatric disorders during
adolescence. Adolescents with psychiatric disorders are at increased risk for greater
conflicts with families and for feeling alienated from their families. Although up to 60
percent of adolescents endorse occasional distress, or a psychiatric symptom, this group
of adolescents functions well academically and with peers and describes themselves as
generally satisfied with their lives.
The developmentalist Erik Erikson characterizes the normative task of adolescence as
identity versus role confusion. The integration of past experiences with current changes
takes place in what Erikson terms ego identity. Adolescents explore various aspects of
their psychological selves by becoming fans of heroes, or other well-known musical or
political idols. Some adolescents appear consumed by their identification with a
particular idol, whereas others are more moderate in their expression. Adolescents who
feel accepted by a peer group and are involved in a variety of activities are less likely to
become consumed by adoration of an idol. Adolescents who are socially isolated, feel
socially rejected, and become overly identified with an idol to the exclusion of all other
activities are at greater risk for serious emotional problems and require psychiatric
intervention.
Erickson uses the term moratorium to describe that interim period between the
concrete thinking of childhood and a more evolved complex ethical development.
Erikson defines identity crisis as a normative part of adolescence in which adolescents
pursue alternative behaviors and styles and, then, successfully mold these different
experiences into a solid identity. A failure to do so would result in identity diffusion, or
role confusion, in which the adolescent lacks a cohesive or confident sense of identity.
Adolescence is the time to bond with peers, experiment with new beliefs and styles, fall
in love for the first time, and explore creative ideas for future endeavors.
Most adolescents go through this developmental process with optimism, develop good
self-esteem, maintain good peer relationships, and sustain basically harmonious
relationships with their families.
Stages of Adolescence
Early Adolescence.
Early adolescence, from 12 to 14 years of age, is the period in
which the most striking initial changes are noticed—physically, attitudinally, and
behaviorally. Growth spurts often begin in these years for boys, whereas girls may have
already had rapid growth for 1 to 2 years. At this stage, boys and girls begin to criticize
usual family habits, insist on spending time with peers with less supervision, have a
greater awareness of style and appearance, and may question previously accepted
family values. A new awareness of sexuality may be displayed by increased modesty
and embarrassment with their current physical development or may exhibit itself in an
increased interest in the opposite sex.
Early adolescents engage in subtle or overt displays of their growing desire for
autonomy, sometimes with challenging behaviors toward authority figures, including
teachers and school administrators, and exhibit disdain for rules themselves. At this age,
some adolescents begin to experiment with cigarettes, alcohol, and marijuana.
During early adolescence, there is normal variation in when new defining behaviors
are acquired. Overall, although many early adolescents make new friends and modify
their public image, most maintain positive connections to family members, old friends,
and their family’s values. However, early adolescence has been viewed as a time of
overwhelming turmoil, during which there is a dramatic rejection of family, friends, and
lifestyle, resulting in a powerful alienation of the adolescent.
Jake, a 13-year-old adolescent, had just started the 8th grade. In the past, he has
been a jovial, fun-loving, and cooperative student, but this year he found the school
rules increasingly irritating and felt that his teachers were too strict. He had always
been a good student while putting in a minimum of work. His older brother Sean, now
in 11th grade, had established himself as a compliant, well-liked, and well-behaved
student who always put maximal effort into school projects in the same school, so
Jake was compared with his brother on a regular basis by many teachers. Jake
resented these comparisons because, unlike his brother, whom Jake felt was a “nerd,”
Jake was more rebellious, took more risks, and made friends with more popular peers.
To distinguish himself from his older brother in school and at home, Jake began to
challenge the rules at school, stating that they were “stupid” and “meaningless.” Jake
began to cut classes, to stay out late, and to experiment with alcohol and marijuana.
He rejected his best friends from 6th and 7th grade, and began to hang out with peers
who were more daring. When Jake was at home, he was able to relate to his older
brother Sean only when they played basketball and video games.
Jake’s grades began to deteriorate only slightly, but his parents noticed that on his
report cards, his effort and behavior were rated as unsatisfactory. During the second
month of school, Jake’s parents received a phone call that Jake was going to be
suspended due to possession of a small amount of marijuana on the school grounds
during recess. During a subsequent meeting with the assistant principal and school
counselor, Jake argued that the suspension was unfair because his grades were still
good, and did not understand why his marijuana possession had triggered a
suspension. When confronted with the fact that he had not only broken the school
rules, but also violated the law, and that he was fortunate because the school did not
involve the police, Jake became angry and continued to insist that he was being
treated unfairly. He also blurted out that all of his teachers and his parents favored his
older brother Sean, and treated him like a second-class citizen. Jake was suspended
for 5 days, but the school indicated that they would report the incident to the police
unless Jake and his family initiated immediate counseling.
Jake begrudgingly began psychotherapy and entered into a weekly therapy group
specializing in substance use, for teens. Jake’s parents also sought therapy to work on
becoming more unified in their parenting. Jake remained in psychotherapy for the
next 1½ years, during which time his attitude and reasoning style changed and
evolved considerably. At age 15, Jake was able to understand why his school had
suspended him for possession of marijuana and came to appreciate their willingness
to give him the chance to seek counseling, rather than be turned over to the police.
Over time, Jake was able to admit the dangers of using drugs, and took responsibility
for his ill-advised behaviors. Alcohol and drug use continued to be a focus of his
therapy and, by 15, Jake had virtually lost interest in alcohol, and admitted to
smoking marijuana rarely at parties. Jake became more open to making friends with
a variety of peers, and he disclosed that he liked himself better now than when he was
13. He now treated his brother respectfully when alone or with friends, and he felt
that his parents appreciated him for “who he was.” (Courtesy of Caroly S. Pataki,
M.D.).
Middle Adolescence.
During the middle phase of adolescence (roughly between
the ages of 14 and 16), adolescents’ lifestyles may reflect their efforts to pursue their
own stated goals of being independent. Their abilities to combine abstract reasoning
with realistic decision-making and the application of social judgment is put to the test in
this phase of adolescent development. In this phase, sexual behavior intensifies, making
romantic relationships more complicated, and self-esteem becomes a pivotal influence
on positive and negative risk-taking behaviors.
In this phase of development, adolescents tend to identify with a group of peers who
become highly influential in their choices of activities, styles, music, idols, and role
models. Adolescents’ underestimation of the risks associated with a variety of
recreational behaviors and their sense of “omnipotence,” mixed with their drive to be
autonomous, frequently cause some conflict with parental requests and expectations.
For most teens, the process of defining themselves as unique and different from their
families can be achieved while still maintaining alliances with family members.
Jenna, a 16-year-old junior in high school, had just gotten her driver’s license. She
realized that she was lucky to have been given a brand new car at 16, because many
of her friends did not yet have cars, she was upset that her parents disapproved of her
agreement to drive all of her friends to places that she did not even want to go. Jenna
was an attractive and well-liked adolescent who had always been an “A” and “B”
student, and she and her family had never had conflicts about school. She played the
flute in the school’s orchestra, and was not involved in any team sports. Jenna started
“going out” with a boy in her grade at school, Brett, who was also 16 years old,
shortly after she got her license, and even though they didn’t know each other that
well, she felt that they had a close relationship. Since he did not yet have a car, she
was the “identified driver” whenever they went out or to parties. Jenna was glad
about this, because she didn’t really like alcohol and was relieved that Brett would not
be driving, given that he like to drink quite a bit at parties. Jenna got along fairly
well with her parents, who were considered very “easy-going” by her friends, and she
felt that she and her parents had similar values and ideas.
Things were going well until Brett began to pressure her to go further in their
sexual relationship. When Jenna told him that she wasn’t ready, Brett hounded her
more. When the subject of sex had come up with her parents “hypothetically” in the
past, they had dismissed the subject, indicating that when it was the right time for her,
Jenna would know. Jenna knew that she was not ready to have sex, although many
of her classmates were sexually active. Jenna was not an impulsive person and liked
to plan things carefully so that they would feel right to her. Jenna realized that she
could not agree with Brett’s request but she was confident that she could make him
understand. One of Jenna’s friends suggested that Brett might break up with her if she
didn’t have sex with him, but Jenna was willing to take that risk. Jenna carefully told
Brett that she loved him but she was not yet ready for sex. Jenna was slightly
surprised that instead of pressuring her more, or breaking up with her, Brett accepted
her decision, in fact, he seemed a little relieved.
Jenna and Brett continued their relationship into their senior year of high school,
and, toward the end of her senior year, Jenna desired to be sexually active with him.
They decided to go to a community clinic known for its positive attitude toward
adolescents, to learn about birth control methods and pick one, without the including
their parents. Jenna and Brett took the time to learn about a variety of birth control
methods and chose to use condoms. When they left the clinic, Jenna and Brett felt
closer than they had before, and realized how they had both grown in their
relationship. Jenna and Brett both felt that they were doing the right thing. (Courtesy
of Caroly S. Pataki, M.D.).
Late Adolescence.
Late adolescence (between the ages of 17 and 19) is a time
when continued exploration of academic pursuits, musical and artistic tastes, athletic
participation, and social bonds lead a teen toward greater definition of self and a sense
of belonging to certain groups or subcultures within mainstream society. Well-adjusted
adolescents can be comfortable with current choices of activities, tastes, hobbies, and
friendships, yet remain aware that their “identities” will continue to be refined during
young adulthood.
Joey was in his second semester of his freshman year of college, living away from
home, and had just turned 18 years of age. He reflected on the fact that he was no
longer a “minor” and could make almost any decision for himself without his parents
being involved.
Joey felt liberated, but at the same time, he was confused and a little lost. Since
10th grade, Joey had planned to pursue a career in medicine like his father, so he had
taken a heavy load of science courses in the first semester, all of which he had
despised. This semester, however, he had signed up only for liberal arts classes. He did
not mention this to his father. He was now enrolled in classes that ranged from art
history to architectural drafting to sociology, philosophy, and music. He had been
influenced, he believed, by his roommate Tony, who was in the architecture program,
and by his girlfriend, Lisa, who was majoring in studio art.
As the semester progressed, Joey found that his favorite course was the drafting
class, just like Tony had predicted. Tony was in a more advanced drafting class than
Joey, and Joey couldn’t help but wonder whether he liked the drafting class so much
because of how much he idolized Tony, or because he really enjoyed the class. He
talked this over with Lisa, who suggested that he chill out and not figure out the rest
of his life right now. She recommended that he take at least two more semesters of
varied classes including those in the architecture curriculum before making a final
decision about a career. Joey realized that Lisa’s approach to college, and to life was
so relaxed, the opposite of his approach, following his parents’ pressure to plan
ahead, make commitments early, and see them through, regardless of how it felt.
Lisa’s approach left more room for reflecting on experiences, and then making a
choice, rather than jumping into what he was “supposed” to do. Joey took her advice
and allowed himself another year to try out majors and then decide on a career. After
experiencing courses in many varied subjects, Joey decided that he did truly enjoy
architecture and was able to switch his focus from premed to architecture. (Courtesy
of Caroly S. Pataki M.D.)
Components of Adolescence
Physical Development.
Puberty is the process by which adolescents develop
physical and sexual maturity, along with reproductive ability. The first signs of the
pubertal process are an increased rate of growth in both height and weight. This process
begins in girls by approximately 10 years of age. By the age of 11 or 12, many girls
noticeably tower over their male classmates, who do not experience a growth spurt, on
average, until they reach 13 years of age. By age 13, many girls have experienced
menarche, and most have developed breasts and pubic hair.
Wide variation exists in the normal range of onset and timing of pubertal
development and its components. A set sequence occurs, however, in the order in which
pubertal development proceeds. Thus, secondary sexual characteristics in boys, such as
increased length and width of the penis, for example, will occur after the release of
androgens from developed enlarged testes.
Sexual maturity ratings (SMR), also referred to as Tanner Stages, range from SMR 1
(prepuberty) to SMR 5 (adult). The SMR ratings include stages of genital maturity in
boys and breast development in girls, as well as pubic hair development. Table 31.1-11
outlines sexual maturity ratings for boys and girls.
Table 31.1-11
Sexual Maturity Ratings for Male and Female Adolescents
The primary female sex characteristic is ovulation, the release of eggs from ovarian
follicles, approximately once every 28 days. When adolescent girls reach SMR 3 to 4,
ovarian follicles are producing enough estrogen to result in menarche, the onset of
menstruation. When adolescent girls reach SMR 4 to 5, an ovarian follicle matures on a
monthly basis and ovulation occurs. Estrogen and progesterone promote sexual
maturation, including further development of fallopian tubes and breasts.
For adolescent boys, the primary sex characteristic is the development of sperm by the
testes. In boys, sperm development occurs in response to follicle-stimulating hormone
acting on the seminiferous tubules within the testes. The pubertal process in boys is
marked by the growth of the testes stimulated by luteinizing hormone. An adolescent
boy’s ability to ejaculate generally emerges within 1 year of reaching SMR 2. Secondary
sexual characteristics in boys include thickening of skin, broadening of the shoulders,
and the development of facial hair.
Cognitive Maturation.
Cognitive maturation in adolescence encompasses a wide
range of expanded abilities that fall within the global category of executive functions of
the brain. These include the transition from concrete thinking to more abstract thinking;
an increased ability to draw logical conclusions in scientific pursuits, with peer
interactions and in social situations; and new abilities for self-observation and selfregulation. Adolescents acquire increased awareness of their own intellectual, artistic,
and athletic gifts and talents; yet it often takes many more years into young adulthood
to establish a practical application for these abilities.
The central cognitive change that occurs gradually during adolescence is the shift from
concrete thinking (concrete operational thinking, according to Jean Piaget) to the
ability to think abstractly (formal operational thinking, in Piaget’s terminology). This
evolution occurs as an adaptation to stimuli that demand an adolescent to produce
hypothetical responses, as well as in response to the adolescent’s expanded abilities to
provide generalizations from specific situations. The development of abstract thinking is
not a sudden epiphany but, rather, a gradual process of expanding logical deductions
beyond concrete experiences and achieving the capacity for idealistic and hypothetical
thinking based on everyday life.
Adolescents often use an omnipotent belief system that reinforces their sense of
immunity from danger, even when confronted with logical risks. Some degree of childlike magical thinking continues to coexist with more mature abstract thinking in many
adolescents. Despite the persistence of magical thinking into adolescence, adolescent
cognition departs from that of younger children insofar as the increased ability for selfobservation and development of strategies to promote strengths and compensate for
weaknesses.
One of the important cognitive tasks in adolescence is to identify and gravitate
toward those pursuits that seem to match the adolescent’s cognitive strengths, in
academic courses and in thinking about future aspirations. Piaget believed that
cognitive adaptation in adolescence is profoundly influenced by social relationships and
the dialogue between adolescents and peers, making social cognition an integral part of
cognitive development in adolescence.
Socialization.
Socialization in adolescence encompasses the ability to find
acceptance in peer relationships, as well as the development of more mature social
cognition. The skills to develop a sense of belonging to a peer group are of central
importance to a sense of well-being. Being viewed as socially competent by peers is a
critical component in building good self-esteem for most early adolescents. Peer
influences are powerful and can foster positive social interactions, as well as apply
pressure in less socially accepted behaviors or even high-risk behavior. Belonging to a
peer group is, in general, a sign of adaptation and a developmentally appropriate step
in separating from parents and turning the focus of loyalty toward friends. Children
between the ages of 6 and 12 are able to engage in exchanges of ideas and opinions and
acknowledge feelings of peers, but the relationships often wax and wane in a
discontinuous way on the basis of altercations and good times. Friendships deepen with
repeated good times but, for some school-aged children, a variety of peers are often
interchangeable—that is, a companion is sought when a given child has free time, rather
than out of a desire to spend time with a specific friend. As adolescence ensues,
friendships become more individualized, and personal secrets are likely shared with a
friend rather than a family member. A comfort level is achieved with one or several
early adolescent peers, and the group may “stick together,” spending most free time
together. In early adolescence, a blend of the above two social modes may emerge,
small “cliques” arise, and, even within the cliques, competition and jealousies regarding
which dyads are “preferred” or higher ranked within the clique may result in some
discontinuities in the relationships. In later adolescence, the peer group solidifies,
leading to increased stability in the friendships and a greater mutuality in the quality of
the interactions.
Moral Development.
Morality is a set of values and beliefs about codes of
behavior that conform to those shared by others in society. Adolescents, as do younger
children, tend to develop patterns of behaviors characteristic of their family and
educational environments and by imitation of specific peers and adults whom they
admire. Moral development is not strictly tied to chronological age but, rather, is an
outgrowth from cognitive development.
Piaget described moral development as a gradual process parallel to cognitive
development, with expanded abilities in differentiating the best interests for society
from those of individuals occurring during late adolescence. Preschool children simply
follow rules set forth by the parents; in the middle years, children accept rules but show
an inability to allow for exceptions; and during adolescence, young persons recognize
rules in terms of what is good for the society at large.
Lawrence Kohlberg integrated Piaget’s concepts and described three major levels of
morality. The first level is preconventional morality, in which punishment and
obedience to the parent are the determining factors. The second level is morality of
conventional role-conformity, in which children try to conform to gain approval and to
maintain good relationships with others. The third and highest level is morality of selfaccepted moral principles, in which children voluntarily comply with rules on the basis
of a concept of ethical principles and make exceptions to rules in certain circumstances.
Although Kohlberg’s and Piaget’s notions of moral development focus on a unified
theory of cognitive maturation for both sexes, Carol Gilligan emphasizes the social
context of moral development leading to divergent patterns in moral development.
Gilligan points out that, in women, compassion and the ethics of caring are dominant
features of moral decision-making, whereas, for men, predominant features of moral
judgments are related more to a perception of justice, rationality, and a sense of
fairness.
Self-Esteem.
Self-esteem is a measure of one’s sense of self-worth based on
perceived success and achievements, as well as a perception of how much one is valued
by peers, family members, teachers, and society in general. The most important
correlates of good self-esteem are one’s perception of positive physical appearance and
high value to peers and family. Secondary features of self-esteem relate to academic
achievement, athletic abilities, and special talents. Adolescent self-esteem is mediated,
to a significant degree, by positive feedback received from a peer group and family
members, and adolescents often seek out a peer group that offers acceptance, regardless
of negative behaviors associated with that group. Adolescent girls have more of a
problem maintaining self-esteem than do boys. Girls continued to rate themselves with
generally lower self-esteem into adulthood.
Current Environmental Influences and Adolescence
Adolescent Sexual Behavior.
Sexual experimentation in adolescents often begins
with fantasy and masturbation in early adolescence followed by noncoital genital
touching with the opposite sex or, in some cases, same-sex partners, oral sex with
partners, and initiation of sexual intercourse at a later point in development. By high
school, most male adolescents report experience with masturbation, and more than half
of adolescent girls report masturbation. The balance between healthy adolescent sexual
experimentation and emotionally and physically safe sexual practices is one of the
major challenges for society.
Estimates vary, but about 50 percent of 9th to 12th grade students reported having had
sexual intercourse. The median age at first intercourse is about 16 years for boys and 17
years for girls. Boys generally have more sexual partners than do girls, and boys are less
likely than girls to seek emotional attachments with their sexual partners.
FACTORS INFLUENCING ADOLESCENT SEXUAL BEHAVIOR. Factors that affect sexual behavior in
adolescents include personality traits, gender, cultural and religious background, racial
factors, family attitudes, and sexual education and prevention programs.
Personality factors have been found to be associated with sexual behavior, as well as
sexual risk-taking. Higher levels of impulsivity are associated with a younger age at first
experience of sexual intercourse; higher number of sexual partners; sexual intercourse
without the use of contraception, including condoms; and a history of sexually
transmitted disease (chlamydia).
Historically, male adolescents have initiated sexual intercourse at a younger age than
female adolescents. The younger a teenage girl is when she has sex for the first time, the
more likely she is to have had unwanted sexual activity. Close to four of ten girls who
had first intercourse at 13 or 14 years of age report it was either not voluntary or
unwanted. Three of four girls and over half of boys report that girls who have sex do so
because their boyfriends want them to. In general, adolescents who initiate sexual
intercourse at younger ages are also more likely to have a greater number of sexual
partners.
The additive effects of more highly educated families, social and religious youth
groups, and school-based educational programs can be credited with a decline in highrisk sexual behavior among adolescents. Responsible sexual behavior among adolescents
has been determined as one of the ten leading health indicators for the next decade. The
primary reason that teenage girls who have never had intercourse give for abstaining
from sex is that having sex would be against their religious or moral values. Other
reasons include desire to avoid pregnancy, fear of contracting a sexually transmitted
disease (STD), and not having met the appropriate partner.
CONTRACEPTIVES. Currently, 98 percent of teenagers 15 to 19 years are using at least one
method of birth control. The two most common methods are condoms and birth control
pills. STDs, despite use of condoms, are still at high levels in teens. Approximately one
in four sexually active teens contracts an STD every year. Approximately half of all new
human immunodeficiency virus (HIV) infections occur in people younger than age 25.
PREGNANCY. Each year 750,000 to 850,000 teenage girls younger than age 19 become
pregnant. Of this number, 432,000 give birth, a 19 percent decline from 532,000 in
1991; the rest (418,000) obtain abortions. The largest decline in teen pregnancy by race
is for black women. Hispanic teen births have declined 20 percent, but continue to have
the highest teen birth rates compared with other races.
Teenage pregnancy creates a plethora of health risks for both mother and child.
Children born to teenage mothers have a greater chance of dying before the age of 5
years. Those who survive are more likely to perform poorly in school and are at greater
risk of abuse and neglect. Teenage mothers are less likely to gain adequate weight
during pregnancy, increasing the risk of premature births and low-birth-weight infants.
Low-birth-weight babies are more likely to have organs that are not fully developed,
resulting in bleeding in the brain, respiratory distress syndrome, and intestinal
problems. Teenage mothers are also less likely to seek regular prenatal care and to take
recommended daily multivitamins, and they are more likely to smoke, drink, or use
drugs during pregnancy. Only one third of teenage mothers obtain high school
diplomas, and only 1.5 percent have a college degree by the age of 30.
The average adolescent mother who cannot care for her child has the child either
placed in foster care or raised by the teenager’s already overburdened parents or other
relatives. Few teenage mothers marry the fathers of their children; the fathers, usually
teenagers, cannot care for themselves, much less the mothers of their children. If the two
do marry, they usually divorce. Many are more likely to end up on welfare.
ABORTION. Nearly four of ten teen pregnancies end in abortion. Almost all the girls are
unwed mothers from low socioeconomic groups; their pregnancies result from sex with
boys to whom they felt emotionally attached. Most (61 percent) teenagers elect to have
abortions with their parents’ consent, but laws of mandatory parental consent put two
rights into competition: a girl’s claim to privacy and a parent’s need to know. Most
adults believe that teenagers should have parental permission for an abortion; but when
parents refuse to give their consent, most states prohibit parents from vetoing the
teenager’s decision.
The abortion rate in many European countries tends to be far lower than that in the
United States. In the United States, the rate of abortion among girls between the ages of
15 and 19 is about 30 per 1,000 girls, according to the Centers for Disease Control and
Prevention. In France, for instance, about 10.5 of every 1,000 girls under the age of 20
had an abortion, according to World Health Organization statistics. The rate of abortion
in Germany was 6.8; in Italy, 6.3; and in Spain, 4.5. Britain has a higher rate, 18.5.
Family planning experts believe that more sex education and availability of
contraceptive devices help keep the number of abortions down. In Holland, where
contraceptives are freely available in schools, the teenage pregnancy rate is among the
lowest in the world.
Risk-Taking Behavior.
Reasonable risk-taking is a necessary endeavor in
adolescence, leading to confidence both in forming new relationships and in sports and
social situations. High-risk behaviors among adolescents are associated with serious
negative consequences, however, and can take many forms, including drug and alcohol
use, unsafe sexual practices, self-injurious behaviors, and reckless driving.
Drug Use
ALCOHOL. About 30 percent of 12th graders report having five or more drinks in a row
within a 2-week period. The average age when youths first try alcohol is 11 years for
boys and 13 years for girls. The national average age at which Americans begin
drinking regularly is 15.9 years of age. People ages 18 to 25 show the highest
prevalence of binge and heavy drinking. Drunk driving has declined since 2002. Alcohol
dependence, along with other drugs, is associated with depression, anxiety, oppositional
defiant disorder, antisocial personality disorder, and an increased rate of suicide.
NICOTINE. The number of younger Americans who smoke has declined since 1990;
however, the rate of smoking among teenagers is still as high as or higher than that of
adults. According to the American Cancer Society, on average more than one of five
students has smoked cigarettes. Each day, more than 4,000 teenagers try their first
cigarette and another 2,000 become regular, daily smokers. Cigarette smokers are more
likely to get into fights, carry weapons, attempt suicide, suffer from mental health
problems such as depression, and engage in high-risk sexual behaviors. One of three will
eventually die from smoking-related diseases. Cigarettes are the most common type of
tobacco used among middle-school students followed by cigars, smokeless tobacco, and
pipes.
CANNABIS. Marijuana is the most popular illicit drug, with 14.6 million people using it
(6.2 percent of the population), two thirds being under the age of 18. Its use, however,
is slowly declining. About 6 percent of 12th graders report daily use of marijuana.
One of the major reasons for such prevalence of marijuana use among teenagers is
because many find that marijuana is easier to get than alcohol or cigarettes. This belief
has declined in recent years. Once teenagers are dependent on marijuana, they often
tumble into truancy, crime, and depression.
COCAINE. About 13 percent of high school seniors use cocaine. exceeding the national
average of 3.6 percent. In addition, about 1 percent of 12th graders admit to using
phencyclidine (PCP). Crystal methamphetamine (ice) has an annual prevalence in 12th
graders of about 2 percent.
OPIOIDS. In recent years, the number of teens using prescription pain relievers for
nonmedical reasons has increased. Prescription drug abuse by people ages 18 to 25 has
increased 15 percent. Drugs of specific concern are the pain relievers oxycodone
(OxyContin) and hydrocodone (Vicodin). OxyContin has gained ground among high
school students since its emergence in 2001, with 5 percent of 12th graders, 3.5 percent
of 10th graders, and 1.7 percent of 8th graders reporting use. Vicodin was used by 9.3
percent of 12th graders, 6.2 percent of 10th graders, and 2.5 percent of 8th graders.
HEROIN. Heroin use is prevalent among adolescents, although less so than cocaine. The
average age of use is 19, but it is used by almost 2 percent of 12th graders, the nasal
route (snorting) being the most common method of use.
Violence.
Although rates of violent crime have decreased throughout the United
States in recent years, violent crimes by young offenders are on the increase. Homicides
are the second leading cause of death among persons ages 15 to 25. (Accidents are first;
suicides are third.) Black male teenagers are far more likely to be murder victims than
are boys from any other racial or ethnic group or girls of any race. The factor most
strongly associated with violence among adolescent boys is growing up in a household
without a father or father surrogate; this factor aside, race, socioeconomic status, and
education show no effect on the propensity toward violence.
BULLYING. Bullying is defined as the use of one’s strength or status to intimidate, injure,
or humiliate another person of lesser strength or status. It can be categorized as
physical, verbal, or social. Physical bullying involves physical injury or threat of injury
to someone. Verbal bullying refers to teasing or insulting someone. Social bullying refers
to the use of peer rejection or exclusion to humiliate or isolate a victim.
Approximately 30 percent of 6th through 10th grade students are involved in some
aspect of moderate-to-frequent bullying, either as a bully, the target of bullying, or both.
Approximately 1.7 million children within this age group can be identified as bullies.
Boys are more likely to be involved in bullying and violent behavior than girls. Girls
tend to use verbal bullying rather than physical.
An estimated 160,000 students miss school each day because of fear of attack or
intimidation from peers; some are forced to drop out. Stresses of “victimization” can
interfere with student’s engagement and learning in school. Children who bully other
children are at risk for engaging in more serious violent behaviors, such as frequent
fighting and carrying a weapon.
Cyber Bullying.
During the last decade, electronic or internet bullying has become of
great concern to adolescents. Cyber bullying is defined broadly, to convey the use of
electronic means to intentionally intimidate or harm someone. The reported prevalence
of cyber bullying is variable, reports ranging from 1% to 62% of youth reporting that
they were victims of cyber victimization. A study of about 700 Australian students,
recruited at age 10 years, and followed until age 14 to 15 years, found that 15% had
engaged in cyber bullying, 21% had engaged in traditional bullying, and 7% had
engaged in both. Another study of self-reported information collected from 399 teens in
the 8th to 10th grades, found that involvement in cyber bullying, either as a victim or a
bully, specifically contributed to the prediction of depressive symptoms and suicidal
ideation. This correlation of cyber bullying and depressive symptomatology was found
to be stronger than the association of traditional bulling and affective disorder.
Gangs.
Gang violence is a problem in various communities throughout the United
States. There are 2,000 different youth gangs around the country with more than
200,000 teens and young adults as members. Most members are between the ages of 12
and 24 years, with an average of 17 to 18 years. Gang membership is a brief phase for
many teenagers; one half to two thirds leave the gang by the 1-year mark. Boys are
more likely to join gangs than girls; however, female gang membership may be
underrepresented. Female gang members are more likely to be found in small cities and
rural areas and tend to be younger than male gang members. Female gang members are
also involved in less delinquent or criminal activity than males and commit fewer
violent crimes.
WEAPONS. Each day, on average, nearly ten American children younger than the age of
18 years are killed in handgun suicides, homicides, and accidents. Many more are
wounded. One in five youths in grades 9 to 12 carries a weapon: knife, gun, or club.
By law, firearms cannot be sold to anyone younger than the age of 18 years. Two
thirds of students in grades 6 to 12 say that they can get a firearm within 24 hours,
however. More than 22 million children live in a home with a firearm. In 40 percent of
these homes, at least one gun is kept unlocked and 13 percent are kept unlocked and
loaded. Two of three students involved in school shootings acquired their guns from
their own home or that of a relative. At least 60 percent of suicide deaths in teens
involve the use of a handgun.
SCHOOL VIOLENCE. According to the CDC of all youth homicides in 2010 about 2 percent
occurred in schools. Approximately 7 percent of teachers report they have been
threatened with injury or physically attacked by a student from their school. In addition,
among students in grades 9 through 12, about 6 percent reported carrying a weapon on
school property on one or more days in the 30 days before the survey.
Many factors can lead to violent acts in teenagers. Some inherited traits include
impulsivity, learning difficulties, low IQ, or fearlessness. A correlation also exists
between witnessing violent acts and involvement in violence. Children who witness
violent acts are more aggressive and grow up more likely to become involved in
violence—either as a victimizer or as a victim. Table 31.1-12 lists some of the early and
imminent warning signs of school violence.
Table 31.1-12
Warning Signs of School Violence
On April 20, 1999, two teenage boys, ages 17 and 18 years, went on a shooting
rampage through Columbine High School of Littleton, Colorado. Armed with shotguns,
a semiautomatic rifle, and a pistol, they laughed and hollered as they shot classmates
and teachers at point-blank range while hurling homemade explosives. Fifteen were
killed, including the two gunmen, and 25 were injured.
The gunmen were members of the “trench coat mafia” at the high school, a clique of
social misfits who stood out at the school for their gothic style of dress and nihilistic
attitude. The two gunmen were obsessed with violent video games and intrigued with
Nazi culture, even though one was part Jewish. The date of the attack was picked
because it was Adolf Hitler’s birthday.
On March 21, 2005, a 16-year-old boy went on a shooting rampage at Red Lake
High School on the Red Lake Indian Reservation in far northern Minnesota. He began
his shooting spree by killing his grandfather and the grandfather’s companion. He
then donned his grandfather’s police-issue gun belt and bulletproof vest before
heading to the school, where he killed a security guard, a teacher, five students, and
then himself. About 15 others were injured.
The gunman had a troubled childhood; his father committed suicide in 1997 and his
mother suffered head injuries in an auto accident. He expressed admiration for Adolf
Hitler on a neo-Nazi website, using the handle “Todesengel,” which is German for
“Angel of Death.” He had bouts of depression, suicide ideation, and was taking
fluoxetine (Prozac). He was a member of a clique of about five students known as
“The Darkers,” who wore black clothes and chains, spiked or dyed their hair, and
loved heavy-metal music. The gunman was usually seen in a long black trench coat,
eyeliner, and combat boots, and was described as a quiet teenager.
SEXUAL OFFENSE. Adolescents younger than age 18 years account for 20 percent of arrests
for all sexual offenses (excluding prostitution), 20 to 30 percent of rape cases, 14
percent of aggravated sexual assault offenses, and 27 percent of child sexual homicides.
These adolescent offenders account for the victimization of approximately one half of
boys and one fourth of girls who are molested or sexually abused. Most instances have
involved adolescent male perpetrators.
There appear to be two types of juvenile sex offenders: those who target children and
those who offend against peers or adults. The main distinction between the two groups
is based on the age difference between the victim and the offender. Table 31.1-13 lists
the differences and similarities of these two groups.
Table 31.1-13
Juvenile Sex Offender Subtypes
Etiological factors of juvenile sex offending include maltreatment experiences,
exposure to pornography, substance abuse, and exposure to aggressive role models. A
significant number of offending adolescents have a childhood history of physical abuse
(25 to 50 percent) or sexual abuse (10 to 80 percent). Half of adolescent offenders lived
with both parents and one other juvenile at the time of their offending. Evidence also
suggests that most juvenile sex offenders are likely to become adult sex offenders. The
most common psychosocial deficits of adolescent sexual offenders include low selfesteem, few social skills, minimal assertive skills, and poor academic performance. The
most common psychiatric diagnoses are conduct disorder, substance abuse disorder,
adjustment disorder, attention-deficit/hyperactivity disorder, specific phobia, and mood
disorders. Male offenders are more often diagnosed with paraphilias and antisocial
behavior, whereas female offenders are more likely to be diagnosed with mood disorders
and engage in self-mutilation.
Prostitution.
Teenagers constitute a large portion of all prostitutes, with estimates
ranging up to 1 million teenagers involved in prostitution. The average age of a new
recruit is 13 years; however, some are as young as 9 years of age. Most adolescent
prostitutes are girls, but boys are involved as homosexual prostitutes. Most teenagers
who enter a life of prostitution come from broken homes; however, a growing number
of teenage prostitutes come from middle- to upper middle-class homes. Many have been
victims of rape, or were abused as children. Most teenagers ran away from home and
were taken in by pimps and substance abusers; the adolescents themselves then became
substance abusers. Twenty-seven percent of teenage prostitution occurs in large cities,
and incidents usually take place at an outside location, such as highways, roads, alleys,
fields, woods, or parking lots. Teenage prostitutes are at high risk for acquired
immunodeficiency syndrome (AIDS), and many (up to 70 percent in some studies) are
infected with HIV.
As many as 17,500 individuals are smuggled into the United States each year as “sex
slaves.” They are brought under the pretenses of a better life and job opportunities, but
once they are in the United States, they are forced into prostitution, making little money
while traffickers make thousands of dollars from their services. Many times they are
raped and abused.
Tattoos and Body Piercing.
Body piercing and tattoos have become more
prevalent among adolescents since the 1980s. In the general population, approximately
10 to 13 percent of adolescents have tattoos. Of the more than 500 adolescents surveyed
in a study, 13.2 percent report at least one tattoo, and 26.9 percent report at least one
body piercing, other than in their ear lobe, at some point in their lives. Both tattoos and
body piercing are more common in girls than in boys. Adolescents who endorsed
possession of at least one tattoo or body piercing are more likely to endorse use of
gateway drugs (cigarettes, alcohol, marijuana), as well as experience with hard drugs
(cocaine, crystal methamphetamine, and ecstasy).
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31.2 Assessment, Examination, and Psychological Testing
A comprehensive evaluation of a child is composed of interviews with the parents, the
child, and other family members; gathering information regarding the child’s current
school functioning; and often, a standardized assessment of the child’s intellectual level
and academic achievement. In some cases, standardized measures of developmental
level and neuropsychological assessments are useful. Psychiatric evaluations of children
are rarely initiated by the child, so clinicians must obtain information from the family
and the school to understand the reasons for the evaluation. In some cases, the court or
a child protective service agency may initiate a psychiatric evaluation. Children can be
excellent informants about symptoms related to mood and inner experiences, such as
psychotic phenomena, sadness, fears, and anxiety, but they often have difficulty with
the chronology of symptoms and are sometimes reticent about reporting behaviors that
have gotten them into trouble. Very young children often cannot articulate their
experiences verbally and do better showing their feelings and preoccupations in a play
situation. Assessment of a child or adolescent includes identifying the reasons for
referral; assessing the nature and extent of the child’s psychological and behavioral
difficulties; and determining family, school, social, and developmental factors that may
be influencing the child’s emotional well-being.
The first step in the comprehensive evaluation of a child or adolescent is to obtain a
full description of the current concerns and a history of the child’s previous psychiatric
and medical problems. This is often done with the parents for school-aged children,
whereas adolescents may be seen alone first, to get their perception of the situation.
Direct interview and observation of the child is usually next, followed by psychological
testing, when indicated.
Clinical interviews offer the most flexibility in understanding the evolution of
problems and in establishing the role of environmental factors and life events, but they
may not systematically cover all psychiatric diagnostic categories. To increase the
breadth of information generated, the clinician may use semistructured interviews such
as the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (KSADS); structured interviews such as the National Institute for Mental Health Diagnostic
Interview Schedule for Children Version IV (NIMH DISC-IV); and rating scales, such as the
Child Behavior Checklist and Connors Parent or Teacher Rating Scale for ADHD.
It is not uncommon for interviews from different sources, such as parents, teachers,
and school counselors, to reflect different or even contradictory information about a
given child. When faced with conflicting information, the clinician must determine
whether apparent contradictions actually reflect an accurate picture of the child in
different settings. Once a complete history is obtained from the parents, the child is
examined, the child’s current functioning at home and at school is assessed, and
psychological testing is completed, the clinician can use all the available information to
make a best-estimate diagnosis and can then make recommendations.
Once clinical information is obtained about a given child or adolescent, it is the
clinician’s task to determine whether criteria are met for one or more psychiatric
disorders according to the Fifth Edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5). This most current version is a categorical classification reflecting the
consensus on constellations of symptoms believed to comprise discrete and valid
psychiatric disorders. Psychiatric disorders are defined by the DSM-5 as a clinically
significant set of symptoms that is associated with impairment in one or more areas of
functioning. Whereas clinical situations requiring intervention do not always fall within
the context of a given psychiatric disorder, the importance of identifying psychiatric
disorders when they arise is to facilitate meaningful investigation of childhood
psychopathology.
CLINICAL INTERVIEWS
To conduct a useful interview with a child of any age, clinicians must be familiar with
normal development to place the child’s responses in the proper perspective. For
example, a young child’s discomfort on separation from a parent and a school-age
child’s lack of clarity about the purpose of the interview are both perfectly normal and
should not be misconstrued as psychiatric symptoms. Furthermore, behavior that is
normal in a child at one age, such as temper tantrums in a 2-year-old, takes on a
different meaning, for example, in a 17-year-old.
The interviewer’s first task is to engage the child and develop a rapport so that the
child is comfortable. The interviewer should inquire about the child’s concept of the
purpose of the interview and should ask what the parents have told the child. If the child
appears to be confused about the reason for the interview, the examiner may opt to
summarize the parents’ concerns in a developmentally appropriate and supportive
manner. During the interview with the child, the clinician seeks to learn about the
child’s relationships with family members and peers, academic achievement and peer
relationships in school, and the child’s pleasurable activities. An estimate of the child’s
cognitive functioning is a part of the mental status examination.
The extent of confidentiality in child assessment is correlated with the age of the child.
In most cases, almost all specific information can appropriately be shared with the
parents of a very young child, whereas privacy and permission of an older child or
adolescent are mandated before sharing information with parents. School-age and older
children are informed that if the clinician becomes concerned that any child is
dangerous to himself or herself or to others, this information must be shared with
parents and, at times, additional adults. As part of a psychiatric assessment of a child of
any age, the clinician must determine whether that child is safe in his or her
environment and must develop an index of suspicion about whether the child is a victim
of abuse or neglect. Whenever there is a suspicion of child maltreatment, the local child
protective service agency must be notified.
Toward the end of the interview, the child may be asked in an open-ended manner
whether he or she would like to bring up anything else. Each child should be
complimented for his or her cooperation and thanked for participating in the interview,
and the interview should end on a positive note.
Infants and Young Children
Assessments of infants usually begin with the parents present, because very young
children may be frightened by the interview situation; the interview with the parents
present also allows the clinician to assess the parent–infant interaction. Infants may be
referred for a variety of reasons, including high levels of irritability, difficulty being
consoled, eating disturbances, poor weight gain, sleep disturbances, withdrawn
behavior, lack of engagement in play, and developmental delay. The clinician assesses
areas of functioning that include motor development, activity level, verbal
communication, ability to engage in play, problem-solving skills, adaptation to daily
routines, relationships, and social responsiveness.
The child’s developmental level of functioning is determined by combining
observations made during the interview with standardized developmental measures.
Observations of play reveal a child’s developmental level and reflect the child’s
emotional state and preoccupations. The examiner can interact with an infant age 18
months or younger in a playful manner by using such games as peek-a-boo. Children
between the ages of 18 months and 3 years can be observed in a playroom. Children
ages 2 years or older may exhibit symbolic play with toys, revealing more in this mode
than through conversation. The use of puppets and dolls with children younger than 6
years of age is often an effective way to elicit information, especially if questions are
directed to the dolls, rather than to the child.
School-Age Children
Some school-age children are at ease when conversing with an adult; others are
hampered by fear, anxiety, poor verbal skills, or oppositional behavior. School-age
children can usually tolerate a 45-minute session. The room should be sufficiently
spacious for the child to move around, but not so large as to reduce intimate contact
between the examiner and the child. Part of the interview can be reserved for
unstructured play, and various toys can be made available to capture the child’s interest
and to elicit themes and feelings. Children in lower grades may be more interested in
the toys in the room, whereas by the sixth grade, children may be more comfortable
with the interview process and less likely to show spontaneous play.
The initial part of the interview explores the child’s understanding of the reasons for
the meeting. The clinician should confirm that the interview was not set up because the
child is “in trouble” or as a punishment for “bad” behavior. Techniques that can
facilitate disclosure of feelings include asking the child to draw peers, family members, a
house, or anything else that comes to mind. The child can then be questioned about the
drawings. Children may be asked to reveal three wishes, to describe the best and worst
events of their lives, and to name a favorite person to be stranded with on a desert
island. Games such as Donald W. Winnicott’s “squiggle,” in which the examiner draws a
curved line and then the child and the examiner take turns continuing the drawing, may
facilitate conversation.
Questions that are partially open-ended with some multiple choices may elicit the
most complete answers from school-age children. Simple, closed (yes or no) questions
may not elicit sufficient information, and completely open-ended questions can
overwhelm a school-age child who cannot construct a chronological narrative. These
techniques often result in a shoulder shrug from the child. The use of indirect
commentary—such as, “I once knew a child who felt very sad when he moved away
from all his friends”—is helpful, although the clinician must be careful not to lead the
child into confirming what the child thinks the clinician wants to hear. School-age
children respond well to clinicians who help them compare moods or feelings by asking
them to rate feelings on a scale of 1 to 10.
Adolescents
Adolescents usually have distinct ideas about why the evaluation was initiated, and can
usually give a chronological account of the recent events leading to the evaluation,
although some may disagree with the need for the evaluation. The clinician should
clearly communicate the value of hearing the story from an adolescent’s point of view
and must be careful to reserve judgment and not assign blame. Adolescents may be
concerned about confidentiality, and clinicians can assure them that permission will be
requested from them before any specific information is shared with parents, except in
situations involving danger to the adolescent or others, in which case confidentiality
must be sacrificed. Adolescents can be approached in an open-ended manner; however,
when silences occur during the interview, the clinician should attempt to reengage the
patient. Clinicians can explore what the adolescent believes the outcome of the
evaluation will be (change of school, hospitalization, removal from home, removal of
privileges).
Some adolescents approach the interview with apprehension or hostility, but open up
when it becomes evident that the clinician is neither punitive nor judgmental. Clinicians
must be aware of their own responses to adolescents’ behavior (countertransference)
and stay focused on the therapeutic process even in the face of defiant, angry, or
difficult teenagers. Clinicians should set appropriate limits and should postpone or
discontinue an interview if they feel threatened or if patients become destructive to
property or engage in self-injurious behavior. Every interview should include an
exploration of suicidal thoughts, assaultive behavior, psychotic symptoms, substance
use, and knowledge of safe sexual practices along with a sexual history. Once rapport
has been established, many adolescents appreciate the opportunity to tell their side of
the story and may reveal things that they have not disclosed to anyone else.
Family Interview
An interview with parents and the patient may take place first or may occur later in the
evaluation. Sometimes, an interview with the entire family, including siblings, can be
enlightening. The purpose is to observe the attitudes and behavior of the parents toward
the patient and the responses of the children to their parents. The clinician’s job is to
maintain a nonthreatening atmosphere in which each member of the family can speak
freely without feeling that the clinician is taking sides with any particular member.
Although child psychiatrists generally function as advocates for the child, the clinician
must validate each family member’s feelings in this setting, because lack of
communication often contributes to the patient’s problems.
Parents
The interview with the patient’s parents or caretakers is necessary to get a chronological
picture of the child’s growth and development. A thorough developmental history and
details of any stressors or important events that have influenced the child’s development
must be elicited. The parents’ view of the family dynamics, their marital history, and
their own emotional adjustment are also elicited. The family’s psychiatric history and
the upbringing of the parents are pertinent. Parents are usually the best informants
about the child’s early development and previous psychiatric and medical illnesses. They
may be better able to provide an accurate chronology of past evaluations and
treatment. In some cases, especially with older children and adolescents, the parents
may be unaware of significant current symptoms or social difficulties of the child.
Clinicians elicit the parents’ formulation of the causes and nature of their child’s
problems and ask about their expectations for the current assessment.
DIAGNOSTIC INSTRUMENTS
The two main types of diagnostic instruments used by clinicians are diagnostic
interviews and questionnaires. Diagnostic interviews are administered to either children
or their parents and typically are designed to elicit sufficient information on various
aspects of functioning in order to determine whether DSM-5 criteria are met.
Semistructured interviews, or “interviewer-based” interviews, such as K-SADS and the
Child and Adolescent Psychiatric Assessment (CAPA), serve as guides for the clinician.
They help the clinician clarify answers to questions about symptoms. Structured
interviews, or “respondent-based” interviews, such as NIMH DISC-IV, the Children’s
Interview for Psychiatric Syndromes (ChIPS), and the Diagnostic Interview for Children and
Adolescents (DICA), provide a script for the interviewer without interpretation of the
patient responses during the interview process. Two other diagnostic instruments, the
Dominic-R and the Pictorial Instrument for Children and Adolescents (PICA-III-R), use
pictures as cues along with an accompanying question to elicit information about
symptoms, which can be especially useful for young children as well as for adolescents.
Diagnostic instruments aid the collection of information in a systematic way.
Diagnostic instruments, even the most comprehensive, however, cannot replace clinical
interviews, because clinical interviews are superior in understanding the chronology of
symptoms, the interplay between environmental stressors and emotional responses, and
developmental issues. Clinicians often find it helpful to combine data from diagnostic
instruments with clinical material gathered in a comprehensive evaluation.
Questionnaires can cover a broad range of symptom areas, such as the Achenbach
Child Behavior Checklist, or they can be focused on a particular type of symptomatology,
such as the Connors Parent Rating Scale for ADHD.
Semistructured Diagnostic Interviews
Kiddie Schedule for Affective Disorders and Schizophrenia for SchoolAge Children.
The K-SADS can be used for children and adolescents from 6 to 18
years of age. It contains multiple items with some space for further clarification of
symptoms. It elicits information on current diagnosis and on symptoms present in the
previous year. Another version can also ascertain lifetime diagnoses. This instrument
has been used extensively, especially in evaluation of mood disorders, and includes
measures of impairment caused by symptoms. The schedule comes in a form for parents
to give information about their child and in a version for use directly with the child. The
schedule takes about 1 to 1.5 hours to administer. The interviewer should have some
training in the field of child psychiatry, but need not be a psychiatrist.
Child and Adolescent Psychiatric Assessment.
The CAPA is an “interviewerbased” instrument that can be used for children from 9 to 17 years of age. It comes in
modular form so that certain diagnostic entities can be administered without having to
give the entire interview. It covers disruptive behavior disorders, mood disorders,
anxiety disorders, eating disorders, sleep disorders, elimination disorders, substance use
disorders, tic disorders, schizophrenia, posttraumatic stress disorder, and somatization
symptoms. It focuses on the 3 months before the interview, called the “primary period.”
In general, it takes about 1 hour to administer. It has a glossary to help clarify
symptoms, and it provides separate ratings for presence and severity of symptoms. The
CAPA can be used to obtain information that is applicable to making diagnoses
according to the DSM-5. Training is necessary to administer this interview, and the
interviewer must be prepared to use some clinical judgment in interpreting elicited
symptoms.
Structured Diagnostic Interviews
National Institute of Mental Health Interview Schedule for Children
Version IV.
The NIMH DISC-IV is a highly structured interview designed to assess
more than 30 DSM-IV diagnostic entities administered by trained “laypersons.” Although
it was formulated to match diagnostic criteria in DSM-IV, information from this
interview can be utilized, along with clinical information for diagnoses in DSM-5. It is
available in parallel child and parent forms. The parent form can be used for children
from 6 to 17 years of age, and the direct child form of the instrument was designed for
children from 9 to 17 years of age. A computer scoring algorithm is available. This
instrument assesses the presence of diagnoses that have been present within the last 4
weeks, and also within the last year. Because it is a fully structured interview, the
instructions serve as a complete guide for the questions, and the examiner need not have
any knowledge of child psychiatry to administer the interview correctly.
Children’s Interview for Psychiatric Syndromes.
The ChIPS is a highly
structured interview designed for use by trained interviewers with children from 6 to 18
years of age. It is composed of 15 sections, and it elicits information on psychiatric
symptoms as well as psychosocial stressors targeting 20 psychiatric disorders, according
to DSM-IV criteria; however, it can also be applied to diagnoses in DSM-5. There are
parent and child forms. It takes approximately 40 minutes to administer the ChIPS.
Diagnoses covered include depression, mania, attention-deficit/hyperactivity disorder
(ADHD), separation disorder, obsessive-compulsive disorder (OCD), conduct disorder,
substance use disorder, anorexia, and bulimia. The ChIPS was designed for use as a
screening instrument for clinicians and a diagnostic instrument for clinical and
epidemiological research.
Diagnostic Interview for Children and Adolescents.
The current version of
the DICA was developed in 1997 to assess information resulting in diagnoses according
to either DSM-IV or DSM-III-R. This instrument can be used to help obtain information
that can be applied to DSM-5 as well. Although the DICA was originally designed to be a
highly structured interview, it can now be used in a semistructured format. This means
that, although interviewers are allowed to use additional questions and probes to clarify
elicited information, the method of probing is standardized so that all interviewers will
follow a specific pattern. When using the interview with younger children, more
flexibility is built in, allowing interviewers to deviate from written questions to ensure
that the child understands the question. Parent and child interviews are expected to be
used. The DICA is designed for use with children 6 to 17 years of age and generally
takes 1 to 2 hours to administer. It covers externalizing behavior disorders, anxiety
disorders, depressive disorders, and substance abuse disorders, among others.
Pictorial Diagnostic Instruments
Dominic-R.
The Dominic-R is a pictorial, fully structured interview designed to
elicit psychiatric symptoms from children 6 to 11 years of age. The pictures illustrate
abstract emotional and behavioral content of diagnostic entities according to the DSMIII-R; however, information gleaned from this instrument can also be applied in
conjunction with clinical information to the DSM-5. The instrument uses a picture of a
child called “Dominic” who is experiencing the symptom in question. Some symptoms
have more than one picture, with a brief story that is read to the child. Along with each
picture is a sentence asking about the situation being shown and asking the child if he
or she has experiences similar to the one that Dominic is having. Diagnostic entities
covered by the Dominic-R include separation anxiety, generalized anxiety, depression
and dysthymia, ADHD, oppositional defiant disorder, conduct disorder, and specific
phobia. Although symptoms of the preceding diagnoses can be fully elicited from the
Dominic-R, no specific provision within the instrument inquires about frequency of the
symptom, duration, or age of onset. The paper version of this interview takes about 20
minutes, and the computerized version of this instrument takes about 15 minutes.
Trained lay-interviewers can administer this interview. Computerized versions of this
interview are available with pictures of a child who is white, black, Latino, or Asian.
Pictorial Instrument for Children and Adolescents.
PICA-III-R is composed
of 137 pictures organized in modules and designed to cover five diagnostic categories,
including disorders of anxiety, mood, psychosis, disruptive disorders, and substance use
disorder. It is designed to be administered by clinicians and can be used for children and
adolescents ranging from 6 to 16 years of age. The PICA-III_R provides a categorical
(diagnosis present or absent) and a dimensional (range of severity) assessment. This
instrument presents pictures of a child experiencing emotional, behavioral, and
cognitive symptoms. The child is asked, “How much are you like him/her?” and a fivepoint rating scale with pictures of a person with open arms in increasing degrees is
shown to the child to help him or her identify the severity of the symptoms. It takes
about 40 minutes to 1 hour to administer the interview. This instrument is currently
keyed to the DSM-III-R, but can be used along with clinical information to make
diagnoses according to the DSM-5. This assessment can be used to aid in clinical
interviews and in research diagnostic protocols.
QUESTIONNAIRES AND RATING SCALES
Achenbach Child Behavior Checklist
The parent and teacher versions of the Achenbach Child Behavior Checklist were
developed to cover a broad range of symptoms and several positive attributes related to
academic and social competence. The checklist presents items related to mood,
frustration tolerance, hyperactivity, oppositional behavior, anxiety, and various other
behaviors. The parent version consists of 118 items to be rated 0 (not true), 1
(sometimes true), or 2 (very true). The teacher version is similar, but without the items
that apply only to home life. Profiles were developed based on normal children of three
different age groups (4 to 5, 6 to 11, and 12 to 16).
Such a checklist identifies specific problem areas that might otherwise be overlooked,
and it may point out areas in which the child’s behavior deviates from that of normal
children of the same age group. The checklist is not used specifically to make diagnoses.
Revised Achenbach Behavior Problem Checklist
Consisting of 150 items that cover a variety of childhood behavioral and emotional
symptoms, the Revised Achenbach Behavior Problem Checklist discriminates between clinicreferred and nonreferred children. Separate subscales have been found to correlate in
the appropriate direction with other measures of intelligence, academic achievement,
clinical observations, and peer popularity. As with the other broad rating scales, this
instrument can help elicit a comprehensive view of a multitude of behavioral areas, but
it is not designed to make psychiatric diagnoses.
Connors Abbreviated Parent-Teacher Rating Scale for ADHD
In its original form, the Connors Abbreviated Parent-Teacher Rating Scale for ADHD
consisted of 93 items rated on a 0 to 3 scale and was subgrouped into 25 clusters,
including problems with restlessness, temper, school, stealing, eating, and sleeping.
Over the years, multiple versions of this scale were developed and used to aid in
systematic identification of children with ADHD. A highly abbreviated form of this
rating scale, the Connors Abbreviated Parent-Teacher Questionnaire, was developed for use
with both parents and teachers by Keith Connors in 1973. It consists of ten items that
assess both hyperactivity and inattention.
Brief Impairment Scale
A newly validated 23-item instrument suitable to obtain information on children
ranging from 4 years to 17 years, the Brief Impairment Scale (BIS) evaluates three
domains of functioning: interpersonal relations, school/work functioning, and care/selffulfillment. This scale is administered to an adult informant about his or her child, does
not take long to administer, and provides a global measure of impairment along the
above three dimensions. This scale cannot be used to make clinical decisions on
individual patients, but it can provide information on the degree of impairment that a
given child is experiencing in a certain area.
COMPONENTS OF THE CHILD PSYCHIATRIC EVALUATION
Psychiatric evaluation of a child includes a description of the reason for the referral, the
child’s past and present functioning, and any test results. An outline of the evaluation is
given in Table 31.2-1.
Table 31.2-1
Child Psychiatric Evaluation
Identifying Data
Identifying data for a child includes the child’s gender, age, as well as the family
constellation surrounding the child.
History
A comprehensive history contains information about the child’s current and past
functioning from the child’s report, from clinical and structured interviews with the
parents, and from information from teachers and previous treating clinicians. The chief
complaint and the history of the present illness are generally obtained from both the
child and the parents. Naturally, the child will articulate the situation according to his or
her developmental level. The developmental history is more accurately obtained from
the parents. Psychiatric and medical histories, current physical examination findings,
and immunization histories can be augmented with reports from psychiatrists and
pediatricians who have treated the child in the past. The child’s report is critical in
understanding the current situation regarding peer relationships and adjustment to
school. Adolescents are the best informants regarding knowledge of safe sexual
practices, drug or alcohol use, and suicidal ideation. The family’s psychiatric and social
histories, and family function are best obtained from the parents.
Mental Status Examination
A detailed description of the child’s current mental functioning can be obtained through
observation and specific questioning. An outline of the mental status examination is
presented in Table 31.2-2. Table 31.2-3 lists components of a comprehensive
neuropsychiatry mental status.
Table 31.2-2
Mental Status Examination for Children
Table 31.2-3
Neuropsychiatric Mental Status Examination*
Physical Appearance.
The examiner should document the child’s size, grooming,
nutritional state, bruising, head circumference, physical signs of anxiety, facial
expressions, and mannerisms.
Parent–Child Interaction.
The examiner can observe the interactions between
parents and child in the waiting area before the interview and in the family session. The
manner in which parents and child converse and the emotional overtones are pertinent.
Separation and Reunion.
The examiner should note both the manner in which
the child responds to the separation from a parent for an individual interview and the
reunion behavior. Either lack of affect at separation and reunion or severe distress on
separation or reunion can indicate problems in the parent–child relationship or other
psychiatric disturbances.
Orientation to Time, Place, and Person.
Impairments in orientation can
reflect organic damage, low intelligence, or a thought disorder. The age of the child
must be kept in mind, however, because very young children are not expected to know
the date, other chronological information, or the name of the interview site.
Speech and Language.
The examiner should evaluate the child’s speech and
language acquisition. Is it appropriate for the child’s age? A disparity between
expressive language usage and receptive language is notable. The examiner should also
note the child’s rate of speech, rhythm, latency to answer, spontaneity of speech,
intonation, articulation of words, and prosody. Echolalia, repetitive stereotypical
phrases, and unusual syntax are important psychiatric findings. Children who do not use
words by age 18 months or who do not use phrases by age 2.5 to 3 years, but who have
a history of normal babbling and responding appropriately to nonverbal cues, are
probably developing normally. The examiner should consider the possibility that a
hearing loss is contributing to a speech and language deficit.
Mood.
A child’s sad expression, lack of appropriate smiling, tearfulness, anxiety,
euphoria, and anger are valid indicators of mood, as are verbal admissions of feelings.
Persistent themes in play and fantasy also reflect the child’s mood.
Affect.
The examiner should note the child’s range of emotional expressivity,
appropriateness of affect to thought content, ability to move smoothly from one affect
to another, and sudden labile emotional shifts.
Thought Process and Content.
In evaluating a thought disorder in a child, the
clinician must always consider what is developmentally expected for the child’s age and
what is deviant for any age group. The evaluation of thought form considers loosening
of associations, excessive magical thinking, perseveration, echolalia, the ability to
distinguish fantasy from reality, sentence coherence, and the ability to reason logically.
The evaluation of thought content considers delusions, obsessions, themes, fears, wishes,
preoccupations, and interests.
Suicidal ideation is always a part of the mental status examination for children who
are sufficiently verbal to understand the questions and old enough to understand the
concept. Children of average intelligence who are older than 4 years of age usually have
some understanding of what is real and what is make-believe and may be asked about
suicidal ideation, although a firm concept of the permanence of death may not be
present until several years later.
Aggressive thoughts and homicidal ideation are assessed here. Perceptual
disturbances, such as hallucinations, are also assessed. Very young children are expected
to have short attention spans and may change the topic and conversation abruptly
without exhibiting a symptomatic flight of ideas. Transient visual and auditory
hallucinations in very young children do not necessarily represent major psychotic
illnesses, but they do deserve further investigation.
Social Relatedness.
The examiner assesses the appropriateness of the child’s
response to the interviewer, general level of social skills, eye contact, and degree of
familiarity or withdrawal in the interview process. Overly friendly or familiar behavior
may be as troublesome as extremely retiring and withdrawn responses. The examiner
assesses the child’s self-esteem, general and specific areas of confidence, and success
with family and peer relationships.
Motor Behavior.
The motor behavior part of the mental status examination
includes observations of the child’s coordination and activity level and ability to pay
attention and carry out developmentally appropriate tasks. It also involves involuntary
movements, tremors, motor hyperactivity, and any unusual focal asymmetries of muscle
movement.
Cognition.
The examiner assesses the child’s intellectual functioning and problemsolving abilities. An approximate level of intelligence can be estimated by the child’s
general information, vocabulary, and comprehension. For a specific assessment of the
child’s cognitive abilities, the examiner can use a standardized test.
Memory.
School-age children should be able to remember three objects after 5
minutes and to repeat five digits forward and three digits backward. Anxiety can
interfere with the child’s performance, but an obvious inability to repeat digits or to add
simple numbers may reflect brain damage, mental retardation, or learning disabilities.
Judgment and Insight.
The child’s view of the problems, reactions to them, and
suggested solutions may give the clinician a good idea of the child’s judgment and
insight. In addition, the child’s understanding of what he or she can realistically do to
help and what the clinician can do adds to the assessment of the child’s judgment.
Neuropsychiatric Assessment
A neuropsychiatric assessment is appropriate for children who are suspected of having a
psychiatric disorder that coexists with neuropsychiatric impairment, or psychiatric
symptoms that may be caused by neuropsychiatric dysfunction, or a neurologic disorder.
Although a neuropsychiatric assessment is not sufficient in most cases to make a
psychiatric diagnosis, neuropsychological profiles have been, in some cases correlated
with particular psychiatric symptoms and syndromes. For example, neuropsychological
differences in executive function, language and memory functions, as well as measures
of mood and anxiety, have been found between youth with histories of childhood
maltreatment and those without it. The neuropsychiatric evaluation combines
information from neurological, neuropsychological testing, and mental status
examinations. The neurological examination can identify asymmetrical abnormal signs
(hard signs) that may indicate lesions in the brain. A physical examination can evaluate
the presence of physical stigmata of particular syndromes in which neuropsychiatric
symptoms or developmental aberrations play a role (e.g., fetal alcohol syndrome, Down
syndrome). In a study of 119 youth with either early onset schizophrenia or
schizoaffective disorder, by Hooper and colleagues, significantly high rates of deficits in
intellectual function and academic skills were found, and the severity of these deficits
was mildly correlated with severity of their psychiatric illness.
A neuropsychiatric examination also includes neurological soft signs and minor
physical anomalies. The term neurological soft signs was first noted by Loretta Bender in
the 1940s in reference to nondiagnostic abnormalities in the neurological examinations
of children with schizophrenia. Soft signs do not indicate focal neurological disorders,
but they are associated with a wide variety of developmental disabilities and occur
frequently in children with low intelligence, learning disabilities, and behavioral
disturbances. Soft signs may refer to both behavioral symptoms (which are sometimes
associated with brain damage, such as severe impulsivity and hyperactivity), physical
findings (including contralateral overflow movements), and a variety of nonfocal signs
(e.g., mild choreiform movements, poor balance, mild incoordination, asymmetry of
gait, nystagmus, and the persistence of infantile reflexes). Soft signs can be divided into
those that are normal in a young child, but become abnormal when they persist in an
older child, and those that are abnormal at any age. The Physical and Neurological
Examination for Soft Signs (PANESS) is an instrument used with children up to the age of
15 years. It consists of 15 questions about general physical status and medical history
and 43 physical tasks (e.g., touch your finger to your nose, hop on one foot to the end
of the line, tap quickly with your finger). Neurological soft signs are important to note,
but they are not useful in making a specific psychiatric diagnosis.
Minor physical anomalies or dysmorphic features occur with a higher than usual
frequency in children with developmental disabilities, learning disabilities, speech and
language disorders, and hyperactivity. As with soft signs, the documentation of minor
physical anomalies is part of the neuropsychiatric assessment, but it is rarely helpful in
the diagnostic process and does not imply a good or bad prognosis. Minor physical
anomalies include a high-arched palate, epicanthal folds, hypertelorism, low-set ears,
transverse palmar creases, multiple hair whorls, a large head, a furrowed tongue, and
partial syndactyl of several toes.
When a seizure disorder is being considered in the differential diagnosis or a structural
abnormality in the brain is suspected, electroencephalography (EEG), computed
tomography (CT), or magnetic resonance imaging (MRI) may be indicated.
Developmental, Psychological, and Educational Testing
Psychological testing, structured developmental assessments and achievement testing
are valuable in evaluating a child’s developmental level, intellectual functioning, and
academic difficulties. A measure of adaptive functioning (including the child’s
competence in communication, daily living skills, socialization, and motor skills) is the
most definitive way to determine the level of intellectual disability in a child. Table
31.2-4 outlines the general categories of psychological tests.
Table 31.2-4
Commonly Used Child and Adolescent Psychological Assessment Instruments
Development Tests for Infants and Preschoolers.
The Gesell Infant Scale, the
Cattell Infant Intelligence Scale, Bayley Scales of Infant Development, and the Denver
Developmental Screening Test include developmental assessments of infants as young as 2
months of age. When used with very young infants, the tests focus on sensorimotor and
social responses to a variety of objects and interactions. When these instruments are
used with older infants and preschoolers, emphasis is placed on language acquisition.
The Gesell Infant Scale measures development in four areas: motor, adaptive functioning,
language, and social.
An infant’s score on one of these developmental assessments is not a reliable way to
predict a child’s future intelligence quotient (IQ) in most cases. Infant assessments are
valuable, however, in detecting developmental deviation and mental retardation and in
raising suspicions of a developmental disorder. Whereas infant assessments rely heavily
on sensorimotor functions, intelligence testing in older children and adolescents includes
later-developing functions, including verbal, social, and abstract cognitive abilities.
Intelligence Tests for School-Age Children and Adolescents.
The most
widely used test of intelligence for school-age children and adolescents is the third
edition of the Wechsler Intelligence Scale for Children (WISC-III-R). It can be given to
children from 6 to 17 years of age and yields a verbal IQ, a performance IQ, and a
combined full-scale IQ. The verbal subtests consist of vocabulary, information,
arithmetic, similarities, comprehension, and digit span (supplemental) categories. The
performance subtests include block design, picture completion, picture arrangement,
object assembly, coding, mazes (supplemental), and symbol search (supplemental). The
scores of the supplemental subtests are not included in the computation of IQ.
Each subcategory is scored from 1 to 19, with 10 being the average score. An average
full-scale IQ is 100; 70 to 80 represents borderline intellectual function; 80 to 90 is in the
low average range; 90 to 109 is average; 110 to 119 is high average; and above 120 is
in the superior or very superior range. The multiple breakdowns of the performance and
verbal subscales allow great flexibility in identifying specific areas of deficit and scatter
in intellectual abilities. Because a large part of intelligence testing measures abilities
used in academic settings, the breakdown of the WISC-III-R can also be helpful in
pointing out skills in which a child is weak and may benefit from remedial education.
The Stanford-Binet Intelligence Scale covers an age range from 2 to 24 years. It relies on
pictures, drawings, and objects for very young children and on verbal performance for
older children and adolescents. This intelligence scale, the earliest version of an
intelligence test of its kind, leads to a mental age score as well as an intelligence
quotient.
The McCarthy Scales of Children’s Abilities and the Kaufman Assessment Battery for
Children are two other intelligence tests that are available for preschool and school-age
children. They do not cover the adolescent age group.
LONG-TERM STABILITY OF INTELLIGENCE. Although a child’s intelligence is relatively stable
throughout the school-age years and adolescence, some factors can influence intelligence
and a child’s score on an intelligence test. The intellectual functions of children with
severe mental illnesses and of those from deprived and neglectful environments may
decrease over time, whereas the IQs of children with intensively enriched environments,
may increase over time. Factors that influence a child’s score on a given test of
intellectual functioning and, thus, affect the accuracy of the test are motivation,
emotional state, anxiety, and cultural milieu. The interactions between cognitive ability
and anxiety, and depression and psychosis are complex. One study of 4,405 youth from
the Canadian National Longitudinal Study of Children and Youth (NLSCY), by Weeks
and colleagues (2013) found that greater cognitive ability was associated with less risk
for anxiety and depressive symptoms in youth from 12 years to 13 years of age,
however, by age 14 years to 15 years, cognitive ability had no effect on the odds of
anxiety or depression.
Perceptual and Perceptual Motor Tests.
The Bender Visual Motor Gestalt Test
can be given to children between the ages of 4 and 12 years. The test consists of a set of
spatially related figures that the child is asked to copy. The scores are based on the
number of errors. Although not a diagnostic test, it is useful in identifying
developmentally age-inappropriate perceptual performances.
Personality Tests.
Personality tests are not of much use in making diagnoses, and
they are less satisfactory than intelligence tests with regard to norms, reliability, and
validity, but they can be helpful in eliciting themes and fantasies.
The Rorschach test is a projective technique in which ambiguous stimuli—a set of
bilaterally symmetrical inkblots—are shown to a child, who is then asked to describe
what he or she sees in each. The hypothesis is that the child’s interpretation of the vague
stimuli reflects basic characteristics of personality. The examiner notes the themes and
patterns.
A more structured projective test is the Children’s Apperception Test (CAT), which is an
adaptation of the Thematic Apperception Test (TAT). The CAT consists of cards with
pictures of animals in scenes that are somewhat ambiguous, but are related to parent–
child and sibling issues, caretaking, and other relationships. The child is asked to
describe what is happening and to tell a story about the scene. Animals are used because
it was hypothesized that children might respond more readily to animal images than to
human figures.
Drawings, toys, and play are also applications of projective techniques that can be
used during the evaluation of children. Dollhouses, dolls, and puppets have been
especially helpful in allowing a child a nonconversational mode in which to express a
variety of attitudes and feelings. Play materials that reflect household situations are
likely to elicit a child’s fears, hopes, and conflicts about the family.
Projective techniques have not fared well as standardized instruments. Rather than
being considered tests, projective techniques are best considered as additional clinical
modalities.
Educational Tests.
Achievement tests measure the attainment of knowledge and
skills in a particular academic curriculum. The Wide-Range Achievement Test-Revised
(WRAT-R) consists of tests of knowledge and skills and timed performances of reading,
spelling, and mathematics. It is used with children from 5 years of age to adulthood. The
test yields a score that is compared with the average expected score for the child’s
chronological age and grade level.
The Peabody Individual Achievement Test (PIAT) includes word identification, spelling,
mathematics, and reading comprehension.
The Kaufman Test of Educational Achievement, the Gray Oral Reading Test-Revised
(GORT-R), and the Sequential Tests of Educational Progress (STEP) are achievement tests
that determine whether a child has achieved the educational level expected for his or her
grade level. Children whose achievement is significantly lower than expected for their
grade level in one or more subjects, often exhibit a specific learning disorder.
Biopsychosocial Formulation.
A clinician’s task is to integrate all of the
information obtained into a formulation that takes into account the biological
predisposition, psychodynamic factors, environmental stressors, and life events that
have led to the child’s current level of functioning. Psychiatric disorders and any specific
physical, neuromotor, or developmental abnormalities must be considered in the
formulation of etiologic factors for current impairment. The clinician’s conclusions are
an integration of clinical information along with data from standardized psychological
and developmental assessments. The psychiatric formulation includes an assessment of
family function as well as the appropriateness of the child’s educational setting. A
determination of the child’s overall safety in his or her current situation is made. Any
suspected maltreatment must be reported to the local child protective service agency.
The child’s overall well-being regarding growth, development, and academic and play
activities is considered.
Diagnosis
Structured and semistructured (evidence-based) assessment tools often enhance a
clinician’s ability to make the most accurate diagnoses. These instruments, described
earlier, include the K-SADS, the CAPA, and the NIMH DISC-IV interviews. The
advantages of including an evidence-based instrument in the diagnostic process include
decreasing potential clinician bias to make a diagnosis without all of the necessary
symptoms information, and serving as guides for the clinician to consider each symptom
that could contribute to a given diagnosis. These data can enable the clinician to
optimize his expertise to make challenging judgments regarding child and adolescent
disorders, which may possess overlapping symptoms. The clinician’s ultimate task
includes making all appropriate diagnoses according to the DSM-5. Some clinical
situations do not fulfill criteria for DSM-5 diagnoses, but cause impairment and require
psychiatric attention and intervention. Clinicians who evaluate children are frequently
in the position of determining the impact of behavior of family members on the child’s
well-being. In many cases, a child’s level of impairment is related to factors extending
beyond a psychiatric diagnosis, such as the child’s adjustment to his or her family life,
peer relationships, and educational placement.
RECOMMENDATIONS AND TREATMENT PLAN
The recommendations for treatment are derived by a clinician who integrates the data
gathered during the evaluation into a coherent formulation of the factors that are
contributing to the child’s current problems, the consequences of the problems, and
strategies that may ameliorate the difficulties. The recommendations can be broken
down into their biological, psychological, and social components. That is, identification
of a biological predisposition to a particular psychiatric disorder may be clinically
relevant to inform a psychopharmacologic recommendation. As part of the formulation,
an understanding of the psychodynamic interactions between family members may lead
a clinician to recommend treatment that includes a family component. Educational and
academic problems are addressed in the formulation and may lead to a recommendation
to seek a more effective academic placement. The overall social situation of the child or
adolescent is taken into account when recommendations for treatment are developed.
Of course, the physical and emotional safety of a child or adolescent is of the utmost
importance and always at the top of the list of recommendations.
The child or adolescent’s family, school life, peer interactions, and social activities
often have a direct impact on the child’s success in overcoming his or her difficulties.
The psychological education and cooperation of a child or adolescent’s family are
essential ingredients in successful application of treatment recommendations.
Communications from clinicians to parents and family members that balance the
observed positive qualities of the child and family with the weak areas are often
perceived as more helpful than a focus only on the problem areas. Finally, the most
successful treatment plans are those developed cooperatively between the clinician,
child, and family members during which each member of the team perceives that he or
she has been given credit for positive contributions.
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03 - 31.3 Intellectual Disability
31.3 Intellectual Disability
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31.3 Intellectual Disability
Intellectual disability, formerly known as mental retardation, can be caused by a range of
environmental and genetic factors that lead to a combination of cognitive and social
impairments. The American Association on Intellectual and Developmental Disability
(AAIDD) defines intellectual disability as a disability characterized by significant
limitations in both intellectual functioning (reasoning, learning, and problem solving)
and in adaptive behavior (conceptual, social, and practical skills) that emerges before
the age of 18 years. Wide acceptance of this definition has led to the international
consensus that an assessment of both social adaptation and intelligence quotient (IQ)
are necessary to determine the level of intellectual disability. Measures of adaptive
function assess competency in social functioning, understanding of societal norms, and
performance of everyday tasks, whereas measures of intellectual function focus on
cognitive abilities. Although individuals with a given intellectual level do not all have
identical levels of adaptive function, epidemiologic data suggest that prevalence of
intellectual disability is largely determined by intellectual level and a level of adaptive
function, which typically corresponds closely with cognitive ability.
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
various levels of severity of intellectual disability are determined on the basis of
adaptive functioning, not on IQ scores. This change in emphasis from prior diagnostic
manuals has been adopted by DSM-5 because adaptive functioning determines the level
of support that is required. Furthermore, IQ scores are less valid in the lower portions of
the IQ range. Making a determination of severity level of intellectual disability,
according to DSM-5, includes assessment of functioning in a conceptual domain (e.g.,
academic skills), a social domain (e.g., relationships), and a practical domain (e.g.,
personal hygiene).
Societal approaches to children with intellectual disability have shifted significantly
over time. Historically, in the mid-1800s many children with intellectual disability were
placed in residential educational facilities based on the belief that with sufficient
intensive training, these children would be able to return to their families and function
in society at a higher level. However, the expectation of educating these children in
order to overcome their disabilities was not realized. Gradually, many residential
programs increased in size, and eventually the focus began to shift from intensive
education to more custodial care. Residential settings for children with intellectual
disability received their maximal use in the mid-1900s, until public awareness of the
crowded, unsanitary, and, in some cases, abusive conditions sparked the movement
toward “deinstitutionalization.” An important force in the deinstitutionalization of
children with intellectual disability was the philosophy of “normalization” in living
situations, and “inclusion” in educational settings. Since the late 1960s, few children
with intellectual disability have been placed in residences, and the concepts of
normalization and inclusion remain prominent among advocacy groups and parents.
The passage of Public Law 94–142 (the Education for all Handicapped Children Act)
in 1975 mandates that the public school system provide appropriate educational service
to all children with disabilities. The Individuals with Disabilities Act in 1990 extended
and modified the above legislation. Currently, provision of public education for all
children, including those with disabilities, “within the least restrictive environment” is
mandated by law.
In addition to the educational system, advocacy groups, including the Council for
Exceptional Children (CEC) and the National Association for Retarded Citizens (NARC)
are well known parental lobbying organizations for children with intellectual disability
and were instrumental in advocating for Public Law 94–142. The American Association
on Intellectual and Developmental Disabilities, formerly known as The American
Association on Intellectual disability (AAMR), is the most prominent advocacy
organization in this field. It has been very influential in educating the public about, and
in supporting research and legislation relating to, intellectual disability.
The AAIDD promotes a view of intellectual disability as a functional interaction
between an individual and the environment, rather than a static designation of a
person’s limitations. Within this conceptual framework, a child or adolescent with
intellectual disability is determined to need intermittent, limited, extensive, or pervasive
“environmental support” with respect to a specific set of adaptive function domains.
These include communication, self-care, home living, social or interpersonal skills, use
of community resources, self-direction, functional academic skills, work, leisure, health,
and safety.
The United Nations Convention on the Rights of Persons with Disabilities (2006) has
created a forum to promote the full social inclusion of people with intellectual disability.
Through its recognition and focus on social barriers, this international forum aims to
provide protections for individuals with intellectual disability, and to seek more
inclusion of those with intellectual disability in social, civic, and educational activities.
NOMENCLATURE
The accurate definition of intellectual disability has been a challenge for clinicians over
the centuries. All current classification systems underscore that intellectual disability is
based on more than cognitive deficits, that is, it also includes impaired social adaptive
function. According to DSM-5, a diagnosis of intellectual disability should be made only
when there are deficits in intellectual functioning and deficits in adaptive functioning
(Table 31.3-1). Once intellectual disability is recognized, the level of severity is
determined by the level of adaptive functional impairment.
Table 31.3-1
DSM-5 Diagnostic Criteria for Intellectual Disability
CLASSIFICATION
DSM-5 criteria for intellectual disability include significantly subaverage general
intellectual functioning associated with concurrent impairment in adaptive behavior,
manifested before the age of 18. The diagnosis is made independent of coexisting
physical or mental disorders. Table 31.3-2 presents an overview of developmental levels
in communication, academic functioning, and vocational skills expected of persons with
various degrees of intellectual disability.
Table 31.3-2
Developmental Characteristics of Intellectual Disability
If the clinician chooses to use a standardized test of intelligence—which is still
common practice—the term significantly subaverage is defined as an IQ of approximately
70 or below or two standard deviations below the mean for the particular test. Adaptive
functioning can be measured by using a standardized scale, such as the Vineland Adaptive
Behavior Scale. This scale scores communications, daily living skills, socialization, and
motor skills (up to 4 years, 11 months) and generates an adaptive behavior composite
that is correlated with the expected skills at a given age.
Approximately 85 percent of individuals who have intellectual disability fall within
the DSM-5 mild intellectual disability category. This is typically defined by a Full Scale
IQ between 50 and 70 and an adaptive function severity in the mild range. Adaptive
function includes skills such as communication, self-care, social skills, work, leisure, and
understanding of safety. Intellectual disability is influenced by genetic, environmental,
and psychosocial factors. A host of subtle environmental and developmental factors,
including subclinical lead intoxication and prenatal exposure to drugs, alcohol, and
other toxins have been implicated as contributors to intellectual disability. Certain
genetic syndromes associated with intellectual disability such as fragile X syndrome,
Down syndrome, and Prader-Willi syndrome, have characteristic patterns of social,
linguistic, and cognitive development and typical behavioral manifestations.
DEGREES OF SEVERITY OF INTELLECTUAL DISABILITY
The severity levels of intellectual disability are expressed in DSM-5 as mild, moderate,
severe, and profound. “Borderline intellectual functioning,” a term previously used to
describe individuals with a full scale IQ in the range of 70 to 80, is no longer described
as a diagnosis in DSM-5. The term is used in DSM-5 as a condition that may be the focus
of clinical attention; however, no criteria are given.
Mild intellectual disability represents approximately 85 percent of persons with
intellectual disability. Children with mild intellectual disability often are not identified
until the first or second grade, when academic demands increase. By late adolescence,
they often acquire academic skills at approximately a sixth-grade level. Specific causes
for the intellectual disability are often unidentified in this group. Many adults with mild
intellectual disability can live independently with appropriate support and raise their
own families. IQ for this level of adaptive function may typically range from 50 to 70.
Moderate intellectual disability represents about 10 percent of persons with
intellectual disability. Most children with moderate intellectual disability acquire
language and can communicate adequately during early childhood. They are challenged
academically and often are not able to achieve above a second to third grade level.
During adolescence, socialization difficulties often set these persons apart, and a great
deal of social and vocational support is beneficial. As adults, individuals with moderate
intellectual disability may be able to perform semiskilled work under appropriate
supervision. IQ for this level of adaptive function may typically range from 35 to 50.
Severe intellectual disability represents about 4 percent of individuals with
intellectual disability. They may be able to develop communication skills in childhood
and often can learn to count as well as recognize words that are critical to functioning.
In this group, the cause for the intellectual disability is more likely to be identified than
in milder forms of intellectual disability. In adulthood, persons with severe intellectual
disability may adapt well to supervised living situations, such as group homes, and may
be able to perform work-related tasks under supervision. IQ in individuals with this level
of adaptive function may typically range from 20 to 35.
Profound intellectual disability constitutes approximately 1 to 2 percent of individuals
with intellectual disability. Most individuals with profound intellectual disability have
identifiable causes for their condition. Children with profound intellectual disability may
be taught some self-care skills and learn to communicate their needs given the
appropriate training. IQ in individuals with this level of adaptive function may typically
be less than 20.
The DSM-5 also includes a disorder called “Unspecified Intellectual Disability”
(Intellectual Developmental Disorder), reserved for individuals over the age of 5 years
who are difficult to evaluate but are strongly suspected of having intellectual disability.
Individuals with this diagnosis may have sensory or physical impairments such as
blindness or deafness, or concurrent mental disorders, making it difficult to administer
typical assessment tools. (e.g., Bayley Scales of Infant Development and Cattell Infant
Scale) to aid in determining adaptive functional impairment.
EPIDEMIOLOGY
The majority of population-based prevalence estimates for intellectual disability in
developing countries range from 10 to 15 per 1,000 children. The prevalence of
intellectual disability at any one time is estimated to range from 1 to 3 percent of the
population in Western societies. The incidence of intellectual disability is difficult to
accurately calculate because mild disabilities may be unrecognized until middle
childhood. In some cases, even when intellectual function is limited, social adaptive
skills may not be challenged until late childhood or early adolescence, and the diagnosis
is not made until that time. The highest incidence of intellectual disability is reported in
school-age children, with the peak at ages 10 to 14 years. Intellectual disability is about
1.5 times more common among males than females.
COMORBIDITY
Prevalence
Epidemiological surveys indicate that up to two thirds of children and adults with
intellectual disability have comorbid psychiatric disorders; and this rate is several times
higher than that in community samples without intellectual disability. The prevalence of
psychopathology appears to be correlated with the severity of intellectual disability; the
more severe the intellectual disability, the higher the risk for coexisting psychiatric
disorders. An epidemiological study found that 40.7 percent of intellectually disabled
children between 4 and 18 years of age met criteria for at least one additional
psychiatric disorder. The severity of intellectual disability influenced the risk for
particular comorbid psychiatric disorders. Disruptive and conduct-disorder behaviors
occurred more frequently in those diagnosed with mild intellectual disability, whereas
those with more severe intellectual disability were more likely to meet criteria for
autism spectrum disorder and exhibited symptoms such as self-stimulation and selfmutilation. Comorbidity of psychiatric disorders with intellectual disability in children in
this study was not correlated with age or gender. Children diagnosed with profound
intellectual disability were less likely to exhibit comorbid psychiatric disorders.
Psychiatric disorders among persons with intellectual disability are varied, and
include mood disorders, schizophrenia, attention-deficit/hyperactivity disorder (ADHD),
and conduct disorder. Children diagnosed with severe intellectual disability have a
particularly high rate of comorbid autism spectrum disorder. Approximately 2 to 3
percent of those with intellectual disability meet diagnostic criteria for schizophrenia,
which is several times higher than the rate for the general population. Up to 50 percent
of children and adults with intellectual disability are found to meet criteria for a mood
disorder when instruments such as the Kiddie Schedule for Affective Disorders and
Schizophrenia (K-SADS), the Beck Depression Inventory, and the Children’s Depression
Inventory were used in studies. However, a limitation of these studies is that these
instruments have not been standardized within intellectual disability populations.
Frequent psychiatric symptoms that occur in children with intellectual disability, outside
the context of a full psychiatric disorder, include hyperactivity and short attention span,
self-injurious behaviors (e.g., head-banging and self-biting), and repetitive stereotypical
behaviors (hand-flapping and toe-walking). In children and adults with milder forms of
intellectual disability, negative self-image, low self-esteem, poor frustration tolerance,
interpersonal dependence, and a rigid problem-solving style are frequent.
Neurological Disorders
Seizure disorders occur more frequently in individuals with intellectual disability than in
the general population, and prevalence rates for seizures increase proportionally to
severity level of intellectual disability. A review of psychiatric disorders in children and
adolescents with intellectual disability and epilepsy, found that approximately one third
had comorbid autism spectrum disorder. The combination of intellectual disability,
epilepsy, and autism spectrum disorder has been estimated to occur in 0.07 percent of
the general population.
Psychosocial Features
A negative self-image and poor self-esteem are common features of mildly and
moderately intellectually disabled persons who are aware of their social and academic
differences from others. Given their experience of repeated failure and disappointment
in being unable to meet their parents’ and society’s expectations, they may also be faced
with falling progressively behind younger siblings. Communication difficulties further
increase their vulnerability to feelings of ineptness and frustration. Inappropriate
behaviors, such as withdrawal, are common. The perpetual sense of isolation and
inadequacy has been linked to feelings of anxiety, anger, dysphoria, and depression.
ETIOLOGY
Etiological
factors
in
intellectual
disability
can
be
genetic,
developmental,
environmental, or a combination. Genetic causes include chromosomal and inherited
conditions; developmental and environmental factors include prenatal exposure to
infections and toxins; and environmental or acquired factors include prenatal trauma
(e.g., prematurity) and sociocultural factors. The severity of intellectual disability may
be related to the timing and duration of a given trauma as well as to the degree of
exposure to the central nervous system (CNS). In about three fourths of persons
diagnosed with severe intellectual disability, the etiology is known, whereas the etiology
is apparent in up to half of those diagnosed with mild intellectual disability. A study of
100 consecutive children diagnosed with intellectual disability admitted to a clinical
genetics unit of a university pediatric hospital reported that in 41 percent of cases, a
causative diagnosis was made. No cause is known for three fourths of persons with IQ
ranging from 70 to 80 and variable adaptive functioning. Among chromosomal
disorders, Down syndrome and fragile X syndrome are the most common disorders that
usually produce at least moderate intellectual disability. A prototype of a metabolic
disorder associated with intellectual disability is phenylketonuria (PKU). Deprivation of
nutrition, nurturance, and social stimulation can potentially contribute to the
development of at least mild forms of intellectual disability. Current knowledge suggests
that genetic, environmental, biological, and psychosocial factors work additively in the
emergence of intellectual disability.
Genetic Etiological Factors in Intellectual Disability
Single-Gene Causes.
One of the most well-known single gene causes of
intellectually disability is found in the FMR1 gene whose mutations cause fragile X
syndrome. It is the most common and first X-linked gene to be identified as a direct
cause of intellectual disability. Abnormalities in autosomal chromosomes are frequently
associated with intellectual disability, whereas aberrations in sex chromosomes can
result in characteristic physical syndromes that do not include intellectual disability
(e.g., Turner’s syndrome with XO and Klinefelter’s syndrome with XXY, XXXY, and
XXYY variations). Some children with Turner’s syndrome have normal to superior
intelligence. Agreement exists on a few predisposing factors for chromosomal disorders
—among them, advanced maternal age, increased age of the father, and X-ray
radiation.
Visible and Submicroscopic Chromosomal Causes of Intellectual Disability.
Trisomy 21 (Down syndrome) is a prototype of a cytogenetically visible abnormality
that accounts for about two-thirds of the 15 percent of intellectual disability attributable
to
visible
abnormal
cytogenetics.
Other
microscopically
visible
chromosomal
abnormalities associated with intellectual disability include deletions, translocations,
and supernumerary marker chromosomes. Typically, microscopic chromosome analysis
is able to identify abnormalities of 5 to 10 million base pairs or greater.
Submicroscopic identification requires the use of microarrays that can identify losses
of chromosomal segments too small to be picked up by light microscopy. The altered
copy number variants (CNVs) in submicroscopic segments of the chromosome have been
identified to be associated with up to 13 to 20 percent of cases of intellectual disability.
That is, the genes associated with a particular developmental abnormality have been
identified to be located in the critical regions of the pathogenic copy number variants.
Genetic Intellectual Disability and Behavioral Phenotype
Specific and predictable behaviors have been found to be associated with certain
genetically based cases of intellectual disability. These behavioral phenotypes are
defined as a syndrome of observable behaviors that occur with a significantly greater
probability than expected among those individuals with a specific genetic abnormality.
Examples of behavioral phenotypes occur in genetically determined syndromes such
as fragile X syndrome, Prader-Willi syndrome, and Down syndrome in which specific
behavioral manifestations can be expected. Persons with fragile X syndrome have
extremely high rates (up to three fourths of those studied) of ADHD. High rates of
aberrant interpersonal behavior and language function often meet the criteria for
autistic disorder and avoidant personality disorder. Prader-Willi syndrome is almost
always associated with compulsive eating disturbances, hyperphagia, and obesity.
Socialization is an area of weakness, especially in coping skills. Externalizing behavior
problems—such as temper tantrums, irritability, and arguing—seem to be heightened in
adolescence.
Down Syndrome.
The etiology of Down syndrome, known to be caused by an
extra copy of the entire chromosome 21, makes it one of the more complex disorders.
The original description of Down syndrome, first made by the English physician
Langdon Down in 1866, was based on physical characteristics associated with
subnormal mental functioning. Since then, Down syndrome has been the most
investigated, and most discussed, syndrome in intellectual disability. Recent data have
suggested that Down syndrome may be more amenable to postnatal interventions to
address the cognitive deficits that it produces than was previously thought. Although still
in the early stages of animal research, data from experiments with one mouse model,
the Ts65Dn, indicates that pharmacologic interventions may influence learning and
memory deficits known to occur in Down syndrome.
Phenotypically, children with Down syndrome are observed to have characteristic
physical attributes, including slanted eyes, epicanthal folds, and a flat nose.
The etiology of Down syndrome is complicated by the recognition of three types of chromosomal aberrations in Down
syndrome:
Patients with trisomy 21 (three chromosomes 21, instead of the usual two) represent
the overwhelming majority; they have 47 chromosomes, with an extra chromosome
The mothers’ karyotypes are normal. A nondisjunction during meiosis, occurring
for unknown reasons, is held responsible for the disorder.
Nondisjunction occurring after fertilization in any cell division results in mosaicism, a
condition in which both normal and trisomic cells are found in various tissues.
In translocation, a fusion occurs of two chromosomes, usually 21 and 15, resulting in
a total of 46 chromosomes, despite the presence of an extra chromosome 21. The
disorder, unlike trisomy 21, is usually inherited, and the translocated chromosome
may be found in unaffected parents and siblings. The asymptomatic carriers have
only 45 chromosomes.
Approximately 6,000 babies are affected with Down syndrome in the United States, which makes the incidence of Down
syndrome 1 in every 700 births, or 15 per 10,000 live births. For women older than 32 years of age, the risk of having a
child with Down syndrome (trisomy 21) is about 1 in 100 births, but when translocation is present, the risk is about 1 in
Most children with Down syndrome are mildly to moderately intellectually disabled, with a minority having an IQ above
Cognitive development appears to progress normally from birth to 6 months of age; IQ scores gradually decrease from
near normal at 1 year of age to about 30 to 50 as development proceeds. The decline in intellectual function may not be
readily apparent. Infant tests may not reveal the full extent of the deficits. According to anecdotal clinical reports, children
with Down syndrome are typically placid, cheerful, and cooperative and adapt easily at home. With adolescence, the
picture changes: youth with Down syndrome may experience more social and emotional difficulties and behavior
disorders, and there is an increased risk for psychotic disorders.
In Down syndrome, language function is a relative weakness, whereas sociability and
social skills, such as interpersonal cooperation and conformity with social conventions,
are relative strengths. Children with Down syndrome typically manifest deficits in
scanning the environment; they are more likely to focus on a single stimulus, leading to
difficulty noticing environmental changes. A variety of comorbid psychiatric disorders
emerge in persons with Down syndrome; however, the rates appear to be lower than in
children with intellectual disability and autism spectrum disorder.
The diagnosis of Down syndrome is made with relative ease in an older child, but it is
often difficult in newborn infants. The most important signs in a newborn include
general hypotonia; oblique palpebral fissures; abundant neck skin; a small, flattened
skull; high cheekbones; and a protruding tongue. The hands are broad and thick, with a
single palmar transversal crease, and the little fingers are short and curved inward.
Moro reflex is weak or absent. More than 100 signs or stigmata are described in Down
syndrome, but rarely are all found in one person. Commonly occurring physical
problems in Down syndrome include cardiac defects, thyroid abnormalities, and
gastrointestinal problems. Life expectancy was once drastically limited to about the age
of 40; however, currently it is vastly increased, although still not as long as those
without intellectual disability.
Down syndrome is characterized by deterioration in language, memory, self-care
skills, and problem-solving by the third decade of life. Postmortem studies of individuals
with Down syndrome older than age 40 have shown a high incidence of senile plaques
and neurofibrillary tangles, similar to those seen in Alzheimer’s disease. Neurofibrillary
tangles are known to occur in a variety of degenerative diseases, whereas senile plaques
seem to be found most often in Alzheimer’s disease and in Down syndrome.
Fragile X Syndrome.
Fragile X syndrome is the second most common single cause
of intellectual disability. The syndrome results from a mutation on the X chromosome at
what is known as the fragile site (Xq27.3). The fragile site is expressed in only some
cells, and it may be absent in asymptomatic males and female carriers. Much variability
is present in both genetic and phenotypic expression. Fragile X syndrome is believed to
occur in about 1 of every 1,000 males and 1 of every 2,000 females. The typical
phenotype includes a large, long head and ears, short stature, hyperextensible joints,
and postpubertal macroorchidism. Associated intellectual disability ranges from mild to
severe. The behavioral profile of persons with the syndrome includes a high rate of
ADHD, learning disorders, and autism spectrum disorder. Deficits in language function
include rapid perseverative speech with abnormalities in combining words into phrases
and sentences. Persons with fragile X syndrome seem to have relatively strong skills in
communication and socialization; their intellectual functions seem to decline in the
pubertal period. Female carriers are often less impaired than males with fragile X
syndrome, but females can also manifest the typical physical characteristics and may
have mild intellectual disability.
Prader-Willi Syndrome.
Prader-Willi syndrome is believed to result from a small
deletion involving chromosome 15, occurring sporadically. Its prevalence is less than 1
in 10,000. Persons with the syndrome exhibit compulsive eating behavior and often
obesity, intellectual disability, hypogonadism, small stature, hypotonia, and small hands
and feet.
Cat’s Cry (Cri-du-Chat) Syndrome.
Children with cat’s cry syndrome have a
deletion in chromosome 5. They are typically severely intellectually disabled and show
many signs often associated with chromosomal aberrations, such as microcephaly, lowset ears, oblique palpebral fissures, hypertelorism, and micrognathia. The characteristic
cat-like cry that gave the syndrome its name is caused by laryngeal abnormalities that
gradually change and disappear with increasing age.
Phenylketonuria.
PKU was first described by Ivar Asbjörn Fölling in 1934 as an
inborn error of metabolism. PKU is transmitted as a simple recessive autosomal
Mendelian trait and occurs in about 1 of every 10,000 to 15,000 live births. For parents
who have already had a child with PKU, the chance of having another child with PKU is
20 to 25 percent of successive pregnancies. PKU is reported predominantly in persons of
North European origin; a few cases have been described in blacks, Yemenite Jews, and
Asians. The basic metabolic defect in PKU is an inability to convert phenylalanine, an
essential amino acid, to paratyrosine because of the absence or inactivity of the liver
enzyme phenylalanine hydroxylase, which catalyzes the conversion. Therefore, PKU is
largely preventable with a screening for it, which, if positive, should be followed with a
low phenylalanine diet. Two other types of hyperphenylalaninemia have recently been
described. One is caused by a deficiency of the enzyme dihydropteridine reductase, and
the other to a deficiency of a cofactor, biopterin. The first defect can be detected in
fibroblasts, and biopterin can be measured in body fluids. Both these rare disorders carry
a high risk of fatality.
Most patients with PKU are severely intellectually disabled, but some are reported to
have borderline or normal intelligence. Eczema, vomiting, and convulsions occur in
about one third of all patients. Although the clinical picture varies, typically, children
with PKU are reported to be hyperactive and irritable. They frequently exhibit temper
tantrums and often display bizarre movements of their bodies and upper extremities,
including twisting hand mannerisms. Verbal and nonverbal communication is commonly
severely impaired or nonexistent. The children’s coordination is poor, and they have
many perceptual difficulties.
Currently, the Guthrie inhibition assay is a widely applied screening test using a
bacteriological procedure to detect phenylalanine in the blood. In the United States,
newborn infants are routinely screened for PKU. Early diagnosis is important, because a
low-phenylalanine diet, in use since 1955, significantly improves both behavior and
developmental progress. The best results seem to be obtained with early diagnosis and
the start of dietary treatment before the child is 6 months of age. Dietary treatment,
however, is not without risk. Phenylalanine is an essential amino acid, and its omission
from the diet can lead to such severe complications as anemia, hypoglycemia, or edema.
Dietary treatment of PKU should be continued indefinitely. Children who receive a
diagnosis before the age of 3 months and are placed on an optimal dietary regimen may
have normal intelligence. A low-phenylalanine diet does not reverse intellectual
disability in untreated older children and adolescents with PKU, but the diet does
decrease irritability and abnormal electroencephalography (EEG) changes and does
increase social responsiveness and attention span. The parents of children with PKU and
some of the children’s normal siblings are heterozygous carriers.
Rett syndrome.
Rett syndrome, now diagnosed in the DSM-5 as a form of autism
spectrum disorder, is believed to be caused by a dominant X-linked gene. It is
degenerative and affects only females. In 1966, Andreas Rett reported on 22 girls with a
serious progressive neurological disability. Deterioration in communications skills,
motor behavior, and social functioning starts at about 1 year of age. Symptoms include
ataxia, facial grimacing, teeth-grinding, and loss of speech. Intermittent
hyperventilation and a disorganized breathing pattern are characteristic while the child
is awake. Stereotypical hand movements, including hand-wringing, are typical.
Progressive gait disturbance, scoliosis, and seizures occur. Severe spasticity is usually
present by middle childhood. Cerebral atrophy occurs with decreased pigmentation of
the substantia nigra, which suggests abnormalities of the dopaminergic nigrostriatal
system.
Neurofibromatosis.
Also called von Recklinghausen’s, neurofibromatosis is the most
common of the neurocutaneous syndromes caused by a single dominant gene, which
may be inherited or occur as a new mutation. The disorder occurs in about 1 of 5,000
births and is characterized by café au lait spots on the skin and by neurofibromas,
including optic gliomas and acoustic neuromas, caused by abnormal cell migration. Mild
intellectual disability occurs in up to one third of those with the disease.
Tuberous Sclerosis.
Tuberous sclerosis is the second most common of the
neurocutaneous syndromes; a progressive intellectual disability occurs in up to two
thirds of all affected persons. It occurs in about 1 of 15,000 persons and is inherited by
autosomal dominant transmission. Seizures are present in all those with intellectual
disability, and in two thirds of those who are not. Infantile spasms may occur as early as
6 months of age. The phenotypic presentation includes adenoma sebaceum and ash-leaf
spots that can be identified with a slit lamp.
Lesch-Nyhan Syndrome.
Lesch-Nyhan syndrome is a rare disorder caused by a
deficiency of an enzyme involved in purine metabolism. The disorder is X-linked;
patients have intellectual disability, microcephaly, seizures, choreoathetosis, and
spasticity. The syndrome is also associated with severe compulsive self-mutilation by
biting the mouth and fingers. Lesch-Nyhan syndrome is another example of a genetically
determined syndrome with a specific, predictable behavioral pattern.
Adrenoleukodystrophy
The
most
common
of
several
disorders
of
sudanophilic
cerebral
sclerosis,
adrenoleukodystrophy is characterized by diffuse demyelination of the cerebral white
matter resulting in visual and intellectual impairment, seizures, spasticity, and
progression to death. The cerebral degeneration in adrenoleukodystrophy is
accompanied by adrenocortical insufficiency. The disorder is transmitted by a sex-linked
gene located on the distal end of the long arm of the X chromosome. The clinical onset is
generally between 5 and 8 years of age, with early seizures, disturbances in gait, and
mild intellectual impairment. Abnormal pigmentation reflecting adrenal insufficiency
sometimes precedes the neurological symptoms, and attacks of crying are common.
Spastic contractures, ataxia, and swallowing disturbances are also frequent. Although
the course is often rapidly progressive, some patients may have a relapsing and
remitting course.
Maple Syrup Urine Disease.
The clinical symptoms of maple syrup urine disease
appear during the first week of life. The infant deteriorates rapidly and has decerebrate
rigidity, seizures, respiratory irregularity, and hypoglycemia. If untreated, maple syrup
urine disease is usually fatal in the first months of life, and the survivors have severe
intellectual disability. Some variants have been reported with transient ataxia and only
mild intellectual disability. Treatment follows the general principles established for PKU
and consists of a diet very low in the three involved amino acids—leucine, isoleucine,
and valine.
Other Enzyme Deficiency Disorders.
Several enzyme deficiency disorders
associated with intellectual disability have been identified, and still more diseases are
being added as new discoveries are made, including Hartnup disease, galactosemia, and
glycogen-storage disease. Table 31.3-3 lists 30 important disorders with inborn errors of
metabolism, hereditary transmission patterns, defective enzymes, clinical signs, and
relation to intellectual disability.
Table 31.3-3
Impairment in Disorders with Inborn Errors of Metabolism
Acquired and Developmental Factors
Prenatal Period.
Important prerequisites for the overall development of the fetus
include the mother’s physical, psychological, and nutritional health during pregnancy.
Maternal chronic illnesses and conditions affecting the normal development of the
fetus’s CNS include uncontrolled diabetes, anemia, emphysema, hypertension, and longterm use of alcohol and narcotic substances. Maternal infections during pregnancy,
especially viral infections, have been known to cause fetal damage and intellectual
disability. The extent of fetal damage depends on such variables as the type of viral
infection, the gestational age of the fetus, and the severity of the illness. Although
numerous infectious diseases have been reported to affect the fetus’s CNS, the following
maternal illnesses have been identified to increase risk of intellectual disability in the
newborn.
Rubella (German measles).
Rubella has replaced syphilis as the major cause of
congenital malformations and intellectual disability caused by maternal infection. The
children of affected mothers may show several abnormalities, including congenital heart
disease, intellectual disability, cataracts, deafness, microcephaly, and microphthalmia.
Timing is crucial, because the extent and frequency of the complications are inversely
related to the duration of the pregnancy at the time of maternal infection. When
mothers are infected in the first trimester of pregnancy, 10 to 15 percent of the children
are affected, but the incidence rises to almost 50 percent when the infection occurs in
the first month of pregnancy. The situation is often complicated by subclinical forms of
maternal infection that go undetected. Maternal rubella can be prevented by
immunization.
Cytomegalic Inclusion Disease.
In many cases, cytomegalic inclusion disease
remains dormant in the mother. Some children are stillborn, and others have jaundice,
microcephaly, hepatosplenomegaly, and radiographic findings of intracerebral
calcification. Children with intellectual disability from the disease frequently have
cerebral calcification, microcephaly, or hydrocephalus. The diagnosis is confirmed by
positive findings of the virus in throat and urine cultures and the recovery of inclusionbearing cells in the urine.
Syphilis.
Syphilis in pregnant women was once the main cause of various
neuropathological changes in their offspring, including intellectual disability. Today, the
incidence of syphilitic complications of pregnancy fluctuates with the incidence of
syphilis in the general population. Some recent alarming statistics from several major
cities in the United States indicate that there is still no room for complacency.
Toxoplasmosis.
Toxoplasmosis can be transmitted by the mother to the fetus. It
causes mild or severe intellectual disability and, in severe cases, hydrocephalus, seizures,
microcephaly, and chorioretinitis.
Herpes Simplex.
The herpes simplex virus can be transmitted transplacentally,
although the most common mode of infection is during birth. Microcephaly, intellectual
disability, intracranial calcification, and ocular abnormalities may result.
Human Immunodeficiency Virus (HIV).
Cognitive impairments are well
known to be associated with transmission of HIV from mothers to their babies. HIV may
have both direct and indirect influences on the developing brain. A subset of infants
born infected with HIV may develop progressive encephalopathy, intellectual
disabilities, and seizures within the first year of life. Fortunately, over the last two
decades, there has been a dramatic decrease in perinatal HIV transmission due to a
combination of antiviral agents provided to mothers during pregnancy and delivery,
obstetric interventions that reduce risk, and administration of zidovudine (ZDV) as a
prophylaxis for six weeks to newborns exposed to HIV. In the United States, the highest
rate of reported pediatric acquired immunodeficiency disease (AIDS) occurred in 1992,
with 1,700 cases reported compared to less than 50 cases reported annually now. In the
United States, fewer than 300 cases of HIV transmission from mother to child were
reported in 2005. However, vertical transmission of HIV from mother to child around
the world, especially in Africa, is considerable. Most babies born to HIV-infected
mothers in the United States are not infected with the virus.
Fetal Alcohol Syndrome.
Fetal alcohol syndrome (FAS) results from prenatal
alcohol exposure and can lead to a wide range of problems in the newborn. According
to the Centers for Disease Control and Prevention, FAS in the United States occurs at a
rate ranging from 0.2 to 1.5 per 1,000 live births. FAS is one of the leading preventable
causes of intellectual disability and physical disabilities. The typical phenotypic picture
of a child with FAS includes facial dysmorphism comprising hypertelorism,
microcephaly, short palpebral fissures, inner epicanthal folds, and a short, turned-up
nose. Often, the affected children have learning disorders and ADHD, and in some cases
intellectual disability. Cardiac defects are also frequent. The entire syndrome occurs in
up to 15 percent of babies born to women who regularly ingest large amounts of
alcohol. Babies born to women who consume alcohol regularly during pregnancy have a
high incidence of ADHD, learning disorders, and intellectual disability without the facial
dysmorphism.
Prenatal Drug Exposure.
Prenatal exposure to opioids, such as heroin, often
results in infants who are small for their gestational age, with a head circumference
below the tenth percentile and withdrawal symptoms that appear within the first 2 days
of life. The withdrawal symptoms of infants include irritability, hypertonia, tremor,
vomiting, a high-pitched cry, and an abnormal sleep pattern. Seizures are unusual, but
the withdrawal syndrome can be life-threatening to infants if it is untreated. Diazepam
(Valium), phenobarbital (Luminal), chlorpromazine (Thorazine), and paregoric have
been used to treat neonatal opioid withdrawal. The long-term sequelae of prenatal
opioid exposure are not fully known; the children’s developmental milestones and
intellectual functions may be within the normal range, but they have an increased risk
for impulsivity and behavioral problems. Infants prenatally exposed to cocaine are at
high risk for low birth weight and premature delivery. In the early neonatal period, they
may have transient neurological and behavioral abnormalities, including abnormal
results on EEG studies, tachycardia, poor feeding patterns, irritability, and excessive
drowsiness. Rather than a withdrawal reaction, the physiological and behavioral
abnormalities are a response to the cocaine, which may be excreted for up to a week
postnatally.
Complications of Pregnancy.
Toxemia of pregnancy and uncontrolled maternal
diabetes present hazards to the fetus and can potentially result in intellectual disability.
Maternal malnutrition during pregnancy often results in prematurity and other
obstetrical complications. Vaginal hemorrhage, placenta previa, premature separation
of the placenta, and prolapse of the cord can damage the fetal brain by causing anoxia.
The use of lithium during pregnancy was recently implicated in some congenital
malformations, especially of the cardiovascular system (e.g., Ebstein’s anomaly).
Perinatal Period.
Some evidence indicates that premature infants and infants with
low birth weight are at high risk for neurological and subtle intellectual impairments
that may not be apparent until their school years. Infants who sustain intracranial
hemorrhages or show evidence of cerebral ischemia are especially vulnerable to
cognitive abnormalities. The degree of neurodevelopmental impairment generally
correlates with the severity of the intracranial hemorrhage. Recent studies have
documented that, among children with very low birth weight (less than 1,000 g), 20
percent had significant disabilities, including cerebral palsy, intellectual disability,
autism, and low intelligence with severe learning problems. Very premature children
and those who had intrauterine growth retardation were found to be at high risk for
developing both social problems and academic difficulties. Socioeconomic deprivation
can also affect the adaptive function of these vulnerable infants. Early intervention may
improve their cognitive, language, and perceptual abilities.
Acquired Childhood Disorders
Infection.
The most serious infections affecting cerebral integrity are encephalitis
and meningitis. Measles encephalitis has been virtually eliminated by the universal use
of measles vaccine, and the incidence of other bacterial infections of the CNS has been
markedly reduced with antibacterial agents. Most episodes of encephalitis are caused by
viruses. Sometimes a clinician must retrospectively consider a probable encephalitic
component in a previous obscure illness with high fever. Meningitis that was diagnosed
late, even when followed by antibiotic treatment, can seriously affect a child’s cognitive
development. Thrombotic and purulent intracranial phenomena secondary to septicemia
are rarely seen today except in small infants.
Head Trauma.
The best-known causes of head injury in children that produces
developmental handicaps, including seizures, are motor vehicle accidents, but more
head injuries are caused by household accidents, such as falls from tables, open
windows, and on stairways. Child maltreatment is not infrequently implicated in head
traumas or intracranial trauma such as bleeding due “shaken baby” syndrome.
Asphyxia.
Brain damage due to asphyxia associated with near drowning is not an
uncommon cause of intellectual disability.
Long-term Exposures.
Long-term exposure to lead is a well-established cause of
compromised intelligence and learning skills. Intracranial tumors of various types and
origins, surgery, and chemotherapy can also adversely affect brain function.
Environmental and Sociocultural Factors
Mild intellectual disability has been associated with significant deprivation of nutrition
and nurturance. Children who have endured these conditions are at risk for a host of
psychiatric disorders including mood disorders, posttraumatic stress disorder, and
attentional and anxiety disorders. Prenatal environment compromised by poor medical
care and poor maternal nutrition may be contributing factors in the development of
mild intellectual disability. Teenage pregnancies are at risk for mild intellectual
disability in the baby due to the increased risk of obstetrical complications, prematurity,
and low birth weight. Poor postnatal medical care, malnutrition, exposure to toxic
substances such as lead, and potential physical trauma are additional risk factors for
mild intellectual disabilities. Child neglect and inadequate caretaking may deprive an
infant of both physical and emotional nurturances, leading to failure to thrive
syndromes.
DIAGNOSIS
The diagnosis of intellectual disability can be made after the history is obtained, using
information from a standardized intellectual assessment, and a standardized measure of
adaptive function indicating that a child is significantly below the expected level in both
areas. The severity of the intellectual disability will be determined on the basis of the
level of adaptive function. A history and psychiatric interview are useful in obtaining a
longitudinal picture of the child’s development and functioning. Examination of physical
signs, neurological abnormalities, and in some cases, laboratory tests can be used to
ascertain the cause and prognosis.
History
The clinician taking the history, which may elucidate pathways to intellectual disability,
should pay particular attention to the mother’s pregnancy, labor, and delivery; the
presence of a family history of intellectual disability; consanguinity of the parents; and
known familial hereditary disorders.
Psychiatric Interview
A psychiatric interview of a child or adolescent with intellectual disability requires a
high level of sensitivity in order to elicit information at the appropriate intellectual
level while remaining respectful of the patient’s age and emotional development. The
patient’s verbal abilities, including receptive and expressive language, can be initially
screened by observing the communication between the caretakers and patient. If the
patient communicates largely through gestures or sign language, the parents may serve
as interpreters. Patients with milder forms of intellectual disability are often well aware
of their differences from others and their failures, and may be anxious and ashamed
during the interview. Approaching patients with a clear, supportive, concrete
explanation of the diagnostic process, particularly patients with sufficiently receptive
language ability, may allay anxiety and fears. Providing support and praise in language
appropriate to the patient’s age and understanding is beneficial. Subtle direction,
structure, and reinforcement may be necessary to keep patients focused on the task or
topic.
In general, the psychiatric examination of an intellectually disabled child or
adolescent should reveal how the patient has coped with stages of development.
Frustration tolerance, impulse control, and over-aggressive motor and sexual behavior
are important areas of attention in the interview. It is equally important to elicit the
patient’s self-image, areas of self-confidence, and an assessment of tenacity, persistence,
curiosity, and willingness to explore the environment.
Structured Instruments, Rating Scales and Psychological Assessment
In children and adolescents who have acquired language, one of several standardized
instruments that include numerous domains of cognitive function are used. For children
ages 6 to 16 years, the Wechsler Intelligence Test for Children is typically administered,
and for children ages 3 to 6 years, the Wechsler Preschool and Primary Scale of
Intelligence-Revised is commonly used. The Stanford-Binet Intelligence Scale, Fourth
Edition, has the advantage that it can be administered to children even younger,
starting at age 2 years. The Kaufman Assessment Battery for Children can be used in
children ages 2½ to 12½ years, whereas the Kaufman Adolescent and Adult Intelligence
Test is applicable to a wide range of ages, from 11 to 85 years. All of the above
standardized instruments evaluate cognitive abilities across multiple domains including
verbal, performance, memory, and problem solving. Standardized instruments
measuring adaptive function (functions of “everyday” life) are based on the construct
that adaptive skills increase with age, and that adaptation may vary across different
settings such as school, peer relationships, and family life. The Vineland Adaptive
Behavior Scales can be used in infants through youth 18 years of age and includes four
basic domains including Communication (Receptive, Expressive, and Written); Daily
Living Skills (Personal, Domestic, and Community); Socialization (Interpersonal Relations,
Play and Leisure, and Coping Skills); Motor Skills (Fine and Gross).
Several behavioral rating scales have been developed for the population with
intellectual disability. General behavioral ratings scales include the Aberrant Behavior
Checklist (ABC) and the Developmental Behavior Checklist (DBC). The Behavior
Problem Inventory (BPI) is a good screening instrument for self-injurious, aggressive,
and stereotyped behaviors. The Psychopathology Inventory for Mentally Retarded
Adults (PIMRA) is utilized to identify the presence of comorbid psychiatric symptoms
and disorders.
Examining clinicians can use several screening instruments for developmental and
intellectual delay or disability in infants and toddlers. However, controversy over the
predictive value of infant psychological tests is heated. Some report the correlation of
abnormalities during infancy with later abnormal functioning as very low, and others
report it to be very high. The correlation rises in direct proportion to the age of the child
at the time of the developmental examination. Some exercises such as copying geometric
figures, the Goodenough Draw-a-Person Test, the Kohs Block Test, and geometric puzzles
all may be used as quick screening tests of visual-motor coordination. The Gesell and
Bayley scales and the Cattell Infant Intelligence Scale are most commonly used with
infants.
The Peabody Vocabulary Test is the most widely used vocabulary test solely based on
pictures. Other tests often found useful in detecting intellectual disability are the Bender
Gestalt Test and the Benton Visual Retention Test. The psychological evaluation should
assess perceptual, motor, linguistic, and cognitive abilities.
Physical Examination
Various parts of the body may demonstrate identifying characteristics of specific
perinatal and prenatal events or conditions associated with intellectual disabilities. For
example, the configuration and the size of the head may offer clues to a variety of
conditions, such as microcephaly, hydrocephalus, or Down syndrome. A patient’s facial
characteristics, for example, hypertelorism, a flat nasal bridge, prominent eyebrows,
epicanthal folds may provide clues to a recognizable syndrome such as FAS. Additional
facial characteristics including corneal opacities, retinal changes, low-set and small or
misshapen ears, a protruding tongue, and disturbance in dentition may be stigmata of a
variety of known syndromes. Facial expression, color and texture of the skin and hair, a
high-arched palate, the size of the thyroid gland, and the proportions of a child’s trunk
and extremities may offer clues for particular syndromes. The circumference of the head
should be measured as part of the clinical investigation. Dermatoglyphics may offer
another diagnostic tool, because uncommon ridge patterns and flexion creases on the
hand are often found in persons who are intellectually disabled. Abnormal
dermatoglyphics occur in chromosomal disorders and in persons who were prenatally
infected with rubella. Table 31.3-4 lists syndromes with intellectual disability and their
behavioral phenotypes.
Table 31.3-4
Syndromes with Intellectual Disability and Behavioral Phenotypes
Neurological Examination
Sensory impairments occur frequently among persons with intellectual disabilities. For
example, hearing impairment occurs in 10 percent of persons with intellectual
disability, a rate that is four times that of the general population. Visual disturbances
can range from blindness to disturbances of spatial concepts, design recognition, and
concepts of body image. Seizure disorders occur in about 10 percent of intellectually
disabled populations and in one third of those with severe intellectual disability.
Neurological abnormalities increase in incidence and severity in direct proportion to the
degree of intellectual disability. Disturbances in motor areas are manifested in
abnormalities of muscle tone (spasticity or hypotonia), reflexes (hyperreflexia), and
involuntary movements (choreoathetosis). Less disability may also be associated with
clumsiness and poor coordination.
CLINICAL FEATURES
Mild intellectual disability may not be recognized or diagnosed in a child until school
challenges the child’s social and communication skills. Cognitive deficits include poor
ability to abstract and egocentric thinking, both of which become more easily evident as
a child reaches middle childhood. Children with milder intellectual disabilities may
function academically at the high elementary level and may acquire vocational skills
sufficient to support themselves in some cases; however, social assimilation may be
problematic. Communication deficits, poor self-esteem, and dependence may further
contribute to a relative lack of social spontaneity.
Moderate levels of intellectual disability are significantly more likely to be observed
at a younger age, since communication skills develop more slowly and social isolation
may ensue in the elementary school years. Academic achievement is usually limited to
the middle-elementary level. Children with moderate intellectual deficits benefit from
individual attention focused on the development of self-help skills. However, these
children are aware of their deficits and often feel alienated from their peers and
frustrated by their limitations. They continue to require a relatively high level of
supervision but can become competent at occupational tasks in supportive settings.
Severe intellectual disability is typically obvious in the preschool years; affected
children have minimal speech and impaired motor development. Some language
development may occur in the school-age years. By adolescence, if language has not
improved significantly, poor, nonverbal forms of communication may have evolved.
Behavioral approaches are useful means to promote some self-care, although those with
severe intellectual disability generally need extensive supervision.
Children with profound intellectual disability require constant supervision and are
severely limited in both communication and motor skills. By adulthood, some speech
development may be present, and simple self-help skills may be acquired. Clinical
features frequently observed in populations with intellectual disability either in isolation
or as part of a mental disorder, include hyperactivity, low frustration tolerance,
aggression, affective instability, repetitive and stereotypic motor behaviors, and selfinjurious behaviors. Self-injurious behaviors occur more frequently and with greater
intensity in more severe intellectual disability.
Dylan was a full-term infant, the second child born to his 42-year-old mother, a
medical technician, and 48-year-old father, a high school basketball coach. The
pregnancy was unremarkable, and Dylan’s sister, who was two years older, was
healthy and developing normally. The family lived in a rural town in the Midwest.
Dylan was an extremely fussy, active newborn with extended periods of crying that
the pediatrician labeled classic colic. As a newborn, it was noticed that Dylan seemed
to have large ears and strabismus, which the pediatrician said would probably resolve
spontaneously. At 2 months of age, at a regular pediatric visit, a systolic heart
murmur was heard and electrocardiography (ECG) revealed a mitral valve prolapse.
Because Dylan was not cyanotic and had no other cardiac symptoms, no treatment
was recommended except monitoring. Although Dylan became less fussy over time, he
remained very active, did not sleep through the night, and was a picky eater, refusing
solid foods.
Milestones were slightly delayed, with Dylan sitting unassisted at 10 months and
walking at 18 months. Language was also delayed, and, although his first words
appeared at 20 months, Dylan had always made his wants and needs known. Dylan’s
parents were concerned about his activity level and his developmental delays
compared with his sister; however, they were reassured by the pediatrician’s sense
that boys often develop more slowly than girls in the first two years.
When Dylan was 3 years of age, his preschool teacher noted that he was unable to
pay attention and he was hyperactive compared to his classmates, prompting his
parents to obtain a developmental evaluation. Results showed modest delays in
cognitive, linguistic, and motor functioning, with a developmental quotient (DQ) of
74. Dylan was described as inattentive, shy, and anxious, and he had poor eye
contact. Enrolled in a special kindergarten, Dylan remained in a combination of
special education and mainstreamed classes throughout his academic life.
At 7 years of age, the school psychologist evaluated Dylan and results indicated that
he met criteria for a “learning disability” profile. Dylan had an overall IQ of 66, with
close to average functioning in short-term memory and pronounced deficits in longterm memory, expressive language, and visual-spatial functioning. Dylan struggled
with writing tasks and arithmetic, but loved science. Due to his significant problems
with inattention and hyperactivity, Dylan was placed on Concerta, which was
beneficial, and titrated up to 54 mg per day. He displayed transient, intense interests
in unusual items, such as vacuum cleaners. When Dylan reached the older elementary
grades, he began to have more difficulty socially, and he was bullied about being in
special education, and teased for his long head and big ears.
As he entered adolescence, Dylan became increasingly anxious, so much so that he
occasionally rubbed his hands or rocked, and he “fretted” about day-to-day issues and
what would happen next. His long-term sensitivities to loud sounds seemed to wane
slightly, but he developed fears of storm clouds and dogs and refused to ride on
elevators. He became tearful and upset after his older sister left for a party, and
worried that she might have a car accident. Dylan was very shy and would
occasionally pace with worry and complain of stomachaches, but he attended school
and had a small group of acquaintances in the Special Olympics bowling league. He
enjoyed activities that did not involve much talking or sustained attention.
When Dylan was 17 years of age, his parents happened to watch a television
documentary on genetic causes of intellectual disability. They were overwhelmed by
the similarities between Dylan and some of the people described in the program. They
later described the experience as a “jolt.” They had always accepted Dylan, quirks and
all, and had stopped pushing their doctors for reasons “why” when Dylan was a
preschooler. Nevertheless, they immediately called the informational number offered
in the show, and within 2 months, they had the genetic tests done that confirmed a
diagnosis of fragile X syndrome.
Although Dylan’s day-to-day life did not change dramatically after the diagnosis, his
parents reported a big difference in their approach to his shyness, restricted interests,
and inattention. Dylan was later treated for anxiety with a selective serotonin
reuptake inhibitor (SSRI) antidepressant, which decreased his social anxiety and
facilitated activities with a few peers. Dylan’s parents reported a mixture of feelings
at having such a late diagnosis—disappointment in their doctors, relief in finally
knowing, and twinges of guilt. They were energized by Dylan’s positive responses to
treatments for his attentional and anxiety symptoms and were pleased with Dylan’s
recent increased interest in sharing activities with classmates and peers.
LABORATORY EXAMINATION
Laboratory tests that may elucidate the causes of intellectual disability include
chromosomal analysis, urine and blood testing for metabolic disorders, and
neuroimaging. Chromosomal abnormalities are the single most known common cause of
intellectual disability.
Chromosome Studies
Chromosome analysis is commonly obtained when multiple physical anomalies,
developmental delays, and intellectual disability present together. Current techniques
are able to chromosomal regions with specific fluorescent in situ hybridization (FISH)
markers, leading to microscopic deletions being identified in up to 7% of persons with
moderate to severe intellectual disability. A history of growth retardation, the presence
of microcephaly, a family history of intellectual disability, short stature, hypertelorism,
and other facial abnormalities increase the risk for finding subtelomeric defects.
Amniocentesis, in which a small amount of amniotic fluid is removed from the
amniotic cavity transabdominally at about the 15 weeks of gestation, has been useful in
diagnosing prenatal chromosomal abnormalities. Its use is considered when an
increased fetal risk exists, such as with increased maternal age. Amniotic fluid cells,
mostly fetal in origin, are cultured for cytogenetic and biochemical studies.
Chronic villi sampling (CVS) is a screening technique to determine fetal chromosomal
abnormalities. It is done at 8 to 10 weeks of gestation, 6 weeks earlier than
amniocentesis is done. The results are available in a short time (hours or days) and, if
the result is abnormal, the decision to terminate the pregnancy can be made within the
first trimester. The procedure has a miscarriage risk between 2 and 5 percent; the risk in
amniocentesis is lower (1 in 200). A non-invasive blood test called materniT21 is a
proprietary prenatal test that detects abnormalities of chromosomes 21,18,13, X and Y.
It is highly specific for Down syndrome (Figure 31.3-1). There is no risk of miscarriage.
FIGURE 31.3-1
A. young child with Down syndrome. B. A young adult with fragile X syndrome.
(Courtesy of L.S. Syzmanski, M.D., and A.C. Crocker, M.D.)
Urine and Blood Analysis
Lesch-Nyhan syndrome, galactosemia, PKU, Hurler’s syndrome (Figure 31.3-2), and
Hunter’s syndrome (Figure 31.3-3) are examples of disorders characterized by
intellectual disability that can be identified through assays of the appropriate enzyme or
organic or amino acids. Enzymatic abnormalities in chromosomal disorders, particularly
Down syndrome, promise to become useful diagnostic tools.
FIGURE 31.3-3
Two brothers, age 6 and 8 years, with Hunter’s syndrome, shown with their normal
older sister. They have had significant developmental delay, trouble with recurrent
respiratory infection, and behavioral abnormalities. (Courtesy of L.S. Syzmanski, M.D.,
and A.C. Crocker, M.D.)
FIGURE 31.3-2
A 6-year-old girl with Hurler’s syndrome. Her care has involved a class for seriously
multihandicapped children, attention to cardiac problems, and special counseling for
patients. (Courtesy of L.S. Syzmanski, M.D., and A.C. Crocker, M.D.)
Electroencephalography
Electroencephalography is indicated whenever a seizure disorder is considered.
“Nonspecific” EEG changes, characterized by slow frequencies with bursts of spikes and
sharp or blunt wave complexes are found with greater frequency among populations
with intellectual disability than in the general population; however, these findings do
not elucidate specific diagnoses.
Neuroimaging
Neuroimaging studies with populations of intellectually disabled patients using either
computerized tomography (CT) or magnetic resonance imaging (MRI) have found high
rates of abnormalities in those patients with microcephaly, significant delay, cerebral
palsy,
and
profound
disability.
Among
patients
with
intellectual
disability,
neuroimaging is indicated, accompanying findings that suggest seizures, microcephaly
or macrocephaly, loss of previously acquired skills, or neurologic signs such as dystonia,
spasticity, or altered reflexes.
Although clinically not diagnostic, neuroimaging studies are currently also utilized to
gather data that may eventually uncover biological mechanisms contributing to
intellectual disability. Structural MRI, functional MRI (fMRI), and diffusion tensor
imaging (DTI) are utilized in current research. For example, current data suggest that
individuals with fragile X syndrome and concurrent attentional deficits are also more
likely to show aberrant frontal-striatal pathways on MRI than those patients without
attentional problems. MRI is also useful to elucidate myelination patterns. MRI studies
can also provide a baseline for comparison of a later, potentially degenerative process
in the brain.
Hearing and Speech Evaluations
Hearing and speech should be evaluated routinely. Speech development may be the
most reliable criterion in investigating intellectual disability. Various hearing
impairments often occur in persons who are intellectually disabled, but in some
instances hearing impairments can simulate intellectual disability. The commonly used
methods of hearing and speech evaluation, however, require the patient’s cooperation
and, thus, are often unreliable in severely disabled persons.
COURSE AND PROGNOSIS
Although the underlying intellectual impairment does not improve, in most cases of
intellectual disability, level of adaptation increases with age and can be influenced
positively by an enriched and supportive environment. In general, persons with mild
and moderate mental intellectual disabilities have the most flexibility in adapting to
various environmental conditions. Comorbid psychiatric disorders negatively impact
overall prognosis. When psychiatric disorders are superimposed on intellectual
disability, standard treatments for the comorbid mental disorders are often beneficial;
however, less robust responses and increased vulnerability to side effects of
psychopharmacologic agents are often the case.
DIFFERENTIAL DIAGNOSIS
By definition, intellectual disability must begin before the age of 18. In some cases,
severe child maltreatment in the form of neglect or abuse may contribute to delays in
development, which can appear to be intellectual disability. However these damages are
partially reversible when a corrective, enriched, and stimulating environment is
provided in early childhood. Sensory disabilities, especially deafness and blindness, can
be mistaken for intellectual disability when a lack of awareness of the sensory deficit
leads to inappropriate testing. Expressive and receptive speech disorders may give the
impression of intellectual disability in a child of average intelligence, and cerebral palsy
may be mistaken for intellectual disability. Chronic, debilitating medical diseases may
depress and delay a child’s functioning and achievement, despite normal intelligence.
Seizure disorders, especially those that are poorly controlled, may contribute to
persisting intellectual disability. Specific organic syndromes leading to isolated
handicaps such as failure to read (alexia), failure to write (agraphia), or failure to
communicate (aphasia), may occur in a child of normal and even superior intelligence.
Children with learning disorders (which can coexist with intellectual disability)
experience a delay or failure of development in a specific area, such as reading or
mathematics, but they develop normally in other areas. In contrast, children with
intellectual disability show general delays in most areas of development.
Intellectual disability and autism spectrum disorder (ASD) often coexist; 70 to 75
percent of those with ASD have an IQ below 70. In addition, epidemiologic data indicate
that ASD occurs in approximately 19.8% of persons with intellectual disability. Children
with ASD have relatively more severe impairment in social relatedness and language
than other children with the same level of intellectual disability.
A child younger than the age of 18 years with significant adaptive functional
impairment, with an IQ less than 70, who also meets diagnostic criteria for dementia,
will receive both a diagnosis of dementia and intellectual disability. However, a child
whose IQ drops below 70 after the age of 18 years with newly acquired cognitive
impairment will receive only the diagnosis of dementia.
TREATMENT
Interventions for children and adolescents with intellectual disability are based on an
assessment of social, educational, psychiatric, and environmental needs. Intellectual
disability is associated with a variety of comorbid psychiatric disorders that often
require specific treatment, in addition to psychosocial support. Of course, when
preventive measures are available, the optimal approach includes primary, secondary,
and tertiary interventions.
Primary Prevention
Primary prevention comprises actions taken to eliminate or reduce the conditions that
lead to development of intellectual disability, as well as associated disorders. For
example, screening babies for PKU, and administrating a low phenylalanine diet when
PKU is present, significantly alters the emergence of intellectual disability in those
affected children. Additional primary prevention steps include education of the general
public about strategies to prevent intellectual disability, such as abstinence from alcohol
during pregnancy; continuing efforts of health professionals to ensure and upgrade
public health policies; and legislation to provide optimal maternal and child health care.
Family and genetic counseling helps reduce the incidence of intellectual disability in a
family with a history of a genetic disorder.
Secondary and Tertiary Prevention
Prompt attention to medical and psychiatric complications of intellectual disability can
diminish their course (secondary prevention) and minimize the sequelae or consequent
disabilities (tertiary prevention). Hereditary metabolic and endocrine disorders, such as
PKU and hypothyroidism, can be treated effectively in an early stage by dietary control
or hormone replacement therapy.
Educational Interventions.
Educational settings for children with intellectual
disability should include a comprehensive program that addresses academics and
training in adaptive skills, social skills, and vocational skills. Particular attention should
focus on communication and efforts to improve the quality of life.
Behavioral and Cognitive-Behavioral Interventions.
The difficulties in
adaptation among the intellectual disability populations are widespread and so varied
that several interventions alone or in combination may be beneficial. Behavior therapy
has been used for many years to shape and enhance social behaviors and to control and
minimize aggressive and destructive behaviors. Positive reinforcement for desired
behaviors and benign punishment (e.g., loss of privileges) for objectionable behaviors
has been helpful. Cognitive therapy, such as dispelling false beliefs and relaxation
exercises with self-instruction, has also been recommended for intellectually disabled
persons who can follow the instructions. Psychodynamic therapy has been used with
patients and their families to decrease conflicts about expectations that result in
persistent anxiety, rage, and depression. Psychiatric treatment modalities require
modifications that take into consideration the patient’s level of intelligence.
Family Education.
One of the most important areas that a clinician can address is
educating the family of a child or adolescent with intellectual disability about ways to
enhance competence and self-esteem while maintaining realistic expectations for the
patient. The family often finds it difficult to balance the fostering of independence and
the providing of a nurturing and supportive environment for an intellectually disabled
child, who is likely to experience some rejection and failure outside the family context.
The parents may benefit from continuous counseling or family therapy and should be
allowed opportunities to express their feelings of guilt, despair, anguish, recurring
denial, and anger about their child’s disorder and future. The psychiatrist should be
prepared to give the parents all the basic and current medical information regarding
causes, treatment, and other pertinent areas (e.g., special training and the correction of
sensory defects).
Social Intervention.
One of the most prevalent problems among persons with
intellectual disability is a sense of social isolation and social skills deficits. Thus,
improving the quantity and quality of social competence is a critical part of their care.
Special Olympics International is the largest recreational sports program geared for this
population. In addition to providing a forum to develop physical fitness, Special
Olympics also enhances social interactions, friendships, and (it is hoped) general selfesteem. A recent study confirmed positive effects of the Special Olympics on the social
competence of the intellectually disabled adults who participated.
Psychopharmacologic Interventions.
Pharmacological approaches to the
treatment of behavioral and psychological symptoms in children with intellectual
disability follow the paradigms of the evidence-based literature on treatment for all
children with psychiatric disorders. However, given the paucity of randomized trials in
the childhood intellectual disability population, an empirical approach must also be
taken.
COMMON COMORBID PSYCHIATRIC SYMPTOMS AND DISORDERS
Aggression, Irritability, and Self-injurious Behavior.
Risperidone has been well
documented as an efficacious treatment for irritability (aggression, self-injury, and
severe tantrums) in children with ASD by the Research Units on Pediatric
Psychopharmacology (RUPP, Autism Network 2002). Risperidone is helpful in treating
disruptive behaviors in children with below-average intelligence, and has a good overall
safety and tolerability profile. Cognitive testing has demonstrated small but significant
improvement in cognitive ability with risperidone use. Children and adolescents with
intellectual disability appear to be at higher risk for the development of tardive
dyskinesia after use of antipsychotic medications; however, the atypical antipsychotics,
including risperidone and clozapine (Clozaril), may provide some relief with a
decreased risk of tardive dyskinesia.
There is evidence to support the use of antipsychotic agents in the management of
self-injurious behavior (SIB). Although data exist on the efficacy of thioridazine in
improving SIB, a “black box” warning regarding QT prolongation with thioridazine has
drastically diminished use of this drug, and atypical antipsychotic agents are currently
preferred.
Attention-Deficit/Hyperactivity Disorder.
Estimates of attention deficit/hyperactivity
(ADHD) and ADHD-like symptoms among children with sub average intelligence,
genetic disorders, and developmental delay is estimated to be significantly higher than
rates in the community. Randomized clinical trials of several psychopharmacologic
agents have been done in children with sub-average intelligence. These include trials
with methylphenidate, clonidine, and risperidone. The existing data for the treatment of
ADHD and ADHD-like symptoms in youth with sub-average intelligence and
developmental disorders suggest that agents, particularly stimulants used to treat ADHD
in typically developing children, provide some degree of benefit to children with
intellectual disability and ADHD. However, the occurrence of side effects within this
population appears to be greater than in children with ADHD in the community. Thus,
recommendations regarding treatment of ADHD in children and adolescents with
comorbid ADHD include close monitoring for side effects. Studies of methylphenidate
(Ritalin) treatment in those mildly intellectually disabled with ADHD have shown
significant improvement in the ability to maintain attention and to stay focused on
tasks. Methylphenidate treatment studies have not shown evidence of long-term
improvement in social skills or learning. Risperidone also has been found to be
beneficial in reducing symptoms of ADHD in this population; however, it may produce
an increase in serum prolactin level. It is prudent to begin with a trial of a stimulant
medication before the use of antipsychotic agents for the treatment of ADHD symptoms
in intellectual disorder. A new extended release methylphenidate oral suspension
(Quillivant XR, 2013) is currently available in 25 mg/5 ml preparation, and is taken
once daily for the treatment of ADHD in children 6 to 12 years of age.
Amphetamine-based preparations have been shown to be efficacious in treating ADHD
in typically developing children; however, it does not appear that these stimulant
preparations have been specifically studied in children with intellectual disability.
Clonidine has been used clinically in this population, especially to ameliorate
hyperactivity and impulsivity. Although there are scant data, clinical ratings by parents
and clinicians suggest its efficacy.
Atomoxetine has been shown to be efficacious in children diagnosed with ASD and
prominent ADHD features, and it is used clinically in the intellectually disabled
population.
Depressive Disorders.
The identification of depressive disorders among individuals with
intellectual disability requires careful evaluation, since it may be inadvertently
overlooked when behavioral problems are prominent. There have been anecdotal
reports of disinhibition in response to SSRIs (e.g., fluoxetine [Prozac], paroxetine
[Paxil], and sertraline [Zoloft]) in intellectually disabled individuals with ASD. Given
the relative safety of SSRI antidepressants, a trial is indicated when a depressive
disorder is diagnosed in a child or adolescent with intellectual disability.
Stereotypical Motor Movements.
Antipsychotic medications—historically, haloperidol
(Haldol) and chlorpromazine, and currently, the atypical antipsychotics—are used in the
treatment of repetitive self-stimulatory behaviors in children with intellectual disability
when these behaviors are either harmful to the child or disruptive. Anecdotal reports
indicate that these agents may diminish self-stimulatory behaviors; however, there is no
improvement seen in adaptive behavior. Obsessive-compulsive symptoms often overlap
with the repetitive stereotypical behaviors seen in children and adolescents with
intellectual disability, particularly in those with comorbid ASD. SSRIs such as fluoxetine,
fluvoxamine (Luvox), paroxetine, and sertraline have been shown to have efficacy in
treating obsessive-compulsive symptoms in children and adolescents and may have some
efficacy for stereotyped motor movements.
Explosive Rage Behavior.
Antipsychotic medications, particularly risperidone, have been
shown to be efficacious for the treatment of explosive rage. Systematic controlled studies
are indicated to confirm the efficacy of these drugs in the treatment of rage outbursts. βAdrenergic receptor antagonists (beta-blockers), such as propranolol (Inderal), have
been reportedly anecdotally to result in fewer explosive rages in some children with
intellectual disability and ASD.
SERVICES AND SUPPORT FOR CHILDREN WITH INTELLECTUAL
DISABILITY
Early Intervention
Early intervention programs serve individuals for the first 3 years of life. Such services
are generally provided by the state and begin with a specialist visiting the home for
several hours per week. Since the passage of Public Law 99–447, the Education of the
Handicapped Amendments of 1986, early intervention services for the entire family are
emphasized. Agencies are required to develop an Individualized Family Service Plan
(IFSP) for each family, which identifies specific interventions to best help the family and
child.
School
From ages 3 to 21 years, school is responsible by law to provide appropriate educational
services to children and adolescents with intellectual disability in the United States.
These mandates were created by the passage of Public Law 94–142, the Education for
all Handicapped Children Act of 1975, and expanded with the addition of the
Individuals with Disabilities Act (IDEA) of 1990. Through these laws, public schools must
develop and provide an individualized educational program for each student with
intellectual disability, determined at a meeting designated as the Individualized
Education Plan (IEP) with school personnel and the family. The education must be
provided for the child in the “least restrictive environment” that will allow the child to
learn.
Supports
A wide variety of organized groups and services are available for children with
intellectual disability and their families. These include short-term respite care, which
allow families a break and is generally set up by state agencies. Other programs include
the Special Olympics, which allows children with intellectual disability to participate in
team sports and in sports competitions. Many organizations also exist for families who
wish to connect with others who have children with intellectual disability.
REFERENCES
American Association on Intellectual and Developmental Disabilities. Overview of intellectual disability: Definition,
classifications and systems of support. 2010.
Arnold LE, Farmer C, Kraemer HC, Davies M, Witwer A, Chuang S, DiSilvestro R, McDougle CJ, McCracken J, Vitello B,
Aman M, Scahill L, Posey DJ, Swiezy NB. Moderators, mediators, and other predictors of risperidone response in
children with autistic disorder and irritability. J Child Adolesc Psychopharmacol. 2010;20:83–93,196–1205.
Boulet S, Boyle C, Schieve L. Trends in health care utilization and health impact of developmental disabilities, 1997–2005.
Arch Pediatr Adolesc Med. 2009;163:19–26.
Correia Filho AG, Bodanase R, Silva TL, Alvarez JP, Aman M, Rohde LA. Comparison of risperidone and methylphenidate
for reducing ADHD symptoms in children and adolescents with moderate intellectual disability. J Am Acad Child Adolesc
Psychiatry. 2005;44:748.
Ellison JW, Rosengeld JA, Shaffer LG. Genetic basis of intellectual disability. Annu Rev Med. 2013
Fowler MG, Gable AR, Lampe MA, Etima M Owor M. Perinatal HIV and its prevention: Progress toward an HIV-free
generation. Clin Perinatol. 2010;37:699–719.
Gothelf D, Furfaro JA, Penniman LC, Glover GH, Reiss AL. The contribution of novel brain imaging techniques to
understanding the neurobiology of intellectual disability and developmental disabilities. Ment Retard Dev Disabil Res Rev.

04 - 31.4 Communication Disorders
31.4 Communication Disorders
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this syndrome treatable? Dev Neurosci. 2010;32:91–100.
Obi O, Braun KVN, Baio J, Drews-Botsch C, Devine O, Yeargin-Allsopp M. Effect of incorporating adaptive functioning
scores on the prevalence of intellectual disability. Am J Intellect Dev Disabil. 2011;116:360–370.
Reyes M, Croonenberghs J, Augustybs I, Eerdekens M. Long-term use of risperidone in children with disruptive behavior
disorders and subaverage intelligence: Efficacy, safety, and tolerability. J Child Adolesce Psychopharmacol. 2006;16:60–
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(ADHD) and ADHD-like symptoms in children and adolescents with developmental disorders. Dev Disabil Res Rev.
2010;16:273–282.
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Psychiatry.2012;25:365–369.
Sturgeon X, Le T, Ahmed MM, Gardiner KJ. Pathways to cognitive deficits in Down syndrome. Prog Brain Res.
2012;197:73–100.
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December 13, 2006.
Wijetunge LS, Chatterji S, Wyllie DJ, Kind PC. Fragile X syndrome: From targets to treatments. Neuropharmacology.
2013;68:83–96.
Willen EJ. Neurocognitive outcomes in pediatric HIV. Ment Retard Dev Disabil Res Rev. 2006;12:223–228.
31.4 Communication Disorders
Communication disorders range from mild delays in acquiring language to expressive or
mixed receptive–expressive disorders, phonological disorders, and stuttering, which may
remit spontaneously or persist into adolescence or even adulthood. Language delay is
one of the most common very early childhood developmental delays, affecting up to
approximately 7 percent of 5-year-olds. The rates of language disorders are
understandably higher in preschoolers than in school-age children; rates were reported
to be close to 20 percent of 4-year-olds in the Early Language in Victoria Study (ELVS).
To communicate effectively, children must have a mastery of multiple aspects of
language—that is, the ability to understand and express ideas—using words and speech,
and express themselves in vernacular language. In the Fifth Edition of the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5),
Language Disorder includes both expressive and mixed receptive–expressive problems.
DSM-5 speech disorders include Speech Sound Disorder (formerly known as Phonological
Disorder) and Childhood-Onset Fluency Disorder (Stuttering). Children with expressive
language deficits have difficulties expressing their thoughts with words and sentences at
a level of sophistication expected for their age and developmental level in other areas.
These children may struggle with limited vocabularies, speak in sentences that are short
or ungrammatical, and often present descriptions of situations that are disorganized,
confusing, and infantile. They may be delayed in developing an understanding and a
memory of words compared with others their age. Children with language disorder are
at higher risk for developing reading difficulties. Current expert consensus considers
reading comprehension impairment a form of language impairment, distinct from other
reading deficits such as dyslexia.
Language and speech are pragmatically intertwined, despite the distinct categories of
language disorders and speech disorders in DSM-5. Language competence spans four
domains: phonology, grammar, semantics, and pragmatics. Phonology refers to the
ability to produce sounds that constitute words in a given language and the skills to
discriminate the various phonemes (sounds that are made by a letter or group of letters
in a language). To imitate words, a child must be able to produce the sounds of a word.
Grammar designates the organization of words and the rules for placing words in an
order that makes sense in that language. Semantics refers to the organization of concepts
and the acquisition of words themselves. A child draws from a mental list of words to
produce sentences. Children with language impairments exhibit a wide range of
difficulties with semantics that include acquiring new words, storage and organization
of known words, and word retrieval. Speech and language evaluations that are
sufficiently broad to test all of the preceding skill levels will be more accurate in
evaluating a child’s remedial needs. Pragmatics has to do with skill in the actual use of
language and the “rules” of conversation, such as pausing so that a listener can answer
a question and knowing when to change the topic when a break occurs in a
conversation. By age 2 years, toddlers without speech or language delay may know a
few words or up to 200 words, and by age 3 years, most children understand the basic
rules of language and can converse effectively. Table 31.4a-1 provides an overview of
typical milestones in language and nonverbal development.
Table 31.4a-1
Normal Development of Speech, Language, and Nonverbal Skills in Children
Over the last decade there have been an increasing number of investigative studies of
speech and language interventions with positive outcomes identified in numerous areas
of language. These include improvements in expressive vocabulary, syntax usage, and
overall phonologic development. Most interventions are targeted strategies for the
child’s particular deficit, and delivered by speech and language therapists.

05 - 31.4a Language Disorder
31.4a Language Disorder
31.4a Language Disorder
Language disorder consists of difficulties in the acquisition and use of language across
many modalities, including spoken and written, due to deficits in comprehension or
production based on both expressive and receptive skills. These deficits include reduced
vocabulary, limited abilities in forming sentences using the rules of grammar, and
impairments in conversing based on difficulties using vocabulary to connect sentences
in descriptive ways.
EXPRESSIVE LANGUAGE DEFICITS
Expressive language deficits are present when a child demonstrates a selective deficit in
expressive language development relative to receptive language skills and nonverbal
intellectual function. Infants and young children with typically developing expressive
language will laugh and coo by about 6 months of age, babble and verbalize syllables
such as dadada or mamama by about 9 months, and by one year, babies imitate
vocalizations and can often speak at least one word. Expressive speech and language
generally continue to develop in a stepwise fashion, so that at a year and a half,
children typically can say a handful of words, and by 2 years, children generally are
combining words into simple sentences. By the age of 2½ years, children can name an
action in a picture, and are able to make themselves understood through their
verbalizations about half of the time. By 3 years, most children can speak
understandably, and are able to name a color and describe what they see with several
adjectives. At 4 years, children typically can name at least 4 colors, and can converse
understandably. In the early years, prior to entering preschool, the development of
proficiency in vocabulary and language usage is highly variable, and influenced by the
amount and quality of verbal interactions with family members, and after beginning
school, a child’s language skills are significantly influenced by the level of verbal
engagement in school. A child with expressive language deficits may be identified using
the Wechsler Intelligence Scale for Children III (WISC-III), in that verbal intellectual level
may appear to be depressed compared with the child’s overall intelligence quotient (IQ).
A child with expressive language problems is likely to function below the expected levels
of acquired vocabulary, correct tense usage, complex sentence constructions, and word
recall. Children with expressive language deficits often present verbally as younger than
their age. Language disability can be acquired during childhood (e.g., secondary to a
trauma or a neurological disorder), although less frequently, or it can be developmental;
it is usually congenital, without an obvious cause. Most childhood language disorders
fall into the developmental category. In either case, deficits in receptive skills (language
comprehension) or expressive skills (ability to use language) can occur. Expressive
language disturbance often appears in the absence of comprehension difficulties,
whereas receptive dysfunction generally diminishes proficiency in the expression of
language. Children with expressive language disturbance alone have better prognoses,
and less interference with learning, than children with mixed receptive–expressive
language disturbances.
Although language use depends on both expressive and receptive skills, the degree of
deficits in a given individual may be severe in one area, and hardly impaired at all in
the other. Thus, language disorder can be diagnosed in children with expressive
language disturbance in the absence of receptive language problems, or when both
receptive and expressive language syndromes are present. In general, when receptive
skills are sufficiently impaired to warrant a diagnosis, expressive skills are also
impaired. In DSM-5 language disorder is not limited to developmental language
disabilities; acquired forms of language disturbances are included. To meet the DSM-5
criteria for language disorder, patients must have scores on standardized measures of
expressive or receptive language markedly below those of standardized nonverbal IQ
subtests and standardized tests.
Epidemiology
The prevalence of expressive language disturbance decreases with a child’s increasing
age, and overall it is estimated to be as high as 6 percent in children between the ages
of 5 and 11 years of age. Surveys have indicated rates of expressive language as high as
20 percent in children younger than 4 years of age. In school-age children over the age
of 11 years, the estimates are lower, ranging from 3 percent to 5 percent. The disorder
is two to three times more common in boys than in girls and is most prevalent among
children whose relatives have a family history of phonologic disorder or other
communication disorders.
Comorbidity
Children with language disorder have above-average rates of comorbid psychiatric
disorders. In one large study of children with speech and language disorders, the most
common comorbid disorders were attention-deficit/hyperactivity disorder (ADHD; 19
percent), anxiety disorders (10 percent), oppositional defiant disorder, and conduct
disorder (7 percent combined). Children with expressive language disorder are also at
higher risk for a speech disorder, receptive difficulties, and other learning disorders.
Many disorders—such as reading disorder, developmental coordination disorder, and
other communication disorders—are associated with expressive language disturbance.
Children with expressive language disturbance often have some receptive impairment,
although not always sufficiently significant for the diagnosis of language disorder on
this basis. Speech sound disorder, formerly known as phonologic disorder, is commonly
found in young children with language disorder, and neurologic abnormalities have
been reported in a number of children, including soft neurologic signs, depressed
vestibular responses, and electroencephalography (EEG) abnormalities.
Etiology
The specific causes of the expressive components of language disorder are likely to be
multifactorial. Scant data are available on the specific brain structure of children with
language disorder, but limited magnetic resonance imaging (MRI) studies suggest that
language disorders are associated with diminished left–right brain asymmetry in the
perisylvian and planum temporale regions. Results of one small MRI study suggested
possible inversion of brain asymmetry (right > left). Left-handedness or ambilaterality
appears to be associated with expressive language problems with more frequency than
right-handedness. Evidence shows that language disorders occur more frequently within
some families, and several studies of twins show significant concordance for
monozygotic twins with respect to language disorders. Environmental and educational
factors are also postulated to contribute to developmental language disorders.
Diagnosis
Language disorder of the expressive disturbance type is diagnosed when a child has a
selective deficit in language skills and is functioning well in nonverbal areas. Markedly
below-age-level verbal or sign language, accompanied by a low score on standardized
expressive verbal tests, is diagnostic of expressive deficits in language disorder.
Although expressive language deficits are frequently exhibited in children with autism
spectrum disorders, these disturbances also occur frequently in the absence of autism
spectrum disorder and are characterized by the following features: limited vocabulary,
simple grammar, and variable articulation. “Inner language” or the appropriate use of
toys and household objects is present. One assessment tool, the Carter Neurocognitive
Assessment, itemizes and quantifies skills in areas of social awareness, visual attention,
auditory comprehension, and vocal communication even when there are compromised
expressive language and motor skills in very young children—up to 2 years of age. To
confirm the diagnosis, a child is given standardized expressive language and nonverbal
intelligence tests. Observations of children’s verbal and sign language patterns in
various settings (e.g., school yard, classroom, home, and playroom) and during
interactions with other children help ascertain the severity and specific areas of a child’s
impairment and aid in early detection of behavioral and emotional complications.
Family history should include the presence or absence of expressive language disorder
among relatives.
Clinical Features
Children with expressive language deficits are vague when telling a story and use many
filler words such as “stuff” and “things” instead of naming specific objects.
The essential feature of expressive deficits in language disorder is marked impairment
in the development of age-appropriate expressive language, which results in the use of
verbal or sign language markedly below the expected level in view of a child’s
nonverbal intellectual capacity. Language understanding (decoding) skills remain
relatively intact. When severe, the disorder becomes recognizable by about the age of 18
months, when a child fails to utter spontaneously or even echo single words or sounds.
Even simple words, such as “Mama” and “Dada,” are absent from the child’s active
vocabulary, and the child points or uses gestures to indicate desires. The child seems to
want to communicate, maintains eye contact, relates well to the mother, and enjoys
games such as pat-a-cake and peek-a-boo. The child’s vocabulary is severely limited. At
18 months, the child may be limited to pointing to common objects when they are
named.
When a child with expressive language deficits begins to speak, the language
impairment gradually becomes apparent. Articulation is often immature; numerous
articulation errors occur but are inconsistent, particularly with such sounds as th, r, s, z,
y, and l, which are either omitted or are substituted for other sounds.
By the age of 4 years, most children with expressive language disturbance can speak
in short phrases, but may have difficulty retaining new words. After beginning to speak,
they acquire language more slowly than do most children. Their use of various
grammatical structures is also markedly below the age-expected level, and their
developmental milestones may be slightly delayed. Emotional problems involving poor
self-image, frustration, and depression may develop in school-age children.
Damien was a friendly, alert, and hyperactive 2-year-old, whose expressive
vocabulary was limited to only two words (mama, daddy). He used these words one at
a time in inappropriate situations. He supplemented his infrequent verbal
communications with pointing and other simple gestures to request desired objects or
actions. He was unable to communicate for other purposes (e.g., commenting or
protesting). Damien appeared to be developing normally in other areas, especially in
gross motor skills, although his fine motor skills were also poor. Damien sat, stood,
and walked, and played happily with other children, enjoying activities and toys that
were appropriate for 2-year-olds. Although he had a history of frequent ear infections,
a recent hearing test revealed normal hearing. Despite his expressive limitations,
Damien exhibited age-appropriate comprehension for the names of familiar objects
and actions and for simple verbal instructions (e.g., “Put that down.” “Get your shirt.”
“Clap your hands.”). However, due to his hyperactivity and impulsivity, he often
required multiple directions to complete a simple task.
Despite Damien’s slow start in language development, his pediatrician had
reassured his parents that most of the time, toddlers like Damien spontaneously
overcome their initial slow start in language development. Fortunately, Damien’s
language delay spontaneously remitted by the time he entered preschool at 3½ years
of age, although he was diagnosed at that time with attention-deficit/hyperactivity
disorder.
Jessica was a sociable, active 5-year-old, who was diagnosed with language
disorder. She was well liked in kindergarten despite her language deficits and played
with many of her classmates. During an activity in which each student recounted the
story of Little Red Riding Hood to her doll, Jessica’s classmate’s story began: “Little
Red Riding Hood was taking a basket of food to her grandmother who was sick. A bad
wolf stopped Red Riding Hood in the forest. He tried to get the basket away from her
but she wouldn’t give it to him.”
When it was Jessica’s turn, she tried to avoid being picked, but when she could not
avoid her turn, Jessica’s story sounded quite different: Jessica struggled and came up
with: “Riding Hood going to grandma house. Her taking food. Bad wolf in a bed.
Riding Hood say, what big ears, and grandma? Hear you, dear. What big eyes,
grandma? See you, dear. What big mouth, grandma? Eat you all up!”
Jessica’s story was characteristic of expressive language deficits at her age:
including short, incomplete sentences; simple sentence structures; omission of
grammatical function words (e.g., is and the) and inflectional endings (e.g.,
possessives and present tense verbs); problems in question formation; and incorrect
use of pronouns (e.g., her for she). Jessica, however, performed as well as her
classmates in understanding the details and plot of the Riding Hood tale, as long as
she was not required to retell the story verbally. Jessica also demonstrated adequate
comprehension skills in her kindergarten classroom, where she readily followed the
teacher’s complex, multistep verbal instructions (e.g., “After you write your name in
the top left corner of your paper, get your crayons and scissors, put your library books
under your chair, and line up at the back of the room.”).
Ramon was a quiet, sullen 8-year-old boy whose expressive language problems had
improved over time and were no longer obvious in play with peers. His speech now
rarely contained the incomplete sentences and grammatical errors that were so
evident when he was younger. Ramon’s expressive problems, however, were still
impairing him in tasks involving abstract use of language, and he was struggling in
his third-grade academic work. An example was Ramon’s explanation of a recent
science experiment: “The teacher had stuff in some jars. He poured it, and it got pink.
The other thing made it white.” Although each sentence was grammatical, his
explanation was difficult to follow, because key ideas and details were vaguely
explained. Ramon also showed problems in word finding, and he relied on vague and
nonspecific terms, such as thing, stuff, and got.
In the first and second grades, Ramon had struggled to keep up with his classmates
in reading, writing, and other academic skills. By third grade, however, the increasing
demands for written work were beyond his abilities. Ramon’s written work was
characterized by poor organization and lack of specificity. In addition, classmates
began to tease him about his difficulties, and he was ashamed of his disability and
reacted quite aggressively, often leading to physical fighting. Nonetheless, Ramon
continued to show relatively good comprehension of spoken language, including
classroom teaching concerning abstract concepts. He also comprehended sentences
that were grammatically and conceptually complex (e.g., “The car the truck hit had
hubcaps that were stolen. Had it been possible, she would have notified us by mail or
by phone.”)
Differential Diagnosis
Language disorders are associated with various psychiatric disorders including other
learning disorders and ADHD, and in some cases, the language disorder is difficult to
separate from another dysfunction. In mixed receptive–expressive language disorder,
language comprehension (decoding) is markedly below the expected age-appropriate
level, whereas in expressive language disorder, language comprehension remains within
normal limits.
In autism spectrum disorders, children often have impaired language, symbolic and
imagery play, appropriate use of gesture, or capacity to form typical social
relationships. In contrast, children with expressive language disorder become very
frustrated with their disorder, and are usually highly motivated to make friends despite
their disability.
Children with acquired aphasia or dysphasia have a history of early normal language
development; the disordered language had its onset after a head trauma or other
neurologic disorder (e.g., a seizure disorder). Children with selective mutism have
normal language development. Often these children will speak only in front of family
members (e.g., mother, father, and siblings). Children affected by selective mutism are
socially anxious and withdrawn outside the family.
Pathology and Laboratory Examination
Children with speech and language disorders should have an audiogram to rule out
hearing loss.
Course and Prognosis
The prognosis for expressive language disturbance worsens the longer it persists in a
child; prognosis is also dependent on the severity of the disorder. Studies of infants and
toddlers who are “late talkers” concur that 50 to 80 percent of these children master
language skills that are within the expected level during the preschool years. Most
children who are delayed in acquiring language catch up during preschool years.
Outcome of expressive language deficits is influenced by other comorbid disorders. If
children do not develop mood disorders or disruptive behavior problems, the prognosis
is better. The rapidity and extent of recovery depends on the severity of the disorder, the
child’s motivation to participate in speech and language therapy, and the timely
initiation of therapeutic interventions. The presence or absence of hearing loss, or
intellectual disability, impedes remediation and leads to a worse prognosis. Up to 50
percent of children with mild expressive language disorder recover spontaneously
without any sign of language impairment, but those children with severe expressive
speech disorder may persist in exhibiting some symptoms into middle childhood or later.
Current literature shows that children who demonstrate poor comprehension, poor
articulation, or poor academic performance tend to continue to have problems in these
areas at follow-up 7 years later. An association is also seen between particular language
impairment profiles and persistent mood and behavior problems. Children with poor
comprehension associated with expressive difficulties seem to be more socially isolated
and impaired with respect to peer relationships.
Treatment
The primary goals for early childhood speech and language treatment are to guide
children and their parents toward greater production of meaningful language. There are
more data to support improvements through speech and language interventions for
expressive language deficit in young school-aged children with primary deficits than in
preschool children. A recent study investigating Parent-Child Interaction Therapy (PCIT)
for school-aged children with expressive language impairment found that PCIT was
particularly efficacious in improving a child’s verbal initiation, mean length of
utterances, and the proportion of child-to-parent utterances. A large-scale randomized
trial of a yearlong intervention targeting preschoolers with language delay in Australia
found that a community-based program did not affect language acquisition in 2- and 3year-olds. Given the high rate of spontaneous remission of language deficits in
preschoolers, and less than robust effects of interventions for children that young,
treatment for expressive language disorder is generally not initiated unless it persists
after the preschool years. Various techniques have been used to help a child improve use
of such parts of speech as pronouns, correct tenses, and question forms. Direct
interventions use a speech and language pathologist who works directly with the child.
Mediated interventions, in which a speech and language professional teaches a child’s
teacher or parent how to promote therapeutic language techniques, have also been
efficacious. Language therapy is often aimed at using words to improve communication
strategies and social interactions as well. Such therapy consists of behaviorally
reinforced exercises and practice with phonemes (sound units), vocabulary, and
sentence construction. The goal is to increase the number of phrases by using blockbuilding methods and conventional speech therapies.
MIXED RECEPTIVE AND EXPRESSIVE DEFICITS
Children with both receptive and expressive language impairment may have impaired
ability in sound discrimination, deficits in auditory processing, or poor memory for
sound sequences. Children with mixed receptive–expressive disturbance exhibit impaired
skills in the expression and reception (understanding and comprehension) of spoken
language. The expressive difficulties in these children may be similar to those of children
with only expressive language disturbance, which is characterized by limited
vocabulary, use of simplistic sentences, and short sentence usage. Children with
receptive language difficulties may be experiencing additional deficits in basic auditory
processing skills, such as discriminating between sounds, rapid sound changes,
association of sounds and symbols, and the memory of sound sequences. These deficits
may lead to a whole host of communication barriers for a child, including a lack of
understanding of questions or directives from others, or inability to follow the
conversations of peers or family members. Recognition of mixed expressive–receptive
language disturbance may be delayed because of early misattribution of their
communication by teachers and parents as a behavioral problem rather than a deficit in
understanding.
The essential features of mixed receptive–expressive language disturbance are shown
on scores on standardized tests; both receptive (comprehension) and expressive
language development scores fall substantially below those obtained from standardized
measures of nonverbal intellectual capacity. Language difficulties must be sufficiently
severe to impair academic achievement or daily social communication.
Epidemiology
Mixed receptive-expressive language deficits occur less frequently than expressive
deficits; however, epidemiologic data are scant regarding specific prevalence rates.
Mixed receptive–expressive language disturbance is believed to occur in about 5 percent
of preschoolers and to persist in approximately 3 percent of school-age children. It is
known to be less common than expressive language disturbance. Mixed receptive–
expressive language disorder is believed to be at least twice as prevalent in boys as in
girls.
Comorbidity
Children with mixed receptive–expressive deficits are at high risk for additional speech
and language disorders, learning disorders, and additional psychiatric disorders. About
half of children with these deficits also have pronunciation difficulties leading to speech
sound disorder, and about half also have reading disorder. These rates are significantly
higher than the comorbidity found in children with only expressive language problems.
ADHD is present in at least one third of children with mixed receptive–expressive
language disturbances.
Etiology
Language disorders most likely have multiple determinants, including genetic factors,
developmental brain abnormalities, environmental influences, neurodevelopmental
immaturity, and auditory processing features in the brain. As with expressive language
disturbance alone, evidence is found of familial aggregation of mixed receptive–
expressive language deficits. Genetic contribution to this disorder is implicated by twin
studies, but no mode of genetic transmission has been proved. Some studies of children
with various speech and language disorders have also shown cognitive deficits,
particularly slower processing of tasks involving naming objects, as well as fine motor
tasks. Slower myelinization of neural pathways has been hypothesized to account for the
slow processing found in children with developmental language disorders. Several
studies suggest an underlying impairment of auditory discrimination, because most
children with the disorder are more responsive to environmental sounds than to speech
sounds.
Diagnosis
Children with mixed receptive–expressive language deficits develop language more
slowly than their peers and have trouble understanding conversations that peers can
follow. In mixed receptive–expressive language disorder, receptive dysfunction coexists
with expressive dysfunction. Therefore, standardized tests for both receptive and
expressive language abilities must be given to anyone suspected of having language
disorder with mixed receptive–expressive disturbance.
A markedly below-expected level of comprehension of verbal or sign language with
intact age-appropriate nonverbal intellectual capacity, confirmation of language
difficulties by standardized receptive language tests, and the absence of autism spectrum
disorder, confirm the diagnosis of mixed receptive–expressive language deficits;
however, in DSM-5, these deficits are included in the diagnosis of language disorder.
Clinical Features
The essential clinical feature of this language disturbance is significant impairment in
both language comprehension and language expression. In the mixed type, expressive
impairments are similar to those of expressive language disturbance, but can be more
severe. The clinical features of the receptive component of the disorder typically appear
before the age of 4 years. Severe forms are apparent by the age of 2 years; mild forms
may not become evident until age 7 (second grade) or older, when language becomes
complex. Children with language disorder characterized by mixed receptive–expressive
disturbance show markedly delayed and below-normal ability to comprehend (decode)
verbal or sign language, although they have age-appropriate nonverbal intellectual
capacity. In most cases of receptive dysfunction, verbal or sign expression (encoding) of
language is also impaired. The clinical features of mixed receptive–expressive language
disturbance in children between the ages of 18 and 24 months result from a child’s
failure to utter a single phoneme spontaneously or to mimic another person’s words.
Many children with mixed receptive–expressive language deficits have auditory
sensory difficulties and compromised ability to process visual symbols, such as
explaining the meaning of a picture. They have deficits in integrating both auditory and
visual symbols—for example, recognizing the basic common attributes of a toy truck
and a toy passenger car. Whereas at 18 months, a child with expressive language
deficits only comprehends simple commands and can point to familiar household objects
when told to do so, a child of the same age with mixed receptive–expressive language
disturbance typically cannot either point to common objects or obey simple commands.
A child with mixed receptive–expressive language deficits may appears to be deaf. He or
she responds normally to sounds from the environment, but not to spoken language. If
the child later starts to speak, the speech contains numerous articulation errors, such as
omissions, distortions, and substitutions of phonemes. Language acquisition is much
slower for children with mixed receptive–expressive language disturbance than for other
children of the same age.
Children with mixed receptive–expressive language disturbance have difficulty
recalling early visual and auditory memories and recognizing and reproducing symbols
in proper sequence. Some children with mixed receptive–expressive language deficits
have a partial hearing defect for true tones, an increased threshold of auditory arousal,
and an inability to localize sound sources. Seizure disorders and reading disorder are
more common among the relatives of children with mixed receptive–expressive
problems than in the general population.
Pathology and Laboratory Examination
An audiogram is indicated for all children thought to have mixed receptive–expressive
language disturbance to rule out or confirm the presence of deafness or auditory deficits.
A history of the child and family and observation of the child in various settings help to
clarify the diagnosis.
Jenna was a pleasant 2-year-old, who did not yet use any spoken words, and did
not respond to simple commands without gestures. She made her needs known with
vocalizations and simple gestures (e.g., showing or pointing) such as those typically
used by younger children. She seemed to understand the names for only a few familiar
people and objects (e.g., mommy, daddy, cat, bottle, and cookie). Compared with other
children her age, she had a small comprehension vocabulary and showed limited
understanding of simple verbal directions (e.g., “Get your doll.” “Close your eyes.”).
Nonetheless, her hearing was normal, and her motor and play skills were developing
as expected for her age. She showed interest in her environment and in the activities
of the other children at her day care.
Lena was a shy, reserved 5-year-old who grew up in a bilingual home. Lena’s
parents and older siblings spoke English and Cantonese proficiently. Her
grandparents, who lived in the same home, spoke only Cantonese. Lena began to
understand and speak both languages much later than her older siblings had.
Throughout her preschool years, Lena continued to develop slowly in comprehension
and production. At the start of kindergarten, Lena understood fewer English words for
objects, actions, and relations than her classmates did. Lena was unable to follow
complex classroom instructions, particularly those that involved words for concepts of
time (e.g., tomorrow, before, or day) and space (e.g., behind, next to, or under). It was
also hard for Lena to match one of several pictures to a syntactically complex
sentence that she had heard (e.g., “It was not the train she was waiting for.” “Because
he had already completed his work, he was not kept after school.”). Lena played with
other children but only rarely tried to speak with them, which led to her being
ostracized by her classmates. Lena’s attempts at conversations usually broke down,
because she misinterpreted what others said or could not express her own thoughts
clearly. Consequently, her classmates generally ignored her, preferring instead to play
with more verbally competent peers. Lena’s infrequent interactions further limited her
opportunities to learn and to practice her already weak language skills. Lena also
showed limited receptive and expressive skills in Cantonese, as revealed by an
assessment conducted with the assistance of a Cantonese interpreter. Nonetheless, her
nonverbal cognitive and motor skills were within the normal range for her age. Lena
was quite proficient in solving spatial and numerical, problems, provided they were
presented on paper and were not word problems.
Mark received a diagnosis of Language Disorder, based on mixed receptive–
expressive deficits when he was a preschooler. By 7 years of age, he had also received
the comorbid diagnoses of reading disorder and ADHD. This combination of language,
reading, and attention problems made it virtually impossible for Mark to succeed in
school, although he was able to engage his peers during free play. His comprehension
and attention difficulties limited his ability to understand and to learn important
information, or to follow classroom instructions or discussions. Mark fell further and
further behind his classmates. He was also disadvantaged because he could read only
a few familiar words. This meant that he was neither motivated nor able to learner
academic information outside of the classroom by reading. Mark received tutoring
and speech and language interventions, and despite some improvements, he
continued to lag behind his classmates academically. Despite his academic problems,
however, Mark made friends during sports activities in which he excelled, and
continued to show nonverbal intellectual skills within the average range.
Differential Diagnosis
Children with language disorder characterized by mixed receptive–expressive deficits
have a deficit in language comprehension as well as in language production. The
receptive deficit may be overlooked at first, because the expressive language deficit may
be more obvious. In expressive language disturbance alone, comprehension of spoken
language (decoding) remains within age norms. Children with speech sound disorder
and child-onset fluency disorder (stuttering) have normal expressive and receptive
language competence, despite the speech impairments.
Most children with mixed receptive–expressive language disturbance have a history of
variable and inconsistent responses to sounds; they respond more often to
environmental sounds than to speech sounds (Table 31.4a-2). Intellectual disability,
selective mutism, acquired aphasia, and autism spectrum disorder should also be ruled
out.
Table 31.4a-2
Differential Diagnosis of Language Disorder
Course and Prognosis
The overall prognosis for language disorder with mixed receptive–expressive disturbance
is less favorable than that for expressive language disturbance alone. When the mixed
disorder is identified in a young child, it is usually severe, and the short-term prognosis
is poor. Language develops at a rapid rate in early childhood, and young children with
the disorder may appear to be falling behind. In view of the likelihood of comorbid
learning disorders and other mental disorders, the prognosis is guarded. Young children
with severe mixed receptive-expressive language deficits are likely to have learning
disorders in the future. In children with mild versions, mixed disorder may not be
identified for several years, and the disruption in everyday life may be less
overwhelming than that in severe forms of the disorder. Over the long run, some
children with mixed receptive–expressive language disturbance achieve close to normal
language functions. The prognosis for children who have mixed receptive–expressive
language disturbances varies widely and depends on the nature and severity of the
damage.
Treatment
A comprehensive speech and language evaluation is recommended for children with
mixed receptive–expressive language disturbance, given the complexities of having both
deficits. Some controversy exists as to whether remediation of receptive deficits before
expressive language provides more efficacy overall. A review of the literature indicates
that it is not more beneficial to address receptive deficits before expressive, and in fact,
in some cases, remediation of expressive language may reduce or eliminate the need for
receptive language remediation. Thus, current recommendations are either to address

06 - 31.4b Speech Sound Disorder
31.4b Speech Sound Disorder
both simultaneously, or to provide interventions for the expressive component first, and
then address the receptive language. Preschoolers with mixed receptive–expressive
language problems optimally receive interventions designed to promote social
communication and literacy as well as oral language. For children at the kindergarten
level, optimal intervention includes direct teaching of key pre-reading skills as well as
social skills training. An important early goal of interventions for young children with
mixed receptive–expressive language disturbance is the achievement of rudimentary
reading skills, in that these skills are protective against the academic and psychosocial
ramifications of falling behind early on in reading. Some language therapists favor a
low-stimuli setting, in which children are given individual linguistic instruction. Others
recommend that speech and language instruction be integrated into a varied setting
with several children who are taught several language structures simultaneously. Often,
a child with receptive and expressive language deficits will benefit from a small, specialeducational setting that allows more individualized learning.
Psychotherapy may be helpful for children with mixed language disorder who have
associated emotional and behavioral problems. Particular attention should be paid to
evaluating the child’s self-image and social skills. Family counseling in which parents
and children can develop more effective, less frustrating means of communicating may
be beneficial.
31.4b Speech Sound Disorder
Children with speech sound disorder have difficulty pronouncing speech sounds correctly
due to omissions of sounds, distortions of sounds, or atypical pronunciation. Formerly
called phonological disorder, typical speech disturbances in speech sound disorder
include omitting the last sounds of the word (e.g., saying mou for mouse or drin for
drink), or substituting one sound for another (saying bwu instead of blue or tup for cup).
Distortions in sounds can occur when children allow too much air to escape from the
side of their mouths while saying sounds like sh or producing sounds like s or z with
their tongue protruded. Speech sound errors can also occur in patterns because a child
has an interrupted airflow instead of a steady airflow preventing their words to be
pronounced (e.g., pat for pass or bacuum for vacuum). Children with a speech sound
disorder can be mistaken for younger children because of their difficulties in producing
speech sounds correctly. The diagnosis of a speech sound disorder is made by comparing
the skills of a given child with the expected skill level of others of the same age. The
disorder results in errors in whole words because of incorrect pronunciation of
consonants, substitution of one sound for another, omission of entire phonemes, and, in
some cases, dysarthria (slurred speech because of incoordination of speech muscles) or
dyspraxia (difficulty planning and executing speech). Speech sound development is
believed to be based on both linguistic and motor development that must be integrated
to produce sounds.
Speech sound disturbances such as dysarthria and dyspraxia are not diagnosed as
speech sound disorder if they are known to have a neurological basis, according to DSM5. Thus, speech sound abnormalities accounted for by cerebral palsy, cleft palate,
deafness or hearing loss, traumatic brain injury, or neurological conditions are not
diagnosed as speech sound disorder. Articulation difficulties not associated with a
neurological condition are the most common components of speech sound disorder in
children. Articulation deficits are characterized by poor articulation, sound substitution,
and speech sound omission, and give the impression of “baby talk.” Typically, these
deficits are not caused by anatomical, structural, physiological, auditory, or neurological
abnormalities. They vary from mild to severe and result in speech that ranges from
completely intelligible to unintelligible.
EPIDEMIOLOGY
Epidemiologic studies suggest that the prevalence of speech sound disorder is at least 3
percent in preschoolers, 2 percent in children 6 to 7 years of age, and 0.5 percent in 17year-old adolescents. Approximately 7 to 8 percent of 5-year-old children in one large
community sample had speech sound production problems of developmental, structural,
or neurological origins. Another study found that up to 7.5 percent of children between
the ages of 7 and 11 years had speech sound disorders. Of those, 2.5 percent had speech
delay (deletion and substitution errors past the age of 4 years) and 5 percent had
residual articulation errors beyond the age of 8 years. Speech sound disorders occur
much more frequently than disorders with known structural or neurological origin.
Speech sound disorder is approximately two to three times more common in boys than
in girls. It is also more common among first-degree relatives of patients with the
disorder than in the general population. Although speech sound mistakes are quite
common in children younger than 3 years of age, these mistakes are usually selfcorrected by age 7 years. Misarticulating after the age of 7 years is likely to represent a
speech sound disorder. The prevalence of speech sound disorders reportedly falls to 0.5
percent by mid to late adolescence.
COMORBIDITY
More than half of children with speech sound disorder have some difficulty with
language. Disorders most commonly present with speech sound disorders are language
disorder, reading disorder, and developmental coordination disorder. Enuresis may also
accompany the disorder. A delay in reaching speech milestones (e.g., first word and first
sentence) has been reported in some children with speech sound, but most children with
the disorder begin speaking at the appropriate age. Children with both speech sound
and language disorders are at greatest risk for attentional problems and specific
learning disorders. Children with speech sound disorder in the absence of language
disorder have lower risk of comorbid psychiatric disorders and behavioral problems.
ETIOLOGY
Contributing factors leading to speech disturbance may include perinatal problems,
genetic factors, and auditory processing problems. Given the high rates of spontaneous
remission in very young children, a maturational delay in the developmental brain
process underlying speech has been postulated in some cases. The likelihood of neuronal
cause is supported by the observation that children with speech sound disorder are also
more likely to manifest “soft neurological signs” as well as language disorder and a
higher-than-expected rate of reading disorder. Genetic factors are implicated by data
from twin studies that show concordance rates for monozygotic twins that are higher
than chance.
Articulation disorders caused by structural or mechanical problems are rare.
Articulation problems that are not diagnosed as speech sound disorder may be caused by
neurological impairment and can be divided into dysarthria and apraxia or dyspraxia.
Dysarthria results from an impairment in the neural mechanisms regulating the
muscular control of speech. This can occur in congenital conditions, such as cerebral
palsy, muscular dystrophy, or head injury, or because of infectious processes. Apraxia or
dyspraxia is characterized by difficulty in the execution of speech, even when no obvious
paralysis or weakness of the muscles used in speech exists.
Environmental factors may play a role in speech sound disorder, but constitutional
factors seem to make the most significant contribution. The high proportion of speech
sound disorder in certain families implies a genetic component in the development of
this disorder. Developmental coordination disorder and coordination in the mouth such
as in chewing and blowing the nose may be associated.
DIAGNOSIS
The essential feature of speech sound disorder is a child’s delay or failure to produce
developmentally expected speech sounds, especially consonants, resulting in sound
omissions, substitutions, and distortions of phonemes. A rough guideline for clinical
assessment of children’s articulation is that normal 3-year-olds correctly articulate m, n,
ng, b, p, h, t, k, q, and d; normal 4-year-olds correctly articulate f, y, ch, sh, and z; and
normal 5-year-olds correctly articulate th, s, and r.
Speech sound disorder cannot be accounted for by structural or neurological
abnormalities, and typically, it is accompanied by normal language development.
CLINICAL FEATURES
Children with speech sound disorder are delayed in, or incapable of, producing accurate
speech sounds that are expected for their age, intelligence, and dialect. The sounds are
often substitutions—for example, the use of t instead of k—and omissions, such as
leaving off the final consonants of words. Speech sound disorder can be recognized in
early childhood. In severe cases, the disorder is first recognized at between 2 and 3 years
of age. In less severe cases, the disorder may not be apparent until the age of 6 years. A
child’s articulation is judged disordered when it is significantly behind that of most
children at the same age level, intellectual level, and educational level.
In very mild cases, a single speech sound (i.e., phoneme) may be affected. When a
single phoneme is affected, it is usually one that is acquired late in normal language
acquisition. The speech sounds most frequently misarticulated are also those acquired
late in the developmental sequence, including r, sh, th, f, z, l, and ch. In severe cases and
in young children, sounds such as b, m, t, d, n, and h may be mispronounced. One or
many speech sounds may be affected, but vowel sounds are not among them.
Children with speech sound disorder cannot articulate certain phonemes correctly and
may distort, substitute, or even omit the affected phonemes. With omissions, the
phonemes are absent entirely—for example, bu for blue, ca for car, or whaa? For what’s
that? With substitutions, difficult phonemes are replaced with incorrect ones—for
example, wabbit for rabbit, fum for thumb, or whath dat? For what’s that? With
distortions, the correct phoneme is approximated but is articulated incorrectly. Rarely,
additions (usually of the vowel uh) occur—for example, puhretty for pretty, what’s uh
that uh? For what’s that?
Omissions are thought to be the most serious type of misarticulating, with
substitutions the next most serious, and distortions the least serious type. Omissions,
which are most frequent in the speech of young children, usually occur at the ends of
words or in clusters of consonants (ka for car, scisso for scissors). Distortions, which are
found mainly in the speech of older children, result in a sound that is not part of the
speaker’s dialect. Distortions may be the last type of misarticulating remaining in the
speech of children whose articulation problems have mostly remitted. The most common
types of distortions are the lateral slip—in which a child pronounces s sounds with the
airstream going across the tongue, producing a whistling effect—and the palatal or lisp
—in which the s sound, formed with the tongue too close to the palate, produces a ssh
sound effect.
The misarticulating of children with speech sound disorder is often inconsistent and
random. A phoneme may be pronounced correctly one time and incorrectly another
time. Misarticulating is most common at the ends of words, in long and syntactically
complex sentences, and during rapid speech.
Omissions, distortions, and substitutions also occur normally in the speech of young
children learning to talk. But, whereas young, normally speaking children soon replace
their misarticulating, children with speech sound disorder do not. Even as children with
articulation problems grow and finally acquire the correct phoneme, they may use it
only in newly acquired words and may not correct the words learned earlier that they
have been mispronouncing for some time.
Most children eventually outgrow speech sound disorder, usually by the third grade.
After the fourth grade, however, spontaneous recovery is unlikely, and so it is important
to try to remediate the disorder before the development of complications. Often,
beginning kindergarten or school precipitates the improvement when recovery from
speech sound disorder is spontaneous. Speech therapy is clearly indicated for children
who have not shown spontaneous improvement by the third or fourth grade. Speech
therapy should be initiated at an early age for children whose articulation is
significantly unintelligible and who are clearly troubled by their inability to speak
clearly.
Children with speech sound disorder may have various concomitant social, emotional,
and behavioral problems, particularly when comorbid expressive language problems are
present. Children with chronic expressive language deficits and severe articulation
impairment are the ones most likely to suffer from psychiatric problems.
Martin was a talkative, likeable 3-year-old with virtually unintelligible speech,
despite excellent receptive language skills and normal hearing. Martin’s level of
expressive language development was difficult to quantify due to his very poor
pronunciation. The rhythm and melody of his speech, however, suggested that he was
trying to produce multiword utterances, as would be expected at his age. Martin
produced only a few vowels (/ee/, /ah/, and /oo/), some early developing consonants
(/m/, /n/, /d/, /t/, /p/, /b/, /h/, and /w/), and limited syllables. This reduced sound
repertoire made many of his spoken words indistinguishable from one another (e.g.,
he said bahbah for bottle, baby, and bubble, and he used nee for knee, need, and Anita
[his sister]). Moreover, he consistently omitted consonant sounds at the end of words
and in consonant cluster sequences (e.g., /tr-/, /st-/, /-nt/, and /-mp/).
Understandably, on occasion Martin reacted with frustration and tantrums to his
difficulties in making his needs understood.
Brad was a pleasant, cooperative 5-year-old, who was recognized as early as
preschool to have articulation problems, and these persisted into kindergarten. His
language comprehension skills, and hearing were within normal limits. He showed
some mild expressive language problems, however, in the use of certain grammatical
features (e.g., pronouns, auxiliary verbs, and past-tense word endings) and in the
formulation of complex sentences. He correctly produced all vowel sounds and most
of the early developing consonants, but he was inconsistent in his attempts to produce
later-developing consonants (e.g., /r/, /l/, /s/, /z/, /sh/, /th/, and /ch/). Sometimes,
he omitted them; sometimes, he substituted other sounds for them (e.g., /w/ for /r/ or
/f/ for /th/); occasionally, he even produced them correctly. Brad had particular
problems in correctly producing consonant cluster sequences and multisyllabic words.
Cluster sequences had omitted or incorrect sounds (e.g., blue might be produced as bue
or bwue, and hearts might be said as hots or hars). Multisyllabic words had syllables
omitted (e.g., efant for elephant and getti for spaghetti) and sounds mispronounced or
even transposed (e.g., aminal for animal and lemon for melon). Strangers were unable
to understand approximately 80 percent of Brad’s speech. Brad often spoke more
slowly and clearly than usual, however, when he was asked to repeat something, as
he often was.
Jane was a hyperactive 8-year-old, with a history of significant speech delay.
During her preschool and early school years, she had overcome many of her earlier
speech errors. A few late-developing sounds (/r/, /l/, and /th/), however, continued
to pose a challenge for her. Jane often substituted /f/ or /d/ for /th/ and produced
/w/ for /r/ and /l/. Overall, her speech was easily understood, despite these minor
errors. Nonetheless, she became somewhat aggressive with her peers because of the
teasing she received from her classmates about her speech.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of speech sound disorder includes a careful determination of
symptoms, severity, and possible medical conditions that might be producing the
symptoms. First, the clinician must determine that the misarticulating is sufficiently
severe to be considered impairing, rather than a normative developmental process of
learning to speak. Second, the clinician must determine that no physical abnormalities
account for the articulation errors and must rule out neurological disorders that may
cause dysarthria, hearing impairment, mental retardation, and pervasive developmental
disorders. Third, the clinician must obtain an evaluation of receptive and expressive
language to determine that the speech difficulty is not solely attributable to the above
mentioned disorders.
Neurological, oral structural, and audiometric examinations may be necessary to rule
out physical factors that cause certain types of articulation abnormalities. Children with
dysarthria, a disorder caused by structural or neurological abnormalities, differ from
children with speech sound disorder in that dysarthria is less likely to remit
spontaneously and may be more difficult to remediate. Drooling, slow, or uncoordinated
motor behavior; abnormal chewing or swallowing; and awkward or slow protrusion and
retraction of the tongue indicate dysarthria. A slow rate of speech also indicates
dysarthria (Table 31.4b-1).
Table 31.4b-1
Differential Diagnosis of Speech Sound Disorder
COURSE AND PROGNOSIS
Spontaneous remission of symptoms is common in children whose misarticulating
involves only a few phonemes. Children who persist in exhibiting articulation problems
after the age of 5 years may be experiencing a myriad of other speech and language
impairments, so that a comprehensive evaluation may be indicated at that time.
Children older than age 5 with articulation problems are at higher risk for auditory
perceptual problems. Spontaneous recovery is rare after the age of 8 years. Some debate
exists regarding the relationship between articulation problems and reading disorder, or
dyslexia. A recent study comparing children with phonological problems only, with
children who had dyslexia only, and those with both phonological difficulties and
dyslexia concluded that children with both disorders have somewhat distinct profiles and
are comorbid disorders rather than one mixed disorder.
TREATMENT
Two main approaches have been used successfully to improve speech sound difficulties.
The first one, the phonological approach, is usually chosen for children with extensive
patterns of multiple speech sound errors that may include final consonant deletion, or
consonant cluster reduction. Exercises in this approach to treatment focus on guided
practice of specific sounds, such as final consonants, and when that skill is mastered,
practice is extended to use in meaningful words and sentences. The other approach, the
traditional approach is utilized for children who produce substitution or distortion errors
in just a few sounds. In this approach, the child practices the production of the problem
sound while the clinician provides immediate feedback and cues concerning the correct
placement of the tongue and mouth for improved articulation. Children who have errors
in articulation because of abnormal swallowing resulting in tongue thrust and lisps are
treated with exercises that improve swallowing patterns and, in turn, improve speech.
Speech therapy is typically provided by a speech-language pathologist, yet parents can
be taught to provide adjunctive help by practicing techniques used in the treatment.
Early intervention can be helpful, because for many children with mild articulation
difficulties, even several months of intervention may be helpful in early elementary
school. In general, when a child’s articulation and intelligibility is noticeably different
than peers by 8 years of age, speech deficits often lead to problems with peers, learning,
and self-image, especially when the disorder is so severe that many consonants are
misarticulated, and when errors involve omissions and substitutions of phonemes, rather
than distortions.
Children with persistent articulation problems are likely to be teased or ostracized by
peers and may become isolated and demoralized. Therefore, it is important to give
support to children with phonological disorders and, whenever possible, to support
prosocial activities and social interactions with peers. Parental counseling and
monitoring of child–peer relationships and school behavior can help minimize social
impairment in children with speech sound and language disorder.

07 - 31.4c Child Onset Fluency Disorder (Stutterin
31.4c Child-Onset Fluency Disorder (Stuttering)
31.4c Child-Onset Fluency Disorder (Stuttering)
Child-onset fluency disorder (stuttering) usually begins during the first years of life and
is characterized by disruptions in the normal flow of speech by involuntary speech
motor events. Stuttering can include a variety of specific disruptions of fluency,
including sound or syllable repetitions, sound prolongations, dysrhythmic phonations,
and complete blocking or unusual pauses between sounds and syllables of words. In
severe cases, the stuttering may be accompanied by accessory or secondary attempts to
compensate such as respiratory, abnormal voice phonations, or tongue clicks. Associated
behaviors, such as eye blinks, facial grimacing, head jerks, and abnormal body
movements, may be observed before or during the disrupted speech.
Early intervention is important because children who receive early intervention have
been found to be more than 7 times more likely to have full resolution of their
stuttering. In severe and some untreated cases, stuttering can become an entrenched
pattern that is more challenging to remediate later in life and is associated with
significant psychological and social distress. When stuttering becomes chronic, persisting
into adulthood, the rates of concurrent social anxiety disorder are reported to be
between 40 and 60 percent.
EPIDEMIOLOGY
An epidemiologic survey of 3- to 17-year-olds derived from the United States National
Health Interview Surveys reports that the prevalence of stuttering is approximately 1.6
percent. Stuttering tends to be most common in young children and has often resolved
spontaneously by the time the child is older. The typical age of onset is 2 to 7 years of
age, with 90 percent of children exhibiting symptoms by age 7 years. Approximately 65
to 80 percent of young children who stutter are likely to have a spontaneous remission
over time. According to the DSM-5, the rate dips to 0.8 percent by adolescence.
Stuttering affects about three to four males for every one female. The disorder is
significantly more common among family members of affected children than in the
general population. Reports suggest that for male persons who stutter, 20 percent of
their male children and 10 percent of their female children will also stutter.
COMORBIDITY
Very young children who stutter typically show some delay in the development of
language and articulation without additional disorders of speech and language.
Preschoolers and school-age children who stutter exhibit an increased incidence of social
anxiety, school refusal, and other anxiety symptoms. Older children who stutter also do
not necessarily have comorbid speech and language disorders, but often manifest
anxiety symptoms and disorders. When stuttering persists into adolescence, social
isolation occurs at higher rates than in the general adolescent population. Stuttering is
also associated with a variety of abnormal motor movements, upper body tics, and
facial grimaces. Other disorders that coexist with stuttering include phonological
disorder, expressive language disorder, mixed receptive–expressive language disorder,
and ADHD.
ETIOLOGY
Converging evidence indicates that cause of stuttering is multifactorial, including
genetic, neurophysiological, and psychological factors that predispose a child to have
poor speech fluency. Although research evidence does not indicate that anxiety or
conflicts cause stuttering or that persons who stutter have more psychiatric disturbances
than those with other forms of speech and language disorders, stuttering can be
exacerbated by certain stressful situations.
Other theories about the cause of stuttering include organic models and learning
models. Organic models include those that focus on incomplete lateralization or
abnormal cerebral dominance. Several studies using EEG found that stuttering males
had right hemispheric alpha suppression across stimulus words and tasks; nonstutterers
had left hemispheric suppression. Some studies of stutterers have noted an
overrepresentation of left-handedness and ambidexterity. Twin studies and striking
gender differences in stuttering indicate that stuttering has some genetic basis.
Learning theories about the cause of stuttering include the semantogenic theory, in
which stuttering is basically a learned response to normative early childhood
disfluencies. Another learning model focuses on classic conditioning, in which the
stuttering becomes conditioned to environmental factors. In the cybernetic model,
speech is viewed as a process that depends on appropriate feedback for regulation;
stuttering is hypothesized to occur because of a breakdown in the feedback loop. The
observations that stuttering is reduced by white noise and that delayed auditory
feedback produces stuttering in normal speakers lend support to the feedback theory.
The motor functioning of some children who stutter appears to be delayed or slightly
abnormal. The observation of difficulties in speech planning exhibited by some children
who stutter suggests that higher-level cognitive dysfunction may contribute to stuttering.
Although children who stutter do not routinely exhibit other speech and language
disorders, family members of these children often exhibit an increased incidence of a
variety of speech and language disorders. Stuttering is most likely to be caused by a set
of interacting variables that include both genetic and environmental factors.
DIAGNOSIS
The diagnosis of childhood-onset fluency disorder (stuttering) is not difficult when the
clinical features are apparent and well developed and each of the following four phases
(described in the next section) are readily recognized. Diagnostic difficulties can arise
when evaluating for stuttering in young children, because some preschool children
experience transient dysfluency. It may not be clear whether the nonfluent pattern is
part of normal speech and language development or whether it represents the initial
stage in the development of stuttering. If incipient stuttering is suspected, referral to a
speech pathologist is indicated.
CLINICAL FEATURES
Stuttering usually appears between the ages of 18 months and 9 years, with two sharp
peaks of onset between the ages of 2 to 3.5 years and 5 to 7 years. Some, but not all,
stutterers have other speech and language problems, such as phonological disorder and
expressive language disorder. Stuttering does not begin suddenly; it typically develops
over weeks or months with a repetition of initial consonants, whole words that are
usually the first words of a phrase, or long words. As the disorder progresses, the
repetitions become more frequent, with consistent stuttering on the most important
words or phrases. Even after it develops, stuttering may be absent during oral readings,
singing, and talking to pets or inanimate objects.
Four gradually evolving phases in the development of stuttering have been identified:
Phase 1 occurs during the preschool period. Initially, the difficulty tends to be
episodic and appears for weeks or months between long interludes of normal speech.
A high percentage of recovery from these periods of stuttering occurs. During this
phase, children stutter most often when excited or upset, when they seem to have a
great deal to say, and under other conditions of communicative pressure.
Phase 2 usually occurs in the elementary school years. The disorder is chronic, with
few if any intervals of normal speech. Affected children become aware of their speech
difficulties and regard themselves as stutterers. In phase 2, the stuttering occurs
mainly with the major parts of speech—nouns, verbs, adjectives, and adverbs.
Phase 3 usually appears after the age of 8 years and up to adulthood, most often in
late childhood and early adolescence. During phase 3, stuttering comes and goes
largely in response to specific situations, such as reciting in class, speaking to
strangers, making purchases in stores, and using the telephone. Some words and
sounds are regarded as more difficult than others.
Phase 4 typically appears in late adolescence and adulthood.
Stutterers show a vivid, fearful anticipation of stuttering. They fear words, sounds,
and situations. Word substitutions and circumlocutions are common. Stutterers avoid
situations requiring speech and show other evidence of fear and embarrassment.
Stutterers may have associated clinical features: vivid, fearful anticipation of
stuttering, with avoidance of particular words, sounds, or situations in which stuttering
is anticipated; and eye blinks, tics, and tremors of the lips or jaw. Frustration, anxiety,
and depression are common among those with chronic stuttering.
DIFFERENTIAL DIAGNOSIS
Normal speech dysfluency in preschool years is difficult to differentiate from incipient
stuttering. In stuttering occurs more nonfluencies, part-word repetitions, sound
prolongations, and disruptions in voice airflow through the vocal track. Children who
stutter appear to be tense and uncomfortable with their speech pattern, in contrast to
young children who are nonfluent in their speech but seem to be at ease. Spastic
dysphonia is a stuttering-like speech disorder distinguished from stuttering by the
presence of an abnormal breathing pattern.
Cluttering is a speech disorder characterized by erratic and dysrhythmic speech
patterns of rapid and jerky spurts of words and phrases. In cluttering, those affected are
usually unaware of the disturbance, whereas, after the initial phase of the disorder,
stutterers are aware of their speech difficulties. Cluttering is often an associated feature
of expressive language disturbance.
COURSE AND PROGNOSIS
The course of stuttering is often long term, with periods of partial remission lasting for
weeks or months and exacerbations occurring most frequently when a child is under
pressure to communicate. In children with mild cases, 50 to 80 percent recover
spontaneously. School-age children who stutter chronically may have impaired peer
relationships as a result of teasing and social rejection. These children may face
academic difficulties, especially if they persistently avoid speaking in class. Stuttering is
associated with anxiety disorders in chronic cases, and approximately half of individuals
with persistent stuttering have social anxiety disorder.
TREATMENT
Evidence-based treatments for stuttering are emerging in the literature. One such
treatment is the Lidcombe Program, which is based on an operant conditioning model in
which parents use praise for periods of time in which the child does not stutter, and
intervene when the child does stutter to request the child to self-correct the stuttered
word. This treatment program is largely administered at home by parents, under the
supervision of a speech and language therapist. A second treatment program being
investigated in clinical trials is a family-based, parent-child interaction therapy that
identifies stressors possibly associated with increased stuttering and aims to diminish
these stressors. A third treatment currently under investigation in clinical trials is based
on the knowledge that speaking each syllable in time to a particular rhythm has led to
diminished stuttering in adults. This treatment program appears to be promising when
administered early on, to preschoolers.
Distinct forms of interventions have historically been used in the treatment of
stuttering. The first approach, direct speech therapy, targets modification of the
stuttering response to fluent-sounding speech by systematic steps and rules of speech
mechanics that the person can practice. The other form of therapy for stuttering targets
diminishing tension and anxiety during speech. These treatments may utilize breathing
exercises and relaxation techniques, to help children slow the rate of speaking and
modulate speech volume. Relaxation techniques are based on the premise that it is
nearly impossible to be relaxed and stutter in the usual manner at the same time.
Current interventions for stuttering use individualized combinations of behavioral

08 - 31.4d Social (Pragmatic) Communication Disord
31.4d Social (Pragmatic) Communication Disorder
distraction, relaxation techniques, and directed speech modification.
Stutterers who have poor self-image, comorbid anxiety disorders or depressive
disorders are likely to require additional treatments with cognitive-behavioral therapy
(CBT) and/or pharmacologic agents such as one of the selective serotonin reuptake
inhibitor (SSRI) antidepressants.
An approach to stuttering proposed by the Speech Foundation of America is labeled
self-therapy, based on the premise that stuttering is not a symptom, but a behavior that
can be modified. Stutterers are told that they can learn to control their difficulty partly
by modifying their feelings about stuttering and attitudes toward it and partly by
modifying the deviant behaviors associated with their stuttering blocks. The approach
includes desensitizing; reducing the emotional reaction to, and fears of, stuttering; and
substituting positive action to control the moment of stuttering.
31.4d Social (Pragmatic) Communication Disorder
Social (pragmatic) communication disorder is a newly added diagnosis to DSM-5
characterized by persistent deficits in using verbal and nonverbal communication for
social purposes in the absence of restricted and repetitive interests and behaviors.
Deficits may be exhibited by difficulty in understanding and following social rules of
language, gesture, and social context. This may limit a child’s ability to communicate
effectively with peers, in academic settings, and in family activities. To successfully
achieve social and pragmatic communication, a child or adolescent would be expected to
integrate gestures, language, and social context of a given interaction to correctly infer
its meaning. Thus, the child or adolescent would be able to understand another speaker’s
“intention” of the communication with verbal and nonverbal cues as well as through an
understanding of the environmental and social context of the interaction. One of the
reasons that social (pragmatic) communication disorder was introduced into the DSM-5
was to include those children with social communication impairment who do not exhibit
restrictive and repetitive interests and behaviors, and therefore do not fulfill the criteria
for autism spectrum disorders. Pragmatic communication encompasses the ability to
infer meaning in a given communication by not only understanding the words used, but
also integrating the phrases into their prior understanding of the social environment.
Social (pragmatic) communication disorder is a new disorder; however, the concept of
children with social communication deficits without repetitive and restrictive interests
and behaviors has been identified for many years, and is often associated with delayed
language acquisition and language disorder.
EPIDEMIOLOGY
It is difficult to estimate the prevalence of social (pragmatic) communication disorder.
Nevertheless, a body of literature has documented a profile of children who present with
these persistent difficulties in pragmatic language, who do not meet criteria for autism
spectrum disorder.
COMORBIDITY
Social (pragmatic) communication disorder is commonly associated with language
disorder, consisting of diminished vocabulary for expected age, deficits in receptive
skills, as well as impaired ability to use expressive language. Attentiondeficit/hyperactivity disorder (ADHD) is often concurrent with social (pragmatic)
communication disorder. Specific learning disorders with impairments in reading and
writing are also commonly comorbid disorders with social (pragmatic) communication
disorder. Although some symptoms of social anxiety disorder may overlap with social
(pragmatic) communication disorder, the full disorder of social anxiety disorder may
emerge comorbidly with social (pragmatic) communication disorder.
ETIOLOGY
A family history of communication disorders, autism spectrum disorder, or specific
learning disorder all appear to increase the risk for social (pragmatic) communication
disorder. This suggests that genetic influences are contributing factors in the
development of this disorder. The etiology of social (pragmatic) communication
disorder, however, is likely to be multifactorial, and given its frequent comorbidity with
both language disorder and ADHD, developmental and environmental influences are
likely to also play a role.
DIAGNOSIS
The diagnosis of social (pragmatic) communication disorder can be difficult to
distinguish from mild variants of autism spectrum disorder in which repetitive and
restricted interests and behaviors are minimal. There have been largely discrepant data
regarding how many children previously diagnosed with autism would be excluded from
the DSM-5 criteria, which now focus on only two symptom domains: social
communication deficits and restricted repetitive interests and behaviors. In one study,
only 60.6 percent of children who had previously met the criteria for autistic spectrum
disorder in the previous edition of the DSM met DSM-5 criteria for autistic spectrum
disorder. However, in another study, up to 91 percent patients with of autism continued
to meet the same DSM-5 criteria.
The essential features of social (pragmatic) communication disorder are persistently
impaired social pragmatic communication resulting in limited effective communication,
compromised social relationships, and difficulties with academic or occupational
achievement.
CLINICAL FEATURES
Social (pragmatic) communication disorder is characterized by impaired ability to
effectively use verbal and nonverbal communication for social purposes and occurs in
the absence of restricted and repetitive interests and behaviors. According to the DSM-5,
all of the following features must be present in order to meet diagnostic criteria: (1)
Deficits in using appropriate communication such as greeting, or sharing information in
a social situation or context. (2) Impaired ability to modulate the tone, level, or
vocabulary used in social communication to match the listener and the situation, such as
inability to simplify communication when speaking to a young child. (3) Impaired
ability in following the rules for conversations such as taking turns or rephrasing a
statement for clarification and failure to recognize and respond socially appropriately
to verbal and nonverbal feedback. (4) Difficulty understanding things that are not
explicitly stated, impaired ability to make inferences, understand humor, or interpret
socially ambiguous stimuli. Although the preceding deficits begin in the early
developmental period, the diagnosis is rarely made in a child younger than 4 years of
age. In milder cases, the difficulties may not become apparent until adolescence when
the demands for language and social understanding are increased. The deficits in social
communication lead to impairment in function in social situations, in developing
relationships, and in family and academic settings.
DIFFERENTIAL DIAGNOSIS
The primary diagnostic consideration in social (pragmatic) communication disorder is
autism spectrum disorder. The two disorders are most easily distinguished when the
prominence of restricted and repetitive interests and behaviors characteristic of autistic
spectrum disorder is present. However, in many cases of autism, the restrictive interests
and repetitive behaviors manifest more prominently in the early developmental period
and are not obvious in older childhood. However, even when these features are not
observable, if they are obtained by history, social (pragmatic) communication disorder
is not diagnosed, rather autism is the diagnosis. Social (pragmatic) communication
disorder is considered only when the restricted interests and repetitive behaviors have
never been present. ADHD may overlap with social (pragmatic) communication disorder
in social communication disturbance; however, the core features of ADHD are not likely
to be confused with autism spectrum disorder. In some cases, however, the two disorders
may coexist. Another childhood disorder with socially impairing symptoms that may
overlap with social (pragmatic) communication disorder is social anxiety disorder. In
social anxiety disorder, however, social communication skills are present, but not
manifested in feared social situations. In social (pragmatic) communication disorder,
appropriate social communication skills are not present in any setting. Both social
anxiety disorder and social (pragmatic) communication disorder may occur comorbidly,
however, and children with social (pragmatic) communication disorder may be at higher
risk for social anxiety disorder. Finally, intellectual disability may be confused with
social (pragmatic) communication disorder, in that social communication skills may be
deficits in children with intellectual disability. A diagnosis of social (pragmatic)
communication disorder is made only when social communication skills are clearly more
severe than the intellectual disability.

09 - 31.4e Unspecified Communication Disorder
31.4e Unspecified Communication Disorder
COURSE AND PROGNOSIS
The course and outcome of social (pragmatic) communication disorder is highly variable
and dependent on both the severity of the disorder and potential interventions
administered. By age 5 years, most children demonstrate enough speech and language
to be able to discern the presence of deficits in social communication. However, in the
milder forms of the disorder, social communication deficits may not be identified until
adolescence, when language and social interactions are sufficiently complex that deficits
stand out. Many children have significant improvement over time; however, even so,
some early pragmatic deficits may cause lasting impairment in social relationships and
in academic progress. There is a newly growing body of investigations on therapeutic
interventions that may affect future outcome and prognosis of social (pragmatic)
communication disorder.
TREATMENT
There are few data to date to inform an evidence-based treatment for social (pragmatic)
communication disorder, or to fully distinguish it from other disorders with overlapping
symptoms such as autism spectrum disorder, ADHD, and social anxiety disorder. A
randomized controlled trial of a social communication intervention directed specifically
at children with social (pragmatic) communication disorder aimed at three areas of
communication: (1) social understanding and social interaction; (2) verbal and
nonverbal pragmatic skills, including conversation; and (3) language processing,
involving making inferences, and learning new words. Although the primary outcome
measure in this study did not show significant differences for the intervention group
versus the “treatment as usual” group, there were several ratings by parents and
teachers that demonstrate potential improvements in social communication skills after a
20-session intensive intervention for social (pragmatic) communication disorder. It is
clear that continued investigation is necessary to both validate the preceding results and
to
promote
evidence-based
treatments
for
children
with
social
(pragmatic)
communication disorder.
31.4e Unspecified Communication Disorder
Disorders that do not meet the diagnostic criteria for any specific communication
disorder fall into the category of unspecified communication disorder. An example is
voice disorder, in which the patient has an abnormality in pitch, loudness, quality, tone,
or resonance. To be coded as a disorder, the voice abnormality must be sufficiently
severe to impair academic achievement or social communication. Operationally, speech
production can be broken down into five interacting subsystems, including respiration
(airflow from the lungs), phonation (sound generation in the larynx), resonance
(shaping of the sound quality in the pharynx and nasal cavity), articulation (modulation
of the sound stream into consonant and vowel sounds with the tongue, jaw, and lips),
and suprasegmentalia (speech rhythm, loudness, and intonation). these systems work
together to convey information, and voice quality conveys information about the
speaker’s emotional, psychological, and physical status. Thus, voice abnormalities can
cover a broad area of communication as well as indicate many different types of
abnormalities.
Cluttering is not listed as a disorder in the DSM-5, but it is an associated speech
abnormality in which the disturbed rate and rhythm of speech impair intelligibility.
Speech is erratic and dysrhythmic and consists of rapid, jerky spurts that are
inconsistent with normal phrasing patterns. The disorder usually occurs in children
between 2 and 8 years of age; in two thirds of cases, the patient recovers spontaneously
by early adolescence. Cluttering is associated with learning disorders and other
communication disorders.
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31.5 Autism Spectrum Disorder
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31.5 Autism Spectrum Disorder
Autism spectrum disorder, previously known as the pervasive developmental disorders,
is a phenotypically heterogeneous group of neurodevelopmental syndromes, with
polygenic heritability, characterized by a wide range of impairments in social
communication and restricted and repetitive behaviors. Prior to the development of the
Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of
Mental Disorders (DSM-5), autism spectrum disorder was conceptualized as five discrete
disorders, including: autistic disorder, Asperger’s disorder, childhood disintegrative disorder,
Rett syndrome, and pervasive developmental disorder not otherwise specified. Autistic
disorder was characterized by impairments in three domains: social communication,
restricted and repetitive behaviors, and aberrant language development and usage. A
less extensive form of autism spectrum disorder, Asperger’s disorder, did not include
language impairment as a diagnostic criterion. Recent clinical consensus has shifted the
conceptualization of autism spectrum disorder toward a continuum model in which
heterogeneity of symptoms is recognized as inherent in the disorder, and core diagnostic
impairments are collapsed into two domains: deficits in social communication, and
restricted and repetitive behaviors. Aberrant language development and usage is no
longer considered a core feature of autism spectrum disorder. This diagnostic change, is
based, in part, on recent studies in siblings with diagnoses of autistic disorder,
suggesting that symptom domains may be transmitted separately, and that aberrant
language development and usage is not a defining feature, but an associated feature in
some individuals with autism spectrum disorder. Autism spectrum disorder is typically
evident during the second year of life, and in severe cases, a lack of developmentally
appropriate interest in social interactions may be noted even in the first year. Some
studies suggest that a decline in social interaction may ensue between the first and
second years of life. However, in milder cases, core impairments in autism spectrum
disorder may not be identified for several more years. Although language impairment is
not a core diagnostic criterion in autism spectrum disorder, clinicians and parents share
concerns about a child who by 12 to 18 months has not developed any language, and
delayed language accompanied by diminished social behavior are frequently the
heralding symptoms in autism spectrum disorder. In up to 25 percent of cases of autism
spectrum disorder, some language develops and is subsequently lost. Autism spectrum
disorder in children with normal intellectual function and mild impairment in language
function may not be identified until middle childhood when both academic and social
demands are increased. Children with autism spectrum disorder often exhibit
idiosyncratic intense interest in a narrow range of activities, resist change, and
typically, do not respond to their social environment in accordance with their peers.
According to the DSM-5, diagnostic criteria for autism spectrum disorder include
deficits in social communication and restricted interests, which present in the early
developmental period, however, when subtle, may not be identified until several years
later. approximately one third of children meeting the current DSM-5 diagnosis of
autism spectrum disorder, exhibit intellectual disability (ID).
Of interest, is that according to DSM-IV-TR, Rett syndrome or disorder appeared to
occur exclusively in females and is characterized by normal development for at least 6
months, followed by stereotyped hand movements, a loss of purposeful motions,
diminishing social engagement, poor coordination, and decreasing language use. In the
formerly labeled childhood disintegrative disorder, development progresses normally for
approximately 2 years, after which the child shows a loss of previously acquired skills in
two or more of the following areas: language use, social responsiveness, play, motor
skills, and bladder or bowel control. The former Asperger’s disorder is characterized by
impairment in social relatedness and repetitive and stereotyped patterns of behavior
without a delay or marked aberrant in language development and usage. In Asperger’s
disorder, cognitive abilities and major adaptive skills are age appropriate, although
social communication is impaired. A survey of children undertaken with the former
autism spectrum disorders, revealed that the average age of diagnosis was 3.1 years for
children with autistic disorder, 3.9 years for children diagnosed with pervasive
developmental disorder not otherwise specified, and 7.2 years for those youth with
Asperger’s disorder. Children with autism spectrum disorder who exhibited severe
language deficits received an autism spectrum disorder diagnosis, on average, a year
earlier than children without impairment in language. Children with autism spectrum
disorder who exhibited repetitive behaviors such as hand-flapping, toe-walking, and odd
play were also identified with autism spectrum disorder disorders at a younger age than
those who did not exhibit such behaviors. The current DSM-5 autism spectrum disorder
criteria provide specifiers for severity of the main domains of impairment and also
specifiers for the presence or absence of language impairment and intellectual
impairment.
HISTORY OF AUTISTIC DISORDER
“Early infantile autism” was described by Leo Kanner in 1943; however, even as early as 1867, the psychiatrist Henry
Maudsley had observed a group of very young children with severe mental disorders characterized by marked deviation,
delay, and distortion in development. In that era, most serious developmental disturbance in young children was believed
to fall within the category of psychoses. Kanner’s classic paper “Autistic Disturbances of Affective Contact,” coined the
term infantile autism and provided a clear, comprehensive account of the early childhood syndrome. Kanner described
children who exhibited extreme “autistic aloneness”; failure to assume an anticipatory posture; delayed or deviant
language development with echolalia and often with pronominal reversal (using you for I); monotonous repetitions of
noises or verbal utterances; excellent rote memory; limited range of spontaneous activities, stereotypies, and mannerisms;
and anxiously obsessive desire for the maintenance of sameness and dread of change. Socially, Kanner’s sample was
described as having poor eye contact; awkward relationships; and a preference for pictures and inanimate objects. Kanner
suspected that the syndrome was more frequent than it seemed, and suggested that some children with infantile autism
may have been misclassified as “mentally retarded” or schizophrenic. Before 1980, children with symptoms of autism
spectrum disorder were generally diagnosed with childhood schizophrenia. Over time, it became evident that autism
spectrum disorder and schizophrenia were two distinct psychiatric entities. In some cases, however, a child with autism
spectrum disorder may develop comorbid schizophrenic disorder later in childhood.
EPIDEMIOLOGY
Prevalence
Autism spectrum disorders have been increasingly diagnosed over the last two decades,
with the current prevalence estimated at approximately 1 percent in the United States.
Autistic disorder, based on DSM-IV-TR criteria, is believed to occur at a rate of about 8
cases per 10,000 children (0.08 percent). By definition, the onset of autism spectrum
disorder is in the early developmental period; however, some cases are not recognized
until the child is much older. Because of this delay between onset and diagnosis, the
prevalence rates increase with age in young children.
Sex Distribution
Autism spectrum disorder is diagnosed four times more often in boys than in girls. In
clinical samples, girls with autism spectrum disorder more often exhibit intellectual
disability than boys. One potential explanation for this is that girls with autism
spectrum disorder without intellectual disability may be less likely to be identified,
referred clinically, and diagnosed.
ETIOLOGY AND PATHOGENESIS
Genetic Factors
Family and twin studies suggest that autism spectrum disorder has a significant heritable
contribution; however, it does not appear to be fully penetrant. Although up to 15
percent of cases of autism spectrum disorder appear to be associated with a known
genetic mutation, in most cases, its expression is dependent on multiple genes. Family
studies have demonstrated increased rates of autism spectrum disorder in siblings of an
index child, as high as 50 percent in some families with two or more children with
autism spectrum disorder. Siblings of a child with autism spectrum disorder are also at
increased risk for a variety of developmental impairments in communication and social
skills, even when they do not meet criteria for autism spectrum disorder.
The concordance rate of autistic disorder in two large twin studies was 36 percent in
monozygotic pairs versus 0 percent in dizygotic pairs in one study and about 96 percent
in monozygotic pairs versus about 27 percent in dizygotic pairs in the second study.
High rates of cognitive impairments, in the nonautistic twin in monozygotic twins with
perinatal complications, suggest that contributions of perinatal environmental factors
interact with genetic vulnerability differentially in autism spectrum disorder.
The heterogeneity in expression of symptoms in families with autism spectrum
disorder suggests that there are multiple patterns of genetic transmission. Studies
indicate that both an increase and decrease in certain genetic patterns may be risk
factors for autism spectrum disorder. In addition to specific genetic factors, gender plays
a strong role in the expression of autism spectrum disorder. Genetic studies have
identified two biological systems that are influenced in autism spectrum disorder: the
consistent finding of elevated platelet serotonin (5-HT), and the mTOR, that is,
mammalian target of rapamycin–linked synaptic plasticity mechanisms, which appear
to be disrupted in autism spectrum disorder. These will be discussed further in the next
section.
A number of known genetically caused syndromes include autism spectrum disorder as
part of a broader phenotype. The most common of these inherited disorders is fragile X
syndrome, an X-linked recessive disorder that is present in 2 to 3 percent of individuals
with autism spectrum disorder. Fragile X syndrome exhibits a nucleotide repeat in the 5’
untranslated region of the FMNR1 gene, resulting in symptoms of autism spectrum
disorder. Children with fragile X syndrome characteristically exhibit intellectual
disability, gross and fine motor impairments, an unusual facies, macroorchidism, and
significantly diminished expressive language ability. Tuberous sclerosis, another genetic
disorder characterized by multiple benign tumors, inherited by autosomal dominant
transmission, is found with greater frequency among children with autism spectrum
disorder. Up to 2 percent of children with autism spectrum disorder also have tuberous
sclerosis.
Researchers who screened the DNA of more than 150 pairs of siblings with autism
spectrum disorder found evidence of two regions on chromosomes 2 and 7 containing
genes that may contribute to autism spectrum disorder. Additional genes hypothesized to
be involved in autism spectrum disorder were found on chromosomes 16 and 17.
Biomarkers in Autism Spectrum Disorder
Autism spectrum disorder is associated with several biomarkers, potentially resulting
from interactions of genes and environmental factors, which then influence neuronal
function, dendrite development, and contribute to altered neuronal information
processing. Several biomarkers of abnormal signaling in the 5-HT system, the mTORlinked synaptic plasticity mechanisms, and alterations of the γ-aminobutyric acid
(GABA) inhibitory system.
The first biomarker identified in autism spectrum disorder was elevated serotonin in
whole blood, almost exclusively in the platelets. Platelets acquire 5-HT through the
process of SERT (serotonin transporter), known to be hereditary, as they pass through
the intestinal circulation. The genes that mediate SERT (SLC64A), and the 5-HT receptor
5-HT 2A gene (HTR2A) are known to be more heritable than autism spectrum disorder,
and encode the same protein in the platelets and in the brain. Because 5-HT is known to
be involved in brain development, it is possible that the changes in 5-HT regulation may
lead to alterations in neuronal migration and growth in the brain.
Both structural and functional neuroimaging studies have suggested specific
biomarkers associated with autism spectrum disorder. Several studies found increased
total brain volume in children younger than 4 years of age with autism spectrum
disorder, whose neonatal head circumferences were within normal limits or slightly
below. By about age 5 years, however, 15 to 20 percent of children with autism
spectrum disorder developed macrocephaly. Additional studies found confirmatory data
in samples of infants who were later diagnosed with autism spectrum disorder, who
exhibited normal head circumferences at birth; by 4 years, 90 percent had larger brain
volumes than controls, with 37 percent of the autism spectrum disorder group meeting
criteria for macrocephaly. In contrast, structural magnetic resonance imaging (sMRI)
studies of children with autism spectrum disorder ranging from 5 to 16 years did not
find mean values of total brain volume increased. One study followed the size of the
amygdala in youth with autism spectrum disorder in the first few years of life, and
similarly, found an increased size in the first few years of life, followed by a decrease in
size over time. The size of the striatum has also been found in several studies to be
enlarged in young children with autism spectrum disorder, with a positive correlation of
striatal size with frequency of repetitive behaviors. The dynamic process of the atypical
and changing total brain volume observed in children with autism spectrum disorder
lends support for the overarching hypothesis that there are sensitive periods or “critical
periods” within the brain’s plasticity that may be disrupted in ways that may contribute
to the emergence of autism spectrum disorder.
Functional MRI (fMRI) studies have focused on identifying biomarkers, that is, the
functional brain correlates of various observed core symptoms in autism spectrum
disorder. fMRI studies of children, adolescents, and adults with autism spectrum disorder
have employed tasks including face perception, neutral face tasks, “theory of mind”
deficits, language and communication impairments, working memory and repetitive
behaviors. fMRI studies have provided evidence that individuals with autism spectrum
disorder have a tendency to scan faces differently than controls, in that they focus more
on the mouth region of the face rather than on the eye region and rather than scan the
entire face multiple times, individuals with autism spectrum disorder focus more on
individual features of the face. In response to socially relevant stimuli, researchers have
come to the conclusion that individuals with autism spectrum disorder have greater
amygdala hyperarousal. In terms of “theory of mind,” that is, the ability to attribute
emotional states to others, and to oneself, fMRI studies find differences in activation in
brain regions such as the right temporal lobe and other areas of the brain known to
become activated in controls during tasks involving theory of mind. This difference has
been hypothesized by some researchers to represent dysfunction of the mirror neuron
system (MNS). Atypical patterns of frontal lobe activation have been found in multiple
studies of autism spectrum disorder during face processing tasks, suggesting that this
area of the brain may be critical in social perception and emotional reasoning.
Decreased activation in individuals with autism spectrum disorder in the left frontal
regions of the brain during memory and language-based tasks led researchers to
hypothesize that individuals with autism spectrum disorder utilized more visual
strategies during language processing than controls did.
Both sMRI and fMRI research has contributed to demonstrating brain correlates of
core impairments observed in individuals with autism spectrum disorder.
Immunological Factors
Several reports have suggested that immunological incompatibility (i.e., maternal
antibodies directed at the fetus) may contribute to autistic disorder. The lymphocytes of
some autistic children react with maternal antibodies, which raises the possibility that
embryonic neural tissues may be damaged during gestation. These reports usually reflect
single cases rather than controlled studies, and this hypothesis is still under
investigation.
Prenatal and Perinatal Factors
A higher-than-expected incidence of prenatal and perinatal complications seems to occur
in infants who are later diagnosed with autism spectrum disorder. The most significant
prenatal factors associated with autism spectrum disorder in the offspring are advanced
maternal and paternal age at birth, maternal gestational bleeding, gestational diabetes,
and first-born baby. Perinatal risk factors for autism spectrum disorder include umbilical
cord complications, birth trauma, fetal distress, small for gestational age, low birth
weight, low 5-minute Apgar score, congenital malformation, ABO blood group system or
Rh factor incompatibility and hyperbilirubinemia. Many of the obstetrical complications
that are associated with risk for autism spectrum disorder are also risk factors for
hypoxia, which may be an underlying risk factor itself. There is not sufficient evidence
to implicate any one single perinatal or prenatal factor in autism spectrum disorder
etiology, and a genetic predisposition to autism spectrum disorder may be interacting
with perinatal factors.
Comorbid Neurological Disorders
Electroencephalography (EEG) abnormalities and seizure disorders occur with greater
than expected frequency in individuals with autism spectrum disorder. Four percent to
32 percent of individuals with autism spectrum disorder have grand mal seizures at
some time, and about 20 to 25 percent show ventricular enlargement on computed
tomography (CT) scans. Various EEG abnormalities are found in 10 to 83 percent of
children with the previously defined autistic disorder, and although no EEG finding is
specific to autistic disorder, there is some indication of failed cerebral lateralization. The
current consensus is that autism spectrum disorder is a set of behavioral syndromes
caused by a multitude of factors acting on the central nervous system.
Psychosocial Theories
Studies comparing parents of children with autism spectrum disorder with parents of
normal children have shown no significant differences in child-rearing skills. Kanner’s
early speculations that parental emotional factors might be implicated as contributing
to the development of autism spectrum disorder have been clearly refuted.
DIAGNOSIS AND CLINICAL FEATURES
The DSM-5 diagnostic criteria for autism spectrum disorder are shown in Table 31.5-1.
Table 31.5-1
DSM-5 Diagnostic Criteria for Autism Spectrum Disorder
Core Symptoms of Autism Spectrum Disorder
Persistent Deficits In Social Communication and Interaction.
Children
with autism spectrum disorder characteristically do not conform to the expected level of
reciprocal social skills and spontaneous nonverbal social interactions. Infants with
autism spectrum disorder may not develop a social smile, and as older babies may lack
the anticipatory posture for being picked up by a caretaker. Less frequent and poor eye
contact is common during childhood and adolescence compared to other children. The
social development of children with autism spectrum disorder is characterized by
atypical, but not absent, attachment behavior. Children with autism spectrum disorder
may not explicitly acknowledge or differentiate the most important persons in their
lives—parents, siblings, and teachers—and on the other hand, may not react as strongly
to being left with a stranger compared to others their age. Children with autism
spectrum disorder often feel and display extreme anxiety when their usual routine is
disrupted. By the time children with autism spectrum disorder reach school age, their
social skills may have increased, and social withdrawal may be less obvious, particularly
in higher-functioning children. An observable deficit, however, often remains in
spontaneous play with peers and in subtle social abilities that promote developing
friendships. The social behavior of children with autism spectrum disorder is often
awkward and may be inappropriate. In older school-aged children, social impairments
may be manifested in a lack of conventional back and forth conversation, fewer shared
interests, and fewer body and facial gestures during conversations. Cognitively, children
with autism spectrum disorder are frequently more skilled in visual-spatial tasks than in
tasks requiring skill in verbal reasoning.
One observation of the cognitive style of children with autism spectrum disorder is an
impaired ability to infer the feelings or emotional state of others around them. That is,
individuals with autism spectrum disorder have difficulty with making attributions about
the motivation or intentions of others (also termed “theory of mind”) and thus have
difficulty developing empathy. The lack of a “theory of mind” produces difficulties
interpreting the social behavior of others and leads to a lack of social reciprocation.
Individuals with autism spectrum disorder generally desire friendships, and higher
functioning children may be aware that their lack of spontaneity and poor skills in
responding to the emotions and feelings of their peers are major obstacles in developing
friendships. Children with autism spectrum disorder are often avoided or shunned by
peers who expect them to conform to their mainstream activities, and experience their
behavior as awkward and alienating. Adolescents and adults with autism spectrum
disorder often desire romantic relationships, and for some, their increase in social
competence and skills over time enables them to develop long-term relationships.
Restricted, Repetitive Patterns of Behavior, Interests, and Activities.
From the first years of life, in a child with autism spectrum disorder, developmentally
expected exploratory play is restricted and muted. Toys and objects may not be used
typically, instead, are often manipulated in a ritualistic manner, with fewer symbolic
features. Children with autism spectrum disorder generally do not show the level of
imitative play or abstract pantomime that other children of their age exhibit
spontaneously. The activities and play of children with autism spectrum disorder may
appear more rigid, repetitive, and monotonous than their peers. Ritualistic and
compulsive behaviors are common in early and middle childhood. Children with autism
spectrum disorder often seem to enjoy spinning, banging, and watching water flowing.
Frank compulsive behaviors are not uncommon among children with autism spectrum
disorder, such as lining up objects, and not infrequently a child with autism spectrum
disorder may exhibit a strong attachment to a particular inanimate object. Children with
autism spectrum disorder who are severely intellectually disabled have increased rates
of self-stimulatory and self-injurious behaviors. Stereotypies, mannerisms, and
grimacing emerge most frequently when a child with autism spectrum disorder is a less-
structured situation. Children with autism spectrum disorder often find transitions and
changes intimidating. Moving to a new house, rearranging furniture in a room, or even
a change such as eating a meal before a bath when the reverse was the routine, may
evoke panic, fear, or temper tantrums in a child with autism spectrum disorder.
Associated Physical Characteristics.
At first glance, children with autism
spectrum disorder do not show any physical signs indicating the disorder. Children with
autism spectrum disorder, overall, do exhibit higher rates of minor physical anomalies,
such as ear malformations, and others that may reflect abnormalities in fetal
development of those organs along with parts of the brain.
A greater than expected number of children with autism spectrum disorder do not
show early handedness and lateralization, and remain ambidextrous at an age when
cerebral dominance is established in most children. Children with autism spectrum
disorder have been observed to have a higher incidence of abnormal dermatoglyphics
(e.g., fingerprints) than those in the general population. This finding may suggest a
disturbance in neuroectodermal development.
Associated Behavioral Symptoms that May Occur in Autism Spectrum
Disorder
Disturbances In Language Development and Usage.
Deficits in language
development and difficulty using language to communicate ideas are not among the
core criteria for diagnosing autism spectrum disorder; however, they occur in a subset of
those individuals with autism spectrum disorder. Some children with autism spectrum
disorder are not simply reluctant to speak, and their speech abnormalities do not result
from lack of motivation. Language deviance, as much as language delay, is
characteristic of more severe subtypes of autism spectrum disorder. Children with severe
autism spectrum disorder have significant difficulty putting meaningful sentences
together, even when they have large vocabularies. When children with autism spectrum
disorder whose language was delayed do learn to converse fluently, their conversations
may impart information without typical prosody or inflection.
In the first year of life, a typical pattern of babbling may be minimal or absent. Some
children with autism spectrum disorder vocalize noises—clicks, screeches, or nonsense
syllables—in a stereotyped fashion, without a seeming intent of communication. Unlike
most young children who generally have better receptive language skills than expressive
ones, children with autism spectrum disorder may express more than they understand.
Words and even entire sentences may drop in and out of a child’s vocabulary. It is not
atypical for a child with autism spectrum disorder to use a word once and then not use it
again for a week, a month, or years. Children with autism spectrum disorder may
exhibit speech that contains echolalia, both immediate and delayed, or stereotyped
phrases that seem out of context. These language patterns are frequently associated with
pronoun reversals. A child with autistic disorder might say, “You want the toy” when she
means that she wants it. Difficulties in articulation are also common. Many children
with autistic disorder use peculiar voice quality and rhythm. About 50 percent of autistic
children never develop useful speech. Some of the brightest children show a particular
fascination with letters and numbers. Children with autism spectrum disorder sometimes
excel in certain tasks or have special abilities; for example, a child may learn to read
fluently at preschool age (hyperlexia), often astonishingly well. Very young children
with autism spectrum disorder who can read many words, however, have little
comprehension of the words read.
Intellectual Disability.
About 30 percent of children with autism spectrum
disorder function in the intellectually disabled range of intellectual function. Of those,
about 30 percent of children function in the mild to moderate range, and about 45 to 50
percent are severely to profoundly intellectually disabled. The intelligent quotient (IQ)
scores of autism spectrum disorder children with intellectual impairments tend to reflect
most severe problems with verbal sequencing and abstraction skills, with relative
strengths in visuospatial or rote memory skills. This finding suggests the importance of
defects in language-related functions.
Irritability.
Broadly defined, irritability includes aggression, self-injurious
behaviors, and severe temper tantrums. These phenomena are commonly encountered
in children and adolescents with autism spectrum disorder. Severe temper tantrums may
be difficult to subdue, and self-injurious behaviors are often problematic to control.
These symptoms are often produced by everyday situations in which these youth are
expected to transition from one activity to another, sit in a classroom setting, or remain
still when they desire to run around. In children with autism spectrum disorder who are
lower functioning and have intellectual deficits, aggression may emerge unexpectedly
without an obvious trigger or purpose, and self-injurious behaviors such as head
banging, skin picking, and biting oneself may also be noted.
Instability of Mood and Affect.
Some children with autism spectrum disorder
exhibit sudden mood changes, with bursts of laughing or crying without an obvious
reason. It is difficult to learn more about these episodes if the child cannot express the
thoughts related to the affect.
Response to Sensory Stimuli.
Children with autism spectrum disorder have been
observed to overrespond to some stimuli and underrespond to other sensory stimuli
(e.g., to sound and pain). It is not uncommon for a child with autism spectrum disorder
to appear deaf, at times showing little response to a normal speaking voice; on the
other hand, the same child may show intent interest in the sound of a wristwatch. Some
children have a heightened pain threshold or an altered response to pain. Indeed, some
children with autism spectrum disorder do not respond to an injury by crying or seeking
comfort. Some youth with autism spectrum disorder perseverate on a sensory
experience; for example, they frequently hum a tune or sing a song or commercial jingle
before saying words or using speech. Some particularly enjoy vestibular stimulation—
spinning, swinging, and up-and-down movements.
Hyperactivity and Inattention.
Hyperactivity and inattention are both common
behaviors in young children with autism spectrum disorder. Lower than average activity
level is less frequent; when present, it often alternates with hyperactivity. Short
attention span, poor ability to focus on a task, may also interfere with daily functioning
Precocious Skills.
Some individuals with autism spectrum disorder have precocious
or splinter skills of great proficiency, such as prodigious rote memories or calculating
abilities, usually beyond the capabilities of their normal peers. Other potential
precocious abilities in some children with autism spectrum disorder include hyperlexia,
an early ability to read well (even though they cannot understand what they read),
memorizing and reciting, and musical abilities (singing or playing tunes or recognizing
musical pieces).
Insomnia.
Insomnia is a frequent sleep problem among children and adolescents
with autism spectrum disorder, estimated to occur in 44 to 83 percent of school-aged
children. Both behavioral and pharmacologic interventions have been applied as
interventions. Behavioral interventions include modification of parental behavior before
and at bedtime, and providing routines that remove reinforcers for remaining awake.
Medication interventions have included melatonin, which appears to be a promising
agent in doses ranging from 1 mg fast-release to 4 mg controlled-release in the few
controlled studies for insomnia in youth with autism spectrum disorder.
Minor Infections and Gastrointestinal Symptoms.
Young children with
autism spectrum disorder have been reported to have a higher-than-expected incidence
of upper respiratory infections and other minor infections. Gastrointestinal symptoms
commonly found among children with autism spectrum disorder include excessive
burping, constipation, and loose bowel movements. Also seen is an increased incidence
of febrile seizures in children with autism spectrum disorder. Some children do not show
temperature elevations with minor infectious illnesses and may not show the typical
malaise of ill children. In other children, behavior problems and relatedness seem to
improve noticeably during a minor illness, and in some, such changes are a clue to
physical illness.
Assessment Tools
A standardized instrument that can be very helpful in eliciting comprehensive
information regarding autism spectrum disorder is the Autism Diagnostic Observation
Schedule-Generic (ADOS-G).
Brett was the first of two children born to middle-class parents both in their early
40s after difficult pregnancy, with an induced labor at 36 weeks due to fetal distress.
As an infant, Brett was undemanding and relatively placid; he did not have colic, and
motor development proceeded appropriately, but language development was delayed.
Brett’s parents first became concerned about his development when he was 18 months
of age and still not speaking; however, upon questioning, they noted that, in
comparison to other toddlers in his play group, Brett had seemed less uninterested in
social interaction and the social games with toddlers and adults. Stranger anxiety
became marked at 18 months, much later compared to the other toddlers in his day
care program. Brett would become extremely upset if his usual day care worker was
not present and would tantrum until his mother took him home. Brett’s pediatrician
initially reassured his parents that he was a “late talker”; however, when Brett was 24
months old he was referred for developmental evaluation. At 24 months, motor skills
were age appropriate. His language and social development, however, was severely
delayed, and he was noted to be resistant to changes in routine and unusually
sensitive to aspects of the inanimate environment. Brett’s play skills were quite
limited, and he played with toys in repetitive and idiosyncratic ways. His younger
sister, now 12 months, was beginning to say a few words, and the family history was
negative for language and developmental disorders. A comprehensive medical
evaluation revealed a normal EEG and CT scan; genetic screening and chromosome
analysis were normal as well.
Brett was diagnosed with autism spectrum disorder, and he was enrolled in a
special education program in which he gradually began to speak. His speech was
extremely literal and characterized by a monotonic voice quality and an occasional
pronoun reversal. Brett often spoke and was able to make his needs known; however,
his language was odd and the other toddlers did not play with him. Brett pursued
mainly solo activities and remained quite isolated. By age 5 years, Brett was quite
attached to his mother and often became separation anxious and upset when she went
out, exhibiting severe tantrums. Brett also had developed a number of self-stimulatory
behaviors in which he engaged, such as waving his fingers in front of his eyes. His
extreme sensitivity to change continued over the next few years. Intelligence testing
revealed a full-scale IQ in the average range with relative weakness in the verbal
subtests compared to the performance subtests. In the 4th grade, Brett began to have
serious behavioral problems at school and at home. Brett was unable to complete his
class work, would wander around the classroom, and would begin to tantrum when
the teacher insisted that he sit in his seat. He would sometimes begin screaming so
loudly that he had to be asked to leave the classroom. He would then become upset
and throw all of his books off his desk in a rage, sometimes inadvertently hitting other
students. It took him up to 2 hours to calm down. At home, Brett would fly into a
tantrum if anyone touched his things, and he would become stubborn and belligerent
when asked to do anything that he was not expecting. Brett’s tantrum behavior
continued into middle school, and by the 8th grade, when he was 13 years old, these
behaviors became so severe that the school warned his parents that he was becoming
unmanageable. Brett was evaluated by a child and adolescent psychiatrist who
recommended a social skills group for him and prescribed risperidone, starting with
0.5 mg p.o. b.i.d. and titrating up to 1.5 mg p.o. bid. At that dose, Brett’s tantrums
were less frequent and less severe. Brett seemed calmer in general, and did not
become physically out of control during tantrums. Brett continued in middle school in
a combination of special education classes and regular classes. Brett’s social skills
group was helpful in terms of teaching him how to approach peers in ways that would
lead to less rejection. Brett had made some acquaintances, and by the time he started
high school, he had acquired two friends who would come to his home and play video
games with him. Brett knew that he was different than the other students, but he had
trouble articulating what was different about him. Brett continued in high school with
a combination of special and regular education and had plans to attend a community
college and live at home for the first year.
(Adapted from a case by Fred Volkmar, M.D.)
DIFFERENTIAL DIAGNOSIS
Disorders to consider in the differential diagnosis of autism spectrum disorder include
social (pragmatic) communication disorder, the newly described DSM-5 communication
disorder; schizophrenia with childhood onset; congenital deafness or severe hearing
disorder; and psychosocial deprivation. It is also difficult to make the diagnosis of
autism spectrum disorder because of its potentially overlapping symptoms with
childhood schizophrenia, intellectual disability syndromes with behavioral symptoms,
and language disorders. In view of the many concurrent problems often encountered in
autism spectrum disorder, Michael Rutter and Lionel Hersov suggested a stepwise
approach to the differential diagnosis.
Social (Pragmatic) communication disorder
This disorder is characterized by difficulty in conforming to typical storytelling,
understanding the rules of social communication through language, exemplified by a
lack of conventional greeting others, taking turns in a conversation, and responding to
verbal and nonverbal cues of a listener. Other forms of language impairment may
accompany social communication disorder such as delay in learning language or
expressive and receptive difficulties. Social communication disorder is found with
greater frequency in relatives of individuals with autism spectrum disorder, which
increases the difficulty in discriminating this disorder from autism spectrum disorder.
Although relationships may be negatively affected by social communication disorder,
this disorder does not include restricted or repetitive behaviors and interests, as autism
spectrum disorder does.
Childhood Onset Schizophrenia
Schizophrenia is rare in children younger than 12 years and almost nonexistent before
the age of 5 years. Characterized by hallucinations or delusions, childhood onset
schizophrenia has a lower incidence of seizures and intellectual disability and poor
social skills. Table 31.5-2 compares autism spectrum disorder and schizophrenia with
childhood onset.
Table 31.5-2
Autism Spectrum Disorder versus Childhood Onset Schizophrenia
Intellectual Disability with Behavioral Symptoms
Children with intellectual disability may exhibit behavioral symptoms that overlap with
some autism spectrum disorder features. The main differentiating features between
autism spectrum disorder and intellectual disability are that children with intellectual
disability syndromes generally display global impairments in both verbal and nonverbal
areas, whereas children with autism spectrum disorder are relatively weak in social
interactions compared to other areas of performance. Children with intellectual
disability generally relate verbally and socially to adults and peers in accordance with
their mental age, and they exhibit a relatively even profile of limitations.
Language Disorder
Some children with language disorders also have autism spectrum disorder features,
which may present a diagnostic challenge. Table 31.5-3 summarizes the major
differences between autism spectrum disorder and language disorders.
Table 31.5-3
Autism Spectrum Disorder versus Language Disorder
Congenital Deafness or Hearing Impairment
Because children with autism spectrum disorder may appear mute or lack language
development, congenital deafness and hearing impairment must be considered and
ruled out. Differentiating factors include the following: infants with autism spectrum
disorder may babble only infrequently, whereas deaf infants often have a history of
relatively normal babbling that then gradually tapers off and may stop at 6 months to 1
year of age. Deaf children generally respond only to loud sounds, whereas children with
autism spectrum disorder may ignore loud or normal sounds and respond to soft or low
sounds. Most importantly, audiogram or auditory-evoked potentials indicate significant
hearing loss in deaf children. Deaf children usually seek out nonverbal social
communication with regularity and seek social interactions with peers and family
members more consistently than children with autism spectrum disorder.
Psychosocial Deprivation
Severe neglect, maltreatment, and lack of parental care can lead children to appear
apathetic, withdrawn, and alienated. Language and motor skills may be delayed.
Children with these signs generally improve when placed in a favorable and enriched
psychosocial environment, but such improvement is not the case with children with
autism spectrum disorder.
COURSE AND PROGNOSIS
Autism spectrum disorder is typically a lifelong, albeit heterogeneous, disorder with a
highly variable severity and prognosis. Children with autism spectrum disorder and IQs
above 70 with average adaptive skills, who develop communicative language by ages 5
to 7 years, have the best prognoses. A longitudinal study comparing symptoms in
children with high-IQ autism spectrum disorder at the age of 5 years, with their
symptoms at age 13 through young adulthood, found that a small proportion no longer
met criteria for autism spectrum disorder. Most of these youth demonstrated positive
changes in communication and social domains over time. Early intensive behavioral
interventions have been found to provide a profound positive impact on many children
with autism spectrum disorder, and in some cases lead to recovery and function in the
average range.
The autism spectrum disorder symptom areas that do not seem to improve
substantively over time with early behavioral interventions are related to ritualistic and
repetitive behaviors. However, currently, evidence-based behavioral interventions
specifically targeting repetitive behaviors may ameliorate them. The prognosis of a
given child with autism spectrum disorder is generally improved if the home
environment is supportive.
TREATMENT
The goals of treatment for children with autism spectrum disorder are to target core
behaviors to improve social interactions, communication, broaden strategies to integrate
into schools, develop meaningful peer relationships, and increase long-term skills in
independent living. Psychosocial treatment interventions aim to help children with
autism spectrum disorder to develop skills in social conventions, increase socially
acceptable and prosocial behavior with peers, and to decrease odd behavioral
symptoms. In many cases, language and academic remediation are also required. In
addition, treatment goals generally include reduction of irritable and disruptive
behaviors that may emerge in school and at home and may exacerbate during
transitions. Children with intellectual disability require developmentally appropriate
behavioral interventions to reinforce socially acceptable behaviors and encourage selfcare skills. In addition, parents of children with autism spectrum disorder often benefit
from psychoeducation, support, and counseling in order to optimize their relationships
and effectiveness with their children. Comprehensive treatment for autism spectrum
disorder including intensive behavioral programs, parent training and participation,
and academic/educational interventions have provided the most promising results.
Components of these comprehensive treatments include expanding social skills,
communication, and language, often through practicing imitation, joint attention, social
reciprocity, and play in a directed but child-centered manner. Five randomized
controlled trials (RCTs) of early intensive comprehensive behavioral interventions
targeting core features of autism spectrum disorder in children ranging in age from 2
years to 5 years of age have shown increases in language acquisition, social
interactions, and educational achievement at the end of the study period compared to
control groups. The study periods ranged from 12 weeks to several years, and the
settings were at home, in clinic, or at school. The comprehensive treatment models or
adapted versions of them were used either alone or in combinations in these RCTs as
described below.
Psychosocial Interventions
Early Intensive Behavioral and Developmental Interventions
UCLA/Lovaas-based Model. This intensive and manualized intervention primarily
utilizes techniques derived from applied behavior analysis, which is administered on a
one-to-one basis for many hours per week. A therapist and a child will work on
practicing specific social skills, language usage, and other target play skills, with
reinforcement and rewards provided for accomplishments and mastery of skills.
Early Start Denver Model (ESDM) Interventions are administered in naturalistic
settings such as in day care, at home, and during play with other children. Parents are
typically taught to be co-therapists and provide the training at home while
educational settings also provide the interventions. The focus of the interventions is
on developing basic play skills and relationship skills, and applied behavior analysis
techniques are integrated into the interventions. This approach is focused on training
for very young children and is applied within the context of the child’s daily routine.
3. Parent Training Approaches This includes Pivotal Response Training, in which
parents are taught to facilitate social and communication development within the
home and during activities by targeting gateway or pivotal social behaviors for
mastery by the child with the expectation that once these central social skills were
mastered, a natural generalizing of social behaviors would follow. Extensive parent
and family components are integrated into this type of intervention. Other parent
training approaches focus on language acquisition, and for parents, may be
administered at a lower intensity such as weekly; however, once parents are trained,
the interventions occur throughout the day with the child. Another example of a
parent training approach is the Hanen More Than Words Program.
Social Skills Approaches
Social Skills Training. Typically provided by therapeutic leaders to children of
various ages in a group setting with peers; children are given guided practice in
initiating social conversation, greetings, initiating games, and joint attention.
Emotion identification and regulation are often included in practice with recognizing
and learning how to label emotions in given social situations, learning to attribute
appropriate emotional reactions in others, and social problem-solving techniques. The
goals are that with practice in the group setting, the child will be able to use the
techniques in less-structured settings and internalize strategies to interact positively
with peers.
Behavioral Interventions (BIs) and Cognitive-Behavioral Therapy (CBT)
for Repetitive Behaviors and Associated Symptoms
Behavioral Therapy. Applied behavioral analysis has been found to be somewhat
effective in reducing some repetitive behaviors in children and adolescents with
autism spectrum disorder. Early intervention is recommended for repetitive behaviors
that are self-injurious; behavioral interventions may need to be combined with
pharmacologic treatments to adequately manage the symptoms.
Cognitive-Behavioral Therapy. There is a significant evidence base from RCTs for
the efficacy of CBT for symptoms of anxiety, depression, and obsessive-compulsive
disorders in children. There are fewer controlled trials of this treatment in children
with autism spectrum disorder, although there are at least two published studies in
which CBT was used to treat repetitive behavior in individuals with autism spectrum
disorder.
Interventions for comorbid symptoms in autism spectrum disorder
Neurofeedback. This modality has been administered in an attempt to influence
symptoms of attention-deficit/hyperactivity disorder (ADHD), anxiety, and increased
social interaction by providing computer games or other games in which the desired
behavior is reinforced, while the child wears electrodes that monitor electrical activity
in the brain. The aim is to influence brainwave activity to prolong or produce
electrical activity present during the desired behaviors. This modality is still under
investigation in the treatment of symptoms in autism spectrum disorder.
2. Management of insomnia in autism spectrum disorder. Insomnia is a prevalent
concern among children and adolescents with autism spectrum disorder, and both
behavioral and pharmacologic interventions may be administered to improve this
condition. The most common behavioral intervention for insomnia in autism spectrum
disorder is based on changing the parents behavior first toward the child at bedtime
and throughout the night, such that there is a removal of reinforcement and attention
for being awake, leading to a gradual extinction of the “staying awake” behavior.
Several studies using massage therapy before bedtime in children with autism
spectrum disorder between the ages of 2 years and 13 years provided an improvement
in falling asleep and a sense of relaxation.
Educational interventions for children with autism spectrum disorder
Treatment and Education of Autistic and Communication-related Handicapped
children (TEACCH). Originally developed at the University of North Carolina at
Chapel Hill in the 1970s, TEACCH involves structured teaching based on the notion
that children with autism spectrum disorder have difficulty with perception, and so
this teaching method incorporates many visual supports and a picture schedule to aid
in teaching academic subjects as well as socially appropriate responses. The physical
environment is arranged to support visual learning, and the day is structured to
promote autonomy and social relatedness.
Broad-based approaches. These educational plans include a blend of teaching
strategies that use behavioral analysis and also focus on language remediation.
Behavioral reinforcement is provided for socially acceptable behaviors while academic
subjects are being taught. TEACCH may also be incorporated into a broader special
educational program for autism spectrum disorder.
Computer-based approaches and virtual reality. Computer-based approaches and
virtual reality teaching are centered on using computer-based programs, games, and
interactive programs to teach language acquisition and reading skills. This provides
the child with a sense of mastery and delivers a behaviorally based instruction in a
modality that is appealing for the child. The Let’s Face It! program is a computerized
game that helps to teach children with autism spectrum disorder to recognize faces. It
consists of seven interactive computer games that target changes in facial expression,
attention to the eye region of the face, holistic face recognition, and identifying
emotional expression. A randomized controlled trial of use of this program with
children with autism spectrum disorder provided evidence that after 20 hours of face
training with Let’s Face It!, compared to the control group, the trained children
demonstrated improvement in their ability to focus on the eye region of a face and
improved their analytic and holistic face-processing skills. Several studies using virtual
reality environments to teach children with autism spectrum disorder social skills and
interaction have provided evidence of their value. In one study, a virtual café for
children with autism spectrum disorder allowed the children to practice ordering and
paying for drinks and food by navigation with the use of a computer mouse.
Psychopharmacological Interventions
Psychopharmacological interventions in autism spectrum disorder are mainly directed at
ameliorating impairing associated behavioral symptoms rather than core features of
autism spectrum disorder. Target symptoms include irritability, broadly including
aggression, temper tantrums and self-injurious behaviors, hyperactivity, impulsivity,
and inattention.
Irritability.
Two second-generation antipsychotics, risperidone and aripiprazole,
have been approved by the Food and Drug Administration (FDA) in the United States for
treatment of irritability in individuals with autism spectrum disorder. Risperidone, a
high-potency antipsychotic with combined dopamine (D2) and serotonin (5-HT2)
receptor antagonist properties, has been shown to subdue aggressive or self-injurious
behaviors in children with and without autism spectrum disorder. Starting with the
National Institutes of Health supported Research Units on Pediatric
Psychopharmacology randomized controlled trial of risperidone for treating irritability
in autism spectrum disorder in 2002, there have been seven randomized controlled
trials, three reanalysis studies, and two add-on studies, which have converged to confirm
risperidone as an efficacious pharmacological treatment for irritability in children and
adolescents with autism spectrum disorder in doses ranging from 0.5 mg to 1.5 mg.
Some of the preschoolers in this study were also receiving intensive behavioral
treatments. Risperidone is considered the first-line of medication treatment for children
and adolescents with autism spectrum disorder who exhibit severe irritability. Despite its
efficacy, risperidone’s main side effects of weight gain and increased appetite; metabolic
side effects such as hyperglycemia, prolactin elevation, and dyslipidemia; along with
other common adverse effects such as fatigue, drowsiness, dizziness, and drooling have
limited its use in some individuals. Risperidone should be used with caution in
individuals with underlying cardiac abnormalities or hypotension, since risperidone may
contribute to orthostatic hypotension. In further continuation studies of risperidone in
the treatment of irritability in autism spectrum disorder, persistent efficacy and
tolerability were found over a 6-month period, with a rapid return of symptoms in good
responders when the risperidone was discontinued. Other drugs studied in the treatment
of irritability in autism spectrum disorder include aripiprazole and olanzapine.
Two large studies utilizing aripiprazole in the treatment of tantrums, aggression, and
self-injury in children and adolescents with autism spectrum disorder found that
aripiprazole was both efficacious and safe. Doses ranged from 5 mg to 15 mg per day.
Main side effects included sedation, dizziness, insomnia, akathisia, nausea, and
vomiting. Although weight gain was not as pronounced as with risperidone, it was still
considered a moderate adverse event, with approximately 1.3 to 1.5 kg gained during
an 8-week study period. The weight gain was similar at the lower and higher doses.
Olanzapine, which specifically blocks 5-HT2A and D2 receptors and also blocks
muscarinic receptors, has been studied in children and adolescents with autism spectrum
disorder for the treatment of irritability with a trend toward a positive response;
however, significant weight gain of approximately 3.5 kg occurred. The main side effect
was sedation.
Hyperactivity, Impulsivity, and Inattention.
Several randomized placebocontrolled trials of methylphenidate have been conducted for the treatment of
hyperactivity, impulsivity, and inattention in children and adolescents with autism
spectrum disorder. The Research Units of Pediatric Psychopharmacology found
methylphenidate to be at least moderately efficacious at doses of 0.25 to 0.5 mg/kg for
youth with autism spectrum disorder and ADHD symptoms. Efficacy of methylphenidate
in this population was less effective than in children with ADHD without autism
spectrum disorder, and children with autism spectrum disorder developed more frequent
side effects, including increased irritability, compared to ADHD children. A study of
methylphenidate in the treatment of hyperactivity and inattention in preschoolers with
autism spectrum disorder found the stimulant safe and relatively efficacious; half of the
preschoolers developed side effects including increased stereotypies, gastrointestinal
upset, sleep problems, and emotional lability. Among nonstimulants, one double-blind
placebo-controlled study of hyperactivity, impulsivity, and inattention using
atomoxetine in children with autism spectrum disorder found that it was significantly
more effective than placebo. Side effects included sedation, irritability, constipation,
and nausea. Clonidine, an α-agonist has also been studied in children with autism
spectrum disorder for the treatment of hyperactivity with mixed results. Guanfacine was
also found to be of use in some cases.
Repetitive and Stereotypic Behavior.
These core symptoms of autism spectrum
disorder have been studied using selective serotonin reuptake inhibitor (SSRI)
antidepressants, second-generation antipsychotics (SGAs), and mood-stabilizing agents
such as valproate. One study with fluoxetine found the medication group only slightly
better and not significantly better than the placebo group regarding the target
symptoms, and another trial with escitalopram found no difference between groups.
Risperidone, however, was found to be effective in targeting irritability, and restrictive
and repetitive behaviors were improved. One recent study using valproate in a 12-week
trial with 55 children with a mean age of 9½ years with autism spectrum disorder,
found that those who were considered responders with respect to irritability were also
found to be spending less time engaging in repetitive behaviors.
Agents Administered For Behavioral Impairment In Autism Spectrum
Disorder Based On Open Trials.
Quetiapine is an antipsychotic with more
potent 5-H2 than D2 receptor blocking properties. Although only open-label trials have
been done with this agent, it is sometimes tried when risperidone and olanzapine are
not efficacious or well tolerated. It has been used in clinical practice at doses ranging
from 50 to 200 mg per day. Adverse effects include drowsiness, tachycardia, agitation,
and weight gain.
Clozapine has a heterocyclic chemical structure that is related to certain conventional
antipsychotics, such as loxapine (Loxitane), although clozapine carries a lower risk of
extrapyramidal symptoms. It is not generally used in the treatment of aggression and
self-injurious behavior unless those behaviors coexist with psychotic symptoms. The most
serious adverse effect is agranulocytosis, which necessitates monitoring white blood cell
count weekly during clozapine use. Its use is generally limited to treatment-resistant
psychotic patients.
Ziprasidone has receptor-blocking properties at the 5-HT2A and D2 receptor sites and
carries little risk of extrapyramidal and antihistaminic effects. No guidelines exist for its
use in autistic children with aggressive and self-injurious behaviors, but it has been used
clinically to treat the latter behaviors in children who are treatment resistant. In studies
of its use in adults with schizophrenia, dose ranges of 40 to 160 mg were found to be
effective. Adverse effects include sedation, dizziness, and lightheadedness. An
electrocardiography (ECG) recording is generally obtained before use of this medication.
Lithium (Eskalith) has been shown to be efficacious in children with aggression
without autism spectrum disorder, and it is used clinically in the treatment of aggressive
or self-injurious behaviors when antipsychotic medications are not effective.
Agents Used For Behavioral Impairment In Autism Spectrum Disorder
Without Evidence Of Efficacy.
A double-blind study investigated the efficacy of
amantadine (Symmetrel), which blocks N-methyl-d-aspartate (NMDA) receptors, in the
treatment of behavioral disturbance, such as irritability, aggression, and hyperactivity,
in children with autism. Some researchers have suggested that abnormalities of the
glutamatergic system may contribute to the emergence of autism spectrum disorders.
High glutamate levels have been found in children with the formerly labeled Rett
syndrome. In the amantadine study, 47 percent of children on amantadine were rated
“improved” by their parents, and 37 percent of children on placebo were rated
“improved” by parents in irritability and hyperactivity, although this difference was not
statistically significant. Investigators rated the children on amantadine “significantly
improved” with respect to hyperactivity. A double-blind, placebo-controlled study of the
efficacy of the anticonvulsant lamotrigine (Lamictal) on hyperactivity in children with
autism showed high rates of placebo improvement in ratings of hyperactivity, which
were similar to response on the medication.
Clomipramine (Anafranil) has been used in autism spectrum disorder, without RCTs to
provide evidence of positive results. Fenfluramine (Pondimin), which reduces blood
serotonin levels, has also been used unsuccessfully in the treatment of autism.
Improvement does not seem to be associated with a reduction in blood serotonin level.
Naltrexone (ReVia), an opioid receptor antagonist, has been investigated without much
success, based on the notion that blocking endogenous opioids would reduce autistic
symptoms.
Tetrahydrobiopterin, a coenzyme that enhances the action of enzymes was used in a
double-blind placebo-controlled crossover study of 12 children with autistic disorder and
low concentrations of spinal tetrahydrobiopterin. The children received a daily dose of 3
mg tetrahydrobiopterin per kilogram during a 6-month period alternating with placebo.
Results indicated small, nonsignificant changes in the total scores on the Childhood
Autism Rating Scale after 3- and 6-month treatment. Post hoc analysis of the three core
symptoms of autism—social interaction, communication, and stereotyped behaviors—
revealed a significant improvement in social interaction score after 6 months of active
treatment. A positive correlation was noted between social response and IQ. These
results suggest that there is a possible effect of tetrahydrobiopterin on the social
functioning of children with autism.
A recent case report suggested that low-dose venlafaxine (Effexor) was efficacious in
three adolescents and young adults with autistic disorder with self-injurious behavior
and hyperactivity. Dose of venlafaxine used was 18.75 mg per day, and efficacy was
reported to be sustained over a 6-month period.
Complementary and Alternative Medicine (CAM) Approaches to Autism
Spectrum Disorder
Complementary and alternative medicine (CAM) is a group of nontraditional treatments
that are generally used in conjunction with conventional treatments. Safe interventions
that have been applied to target both core and associated behavioral features of autism
spectrum disorder with unknown efficacy include the following: music therapy, to
promote communication and expression; and yoga, to promote attention and decrease
activity level. A biologically based practice that is deemed safe and shown to be
efficacious is melatonin, which is effective in reducing sleep-onset latency in children.
Other biological practices that are recognized as safe but with unknown efficacy include
vitamin C, multivitamins, essential fatty acids, and the amino acids carnosine and
carnitine. Secretin has been shown to be ineffective in RCTs in the treatment of autism
spectrum disorder.
DISORDERS INCLUDED IN AUTISTIC SPECTRUM DISORDER
The autistic spectrum covers a range of behaviors which, prior to the change in the DSM5 were listed separately, and which are now no longer diagnosed as separate entities in
the diagnostic manual. Nevertheless, the descriptive value of these entities remains
important, and it may be some time before the disorders described herein disappear
from the psychiatric lexicon. In addition, they remain in use in Europe and around the
world as useful diagnostic entities and are still coded as separate disorders in ICD-10 as
discussed.
International Classification of Diseases, Tenth Edition (ICD-10)
The classification system used in International Classification of Diseases, Tenth Revision
(ICD-10) is not congruent with the revisions made in DSM-5 about autistic disorders.
ICD-10 still includes separate designations for Rett syndrome, Childhood Disintegrative
Disorder, Asperger’s Disorder, and Pervasive Development Disorder Not Otherwise
Specified (Table 31.5-4). The authors of Synopsis believe these subtypes to be clinically
useful, and each is described below. The reader should be aware, however, that
according to DSM-5, each is subsumed under the rubric of Autism Spectrum Disorder and
should so be diagnosed.
Table 31.5-4
ICD-10 Diagnostic Criteria for Pervasive Developmental Disorders
Rett Syndrome
In 1965, Andreas Rett, an Australian physician, identified a syndrome in 22 girls who
appeared to have developed normally for at least 6 months followed by devastating
developmental deterioration. Rett syndrome is a progressive condition that has its onset
after some months of what appears to be normal development. Head circumference is
normal at birth and developmental milestones are unremarkable in early life. Between 5
and 48 months of age, generally between 6 months and 1 year, head growth begins to
decelerate.
Available data indicate a prevalence of 6 to 7 cases of Rett syndrome per 100,000
girls. Originally, it was believed that Rett syndrome occurred only in females, but males
with the disorder or syndromes that are very close to this disorder have now been
described. Rett syndrome is not fully included within autism spectrum disorder, and if
present along with autism spectrum disorder it should be diagnosed as an associated
disorder.
Etiology.
The cause of Rett syndrome is unknown, although the progressive
deteriorating course after an initial normal period is compatible with a metabolic
disorder. In some patients with Rett syndrome, the presence of hyperammonemia has
led to postulation that an enzyme metabolizing ammonia is deficient, but
hyperammonemia has not been found in most patients with Rett syndrome. It is likely
that Rett syndrome has a genetic basis. It has been seen primarily in girls, and case
reports so far indicate complete concordance in monozygotic twins.
Diagnosis and Clinical Features.
During the first 5 months after birth, infants
have age-appropriate motor skills, normal head circumference, and normal growth.
Social interactions show the expected reciprocal quality. At 6 months to 2 years of age,
however, these children develop progressive encephalopathy with a number of
characteristic features. The signs often include the loss of purposeful hand movements,
which are replaced by stereotypic motions, such as hand-wringing; the loss of previously
acquired speech; psychomotor retardation; and ataxia. Other stereotypical hand
movements may occur, such as licking or biting the fingers and tapping or slapping. The
head circumference growth decelerates and produces microcephaly. All language skills
are lost, and both receptive and expressive communicative and social skills seem to
plateau at developmental levels between 6 months and 1 year. Poor muscle
coordination and an apraxic gait with an unsteady and stiff quality develop.
Associated features include seizures in up to 75 percent of affected children and
disorganized EEG findings with some epileptiform discharges in almost all young
children with Rett syndrome, even in the absence of clinical seizures. An additional
associated feature is irregular respiration, with episodes of hyperventilation, apnea, and
breath holding. The disorganized breathing occurs in most patients while they are
awake; during sleep, the breathing usually normalizes. Many patients with Rett
syndrome also have scoliosis. As the disorder progresses, muscle tone seems to change
from an initial hypotonic condition to spasticity to rigidity.
Although children with Rett syndrome may live for well over a decade after the onset
of the disorder, after 10 years, many patients are wheelchair-bound, with muscle
wasting, rigidity, and virtually no language ability. Long-term receptive and expressive
communication and socialization abilities remain at a developmental level of less than 1
year.
Dana was born as a full-term and healthy baby term after an uncomplicated
pregnancy. An amniocentesis had been obtained because of advanced maternal age of
40 years, and findings were normal. At birth, Dana received good Apgar scores and
her weight, height, and head circumference were all near the 50th percentile. Her
development during the first months of life was unremarkable. At approximately 8
months of age, her development seemed to wane, and her interest in the
environment, including the social environment, declined. Dana’s developmental
milestones failed to progress, and she became markedly delayed; she was just starting
to walk at her second birthday and had no spoken language. Evaluation at that time
revealed that head growth had decelerated. Self-stimulatory behaviors emerged, and
in addition, marked cognitive and communicative delays were noted on formal
testing. Dana began to lose purposeful hand movements and developed unusual
stereotypical hand-washing behaviors. By age 6, her EEG was abnormal and abnormal
hand movements were prominent. Subsequently, Dana developed truncal ataxia and
breath-holding spells, and motor skills further deteriorated. (Adapted from Fred
Volkmar, M.D.)
Differential Diagnosis.
Rett syndrome shares some features with autism spectrum
disorder; however, the two disorders have some predictable differences. In Rett
syndrome, there is deterioration of developmental milestones, head circumference, and
overall growth, whereas in autism spectrum disorder, aberrant development is usually
present from early on. In Rett syndrome, specific and characteristic hand motor
movements are always present; in autism spectrum disorder hand mannerisms may or
may not appear. Poor coordination, ataxia, and apraxia are predictably part of Rett
syndrome; however, individuals with autism spectrum disorder may have unremarkable
gross motor function. In Rett syndrome, verbal abilities are usually lost completely,
whereas in autism spectrum disorder language is widely variable from markedly
aberrant to relatively mildly impaired. Respiratory irregularity is characteristic of Rett
syndrome, and seizures often appear early. In autistic disorder, no respiratory
disorganization is seen, and seizures do not develop in most patients; when seizures do
develop, they are more likely in adolescence than in childhood. For autism spectrum
disorder that is associated with another neurodevelopmental disorder such as Rett
syndrome, the latter disorder is diagnosed in association with autism spectrum disorder.
Course and Prognosis.
Rett syndrome is progressive, and those individuals who
live into adolescence and adulthood function at a cognitive and social level equivalent
to that in the first year of life.
Treatment.
Treatment is symptomatic. Physiotherapy has been beneficial for the
muscular dysfunction, and anticonvulsant treatment is usually necessary to control the
seizures. Behavior therapy, along with medication, may help control self-injurious
behaviors, as it does in the treatment of autistic disorder, and it may help regulate the
breathing disorganization.
Childhood Disintegrative Disorder
The previous diagnosis of childhood disintegrative disorder, now included in autism
spectrum disorder, is characterized by marked regression in several areas of functioning
after at least 2 years of apparently normal development. Childhood disintegrative
disorder, also called Heller’s syndrome and disintegrative psychosis, was described in 1908
as a deterioration over several months of intellectual, social, and language function
occurring in 3- and 4-year-olds with previously normal function. After the deterioration,
the children closely resembled children with autistic disorder.
Epidemiology.
Epidemiological data have been complicated by the variable
diagnostic criteria used, but childhood disintegrative disorder is estimated to be much
less common than the formerly diagnosed autistic disorder. The prevalence has been
estimated to occur in about 1 in 100,000 boys. The ratio of boys to girls is estimated to
be between 4 and 8 boys to 1 girl.
Etiology.
The cause of childhood disintegrative disorder is unknown, but it has been
associated with other neurological conditions, including seizure disorders, tuberous
sclerosis, and various metabolic disorders.
Diagnosis and Clinical Features.
The diagnosis is made based on features that
fit a characteristic age of onset, clinical picture, and course. Cases reported have ranged
in onset from ages 1 to 9 years, but in most, the onset is between 3 and 4 years.
Whereas previously diagnosed as a separate entity, DSM-5 conceives of childhood
disintegrative disorder as a subset of autism spectrum disorder. The onset may be
insidious over several months or relatively abrupt, with abilities diminishing in days or
weeks. In some cases, a child displays restlessness, increased activity level, and anxiety
before the loss of function. The core features of the disorder include loss of
communication skills, marked regression of reciprocal interactions, and the onset of
stereotyped movements and compulsive behavior. Affective symptoms are common,
particularly anxiety, as is the regression of self-help skills, such as bowel and bladder
control.
To receive the diagnosis, a child must exhibit loss of skills in two of the following
areas: language, social or adaptive behavior; bowel or bladder control; play; and motor
skills. Abnormalities must be present in both of the following categories: reciprocal
social communication skills, and restricted and repetitive behavior. The main
neurological associated feature is seizure disorder.
Ron’s early history was within normal limits. By age 2, he was speaking in
sentences, and his development appeared to be proceeding appropriately. At 3½
years of age, he abruptly exhibited a period of marked behavioral regression shortly
after the birth of a sibling. Ron lost previously acquired skills in communication and
was no longer toilet trained. Ron became more withdrawn and less interested in
social
interaction,
exhibiting
various
self-stimulatory
behaviors
repeatedly.
Comprehensive medical examination failed to reveal any conditions that might
account for this developmental regression. Behaviorally, Ron exhibited features of
autism spectrum disorder. At follow-up at age 12, he spoke only an occasional single
word and had severe mental retardation. (Adapted from Fred Volkmar, M.D.)
Differential Diagnosis.
The differential diagnosis of the formerly diagnosed
childhood disintegrative disorder includes receptive and expressive language disorder,
mental retardation with behavioral problems, and Rett syndrome. Childhood
disintegrative disorder is characterized by the loss of previously acquired development.
Before the onset of childhood disintegrative disorder (occurring at 2 years or older),
language has usually progressed to sentence formation. This skill is strikingly different
from the premorbid history of even high-functioning patients with autistic disorder, in
whom language generally does not exceed single words or phrases before diagnosis of
the disorder. Once the disorder occurs, however, those with childhood disintegrative
disorder are more likely to have no language abilities than are high-functioning patients
with autistic disorder. In Rett syndrome, the deterioration occurs much earlier than in
childhood disintegrative disorder, and the characteristic hand stereotypies of Rett
syndrome do not occur in childhood disintegrative disorder.
Course and Prognosis.
The course of childhood disintegrative disorder is variable,
with a plateau reached in most cases, a progressive deteriorating course in rare cases,
and some improvement in occasional cases to the point of regaining the ability to speak
in sentences. Most patients are left with at least moderate mental retardation.
Treatment.
Treatment of childhood disintegrative disorder includes the same
components available in the treatment of autistic disorder.
Asperger’s Disorder
The former diagnosis of Asperger’s disorder is characterized by impairment and oddity
of social interaction and restricted interest and behavior. Unlike the former autistic
disorder, in Asperger’s disorder there are no significant delays in language or cognitive
development. In 1944, Hans Asperger, an Austrian physician, described a syndrome that
he named “autistic psychopathy.” His original description of the syndrome described
individuals with normal intelligence who exhibit a qualitative impairment in reciprocal
social interaction and behavioral oddities without delays in language development.
Asperger’s disorder occurs in a wide variety of severities, including cases in which very
subtle social cues are missed, but overall social interactions are mastered.
Etiology.
Asperger’s disorder, a version of autism spectrum disorder, has a complex
etiology including genetic contribution and potentially environmental and perinatal
contributing factors.
Diagnosis and Clinical Features.
The clinical features include at least two of
the following indications of qualitative social impairment: Markedly abnormal
nonverbal communicative gestures, the failure to develop peer relationships at the
expected level. Restricted interests and patterns of behavior are present, but when they
are subtle, they may not be immediately identified or singled out as different from those
of other children. According to DSM-IV-TR, individuals with Asperger’s disorder exhibit
no language delay, clinically significant cognitive delay, or adaptive impairment.
Currently, the clinical phenotype of Asperger’s disorder is subsumed within the DSM-5
diagnosis of autism spectrum disorder.
Jared was an only child. Birth, medical, and family histories were unremarkable.
His motor development was slightly delayed, but language milestones were within
normal limits. His parents became concerned about him at age 4 when he was
enrolled in a nursery school and was noted to have difficulties in peer interaction,
joining activities, and following the rules that were so pronounced that he could not
continue in the program. In grade school, he was enrolled in regular education classes
and was noted to have difficulties making friends and playing sports with the other
students, and he often played alone and spent time alone at lunch and recess. His
greatest difficulties arose in peer interactions—he was viewed as eccentric and did not
seem to understand how to interact with peers. At home, he seemed captivated by
watching the weather channel on television, which he insisted on watching and
pursued with great interest and intensity. On examination at age 13, Jared had
markedly restricted and intense interests and exhibited pedantic and odd patterns of
communication with a monotonic voice quality. Psychological testing revealed an IQ
within the normal range. Formal communication examination revealed ageappropriate skills in receptive and expressive language but marked impairment in
pragmatic language skills. (Adapted from Fred Volkmar, M.D.)
Differential Diagnosis.
The differential diagnosis includes social anxiety disorder,
obsessive-compulsive disorder, and schizoid personality disorder. According to the
previous DSM-IV-TR, the most obvious characteristics of Asperger’s disorder compared to
autistic disorder are the absence of language delay and dysfunction. The lack of
language delay and impaired use of language were previous requirements for Asperger’s
disorder; however, social and communication deficits are present. Studies comparing
children with Asperger’s disorder and autistic disorder found that children with
Asperger’s disorder were more likely to seek social interaction, and due to their
awareness of their impairment sought more vigorously to make friends. Although in this
subgroup within autism spectrum disorder significant delay in language is not a feature,
some delay in the acquisition of language, and some impairment in verbal
communication has been noted in more than one third of clinical samples.
Course and Prognosis.
The factors associated with a good prognosis in this
subgroup within autism spectrum disorder are a normal IQ and more competencies in
social skills. Reports of some adults diagnosed with Asperger’s disorder indicate that
their social and communication deficits remain and they continue to relate in an
awkward way and appear socially uncomfortable.
Treatment.
Treatment of individuals who meet the criteria for the previous
Asperger’s disorder diagnosis aims to promote social communication and peer
relationships. Interventions are initiated with the goal of shaping interactions so that
they better match those of peers. Very often children with Asperger’s disorder are highly
verbal and have excellent academic achievement. The tendency of children and
adolescents with Asperger’s disorder to rely on rigid rules and routines can become a
source of difficulty for them and be an area that requires therapeutic intervention. A
comfort with routines, however, can be utilized to foster positive habits that may
enhance the social life of a child with Asperger’s disorder. Self-sufficiency and problemsolving techniques are often helpful for these individuals in social situations and work
settings. Some of the same techniques used for autistic disorder are likely to benefit
patients with Asperger’s disorder with severe social impairment.
Pervasive Developmental Disorder Not Otherwise Specified
Whereas the DSM-IV-TR defines pervasive disorder not otherwise specified as a
condition with severe, pervasive impairment in communication skills or the presence of
restricted and repetitive activities and associated impairment in social interactions,
DSM-5 conceives of this as encompassed within a diagnosis of autism spectrum disorder.
Anna was the older of two children. She had been a difficult baby who was not easy
to console but her motor and communicative development seemed appropriate. She
was socially related and sometimes enjoyed interaction, but she was easily
overstimulated. She exhibited some hand flapping behavior, especially when she was
excited. Anna’s parents sought evaluation when she was 4 years of age because of
problems with getting along with other children. At evaluation Anna was found to
have language and cognitive function within the normal range. Anna had difficulty
relating to her parents as sources of support and comfort. She displayed behavioral
rigidity and a tendency to impose routines on social skills. Anna was placed in a
special education kindergarten and did well academically, although problems in peer
interactions and unusual affective responses persisted. As an adolescent, Anna
describes herself as a “loner,” who often retreats from others and avoids social
interaction and tends to be comfortable with solitary activities. (Adapted from Fred
Volkmar, M.D.)
Treatment.
The treatment approach is identical to that of other autism spectrum
disorder. Mainstreaming in school may be possible. Compared with previously
diagnosed autistic children, those with the former pervasive developmental disorder not
otherwise specified generally have less impairment in language skills and more selfawareness.
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11 - 31.6 Attention DeficitHyperactivity Disorder
31.6 Attention Deficit/Hyperactivity Disorder
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31.6 Attention Deficit/Hyperactivity Disorder
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
Attention-deficit/hyperactivity disorder (ADHD) is a neuropsychiatric condition
affecting preschoolers, children, adolescents, and adults around the world, characterized
by a pattern of diminished sustained attention, and increased impulsivity or
hyperactivity. Based on family history, genotyping, and neuroimaging studies, there is
clear evidence to support a biological basis for ADHD. Although multiple regions of the
brain and several neurotransmitters have been implicated in the emergence of
symptoms, dopamine continues to be a focus of investigation regarding ADHD
symptoms. The prefrontal cortex of the brain has been implicated because of its high
utilization of dopamine and its reciprocal connections with other brain regions involved
in attention, inhibition, decision-making, response inhibition, working memory, and
vigilance. ADHD affects up to 5 to 8 percent of school-aged children, with 60 to 85
percent of those diagnosed as children continuing to meet criteria for the disorder in
adolescence, and up to 60 percent continuing to be symptomatic into adulthood.
Children, adolescents, and adults with ADHD often have significant impairment in
academic functioning as well as in social and interpersonal situations. ADHD is
frequently associated with comorbid disorders including learning disorders, anxiety
disorders, mood disorders, and disruptive behavior disorders.
The Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM5) has made several changes to the diagnostic criteria of ADHD in youth and in adults. Whereas in the past, ADHD
symptoms had to be present by age 7 years, in DSM-5, “several inattentive or hyperactive-impulsive symptoms” must be
present by age 12 years. Previously, there were two subtypes: Inattentive and Hyperactive/Impulsive type. In DSM-5,
however, subtypes have been replaced by the following three specifiers, which essentially denote the same groups: (1)
combined presentation, (2) predominantly inattentive presentation, and (3) predominantly hyperactive/impulsive
presentation. Additional changes in DSM-5 include permitting a comorbid ADHD and autism spectrum diagnosis to be
made. Finally, in DSM-5, for adolescents 17 years and older and for adults, only five symptoms, rather than six symptoms
of either inattention or hyperactivity and impulsivity are required. In addition, to reflect the developmental differences in
ADHD across the life span, examples of symptoms have been added to the DSM-5 criteria for ADHD. To confirm a
diagnosis of ADHD, impairment from inattention and/or hyperactivity and impulsivity must be present in at least two
settings and interfere with developmentally appropriate social or academic functioning. For current DSM-5 changes see
Table 31.6-1.
Table 31.6-1
DSM-5 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder
ADHD has historically been described in the literature using different terminology. In
the early 1900s, impulsive, disinhibited, and hyperactive children—many of whom also
had neurological damage due to encephalitis—were grouped under the label hyperactive
syndrome. In the 1960s, a heterogeneous group of children with poor coordination,
learning disabilities, and emotional lability, but without specific neurological disorders,
were described as having “minimal brain damage”; however, over time, it became clear
that this was an inappropriate term. Many hypotheses have been suggested to explain
ADHD symptoms including theories of abnormal arousal and poor ability to modulate
emotions. This theory was initially supported by the observation that stimulant
medications increased sustained attention and improved focus. ADHD is one of the most
well-researched childhood psychiatric disorders with strong evidence-based treatments.
Epidemiology
Rates of ADHD have been reported to be 7 to 8 percent in prepubertal elementary
school children. Epidemiologic studies suggest that ADHD occurs in about 5 percent of
youth including children and adolescents, and about 2.5 percent of adults. The rate of
ADHD in parents and siblings of children with ADHD is 2 to 8 times greater than in the
general population. ADHD is more prevalent in boys than in girls, with the ratio
ranging from 2:1 to as high as 9:1. First-degree biological relatives (e.g., siblings of
probands with ADHD) are at high risk for developing ADHD as well as other psychiatric
disorders, including disruptive behavior disorders, anxiety disorders, and depressive
disorders. Siblings of children with ADHD are also at higher risk than the general
population for learning disorders and academic difficulties. The parents of children with
ADHD show an increased incidence of substance use disorders. Symptoms of ADHD are
often present by age 3 years, but unless they are very severe, the diagnosis is frequently
not made until the child is in kindergarten, or elementary school, when teacher
information is available comparing the index child peers of the same age.
Etiology
Data suggest that the etiology of ADHD is largely genetic, with a heritability of
approximately 75 percent. ADHD symptoms are the product of complex interactions of
neuroanatomical and neurochemical systems evidenced by data from twin and adoption
family genetic studies, dopamine transport gene studies, neuroimaging studies, and
neurotransmitter data. Most children with ADHD have no evidence of gross structural
damage in the central nervous system (CNS). In some cases, contributory factors for
ADHD may include prenatal toxic exposures, prematurity, and prenatal mechanical
insult to the fetal nervous system. Food additives, colorings, preservatives, and sugar
have been proposed as possible contributing causes of hyperactive behavior; however,
studies have not confirmed these theories. Neither artificial food coloring nor sugar have
been established as causes of ADHD. There is no clear evidence that omega-3 fatty acids
are beneficial in the treatment of ADHD.
Genetic Factors.
Evidence for a significant genetic contribution to ADHD has
emerged from family studies, which reveal an increased concordance in monozygotic
compared to dizygotic twins, as well as a marked increased risk of 2 to 8 times for
siblings as well as parents of an ADHD child, compared to the general population.
Clinically, one sibling may have predominantly impulsivity/hyperactivity symptoms
and others may have predominantly inattention symptoms. Up to 70 percent of children
with ADHD meet criteria for a comorbid psychiatric disorder, including learning
disorders, anxiety disorders, mood disorder conduct disorders, and substance use
disorders. Several hypotheses of the mode of transmission of ADHD have been proposed,
including a sex-linked hypothesis, which would explain the significantly increased rates
of ADHD in males. Other theories have focused on a model of interaction of multiple
genes that produces the various symptoms of ADHD. Numerous investigations continue
to identify specific genes involved in ADHD. Cook and colleagues have found an
association of the dopamine transporter gene (DAT1) with ADHD, although data from
other research groups have not confirmed that result. Family studies and populationbased studies have found an association between the dopamine 4 receptor seven-repeat
allele gene (DRD4) gene and ADHD. Most molecular research on ADHD has focused on
genes that influence the metabolism or action of dopamine. Continued investigation is
necessary to clarify the complex relationships between multiple interactive genes and
the emergence of ADHD.
Neurochemical Factors.
Many neurotransmitters are postulated to be associated
with ADHD symptoms; however, dopamine is a major focus of clinical investigation, and
the prefrontal cortex has been implicated based on its role in attention and regulation of
impulse control. Animal studies have shown that other brain regions such as locus
ceruleus, which consists predominantly of noradrenergic neurons, also play a major role
in attention. The noradrenergic system includes the central system (originating in the
locus ceruleus) and the peripheral sympathetic system. Dysfunction in peripheral
epinephrine, which causes the hormone to accumulate peripherally, may potentially
feed back to the central system and “reset” the locus ceruleus to a lower level. In part,
hypotheses regarding the neurochemistry of ADHD have arisen from the predictable
effect of medications. Simulants, known to be the most effective medications in the
treatment of ADHD, affect both dopamine and norepinephrine, leading to
neurotransmitter hypotheses that may include dysfunction in both the adrenergic and
dopaminergic systems. Stimulants increase catecholamine concentrations by promoting
their release and blocking their uptake.
Neurophysiological Factors.
EEG studies in ADHD children and adolescents over
the last several decades have found evidence of increased theta activity, especially in
the frontal regions. Further studies of youth with ADHD have provided data showing
elevated beta activity in their electroencephalography (EEG) studies. Clarke and
colleagues, studying EEG findings in children and adolescents over the last two decades
found that those ADHD children with combined type of ADHD were the ones who
showed significantly elevated beta activity on EEG, and further studies indicate that
these youth also tend to show increased mood lability and temper tantrums. Current
investigation of EEG in youth with ADHD have identified behavioral symptom clusters
among children with similar EEG profiles.
Neuroanatomical Aspects.
Researchers have hypothesized networks within the
brain for promoting components of attention including focusing, sustaining attention,
and shifting attention. They describe neuroanatomical correlations for the superior and
temporal cortices with focusing attention; external parietal and corpus striatal regions
with motor executive functions; the hippocampus with encoding of memory traces; and
the prefrontal cortex with shifting from one stimulus to another. Further hypotheses
suggest that the brainstem, which contains the reticular thalamic nuclei function, is
involved in sustained attention. A review of magnetic resonance imaging (MRI),
positron emission tomography (PET), and single photon emission computerized
tomography (SPECT) suggests that populations of children with ADHD show evidence of
both decreased volume and decreased activity in prefrontal regions, anterior cingulated,
globus pallidus, caudate, thalamus, and cerebellum. PET scans have also shown that
female adolescents with ADHD have globally lower glucose metabolism than both
control female and male adolescents without ADHD. One theory postulates that the
frontal lobes in children with ADHD do not adequately inhibit lower brain structures, an
effect leading to disinhibition.
Developmental Factors.
Higher rates of ADHD are present in children who were
born prematurely and whose mothers were observed to have maternal infection during
pregnancy. Perinatal insult to the brain during early infancy caused by infection,
inflammation, and trauma may, in some cases, be contributing factors in the emergence
of ADHD symptoms. Children with ADHD have been observed to exhibit nonfocal (soft)
neurological signs at higher rates than those in the general population. Reports in the
literature indicate that September is a peak month for births of children with ADHD with
and without comorbid learning disorders. The implication is that prenatal exposure to
winter infections during the first trimester may contribute to the emergence of ADHD
symptoms in some susceptible children.
Psychosocial Factors.
Severe chronic abuse, maltreatment, and neglect are
associated with certain behavioral symptoms that overlap with ADHD including poor
attention and poor impulse control. Predisposing factors may include the child’s
temperament and genetic–familial factors.
Diagnosis
The principal signs of inattention, impulsivity, and hyperactivity may be elicited on the
basis of a detailed history of a child’s early developmental patterns along with direct
observation of the child, especially in situations that require sustained attention.
Hyperactivity may be more severe in some situations (e.g., school) and less marked in
others (e.g., one-on-one interviews), and may be less obvious in pleasant structured
activities (sports). The diagnosis of ADHD requires persistent, impairing symptoms of
either hyperactivity/impulsivity or inattention in at least two different settings. For
example, most children with ADHD have symptoms in school and at home. The
diagnostic criteria for ADHD are outlined in Table 31.6-1.
Distinguishing features of ADHD are short attention span and high levels of
distractibility for chronological age and developmental level. In school, children with
ADHD often exhibit difficulties following instructions and require increased
individualized attention from teachers. At home, children with ADHD frequently have
difficulty complying with their parents’ directions and may need to be asked multiple
times to complete relatively simple tasks. Children with ADHD typically act impulsively,
are emotionally labile, explosive, lack focus, and are irritable.
Children for whom hyperactivity is a predominant feature are more likely to be
referred for treatment earlier than are children whose primarily symptoms are attention
deficit. Children with the combined inattentive and hyperactive-impulsive symptoms of
ADHD, or predominantly hyperactive-impulsive symptoms of ADHD, are more apt to
have a stable diagnosis over time and to exhibit comorbid conduct disorder than those
children with inattentive ADHD. Specific learning disorders in the areas of reading,
arithmetic, language, and writing occur frequently in association with ADHD. Global
developmental assessment must be considered to rule out other sources of inattention.
School history and teachers’ reports are critical in evaluating whether a child’s
difficulties in learning and school behavior are caused primarily by inattention or
compromised understanding of the academic material. In addition to intellectual
limitations, poor performance in school may result from maturational problems, social
rejection, mood disorders, anxiety, or poor self-esteem due to learning disorders.
Assessment of social relationships with siblings, peers, and adults, and engagement in
free and structured activities may yield valuable diagnostic clues to the presence of
ADHD.
The mental status examination in a given child with ADHD who is aware of his or her
impairment may reflect a demoralized or depressed mood; however, thought disorder or
impaired reality testing is not expected. A child with ADHD may exhibit distractibility
and perseveration and signs of visual-perceptual, auditory-perceptual, or languagebased learning disorders. A neurological examination may reveal visual, motor,
perceptual, or auditory discriminatory immaturity or impairments without overt signs of
visual or auditory disorders. Children with ADHD often have problems with motor
coordination and difficulty copying age-appropriate figures, rapid alternating
movements, right–left discrimination, ambidexterity, reflex asymmetries, and a variety
of subtle nonfocal neurological signs (soft signs).
If there are indications of possible absence spells, clinicians should obtain a
neurological consultation and an EEG to rule out seizure disorders. A child with an
unrecognized temporal lobe seizure focus may have behavior disturbances, which can
resemble those of ADHD.
Clinical Features
ADHD can have its onset in infancy, although it is rarely recognized until a child is at
least toddler age. More commonly, infants with ADHD are active in the crib, sleep little,
and cry a great deal.
In school, children with ADHD may attack a test rapidly, but may answer only the
first two questions. They may be unable to wait to be called on in school and may
respond before everyone else. At home, they cannot be put off for even a minute.
Impulsiveness and an inability to delay gratification are characteristic. Children with
ADHD are often susceptible to accidents.
The most cited characteristics of children with ADHD, in order of frequency, are
hyperactivity, attention deficit (short attention span, distractibility, perseveration,
failure to finish tasks, inattention, poor concentration), impulsivity (action before
thought, abrupt shifts in activity, lack of organization, jumping up in class), memory
and thinking deficits, specific learning disabilities, and speech and hearing deficits.
Associated features often include perceptual motor impairment, emotional lability, and
developmental coordination disorder. A significant percent of children with ADHD show
behavioral symptoms of aggression and defiance. School difficulties, both learning and
behavioral, commonly exist with ADHD. Comorbid communication disorders or learning
disorders that hamper the acquisition, retention, and display of knowledge complicate
the course of ADHD.
Justin was a 9-year-old African American adopted boy who was referred for an
evaluation by his 4th grade teacher, who informed his adoptive parents that she was
unable to manage Justin’s impulsive and aggressive behaviors in the classroom. Justin
was attending public school and was in a regular classroom with two resource room
periods per day to help him with reading and math. Justin also received speech
therapy once a week. Justin had been referred in the past for psychiatric evaluation,
but his adoptive parents were opposed to medication so they did not follow through.
Justin’s adoptive parents knew very little about his biological family other than that
his biological mother was known to be a polydrug abuser and was currently
incarcerated. Justin was adopted as an infant and his pediatrician had told his
adoptive parents that Justin was entirely healthy at birth. However, ever since
kindergarten, Justin’s teachers had complained that Justin did “not seem to listen,”
had “poor concentration,” and was unable to stay in his seat. Because Justin was an
engaging and cute child, his teachers in kindergarten and first grade made
accommodations for him in their classrooms despite their complaints. When Justin
entered the 2nd grade, however, it became clear that he was struggling with reading
and writing, and an individualized educational program (IEP) evaluation was
initiated. Justin was provided with resource room periods for remediation during the
school day, but Justin continued to have additional problems getting along with his
peers during lunch, and even at recess. Justin was often found arguing or fighting
with other children who said that he did not know the rules of their games. Justin
became angry when he was criticized by his peers and would often push his
classmates. At home, Justin’s adoptive parents were becoming more and more
frustrated with Justin because he seemed to take hours to do a few math problems,
and was unable to write a paragraph without a lot of help. Justin would become
easily annoyed when frustrated with himself and then run around the house in a silly
and disruptive manner. Justin was a good-hearted child who seemed to get along best
with children who were younger than he was. Justin did not seem to make any close
friends among his classmates, and the teachers indicated that Justin’s peers sometimes
avoided him because he was too rough during play and he did not follow the rules of
their games. Justin had a difficult time waiting his turn and he became easily
provoked when he was reprimanded. Consequently, Justin became alienated and
often bullied by his classmates. Justin was aware that he was not able to keep up with
the classwork, and he told his adoptive parents that he was just “stupid.” Although
Justin acted in a rambunctious and impulsive manner, he also appeared sad, and one
day after a fight with several peers, he told his adoptive parents that he was going to
“kill” himself. At this point, Justin’s parents became worried and decided that Justin’s
teacher was right, and they would seek a psychiatric evaluation for Justin. During the
initial evaluation with a child and adolescent psychiatrist, Justin was found to be a
well-developed, cute, and active child, who appeared distracted and fidgety and
somewhat sad. When asked about it, Justin said that he wanted to do “better” in
school but that nobody liked him, he was failing his classes, and that he didn’t like
doing homework. He denied suicidal thoughts and reported that he had only said that
to his parents because he was angry at his peers. Justin admitted that it was very
difficult for him to understand his school work and impossible to complete his
assignments. During the evaluation, several parent and teacher rating scales were
obtained. These included The Child Behavior Checklist, and the SNAP Rating Scale.
Justin’s teacher and parents endorsed similar symptoms including poor organization,
inability to follow directions, being forgetful in daily activities, impulsivity, with
several episodes of running into the street without looking, blurting things out in the
classroom without raising his hand, and recurrent fights with peers. Justin was
observed to look dejected in school when he was excluded from play activities by
peers, and sullen or angry at home when he was asked to read or do homework.
Based on the clinical history, the rating scales and teacher’s report, a diagnosis of
Attention-Deficit/Hyperactivity Disorder, with the DSM-5 specifier of combined
presentation, was made. In addition, Justin was noted to have a mood disorder with
depressed mood, which did not qualify for a major depression. A treatment plan was
suggested including a behavioral plan allowing Justin to receive rewards for effort on
his homework along with a trial of a stimulant medication. After an extensive medical
history was obtained and a recent physical examination by his pediatrician did not
reveal any systemic illnesses, an EEG was decided upon, mainly because it was not
possible to obtain a full medical and cardiac history due to an absence of early
medical records, and his adoptive parents did not have access to his birth and
neonatal medical records. After obtaining a normal EEG, Justin was started on a trial
dose of a short-acting stimulant, methylphenidate (Ritalin) at 10 mg, to determine if
he could tolerate a stimulant without any unexpected sensitivities. Justin had no
adverse effects and was shortly switched to the long-acting stimulant Concerta, 36 mg
which would last between 10 and 12 hours. Justin became more vigilant in class and
seemed to be less restless and more focused, and his teacher reported that he was not
getting out of his seat as often, although he continued to blurt out in class when he
was not called on, and he continued to have difficulty following directions and
forgetting things. Because Justin was not experiencing any adverse effects and was
still displaying some ADHD symptoms, his Concerta was increased to 54 mg per day.
At this dose both his teacher and parents noticed a marked improvement in his ability
to sit and finish his classwork and homework. However, he began to have significant
problems with insomnia, and was becoming fatigued from not being able to fall
asleep until about 2 a.m. on a nightly basis. The child and adolescent psychiatrist and
Justin’s parents discussed two options to address the insomnia. One was to add a dose
of short-acting clonidine in the evenings to cause a calming effect along with some
sedative properties, and the other was to initiate a trial of Daytrana, the
methylphenidate transdermal patch, which could be applied to deliver a similar dose
of methylphenidate throughout the day, and the patch could be removed at
approximately 4 pm or 5 pm to determine which produced the desired effect for the
target symptoms for the most optimal amount of time. Because the Daytrana patch
may deliver medication for an hour or so after its removal, Justin would need to try
several different removal times to find the optimal treatment time. Justin’s family and
his child psychiatrist determined that it would be the best next step for Justin to try
the Daytrana patch rather than add an additional medication to treat his insomnia.
Justin was tried on the Daytrana transdermal 20 mg patch and found that if it was
removed by 5 p.m., he was able to fall asleep within 30 to 45 minutes after getting
into bed. Despite some mild erythema around the site of the patch, Justin experienced
no other side effects and was glad that he did not have to take pills each morning. It
was determined by Justin’s parents, teachers, and child and adolescent psychiatrist
that Justin’s ADHD symptoms were now under much improved control. Justin began
to receive better grades and his self-esteem was noticeably increased. However, Justin
still had difficulties with peers and felt that he wasn’t making as many friends as he
wanted. Justin’s child psychiatrist suggested that Justin be placed in a weekly social
skills group that was led by a psychologist who had experience with group
interventions for children with ADHD. This was arranged, and although Justin, at
first, did not want to attend, after a few sessions, in which Justin was praised for
appropriate interactions with peers within his group, Justin decided that he liked the
group, and over time, even invited a few of his peers from the group to his home to
play. The combination of the medication and the social skills group resulted in a
significant improvement in Justin’s ADHD symptoms as well as in the quality of his
relationships with peers and even his family. (Adapted from Greenhill LL, Hechtman
LI. Attention-Deficit/Hyperactivity Disorder In: Sadock BJ, Sadock VA, Ruiz P, eds.
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 2. Philadelphia:
Lippincott Williams & Wilkins; 2009:3571.)
Pathology and Laboratory Examination
A child being evaluated for ADHD should receive a comprehensive psychiatric and
medical history. Prenatal, perinatal, and toddler information should be included in the
history. Complications of mother’s pregnancy should also be obtained. Medical problems
that may produce symptoms overlapping with ADHD include petit mal epilepsy, hearing
and visual impairments, thyroid abnormalities, and hypoglycemia. A thorough cardiac
history should be taken, including an investigation of the lifetime history of syncope,
family history of sudden death, and a cardiac examination of the child. Although it is
reasonable to obtain an electrocardiography (ECG) study prior to treatment, if any
cardiac risk factors are present, a cardiology consultation and examination are
warranted. No specific laboratory measures are pathognomonic of ADHD.
A continuous performance task, a computerized task in which a child is asked to press a button each time a particular
sequence of letters or numbers is flashed on a screen, is not specifically a useful diagnostic tool for ADHD; however, it may
be useful in comparing a child’s performance before and after medication treatment, particularly at different doses.
Children with poor attention tend to make errors of omission—that is, they fail to press the button when the sequence has
flashed. Impulsivity is often manifested by errors of commission, in which an impulsive child cannot resist pushing the
button, even when the desired sequence has not yet appeared on the screen.
Differential Diagnosis
A temperamental constellation of high activity level and short attention span, in the
normal range for the child’s age, and without impairment, should be ruled out.
Differentiating these temperamental characteristics from the cardinal symptoms of
ADHD before the age of 3 years is difficult, mainly because of the overlapping features
of a normally immature nervous system and the emerging signs of visual-motorperceptual impairments frequently seen in ADHD. Anxiety in a child needs to be
evaluated. Anxiety can accompany ADHD as a symptom or comorbid disorder, and
anxiety can manifest with overactivity and easy distractibility.
It is not uncommon for a child with ADHD to become demoralized or, in some cases,
to develop depressive symptoms in reaction to persistent frustration with academic
difficulties and resulting low self-esteem. Mania and ADHD share many core features,
such as excessive verbalization, motoric hyperactivity, and high levels of distractibility.
In addition, in children with mania, irritability seems to be more common than
euphoria. Although mania and ADHD can coexist, children with bipolar I disorder
exhibit more waxing and waning of symptoms than those with ADHD. Recent follow-up
data for children who met the criteria for ADHD and subsequently developed bipolar
disorder suggest that certain clinical features occurring during the course of ADHD
predict future mania. Children with ADHD who had developed bipolar I disorder at 4year follow-up had a greater co-occurrence of additional disorders and a greater family
history of bipolar disorders and other mood disorders than children without bipolar
disorder.
Frequently, oppositional defiant disorder, or conduct disorder and ADHD may coexist,
and when that occurs, both disorders are diagnosed. Specific learning disorders of
various kinds must also be distinguished from ADHD; a child may be unable to read or
do mathematics because of a learning disorder, rather than because of inattention.
ADHD often coexists with one or more learning problems, including deficits in reading,
mathematics or written expression.
Course and Prognosis
The course of ADHD is variable. Symptoms have been shown to persist into adolescence
in 60 to 85 percent of cases, and into adult life in approximately 60 percent of cases.
The remaining 40 percent of cases may remit at puberty, or in early adulthood. In some
cases, the hyperactivity may disappear, but the decreased attention span and impulsecontrol problems persist. Overactivity is usually the first symptom to remit, and
distractibility is the last. ADHD does not usually remit during middle childhood.
Persistence is predicted by a family history of the disorder, negative life events, and
comorbidity with conduct symptoms, depression, and anxiety disorders. When remission
occurs, it is usually between the ages of 12 and 20. Remission can be accompanied by a
productive adolescence and adult life, satisfying interpersonal relationships, and few
significant sequelae. Most patients with the disorder, however, undergo partial
remission and are vulnerable to antisocial behavior, substance use disorders, and mood
disorders. Learning problems often continue throughout life.
In about 60 percent of cases, some symptoms persist into adulthood. Those who
persist with the disorder may show diminished hyperactivity but remain impulsive and
accident-prone. Although the educational attainments of people with ADHD as a group
are lower than those of people without ADHD, early employment histories do not differ
from those of people with similar educations.
Children with ADHD whose symptoms persist into adolescence are at higher risk for
developing conduct disorder. Children with both ADHD and conduct disorder are also at
risk for developing substance use disorders. The development of substance abuse
disorders among ADHD youth in adolescence appears to be more related to the presence
of conduct disorder rather than to ADHD.
Most children with ADHD have some social difficulties. Socially dysfunctional children
with ADHD have significantly higher rates of comorbid psychiatric disorders, and
experience more problems with behavior in school as well as with peers and family
members. Overall, the outcome of ADHD in childhood seems to be related to the degree
of persistent comorbid psychopathology, especially conduct disorder, social disability,
and chaotic family factors. Optimal outcomes may be promoted by ameliorating
children’s social functioning, diminishing aggression, and improving family situations as
early as possible.
Treatment
Pharmacotherapy.
Pharmacologic treatment is considered the first line of
treatment for ADHD. Central nervous system stimulants are the first choice of agents in
that they have been shown to have the greatest efficacy with generally mild tolerable
side effects. Stimulants are contraindicated in children, adolescents, and adults with
known cardiac risks and abnormalities. In medically healthy youth, however, excellent
safety records are documented for short- and sustained-release preparations of
methylphenidate (Ritalin, Ritalin-SR, Concerta, Metadate CD, Metadate ER),
dextroamphetamine (Dexedrine, Dexedrine spansules, Vyvanse), and
dextroamphetamine and amphetamine salt combinations (Adderall, Adderall XR).
Newer preparations of methylphenidate, include Methylin, a chewable form of
methylphenidate; Daytrana, a methylphenidate patch; and dexmethylphenidate, the denantiomer (Focalin), and its longer acting form Focalin XR. These newer preparations
aim to maximize the target effects and minimize the adverse effects in individuals with
ADHD who obtain partial response from methylphenidate or whose dose was limited by
side effects. Vyvanse (lisdexamfetamine dimesylate) is a pro-drug of
dextroamphetamine, which requires intestinal metabolism in order to reach its active
form. Vyvanse is approved by the U.S. Food and Drug Administration (FDA) for children
6 years and older. Vyvanse, inactive until it is metabolized, is a less likely agent to have
risks of abuse or overdose. It has side effects and efficacy similar to the other forms of
amphetamines used in the treatment of ADHD.
Current strategies favor once a day sustained-release stimulant preparations for their
convenience and diminished rebound side effects. Advantages of the sustained-release
preparations for children are that one dose in the morning will sustain the effects all
day, and the child is no longer required to interrupt his or her school day, as well as the
physiologic advantage that the medication is sustained at an approximately even level
in the body throughout the day so that periods of rebound and irritability are avoided.
Table 31.6-2 contains comparative information on the above medications.
Table 31.6-2
Stimulant Medications in the Treatment of Attention-Deficit/Hyperactivity
Disorder (ADHD)
Nonstimulant medications approved by the FDA in the treatment of ADHD include
atomoxetine (Strattera), a norepinephrine uptake inhibitor. Unlike the stimulants,
Strattera carries with it a black box warning for potential increases in suicidal thoughts
or behaviors and requires children with ADHD to be monitored for these symptoms,
similarly to children who are administered antidepressants. A-agonists including
clonidine (Catapres) and guanfacine (Tenex) have also been found to be effective in
treating ADHD. The FDA has recently approved the extended-release forms of clonidine
(Kapvay) and the extended release form of guanfacine (Intuniv) for the treatment of
ADHD in children 6 years and older. Antidepressants, such as bupropion (Wellbutrin,
Wellbutrin SR), have been used with variable success in the treatment of ADHD. (Table
31.6-3 contains comparative information on the nonstimulant medications and Table
31.6-4 indicates FDA-approved ages for ADHD medications.)
Table 31.6-3
Nonstimulant
Medications
for
Attention-Deficit/Hyperactivity
Disorder
(ADHD)
Table 31.6-4
FDA Approval for ADHD Medications
STIMULANT MEDICATIONS. Methylphenidate and amphetamine preparations are dopamine
agonists; however, the precise mechanism of the stimulant’s central action remains
unknown. Methylphenidate preparations have been shown to be highly effective in up
to three fourths of children with ADHD, with relatively few adverse effects. Concerta,
the 10- to 12-hour extended-release OROS (osmotic controlled-release extended delivery
system) form of methylphenidate, is administered once daily in the morning and is
effective during school hours as well as after school during the afternoon and early
evening. Both shorter forms of methylphenidate and Concerta have similar common
adverse effects including headaches, stomachaches, nausea, and insomnia. Some
children experience a rebound effect, in which they become mildly irritable and appear
to be slightly hyperactive for a brief period when the medication wears off. In children
with a history of motor tics, some observations must be made as, in some cases,
methylphenidate can exacerbate the tics, whereas in other children the tics are
unaffected or even improved. Because tics wax and wane, it is important to observe
their patterns over some time. Another common concern about use of methylphenidate
preparations over long periods is potential growth suppression. During periods of use,
methylphenidate is associated with slightly decreased rates of growth, and if used over
many years continuously without any drug holidays growth suppression of about several
centimeters has been noted. When given “drug holidays” on weekends or summers,
children tend to eat more and also make up the growth. The methylphenidate products
have been shown to improve ADHD children’s scores on tasks of vigilance, such as on
math calculation tests, the continuous performance task, and paired associations.
Daytrana, a transdermal delivery system designed to release methylphenidate
continuously on application of the patch to the skin, has been developed and approved
for use in children and adolescents. Advantages of Daytrana include an alternative for
children who have difficulties swallowing pills, and that the patch can individualize how
many hours per day a given child with ADHD is receiving medication. This is important
because a child with ADHD who needs the medication in the late afternoons to do
homework but develops insomnia if the medication is still present after dinner, is able to
remove the patch at the desired time. Thus, an individualized delivery time may be
provided for each child by virtue of how many hours the patch is left on the skin. This is
in contrast to oral sustained-release forms of methylphenidate, such as Concerta, in
which the release time continues for 12 hours after the pill is swallowed. A double-blind
randomized study in children with ADHD who wore the methylphenidate patch for 12
hours at a time, showed efficacy of the patch preparation doses ranging from patches
delivering 0.45 mg per hour to 1.8 mg per hour of methylphenidate. The effectiveness of
the patch reached a plateau without much further improvement as dose was increased,
but intensive behavioral interventions were also being administered. A delay in the
onset of the transdermal medication effect was approximately an hour. Side effects were
similar to oral preparations of methylphenidate. Approximately half of the children
exhibited at least minor erythematous reactions to the patch; however, these side effects
are usually well tolerated by children on the patch. Dextroamphetamine and
dextroamphetamine/amphetamine salt combinations are usually the second drugs of
choice when methylphenidate is not effective. Vyvanse is advantageous because it is
inactive until it is metabolized.
NONSTIMULANT MEDICATIONS. Atomoxetine HCl (Strattera) is a norepinephrine uptake
inhibitor approved by the FDA for the treatment of ADHD in children age 6 years and
older. The mechanism of action is not well understood, but it is believed to involve
selective inhibition of presynaptic norepinephrine transporter. Atomoxetine is well
absorbed by the gastrointestinal tract, and maximal plasma levels are reached in 1 to 2
hours after ingestion. It has been shown to be effective for inattention as well as
impulsivity in children and in adults with ADHD. Its half-life is approximately 5 hours
and it is usually administered twice daily. Most common side effects include diminished
appetite, abdominal discomfort, dizziness, and irritability. In some cases, increases in
blood pressure and heart rate have been reported. Atomoxetine is metabolized by the
cytochrome P450 (CYP) 2D6 hepatic enzyme system. A small fraction of the population
are poor metabolizers of CYP 2D6–metabolized drugs and, for those individuals, plasma
concentrations of the drug may rise as much as fivefold for a given dose of medication.
Drugs that inhibit CYP 2D6, including fluoxetine, paroxetine, and quinidine, may lead to
increased plasma levels of this medication. Despite its short half-life, atomoxetine has
been shown in a recent study to be effective in reducing symptoms of ADHD in children
during the school day when administered once daily. Another recent study of a
combination of atomoxetine alone and combined with fluoxetine in the treatment of 127
children with ADHD and symptoms of anxiety or depression suggested that atomoxetine
alone can lead to improvements in mood and anxiety. Children who received combined
atomoxetine and fluoxetine experienced greater increases in blood pressure and pulse
than those who were treated with atomoxetine only.
α-Agonists, short-acting, and the extended-release forms of clonidine hydrochloride
(Kapvay) and Guanfacine (Intuniv) are FDA approved for the treatment of ADHD in
children and adolescents from 6 to 7 years of age. Kapvay, a centrally acting α-2adrenergic receptor agonist is believed to exert its effect on the prefrontal cortex,
although the mechanism of action is unknown. Kapvay is available in 0.1 mg and 0.2
mg tablets, and is generally used twice daily, once in the morning and once at night, to
provide a round-the-clock effect. Kapvay is initiated at 0.1 mg at bedtime and can be
increased in increments of 0.1 mg at weekly intervals. The maximal dose recommended
is 0.2 mg twice daily. Kapvay is not used interchangeably with the short-acting
clonidine. Because Kapvay is an antihypertensive agent, it causes a decrease in blood
pressure and heart rate. These vital signs must be monitored in patients, especially
during initiation and titration of the dose. Common side effects include somnolence,
headache, upper abdominal pain, and fatigue. When Kapvay is tapered, it is
recommended to taper no more than 0.1 mg every 3 to 7 days. Intuniv, the extended
release preparation of guanfacine, is a once-a-day medication for children between 6
and 17 years of age, available in 1 mg, 2 mg, 3 mg, and 4 mg tabs. Intuniv is a tablet
that is swallowed whole, and should be taken with water, milk or other liquids; it is not
recommended to take Intuniv with a high-fat meal. Intuniv is typically initiated as a 1
mg tab daily and titrated by 1 mg per day at 1-week intervals. The maximum dose
approved is 4 mg per day. As a monotherapy, improvement in ADHD symptoms have
been found to occur at 0.05 to 0.08 mg/kg once daily. As an adjunctive treatment,
optimal doses are reported to range from 0.05 to 0.12 mg/kg/day. Common side effects
for Intuniv include somnolence, sedation, fatigue, nausea, hypotension, insomnia, and
dizziness. Heart rate and blood pressure must be monitored as in Kapvay. When
discontinuing Intuniv, a gradual taper decreasing by 1 mg every 3 to 7 days is
recommended. α-Adrenergic agents including the short- and extended-release
preparations of guanfacine and clonidine are sometimes preferred treatments in
children with ADHD and comorbid tic disorders that have been exacerbated while the
patient was taking stimulants. Bupropion has been shown to be somewhat effective for
some children and adolescents in the treatment of ADHD. One multisite, double-blind,
placebo-controlled study found a positive result regarding the efficacy of bupropion. No
further studies have compared bupropion with other stimulants. The risk of seizure
development while on this drug is increased when using doses of greater than 400 mg
per day.
Few data confirm the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the
treatment of ADHD, but due to the frequency of comorbid depression and anxiety with
ADHD, in cases of comorbidity, the SSRIs are likely to be considered at least in
conjunction with a stimulant.
Tricyclic drugs are not recommended in the treatment of ADHD due to potential
cardiac arrhythmia effects. The reports of sudden death in at least four children with
ADHD who were being treated with desipramine (Norpramin, Pertofrane) have made
the tricyclic antidepressants an unlikely choice. Antipsychotics are occasionally
introduced to treat refractory severely hyperactive children and adolescents who are
significantly dysfunctional. Antipsychotics are generally not chosen in the treatment of
ADHD due to the risks of tardive dyskinesia, withdrawal dyskinesia, neuroleptic
malignant syndrome, and weight gain.
Modafinil (Provigil), another type of CNS stimulant, originally developed to reduce
daytime sleepiness in patients with narcolepsy, has been tried clinically in the treatment
of adults with ADHD. Only one randomized, double-blind, placebo-controlled study of
the efficacy and safety of modafinil film-coated tablets in approximately 250
adolescents with ADHD showed that 48 percent of those on active treatment were rated
as “much” or “very much” improved compared with 17 percent of patients receiving
placebo. The dosage range was from 170 to 425 mg administered once daily, titrated to
optimal doses based on efficacy and tolerability. Modafinil failed to receive FDA
approval based on a Stevens-Johnson skin rash that occurred in a patient during the
trial. The most common side effects included insomnia, headache, and decreased
appetite.
Venlafaxine has been tried in clinical practice, especially for children and adolescents
with combinations of ADHD and depression or anxiety features. No clear empirical
evidence supports the use of venlafaxine in the treatment of ADHD.
One open-label report of reboxetine, a selective norepinephrine reuptake inhibitor in
31 children and adolescents with ADHD who were resistant to methylphenidate
treatment suggested that this agent may have efficacy. In this open trial, reboxetine was
initiated and maintained at 4 mg per day. Most common side effects included
drowsiness, sedation, and gastrointestinal symptoms. Reboxetine and other new agents
in this class await controlled studies to further evaluate their potential efficacy.
TREATMENT OF CNS STIMULANT SIDE EFFECTS. CNS stimulants are generally well tolerated,
and current consensus is that once a day dosing is preferable for convenience and to
minimize rebound side effects. Long-term tolerability of once-daily mixed amphetamine
salts has shown mild side effects, most commonly decreased appetite, insomnia, and
headache. A variety of strategies have been suggested for children and/or adolescents
with ADHD who respond favorably to methylphenidate, but for whom insomnia has
become a significant problem. Clinical strategies to manage insomnia include use of
diphenhydramine (25 to 75 mg), low dose of trazodone (25 to 50 mg), or the addition of
an α-adrenergic agent, such as guanfacine. In some cases, insomnia may attenuate on
its own after several months of treatment.
Monitoring Pharmacological Treatment
STIMULANTS. Stimulant medications have adrenergic effects and cause moderate
increases in blood pressure and pulse rate. At baseline, the most recent American
Academy of Child and Adolescent Psychiatry (AACAP) practice parameters recommend
the following workup before starting use of stimulant medications: physical
examination, blood pressure, pulse, weight, and height.
It is recommended that children and adolescents being treated with stimulants have
their height, weight, blood pressure, and pulse checked on a quarterly basis and have a
physical examination annually. Monitoring starts with the initiation of medication.
Because school performance is most markedly affected, special attention and effort
should be given to establishing and maintaining a close collaborative working
relationship with a child’s school personnel. In most patients, stimulants reduce
overactivity, distractibility, impulsiveness, explosiveness, and irritability. No evidence
indicates that medications directly improve any existing impairments in learning,
although, when the attention deficits diminish, children can learn more effectively. In
addition, medication can improve self-esteem when children are no longer constantly
reprimanded for their behavior. Children treated with medications should be taught the
purpose of the medication and given the opportunity to describe any side effects that
they may be experiencing.
Psychosocial Interventions.
Psychosocial interventions for children with ADHD
include psychoeducation, academic organization skills remediation, parent training,
behavior modification in the classroom and at home, cognitive behavioral therapy
(CBT), and social skills training. Social skills groups, behavioral training for parents of
children with ADHD, and behavioral interventions at school and at home have been
studied alone and in combination with medication management for ADHD. Evaluation
and treatment of coexisting learning disorders or additional psychiatric disorders is
important.
When children are helped to structure their environment, their anxiety diminishes. It
is beneficial for parents and teachers to work together to develop a concrete set of
expectations for the child and a system of rewards for the child when the expectations
are met.
A common goal of therapy is to help parents of children with ADHD recognize and
promote the notion that, although the child may not “voluntarily” exhibit symptoms of
ADHD, he or she is still capable of being responsible for meeting reasonable
expectations. Parents should also be helped to recognize that, despite their child’s
difficulties, every child faces the normal tasks of maturation, including significant
building of self-esteem when he or she develops a sense of mastery. Therefore, children
with ADHD do not benefit from being exempted from the requirements, expectations,
and planning applicable to other children. Parental training is an integral part of the
psychotherapeutic interventions for ADHD. Most parental training is based on helping
parents develop usable behavioral interventions with positive reinforcement that target
both social and academic behaviors.
Group therapy aimed at both refining social skills and increasing self-esteem and a
sense of success may be very useful for children with ADHD who have great difficulty
functioning in group settings, especially in school. A recent year-long group therapy
intervention in a clinical setting for boys with the disorder described the goals as
helping the boys improve skills in game playing and feeling a sense of mastery with
peers. The boys were first asked to do a task that was fun, in pairs, and then were
gradually asked to do projects in a group. They were directed in following instructions,
waiting, and paying attention, and were praised for successful cooperation.
MULTIMODAL TREATMENT STUDY OF CHILDREN WITH ADHD (MTA
STUDY)
The National Institute of Mental Health (NIMH)–supported Multimodal Treatment Study
of Children with ADHD (The MTA Cooperative Group, 1999) was a 14-month–long
randomized clinical trial involving six clinical sites comparing four treatment strategies.
More than 500 children diagnosed with DSM-IV ADHD, combined type, were randomly
assigned to (1) systematic medication management utilizing an initial placebocontrolled titration and t.i.d. dosing 7 days per week and monthly 30-minute clinic
visits, (2) behavior therapy consisting of 27 sessions of group parent training, eight
individual parent sessions, an 8-week summer treatment program, 12 weeks of
classroom administered behavior therapy with a half-time aide, and 10 teacher
consultation sessions, (3) a combination of medication and behavior therapy, or (4)
usual community care. All groups showed improvement over baseline; however, a
combination of medication management and behavior therapy led to greater reduction
in symptoms in children with ADHD alone or ADHD and Oppositional Defiant Disorder
than behavior therapy alone or community care. The combination treatment had
significantly better outcomes for those children with ADHD and anxiety and/or mood
disorders compared to behavioral treatment and community care. Combined treatment
but not medication management was superior for improvement in oppositional and
aggressive symptoms, anxiety and mood symptoms, teacher rated social skills, parent–
child relationships, and reading achievement. Furthermore, mean dose of medication
per day was less in the combination group than in the medication-only management
group.
Results
A follow-up of the MTA sample at 6 and 8 years revealed that the clinical presentation
of the disorder, including severity of ADHD, comorbid conduct disturbance, and intellect
were stronger predictors of later functioning than the type of treatment received in
childhood during the 14-month study period. Although treatment-related improvements
for the children who participated in the MTA study are maintained as long as treatment
continues, the differential treatment efficacy appeared to be lost at approximately the 3-
year mark.
Overall, the evidence suggests that medication and psychosocial interventions for the
combined type of ADHD in childhood provides the broadest benefit in functioning for
this population. This is especially pertinent in view of the comorbidity of learning
disorders, anxiety, mood disorders, and other disruptive behavior disorders that occur in
children with ADHD.
UNSPECIFIED ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
The DSM-5 includes Unspecified ADHD as a category for disturbances of inattention or
hyperactivity that cause impairment, but do not meet the full criteria for ADHD.
ADULT MANIFESTATIONS OF ADHD
ADHD was historically believed to be a childhood condition resulting in delayed
development of impulse control that would be generally outgrown by adolescence. In
the last few decades many more adults with ADHD have been identified, diagnosed, and
successfully treated. Longitudinal follow-up has shown that up to 60 percent of children
with ADHD have persistent impairment from symptoms into adulthood. Genetic studies,
brain imaging, and neurocognitive and pharmacological studies in adults with ADHD
have replicated findings demonstrated in children with ADHD. Increased public
awareness and treatment studies within the last decade have led to widespread
acceptance of the need for diagnosis and treatment of adults with ADHD.
Epidemiology
Among adults, evidence suggests an approximate 4 percent prevalence of ADHD in the
population. ADHD in adulthood is generally diagnosed by self-report, given the lack of
school information and observer information available; therefore, it is more difficult to
make an accurate diagnosis.
Etiology
Currently, ADHD is believed to be largely transmitted genetically, and increasing
evidence supports this hypothesis, including the genetic studies, twin studies, and family
studies outlined in the child and adolescent ADHD section. Brain imaging studies have
obtained data suggesting that adults with ADHD exhibit decreased prefrontal glucose
metabolism on PET compared with adults without ADHD. It is unclear whether these
data reflect the presence of the disorder or a secondary effect of having ADHD over a
period of time. Further studies using SPECT have revealed increased dopamine
transporter (DAT) binding densities in the striatum of the brain in samples of adults
with ADHD. This finding may be understood within the context of treatment for ADHD,
in that standard stimulant treatment for ADHD, such as methylphenidate, acts to block
DAT activity, possibly leading to a normalization of the striatal brain region in
individuals with ADHD.
Diagnosis and Clinical Features
The clinical phenomenology of ADHD features inattention and manifestations of
impulsivity prevailing as the core of this disorder. A leading figure in the development
of criteria for adult manifestations of ADHD is Paul Wender, from the University of
Utah, who began his work on adult ADHD in the 1970s. Wender developed criteria that
could be applied to adults (Table 31.6-5). They included a retrospective diagnosis of
ADHD in childhood, and evidence of current impairment from ADHD symptoms in
adulthood. Furthermore, evidence exists of several additional symptoms that are typical
of adult behavior as opposed to childhood behaviors.
Table 31.6-5
Utah Criteria for Adult Attention-Deficit/Hyperactivity Disorder (ADHD)
In adults, residual signs of the disorder include impulsivity and attention deficit (e.g.,
difficulty in organizing and completing work, inability to concentrate, increased
distractibility, and sudden decision-making without thought of the consequences). Many
people with the disorder have a secondary depressive disorder associated with low selfesteem related to their impaired performance and which affects both occupational and
social functioning.
Brett was a 26-year-old man convinced by his new wife to seek an evaluation for
his distractibility, forgetfulness, and “not listening” after a minor traffic accident.
After consulting his mother, Brett reported that in grade school, he was often “in
trouble” for talking out of turn, and his mother recalled teachers’ reports that Brett
often made careless mistakes on tests, forgot his assignments, and had great difficulty
sitting still. Although as a young child he was considered gifted intellectually, when he
got to the third grade his grades were only average, and he seemed more interested in
getting his work done quickly than correctly. Brett was talkative and loud and
enjoyed sports, although he was not particularly talented at them. Nevertheless, Brett
had acquaintances and superficial friends because he was likeable, funny, and even
entertaining. Brett had no idea what he wanted to do when he grew up, and during
his senior year in high school, he neglected to finish any of his college applications on
time, and ended up attending a community college part-time. During the two years
after high school, Brett held down a series of jobs only briefly, including a
construction job, a waiter position in a restaurant, and a Fed-Ex driver, and then
decided that he wanted to become an actor. Brett went on a series of auditions, but
found that he would become distracted and did poorly remembering his lines and even
spaced out during readings. Despite that, he was chosen for one commercial. Brett
reported that he had never had problems with abuse of drugs or alcohol, and he
occasionally drank beer socially. During his evaluation with a child and adolescent
psychiatrist, Brett disclosed that his greatest difficulties were with tasks that seemed
boring to him. He had difficulty maintaining his attention, was easily distracted, felt
restless most of the time, and became frustrated when he was expected to sit still for
long periods of time. Brett endorsed 6 inattentive and 5 hyperactive/impulsive
symptoms on a DSM ADHD Checklist of current symptoms. Brett met the diagnostic
criteria for Adult ADHD, combined type, with a probable onset in childhood. Brett’s
medical history was negative for all major illnesses, and neither he nor his parents
had a history of cardiac abnormalities. He took no prescribed medications. After
discussing the situation with his psychiatrist and his wife, Brett decided that he would
like to try a stimulant medication. A trial of a once-a-day extended-release
formulation of a stimulant medication was selected: Adderall XR 10 mg. At his first
follow-up visit, a week later, Brett reported that he felt a slight effect from this
medication but it was not enough to improve his functioning, so Brett and his
psychiatrist agreed that he would increase his dose to 20 mg per day. At his next
follow-up appointment, Brett reported that he had noticed significant improvement in
his ability to focus, concentrate, and remember his lines in auditions. In fact, he had
just received a small part in an upcoming movie. Brett and his wife were both thrilled
with the results, and Brett continued to return monthly for follow up visits. (Adapted
from McGough J. Adult manifestations of attention-deficit/hyperactivity disorder. In:
Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of
Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:3577.)
Differential Diagnosis
A diagnosis of ADHD is likely when symptoms of inattention and impulsivity are
described by adults as a life-long problem, not as episodic events. The overlap of ADHD
and hypomania, bipolar II disorder, and cyclothymia is controversial and difficult to sort
out retrospectively. Clear-cut histories of discrete episodes of hypomania and mania,
with or without periods of depression, are suggestive of a mood disorder rather than a
clinical picture of ADHD; however, ADHD may have predated the emergence of a mood
disorder in some individuals. In such a case, ADHD and bipolar disorder may be
diagnosed comorbidly. Adults with an early history of chronic school difficulties related
to paying attention, activity level, and impulsive behavior are generally diagnosed with
ADHD, even when a mood disorder occurs later in life. Anxiety disorders can coexist
with ADHD, and are less difficult than hypomania to distinguish from it.
Course and Prognosis
The prevalence of ADHD diminishes over time, although at least half of children and
adolescents may have the disorder into adulthood. Many children initially diagnosed
with ADHD, combined type, exhibit fewer impulsive-hyperactive symptoms as they get
older and, by the time they are adults, will meet criteria for ADHD, inattentive type. As
with children, adults with ADHD demonstrate higher rates of learning disorders, anxiety
disorders, mood disorders, and substance use disorder compared with the general
population.
Treatment
Treatment of ADHD in adults targets pharmacotherapy, mainly long-acting stimulants,
similar to that used with children and adolescents with ADHD. In adults, only the longacting stimulants are FDA approved in the treatment of ADHD. Signs of a positive
response are an increased attention span, decreased impulsiveness, and improved mood.
Psychopharmacological therapy may be needed indefinitely. Clinicians should use
standard ways to monitor drug response and patient compliance.
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31.7 Specific Learning Disorder
Specific learning disorder in youth is a neurodevelopmental disorder produced by the
interactions of heritable and environmental factors that influence the brain’s ability to
efficiently perceive or process verbal and nonverbal information. It is characterized by
persistent difficulty learning academic skills in reading, written expression, or
mathematics, beginning in early childhood, that is inconsistent with the overall
intellectual ability of a child. Children with specific learning disorder often find it
difficult to keep up with their peers in certain academic subjects, whereas they may
excel in others. Academic skills that may be compromised in specific learning disorder
include reading single words and sentences fluently, written expression and spelling,
and calculation and solving mathematical problems. Specific learning disorder results in
underachievement that is unexpected based on the child’s potential as well as the
opportunity to have learned more. Specific learning disorder in reading, spelling, and
mathematics appears to aggregate in families. There is an increased risk of four to eight
times in first-degree relatives for reading deficits, and about five to ten times for
mathematics deficits, compared to the general population. Specific learning disorder
occurs two to three times more often in males than in females. Learning problems in a
child or adolescent identified in this manner can establish eligibility for academic
services through the public school system.
The American Psychiatric Association’s Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5), combines the DSM-IV diagnoses of reading disorder, mathematics disorder, and disorder of written expression and
learning disorder not otherwise specified into a single diagnosis: Specific learning disorder. Learning deficits in reading,
written expression, and mathematics in the DSM-5 are designated using specifiers. DSM-5 notes that the term dyslexia is an
equivalent term describing a pattern of learning difficulties, including deficits in accurate or fluent word recognition, poor
decoding, and poor spelling skills. Dyscalculia is noted to be an alternative term referring to a pattern of deficits related to
learning arithmetic facts, processing numerical information, and performing accurate calculations.
Specific learning disorder of all types affects approximately 10 percent of youth. This
represents approximately half of all public school children who receive special education
services in the United States. In 1975, Public Law 94–142 (the Education for All
Handicapped Children Act now known as the Individual with Disabilities Education Act
[IDEA]) mandated all states to provide free and appropriate educational services to all
children. Since that time, the number of children identified with learning disorders has
increased, and a variety of definitions of learning disabilities have arisen. To meet the
criteria for specific learning disorder, a child’s achievement must be significantly lower
than expected in one or more of the following: reading skills, comprehension, spelling,
written expression, calculation, mathematical reasoning, and/or the learning problems
interfere with academic achievement or activities of daily living. It is common for
specific learning disorder to include more than one area of skills deficits.
Children with specific learning disorder in the area of reading can be identified by
poor word recognition, slow reading rate, and impaired comprehension compared with
most children of the same age. Current data suggest that most children with reading
difficulties have deficits in speech sound processing skills, regardless of their intelligence
quotient (IQ), and in DSM-5, there is no longer a diagnostic criterion for specific
learning disorder comparing the specific deficit to overall IQ. Current consensus is that
children with reading impairment have trouble with word recognition and “sounding
out” words because they cannot efficiently process and use phonemes (the smaller bits
of words that are associated with particular sounds). A recent epidemiologic study found
four profiles including (1) weak reading, (2) weak language, (3) weak math, or (4)
combined weak math and reading, accounting for 70 percent of children with specific
learning impairments. Low scores in short-term memory for speech sounds characterized
the profile with weak language, whereas, low speech sound awareness was associated
with the weak reading group, but not the weak language group. Finally, in another
recent study it was found that the weak math group did not show speech sound deficits,
Severe specific learning disorder may make it agonizing for a child to succeed in
school, often leading to demoralization, low self-esteem, chronic frustration, and
compromised peer relationships. Specific learning disorder is associated with an
increased risk of comorbid disorders, including attention-deficit/hyperactivity disorder
(ADHD), communication disorders, conduct disorders, and depressive disorders.
Adolescents with specific learning disorder are at least 1.5 times more likely to drop out
of school, approximating rates of 40 percent. Adults with specific learning disorder are
at increased risk for difficulties in employment and social adjustment. Specific learning
disorder often extends to skills deficits in multiple areas such as reading, writing, and
mathematics.
Moderate to high heritability is believed to contribute to specific learning disorder,
and furthermore, it appears that many cognitive traits are polygenic. In addition, there
is pleiotropy, that is, the same genes may affect skills necessary for diverse learning
tasks. Factors such as perinatal injury and specific neurological conditions may
contribute to the development of specific learning disorder. Conditions such as lead
poisoning, fetal alcohol syndrome, and in utero drug exposure are also associated with
increased rates of specific learning disorder.
SPECIFIC LEARNING DISORDER WITH IMPAIRMENT IN READING
Reading impairment is present in up to 75 percent of children and adolescents with
specific learning disorder. Students who have learning problems in other academic areas
most commonly experience difficulties with reading as well.
Reading impairment is characterized by difficulty in recognizing words, slow and
inaccurate reading, poor comprehension, and difficulties with spelling. Reading
impairment is often comorbid with other disorders in children, particularly, ADHD. The
term developmental alexia was historically used to define a developmental deficit in the
recognition of printed symbols. This was simplified by adopting the term dyslexia in the
1960s. Dyslexia was used extensively for many years to describe a reading disability
syndrome that often included speech and language deficits and right–left confusion.
Reading impairment is frequently accompanied by disabilities in other academic skills,
and the term dyslexia remains as an alternate term for a pattern of reading and spelling
difficulties.
Epidemiology
An estimated 4 to 8 percent of youth in the United States have been identified with
dyslexia, encompassing a variety of reading, spelling, and comprehension deficits. Three
to four times as many boys as girls are reported to have reading impairments in
clinically referred samples. In epidemiological samples, however, rates of reading
impairments are much closer among boys and girls. Boys with reading impairment are
referred for psychiatric evaluation more often than girls due to comorbid ADHD and
disruptive behavior problems. No clear gender differential is seen among adults who
report reading difficulties.
Comorbidity
Children with reading difficulties are at high risk for additional learning deficits
including mathematics and written expression. The DSM-5 Language disorder, also
known as specific language impairment, has traditionally been viewed as distinct from
dyslexia and dyscalculia. Children with language disorder have poor word knowledge,
limited abilities to form accurate sentence structure, and impairments in the ability to
put words together to produce clear explanations. Children with language disorder may
have delayed development of language acquisition, and difficulties with grammar and
syntactical knowledge. Specific learning disorder in the areas of reading and
mathematics frequently occur comorbidly with language disorder. In one study, it was
found that among dyslexic samples, 19 percent to 63 percent also have language
impairment. Conversely, reading impairment has been found in 12.5 percent to 85
percent of individuals with language disorder. In twin studies, reading impairments
were found to be significantly higher in those children with specific learning impairment
and in family members of children with the disorder. There are also high rates of
comorbidity between reading impairment and mathematics impairment; in some studies
the comorbidity has been reported to be up to 60 percent. It appears that children with
both reading and math impairment may perform more poorly in mathematics; however,
the reading skills of the comorbid children were no different from children who had only
reading disorder and not math disorder. Comorbid psychiatric disorders are also
frequent, such as ADHD, Oppositional Defiant Disorder, Conduct Disorders, and
Depressive Disorders, especially in adolescents. Data suggest that up to 25 percent of
children with reading impairment may have comorbid ADHD. Conversely, it is estimated
that between 15 and 30 percent of children diagnosed with ADHD have specific learning
disorder. Family studies suggest that ADHD and reading impairment may share some
degree of heritability. That is, some genetic factors contribute to both reading
impairment and attentional syndromes. Youth with reading impairments have higher
than average rates of depression on self-report measures and experience higher levels of
anxiety symptoms than children without specific learning disorder. Furthermore,
children with reading impairment are at increased risk for poor peer relationships and
exhibit less skill in responding to subtle social cues.
Etiology
Data from cognitive, neuroimaging, and genetic studies suggest that reading
impairment is a neurobiological disorder with a significant genetic contribution. It
reflects a deficiency in processing sounds of speech sounds, and thus, spoken language.
Children who struggle with reading most likely also have a deficit in speech sound
processing skills. Children with this deficit cannot effectively identify the parts of words
that denote specific sounds, leading to difficulty in recognizing and “sounding out”
words. Youth with reading impairment are slower than peers in naming letters and
numbers. The core deficits for children with reading impairment include poor processing
of speech sounds and deficits in comprehension, spelling, and sounding out words.
Because reading impairment typically includes a language deficit, the left brain has
been hypothesized to be the anatomical site of this dysfunction. Several studies using
magnetic resonance imaging (MRI) studies have suggested that the planum temporale in
the left brain shows less asymmetry than the same site in the right brain in children with
both language disorders and specific learning disorder. Positron emission tomographic
(PET) studies have led some researchers to conclude that left temporal blood flow
patterns during language tasks differ between children with and without learning
disorders. Cell analysis studies suggest that in reading impaired individuals, the visual
magnocellular system (which normally contains large cells) contains more disorganized
and smaller cell bodies than expected. Studies indicate that 35 to 40 percent of firstdegree relatives of children with reading deficits also have reading disability. Several
studies have suggested that phonological awareness (i.e., the ability to decode sounds
and sound out words) is linked to chromosome 6. Furthermore, the ability to identify
single words has been linked to chromosome 15. Impairment in reading and spelling has
now been linked to susceptibility loci on multiple chromosomes, including chromosomes
1, 2, 3, 6, 15, and 18. Although a recent research study identified a locus on chromosome
18 as a strong influence on single word reading and phoneme awareness, generalist
genes have also been implicated as responsible for learning disorders. Many genes
believed to be associated with specific learning disorder, may also influence normal
variation in learning abilities. In addition, genes that affect abilities in reading, for
example, are hypothesized to also affect written expression and potentially mathematics
skills.
Several historical hypotheses about the origin of reading deficits are now known to be
untrue. The first myth is that reading impairments are caused by visual–motor problems,
or what has been termed scotopic sensitivity syndrome. There is no evidence that children
with reading impairment have visual problems or difficulties with their visual–motor
system. The second false theory is that allergies can cause, or contribute to, reading
disability. Finally, unsubstantiated theories have implicated the cerebellar–vestibular
system as the source of reading disabilities.
Research in cognitive neuroscience and neuropsychology supports the hypothesis that
encoding processes and working memory, rather than attention or long-term memory,
are areas of weakness for children with reading impairment. One study found an
association between dyslexia and birth in the months of May, June, and July, suggesting
that prenatal exposure to a maternal infectious illness, such as influenza, in the winter
months may contribute to reading disabilities. Complications during pregnancy and
prenatal and perinatal difficulties are common in the histories of children with reading
disabilities. Extremely low birth weight and severely premature children are at higher
risk for specific learning disorder. Children born very preterm have been noted to be at
increased risk of minor motor, behavioral, and specific learning disorder.
An increased incidence of reading impairment occurs in intellectually average
children with cerebral palsy and epilepsy. Children with postnatal brain lesions in the
left occipital lobe, resulting in right visual-field blindness, as well as youth with lesions
in the splenium of the corpus callosum that blocks transmission of visual information
from the intact right hemisphere to the language areas of the left hemisphere experience
reading impairments.
Children malnourished for long periods during early childhood are at increased risk of
compromised performance cognition, including reading.
Diagnosis
Reading impairment is diagnosed when a child’s reading achievement is significantly
below that expected of a child of the same age (Table 31.7-1). Characteristic diagnostic
features include difficulty recalling, evoking, and sequencing printed letters and words;
processing sophisticated grammatical constructions; and making inferences. School
failure and ensuing poor self-esteem can exacerbate the problems as a child becomes
more consumed with a sense of failure and spends less time focusing on academic work.
Students with reading impairment are entitled to an educational evaluation through the
school district to determine eligibility for special education services. Special education
classification, however, is not uniform across states or regions, and students with
identical reading difficulties may be eligible for services in one region, but ineligible in
another.
Table 31.7-1
DSM-5 Diagnostic Criteria for Specific Learning Disorder
Clinical Features
Children with reading disabilities are usually identified by the age of 7 years (second
grade). Reading difficulty may be apparent among students in classrooms where
reading skills are expected as early as the first grade. Children can sometimes
compensate for reading disorder in the early elementary grades by the use of memory
and inference, particularly in children with high intelligence. In such instances, the
disorder may not be apparent until age 9 (fourth grade) or later. Children with reading
impairment make many errors in their oral reading. The errors are characterized by
omissions, additions, and distortions of words. Such children have difficulty in
distinguishing between printed letter characters and sizes, especially those that differ
only in spatial orientation and length of line. The problems in managing printed or
written language can pertain to individual letters, sentences, and even a page. The
child’s reading speed is slow, often with minimal comprehension. Most children with
reading disability have an age-appropriate ability to copy from a written or printed
text, but nearly all spell poorly.
Associated problems include language difficulties: discrimination and difficulty in
sequencing words properly. A child with reading disorders may start a word either in the
middle or at the end of a printed or written sentence. Most children with reading
disorder dislike and avoid reading and writing. Their anxiety is heightened when they
are confronted with demands that involve printed language. Many children with specific
learning disorder who do not receive remedial education have a sense of shame and
humiliation because of their continuing failure and subsequent frustration. These
feelings grow more intense with time. Older children tend to be angry and depressed
and exhibit poor self-esteem.
Jackson, a 10-year-old boy, was referred for evaluation of failing to complete inclass assignments and homework, and failing tests in reading, spelling, and
arithmetic. For the past 2 years (grades 5 and 6), he had been attending a special
education class every morning in the local community school, based on an assessment
from the second grade. A subsequent psychoeducational assessment by a clinical
psychologist confirmed reading problems. Jackson was eligible for a full-day special
education class, whereupon he started attending a program with eight other students
ranging from 6 to 12 years of age.
Clinical interview with his parents revealed a normal pregnancy and neonatal
period, and a history of language delay. In preschool and kindergarten, Jackson was
reported to have had difficulty with rhyming games and showed a lack of interest in
books and preferred to play with construction toys. In the first grade, Jackson had
more difficulty learning to read than other boys in his class and continued to have
problems pronouncing multisyllabic words (e.g., he said “aminals” for “animals” and
“sblanation” for “explanation”). Family history was positive for reading deficits and
ADHD. Jackson’s father disclosed a history of his own reading problems, and
Jackson’s older brother, 15 years of age, had ADHD, which was well controlled with
stimulant medication. Jackson’s parents were concerned about his poor focus in
school, and wondered whether he had ADHD. In the clinical interview with Jackson,
he rarely made eye contact, mumbled a lot, and struggled to find the right words
(e.g., manifested many false starts, hesitations, and nonspecific terms, such as “the
thing that you draw . . . um . . . pencil—no . . . um . . . lines with”). He admitted to
disliking school, adding “Reading is boring and stupid—I’d rather be skateboarding.”
Jackson complained about how much reading he was given—even in math—and
commented, “Reading takes so much time. By the time I figure out a word, I can’t
remember what I just read and so have to read the stuff again.”
Psychoeducational assessment included the Wechsler Intelligence Scale for ChildrenIV, Clinical Evaluation of Language Fundamentals-IV (CELF-IV), the Wechsler
Individual Achievement Test-II, and self-ratings of anxiety, depression, and selfesteem. Results indicated low-average verbal and above average performance IQ,
poor word attack and word identification skills (below 12th percentile), poor
comprehension (below 9th percentile), poor spelling (below 6th percentile), weak
comprehension of oral language (below 16th percentile), elevated but subthreshold
scores on the Children’s Depression Inventory, and low self-esteem. Although Jackson
manifested symptoms of inattention, restlessness, and oppositional behavior
(particularly at school), he did not meet criteria for ADHD. Jackson met DSM-5
criteria for specific learning disorder, with deficits in reading and written expression.
Recommendations included continuation in special education plus attendance at a
summer camp specializing in children with reading disorder, as well as ongoing
monitoring of self-esteem and depressive traits.
At 1-year follow-up, Jackson and his parents reported striking improvements in his
reading, overall school performance, mood, and self-esteem. Both Jackson and his
family felt that the specialized instruction provided during the summer camp was very
helpful. The program had provided one-on-one focused and explicit instruction for 1
hour a day for a total of 70 hours. Jackson explained that he had been taught “like a
game plan” to read, and challenged the clinician to give him a “really tough long
word to read.” He demonstrated strategies that he had learned to read the word
“unconditionally” and also explained what it meant. To boost his fluency in reading
and comprehension, he was provided with assignments to read along with audiotaped versions of books, use of graphic organizers to facilitate reading
comprehension, and continued participation in the summer camp reading program.
(Adapted from Rosemary Tannock, Ph.D.)
Pathology and Laboratory Examination
No specific physical signs or laboratory measures are helpful in the diagnosis of reading
deficits. Psychoeducational testing, however, is critical in determining these deficits. The
diagnostic battery generally includes a standardized spelling test, written composition,
processing and using oral language, design copying, and judgment of the adequacy of
pencil use. The reading subtests of the Woodcock-Johnson Psycho-Educational BatteryRevised, and the Peabody Individual Achievement Test-Revised are useful in identifying
reading disability. A screening projective battery may include human-figure drawings,
picture-story tests, and sentence completion. The evaluation should also include
systematic observation of behavioral variables.
Course and Prognosis
Children with reading disability may gain knowledge of printed language during their
first 2 years in grade school, without remedial assistance. By the end of the first grade,
many children with reading problems, in fact, have learned how to read a few words;
however, by the third grade, keeping up with classmates is exceedingly difficult without
remedial educational intervention. When remediation is instituted early, in milder cases,
it may not be necessary after the first or second grade. In severe cases and depending
on the pattern of deficits and strengths, remediation may be continued into the middle
and high school years.
Differential Diagnosis
Reading deficits are often accompanied by comorbid disorders, such as language
disorder, disability in written expression, and ADHD. Data indicate that children with
reading disability consistently present difficulties with linguistic skills, whereas children
with ADHD only, do not. Children with reading disability, without ADHD, however, may
have some overlapping deficits in cognitive inhibition, for example, they perform
impulsively on continuous performance tasks. Deficits in expressive language and
speech discrimination along with reading disorder may lead to a comorbid diagnosis of
language disorder. Reading impairment must be differentiated from intellectual
disability syndromes in which reading, along with most other skills, are below the
achievement expected for a child’s chronological age. Intellectual testing helps to
differentiate global deficits from more specific reading difficulties.
Poor reading skills resulting from inadequate schooling can be detected by comparing
a given child’s achievement with classmates on reading performance on standardized
reading tests. Hearing and visual impairments should be ruled out with screening tests.
Treatment
Remediation strategies for children with reading impairments focus on direct instruction
that leads a child’s attention to the connections between speech sounds and spelling.
Effective remediation programs begin by teaching the child to make accurate
associations between letters and sounds. This approach is based on the theory that the
core deficits in reading impairments are related to difficulty recognizing and
remembering the associations between letters and sounds. After individual letter-sound
associations have been mastered, remediation can target larger components of reading
such as syllables and words. The exact focus of any reading program can be determined
only after accurate assessment of a child’s specific deficits and weaknesses. Positive
coping strategies include small, structured reading groups that offer individual attention
and make it easier for a child to ask for help.
Children and adolescents with reading difficulties are entitled to an individual
education program (IEP) provided by the public school system. Yet, for high school
students with persistent reading disorders and ongoing difficulties with decoding and
work identification, IEP services may not be sufficient to remediate their problems. A
study of students with reading disorders in 54 schools indicated that, at the high school
level, specific goals are not adequately met solely through school remediation. It is
likely that high schoolers with persisting reading difficulties may have greater benefit
from individualized reading remediation.
Reading instruction programs such as the Orton Gillingham and Direct Instructional
System for Teaching and Remediation (DISTAR) approaches begin by concentrating on
individual letters and sounds, advance to the mastery of simple phonetic units, and then
blend these units into words and sentences. Thus, if children are taught to cope with
graphemes, they will learn to read. Other reading remediation programs, such as the
Merrill program, and the Science Research Associates, Inc. (SRA) Basic Reading Program,
begin by introducing whole words first and then teach children how to break them down
and recognize the sounds of the syllables and the individual letters in the word. Another
approach teaches children with reading disorders to recognize whole words through the
use of visual aids and bypasses the sounding-out process. One such program is called the
Bridge Reading Program. The Fernald method uses a multisensory approach that combines
teaching whole words with a tracing technique so that the child has kinesthetic
stimulation while learning to read the words.
SPECIFIC LEARNING DISORDER WITH IMPAIRMENT IN MATHEMATICS
Children with mathematics difficulties have difficulty learning and remembering
numerals, cannot remember basic facts about numbers, and are slow and inaccurate in
computation. Poor achievement in four groups of skills have been identified in
mathematics disorder: linguistic skills (those related to understanding mathematical
terms and converting written problems into mathematical symbols), perceptual skills
(the ability to recognize and understand symbols and order clusters of numbers),
mathematical skills (basic addition, subtraction, multiplication, division, and following
sequencing of basic operations), and attentional skills (copying figures correctly and
observing operational symbols correctly). A variety of terms over the years, including
dyscalculia,
congenital
arithmetic
disorder,
acalculia,
Gerstmann
syndrome,
and
developmental arithmetic disorder have been used to denote the difficulties present in
mathematics disorder. Core deficits in dyscalculia are in processing numbers, and good
language abilities are skills needed for accurate counting, calculating, and
understanding mathematical principles.
Mathematics deficits can, however, occur in isolation or in conjunction with language
and reading impairments. According to the DSM-5, the diagnosis of specific learning
disorder with impairment in mathematics consists of deficits in arithmetic counting and
calculations, has difficulty remembering mathematics facts, and may count on fingers
instead. Additional deficits include difficulty with mathematic concepts and reasoning,
leading to difficulties in applying procedures to solve quantitative problems. These
deficits lead to skills that are substantially below what is expected for the child’s
chronological age and cause significant interference in academic success, as documented
by standardized academic achievement testing.
Epidemiology
Mathematics disability alone is estimated to occur in about 1 percent of school-age
children, that is about one of every five children with specific learning disorder.
Epidemiological studies have indicated that up to 6 percent of school-age children have
some difficulty with mathematics, and prevalence estimates of 3.5 to 6.5 percent have
been reported for impairing forms of dyscalculia. Although specific learning disorder
overall occurs two to three times more often in males, mathematics deficits may be
relatively more frequent in girls than reading deficits. Many studies of learning
disorders in children have grouped reading, writing, and mathematics disability
together, which makes it more difficult to ascertain the precise prevalence of
mathematics disability.
Comorbidity
Mathematics deficits are commonly found to be comorbid, with deficits in both reading
and written expression. Children with mathematics difficulties may also be at higher risk
for expressive language problems, and developmental coordination disorder.
Etiology
Mathematics deficiency, as with other areas of specific learning disorder, has a
significant genetic contribution. High rates of comorbidity with reading deficits have
been reported in the range of 17 percent up to 60 percent. One theory proposed a
neurological deficit in the right cerebral hemisphere, particularly in the occipital lobe
areas. These regions are responsible for processing visual–spatial stimuli that, in turn,
are responsible for mathematical skills. This theory, however, has received little support
in subsequent neuropsychiatric studies.
Causes of deficits in mathematics are believed to be multifactorial, including genetic,
maturational, cognitive, emotional, educational, and socioeconomic factors. Prematurity
and very low birth weight are also a risk factor for specific learning disorder, including
mathematics. Compared with reading abilities, arithmetic abilities seem to depend more
on the amount and quality of instruction.
Diagnosis
The diagnosis of specific learning disorder in mathematics is made when a child’s skill in
mathematical reasoning, or calculation, remain significantly below what is expected for
that child’s age, for a period of at least 6 months, even when remedial interventions
have been administered. Many different skills contribute to mathematics proficiency.
These include linguistic skills, conceptual skills, and computational skills. Linguistic
skills involve being able to understand mathematical terms, understand word problems,
and translate them into the proper mathematical process. Conceptual skills involve
recognition of mathematical symbols and being able to use mathematical signs
correctly. Computational skills include the ability to line up numbers correctly and to
follow the “rules” of the mathematical operation. The DSM-5 diagnostic criteria for
specific learning disorder with impairment in mathematics are provided in Table 31.7-1.
Clinical Features
Common features of mathematics deficit include difficulty learning number names,
remembering the signs for addition and subtraction, learning multiplication tables,
translating word problems into computations, and performing calculations at the
expected pace. Most children with mathematics deficits can be detected during the
second and third grades in elementary school. A child with poor mathematics abilities
typically has problems with concepts, such as counting and adding even one-digit
numbers, compared with classmates of the same age. During the first 2 or 3 years of
elementary school, a child with poor mathematics skill may just get by in mathematics
by relying on rote memory. But soon, as mathematics problems require discrimination
and manipulation of spatial and numerical relations, a child with mathematics
difficulties is overwhelmed.
Some investigators have classified mathematics deficiencies into the following
categories: difficulty learning to count meaningfully; difficulty mastering cardinal and
ordinal systems; difficulty performing arithmetic operations; and difficulty envisioning
clusters of objects as groups. Children with mathematics difficulty have trouble
associating auditory and visual symbols, understanding the conservation of quantity,
remembering sequences of arithmetic steps, and choosing principles for problem-solving
activities. Children with these problems are presumed to have good auditory and verbal
abilities; however, in many cases, the mathematics deficits may occur in conjunction
with reading, writing, and language problems. In these cases, the other deficiencies may
compound the impairment of the poor mathematics skill.
Mathematics difficulty, in fact, often coexists with other disorders affecting reading,
expressive writing, coordination, and language. Spelling problems, deficits in memory
or attention, and emotional or behavioral problems may be present. Young grade-school
children may exhibit specific learning problems in reading and writing, and these
children should also be evaluated for mathematics deficits. The exact relationship
between mathematics deficits and the deficits in language and dyslexia is not clear.
Although children with language disorder do not necessarily experience mathematics
deficiencies, these conditions often coexist, and both are associated with impairments in
decoding and encoding processes.
Lena, an 8-year-old girl, was referred for evaluation of impairing problems in
attention and academic achievement, which were first noted in kindergarten but were
now causing difficulty at home and school. Lena attended a regular third-grade class
in a local public school, which she had been attending since midway through
kindergarten.
Lena’s history included a mild delay in speech acquisition (e.g., first words at
approximately 18 months of age and short sentences at approximately 3 years of
age), but otherwise she had no major developmental problems until kindergarten,
when her teacher had raised concerns about inattentiveness, difficulty following
instructions, and her difficulty in mastering basic number concepts (e.g., inaccurate
counting of sets of objects). A speech, language, and hearing assessment completed at
the end of kindergarten revealed mild language problems that did not warrant
specific intervention. School reports from grades 1 and 2 noted ongoing concerns
about inattention, poor reading skills, and difficulty mastering simple arithmetic
facts, and “making careless mistakes in copying numbers from the board and in doing
addition and subtraction.” These problems continued through grade 2, despite some
in-school accommodations (e.g., moving Lena’s seat closer to the teacher) and
modifications (e.g., providing her with printed sheets of arithmetic problems so she
did not need to copy them herself). Lena’s parents reported a 3-year history of losing
things, fidgeting at the dinner table, and difficulty concentrating on games and
homework, and forgetting to bring notes to and from school. Psychological assessment
included the Wechsler Intelligence Scale for Children-III, Clinical Evaluation of
Language Fundamentals-IV, Comprehensive Test of Phonological Processing, and the
Woodcock-Johnson
Psycho-Educational
Battery–III.
Results
indicated
average
intelligence, with relatively weaker performance on tests of perceptual organization,
weak phonological (speech sound) awareness, mild deficits in receptive and
expressive language, and reading and arithmetic abilities that were well below grade
level. Parent and teacher ratings on a standardized behavior questionnaire (Conners’
Rating Scales-Long Form) were above clinical threshold for ADHD.
Lena was given a diagnosis of ADHD, predominantly inattentive type, and specific
learning disorder with impairment in reading, based on the history, school
achievement, and standardized assessment. She did not meet criteria for
communication disorder, and it was speculated that her mathematics problems did not
cause impairment like her reading disorder and ADHD did. Recommendations
included the following: family psychoeducation clarifying the ADHD and specific
learning disorder, remedial interventions for reading, and treatment of her ADHD
with a long-acting stimulant agent.
At 1-year follow-up, Lena and her parents reported noticeable improvement with
inattention, but ongoing problems with reading and more significant deficits in
mathematics. Mathematics remediation was added to her weekly schedule. Two years
later, when Lena was 11 years of age, her parents called for an “urgent reevaluation”
due to a sudden worsening of her difficulties at home and school. Clinical evaluation
revealed adequate stimulant treatment response of her ADHD, more marked deficits in
reading speed accuracy compared to others her age, and significant deficits in
mathematics. Lena’s parents reported that she had started lying about having
mathematics homework or refused to do it, was suspended from mathematics class
twice in the past 3 months because of oppositional behavior, and had failed sixthgrade mathematics. Lena acknowledged disliking and worrying about math:
“whenever the teacher starts asking questions and looks in my direction, my mind just
goes blank and I feel sort of shaky—it’s so bad in tests that I have to leave class to get
myself together.” At this point, an additional component of anxiety was noted to be
contributing to her school impairments. Recommendations were expanded to include
increased specific educational remediation for mathematics. At follow-up, Lena
reported that the resource teacher had taught her some helpful strategies to address
her anxiety about mathematics, as well as ways of classifying word problems and
differentiating critical information from irrelevant information. She continued to be a
robust responder to long-acting stimulants for her ADHD, and had only minimal
difficulties concentrating on homework after school. (Adapted from case material by
Rosemary Tannock, Ph.D.)
Pathology and Laboratory Examination
No physical signs or symptoms indicate mathematics disorder, but educational testing
and standardized measurement of intellectual function are necessary to make this
diagnosis. The Keymath Diagnostic Arithmetic Test measures several areas of mathematics
including knowledge of mathematical content, function, and computation. It is used to
assess ability in mathematics of children in grades 1 to 6.
Course and Prognosis
A child with a specific learning disorder in mathematics can usually be identified by the
age of 8 years (third grade). In some children, the disorder is apparent as early as 6
years (first grade); in others, it may not be apparent until age 10 (fifth grade) or later.
Too few data are currently available from longitudinal studies to predict clear patterns
of developmental and academic progress of children classified as having mathematics
disorder in early school grades. On the other hand, children with a moderate
mathematics disorder who do not receive intervention may have complications,
including continuing academic difficulties, shame, poor self-concept, frustration, and
depression. These complications can lead to reluctance to attend school, and
demoralization about academic success.
Differential Diagnosis
Mathematics deficits must be differentiated from global causes of impaired functioning
such as intellectual disability. Arithmetic difficulties in intellectual disability are
accompanied by similar impairments in overall intellectual functioning. Inadequate
schooling can affect a child’s arithmetic performance on a standardized arithmetic test.
Conduct disorder or ADHD can occur comorbidly with specific learning disorder in
mathematics and, in these cases, both diagnoses should be made.
Treatment
Mathematics difficulties for children are best remediated with early interventions that
lead to improved skills in basic computation. The presence of specific learning disorder
in reading along with mathematics difficulties can impede progress; however, children
are quite responsive to remediation in early grade school. Children with indications of
mathematics disorder as early as in kindergarten require help in understanding which
digit in a pair is larger, counting abilities, identification of numbers, and remembering
sequences of numbers. Flash cards, workbooks, and computer games can be a viable
part of this treatment. One study indicated that mathematics instruction is most helpful
when the focus is on problem-solving activities, including word problems, rather than
only computation. Project MATH, a multimedia self-instructional or group-instructional
in-service training program, has been successful for some children with mathematics
disorder. Computer programs can be helpful and can increase compliance with
remediation efforts.
Social skills deficits can contribute to a child’s hesitation in asking for help, so a child
identified with a mathematics disorder may benefit from gaining positive problemsolving skills in the social arena as well as in mathematics.
SPECIFIC LEARNING DISORDER WITH IMPAIMRENT IN WRITTEN
EXPRESSION
Written expression is the most complex skill acquired to convey an understanding of
language and to express thoughts and ideas. Writing skills are highly correlated with
reading for most children; however, for some youth, reading comprehension may far
surpass their ability to express complex thoughts. Written expression in some cases is a
sensitive index of more subtle deficits in language usage that typically are not detected
by standardized reading and language tests.
Deficits in written expression are characterized by writing skills that are significantly
below the expected level for a child’s age and education. Such deficits impair the child’s
academic performance and writing in everyday life. Components of writing disorder
include poor spelling, errors in grammar and punctuation, and poor handwriting.
Spelling errors are among the most common difficulties for a child with a writing
disorder. Spelling mistakes are most often phonetic errors; that is, an erroneous spelling
that sounds like the correct spelling. Examples of common spelling errors are: fone for
phone, or beleeve for believe.
Historically, dysgraphia (i.e., poor writing skills) was considered to be a form of
reading disorder; however, it is now clear that impairment in written expression can
occur on its own. Terms once used to describe writing disability include spelling disorder
and spelling dyslexia. Writing disabilities are often associated with other forms of specific
learning disorders; however, impaired writing ability may be identified later than other
forms because it is generally acquired later than verbal language and reading.
In contrast with the DSM-5, which includes specific learning disorder in written
expression, the 10th Edition of the International Statistical Classification of Diseases and
Related Health Problems (ICD-10) includes a separate specific spelling disorder.
Epidemiology
The prevalence of specific learning disorder with impairment in written expression has
been reported to occur in the range of 5 to –15 percent of school-age children. Over
time, specific learning disorder remits in many youth, leading to a persistent rate of
specific learning disorder of 4 percent in adults. The gender ratio in writing deficits is
two to three to one in boys compared with girls. Impaired written expression often
occurs along with deficits in reading, but not always.
Comorbidity
Children with impaired writing ability are significantly more likely to have language
disorder and impairments in reading and mathematics compared to the general
population of youth. ADHD occurs with greater frequency in children with writing
disability than in the general population. Youth with specific learning disorder,
including writing disability, are at higher risk for social skills difficulties, and some
develop poor self-esteem and depressive symptoms.
Etiology
Causes of writing disability are believed to be similar to those of reading disorder, that
is, underlying deficits in using the components of language related to letter sounds.
Genetic factors are a significant factor in the development of writing disability. Writing
difficulties often accompany language disorder, leading an affected child to have trouble
with understanding grammatical rules, finding words, and expressing ideas clearly.
According to one hypothesis, impairment in written expression may result from
combined effects of language disorder, and reading disorder. Hereditary predisposition
to writing impairment is supported by the finding that most youth with impaired
written expression have first-degree relatives with similar difficulties Children with
limited attention spans and high levels of distractibility may find writing an arduous
task.
Diagnosis
The DSM-5 diagnosis of specific learning disorder with impairment in written expression
is based on a child’s poor ability to use punctuation and grammar accurately in
sentences, inability to organize paragraphs, or to clearly articulate ideas in writing.
Poor performance on composing written text may also include poor handwriting and
impaired ability to spell and to place words sequentially in coherent sentences,
compared to others of the same age. In addition to spelling mistakes, youth with
impaired written expression make grammatical mistakes, such as using incorrect tenses,
forgetting words in sentences, and placing words in the wrong order. Punctuation may
be incorrect, and the child may have poor ability to remember which words begin with
capital letters. Additional symptoms of impaired written expression include the
formation of letters that are not legible, inverted letters, and mixtures of capital and
lowercase letters in a given word. Other features of writing disorders include poor
organization of written stories, which lack critical elements such as “where,” “when,”
and “who” or clear expression of the plot.
Clinical Features
Youth with impairments in written expression struggle early in grade school with
spelling words and expressing their thoughts according to age-appropriate grammatical
norms. Their spoken and written sentences contain an unusually large number of
grammatical errors and poor paragraph organization. Affected children commonly make
simple grammatical errors, even when writing a short sentence. For example, despite
constant reminders, affected youth frequently fail to capitalize the first letter of the first
word in a sentence, and fail to end the sentence with a period. Typical features of
impaired written expression include spelling errors, grammatical errors, punctuation
errors, poor paragraph organization, and poor handwriting.
In higher grades in school, affected youth’s written sentences become more
conspicuously primitive, odd, and inaccurate compared to what is expected of students
at their grade level. For youth with impaired written expression, word choices are often
erroneous and inappropriate, paragraphs are disorganized and not in proper sequence,
and spelling accuracy becomes increasingly difficult as their vocabulary becomes larger
and more abstract. Associated features of writing impairments may include reluctance to
go to school, refusal to do assigned written homework, and concurrent academic
difficulties in other areas.
Many children with impaired written expression understandably become frustrated
and angry, and harbor feelings of shame and inadequacy regarding poor academic
achievement. In some cases, depressive disorders can result from a growing sense of
isolation, estrangement, and despair. Young adults with impaired written expression
who do not receive remedial intervention continue to have writing skills deficits and a
persistent sense of incompetence and inferiority.
Brett, an 11-year-old boy, was referred for evaluation of increasing problems in
school over a 2-year period, including failure to complete assigned schoolwork and
homework, inattention and oppositional behavior, and deteriorating grades and test
scores. At the time of assessment, he was enrolled in a regular fifth-grade class in a
public school, which he had been attending since grade 1.
Clinical interview with parents revealed that Brett had a twin brother
(monozygotic) with a history of language problems for which he had received speechlanguage therapy in the preschool years and remedial reading in the primary grades.
Brett, however, had not exhibited difficulty in speech or language development,
according to parental report and scores on standardized tests of oral language
administered in the preschool years. His current and previous school reports indicate
that Brett participated well in class discussions and had no difficulty in reading or
mathematics; however, his written work was far below grade level. In each of the last
2 years, his teachers had expressed increasing concerns about Brett’s refusal to
complete written work, failure to hand in homework, daydreaming and fidgeting in
class, and withdrawal from class activities. Brett admitted to an increasing dislike of
school and especially writing assignments. He explained, “It’s writing, writing all day
long—even in math and science. I know how to do the problems and the experiments,
but I hate having to write it all down—my mind just goes blank.” Brett complained
“My teacher is always on at me, telling me that I’m lazy and haven’t done enough,
and that my writing is atrocious. He tells me, I’ve got a bad attitude—so why would I
want to go to school?” Brett and his parents reported that, over the past year, he has
been down, increasing frustrated with school, and has refused to do homework. They
all agree that Brett has had a few brief episodes of depressed mood.
Testing by a clinical psychologist revealed average to high-average scores on the
verbal and performance scales of the Wechsler Intelligence Scale for Children-III and
average scores on the reading and arithmetic subtests of the Wide Range Achievement
Test-3 (WRAT-3). However, scores on the WRAT-3 spelling subtest were below the 9th
percentile, which was significantly below expectations for age and ability.
Examination of his spelling errors revealed that, although his spelling was typically
phonologically accurate (i.e., could plausibly be pronounced to sound like the target
word), it was unacceptable in that he used letter sequences that did not resemble
English, regardless of pronunciation (e.g., “houses” was written as “howssis,”
“phones” was written as “fones,” and “exact” was written as “egszakt”). Moreover, his
performance was well below age and grade on standardized tests of written
expression (TOWL-3), as well as on a brief (5-minute) informal assessment of
expository text generation on a favorite topic (e.g., newspaper article on recent
sports event). During the 5-minute writing activity, he was observed to frequently
stare out of the window, to shift positions and to chew on his pencil, to get up to
sharpen his pencil and to sigh when he did put pencil to paper, and to write slowly
and laboriously. At the end of 5 minutes, he had produced three short sentences
without any punctuation or capitalization that were barely legible, containing several
misspellings and grammatical errors, and that were not linked semantically. By
contrast, later in the assessment, he described the sporting event with detail and
enthusiasm. A speech-language evaluation revealed average scores on standard tests
of oral language (Clinical Evaluation of Language Fundamentals-IV), but he was
noted to omit sounds or syllables in a multisyllabic word in a nonword repetition test,
which has been found to be sensitive to mild residual language impairments and
written language impairments.
The clinical team formulated a diagnosis of specific learning disorder with
impairment in written expression, based on Brett’s inability to compose written text,
poor spelling, and grammatical errors, without problems in reading or mathematics or
a history of language impairments. He did not meet full diagnostic criteria for any
other DSM-5 disorder, including oppositional defiant disorder, ADHD, or mood
disorder. Recommendations included the following: psychoeducation, the need for
educational accommodations (e.g., provision of additional time for test taking and
written assignments, specific educational intervention to facilitate written expression
and to teach note taking, and use of specific computer software to support written
composition and spelling), and counseling should his depressed mood continue or
worsen. (Adapted from case material from Rosemary Tannock, Ph.D.)
Pathology and Laboratory Examination
Whereas no physical signs of a writing disorder exist, educational testing is used in
making a diagnosis of writing disorder. Diagnosis is based on a child’s writing
performance being markedly below expected production for his age, as confirmed by an
individually administered standardized expressive writing test. Currently available tests
of written language include the Test of Written Language (TOWL), the DEWS, and the
Test of Early Written Language (TEWL). Evaluation for impaired vision and hearing is
recommended.
When impairments in written expression are noted, a child should be administered a
standardized intelligence test, such as WISC-R to determine the child’s overall
intellectual capacity.
Course and Prognosis
Specific learning disorder with impairment in writing, reading, and mathematics often
coexist, and additional language disorder may be present as well. A child with all of the
above disabilities will likely be diagnosed with language disorder first and impaired
written expression last. In severe cases, an impaired written expression is apparent by
age 7 (second grade); in less severe cases, the disorder may not be apparent until age 10
(fifth grade) or later. Youth with mild and moderate impairment in written expression
fare well if they receive timely remedial education early in grade school. Severely
impaired written expression requires continual, extensive remedial treatment through
the late part of high school and even into college.
The prognosis depends on the severity of the disorder, the age or grade when the
remedial intervention is started, the length and continuity of treatment, and presence or
absence of associated or secondary emotional or behavioral problems.
Differential Diagnosis
It is important to determine whether disorders such as ADHD or major depression are
interfering with a child’s focus and thereby preventing the production of adequate
writing in the absence of a specific writing impairment. If true, treatment for the other
disorder should improve a child’s writing performance. Commonly comorbid disorders
with writing disability are language disorder, mathematics disorder, developmental
coordination disorder, disruptive behavior disorders, and ADHD.
Treatment
Remedial treatment for writing disability includes direct practice in spelling and
sentence writing as well as a review of grammatical rules. Intensive and continuous
administration of individually tailored, one-on-one expressive and creative writing
therapy appears to effect favorable outcome. Teachers in some special schools devote as
much as 2 hours a day to such writing instruction. The effectiveness of a writing
intervention depends largely on an optimal relationship between the child and the
writing specialist. Success or failure in sustaining the patient’s motivation greatly affects
the treatment’s long-term efficacy. Associated secondary emotional and behavioral
problems should be given prompt attention, with appropriate psychiatric treatment and
parental counseling.
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13 - 31.8 Motor Disorders
31.8 Motor Disorders

14 - 31.8a Developmental Coordination Disorder
31.8a Developmental Coordination Disorder
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31.8 Motor Disorders
31.8a Developmental Coordination Disorder
Developmental coordination disorder is a neurodevelopmental disorder in which a
child’s fine and/or gross motor coordination is slower, less accurate, and more variable
than in peers of the same age. Affecting about 5 to 6 percent of school-age children, 50
percent of children with developmental coordination disorder also have comorbid
attention-deficit/hyperactivity disorder (ADHD) or dyslexia. A meta-analysis of recent
research on developmental coordination disorder concluded that three general areas of
deficits contribute to the disorder: (1) Poor predictive control of motor movements; (2)
deficits in rhythmic coordination and timing; and (3) deficits in executive functions,
including working memory, inhibition, and attention.
Children with developmental motor coordination struggle to perform accurately the
motor activities of daily life, such as jumping, hopping, running, or catching a ball.
Children with coordination problems may also agonize to use utensils correctly, tie their
shoelaces, or write. A child with developmental coordination disorder may exhibit delays
in achieving motor milestones, such as sitting, crawling, and walking, because of
clumsiness, and yet excel at verbal skills.
Developmental coordination disorder, thus, may be characterized by either clumsy
gross and/or fine motor skills, resulting in poor performance in sports and even in
academic achievement because of poor writing skills. A child with developmental
coordination disorder may bump into things more often than siblings or drop things. In
the 1930s, the term clumsy child syndrome began to be used in the literature to denote a
condition of awkward motor behaviors that could not be correlated with any specific
neurological disorder or damage. This term continues to be used to identify imprecise or
delayed gross and fine motor behavior in children, resulting in subtle motor inabilities,
but often significant social rejection. Gross and fine motor impairment in developmental
coordination disorder cannot be explained on the basis of a medical condition, such as
cerebral palsy, muscular dystrophy, or a neuromuscular disorder. Currently, certain
indications are that perinatal problems, such as prematurity, low birth weight, and
hypoxia may contribute to the emergence of developmental coordination disorders.
Children with developmental coordination disorder are at higher risk for language and
learning disorders. A strong association is seen between speech and language problems
and coordination problems, as well as an association of coordination difficulties with
hyperactivity, impulsivity, and poor attention span.
Children with developmental coordination disorder may resemble younger children
because of their inability to master motor activities typical for their age group. For
example, children with developmental coordination disorder in elementary school may
not be adept at bicycle riding, skateboarding, running, skipping, or hopping. In the
middle school years, children with this disorder may have trouble in team sports, such as
soccer, baseball, or basketball. Fine motor skill manifestations of developmental
coordination disorder typically include clumsiness using utensils and difficulty with
buttons and zippers in the preschool age group. In older children, using scissors and
more complex grooming skills, such as styling hair or putting on makeup, is difficult.
Children with developmental coordination disorder are often ostracized by peers
because of their poor skills in many sports, and they often have long-standing
difficulties with peer relationships. Developmental coordination disorder is categorized
in the Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) as a Motor Disorder, along with stereotypic
movement disorder and tic disorders.
EPIDEMIOLOGY
The prevalence of developmental coordination disorder has been estimated at about 5 to
6 percent of school-age children. The male-to-female ratio in referred populations tends
to show increased rates of the disorder in males, but schools refer boys more often for
testing and special education evaluations. Reports in the literature of the male-to-female
ratio have ranged from 3 to 1 to as high as 7 to 1; however, the most current estimates
are approximately 2 males for every one female.
COMORBIDITY
Developmental coordination disorder is strongly associated with ADHD, specific
learning disorder, particularly in reading, as well as language disorder. Children with
coordination difficulties have higher than expected rates of language disorder, and
studies of children with language disorder report very high rates of “clumsiness.”
Developmental coordination disorder is also associated, but less strongly, with specific
learning disorder with impairment in mathematics, and in written expression. A study of
children with developmental coordination disorder reported that, although motor
coordination is critical for accuracy in tasks that require speed, poor motor coordination
is not directly correlated with degree of inattention. Thus, in children comorbid for
ADHD and developmental coordination disorder, children with the most severe ADHD do
not necessarily have the worst developmental coordination disorder. Functional
neuroimaging, pharmacological, and neuroanatomical studies suggest that motor
coordination depends on the integration of sensory input and an action response, not
purely through sensorimotor function and higher level thinking. Investigations of
comorbid developmental coordination disorder and ADHD are trying to ascertain
whether this comorbidity is due to overlapping genetic factors.
Peer relationship problems are common among children with developmental
coordination disorders, because of rejection that often occurs along with their poor
performance in sports and games that require good motor skill. Adolescents with
coordination problems often exhibit poor self-esteem and academic difficulties. Recent
studies underscore the importance of attention to both victimization of children and
adolescents with developmental motor coordination by peers and the potential resulting
damage to self-worth. Children and adolescents with developmental coordination
disorder who are bullied have higher rates of poor self-esteem that often deserves
clinical attention.
ETIOLOGY
The causes of developmental coordination disorder are believed to be multifactorial, and
likely include both genetic and developmental factors. Risk factors postulated to
contribute to this disorder include prematurity, hypoxia, perinatal malnutrition, and low
birth weight. Prenatal exposure to alcohol, cocaine, and nicotine has also been
hypothesized to contribute to both low birth weight and cognitive and behavioral
abnormalities. Developmental coordination disorder rates of up to 50 percent have been
reported in children born prematurely. Researchers have proposed that the cerebellum
may be the neurological substrate for comorbid cases of developmental coordination
disorder and ADHD. Neurochemical abnormalities and parietal lobe lesions have also
been suggested to contribute to coordination deficits. Studies of postural control, that is,
the ability to regain balance after being in motion, indicate that children with
developmental coordination disorder who have adequate balance when standing still,
are unable to accurately correct for movement, resulting in impaired balance, compared
with other children. A study concluded that, in children with developmental
coordination disorder, neural signals from the brain to particular muscles involved in
balance, are neither being optimally sent or received. These findings have also
implicated the cerebellum as a potential anatomical site for the dysfunction of
developmental coordination disorder. Two mechanisms of developmental coordination
disorder have been hypothesized for the disabilities of the disorder. The first one, called
the automatization deficit hypothesis, suggests that, similar to dyslexia, children with
developmental coordination disorder have difficulty developing automatic motor skills.
The second hypothesis, the internal modeling deficit hypothesis, suggests that children
with developmental coordination disorder are unable to perform the typical internal
cognitive models that predict the sensory consequences of motor commands. In both
scenarios, the cerebellum is believed to play an important role in motor coordination
and in developmental coordination disorder.
DIAGNOSIS
The diagnosis of developmental coordination disorder depends on poor performance in
activities requiring coordination for a child’s age and intellectual level. Diagnosis is
based on a history of the child’s delay in achieving early motor milestones, as well as on
direct observation of current deficits in coordination. An informal screen for
developmental coordination disorder involves asking the child to perform tasks
involving gross motor coordination (e.g., hopping, jumping, and standing on one foot);
fine motor coordination (e.g., finger-tapping and shoelace tying); and hand-eye
coordination (e.g., catching a ball and copying letters). Judgments regarding poor
performance must be based on what is expected for a child’s age. A child who is mildly
clumsy, but whose functioning is not impaired, does not qualify for a diagnosis of
developmental coordination disorder.
The diagnosis may be associated with below-normal scores on performance subtests of
standardized intelligence tests and by normal or above-normal scores on verbal subtests.
Specialized tests of motor coordination can be useful, such as the Bender Visual Motor
Gestalt Test, the Frostig Movement Skills Test Battery, and the Bruininks-Oseretsky Test of
Motor Development. The child’s chronological age must be taken into account, and the
disorder cannot be caused by a neurological or neuromuscular condition. Examination,
however, may occasionally reveal slight reflex abnormalities and other soft neurological
signs.
CLINICAL FEATURES
The clinical signs suggesting the existence of developmental coordination disorder are
evident as early as infancy in some cases, when a child begins to attempt tasks requiring
motor coordination. The essential clinical feature is significantly impaired performance
in motor coordination. The difficulties in motor coordination may vary with a child’s
age and developmental stage (Table 31.8a-1).
Table 31.8a-1
Manifestations of Developmental Coordination Disorder
In infancy and early childhood the disorder may be manifested by delays in
developmental motor milestones, such as turning over, crawling, sitting, standing,
walking, buttoning shirts, and zipping up pants. Between the ages of 2 and 4 years,
clumsiness appears in almost all activities requiring motor coordination. Affected
children cannot hold objects and drop them easily, their gait may be unsteady, they
often trip over their own feet, and they may bump into other children while attempting
to go around them. Older children may display impaired motor coordination in table
games, such as putting together puzzles or building blocks, and in any type of ball
game. Although no specific features are pathognomonic of developmental coordination
disorder, developmental milestones are frequently delayed. Many children with the
disorder also have speech and language difficulties. Older children may have secondary
problems, including academic difficulties, as well as poor peer relationships based on
social rejection. It has been reported widely that children with motor coordination
problems are more likely to have problems understanding subtle social cues and are
often rejected by peers. A recent study indicated that children with motor difficulties
were found to perform more poorly on scales that measure recognition of static and
changing facial expressions of emotion. This finding is likely to be correlated to the
clinical observations that children with motor coordination have difficulties in social
behavior and peer relationships.
Billy was brought for evaluation of suicidal ideation at 8 years of age, after
complaining to his parents that he was being bullied by peers for being “bad” in
sports, and that nobody liked him. He only had one friend who also laughed at him
sometimes, because he always dropped the ball and he looked “funny” while running.
He was so upset about being rejected by peers when he tried to play sports that he
refused to go to physical education class. Instead, he voluntarily went to the school
counselor’s office and stayed there until the period was over. Billy was already
irritated because he had been diagnosed with ADHD and was on medication, and on
top of that, he had difficulty with reading. Billy became so distraught that one day he
told his school counselor that he wanted to kill himself. A developmental history
revealed that had been delayed for sitting, which he finally did at 10 months of age,
and he could not walk without falling over until 30 months of age. Billy’s parents
were aware that he was very clumsy, but they believed that he would outgrow that.
Even at 8 years of age, Billy’s parents reported that, during meals, Billy often spilled
his drinks and was quite awkward when he used a fork. Some of his food typically fell
off of his fork or spoon before it reached his mouth, and he had great difficulty using a
knife and a fork.
A comprehensive assessment of fine and gross motor skills demonstrated the
following: Billy was able to hop, but he could not skip without briefly stopping after
each step. Billy could stand with both feet together, but was unable to stand on tiptoe.
Although Billy could catch a ball, he held a ball bounced to himself at chest level, and
was unable to catch a ball bounced to him on the ground from a distance of 15 feet.
Billy’s agility and coordination were measured with the Bruininks-Oseretsky Test of
Motor Development, which revealed functioning levels commensurate with those of
an average 6-year-old child.
Billy was referred to a neurologist for a comprehensive evaluation, because he
appeared to be generally weak, and his muscles seemed floppy. Neurological
evaluation was negative for diagnosable neurological disorders, and his muscle
strength was actually found to be normal, despite his appearance. Based on the
negative neurological examination and the finding of the Bruininks-Oseretsky Test of
Motor Development, Billy was given a diagnosis of developmental coordination
disorder. Billy’s symptoms included mild hypotonia and fine motor clumsiness.
After the diagnosis of developmental motor coordination was made, in addition to
his already diagnosed ADHD and reading disorder, his treatment plan included
private sessions with an occupational therapist who used perceptual-motor exercises
to improve Billy’s fine motor skills, targeting particularly writing and use of utensils.
A written request was made for an Individualized Educational Plan (IEP) evaluation
from the school with a goal of obtaining an adaptive physical education program. In
addition, the request for a reading tutor, and a seat close to the front of the classroom
were recommended to maximize his attention. Billy was enrolled in a treatment
program using motor imagery training to reduce his clumsiness and improve
coordination.
Billy was relieved to be receiving help, especially for his reading and for sports
activities, and no longer felt suicidal. Over a period of 3 months of treatment, Billy
showed a noticeable improvement in his reading. His mood improved further,
especially because he was receiving praise from his teachers and parents. Billy’s
classmates were not picking on him the way they used to. As Billy began to feel better
about himself, he began to play sports informally with his peers, although not
competitively. Billy was granted an adaptive physical education program in school,
and he was not required to play on teams. Instead, he practiced throwing and
catching a ball and playing basketball with a staff member.
Billy continued to show some degree of clumsiness, especially in his fine motor skills
over the next few years, yet he was cooperative, with the occupational therapy
interventions, his mood was bright, and he demonstrated continual improvement.
(Courtesy of Caroly Pataki, M.D. and Sarah Spence, M.D.)
DIFFERENTIAL DIAGNOSIS
The differential diagnosis includes medical conditions that produce coordination
difficulties (e.g., cerebral palsy and muscular dystrophy). In autism spectrum disorder
and intellectual disability, coordination usually does not stand out as a significant
deficit compared with other skills. Children with neuromuscular disorders may exhibit
more global muscle impairment rather than clumsiness and delayed motor milestones.
Neurological examination and workup usually reveal more extensive deficits in
neurological conditions than in developmental coordination disorder. Extremely
hyperactive and impulsive children may be physically careless because of their high
levels of motor activity. Clumsy gross and fine motor behavior and ADHD as well as
reading difficulties are highly associated.
COURSE AND PROGNOSIS
Historically, it was believed that developmental coordination spontaneously improved
over time; however, longitudinal studies have shown that motor coordination problems
can persist into adolescence and adulthood. When mild to moderate clumsiness is
persistent, some children can compensate by developing interests in other skills. Some
studies suggest a more favorable outcome for children who have average or aboveaverage intellectual capacity, in that they come up with strategies to develop
friendships that do not depend on physical activities. Clumsiness typically persists into
adolescence and adult life. One study following a group of children with developmental
coordination problems over a decade found that the clumsy children remained less
dexterous, showed poor balance, and continued to be physically awkward. The affected
children were also more likely to have both academic problems and poor self-esteem.
Children with developmental coordination disorder have also been shown to be at
higher risk for obesity, have difficulties with running, and are at greater risk of future
cardiovascular diseases.
TREATMENT
Interventions for children with developmental coordination disorder utilize multiple
modalities, including visual, auditory, and tactile materials targeting perceptual motor
training for specific motor tasks. Two broad categories of interventions are the
following: (1) deficit-oriented approaches, including sensory integration therapy,
sensorimotor-oriented treatment, and process-oriented treatment; and (2) task-specific
interventions, including neuromotor task training and cognitive orientation to daily
occupational performance (CO-OP). More recently, motor imagery training has been
incorporated into treatment. These approaches involve visual imagery exercises using
CD-ROM; they have a broad range of foci, including predictive timing for motor tasks,
relaxation and mental preparation, visual modeling of fundamental motor skills, and
mental rehearsal of various tasks. This type of intervention is based on the notion that
improved internal representation of a movement task will improve a child’s actual
motor behavior.
The treatment of developmental coordination disorder generally includes versions of
sensory integration programs and modified physical education. Sensory integration
programs, usually administered by occupational therapists, consist of physical activities
that increase awareness of motor and sensory function. For example, a child who bumps
into objects often might be given the task of trying to balance on a scooter, under
supervision, to improve balance and body awareness. Children who have difficulty
writing letters are often given tasks to increase awareness of hand movements. Schoolbased occupational therapies for motor coordination problems in writing include
utilizing mechanisms that provide resistance or vibration during writing exercises, to
improve grip, and practicing vertical writing on a chalk board to increase arm strength
and stability while writing. These programs have been shown to improve legibility of
student’s writing, but not necessarily speed, because students learn to write with greater
accuracy and deliberate letter formation. Currently, many schools also allow and may
even encourage children with coordination difficulties that affect writing to use
computers to aid in writing reports and long papers.
Adaptive physical education programs are designed to help children enjoy exercise
and physical activities without the pressures of team sports. These programs generally
incorporate certain sports actions, such as kicking a soccer ball or throwing a
basketball. Children with coordination disorder may also benefit from social skills
groups and other prosocial interventions. The Montessori technique may promote motor
skill development, especially with preschool children, because this educational program
emphasizes the development of motor skills. Small studies have suggested that exercise
in rhythmic coordination, practicing motor movements, and learning to use word
processing keyboards may be beneficial. Parental counseling may help reduce parents’
anxiety and guilt about their child’s impairment, increase their awareness, and facilitate
their confidence to cope with the child.
An investigation of children with developmental coordination disorder showed
positive results using a computer game designed to improve ability to catch a ball. These
children were able to improve their game score by practicing virtual catching without
specific instructions on how to utilize the visual cues. This has implications for

15 - 31.8b Stereotypic Movement Disorder
31.8b Stereotypic Movement Disorder
treatment, in that certain types of motor task coordination can be positively influenced
through the practice of specific motor tasks, even without overt instructions.
REFERENCES
Blank R, Smits-Engelsman B, Polatajko H, Wilson P. European Academy for Childhood Disability. European Academy of
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Cairney J, Veldhuizen S, Szatmari P. Motor coordination and emotional-behavioral problems in children. Curr Opin
Psychiatry. 2010;23:324–329.
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Kargerer FA, Cfontreras-Vidal JL, Bo J, Clark JE. Abrupt, but not gradual visuomotor distortion facilitates adaptation in
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coordination disorder: A meta-analysis of recent research. Dev Med Child Neurol. 2013;55:217–228.
Zwicker JG, Harris SR, Klassen AF. Quality of life domains affected in children with developmental coordination disorder:
a systematic review. Child Care Health Dev. 2013;39:562–580.
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Neurol. 2012;6:573–581.
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developmental motor coordination disorder: An fMRI study. Int J Dev Neurosci. 2011;29:145–152.
31.8b Stereotypic Movement Disorder
Stereotypic movements include a diverse range of repetitive behaviors that usually
emerge in the early developmental period, appear to lack a clear function, and
sometimes cause interruption in daily life. These movements are typically rhythmic,
such as hand flapping, body rocking, hand waving, hair-twirling, lip-licking, skin
picking, or self-hitting. Stereotypic movements often appear to be self-soothing or selfstimulating; however, they can result in self-injury in some cases. Stereotypic
movements appear to be involuntary; however, they frequently can be suppressed with
a concentrated effort. Stereotypic movement disorder occurs with increased frequency in
children with autism spectrum disorder and intellectual disability, but they also exist in
typically developing children. Stereotypic movements, such as head-banging, face
slapping, eye poking, or hand-biting, can cause significant self-harm. Nail-biting,
thumb-sucking, and nose-picking are often not included as symptoms of stereotypic
movement disorder because they rarely cause impairment. When impairment occurs,
however, they can be included in stereotypic movement disorder. Stereotypic
movements share several features with tics, including the repetitive, seemingly
involuntary, and characteristically identical nature of the movements each time they are
displayed. However, distinguishing features of stereotypical movements compared to
tics include a younger age of onset, lack of changing anatomical locations, lack of
premonitory “urge,” and decreased response to medication management.
According to the Fifth Edition of the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM-5), stereotypic movement disorder is
characterized by repetitive, seemingly driven, and apparently purposeless motor
behavior that interferes with social, academic, or other activities and may result in selfharm.
EPIDEMIOLOGY
Repetitive movements are common in infants and young children, with greater than 60
percent of parents of children between the ages of 2 and 4 years reporting transient
emergence of these behaviors. The most frequent age of onset is in the second year of
life. Epidemiologic surveys estimate that up to 7 percent of otherwise typically
developing children exhibit stereotypic behaviors. A prevalence of about 15 to 20
percent in children younger than the age of 6 years display stereotypic behavior, with
diminishing rates over time. The prevalence of self-injurious behaviors, however, has
been estimated to be in the range of 2 to 3 percent among children and adolescents with
intellectual disability. Stereotypic movements appear to occur in about twice as many
boys as girls. Determining which cases are sufficiently severe to confirm a diagnosis of
stereotypic movement disorder may be difficult. Stereotypic behaviors occur in 10 to 20
percent of children with intellectual disability, with increased rates being proportional
to level of severity. Self-injurious behaviors frequently occur in genetic syndromes, such
as Lesch-Nyhan syndrome, and in children with sensory impairments, such as blindness
and deafness.
ETIOLOGY
The etiology of stereotypic movement disorder includes environmental, genetic, and
neurobiological factors. Although the neurobiological mechanisms of stereotypic
movement disorder have yet to be proven, given their similarity to other involuntary
movements, stereotypic movement disorder is hypothesized to originate from the basal
ganglia. Dopamine and serotonin are likely to be involved in their emergence.
Dopamine agonists tend to induce or increase stereotypic behaviors, whereas dopamine
antagonists sometimes decrease them. One study found that 17 percent of typically
developing children with stereotypic movement disorder had a first-degree relative with
the disorder, and 25 percent had a first- or second-degree relative with stereotypic
movement disorder. Transient stereotypic behaviors in very young children can be
considered a normal developmental phenomenon. Genetic factors likely play a role in
some stereotypic movements, such as the X-linked recessive deficiency of enzymes
leading to Lesch-Nyhan syndrome, which has predictable features including intellectual
disability, hyperuricemia, spasticity, and self-injurious behaviors. Other minimal
stereotypic movements that do not usually cause impairment (e.g. nail-biting) appear to
run in families as well. Some stereotypic behaviors seem to emerge or become
exaggerated in situations of neglect or deprivation; such behaviors as head-banging
have been associated with psychosocial deprivation.
DIAGNOSIS AND CLINICAL FEATURES
The presence of multiple repetitive stereotyped symptoms tends to occur frequently
among children with autism spectrum disorder and intellectually disability, particularly
when the intellectual disability is severe. Patients with multiple stereotyped movements
frequently have other significant mental disorders, including disruptive behavior
disorders, or neurological conditions. In extreme cases, severe mutilation and lifethreatening injuries can result from self-inflicted trauma.
Head-Banging
Head-banging exemplifies a stereotypic movement disorder that can result in functional
impairment. Typically, head-banging begins during infancy, between 6 and 12 months
of age. Infants strike their heads with a definite rhythmic and monotonous continuity
against the crib or another hard surface. They seem to be absorbed in the activity, which
can persist until they become exhausted and fall asleep. The head-banging is often
transitory, but sometimes persists into middle childhood. Head-banging that is a
component of temper tantrums differs from stereotypic head-banging and ceases after
the tantrums and their secondary gains have been controlled.
Nail-Biting
Nail-biting begins as early as 1 year of age and increases in incidence until age 12. Most
cases are not sufficiently severe to meet the DSM-5 diagnostic criteria for stereotypic
movement disorder. In rare cases, children cause physical damage to the fingers
themselves, usually by associated biting of the cuticles, which leads to secondary
infections of the fingers and nail beds. Nail-biting seems to occur or increase in intensity
when a child is either anxious or stressed. Some of the most severe nail-biting occurs in
children with severe or profound intellectual disability, however many nail-biters have
no obvious emotional disturbance.
PATHOLOGY AND LABORATORY EXAMINATION
No specific laboratory measures are helpful in the diagnosis of stereotypic movement
disorder.
Tim, a 14-year-old with autism spectrum disorder (ASD), and severe intellectual
disability was evaluated when he transferred to a new private school for children with
ASD. Observed in his classroom, he was noted to be a small boy who appeared
younger than his age. He held his hands in his pockets and spun around in place.
When offered a toy he took it and manipulated it for a while. When he was prompted
to engage in various tasks that required that he take his hands out of his pockets, he
began hitting his head with his hands. If his hands were held by the teacher, he hit his
head with his knees. He was adept in contorting himself, so that he could hit or kick
himself in almost any position, even while walking. Soon, his face and forehead were
covered with bruises.
His development was delayed in all spheres, and he never developed language. He
lived at home and attended a special educational program. His self-injurious
behaviors developed early in life, and, when his parents tried to stop him, he became
aggressive. Gradually, he became too difficult to be managed in public school, and, at
5 years of age, he was placed in a special school. The self-abusive and self-restraining
(i.e., holding his hands in his pockets) behavior was present throughout his stay there,
and, virtually all of the time; he had been tried on several second-generation
antipsychotics with only minimal improvement. Although the psychiatrist’s notes
mentioned some improvement in his self-injurious behavior, it was described as
continuing and fluctuating. He was transferred to a new school because of lack of
progress and difficulties in managing him as he became bigger and stronger. His
intellectual functioning was within the 34 to 40 intelligence quotient (IQ) range. His
adaptive skills were poor. He required full assistance in self-care, could not provide
even for his own simple needs, and required constant supervision for his safety.
In a few months, Tim settled into the routine in his new school. His self-injurious
behavior fluctuated. It was reduced or even absent when he restrained himself by
holding his hands in his pockets or inside his shirt or even by manipulating some
object with his hands. If left to himself, he could contort himself, while holding his
hands inside his shirt. Because the stereotypic self-injurious and self-restraining
behavior interfered with his daily activities and education, it became a primary focus
of a behavior modification program. For a few months, he did well, especially when
he developed a good relationship with a new teacher, who was firm, consistent, and
nurturing. With him, Tim could successfully engage in some school tasks. When the
teacher left, Tim regressed. To prevent injuries, the staff started blocking his self-
hitting with a pillow. He was offered activities that he liked and in which he could
engage without resorting to self-injury. After several months, his antipsychotic
medication was slowly discontinued, over a period of 11 months, without any
behavioral deterioration. (Adapted from case material from Bhavik Shah, M.D.)
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of stereotypic movement disorder includes obsessivecompulsive disorder (OCD) and tic disorders, both of which are exclusionary criteria in
DSM-5. Although stereotypic movements can often be voluntarily suppressed, and are
not spasmodic, it is difficult to differentiate these features from tics in all cases. A study
of stereotyped movements compared with tics found that stereotyped movements tended
to be longer in duration, and displayed more rhythmic qualities than tics. Tics seemed to
occur more when a child was in an “alone” condition, rather than when the child was in
a play condition, whereas stereotypic movements occurred with the same frequency in
these two different conditions. Stereotypic movements are often observed to seem selfsoothing, whereas tics are often associated with distress.
Differentiating dyskinetic movements from stereotypic movements can be difficult.
Because antipsychotic medications can sometimes suppress stereotypic movements,
clinicians should note any stereotypic movements before initiating treatment with an
antipsychotic agent. Stereotypic movement disorder may be diagnosed concurrently
with substance-related disorders (e.g., amphetamine use disorders), severe sensory
impairments, central nervous system and degenerative disorders (e.g., Lesch-Nyhan
syndrome), and severe schizophrenia.
COURSE AND PROGNOSIS
The duration and course of stereotypic movement disorder vary, and the symptoms may
wax and wane. Up to 60 to 80 percent of normal toddlers show transient rhythmic
activities that seem purposeful and comforting and tend to disappear by 4 years of age.
When stereotypic movements emerge more severely later in childhood they typically
range from brief episodes occurring under stress, to an ongoing pattern in the context of
a chronic condition, such as ASD or intellectual disability. Even in chronic conditions,
stereotypic behaviors may come and go. In many cases, stereotypic movements are
prominent in early childhood and diminish as a child gets older.
The severity of the dysfunction caused by stereotypic movements varies with the
frequency, amount, and degree of associated self-injury. Children who exhibit frequent,
severe, self-injurious stereotypic behaviors have the poorest prognosis. Repetitive
episodes of head-banging, self-biting, and eye-poking can be difficult to control without
physical restraints. Most nail-biting is benign and often does not meet the diagnostic
criteria for stereotypic movement disorder. In severe cases in which the nail beds are
repetitively damaged, bacterial and fungal infections can occur. Although chronic
stereotypic movement disorders can severely impair daily functioning, several
treatments help control the symptoms.
TREATMENT
When stereotypic movements occur in the absence of any other symptoms or disorders,
they may not warrant pharmacologic treatment. Treatment modalities yielding the most
promising effects include behavioral techniques, such as habit reversal and differential
reinforcement of other behavior, as well as pharmacological interventions. A recent
report on utilizing both habit reversal (in which the child is trained to replace the
undesired repetitive behavior with a more acceptable behavior) and reinforcement for
reducing the unwanted behavior, indicated that these treatments had efficacy among 12
typically developing children between 6 and 14 years. One case report detailed a
successful habit reversal treatment of a 3-year-old with severe stereotypic movements,
which was largely implemented at home by her parents. The estimated change in
stereotypic behaviors during regular recorded intervals during treatment diminished
from presence in 85 percent of recordings to presence in less than 2 percent of
recordings over a period of 4 weeks.
Pharmacological interventions have been used in clinical practice to minimize selfinjury in children whose stereotyped movements caused significant harm to their bodies.
Small open-label studies have reported benefit of atypical antipsychotics, and case
reports have indicated use of selective serotonin reuptake inhibitor (SSRIs) in the
management of self-injurious stereotypies. The dopamine receptor antagonists have
been tried most often for treating stereotypic movements and self-injurious behavior.
The SSRI agents may be influential in diminishing stereotypies; however, this is still
under investigation. Open trials suggest that both clomipramine and fluoxetine may
decrease self-injurious behaviors and other stereotypic movements in some patients.
REFERENCES
Barry S, Baird G, Lascelles K, Bunton P, Hedderly T. Neurodevelopmental movement disorders—an update on childhood
motor stereotypies. Dev Med Child Neurol. 2011;53:979–985.
Doyle RL. Stereotypic movement disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive
Textbook of Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins; 2009:3642.
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Fernandez AE. Primary versus secondary stereotypic movements. Rev Neurol. 2004; 38[Suppl 1]:21.
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16 - 31.8c Tourettes Disorder
31.8c Tourette’s Disorder
children. J Pediatr. 2004;145:391.
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31.8c Tourette’s Disorder
Tics are neuropsychiatric events characterized by brief rapid motor movements or
vocalizations that are typically performed in response to irresistible premonitory urges.
Although frequently rapid, tics may include more complex patterns of movements and
longer vocalizations. Converging evidence from many lines of research suggests that the
production of tics involves dysfunction in the basal ganglia region of the brain,
particularly of dopaminergic transmission in the cortico-striatothalamic circuits. Because
tic disorders are significantly more common in children than in adults, the postulated
alterations in dopamine circuitry in many affected children appear to spontaneously
improve over time. Tics may be transient or chronic, with a waxing and waning course.
Tics typically emerge at age 5 to 6 years of age and tend to reach their greatest severity
between 10 and 12 years. About one half to two thirds of children with tic disorders will
be much improved or in remission by adolescence or early adulthood. Tic disorder is
distinguished by the type of tics, their frequency, and the pattern in which they emerge
over time. Motor tics most commonly affect the muscles of the face and neck, such as
eye-blinking, head-jerking, mouth-grimacing, or head-shaking. Typical vocal tics include
throat-clearing, grunting, snorting, and coughing. Tics are repetitive muscle
contractions resulting in movements or vocalizations that are experienced as
involuntary, although they can sometimes be suppressed voluntarily Children and
adolescents may exhibit tic behaviors that occur after a stimulus or in response to a
premonitory internal urge.
The most widely studied and most severe tic disorder is Gilles de la Tourette
syndrome, also known as Tourette’s disorder. Georges Gilles de la Tourette (1857–1904)
first described a patient with a syndrome, which became known as Tourette’s disorder in
1885, while he was studying with Jean-Martin Charcot in France. De la Tourette noted a
syndrome in several patients that included multiple motor tics, coprolalia, and
echolalia. Tics often consist of motions that are used in volitional movements. One half
to two thirds of children with Tourette’s disorder exhibit a reduction in or complete
remission of tic symptoms during adolescence. There are many common comorbid
psychiatric disorders and behavioral problems likely to emerge along with Tourette’s
disorder. For example, the relationship between Tourette’s disorder, attentiondeficit/hyperactivity disorder (ADHD), and obsessive-compulsive disorder (OCD) has not
been clearly delineated. Epidemiological surveys indicate that more than half of children
with Tourette’s disorder also meet criteria for ADHD. There appears to be a bidirectional
relationship between Tourette’s disorder and OCD, with 20 to 40 percent of Tourette’s
disorder patients meeting full criteria for OCD. First-degree relatives of patients with
OCD have been shown to have higher rates of tic disorders compared to the general
population. There have been a few small reports suggesting that the obsessivecompulsive symptoms most likely to occur in Tourette’s disorder are characteristically
related to ordering and symmetry, counting, and repetitive touching, whereas OCD
symptoms in the absence of tic disorders are more often associated with fears of
contamination and fears of doing harm. Motor and vocal tics are divided into simple
and complex types. Simple motor tics are those composed of repetitive, rapid contractions
of functionally similar muscle groups—for example, eye-blinking, neck-jerking,
shoulder-shrugging, and facial-grimacing. Common simple vocal tics include coughing,
throat-clearing, grunting, sniffing, snorting, and barking. Complex motor tics appear to
be more purposeful and ritualistic than simple tics. Common complex motor tics include
grooming behaviors, the smelling of objects, jumping, touching behaviors, echopraxia
(imitation of observed behavior), and copropraxia (display of obscene gestures).
Complex vocal tics include repeating words or phrases out of context, coprolalia (use of
obscene words or phrases), palilalia (a person’s repeating his or her words), and
echolalia (repetition of the last-heard words of others).
Although older children and adolescents with tic disorders may be able to suppress
their tics for minutes or hours, young children are often not cognizant of their tics or
experience their urges to perform their tics as irresistible. Tics may be attenuated by
sleep, relaxation, or absorption in an activity. Tics often disappear during sleep.
EPIDEMIOLOGY
The estimated prevalence of Tourette’s disorder ranges from 3 to 8 per 1,000 school-age
children. Males are affected between 2 and 4 times more often than females. The unique
features of Tourette’s disorder in which tics wax and wane and may change in character,
frequency, and severity over relatively short periods of time, has made ascertainment of
its prevalence challenging. Furthermore, remission of tics is particularly age-dependent
in that tics tend to emerge and increase from ages 5 to 10 years of age, and in many
cases, decrease in frequency and severity after the age of 10 to 12 years. At age 13
years, however, using stringent criteria, the prevalence rate for Tourette’s disorder
drops to 0.3 percent. The lifetime prevalence of Tourette’s disorder is estimated to be
approximately 1 percent.
ETIOLOGY
Genetic Factors
Twin studies, adoption studies, and segregation analysis studies all support a genetic
basis, albeit a complex one, for Tourette’s disorder. Twin studies indicate that
concordance for the disorder in monozygotic twins is significantly greater than that in
dizygotic twins. Tourette’s disorder and chronic motor or vocal tic disorder are likely to
occur in the same families; this lends support to the view that the disorders are part of a
genetically determined spectrum. The sons of mothers with Tourette’s disorder seem to
be at the highest risk for the disorder. Evidence in some families indicates that Tourette’s
disorder is transmitted in an autosomal dominant fashion. Studies of a long family
pedigree suggest that Tourette’s disorder may be transmitted in a bilinear mode; that is,
Tourette’s disorder appears to be inherited through an autosomal pattern in some
families, intermediate between dominant and recessive. A study of 174 unrelated
probands with Tourette’s disorder identified a greater than chance occurrence of a rare
sequence variant in SLITRK1, believed to be a candidate gene on chromosome 13q31.
Up to half of all patients with Tourette’s disorder also have ADHD, and up to 40
percent of those with Tourette’s disorder also have OCD. These frequent comorbidities
with Tourette’s disorder can lead to a plethora of overlapping symptoms. Family studies
have provided compelling evidence for the association between tic disorders and OCD.
First-degree relatives of persons with Tourette’s disorder are at high risk for the
development of Tourette’s disorder, chronic motor or vocal tic disorder, and OCD.
Current understanding of the genetic bases of Tourette’s disorder implicates multiple
vulnerability genes that may serve to mediate the type and severity of tics. Candidate
genes associated with Tourette’s disorder include dopamine receptor genes, dopamine
transporter genes, several noradrenergic genes, and serotonergic genes.
Neuroimaging Studies
A functional magnetic resonance imaging (fMRI) study of brain activity two seconds
before and after a tic, found that paralimbic and sensory association areas were
involved. Furthermore, evidence suggests that voluntary tic suppression involves
deactivation of the putamen and globus pallidus, along with partial activation of
regions of the prefrontal cortex and caudate nucleus. Compelling, but indirect, evidence
of dopamine system involvement in tic disorders includes the observations that
pharmacological agents that antagonize dopamine (haloperidol [Haldol], pimozide
[Orap], and fluphenazine [Prolixin]) suppress tics and that agents that increase central
dopaminergic activity (methylphenidate [Ritalin], amphetamines, and cocaine) tend to
exacerbate tics. The relation of tics to neurotransmitter systems is complex and not yet
well understood; for example, in some cases, antipsychotic medications, such as
haloperidol, are not effective in reducing tics, and the effect of stimulants on tic
disorders reportedly varies. In some cases, Tourette’s disorder has emerged during
treatment with antipsychotic medications.
More direct analyses of the neurochemistry of Tourette’s disorder have been possible
utilizing brain proton magnetic resonance spectroscopy (MRS). Neuroimaging studies
using cerebral blood flow in positron emission tomography (PET) and single photon
emission tomography (SPECT) suggest that alterations of activity may occur in various
brain regions in patients with Tourette’s disorder compared to controls, including the
frontal and orbital cortex, striatum, and putamen. An investigation examining the
cellular neurochemistry of patients with Tourette’s disorder utilizing MRS of the frontal
cortex, caudate nucleus, putamen, and thalamus demonstrated that these patients had a
reduced amount of choline and N-acetylaspartate in the left putamen along with
reduced levels bilaterally in the putamen. In the frontal cortex, patients with Tourette’s
disorder were found to have lower concentrations of N-acetylaspartate bilaterally, lower
levels of creatine on the right side, and reduced myoinositol on the left side. These
results suggest that deficits in the density of neuronal and nonneuronal cells are present
in patients with the disorder. Abnormalities in the noradrenergic system have been
implicated in some cases by the reduction of tics with clonidine (Catapres). This
adrenergic agonist reduces the release of norepinephrine in the central nervous system
and, thus, may reduce activity in the dopaminergic system. Abnormalities in the basal
ganglia are known to result in various movement disorders, such as Huntington’s
disease, and are also implicated as likely sites of disturbance in Tourette’s disorder.
Immunological Factors and Post Infection
An autoimmune process and, in particular, one that is secondary to group A betahemolytic streptococcal infections was hypothesized as a potential mechanism for the
development of tics and obsessive-compulsive symptoms in some case. Data have been
conflicting and controversial, and this mechanism appears to be unlikely as an etiology
of Tourette’s disorder in most cases. One case-control study found little evidence of the
development or exacerbation of tics, or obsessions or compulsions, in children with welldocumented and treated group A beta-hemolytic streptococcal infections.
DIAGNOSIS AND CLINICAL FEATURES
A diagnosis of Tourette’s disorder depends on a history of multiple motor tics that
generally emerge over a period of months or years, and the emergence of at least one
vocal tic at some point. According to the American Psychiatric Association’s Fifth Edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), tics may wax and
wane in frequency, but must have persisted for more than a year since the first tic
emerged to meet the diagnosis. The average age of onset of tics is between 4 years and
6 years of age, although in some cases, tics may occur as early as 2 years of age. The
peak age for severity of tics is between 10 and 12 years. To meet diagnostic criteria for
Tourette’s disorder, the onset must occur before the age of 18 years.
In Tourette’s disorder, typically the initial tics are in the face and neck. Over time, the
tics tend to occur in a downward progression. The most commonly described tics are
those affecting the face and head, the arms and hands, the body and lower extremities,
and the respiratory and alimentary systems. In these areas, the tics take the form of
grimacing; forehead puckering; eyebrow-raising; eyelid-blinking; winking; nosewrinkling; nostril-trembling; mouth-twitching; displaying the teeth; biting the lips and
other parts; tongue-extruding; protracting the lower jaw; nodding, jerking, or shaking
the head; twisting the neck; looking sideways; head-rolling; hand-jerking; arm-jerking;
plucking fingers; writhing fingers; fist-clenching; shoulder-shrugging; foot, knee, or toe
shaking; walking peculiarly; body writhing; jumping; hiccupping; sighing; yawning;
snuffing; blowing through the nostrils; whistling; belching; sucking or smacking sounds;
and clearing the throat. Several assessment instruments are currently available that are
useful in making diagnoses of tic disorders, including comprehensive self-report
assessment tools, such as the Tic Symptom Self Report and the Yale Global Tic Severity
Scale, administered by a clinician (Table 31.8c-1).
Table 31.8c-1
Clinical Assessment Tools in Tic Disorders
Because Tourette’s disorder is frequently comorbid with attentional, obsessional, and
oppositional behaviors, these symptoms often emerge prior to the tics. In some studies,
more than 25 percent of children with Tourette’s disorder received stimulants for a
diagnosis of ADHD before receiving a diagnosis of Tourette’s disorder. The most frequent
initial symptom is an eye-blink tic, followed by a head tic or a facial grimace. Most
complex motor and vocal symptoms emerge several years after the initial symptoms.
Coprolalia, a very unusual symptom involving shouting or speaking socially
unacceptable or obscene words, occurs in less than 10 percent of patients and rarely in
the absence of comorbid psychiatric disturbance. Mental coprolalia—in which a patient
experiences a sudden, intrusive, socially unacceptable thought or obscene word—occurs
more often than coprolalia. In severe cases, physical self-injury has occurred due to tic
behaviors.
Jake, age 10 years, came to the Tourette Disorder Clinic for an evaluation of motor
tics in the head and neck, occasional coughing and grunting, and a new symptom of
throat clearing many times per day. Jake had a past history of ADHD, which included
significant hyperactivity, and impulsive and oppositional behavior He is a fifth-grade
student in a regular class at the local public school. Before the consultation, parent
and teacher ratings, including the Child Behavior Checklist (CBCL), Swanson, Nolan, and
Pelham-IV (SNAP-IV), Conners’ Parent and Teacher Questionnaires, Tic Symptom SelfReport (TSSR), and medical history survey, were sent to his family. His mother and the
classroom teacher rated him well above the norm for hyperactivity, inattention, and
impulsiveness. He was failing several subjects in school, often argued with adults, was
occasionally aggressive, and had few friends. His tics were rated as moderate.
Jake’s mother recalls difficulties with overactivity, oppositional and defiant
behaviors and behavior since preschool. At age 5, due to his activity level and
argumentative and aggressive behavior, his kindergarten teacher encouraged the
family to obtain a psychiatric consultation. Jake’s pediatrician made a diagnosis of
ADHD and recommended a trial of Concerta (methylphenidate extended-release
tablets) at 36 mg per day, which was started at the beginning of the first grade.
Within a week of starting medication, Jake’s overly active and impulsive behavior
showed a dramatic improvement; however, he remained argumentative and
oppositional. However, when on his Concerta, Jake was able to stay in his seat and
complete his work and was better able to wait his turn on the playground. The next
few months went well, however, by early spring, Jake seemed to be returning back to
some of his old ways. He was talking out of turn in class, and getting out of his seat,
which was disruptive to the class. After an increase in Concerta to 54 mg per day, in
the spring of his first-grade year, however, he began showing motor and phonic tics
consisting of head-jerking, facial movements, coughing, and grunting. The Concerta
was discontinued to see if this made a difference and was immediately stopped and,
although the tics transiently decreased, they came back in full force within a month.
In hindsight, Jake’s mother recalled that Jake had exhibited eye blinking and grunting
prior to starting the Concerta, but she had dismissed these events as unimportant and
they did not seem to disrupt Jake’s daily life.
While Jake was off Concerta during a period when he began middle school in the
6th grade, Jake was disruptive to his classes and he began to be severely teased by
several classmates for his impulsivity, frequent motor tics, and loud grunting and
throat clearing. Jake became despondent and began to refuse to go to school. At this
point, it was decided to place Jake in a special education class. However, after several
months of this placement, Jake felt worse about himself, despised school, and begged
to be returned to regular classes. At this point Jake’s pediatrician made the referral to
a child and adolescent psychiatrist at a local university Tourette Disorder Clinic.
During his evaluation at the Tourette Disorder Clinic, Jake was reported to be a
healthy child who was the product of an uncomplicated pregnancy, labor, and
delivery, and whose developmental milestones were achieved at appropriate times.
Intellectual testing completed by the school psychologist revealed a full scale IQ of
105. Jake’s mother noted that Jake has had long-standing trouble falling asleep but
sleeps through the night. Jake has always been described as argumentative and easily
frustrated with frequent outbursts of temper; however, when he is not having a
tantrum, his mood is generally upbeat.
Jake was noted by the child and adolescent psychiatrist to be of average height and
weight with no dysmorphic features. His speech was rapid in tempo but normal in
tone and volume. His speech is coherent and developmentally appropriate, without
evidence of thought disorder; however, vocal tics including grunting, coughing, and
obvious throat clearing were observed. Jake denied depressed mood or suicidal
ideation, although he reported distress about everyday issues such as being teased by
peers, not having enough friends, and his poor school performance. Jake also denied
recurring worries about contamination or harm coming to him or family members, or
fears of acting on unwanted impulses. Other than mild touching habits involving the
need to touch objects with each hand three times or in combinations of three, Jake
denies repetitive rituals. Several motor tics were also observed during the evaluation
session, including blinking, head-jerking, and shoulder tics. Jake was restless and
easily distracted throughout the session and often needed assistance with entertaining
himself when not directly involved in conversation.
Given the history of enduring motor and phonic tics, confirmed by direct
observation, the diagnosis of Tourette’s disorder and ADHD, as well as oppositional
defiant disorder were confirmed.
Jake and his family attended several sessions with the child and adolescent
psychiatrist to learn about the waxing and waning nature of tic symptoms and the
natural history of Tourette’s Disorder, as well as ADHD. Jake and his family were
heartened to hear that, in general, tics tend to be at their maximum around his age,
and it was somewhat likely that Jake’s tics would lessen over time or possibly fully
remit. Jake was referred to a behavioral psychologist specializing in habit reversal
training. In this treatment Jake was taught to engage in a behavior physically
incompatible with his tic (a competing response) each time he experienced the urge to
perform this tic. The competing response for Jake’s shoulder tic, which consisted of
raising his shoulders up as far as he could, was to gently press his shoulders down and
extend his neck each time he felt the urge to engage in this tic. With repeated practice
of his competing response, Jake’s urge to engage in this tic greatly diminished to the
point where he was able to manage the urge without performing the tic. Jake was
referred to a child and adolescent psychiatrist who decided to re-start the Concerta at
36 mg per day and titrated it back up to 54 mg per day without worsening of the tics.
Jake responded well to his behavioral therapy, and over a period of 8 weeks, he had
learned how to become aware of the urges that occurred prior to his tics and to
voluntarily replace his usual tics with less-distressing and less-disruptive behaviors.
However, when Jake entered the 7th grade, he had an exacerbation of his motor
and vocal tics, and was also touching objects repeatedly throughout the day. Jake
again became despondent, not wanting to go to school. It was decided by his
psychologist to add relaxation training to his behavioral treatment, and his child and
adolescent psychiatrist another medication to his pharmacological regimen. Jake was
prescribed risperidone, 0.5 mg per day, which was titrated up to 1 mg twice daily.
With the addition of these psychological and pharmacological interventions, Jake
became stabilized within a month, and was able to continue in his school and even
went to some parties. Jake and his parents understood the waxing and waning nature
of his tics, and were hopeful that they would begin to see some decrease in his tic
symptoms within the next few years. At follow-up, when Jake was 15 years of age,
Jake had minimal tic symptoms; an occasional eye blink and rare throat clearing was
all that was observable. Jake was not currently in behavioral treatment, however,
over the years, he had, on a few occasions received some booster therapy sessions to
brush up on his habit reversal training when he had a minor exacerbation of tics. Jake
had been taken off his risperidone a 2 years before without an exacerbation of tics.
Jake continued on Concerta 54 mg per day and was well controlled on that dose, was
doing well in school, and had become more popular since he had joined the soccer
team. (Adapted from L. Scahill M.S.N., Ph.D. and J.F. Leckman, M.D.)
PATHOLOGY AND LABORATORY EXAMINATION
No specific laboratory diagnostic test exists for Tourette’s disorder, but many patients
with Tourette’s disorder have nonspecific abnormal electroencephalographic findings.
Computed tomography (CT) and magnetic resonance imaging (MRI) scans have
revealed no specific structural lesions, although about 10 percent of all patients with
Tourette’s disorder show some nonspecific abnormality on CT scans.
DIFFERENTIAL DIAGNOSIS
Tics must be differentiated from other movements and movement disorders (e.g.,
dystonic, choreiform, athetoid, myoclonic, and hemiballismic movements) and the
neurological diseases that they may characterize (e.g., Huntington’s disease,
parkinsonism, Sydenham’s chorea, and Wilson’s disease), as listed in Table 31.8c-2.
Tremors, mannerisms, and stereotypic movement disorder (e.g., head-banging or bodyrocking) must also be distinguished from tic disorders. Stereotypic movement disorders,
including movements such as rocking, hand-gazing, and other self-stimulatory
behaviors, seem to be voluntary and often produce a sense of comfort, in contrast to tic
disorders. Although tics in children and adolescents may or may not feel controllable,
they rarely produce a sense of well-being. Compulsions are sometimes difficult to
distinguish from complex tics and may be on the same continuum biologically. Tic
disorders may also occur comorbidly with mood disturbances. In a recent survey, the
greater the severity of tics, the higher the probability of both aggressive and depressive
symptoms in children. When a child experiences an exacerbation of tic symptoms,
behavior and mood also seem to deteriorate.
Table 31.8c-2
Differential Diagnosis of Tic Disorders
COURSE AND PROGNOSIS
Tourette’s disorder is a childhood-onset neuropsychiatric disorder characterized by both
motor and vocal tics, which usually emerge in early childhood, with a natural history
leading to reduction or complete resolution of tics symptoms in most cases by
adolescence or early adulthood. During childhood, individual tic symptoms may
decrease, persist, or increase, and old symptoms may be replaced by new ones. Severely
afflicted persons may have serious emotional problems, including major depressive
disorder. Impairment may also be associated with the motor and vocal tic symptoms of
Tourette’s disorder; however, in many cases, interference in function is exacerbated by
comorbid ADHD and OCD, both of which frequently coexist with the disorder. When the
above three disorders are comorbid, severe social, academic, and occupational problems
may ensue. Although most children with Tourette’s disorder will experience a decline in
the frequency and severity of tic symptoms during adolescence, at present, no clinical
measures exist to predict which children may have persistent symptoms into adulthood.
Children with mild forms of Tourette’s disorder often have satisfactory peer
relationships, function well in school, and develop adequate self-esteem, and may not
require treatment.
TREATMENT
Once a diagnosis of Tourette’s disorder is made, psychoeducation is a useful intervention
in order for families to gain an understanding of the variability of tics, the natural
history of the disorder, and ways to support reduction of stress. It is particularly
important for families to be well-informed advocates for their children, since tics may be
misinterpreted by an uneducated observer as a child’s purposeful misbehavior, rather
than a response to an irresistible urge. The need for treatment is based on subjective
distress of a child with respect to tics as well as observable disruptions in functioning. In
mild cases, children with tic disorders who are functioning well socially and
academically may not seek, nor require treatment. In more severe cases, children with
tic disorders may be ostracized by peers and have academic work compromised by the
disruptive nature of tics, and a variety of interventions including psychosocial,
pharmacological, and school based may be considered. A scale to measure tic severity,
the Premonitory Urge for Tics Scale (PUTS), was examined psychometrically, and found to
be internally consistent and correlated with overall tic severity in youth over 10 years of
age.
The European clinical guidelines for Tourette’s syndrome and other tic disorders
summarized and reviewed the evidence-based treatments for Tourette’s disorder and
developed a consensus for psychosocial and pharmacological treatments. This guideline
recommends that both behavioral and pharmacological interventions be considered in
more severe cases, with behavioral interventions typically the first line of treatment.
Indications for treatment include, but are not limited to, the following clinical
presentations. Tics require treatment when they cause social and emotional problems,
depression, or isolation. Children who are prone to severe persistent complex motor tics
or loud vocal tics may be the objects of bullying and social rejection. In these cases,
depressive symptoms commonly result. Tic reduction and psychoeducation to the school
may be indicated in order to preserve healthy social relationships, and to diminish
depressive and anxiety symptoms. Tics may also lead to impairment in academic
achievement, when school functioning is disrupted. School difficulties in children with
Tourette’s disorder are not uncommon, and reduction in tics may support increased
academic success. Tics may also lead to physical discomfort, based on the repetitive
musculoskeletal exertion, especially in relation to head and neck tics. In some children
with Tourette’s disorder, tics can worsen headaches and migraines. Behavioral and
pharmacological interventions can both target tic reductions, which can lead to
improved quality of life.
Evidence-based Behavioral and Psychosocial Treatment
The Canadian guidelines for the evidence-based treatment of tic disorders: behavioral
therapy, deep brain stimulation and transcranial magnetic stimulation, and a large
multi-site randomized controlled trial of “Comprehensive Behavioral Intervention for
Tics,” (CBIT) both found converging evidence supporting habit-reversal training and
exposure and response prevention as efficacious treatments for tic reduction. In a
randomized controlled trial of CBIT, 61 children received habit reversal training as their
main component of treatment, and they also received relaxation treatment and a
functional intervention to identify situations that worsened or sustained tics and
strategies to decrease exposure to these situations. The control group of 65 children
received supportive psychotherapy and psychoeducation. After 10 weeks of treatment,
the Yale Global Tic Severity Scale Total Tic score was significantly reduced in the
behavioral intervention group compared with the control group.
Habit Reversal.
The primary components of habit reversal are awareness training,
in which the child uses self-monitoring to enhance awareness of tic behaviors and the
premonitory urges or sensations indicating that a tic is about to occur. In competingresponse training, the patient is taught to voluntarily perform a behavior that is
physically incompatible with the tic, contingent on the onset of the premonitory urge or
the tic itself, blocking expression of the tic. The competing-response strategy is based on
the self-reported observations of patients that tics are performed in response to
irresistible premonitory urges in order to diminish the urge. Because performing the tic
satisfies or reduces the premonitory urges, the tics are reinforced, and over time, become
repeated entrenched behaviors. Competing-response training is different from voluntary
tic suppression in that the patient initiates a voluntary behavior to manage the
premonitory urge and thus disrupts the reinforcement of the tic, rather than simply
trying to suppress the tic. Successful competing-response training results in significant
reduction in premonitory urge intensity or complete elimination of the urge altogether
so that tics are no longer provoked. For motor tics, a behavior that is less noticeable
may be chosen, whereas for vocal tics, slow rhythmic breathing is the most common
voluntary competing response. The competing responses are designed to be performed
without disrupting usual activities.
Exposure and Response Prevention.
The rationale for this treatment is based
on the notion that tics occur as a conditioned response to unpleasant premonitory urges,
and since the tics reduce the urge, they become associated with the premonitory urge.
Each time the urge is reduced by the tic, their association is further strengthened. Rather
than using competing responses, as in habit-reversal training, exposure and response
prevention asks the patient to suppress tics for increasingly prolonged periods in order
to break the association between the urges and the tics. Theoretically, if a patient learns
to resist performing the tic in response to the urge for long enough periods, the urge
may become more tolerable, or attenuate, and the need to perform the tic may diminish.
Many other behavioral interventions such as relaxation training, self-monitoring, bio
(neuro) feedback, and cognitive-behavioral treatment (CBT), have not been shown to be
efficacious in the reduction of tics on their own; however, some of these strategies may
be included in comprehensive treatment programs for children with tic disorders who
are receiving habit-reversal training. Habit reversal has been the most extensively
researched behavioral treatment for tic disorders; it has been shown to be highly
effective, and is currently the first-line behavioral treatment for tic disorders.
Evidence-based Pharmacotherapy
Several reviews of pharmacological treatments for tics suggest that the following classes
of pharmacologic agents have an evidence base for treating tics: typical and atypical
antipsychotics; noradrenergic agents; and alternative treatments such as tetrabenazine,
topiramate, and tetrahydrocannabinol.
Atypical and Typical Antipsychotic Agents.
Risperidone, with its high
affinity for dopamine D2 and serotonin 5-HT2 receptors, is the most well-studied
atypical antipsychotic in the treatment of tics. There is considerable evidence for its
efficacy. Multiple randomized, controlled studies in children and adolescents have
shown favorable results compared to placebo as well as in head-to-head studies with the
typical antipsychotic agents haloperidol and pimozide. Risperidone was associated with
fewer adverse events compared to typical antipsychotics; however, it was frequently
associated with weight gain, metabolic side effects, and hyperprolactinemia. In a
randomized, double-blind, parallel group study of Tourette’s disorder comparing
risperidone to pimozide, risperidone showed superiority in reducing comorbid obsessivecompulsive symptoms as well as reducing tics. In other randomized clinical trials,
efficacy of tic reduction was achieved in studies of children, adolescents, and adults with
mean daily doses of 2.5 mg daily with a range of 1 to 6 mg daily.
Haloperidol (Haldol) and pimozide (Orap) are the two most well-investigated and
Food and Drug Administration (FDA)–approved antipsychotic agents in the treatment of
Tourette’s disorder, although atypical antipsychotics such as risperidone are often
chosen as first-line agents due to their safer side-effect profiles. Both haloperidol and
pimozide have been shown to be efficacious in multiple randomized clinical trials in the
treatment of Tourette’s disorder. Both haloperidol and pimozide present significant risks
for extrapyramidal side effects; in a long-term naturalistic follow-up study, haloperidol
was found to produce more significant acute dyskinesia and dystonia compared to
pimozide.
A third typical antipsychotic, fluphenazine, has been used in the United States for
many years in the treatment of tic disorders, in the absence of robust data supporting its
efficacy. A small controlled study of fluphenazine, trifluphenazine, and haloperidol
found similar reductions in tics; however, haloperidol was associated with more
extrapyramidal side effects and more sedation. The frequency of sedation, dystonia, and
akathisia of typical antipsychotics, probably due to their predominant dopaminergic
blockade in the nigrostriatal pathways, limits their use and increases the appeal of the
atypical antipsychotics. Risperidone and pimozide were found to be of equal efficacy in
one study of children, adolescents, and adults with Tourette’s disorder.
Aripiprazole has become a pharmacological agent of interest in the treatment of tic
disorders due to its mode of action; in addition to its D2 receptor antagonistic actions,
aripiprazole is also a partial D2 and 5-HT1A receptor agonist and a 5-HT2A antagonist.
A multisite double-blind controlled study of aripiprazole in children with Tourette’s
disorder in China found a reduction in tic behaviors in about 60 percent of the
aripiprazole group compared to about 64 percent reduction in a group treated with
tiapride, a benzamide with selective D2 receptor antagonism. There was no significant
difference between the two groups. Although sedation and sleep disturbance are
common side effects with aripiprazole, weight gain is less pronounced than with
risperidone.
Olanzapine and ziprasidone were shown to be efficacious in the treatment of tic
disorders in at least one randomized controlled trial. Sedation and weight gain were
prominent side effects with olanzapine, and potential QT prolongation was an issue
with ziprasidone. Quetiapine has been suggested as a potentially useful agent in the
treatment of tics, with its greater affinity for 5-HT2 receptors than for D2 receptors,
however, randomized clinical trials are needed. Clozapine, contrary to many other
atypical antipsychotics, has not been found to be useful in the treatment of tics.
Noradrenergic Agents.
Noradrenergic agents including clonidine and guanfacine,
as well as atomoxetine, are frequently used in children as primary treatments or
adjunctive treatments for comorbid ADHD and tics. Several studies have provided some
evidence for the efficacy of clonidine, an alpha 2-adrenergic agent, in the treatment of
tics in children, adolescents, and adults with tic disorders. The largest randomized trial
with oral clonidine compared to placebo found a modest reduction in tics with clonidine.
A multisite randomized double-blind placebo controlled trial using the clonidine patch in
the treatment of tic disorders in children found a significant improvement in tic
symptoms (about 69 percent) compared to about 47 percent of the children in the
control group. Clonidine has generally been used in dosages ranging from 0.05 mg
orally three times daily to 0.1 mg four times daily; and guanfacine is usually used in
dosages ranging from 1 to 4 mg per day. When used in these dosage ranges, adverse
effects of the α-adrenergic agents may include drowsiness, headache, irritability, and
occasional hypotension.
Guanfacine has been used frequently to treat children with ADHD successfully,
although its efficacy regarding reducing tics is controversial. In one randomized clinical
trial treating 34 children with ADHD and tics, guanfacine was found to be superior to
placebo in the reduction of tics. In another double-blind placebo-controlled trial of 24
children with Tourette’s disorder, guanfacine was not superior to placebo.
Atomoxetine, a selective noradrenaline reuptake inhibitor, was found to reduce both
tics and ADHD symptoms in a multicenter industry trial of 148 children. Atomoxetine
also reduced both tics and ADHD in a subgroup of patients in this study who were
diagnosed with Tourette’s disorder. Additional studies are needed to confirm safety and
efficacy of atomoxetine in the treatment of children with Tourette’s disorder.
In view of the frequent comorbidity of tic behaviors and obsessive-compulsive
symptoms or disorders, the SSRIs have been used alone or in combination with
antipsychotics in the treatment of Tourette’s disorder. Data, thus far, have supported the
efficacy of SSRIs in the treatment of OCD, however there have not been controlled trials
yet to determine the effect of SSRIs on tic reduction.
Although clinicians must weigh the risks and benefits of using stimulants in cases of
severe hyperactivity and comorbid tics, data suggest that methylphenidate does not
increase the rate or intensity of motor or vocal tics in most children with hyperactivity
and tic disorders.
Alternative Agents: Tetrabenazine, Topiramate, and
Tetrahydrocannabinol
TETRABENAZINE. A vesicular monoamine transporter type 2 inhibitor, tetrabenazine
depletes presynaptic dopamine and serotonin, and blocks postsynaptic dopamine
receptors. There are no randomized clinical trials of this agent in the treatment of
Tourette’s disorder in children; however, clinical experience suggests that this agent may
have benefit in tic reduction. In a follow-up of 2 years of treatment in 77 children and
adolescents, one study reports tic reduction improvement in 80 percent of subjects. Side
effects of this agent include sedation, parkinsonism, depression, insomnia, anxiety, and
akathisia.
TOPIRAMATE. A γ-aminobutyric acid (GABA)ergic drug, used primarily as an
anticonvulsant, topiramate was found to be efficacious compared to placebo in reducing
tics in a small randomized clinical trial of children and adults with Tourette’s disorder.
Side effects were minimal. Although this does not confirm its efficacy, GABA-modulating
agents require further study in the treatment of tic disorders.
TETRAHYDROCANNABINOL. A suggestion that tetrahydrocannabinol (THC) may be safe and
efficacious in the treatment of tics, without neuropsychological impairment, is based on
a randomized double-blind placebo-controlled trial with 24 patients treated with THC
for 6 weeks at doses of up to 10 mg with significant improvement in tic severity. In this
trial, reported adverse effects included dizziness, fatigue, and dry mouth. Potential
additional side-effects include anxiety, depressive symptoms, tremor, and insomnia. This
small trial does not confirm efficacy for this agent in the treatment of tics, rather it
raises questions about the potential improvements in treatment-resistant tic disorders
using this agent.
In summary, the greatest evidence for the safe and efficacious pharmacological
treatment of Tourette’s disorder seems to be associated with the atypical antipsychotics,
in particular, risperidone. Pharmacological treatment may be combined with and
enhanced by a variety of behavioral interventions such as habit reversal and school
interventions that may diminish stressful situations in the school environment.
REFERENCES
Debes NM, Hansen A, Skov L, Larsson H. A functional magnetic resonance imaging study of a large clinical cohort of
children with Tourette syndrome. J Child Neurol. 2011;26:560–569.
Eddy CM, Rickards HE, Cavanna AE. Treatment strategies for tics in Tourette syndrome. Ther Adv Neurol Disord.
2011;4:25–45.
Hartmann A, Worbe Y. Pharmacological treatment of Gilles de la Tourette syndrome. Neurosci Biobehav Rev. 2013;37:1157–
1161.
Janovic J, Jimenez-Shahed J, Brown L. A randomized, double-blind, placebo-controlled study of topiramate in the
treatment of Tourette syndrome. J Neurol Neurosurg Psychiatry. 2010;81:70–73.
Jummani R, Coffey BJ. Tic disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of
Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:3609.
Knight T, Stevvers T, Day L, Lowerison M, Jette N, Pringsheim T. Prevalence of tic disorders: A systematic review and
meta-analysis. Pediatr Neurol. 2012;47:77–90.
Kraft JT, Dalsgaard S, Obel C, Thomsen PH, Henriksen TB, Scahill L. Prevalence and clinical correlates of tic disorders in a
community sample of school-age children. Eur Child Adolesc Psychiatry. 2012;21:5–13.
Liu ZS, Chen YH, Zhong YQ, Zou LP, Wang H, Sun D. A multicentre controlled study on aripiprazole treatment for children
with Tourette syndrome in China. Zhonghua Er Ke Za Zhi. 2011;49:572–576.
Paschou P. The genetic basis of Gilles de la Tourette Syndrome. Neurosci Biobehav Rev. 201337:1026–1039.

17 - 31.8d Persistent (Chronic) Motor or Vocal Tic
31.8d Persistent (Chronic) Motor or Vocal Tic Disorder
Piacentini J, Woods DW, Scahill L, Wilhelm S, Peterson AL, Chang S. Behavior therapy for children with Tourette disorder.
A randomized controlled trial. JAMA. 2010;303:1929–1937.
Porta M, Sassi M, Cavallazzi M, Fornari M, Brambilla A. Servello D. Tourette’s syndrome and the role of tetrabenzine:
review and personal experience. Clin Drug Investig. 2008;28:443–459.
Roessner V, Plessen KJ, Rothenberger A, Ludolph AG, Rizzo R, Skov L. European clinical guidelines for Tourette syndrome
and other tic disorders. Part II: Pharmacologic treatment. Eur Child Adolesc Psychiatry. 2011;20:173–196.
Rothenbertger A, Roessner V. Functional neuroimaging investigations of motor networks in Tourette syndrome. Behav
Neurol. 2013;27:47–55.
Scharf JM, Miller LL, Mathews CA, Ben-Shlomo Y. Prevalence of Tourette syndrome and chronic tics in the populationbased Avon longitudinal study of parents and children cohort. J Am Acad Child Adolesc Psychiatry. 2012;51:192–201.
Steeves T, McKinlay BD, Gorman D, Billinghurst L, Day L, Carrol A. Canadian guidelines for the evidence-based treatment of
tic disorders: Behavioural therapy, deep brain stimulation and transcranial magnetic stimulation. Can J Psychiatry.
2012;57:144–151.
Thomas R, Cavanna AE. The pharmacology of Tourette syndrome. J Neural Transm. 2013;120(4):689–94.
Verdellen C, Griendt JVD, Hartmann A, Murphy T, the ESSTS Guidelines Group. European clinical guidelines for Tourette
syndrome and other tic disorders. Part III: behavioural and psychosocial interventions. Eur Child Adolesc Psychiatry.
2011;20:97–207.
Weisman H, Qureshi IA, Leckman JF, Scahill L, Bloch MH. Systematic review: Pharmacological treatment of tic disorders
—Efficacy of antipsychotic and alpha-2 adrenergic agonist agents. Neurosci Biobehav Rev. 2013;37(6):1162–71.
Woods DW, Piacentini JC, Scahill L, Peterson AL, Wilhelm S, Chang S. Behavior therapy for tics in children: acute and
long-term effects on psychiatric and psychosocial functioning. J Child Neurol. 2011;7:858–865.
31.8d Persistent (Chronic) Motor or Vocal Tic Disorder
Chronic motor or vocal tic disorder is defined as the presence of either motor tics or
vocal tics, but not both. Tics may wax and wane but must have persisted for more than
1 year since the first tic onset to meet the diagnosis for persistent (chronic) motor or
vocal tic disorder. According to the Fifth Edition of the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, this
disorder must have its onset before the age of 18 years. Chronic motor or vocal tic
disorder cannot be diagnosed if the criteria for Tourette’s disorder have ever been met.
EPIDEMIOLOGY
The rate of chronic motor or vocal tic disorder has been estimated to be 100 to 1,000
times greater than that of Tourette’s disorder in school-age children. School-age boys are
at highest risk. Although the disorder was once believed to be rare, current estimates of
the prevalence of chronic motor or vocal tic disorder range from 1 to 2 percent.
ETIOLOGY
Chronic motor or vocal tic disorder as well as Tourette’s disorder tend to aggregate in
the same families. Twin studies have found a high concordance for either Tourette’s
disorder or chronic motor tics in monozygotic twins. This finding supports the
importance of hereditary factors in the transmission of tic disorders.
DIAGNOSIS AND CLINICAL FEATURES
The onset of chronic motor or vocal tic disorder typically occurs in early childhood.
Chronic vocal tics are considerably rarer than chronic motor tics. Chronic vocal tics, in
the absence of motor tics, are typically less conspicuous than the vocal tics in Tourette’s
disorder. The vocal tics are usually not loud or intense and are not primarily produced
by the vocal cords; they consist of grunts or other noises caused by thoracic, abdominal,
or diaphragmatic contractions.
DIFFERENTIAL DIAGNOSIS
Chronic motor tics must be differentiated from a variety of other motor movements,
including choreiform movements, myoclonus, restless legs syndrome, akathisia, and
dystonias. Involuntary vocal utterances can occur in certain neurological disorders, such
as Huntington’s disease and Parkinson’s disease.
COURSE AND PROGNOSIS
Children whose tics emerge between the ages of 6 and 8 years seem to have the best
outcomes. Symptoms often last for 4 to 6 years and remit in early adolescence. Children
whose tics involve the limbs or trunk may have less prompt remission than those with
only facial tics.
TREATMENT
The treatment of chronic motor or vocal tic disorder depends on several factors
including the severity and frequency of the tics; the patient’s subjective distress; the
effects of the tics on school or work, job performance, and socialization; and the
presence of any other concomitant mental disorder. Psychotherapy may be indicated to
minimize the secondary social difficulties caused by severe tics. Behavioral techniques,
particularly habit reversal treatments, are effective in treating chronic motor or vocal
tic disorder. When severe, tics may be reduced through the use of atypical antipsychotics
such as risperidone. If not effective, typical antipsychotics such as pimozide or
haloperidol may be helpful. Behavioral interventions are the first line of treatment.
REFERENCES
Du YS, Li HF, Vance A, Zhong YQ, Jiao FY, Wang HM. Randomized double-blind multicentre placebo-controlled clinical
trial of the clonidine adhesive patch for the treatment of tic disorders. Aust NZJ Psychiatry. 2008;42:807–813.
Jummani R, Coffey BJ. Tic disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of
Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:3609.
Knight T, Stevvers T, Day L, Lowerison M, Jette N, Pringsheim T. Prevalence of tic disorders: A systematic review and

18 - 31.9 Feeding and Eating Disorders of Infancy
31.9 Feeding and Eating Disorders of Infancy or Early Childhood

19 - 31.9a Pica
31.9a Pica
meta-analysis. Pediatr Neurol. 2012;47:77–90.
Kraft JT, Dalsgaard S, Obel C, Thomsen PH, Henriksen TB, Scahill L. Prevalence and clinical correlates of tic disorders in a
community sample of school-age children. Eur Child Adolesc Psychiatry 2012;21:5–13.
Roessner V, Plessen KJ, Rothenberger A, Ludolph AG, Rizzo R, Skov L. European clinical guidelines for Tourette syndrome
and other tic disorders. Part II: Pharmacologic treatment. Eur Child Adolesc Psychiatry. 2011;20:173–196.
Scharf JM, Miller LL, Mathews CA, Ben-Shlomo Y. Prevalence of Tourette syndrome and chronic tics in the populationbased Avon longitudinal study of parents and children cohort. J Am Acad Child Adolesc Psychiatry 2012;51:192–201.
Spencer TJ, Sallee FR, Gilbert DL, Dunn DW, McCracken JT, Coffey BJ. Atomoxetine treatment of ADHD in children with
comorbid Tourette syndrome. J Atten Disord. 2008;11:470–481.
Steeves T, McKinlay BD, Gorman D, Billinghurst L, Day L, Carrol A, et al. Canadian guidelines for the evidence-based
treatment of tic disorders: Behavioural therapy, deep brain stimulation and transcranial magnetic stimulation. Can J
Psychiatry. 2012;57:144–151.
Storch EA, Murphy TK, Geffken GR, Sajid M, Allen P, Roberti JW, Goodman WK. Reliability and validity of the Yale Global
Tic Severity Scale. Psychol Assess. 2005;17:486.
Verdellen C, Griendt JVD, Hartmann A, Murphya T, the ESSTS Guidelines Group. European clinical guidelines for Tourette
syndrome and other tic disorders. Part III: Behavioural and psychosocial interventions. Eur Child Adolesc Psychiatry.
2011;20:97–207.
Woods DW, Piacentini JC, Scahill L, Peterson AL, Wilhelm S, Chang S. Behavior therapy for tics in children: acute and
long-term effects on psychiatric and psychosocial functioning. J Child Neurol. 2011;7:858–865.
31.9 Feeding and Eating Disorders of Infancy or Early
Childhood
Feeding and eating disorders of infancy and childhood are characterized by persistent
disturbances in eating or eating-related disorders that can lead to significant
impairments in physical health and psychosocial functioning. The American Psychiatric
Association’s Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) category Feeding and Eating Disorders includes three disorders that are often, but
not always, associated with infancy and early childhood: pica, rumination disorder, and
avoidant/restrictive food intake disorder (formerly known as feeding disorder of infancy
or early childhood). These three disorders are discussed in this section. Anorexia
nervosa, bulimia nervosa, and binge-eating disorder are more often associated with
young adulthood and discussed separately in Chapter 15.
31.9a Pica
Pica is defined as persistent eating of nonnutritive substances. Typically, no specific
biological abnormalities account for pica, and in many cases, pica is identified only
when medical problems such as intestinal obstruction, intestinal infections, or
poisonings arise, such as lead poisoning due to ingestion of lead containing paint chips.
Pica is more frequent in the context of autism spectrum disorder or intellectual
disability; however, pica is diagnosed only when it is of sufficient severity and
persistence to warrant clinical attention. Pica can emerge in young children,
adolescents, or adults; however, a minimum of 2 years of age is suggested by DSM-5 in
the diagnosis of pica, in order to exclude developmentally appropriate mouthing of
objects by infants that may accidentally result in ingestion. Pica occurs in both males
and females, and in rare cases, it may be associated with a cultural belief in the spiritual
or medicinal benefit of ingesting nonfood substances. In this context, a diagnosis of pica
is not made. Among adults, certain forms of pica, including geophagia (clay eating) and
amylophagia (starch eating), have been reported in pregnant women.
EPIDEMIOLOGY
The prevalence of pica is unclear. A survey of a large clinic population reported that 75
percent of 12-month-old infants and 15 percent of 2- to 3-year-old toddlers placed
nonnutritive substances in their mouth; however, this behavior is developmentally
appropriate and typically does not result in ingestion. Pica is more common among
children and adolescents with autism spectrum disorder and intellectual disability. It has
been reported that up to 15 percent of persons with severe intellectual disability have
engaged in pica. Pica appears to affect both sexes equally.
ETIOLOGY
Pica is most often a transient disorder that typically lasts for several months and then
remits. In younger children, it is more frequently seen among children with
developmental speech and social developmental delays. Among adolescents with pica, a
substantial number of them exhibited depressive symptoms and use of substances.
Nutritional deficiencies in minerals such as zinc or iron have been anecdotally reported
in some instances; however, these reports are rare. For example, cravings for dirt and
ice have been reported to be associated with iron and zinc deficiencies, which are
corrected by their administration. Severe child maltreatment in the form of parental
neglect and deprivation has been reported in some cases of pica. Lack of supervision, as
well as adequate feeding of infants and toddlers may increase the risk of pica.
DIAGNOSIS AND CLINICAL FEATURES
Eating nonedible substances repeatedly after 18 months of age is not typical; however,
DSM-5 suggests a minimum age of 2 years when making a diagnosis of pica. Pica
behaviors, however, may begin in infants 12 months to 24 months of age. Specific
substances ingested vary with their accessibility, and they increase with a child’s
mastery of locomotion and the resultant increased independence and decreased parental
supervision. Typically, in infants, paint, plaster, string, hair, and cloth are objects that
may be ingested, whereas older toddlers and young children with pica may ingest dirt,
animal feces, small stones, and paper. The clinical implications can be benign or lifethreatening, depending on the objects ingested. Among the most serious complications
are lead poisoning (usually from lead-based paint), intestinal parasites after ingestion
of soil or feces, anemia and zinc deficiency after ingestion of clay, severe iron deficiency
after ingestion of large quantities of starch, and intestinal obstruction from the ingestion
of hair balls, stones, or gravel. Except in autism spectrum disorder and intellectual
disability, pica often remits by adolescence. Pica associated with pregnancy is usually
limited to the pregnancy itself.
Chantal was 2½ years of age when her mother urgently brought her to her
pediatrician due to severe abdominal pain and lack of appetite. Chantal’s mother
complained that she still put everything in her mouth but refused to eat regular food.
The pediatrician observed that Chantal to be pale, thin, and withdrawn. She sucked
her thumb and quietly looked down while her mother reported that Chantal often
chewed on newspapers and put plaster in her mouth.
The medical examination revealed that Chantal was anemic and suffered from lead
poisoning. She was admitted to the hospital for treatment, and a child psychiatric
consultation was obtained.
Further exploration of the history and the observation of mother and child during
feeding and play revealed that Chantal’s mother was overwhelmed, caring for five
young children and had little affection for Chantal. Chantal’s mother was a single
mother, living with her five children and four other family members in a threebedroom apartment in an old housing project. Her 7-year-old daughter had behavior
problems, and her 6-year-old and 4-year-old sons were impulsive and hyperactive and
required constant supervision. Chantal’s 18-month-old sister was an engaging and
active little girl, whereas Chantal was withdrawn, and would sit quietly, rocking
herself, sucking her thumb, or chewing on newspaper.
The treatment plan included the involvement of social services and protective
services to remove any lead paint from the walls in their current apartment, seek
better living arrangements for the family, and provide a safe environment for the
children. Chantal’s mother received guidance in enrolling Chantal in a preschool
program, and her older sister and two brothers in an after-school program that
provided structure and stimulation, and some respite time for her mother. Chantal,
her mother, and her younger sister started family therapy to help their mother’s
understanding of her children’s needs and to increase her positive interactions with
Chantal. Once Chantal’s mother felt more supported and less overwhelmed, she was
able to become more empathic and warm toward Chantal. When Chantal began
chewing on paper, her mother was coached to engage her in a play activity rather
than screaming at her and grabbing her mouth. Chantal and her mother continued in
therapy for a year, during which their relationship gradually became more interactive
and warm, while Chantal’s chewing behaviors decreased, and even her thumb sucking
abated.
PATHOLOGY AND LABORATORY EXAMINATION
No single laboratory test confirms or rules out a diagnosis of pica, but several laboratory
tests are useful because pica has sometimes been associated with abnormal levels of
lead. Levels of iron and zinc in serum should be determined and corrected if low. In rare
cases when this is the etiology, pica may disappear when oral iron and zinc are
administered. Hemoglobin level should be determined to rule out anemia.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of pica includes avoidance of food, anorexia, or rarely iron
and zinc deficiencies. Pica may occur in conjunction with failure to thrive, and be
comorbid with schizophrenia, autism spectrum disorder and Kleine-Levin syndrome. In
psychosocial dwarfism, a dramatic but reversible endocrinological and behavioral form
of failure to thrive, children often show bizarre behaviors, including ingesting toilet
water, garbage, and other nonnutritive substances. Lead intoxication may be associated
with pica. In children who exhibit pica that warrants clinical intervention, along with a
known medical disorder, both disorders should be coded according to DSM-5.
In certain regions of the world and among certain cultures, such as the Australian
aborigines, rates of pica in pregnant women are reportedly high. According to DSM-5,
however, if such practices are culturally accepted, the diagnostic criteria for pica are not
met.
COURSE AND PROGNOSIS
The prognosis for pica is usually good, and typically in children with normal intellectual
function, pica generally remits spontaneously within several months. In childhood, pica
usually resolves with increasing age; in pregnant women, pica is usually limited to the
term of the pregnancy. In some adults with pica, particularly those who also have
autism spectrum disorder and intellectual disability, pica can continue for years. Followup data on these populations are too limited to permit conclusions.
TREATMENT
The first step in determining appropriate treatment of pica is to investigate the specific
situation whenever possible. When pica occurs in the context of child neglect or
maltreatment, clearly those circumstances must be immediately corrected. Exposure to
toxic substances, such as lead, must also be eliminated. No definitive treatment exists for
pica per se; most treatment is aimed at education and behavior modification.
Treatments emphasize psychosocial, environmental, behavioral, and family guidance
approaches. An effort should be made to ameliorate any significant psychosocial
stressors. When lead is present in the surroundings, it must be eliminated or rendered
inaccessible or the child must be moved to new surroundings.
When pica persists in the absence of any toxic manifestations, behavioral techniques
have been utilized. Positive reinforcement, modeling, behavioral shaping, and
overcorrection treatment have been used. Increasing parental attention, stimulation,

20 - 31.9b Rumination Disorder
31.9b Rumination Disorder
and emotional nurturance may yield positive results. A study found that pica occurred
most frequently in impoverished environments, and in some patients, correcting an iron
or zinc deficiency has eliminated pica. Medical complications (e.g., lead poisoning) that
develop secondarily to the pica must also be treated.
31.9b Rumination Disorder
Rumination is an effortless and painless regurgitation of partially digested food into the
mouth soon after a meal, which is either swallowed or spit out. Rumination can be
observed in developmentally normal infants who put their thumb or hand in the mouth,
suck their tongue rhythmically, and arch their back to initiate regurgitation. This
behavior pattern may be observed in infants who receive inadequate emotional
interaction and have learned to soothe and may stimulate themselves through
rumination. However, rumination syndromes can be found to occur in children and
adolescents, and rumination is considered to a functional gastrointestinal disorder. The
pathophysiology of rumination is not well understood; however, it often involves a rise
in intragastric pressure, generated by either voluntary or unintentional contraction of
the abdominal wall muscles causing movement of gastric contents back up into the
esophagus. The onset of the disorder can occur in infancy, childhood, or adolescence. In
infants, it typically occurs between 3 months and 12 months of age, and once the
regurgitation occurs, the food may be swallowed or spit out. Infants who ruminate are
characteristically observed to strain with their backs arched and head back to bring the
food back into their mouths and appear to find the experience pleasurable. Infants who
are “experienced” ruminators are able to bring up the food through tongue movements
and may not spit out the food at all, but hold it in their mouths and re-swallow it. The
disorder is less common in older children, adolescents, and adults. It varies in severity
and is sometimes associated with medical conditions, such as hiatal hernia, that result in
esophageal reflux. In its most severe form, the disorder can cause malnutrition and be
fatal.
The diagnosis of rumination disorder can be made even if an infant has attained a
normal weight for his or her age. Failure to thrive, therefore, is not a necessary criterion
of this disorder, but it is sometimes a sequela. According to DSM-5, the disorder must be
present for at least 1 month after a period of normal functioning, and not better
accounted for by gastrointestinal illness, or psychiatric or medical conditions.
Rumination has been recognized for hundreds of years. An awareness of the disorder
is important so that it is correctly diagnosed and that unnecessary surgical procedures
and inappropriate treatment are avoided. Rumination is derived from the Latin word
ruminare, which means, “to chew the cud.” The Greek equivalent is merycism, the act of
regurgitating food from the stomach into the mouth, re-chewing the food, and reswallowing it.
EPIDEMIOLOGY
Rumination is a rare disorder. It seems to be more common among male infants, and
emerges between 3 months and 1 year of age. It persists more frequently among
children, adolescents, and adults with intellectual disability. Adults with rumination
usually maintain a normal weight.
ETIOLOGY
Rumination is associated with high intragastric pressure and the ability to contract the
abdominal wall to cause retrograde movement of the gastric contents into the
esophagus. Several studies have elucidated other gastrointestinal symptoms such as
gastroesophageal reflux that may accompany rumination.
In a study of 2,163 children in Sri Lanka, between the ages of 10 years and 16 years, it was found that rumination
behaviors were present in 5.1 percent of boys and 5.0 percent of girls. In 94.5 percent of youth who ruminated, the
regurgitation occurred in the first hour after the meal, and 73.6 percent reported re-swallowing of the regurgitated food,
whereas the rest spit it out. Only 8.2 percent of this sample reported daily episodes of regurgitation, whereas 62.7 percent
experienced weekly symptoms. Associated gastrointestinal symptoms reported in this sample included abdominal pain,
bloating, and weight loss. Approximately 20 percent of youth with rumination in this sample also experienced other
gastrointestinal symptoms. Another survey of 147 patients from 5 years to 20 years of age found that in their sample, the
mean age of onset of rumination was 15 years, and these patients were symptomatic after each meal; 16 percent of this
sample met criteria for a psychiatric disorder, 3.4 percent had anorexia or bulimia nervosa, and 11 percent had been
treated with a surgical procedure for evaluation of management of their symptoms. Additional gastrointestinal symptoms
in this sample included abdominal pain in 38 percent, constipation in 21 percent, nausea in 17 percent, and diarrhea in 8
percent. In some cases, vomiting secondary to gastroesophageal reflux or an acute illness precedes a pattern of rumination
that lasts for several months. In many cases, children classified as ruminators are shown to have gastroesophageal reflux or
hiatal hernia.
It appears, for some infants, that the rumination behavior is self-soothing or produces
a sense of relief, leading to a continuation of behaviors to bring it about. In youth with
autism spectrum disorder or intellectual disability, rumination may serve as a selfstimulatory behavior. Overstimulation and tension have also been suggested as
contributing factor in rumination. Behaviorists attribute persistent rumination to the
positive reinforcement of pleasurable self-stimulation and to the attention a baby
receives from others as a consequence of the disorder.
DIAGNOSIS AND CLINICAL FEATURES
The DSM-5 notes that the essential feature of the disorder is repeated regurgitation and
re-chewing of food for a period of at least 1 month after a period of normal functioning.
Partially digested food is brought up into the mouth without nausea, retching, or disgust;
on the contrary it may appear to be pleasurable. This activity may be distinguished from
vomiting by painless and purposeful movements observable in some infants who induce
it. The food is then ejected from the mouth or swallowed. A characteristic position of
straining and arching of the back, with the head held back, is observed. The infant
makes sucking movements with the tongue and gives the impression of gaining
considerable satisfaction from the activity. Usually, the infant is irritable and hungry
between episodes of rumination.
Initially, rumination may be difficult to distinguish from the regurgitation that
frequently occurs in normal infants. In infants with persistent and frequent rumination
behaviors, however, the differences are obvious. Although spontaneous remissions are
common, secondary complications can develop, such as progressive malnutrition,
dehydration, and lowered resistance to disease. Failure to thrive, with absence of growth
and developmental delays in all areas, can occur in the most severe cases. Additional
complications may occur if the mother of a given infant with rumination becomes
discouraged by the persistent symptoms, viewing it as her feeding failure, as this may
lead to more tension and more rumination after feedings.
Luca was 9-months-old when he was referred by his pediatrician to a
gastroenterologist, and by his gastroenterologist for a psychiatric evaluation due to
persistent and frequent rumination. Luca was born full-term and had developed
typically until 6 weeks of age, when he began to regurgitate large amounts of milk
just after feedings. He was evaluated and diagnosed with gastroesophageal reflux, for
which it was recommended to thicken his feedings. Luca responded well to the
treatment; his regurgitation was markedly diminished, and he gained weight
adequately. Luca continued to do well, and his mother decided to go back to work
when Lucas was 8-months-old. Luca’s mother transitioned his care to a young nanny
who cared for Luca while she worked. Luca and the nanny seemed to have a warm
relationship; however, he started again to regurgitate his meals soon after his mother
left the house. The regurgitation seemed to increase in frequency and intensity within
2 weeks of the mother’s return to work. At this point, Luca regurgitated after almost
every meal, and he was losing weight. Luca was evaluated by a gastroenterologist,
and during the barium swallow, his doctor noted that Luca put his hand in his mouth,
which seemed to induce the regurgitation. Luca was administered some medication for
gastroesophageal reflux; however, he continued to induce regurgitation after meals
with increasing frequency, prompting the psychiatric consultation.
Observation of mother and infant during feeding at home revealed that as soon as
Luca finished feeding, he purposefully placed his hand in his mouth and induced the
regurgitation. When his mother restricted his hand, Luca moved his tongue back and
forth in a rhythmic manner until he regurgitated again. Luca engaged in this rhythmic
tongue movement repeatedly, even when he could not bring up any more milk, and
appeared to be enjoying this behavior.
Due to Luca’s poor nutritional state and moderate dehydration, he was admitted to
the hospital, and a nasojejunal tube was inserted for feedings. When Luca was awake
during feedings, a special duty nurse or his parents played with him and distracted
him during attempts to put his hand in his mouth or thrust his tongue rhythmically.
Luca became increasingly engaged in this playful activity, and his ruminatory activity
decreased accordingly. After 1 week in the hospital, small feedings were started;
however, Luca again successfully was able to bring up his food by his rumination
activity, and the oral feedings had to be temporarily stopped. At this point, Luca’s
mother decided to stop working and take Luca home to continue an intensive
behavioral “distracting” intervention in order to interrupt his rumination during
meals. Luca’s mother started small feedings while playing with him during and after
feedings, and was able to interest him in other activities, so that he would not
ruminate. After 4 weeks of slow increments in his feedings, Luca was able to take all
his feedings by mouth without ruminating, and the nasojejunal tube could be
removed. Luca and his mother continued to use simulating and distracting activities
during and just after meals, which over time became more interesting to Luca than his
previous ruminating behavior.
PATHOLOGY AND LABORATORY EXAMINATION
No specific laboratory examination is pathognomonic of rumination disorder; however,
rumination disorder is not uncommonly associated with gastrointestinal abnormalities.
Clinicians are recommended to evaluate other physical causes of vomiting, such as
pyloric stenosis and hiatal hernia, before making the diagnosis of rumination disorder.
Rumination disorder can lead to states of malnutrition and dehydration. In very severe
cases, laboratory measures of endocrinological function, serum electrolytes, and a
hematological workup may determine the need for medical intervention.
DIFFERENTIAL DIAGNOSIS
To make the diagnosis of rumination disorder, clinicians must rule out primary
gastrointestinal congenital anomalies, infections, and other medical illnesses that could
account for frequent regurgitation. Pyloric stenosis is usually associated with projectile
vomiting and is generally evident before 3 months of age, when rumination has its
onset. Rumination has been associated with both autism spectrum disorder and
intellectual disability in which stereotypic behaviors and eating disturbances are not
uncommon. Rumination behavior may occur comorbidly in youth with severe anxiety
disorders as well. Rumination disorder may also occur in patients with other eating
disorders, such as anorexia nervosa and bulimia nervosa.
COURSE AND PROGNOSIS
Rumination disorder is believed to have a high rate of spontaneous remission. Indeed,
many cases of rumination disorder may develop and remit without ever being
diagnosed. Limited data are available about the prognosis of rumination disorder in
adolescents and adults. Behavioral interventions using habit-reversal techniques may
significantly lead to improved prognosis.

21 - 31.9c AvoidantRestrictive Food Intake Disorde
31.9c Avoidant/Restrictive Food Intake Disorder
TREATMENT
The treatment of rumination disorder is often a combination of education and
behavioral techniques. Sometimes, an evaluation of the mother–child relationship
reveals deficits that can be influenced by offering guidance to the mother. Behavioral
interventions, such as habit-reversal are aimed at reinforcing an alternate behavior that
becomes more compelling than the behaviors leading to regurgitation. Aversive
behavioral interventions, such as squirting lemon juice into the infant’s mouth whenever
rumination occurs, have been used in the past to diminish rumination behavior.
Although aversive behavioral interventions have been reported anecdotally to be
effective in some cases, current recommendations support the use of habit-reversal
techniques.
When features of child maltreatment of neglect may have contributed to rumination
behaviors in an infant, treatments include improvement of the child’s psychosocial
environment, increased tender loving care from the mother or caretakers, and
psychotherapy for the mother or both parents. Anatomical abnormalities, such as hiatal
hernia, are not uncommon, and must be evaluated, in some cases leading to surgical
repair. In severe cases in which malnutrition and weight loss have occurred, placement
of a jejunal tube may need to be inserted before other treatments can be utilized.
Medication is not a standard part of the treatment of rumination. Case reports,
however, cite a variety of medications that have been tried, including metoclopramide
(Reglan), cimetidine (Tagamet), and even antipsychotics such as haloperidol (Haldol)
have been cited to be helpful according to anecdotal reports. The treatment of
adolescents with rumination disorder is often complex and includes a multidisciplinary
approach consisting of individual psychotherapy, nutritional intervention, and
pharmacologic treatment for the frequent comorbid anxiety and depressive symptoms.
31.9c Avoidant/Restrictive Food Intake Disorder
Avoidant/restrictive food intake disorder, formerly known as feeding disorder of infancy
or early childhood, is characterized by a lack of interest in food, or its avoidance based
on the sensory features of the food or the perceived consequences of eating. This newly
included DSM-5 disorder adds more detail about the nature of the eating problems, and
has also been expanded to include adolescents and adults. The disorder is manifested by
a persistent failure to meet nutritional or energy needs as evidenced by one or more of
the following: significant weight loss or failure to achieve expected weight, nutritional
deficiency, dependence on enteral feedings or nutritional supplements, or marked
interference with psychosocial functioning. It may take the form of outright food
refusal, food selectivity, eating too little, food avoidance, and delayed self-feeding. The
diagnosis should not be made in the context of anorexia nervosa or bulimia nervosa, or
if caused by a medical condition, by another mental disorder, or by a true lack of
available food.
Infants and children with the disorder may be withdrawn, irritable, apathetic, or
anxious. Because of the avoidant behavior during feeding, touching and holding
between mothers and infants are diminished during the entire feeding process compared
with other children. Some reports suggest that food avoidance or restriction may be
relatively long-standing; however, in many cases, normal adult functioning is
eventually achieved.
EPIDEMIOLOGY
It is estimated that between 15 percent and 35 percent of infants and young children
have transient feeding difficulties. A study of restrictive eating difficulties in Swedish 9year-olds and 12-year-olds found that restrictive eating problems were present in 0.6
percent of their sample. However, another study of avoidant eating patterns in young
children in Germany, found that some degree of avoidance was present in up to 53
percent of children. Thus, avoidant eating behaviors without impairment of nutritional
state or psychosocial functioning must be separated from restricted eating disturbances
leading to significant functional impairment. A survey of feeding problems in nursery
school children revealed a prevalence of 4.8 percent with equal gender distribution. In
that study, children with feeding problems exhibited more somatic complaints and
mothers of affected infants exhibited increased risk of anxiety symptoms. Data from
community samples estimate a prevalence of failure to thrive syndromes in
approximately 3 percent of infants, with approximately half of those infants exhibiting
feeding disorders.
DIFFERENTIAL DIAGNOSIS
The disorder must be differentiated from structural problems with the infants’
gastrointestinal tract that may be contributing to discomfort during the feeding process.
Because feeding disorders and organic causes of swallowing difficulties often coexist, it
is important to rule out medical reasons for feeding difficulties. A study of
videofluoroscopic evaluation of children with feeding and swallowing problems revealed
that clinical evaluation was 92 percent accurate in identifying those children at
increased
risk
of
aspiration.
This
type
of
evaluation
is
necessary
before
psychotherapeutic interventions in cases where a medical contribution to feeding
problems is suspected.
COURSE AND PROGNOSIS
Most infants with feeding disorder who are identified within the first year of life and
who receive treatment do not go on to develop malnutrition, growth delay, or failure to
thrive. When feeding disorders have their onset later, in children 2 to 3 years of age,
growth and development can be affected when the disorder lasts for several months. In
older children, or adolescents, the feeding disorder typically interferes with social
functioning, until treated. It is estimated that about 70 percent of infants who
persistently refuse food in the first year of life continue to have some eating problems
during childhood.
Jennifer was 6 months old when she was referred for a psychiatric evaluation
because of feeding difficulties, irritability, and poor weight gain since birth. She was
small and slight, but she did not appear to be lethargic or malnourished. Her parents
were college-educated, and both had pursued their professional careers until Jennifer
was born. Although Jennifer was full-term and weighed 7 pounds at birth, she had
been unable to be breast feed due to turning away and not ingesting enough milk.
When she was 4-weeks-old, Jennifer’s mother had reluctantly switched her to bottle
feedings because Jennifer was losing weight. Although her intake improved somewhat
on bottle feedings, she gained weight very slowly and was still less than 8 pounds at 3
months of age. Since then, she had gained a minimal amount each month to maintain
a low but adequate weight. Jennifer’s mother appeared tired and described that
Jennifer would drink only up to about 6 ounces at a time, or two bites of baby food,
and then wiggle and cry; and refuse to continue with the feeding. But after a few
hours, she might cry again as if she were hungry. However, she could not settle her
into a good rhythm of feeding, and continued attempts to feed her would lead her to
cry inconsolably. Jennifer’s mother described approximately 10 to 15 attempts at
feeding her both liquids and solids in a 24-hour period. Jennifer was reported to be an
irritable and fussy infant, who cried multiple times during the day and at night, and
woke her family often during the night with her crying. Jennifer’s developmental
milestones such as sitting up, tracking, and making sounds were within normal limits.
The observation of mother–infant interactions during feeding and play revealed
that Jennifer was a very alert and wiggly baby who had difficulty sitting still. While
drinking from the bottle she would kick her feet and move around, and if the bottle
slipped out of her mouth, she did not try to recapture it. When eating baby foods, she
was not interested and her mother had to coax her to open her mouth. This upset
Jennifer, and she would start crying. Jennifer’s mother reported that she was always
anxious during meals, and would try to convince Jennifer to take spoonfuls of baby
food while sitting in her high chair. After repeated unsuccessful attempts of adequate
feeding, Jennifer and her mother both appeared exhausted and took a break.
The history and examination revealed that Jennifer was a very active and excitable
baby who had difficulty keeping calm during feedings. After reviewing the videotape
with the mother, the therapist explored ways in which the mother could better
facilitate calming Jennifer before and during meals. Using a quiet corner in the house,
and singing to Jennifer before meals resulted in Jennifer remaining more calm during
meals, and she was able to drink larger amounts of milk, eat more solid foods, and
waited longer between meals. This, in turn, relieved her mother’s anxiety and helped
both to have calmer interactions.
(Adapted by Caroly Pataki, M.D.)
TREATMENT
Most interventions for feeding disorders are aimed at optimizing the interaction
between the mother and infant during feedings and identifying any factors that can be
changed to promote greater ingestion. The mother is helped to become more aware of
the infant’s stamina for length of individual feedings, the infant’s biological regulation
patterns, and the infant’s fatigue level with a goal of increasing the level of engagement
between mother and infant during feeding.
A transactional model of intervention has been proposed for infants who exhibit the
“difficult” temperamental traits of emotional intensity, stubbornness, lack of hunger
cues, and irregular eating and sleeping patterns. The treatment includes education for
the parents regarding the temperamental traits of the infant, exploration of the parents’
anxieties about the infant’s nutrition, and training for the parents regarding changing
their behaviors to promote internal regulation of eating in the infant. Parents are
encouraged to feed the infant on a regular basis at 3- to 4-hour intervals, and offer only
water between meals. The parents are trained to deliver praise to the infant for any
self-feeding efforts, regardless of the amount of food ingested. Furthermore, parents are
guided to limit any distracting stimulation during meals and give attention and praise to
positive eating behaviors rather than intense negative attention to inappropriate
behavior during meals. This training process for parents is done in an intense manner
within a short period of time. Many parents are able to facilitate improved eating
patterns in the infant as a result. If the mother or caregiver is unable to participate in
the intervention, it may be necessary to include additional caregivers to contribute to
feeding the infant. In rare cases, an infant may require hospitalization until adequate
nutrition on a daily basis is accomplished. If an infant tires before ingesting an
adequate amount of nutrition, it may be necessary to begin treatment with the
placement of a nasogastric tube for supplemental oral feedings.
For older children with failure-to-thrive syndromes, hospitalization and nutritional
supplementation may be necessary. Medication is not a standard component of
treatment for feeding disorders; however, there are anecdotal reports of preadolescents
with failure-to-thrive and feeding disorders who were comorbid for anxiety and mood
symptoms and who received enteral nutritional interventions in addition to risperidone
(Risperdal), and who were observed to have an increase in oral intake and accelerated
weight gain.
REFERENCES
Araujo CL, Victora CG, Hallal PC, Gigante DP. Breastfeeding and overweight in childhood: Evidence from the Pelotas 1993
birth cohort study. Int J Obes. 2005;30(3):500.
Berger-Gross P, Colettoi DJ, Hirschkorn K, Terranova E, Simpser EF. The effectiveness of risperidone in the treatment of
three children with feeding disorders. J Child Adolesc Psychopharmacol. 2004;14:621.
Bryant-Waugh R. Feeding and eating disorders in children. Curr Opin Psychiatry. 2013;26:537–542.
Bryant-Waugh R. Avoidant restrictive food intake disorder: An illustrative case example. Int J Eat Disord. 2013;46:420–423.
Call C, Walsh BT, Attia E. From DSM-IV to DSM-5: Changes to eating disorder diagnoses. Curr Opin Psychiatry.

22 - 31.10 Elimination Disorders
31.10 Elimination Disorders
2013;26:532–536.
Chatoor I. Feeding and eating disorders of infancy or early childhood. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s
Comprehensive Textbook of Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins; 2009:3597.
Chial HJ, Camilleri M, Williams DE, Litzinger K, Perrault J. Rumination syndrome in children and adolescents: Diagnosis,
treatment, and prognosis. Pediatrics. 2003;111:158–162.
Cohen E, Rosen Y, Yehuda B, Iancu I. Successful multidisciplinary treatment in an adolescent case of rumination. Isr J
Psychiatry Relat Sci. 2004;41:222.
DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding
and swallowing difficulties. Dev Med Child Neurol. 2005;47:149.
Esparo G, Canals J, Ballespi S, Vinas F, Domenech E. Feeding problems in nursery children: Prevalence and psychosocial
factors. Acta Pediatr 2004;93:663.
Equit M, Palmke M, Beckner N. Problems in young children: a population based study. Acta Paediatr. 2013:10.
Feldaman R, Keren M, Gross-Rozval O, Tyano S. Mother-child touch patterns in infant feeding disorders: Relation to
maternal, child, and environmental factors. J Am Acad Child Adolesc Psychiatry. 2004;43:1089.
Hughes SO, Anderson CB, Power TG, Micheli N, Jaramillo S, Nicklas TA. Measuring feeding in low-income AfricanAmerican and Hispanic parents. Appetite. 2006;46(2):215.
Jacobi C, Agras WS, Bryson S, Hammer LD. Behavioral validation, precursors, and concomitants of picky eating in
childhood. J Am Acad Child Adolesc Psychiatry. 2003;42:76.
Lewinsohn PM, Holm-Denoma JM, Gau JM, Joiner TE Jr, Striegel-Moore R, Bear P, Lamoureux B. Problematic eating and
feeding behaviors of 36-month-old children. Int J Eat Disord. 2005;38(3):208–219.
Linscheid TN. Behavioral treatments for pediatric feeding disorders. Behav Modif. 2006;30:6–23.
Liu YL, Malik N, Sanger GJ, Friedman MI, Andrews PL. Pica—A model of nausea? Species differences in response to
cisplatin. Physiol Behav. 2005;85(3):271–277.
Ornstein RM, Rosen DS, Mammel K, Callahan ST, Forman S. Distribution of eating disorders in children and adolescents
using the proposed DSM-5 criteria for feeding and eating disorders. J Adolesc Health. 2013;53:303–305.
Rajindrajith S., Devanarayana NM, Perera BJC. Rumination syndrome in children and adolescents: a school survey assessing
prevalence and symptomatology. BMC Gastroenterol. 2012;12:163–169.
Rastam M, Taljemark J, Tajnia A. Eating problems and overlap with ADHD and autism spectrum disorders in a nationwide
twin study of 9- and 12-year-old children Sci World J. 2013;15:315429.
Tack J, Blondeau K, Boecxstaens V, Rommel N. Review article: The pathophysiology, differential diagnosis and
management of rumination syndrome. Ailment Pharmacol Ther. 2011;33:782–788.
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Psychiatry. 2012;11:80–92.
Williams DE, McAdam D. Assessment, behavioral treatment, and prevention of pica: Clinical guidelines and
recommendations for practitioners. Res Develop Disab. 2012;33:2050–2057.
31.10 Elimination Disorders
The developmental milestones of mastering control over bowel and bladder function are
complex processes that involve motor and sensory functions, coordinated through
frontal lobe activities, and regulated by neurons in the pons and midbrain area. Mastery
of bowel and bladder function is achieved over a period of months for the typical

23 - 31.10a Encopresis
31.10a Encopresis
toddler. Infants generally void small volumes of urine approximately every hour,
commonly stimulated by feeding, and may have incomplete emptying of the bladder. As
the infant matures to be a toddler, bladder capacity increases, and between 1 and 3
years of age, cortical inhibitory pathways develop that allow the child to have voluntary
control over reflexes that control the bladder muscles. The ability to have muscular
control over the bowel occurs even before bladder control for most toddlers, and the
assessment of fecal soiling includes determining whether the clinical presentation occurs
with or without chronic constipation and overflow soiling. The normal sequence of
developing control over bowel and bladder functions is the development of nocturnal
fecal continence, diurnal fecal continence, diurnal bladder control, and nocturnal
bladder control. Bowel and bladder control develops gradually over time. Toilet training
is affected by many factors, such as a child’s intellectual capacity and social maturity,
cultural determinants, and the psychological interactions between child and parents.
The ability to control bowel and bladder functions depends on the maturation of
neurobiological systems, so that children with developmental delays may also display
delayed continence of bowel and bladder. When children exhibit incontinence of urine
or feces on a regular basis, it is troubling to the child and families, and often
misunderstood as voluntary misbehavior.
Encopresis (repeated passage of feces into inappropriate places) and enuresis
(repeated urination into bed or clothes) are the two elimination disorders described in
the Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders (DSM-5). These diagnoses are not made until after age 4
years, for encopresis, and after age 5 years for enuresis, the ages at which a typically
developing child is expected to master these skills. Normal development encompasses a
range of time in which a given child is able to devote the attention, motivation, and
physiological skills to exhibit competency in elimination processes. Encopresis is
characterized by a pattern of passing feces in inappropriate places, such as in clothing
or other places, at least once per month for 3 consecutive months, whether the passage
is involuntary or intentional. Up to about 80 percent of children with fecal incontinence
have associated constipation. A child with encopresis typically exhibits dysregulated
bowel function; for example, with infrequent bowel movements, constipation, or
recurrent abdominal pain and sometimes pain on defecations. Enuresis is characterized
by repeated voiding of urine into clothes or bed, whether the voiding is involuntary or
intentional. The behavior must occur twice weekly for at least 3 months or must cause
clinically significant distress or impairment socially or academically. The child’s
chronological or developmental age must be at least 5 years.
31.10a Encopresis
EPIDEMIOLOGY
Encopresis has been estimated to affect 3 percent of 4-year-olds and 1.6 percent of 10-
year-old children. Incidence rates for encopretic behavior decrease drastically with
increasing age. Between the ages of 10 years and 12 years, it is estimated to affect 0.75
percent of typically developing children. Globally, community prevalence of encopresis
ranges from 0.8 to 7.8 percent. In Western cultures, bowel control is established in more
than 95 percent of children by their fourth birthday and in 99 percent by the fifth
birthday. Encopresis is virtually absent in youth with normal intellectual function by the
age of 16 years. Males are found to from three to six times more likely to have
encopresis than females. A significant relation exists between encopresis and enuresis.
ETIOLOGY
Ninety percent of chronic childhood encopresis is considered to be functional. Children
with this disorder typically withhold feces by contracting their gluteal muscles, holding
their legs together, and tightening their external anal sphincter. In some cases, this is an
entrenched behavioral response to previously painful bowel movements due to hard
stool, which leads to fear of defecation and withholding behaviors. Encopresis involves
an often-complicated interplay between physiological and psychological factors leading
to an avoidance of defecation. However, when children chronically hold in bowel
movements, the result is often fecal impaction and eventual overflow soiling. This
pattern is observed in more than 75 percent of children with encopretic behavior. This
common set of circumstances in most children with encopresis supports a behavioral
intervention with a focus on ameliorating constipation while increasing appropriate
toileting behavior. Inadequate training or the lack of appropriate toilet training may
delay a child’s attainment of continence.
Evidence indicates that some encopretic children have lifelong inefficient and
ineffective sphincter control. Other children may soil involuntarily, either because of an
inability to control the sphincter adequately or because of excessive fluid caused by a
retentive overflow.
In about 5 to 10 percent of cases, fecal incontinence is caused by medical conditions
including abnormal innervation of the anorectal region, ultrashort segment
Hirschsprung disease, neuronal intestinal dysplasia, or spinal cord damage.
One study found encopresis to occur with significantly greater frequency among
children with known sexual abuse, and other psychiatric disorders, compared with a
sample of healthy children. Encopresis, however, is not a specific indicator of sexual
abuse.
It is evident that once a child has developed a pattern of withholding bowel
movements, and attempts to defecate have become painful, a child’s fear and resistance
to changing the pattern are high. Battles with parents who insist that their children
attempt to defecate before they are adequately treated may aggravate the condition and
cause secondary behavioral difficulties. Children with encopresis who are not promptly
treated, however, frequently end up being socially ostracized and rejected. The social
consequences of soiling can lead to the development of emotional problems. On the
other hand, children with encopresis who clearly can control their bowel function
adequately but chronically deposit feces of relatively normal consistency in abnormal
places are likely to have preexisting neurodevelopmental problems. Occasionally, a
child has a specific fear of using the toilet, leading to a phobia.
Encopresis, in some cases can be considered secondary, that is, emerging after a
period of normal bowel habits in conjunction with a disruptive life event, such as the
birth of a sibling or a move to a new home. When encopresis manifests after a long
period of fecal continence, it may reflect a developmental regressive behavior based on
a severe stressor, such as a parental separation, loss of a best friend, or an unexpected
academic failure.
Megacolon
Most children with encopresis retain feces and become constipated, either voluntarily or
secondary to painful defecation. In some cases a subclinical preexisting anorectal
dysfunction exists that contributes to the constipation. In either case, resulting chronic
rectal distention from large, hard fecal masses can cause loss of tone in the rectal wall
and desensitization to pressure. Thus, children in this situation become even less aware
of the need to defecate, and overflow encopresis occurs, usually with relatively small
amounts of liquid or soft stool leaking out.
DIAGNOSIS AND CLINICAL FEATURES
According to DSM-5, encopresis is diagnosed when feces are passed into inappropriate
places on a regular basis (at least once a month) for 3 months. Encopresis may be
present in children who have bowel control and intentionally deposit feces in their
clothes or other places for a variety of emotional reasons. Anecdotal reports have
suggested that occasionally encopresis is attributable to an expression of anger or rage
in a child whose parents have been punitive or of hostility at a parent. In a case such as
this, once a child develops this inappropriate repetitive behavior eliciting negative
attention, it is difficult to break the cycle of continuous negative attention. In other
children, sporadic episodes of encopresis can occur during times of stress—for example,
proximal to the birth of a new sibling—but in such cases, the behavior is usually
transient and does not fulfill the diagnostic criteria for the disorder.
Encopresis can also be present on an involuntary basis in the absence of physiological
abnormalities. In these cases, a child may not exhibit adequate control over the
sphincter muscles, either because the child is absorbed in another activity or because he
or she is unaware of the process. The feces may be of normal, near-normal, or liquid
consistency. Some involuntary soiling occurs from chronic retaining of stool, which may
result in liquid overflow. In rare cases, the involuntary overflow of stool results from
psychological causes of diarrhea or anxiety disorder symptoms.
The DSM-5 includes two specifiers to encopresis: with constipation and overflow
incontinence and without constipation and overflow incontinence. To receive a diagnosis
of encopresis, a child must have a developmental or chronological level of at least 4
years. If the fecal incontinence is directly related to a medical condition, encopresis is
not diagnosed.
Studies have indicated that children with encopresis who do not have gastrointestinal
illnesses have high rates of abnormal anal sphincter contractions. This finding is
particularly prevalent among children with encopresis with constipation and overflow
incontinence who have difficulty relaxing their anal sphincter muscles when trying to
defecate. Children with constipation who have difficulties with sphincter relaxation are
not likely to respond well to laxatives in the treatment of their encopresis. Children with
encopresis without abnormal sphincter tone are likely to improve over a short period.
Jack was a 7-year-old boy with daily encopresis, enuresis, and a history of hoarding
behaviors, along with hiding the feces around the house. He lived with his adoptive
parents, having been removed from his biological parents at age 3 years because of
neglect and physical abuse. He was reported to be cocaine addicted at birth, but was
otherwise healthy. Jack’s biological mother was a known methamphetamine and
alcohol user, and his father had spent time in jail for drug dealing. Jack had always
been enuretic at night, and until this year, he had a history of daytime enuresis as
well. Jack had a short attention span, was highly impulsive, and had great difficulty
staying in his seat at school and remaining on task. He had reading difficulties and
was placed in a contained special education classroom because of his disruptive
behavior as well as his academic difficulties. Despite experiencing physical abuse, he
has not experienced flashbacks or other symptoms that would indicate the presence of
posttraumatic stress disorder. Jack was treated for attention-deficit/hyperactivity
disorder (ADHD) with good response to methylphenidate (Concerta 36 mg per day).
Jack’s adoptive family sought help at a university hospital’s outpatient program
that had expertise in the behavioral treatments of many psychiatric disorders
including encopresis. The treatment program combined use of regular laxatives and a
bowel training method with cognitive-behavioral therapy for Jack and for his family.
Jack was started on a regimen of daily polyethylene glycol (PEG) solution and was
seen by a pediatrician who was able to perform a manual disimpaction under
sedation. Following that, Jack was continued on daily PEG solution combined with
therapy. He learned to empty his bowel while sitting on the toilet for 10 minutes after
each meal, whether or not he felt like he had to go. He soon was eager to stay on this
regular bathroom schedule, and felt proud when he was able to have a bowel
movement in the toilet. Over a period of 3 months, Jack was noticeably improved,
and at 6 months, he was almost completely better. (Courtesy of Edwin J. Mikkelsen,
M.D. and Caroly Pataki, M.D.)
PATHOLOGY AND LABORATORY EXAMINATION
Although no specific test indicates a diagnosis of encopresis, clinicians must rule out
medical illnesses, such as Hirschsprung’s disease, before making a diagnosis. It must be
determined whether fecal retention is responsible for encopresis with constipation and
overflow incontinence; a physical examination of the abdomen is indicated, and an
abdominal X-ray can help determine the degree of constipation present. Tests to
determine whether sphincter tone is abnormal are generally not conducted in simple
cases of encopresis.
DIFFERENTIAL DIAGNOSIS
In encopresis with constipation and overflow incontinence, constipation can begin as
early as the child’s first year and can peak between the second and fourth years. Soiling
usually begins by age 4. Frequent liquid stools and hard fecal masses are found in the
colon and the rectum on abdominal palpation and rectal examination. Complications
include impaction, megacolon, and anal fissures.
Encopresis with constipation and overflow incontinence is rarely caused by faulty
nutrition; structural disease of the anus, rectum, and colon; medicinal adverse effects; or
nongastrointestinal medical (endocrine or neurological) disorders. The chief differential
medical problem is aganglionic megacolon or Hirschsprung’s disease, in which a patient
may have an empty rectum and no desire to defecate, but may still have an overflow of
feces. The disorder occurs in 1 in 5,000 children; signs appear shortly after birth.
COURSE AND PROGNOSIS
The outcome of encopresis depends on the etiology, the chronicity of the symptoms, and
coexisting behavioral problems. In some cases, encopresis is self-limiting, and it rarely
continues beyond middle adolescence. Encopresis in children who have contributing
physiological factors, such as poor gastric motility and an inability to relax the anal
sphincter muscles, is more difficult to treat than that in those with constipation but
normal sphincter tone.
Encopresis is a particularly objectionable disorder to family members, who may
assume that the behavior is due to “laziness,” and family tensions are often high. Peers
are intolerant of the developmentally inappropriate behavior and typically taunt and
reject a child with encopresis. Many affected children have abysmally low self-esteem
and are plagued by constant social rejection. Psychologically, a child may appear
blunted toward the symptoms or less frequently, may be entrenched in a pattern of
encopresis as a mode of expressing anger. The outcome of encopresis is influenced by a
family’s willingness and ability to participate in treatment without being overly
punitive and by the child’s ability and motivation to engage in treatment.
TREATMENT
A typical treatment plan for a child with encopresis includes daily oral administration of
laxatives such as PEG at 1 g/kg per day, and often a surgical disimpaction under
general anesthesia before maintenance laxatives can be administered. In addition, an
ongoing cognitive-behavioral intervention to begin regular attempts to have bowel
movements in the toilet, and to diminish anxiety related to bowel movement. By the
time a child is brought for treatment, considerable family discord and distress are
common. Family tensions about the symptom must be reduced, and a nonpunitive
atmosphere established. Similar efforts should be made to reduce the child’s
embarrassment at school. Many changes of underwear with a minimum of
embarrassment should be arranged. Education of the family and correction of
misperceptions that a family may have about soiling must occur before treatment.
Laxatives are not necessary for children who are not constipated and do have good
bowel control, but regular, timed intervals on the toilet may be useful with these
children as well.
A report confirms the success of an interactive parent–child family guidance
intervention for young children with encopresis based on psychological and behavioral
interventions for children younger than age 9 years.
Supportive psychotherapy and relaxation techniques may be useful in treating the
anxieties and other sequelae of children with encopresis, such as low self-esteem and
social isolation. Family interventions can be helpful for children who have bowel control
but who continue to deposit their feces in inappropriate locations. An optimal outcome
occurs when a child achieves a feeling of control over his or her bowel function.
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Acad Child Adolesc Psychiatry. 2008;47:491–498.
Rowan-Legg A. Managing functional constipation in children. Paediatr Child Health. 2011;16:661–665.
Von Gontard A, Hollmann E. Comorbidity of functional urinary incontinence and encopresis: somatic and behavioral
associations. J Urology. 2004;171:2644.

24 - 31.10b Enuresis
31.10b Enuresis
Yilmaz S, Bigic A, Herguner S. Effect of OROS methylphenidate on encopresis in children with attentiondeficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2013; Oct 29. [Epub ahead of print].
31.10b Enuresis
EPIDEMIOLOGY
The prevalence of enuresis ranges from 5 to 10 percent in 5-year-olds, 1.5 to 5 percent
in 9- to 10-year-olds, and about 1 percent in adolescents 15 years and older. The
prevalence of enuresis decreases with increasing age. Enuretic behavior is considered
developmentally appropriate among young toddlers, precluding diagnoses of enuresis;
however, enuretic behavior occurs in 82 percent of 2-year-olds, 49 percent of 3-yearolds, and 26 percent of 4-year-olds on a regular basis.
In the epidemiological Isle of Wight study, investigators reported that 15.2 percent of
7-year-old boys were enuretic occasionally and that 6.7 percent of them were enuretic at
least once a week. The study reported that 3.3 percent of girls at the age of 7 years were
enuretic at least once a week. By age 10, the overall prevalence of enuresis was
reported to be 3 percent. The rate drops drastically for teenagers: a prevalence of 1.5
percent has been reported for 14-year-olds. Enuresis affects about 1% of adults.
Although most children with enuresis do not have a comorbid psychiatric disorder,
children with enuresis are at higher risk for the development of another psychiatric
disorder.
Nocturnal enuresis is about 50 percent more common in boys and accounts for about
80 percent of children with enuresis. Diurnal enuresis is also seen more often in boys
who often delay voiding until it is too late. A spontaneous resolution of nocturnal
enuresis is about 15 percent per year. Nocturnal enuresis consists of a normal volume of
voided urine, whereas when small volumes of urine are voided at night, other medical
causes may be present.
ETIOLOGY
Enuresis involves complex neurobiological systems that include contributions from
cerebral and spinal cord centers, motor and sensory functions, and autonomic and
voluntary nervous systems. Urination is regulated by neurons in the pons and midbrain
regions. Bladder detrusor muscle contraction occurs whenever bladder capacity is
reached, which can lead to enuresis in a sleeping child. Therefore, excessive volumes of
urine produced at night may lead to enuresis at night in children without any
physiologic abnormalities. Nighttime enuresis often occurs in the absence of a specific
neurogenic cause. Daytime enuresis may develop based on behavioral habits developed
over time.
Daytime enuresis may occur in the absence of neurological abnormalities resulting
from habitual, voluntary tightening of the external sphincter during urges to urinate.
The pattern may be set in a young child who may start out with a normal or overactive
detrusor muscle in the bladder, but with repeated attempts to prevent leaking or
urination when there is an urge to void. Over time, the sensation of the urge to urinate
is diminished and the bladder does not empty regularly, leading to enuresis at night
when the bladder is relaxed and can empty without resistance. This immature pattern of
urinating can account for some cases of enuresis, especially when the pattern has been
in place since early childhood. Most children are not enuretic by intention or even with
awareness until after they are wet. Physiological factors often play a role in the
development of enuresis, and behavioral patterns are likely to maintain the
maladaptive urination. Normal bladder control, which is acquired gradually, is
influenced by neuromuscular and cognitive development, socioemotional factors, toilet
training, and genetic factors. Difficulties in one or more of these areas can delay urinary
continence.
Genetic factors are believed to play a role in the expression of enuresis, given that the
emergence of enuresis has been found to be significantly greater in first-degree
relatives. A longitudinal study of child development found that children with enuresis
were about twice as likely to have concomitant developmental delays as those who did
not have enuresis. About 75 percent of children with enuresis have a first-degree relative
who has or has had enuresis. A child’s risk for enuresis has been found to be more than
seven times greater if the father was enuretic. The concordance rate is higher in
monozygotic twins than in dizygotic twins. A strong genetic component is suggested,
and much can be accounted for by tolerance for enuresis in some families and by other
psychosocial factors.
Studies indicate that children with enuresis with a normal anatomical bladder
capacity report urge to void with less urine in the bladder than children without
enuresis. Other studies report that nocturnal enuresis occurs when the bladder is full
because of lower than expected levels of nighttime antidiuretic hormone. This could lead
to a higher-than-usual urine output. Enuresis does not appear to be related to a specific
stage of sleep or time of night; rather, bed-wetting appears randomly. In most cases, the
quality of sleep is normal. Little evidence indicates that children with enuresis sleep
more soundly than other children.
Psychosocial stressors appear to precipitate enuresis in a subgroup of children with
the disorder. In young children, the disorder has been particularly associated with the
birth of a sibling, hospitalization between the ages of 2 and 4 years, the start of school,
separation of a family due to divorce, or a move to a new environment.
DIAGNOSIS AND CLINICAL FEATURES
Enuresis is the repeated voiding of urine into a child’s clothes or bed; the voiding may be
involuntary or intentional. For the diagnosis to be made, a child must exhibit a
developmental or chronological age of at least 5 years. According to DSM-5, the
behavior must occur twice weekly for a period of at least 3 months or must cause
distress and impairment in functioning to meet the diagnostic criteria. Enuresis is
diagnosed only if the behavior is not caused by a medical condition. Children with
enuresis are at higher risk for ADHD compared with the general population. They are
also more likely to have comorbid encopresis. DSM-5 and the 10th revision of
International Statistical Classification of Diseases and Related Health Problems (ICD-10)
break down the disorder into three types: nocturnal only, diurnal only, and nocturnal
and diurnal.
PATHOLOGY AND LABORATORY EXAMINATION
No single laboratory finding is pathognomonic of enuresis; but clinicians must rule out
organic factors, such as the presence of urinary tract infections, which may predispose a
child to enuresis. Structural obstructive abnormalities may be present in up to 3 percent
of children with apparent enuresis. Sophisticated radiographic studies are usually
deferred in simple cases of enuresis with no signs of repeated infections or other medical
problems.
DIFFERENTIAL DIAGNOSIS
To make the diagnosis of enuresis, organic causes of bladder dysfunction must be
investigated and ruled out. Organic syndromes, such as urinary tract infections,
obstructions, or anatomical conditions are found most often in children who experience
both nocturnal and diurnal enuresis combined with urinary frequency and urgency. The
organic features include genitourinary pathology—structural, neurological, and
infectious—such as obstructive uropathy, spina bifida occulta, and cystitis; other organic
disorders that can cause polyuria and enuresis, such as diabetes mellitus and diabetes
insipidus; disturbances of consciousness and sleep, such as seizures, intoxication, and
sleepwalking disorder, during which a child urinates; and adverse effects from treatment
with antipsychotic agents.
COURSE AND PROGNOSIS
Enuresis is often self-limited, and a child with enuresis may have a spontaneous
remission. Most children who master the task of control over their bladder gain selfesteem and improved social confidence when they become continent. About 80 percent
of affected children have never achieved a year-long period of dryness. Enuresis after at
least one dry year usually begins between the ages of 5 and 8 years; if it occurs much
later, especially during adulthood, organic causes must be investigated. Some evidence
indicates that late onset of enuresis in children is more frequently associated with a
concomitant psychiatric difficulty than is enuresis without at least one dry year.
Relapses occur in children with enuresis who are becoming dry spontaneously and in
those who are being treated. The significant emotional and social difficulties of these
children usually include poor self-image, decreased self-esteem, social embarrassment
and restriction, and intrafamilial conflict. The course of children with enuresis may be
influenced by whether they receive appropriate evaluation and treatment for common
comorbid disorders such as ADHD.
TREATMENT
A relatively high rate of spontaneous remission of enuresis occurs over time in
childhood; however, in many cases, interventions are necessary because enuresis is
causing functional impairment. The first step in any treatment plan is to review
appropriate toilet training. If toilet training was not attempted, the parents and the
patient should be guided in this undertaking. Record-keeping is helpful in determining a
baseline and following the child’s progress, and may itself be a reinforcer. A star chart
may be particularly helpful. Other useful techniques include restricting fluids before bed
and night lifting to toilet train the child. Interventions with alarm therapy, which is
triggered by wet underwear, has been a mainstay of treatment for enuresis. Alarm
therapy works by alerting a child to respond when voiding begins during sleep. The
alarm is a battery-operated device that can be attached to a child’s underwear or a mat.
The alarm is triggered as soon as voiding begins by emitting a loud noise that awakens
the child. The success of this method is based on the child’s ability to awaken promptly
and respond to the alarm by getting up and voiding in the toilet. A child who can
respond optimally is at least 6 or 7 years old. Pharmacological interventions including
desmopressin therapy in managing nocturnal enuresis have been shown to be effective
in some patients. Desmopressin is a “synthetic analogue” of vasopressin, which can be
administered as a pill, a sublingual melt, or a nasal spray. Its effect can last up to 8
hours, and it works by reducing urine production at night. This method is optimal when
no fluids are ingested in the evening.
Another basic intervention for those children with enuresis and bowel dysfunction is
to assess whether chronic constipation is contributing to urinary dysfunction, and to
consider increasing dietary fiber to diminish constipation.
Behavioral Therapy
Classic conditioning with the bell (or buzzer) and pad (alarm) apparatus is generally the
most effective treatment for enuresis, with dryness resulting in more than 50 percent of
cases. Bladder training—encouragement or reward for delaying micturition for
increasing times during waking hours—has also been used. Although sometimes
effective, this method is decidedly inferior to the bell and pad.
Pharmacotherapy
Medication is considered when enuresis is causing impairment in social, family, and
school function and behavioral, dietary, and fluid restriction have not been efficacious.
When the problem interferes significantly with a child’s functioning, several medications
can be considered, although the problem often recurs as soon as medications are
withdrawn.
Desmopressin (DDAVP), an antidiuretic compound that is available as an intranasal
spray, has shown success in reducing enuresis. Reduction of enuresis has varied from 10
to 90 percent with the use of desmopressin. In most studies, enuresis recurred shortly
after discontinuation of this medication. Adverse effects that can occur with
desmopressin include headache, nasal congestion, epistaxis, and stomachache. The most
serious adverse effect reported with the use of desmopressin to treat enuresis was a
hyponatremic seizure experienced by a child.
Reboxetine (Edronax, Vestra), a norepinephrine reuptake inhibitor with a
noncardiotoxic side effect profile has recently been investigated as a safer alternative to
imipramine in the treatment of childhood enuresis. A trial in which 22 children with
enuresis causing social impairment, who had not responded to an enuresis alarm,
desmopressin, or anticholinergics were administered 4 to 8 mg of reboxetine at bedtime.
Of the 22 children, 13 (59 percent) in this open trial achieved complete dryness with
reboxetine alone, or in combination with desmopressin. Side effects were minimal and
did not lead to discontinuation of the medication in this trial.
Psychotherapy
Psychotherapy may be useful in dealing with the coexisting psychiatric problems and the
emotional and family difficulties that arise secondary to chronic enuresis.
REFERENCES
Baeyens D, Roeyers H, D’Haese L, Pieters F, Hoebeke P, Vande Walle J. The prevalence of ADHD in children with enuresis:
Comparison between a tertiary and non-tertiary care sample. Acta Paediatr. 2006;95:347.
Brown ML, Pope AW, Brown EJ. Treatment of primary nocturnal enuresis in children: A review. Child Care Health Dev.
2010;37:153–160.
Butler RJ, Heron J. The prevalence of infrequent bedwetting and nocturnal enuresis in childhood: A large British cohort.
Scand J Urol Nephrol. 2008;42:257–264.
Feldman AS, Bauer SB. Diagnosis and management of dysfunctional voiding. Curr Opin Pediatr. 2006;18:139.
Fitzgerald MP, Thom DH, Wassel-Fyr C, Subak L, Brubaker L, Van Den Deden SK, Brown JS. Childhood urinary symptoms
predict adult overactive bladder symptoms. J Urol. 2006;175:989.
Friedman FM, Weiss JP. Desmopressin in the treatment of nocturia: clinical evidence and experience. Ther Adv Urol.
2013;5:310–317.
Kajiwara M, Inoue K, Kato M, Usui A, Kurihara M, Usui T. Nocturnal enuresis and overactive bladder in children: An
epidemiological study. Int J Urol. 2006;13:36.
Klages T, Geller B, Tillman R, Bolhofner K, Zimerman B. Controlled study of encopresis and enuresis in children with a
prepubertal and early adolescent bipolar-I disorder phenotype. J Am Acad Child Adolesc Psychiatry. 2005;44:1050.
Landgraf JM, Abidari J, Cilento BG Jr., Cooper CS, Schulman SL, Ortenberg J. Coping, commitment, and attitude:
Quantifying the everyday burden of enuresis on children and their families. Pediatrics. 2004;113:334.
Mikkelsen EJ. Elimination disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of
Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins; 2009:3624.
Nevus T. Reboxetine in therapy-resistant enuresis: results and pathogenetic implications. Scand J Urol Nephrol.
2006;40:31.
Pennesi M, Pitter M, Borduga A, Minisini S, Peratoner L. Behavioral therapy for primary nocturnal enuresis. J Urol. 2004;
171:408.
Perrin N, Sayer L, White A. The efficacy of alarm therapy versus desmopressin therapy in the treatment of primary mono-

25 - 31.11 Trauma and Stressor Related Disorders i
31.11 Trauma- and Stressor-Related Disorders in Children

26 - 31.11a Reactive Attachment Disorder and Disin
31.11a Reactive Attachment Disorder and Disinhibited Social Engagement Disorder
symptomatic nocturnal enuresis: A systematic review. Prim Health Care Res Dev. 2013; 1–11 Doi:
10.1p17/S146342361300042X.
Reiner WG. Pharmacotherapy in the management of voiding and storage disorders, including enuresis and encopresis. J Am
Acad Child Adolesc Psychiatry. 2008;47:5:491–498.
Rutter M, Tizard J, Yule W, Graham P, Whitmore K. Research report: Isle of Wight Studies, 1964–1974. Psychol Med.
1976;6:313–332.
Von Gontard A, Hollmann E. Comorbidity of functional urinary incontinence and encopresis: Somatic and behavioral
associations. J Urol. 2004;171:2644.
31.11 Trauma- and Stressor-Related Disorders in Children
This section includes disorders in which a traumatic or significantly stressful event is a
necessary diagnostic criterion, according to the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Included are
reactive
attachment
disorder,
disinhibited
social
engagement
disorder,
and
posttraumatic stress disorder (see 31.11b). The psychological and psychiatric symptoms
that follow exposure to trauma and severe stress are variable and often include
symptoms of anxiety, depression, dissociation, anger, and withdrawal. Previously, in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR), reactive attachment disorder was divided into two subtypes: emotionally
withdrawn/inhibited and indiscriminately social/disinhibited. In DSM-5, however, the
preceding two subtypes have been defined as two distinct disorders, with the DSM-5
reactive
attachment
disorder
equivalent
to
the
previous
emotionally
withdrawn/inhibited subtype, and disinhibited social engagement disorder representing
the previous indiscriminately social disinhibited subtype.
31.11a Reactive Attachment Disorder and Disinhibited
Social Engagement Disorder
Reactive attachment disorder and disinhibited social engagement disorder are clinical
disorders characterized by aberrant social behaviors in a young child that reflect grossly
negligent parenting and maltreatment that disrupted the development of normal
attachment behavior. A diagnosis of either reactive attachment disorder or disinhibited
social engagement disorder is based on the presumption that the etiology is directly
linked to the caregiving deprivation experienced by the child. The diagnosis of reactive
attachment disorder was first defined in the DSM, Third Edition (DSM-III) in 1980. The
formation of this diagnosis is based on the building blocks of attachment theory, which
describes the quality of a child’s affective relationship with primary caregivers, usually
parents. This basic relationship is the product of a young child’s need for protection,
nurturance, and comfort and the interaction of the parents and child in fulfilling these
needs.
Based on observations of a young child and parents during a brief separation and
reunion, designated the “strange situation procedure,” pioneered by Mary Ainsworth
and colleagues, researchers have designated a child’s basic pattern of attachment to be
characterized as secure, insecure, or disorganized. Children who exhibit secure
attachment behavior are believed to experience their caregivers as emotionally
available and appear to be more exploratory and well adjusted than children who
exhibit insecure or disorganized attachment behavior. Insecure attachment is believed to
result from a young child’s perception that the caregiver is not consistently available,
whereas disorganized attachment behavior in a child is believed to result from
experiencing both the need for proximity to the caregiver and apprehension in
approaching the caregiver. These early patterns of attachment are believed to influence
a child’s future capacities for affect regulation, self-soothing, and relationship building.
According to the DSM-5, reactive attachment disorder is characterized by a consistent
pattern of emotionally withdrawn responses toward adult caregivers, limited positive
affect, sadness, and minimal social responsiveness to others, and concomitant neglect,
deprivation, and lack of appropriate nurturance from caregivers. It is presumed that
reactive attachment disorder is due to grossly pathological caregiving received by the
child. The pattern of care may exhibit disregard for a child’s emotional or physical needs
or repeated changes of caregivers, as when a child is frequently relocated during foster
care. Reactive attachment disorder is not accounted for by autism spectrum disorder,
and the child must have a developmental age of at least 9 months.
Pathological caretaking can result in two distinct disorders: reactive attachment
disorder, in which the disturbance takes the form of the child’s constantly failing to
initiate and respond to most social interactions in a developmentally normal way; and
disinhibited social engagement disorder, in which the disturbance takes the form of
undifferentiated, unselective, and inappropriate social relatedness, with familiar and
unfamiliar adults.
In disinhibited social engagement disorder, according to DSM-5, a child actively
approaches and interacts with unfamiliar adults in an overly familiar way, either
verbally or physically. There is diminished checking with or seeking of a known
caregiver, and a willingness to go with unfamiliar adults without hesitation. These
behaviors in disinhibited social engagement disorder are not accounted for by
impulsivity, although socially disinhibited behavior is predominant. These patterns of
disinhibited, developmentally inappropriate behaviors are presumed to be caused by
pathogenic caregiving. Thus, for both reactive attachment disorder and disinhibited
social engagement disorder, aberrant caretaking is presumed to be the predominant
cause of the child’s inappropriate behaviors. However, there have been cases of less
severe disturbances in parenting that may also be associated with young children who
exhibit some characteristics of reactive attachment disorder or disinhibited social
engagement disorder. The DSM-5 criteria for reactive attachment disorder are described
in Table 31.11a-1 and those for disinhibited social engagement disorder are described in
Table 31.11a-2.
Table 31.11a-1
DSM-5 Diagnostic Criteria for Reactive Attachment Disorder
Table 31.11a-2
DSM-5 Diagnostic Criteria for Disinhibited Social Engagement Disorder
These disorders may also result in a picture of failure to thrive, in which an infant
shows physical signs of malnourishment and does not exhibit the expected
developmental motor and verbal milestones.
EPIDEMIOLOGY
Few data exist on the prevalence, sex ratio, or familial pattern of reactive attachment
disorder and disinhibited social engagement disorder. It has been estimated for either
one to occur in less than 1 percent of the population. A study of 1,646 children aged 6to 8-years-old living in a deprived sector of urban United Kingdom, found that the
prevalence of reactive attachment disorder in this population was 1.4 percent.
However, other studies of selected high-risk populations have estimated that about 10
percent of young children with documented neglectful and grossly pathological
caregiving exhibit reactive attachment disorder, and up to 20 percent of children in this
situation exhibit disinhibited social engagement disorder. In a retrospective report of
children in one county of the United States who were removed from their homes because
of neglect or abuse before the age of 4 years, 38 percent exhibited signs of either
reactive attachment disorder or disinhibited social engagement disorder. Another study
established the reliability of the diagnosis by reviewing videotaped assessments of atrisk children interacting with caregivers, along with a structured interview with
caregivers. Given that pathogenic care, including maltreatment, occurs more frequently
in the presence of general psychosocial risk factors, such as poverty, disrupted families,
and mental illness among caregivers, these circumstances are likely to increase the risk
of reactive attachment disorder and disinhibited social engagement disorder.
ETIOLOGY
The core features of reactive attachment disorder and disinhibited social engagement
disorder are disturbances of normal attachment behaviors. The inability of a young child
to develop normative social interactions that culminate in aberrant attachment
behaviors in reactive attachment disorder is inherent in the disorder’s definition.
Reactive attachment disorder and disinhibited social engagement disorder are presumed
to be linked to maltreatment of the child, including emotional neglect, physical abuse,
or both. Grossly pathogenic care of an infant or young child by the caregiver
presumably causes the markedly disturbed social relatedness that is evident. The
emphasis is on the unidirectional cause; that is, the caregiver does something inimical or
neglects to do something essential for the infant or child. In evaluating a patient for
whom such a diagnosis is appropriate, however, clinicians should consider the
contributions of each member of the caregiver–child dyad and their interactions.
Clinicians should weigh such things as infant or child temperament, deficient or
defective bonding, a developmentally disabled child, and a particular caregiver–child
mismatch. The likelihood of neglect increases with parental psychiatric disorder,
substance abuse, intellectual disability, the parent’s own harsh upbringing, social
isolation, deprivation, and premature parenthood (i.e. adolescent). These factors
compromise parental ability to attend to the needs of the child, as they focus primarily
on their own existence rather than on their child. Frequent changes of the primary
caregivers, for example, from multiple foster care placements or repeated lengthy
hospitalizations, may also lead to impaired attachment. In the general population, a
study of 1,600 children found that those children with reactive attachment
disorder/disinhibited social engagement disorder showed a constellation of symptoms
characterized by early emergence of symptoms eliciting neurodevelopmental
examination (ESSENCE). Some of the associated symptoms in children with reactive
attachment disorder/disinhibited social engagement disorder include higher risk of
failure to gain weight as neonates, feeding difficulty, and poor impulse control. These
traits are likely to emerge because of both genetic and environmental factors. The
authors found that children with reactive attachment disorder/disinhibited social
engagement disorder were more likely to have multiple psychiatric comorbidities, lower
intelligence quotients (IQs) compared to the general population, and more behavioral
problems. Thus, a broad assessment may be necessary to identify symptoms and
disorders associated with reactive attachment disorder/disinhibited social engagement
disorder.
DIAGNOSIS AND CLINICAL FEATURES
Children with reactive attachment disorder and disinhibited social engagement disorder
may initially be identified by a preschool teacher or by a pediatrician based on direct
observation of the child’s inappropriate social responses. The DSM-5 diagnostic criteria
for reactive attachment disorder and disinhibited social engagement disorder are
described in Tables 31.11a-1 and 31.11a-2, respectively. The diagnoses of reactive
attachment disorder and disinhibited social engagement disorder are based partially on
documented evidence of pervasive disturbance of attachment leading to inappropriate
social behaviors present before the age of 5 years. The clinical picture varies greatly,
depending on a child’s chronological and mental ages, but expected social interaction
and liveliness are not present. Often, the child is not progressing developmentally or is
frankly malnourished. Perhaps the most common clinical picture of an infant with
reactive attachment disorder is the nonorganic failure to thrive. Such infants usually
exhibit hypokinesis, dullness, listlessness, and apathy, with a poverty of spontaneous
activity. Infants look sad, joyless, and miserable. Some infants also appear frightened
and watchful, with a radar-like gaze. Nevertheless, they may exhibit delayed
responsiveness to a stimulus that would elicit fright or withdrawal from a normal infant.
Infants with failure to thrive and reactive attachment disorder appear significantly
malnourished, and many have protruding abdomens. Occasionally, foul-smelling, celiaclike stools are reported. In unusually severe cases, a clinical picture of marasmus
appears.
The infant’s weight is often below the third percentile and markedly below the
appropriate weight for his or her height. If serial weights are available, the weight
percentiles may have decreased progressively because of an actual weight loss or a
failure to gain weight as height increases. Head circumference is usually normal for the
infant’s age. Muscle tone may be poor. The skin may be colder and paler or more
mottled than skin of a normal child. Laboratory findings may indicate coincident
malnutrition, dehydration, or concurrent illness. Bone age is usually retarded. Growth
hormone levels are usually normal or elevated, a finding suggesting that growth failure
in these children is secondary to caloric deprivation and malnutrition. Cortisol secretion
in children with reactive attachment disorder or disinhibited social engagement disorder
is lower than in typical developing children. For children with failure to thrive,
improvement physically and weight gain generally occur rapidly after they are
hospitalized.
Socially, the infants with reactive attachment disorder usually show little spontaneous
activity and a marked diminution of both initiative toward others and reciprocity in
response to the caregiving adult or examiner. Both mother and infant may be indifferent
to separation on hospitalization or to termination of subsequent hospital visits. The
infants frequently show none of the normal upset, fretting, or protest about
hospitalization. Older infants usually show little interest in their environment. They
may not play with toys, even if encouraged; however, they rapidly or gradually take an
interest in, and relate to, their caregivers in the hospital.
Psychosocial δwarfism.
Classic psychosocial dwarfism or psychosocially
determined short stature is a syndrome that usually is first manifest in children 2 to 3
years of age. The children are typically unusually short and have frequent growth
hormone abnormalities and severe behavioral disturbances. All of these symptoms result
from an inimical caregiver–child relationship. The affectionless character may appear
when there is a failure, or lack of opportunity, to form attachments before the age of 2
to 3 years. Children cannot form lasting relationships, and their inability is sometimes
accompanied by an inability to obey rules, a lack of guilt, and a need for attention and
affection. Children with disinhibited social engagement disorder appear to be overly
friendly and familiar with little fear.
A 7-year-old boy was referred by his adoptive parents because of hyperactivity and
inappropriate social behavior at school. He had been adopted at 4 years of age, after
living most of his life in a Chinese orphanage in which he received care from a
rotating shift of caregivers. Although he had been below the 5th percentile for height
and weight on arrival, he quickly approached the 15th percentile in his new home.
However, his adoptive parents were frustrated by his inability to bond with them.
They had initially worried about an intellectual problem, although testing and his
capacity to engage almost any adult and many children verbally suggested otherwise.
He appeared to be too friendly, talking to anyone and often following strangers
willingly. He showed little empathy when others were hurt and yet he would sit on
the laps of teachers and students without asking. He was frequently injured because of
seemingly reckless behavior, although he had an extremely high tolerance for pain.
His parents focused on problem behaviors at home to decrease his impulsive behavior,
which improved with much prompting; however, he remained oddly overfriendly at
home and in school. The child was diagnosed with disinhibited social engagement
disorder. (Adapted from Neil W. Boris, M.D. and Charles H. Zeanah, Jr., M.D.)
PATHOLOGY AND LABORATORY EXAMINATION
Although no single specific laboratory test is used to make a diagnosis, many children
with reactive attachment disorder have disturbances of growth and development. Thus,
establishing a growth curve and examining the progression of developmental milestones
may be helpful in determining whether associated phenomena, such as failure to thrive,
are present.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of reactive attachment disorder and disinhibited social
engagement disorder must take into account that many other psychiatric disorders may
arise in conjunction with maltreatment, including depressive disorders, anxiety
disorders, and posttraumatic stress disorders. Psychiatric disorders to consider in the
differential diagnosis include language disorders, autism spectrum disorder, intellectual
disability, and metabolic syndromes. Children with autism spectrum disorders are
typically well nourished and of age-appropriate size and weight, and are generally alert
and active, despite their impairments in reciprocal social interactions. Significant
intellectual disability is often present in children with autism spectrum disorder,
whereas when intellectual disability occurs with reactive attachment disorder or
disinhibited social engagement disorder, it is generally relatively mild. Children with
disinhibited
social
engagement
disorder
often
show
comorbid
attentiondeficit/hyperactivity disorder, posttraumatic stress disorder, and language disorder or
delay. Furthermore, children with disinhibited social engagement disorder symptoms
may have complex neuropsychiatric problems.
COURSE AND PROGNOSIS
Most of the data available on the natural course of children with reactive attachment
disorder and disinhibited social engagement disorder come from follow-up studies of
children in residential facilities with histories of serious neglect. Findings from these
studies suggest that children with reactive attachment disorder, who are later adopted
into caring environments, improve in their attachment behaviors and may normalize
over time. Children with disinhibited social engagement disorder, however, appear to
have more difficulty developing attachments to new caregivers. Children with
disinhibited social engagement disorder who exhibit indiscriminate social behavior also
tend to have poor peer relationships. The prognosis for children with reactive
attachment disorder and disinhibited social engagement disorder is influenced by the
duration and severity of the neglect and the degree of impairment that results.
Constitutional and nutritional factors interact in children, who may either respond
resiliently to treatment or continue to fail to thrive. After a pathological caregiving
situation has been recognized, the amount of treatment and rehabilitation that the
family receives affects the child. Children who have multiple problems stemming from
pathogenic caregiving may recover physically faster and more completely than they do
emotionally.
TREATMENT
The first consideration in treating reactive attachment disorder or disinhibited social
engagement disorder is a child’s safety. Thus, the management of these disorders must
begin with a comprehensive assessment of the current level of safety and adequate
caregiving. When there is suspicion of maltreatment persisting in the home, the first
decision is often whether to hospitalize the child or to attempt treatment while the child
remains in the home. If neglect, or emotional, physical, or sexual abuse is suspected,
legally, such must be reported to the appropriate law enforcement and child protective
services in the area. The child’s physical and emotional state and the level of
pathological caregiving determine the therapeutic strategy. A determination must be
made regarding the nutritional status of the child and the presence of ongoing physical
abuse or threat. Hospitalization is necessary for children with malnourishment. Along
with an assessment of the child’s physical well-being, an evaluation of the child’s
emotional condition is important. Immediate intervention must address the parents’
awareness and capacity to participate in altering the injurious patterns that have
heretofore ensued. The treatment team must begin to improve the unsatisfactory
relationship between caregiver and child. This usually requires extensive and intensive
intervention and education with the mother or with both parents when possible.
In one study, parents of 120 children between 11.7 months and 31.9 months,
identified as being at risk for neglect, were randomly assigned to an intervention for atrisk parents called Attachment and Biobehavioral Catch-up (ABC) or to a control
intervention. The ABC intervention was designed to decrease frightening behavior
toward the infant by parents, and to increase sensitive and nurturing interactions
between parents and infant. The intervention was manualized so that parents were
specifically guided in how to provide those interactions with their infants. Children were
evaluated after 10 sessions, and the 60 children who received the ABC intervention
showed significantly lower rates of disorganized attachment (32%), and higher rates of
secure attachment (52%) compared to those who received the control intervention
(disorganized attachment 57%; secure attachment 33%). The authors concluded that
parental nurturance and sensitivity can be enhanced by a comprehensive and explicit
intervention such as the ABC intervention, and significant improvements in attachment
behaviors can be measured in young children after 10 sessions.
The caregiver–child relationship is the basis of the assessment of reactive attachment
disorder and disinhibited social engagement disorder symptoms, and the substrate from
which to modify attachment behaviors. Structured observations allow a clinician to
determine the range of attachment behaviors established with various family members.
The clinician may work closely with the caregiver and the child to facilitate greater
sensitivity in their interactions. Three basic psychotherapeutic modalities are helpful in
promoting positive bonds between children and caregiver. First, a clinician can target
the caregiver to promote positive interaction with a child who does not yet have the
repertoire to respond positively. Second, a clinician can work with the child and the
caregiver together as a dyad to advocate for practicing appropriate positive
reinforcement for each other. Through the use of videotapes, parent–child interactions
can then be viewed and modifications can be suggested to increase positive
engagement. The third modality for clinical intervention is through individual work with
the child. Working with the child and caregiver together is often more effective in
producing more emotionally meaningful exchanges than working with parent or child
individually.
Psychosocial interventions for families in which a child has reactive attachment
disorder or disinhibited social engagement disorder include (1) psychosocial support
services, including hiring a homemaker, improving the physical condition of the
apartment, or obtaining more adequate housing; improving the family’s financial status;
and decreasing the family’s isolation; (2) psychotherapeutic interventions, including
individual psychotherapy, psychotropic medications, and family or marital therapy; (3)
educational counseling services, including mother–infant or mother–toddler groups, and
counseling to increase awareness and understanding of the child’s needs and to develop
parenting skills; and (4) provisions for close monitoring of the progression of the
patient’s emotional and physical well-being. Sometimes, separating a child from the
stressful home environment temporarily, as in hospitalization, allows the child to break
out of the accustomed pattern. A neutral setting, such as the hospital, is the best place to
start with families who are genuinely available emotionally and physically for
intervention. If interventions are unfeasible or inadequate or if they fail, placement
with relatives or in foster care, adoption, or a group home or residential treatment
facility must be considered.
REFERENCES
Bernard K, Dozier M, Carlson E, Bick J, Lewis-Morrarty, Lindheim O. Enhancing attachment organization among
maltreated children: Results of a randomized clinical trial. Child Dev. 2012;83:623–636.
Boris NW, Zeanah CH. Reactive attachment disorder of infancy, childhood and adolescence. In: BJ Sadock, VA Sadock, Ruiz
P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams &
Wilkins; 2009:3636.
Chaffin M, Hanson R, Saunders BE, Nichols T, Barnett D, Zeanah C, Berliner L, Egeland B, Newman E, Lyon T, LeTourneau
E, Miller-Perrin C. Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment
problems. Child Maltreat. 2006;11:76.
Heller SS, Boris NW, Fuselier SH, Pate T, Koren-Karie N, Miron D. Reactive attachment disorder in maltreated twins
follow-up: From 18 months to 8 years. Attach Hum Dev. 2006;8:63.
Kay C, Green J. Reactive attachment disorder following maltreatment: Systematic evidence beyond the institution. J
Abnorm Child Psychol. 2013;41:571–581.
Kocovska E, Puckering C, Follan M, Smillie M, Gorski C. Neurodevelopmental problems in maltreated children referred
with indiscriminate friendliness. Res Dev Disabil. 2012;33:1560–1565.

27 - 31.11b Posttraumatic Stress Disorder of Infan
31.11b Posttraumatic Stress Disorder of Infancy, Childhood, and Adolescence
Kocovska E., Wilson P, Young D, Wallace AM, Gorski C. Cortisol secretion in children with symptoms of reactive
attachment disorder. Psychiatr Res. 2013;209:74–77.
Minnis H, Macmillan S, Pritchett R, Young D, Wallace B. Prevalence of reactive attachment disorder in a deprived
population. Br J Psychiatry. 2013;202:342–346.
O’Connor TG, Marvin RS, Rutter M, Olrick J, Britner PA. The ERA Study Team. Child–parent attachment following early
institutional deprivation. Dev Psychopathol. 2003;15:19–38.
O’Connor TG, Zeanah CH. Attachment disorders: Assessment strategies and treatment approaches. Attach Hum Dev.
2003;5:223–244.
Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of
infancy and early childhood. J Am Acad Child Adolesc Psychiatry. 2005;44:1206.
Pritchett R, Pritchett J, Marshall E, Davidson C, Minnis H. Reactive attachment disorder in the general population: A
hidden ESSENCE disorder. Sci World J. 2013;2013:818157.
Task Force on Research Diagnostic Criteria: Infancy and preschool: Research diagnostic criteria for infants and preschool
children. J Am Acad Child Adolesc Psychiatry. 2003;42:1504.
Zeanah CH, Scheeringa MS, Boris NW, Heller SS, Smyke AT, Trapani J. Reactive attachment disorder in maltreated
toddlers. Child Abuse Negl. 2004;28:877.
Zeanah CH, Smyke T, Dumitrescu A. Attachment disturbances in young children II: Indiscriminate behavior and
institutional care. J Am Acad Child Adolesc Psychiatry. 2002;41:983.
Zilberstein K. Clarifying core characteristics of attachment disorders: A review of current research and theory. Am J
Orthopsychiatry. 2006;76:55.
31.11b Posttraumatic Stress Disorder of Infancy, Childhood,
and Adolescence
Posttraumatic stress disorder (PTSD), formerly grouped with anxiety disorders, currently
falls under a new chapter in the Fifth Edition of the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) called trauma- and stressorrelated disorders, a group comprising disorders in which exposure to a traumatic or
stressful event is a diagnostic criterion. PTSD is characterized by a set of symptoms
including intrusive memories of the trauma, persistent avoidance of stimuli that are
reminders of the traumatic event, persistent negative alterations in cognition and mood,
and alterations in arousal, mainly seen as hyperarousal and irritability following the
traumatic event. In DSM-5, the traumatic event criterion is defined as exposure to actual
or threatened death, serious injury, or sexual violence, whether directly, by witnessing
it, learning of a traumatic event to a family member, or experiencing repeated
exposures to trauma precipitated by social or natural disasters. Exposure to trauma
through electronic media, movies, television or photographs is excluded from the
criteria. In children 6 years or younger, diagnostic criteria fall under the “preschool
subtype,” in which either persistent avoidance of trauma-evoking stimuli or negative
alterations in cognitions suffice as indications for PTSD.
In the United States, the rates of children and adolescents being exposed to violence
and traumatic events are extremely high. In a nationally representative sample of
children and adolescents, exposure to a traumatic event was reported to be 60.4
percent, with a lifetime rate ranging from 80 to 90 percent. A significant number of
children and adolescents who are exposed to traumatic events, ranging from direct
experiences with physical or sexual abuse, domestic violence, motor vehicle accidents,
severe medical illnesses, or natural or human-created disasters, will develop PTSD. In
children younger than the age of 6 years, spontaneous and intrusive memories may be
expressed in play, or occur in frightening dreams; these intrusive thoughts may not be
easily identified as related to the traumatic event.
Although posttraumatic stress symptoms have been described in adults for more than
a century, PTSD was first officially recognized as a psychiatric disorder in 1980 in the
DSM, Third Edition (DSM-III). Recognition of the frequency of PTSD in children and
adolescents has increased over the last decade. Reports indicate that up to 6 percent of
youth are likely to meet full criteria for PTSD at some point in their development.
Developmental factors strongly influence the manifestations of symptoms of PTSD. In
children and adolescents, reexperiencing of a traumatic event is often observed through
play, recurrent nightmares without recall of the traumatic events, and behaviors that
reenact the traumatic situation, along with agitation, fear, or disorganization.
EPIDEMIOLOGY
In the United States, it is estimated that approximately 80 percent of individuals have
been exposed to at least one traumatic event; however, less than 10 percent of trauma
victims develop posttraumatic stress disorder. The rates of traumatic events, including
assaultive violence, exposure to unexpected deaths, being a witness of trauma to others,
and bodily injury, all peak sharply between the ages of 16 to 20 years. PTSD is more
common in females than in males throughout the life span mainly due to their increased
risk for exposure to traumatic events. In situations of natural disaster, the rates of PTSD
in males and females are similar. Lifetime risk for PTSD in the United States ranges
from 6.8 percent to 12.2 percent. A consistent epidemiologic finding in the United States
and in other countries is that PTSD is more prevalent in women than in men.
Epidemiological studies of children 9 to 17 years of age have found 3-month prevalence
rates of PTSD ranging from 0.5 to 4 percent. An epidemiological survey of preschoolers
aged 4 to 5 years found a rate of 1.3 percent of PTSD.
Among trauma-exposed samples of persons not referred for treatment, a wide range
of 25 percent to 90 percent have been reported to exhibit the full diagnosis of PTSD.
Children exposed chronically to trauma, such as child abuse, or traumas resulting in a
broader disruption of entire communities, such as war, have the greatest risk of
developing PTSD. In addition to the staggering rate of the full-blown disorder of PTSD
among youth, several studies indicate that most children exposed to severe or chronic
trauma develop PTSD symptoms sufficiently severe to disrupt functioning, even in the
absence of the full diagnosis.
ETIOLOGY
Biological Factors
Risk factors in children for developing PTSD include preexisting anxiety disorders and
depressive disorders. A prospective study found that among children exposed to
traumatic events, those with anxiety disorders and teacher ratings of externalizing
behavior problems by the age of 6 years were at increased risk for PTSD. Furthermore,
children with an IQ greater than 115 at age 6 years were at lower risk for developing
PTSD. In addition, among children exposed to trauma, those who developed PTSD were
also at higher risk of developing comorbid disorders such as depression. This suggests
that a genetic predisposition for anxiety disorders, as well as a family history indicating
increased risk of depressive disorders, may predispose a trauma-exposed child to
develop PTSD. Children with PTSD have been found to exhibit increased excretion of
adrenergic and dopaminergic metabolites, smaller intracranial volume and corpus
callosum, memory deficits, and lower intelligence quotients (IQs) compared with agematched controls. Adults with PTSD have been found to have an overactive amygdala
and decreased hippocampal volume. Whether the above findings are sequelae of PTSD
or markers of vulnerability to the disorder remains a focus of investigation.
Psychological Factors
Although the exposure to trauma is the initial etiological factor in the development of
PTSD, the enduring symptoms typical of PTSD, such as avoidance of the place where the
trauma occurred, can be conceptualized, in part, as the result of both classic and
operant conditioning. Extreme physiological responses may accompany fear of a given
traumatic event, such as an adolescent who was terrorized by an attack by a group of
students near school, who then develops an extreme negative physiological reaction
each time he or she is near the school. This is an example of classic conditioning in that
a neutral cue (the school) has become paired with an intensely fearful past event.
Operant conditioning occurs when a child learns to avoid traumatic reminders to
prevent distressing feelings from arising. For example, if a child was in a motor vehicle
accident, the child may then refuse to ride in cars altogether to prevent negative
physiological reactions and fear from occurring.
Another mechanism in developing and maintaining symptoms of PTSD is through
modeling, which is a form of learning. For example, when parents and children are
exposed to traumatic events, such as natural disasters, children may emulate parental
responses, such as avoidance, withdrawal, or extreme expressions of fear, and “learn” to
respond to their own memories of the traumatic event in the same manner.
Social Factors
Family support and reactions to traumatic events in children may play a significant role
in the development of PTSD, in that adverse parental emotional reactions to a child’s
abuse may increase that child’s risk of developing PTSD. Lack of parental support and
psychopathology among parents—especially maternal depression—have been identified
as risk factors in the development of PTSD after a child has been exposed to a traumatic
event.
DIAGNOSIS AND CLINICAL FEATURES
For PTSD to ensue, exposure to a traumatic event consisting of either a direct personal
experience or witnessing an event involving the threat of death, serious injury, or
serious harm must occur. Most common traumatic exposures for children and
adolescents include physical or sexual abuse; domestic, school or community violence;
being kidnapped; terrorist attacks; motor vehicle or household accidents; or disasters,
such as floods, hurricanes, tornadoes, fires, explosions, or airline crashes. A child with
PTSD experiences either intrusive memories of the event, recurrent frightening dreams,
dissociative reactions including flashbacks in which the child feels as if the traumatic
event is recurring, or intense psychological distress when exposed to reminders of the
trauma (Fig. 31.11b-1).
FIGURE 31.11b-1
The face of a boy in Pakistan shortly after a 7.6 magnitude earthquake hit South Asia
leaving millions homeless. (Courtesy of Samoon Ahmad, M.D.)
Symptoms of PTSD include reexperiencing the traumatic event in at least one of the
following ways. Children may have intrusive thoughts, memories, or images that
spontaneously recur, or body sensations that remind them of the event. In very young
children, it is common to observe play that includes elements of the traumatic event, or
behaviors, such as sexual behaviors that are not developmentally expected. Children
may experience periods during which they either act or feel as though the event is
taking place presently; this is a dissociative event usually described by adults as
“flashbacks.”
Another critical symptom cluster of PTSD is avoidance, which in childhood may be
displayed by making active physical efforts to avoid the places, people, or situations
that would present traumatic reminders of the event. A third cluster of diagnostic
criteria for PTSD is negative alterations in cognition and mood following the trauma. In
children 6 years or younger, according to DSM-5, negative alterations in cognitions may
take the form of socially withdrawn behavior, reduction of expressing positive emotions,
diminished interest in play, and feelings of shame, fear, and confusion. In children older
than 6 years of age, these may take the form of an inability to remember parts of a
traumatic event, that is, psychological amnesia, or persistent negative feelings about
oneself, including horror, anger, guilt or shame. After a traumatic event, children may
experience a sense of detachment from their usual play activities (“psychological
numbing”) or a diminished capacity to feel emotions. Older adolescents may express a
fear that they expect to die young (sense of foreshortened future).
Other typical responses to traumatic events include symptoms of hyperarousal that
were not present before the traumatic exposure, such as difficulty falling asleep or
staying asleep; hypervigilance regarding safety and increased checking that doors are
locked; or exaggerated startle reaction. In some children, hyperarousal can present as a
generalized inability to relax with increased irritability, outbursts, and impaired ability
to concentrate.
To meet the diagnostic criteria for PTSD, according to the DSM-5 the symptoms must
be present for at least 1 month, and cause distress and impairment in important
functional areas of life. When all of the diagnostic symptoms of PTSD are met following
the traumatic event, persist for at least 3 days, but resolve within 1 month, acute PTSD
is diagnosed. When the full syndrome of PTSD persists beyond 3 months, it is designated
as chronic PTSD. In some cases, the PTSD symptoms increase over time, and it is not
until more than 6 months have elapsed after the exposure to the trauma that the whole
syndrome emerges; in that case, the diagnosis is PTSD, delayed onset. DSM-5 criteria for
PTSD are described in Table 11.1-3.
It is not uncommon for children and adolescents with PTSD to experience feelings of
guilt, especially if they have survived the trauma and others in the situation did not.
They may blame themselves for the demise of the others and may go on to develop a
comorbid depressive episode. Childhood PTSD is also associated with increased rates of
other anxiety disorders, depressive episodes, substance use disorders, and attentional
difficulties. DSM-5 includes a specifier With dissociative symptoms, which can present as
either Depersonalization, in which there are recurrent experiences of feeling detached, as
if outside of one’s own body; or Derealization, in which the world feels unreal, dreamlike,
and distant. A final specifier, With delayed expression, indicates that the full diagnostic
criteria were not met until 6 months after the traumatic event, although some symptoms
may present earlier.
PATHOLOGY AND LABORATORY EXAMINATION
Although reports indicate some alterations in both neurophysiological and neuroimaging
studies of children and adolescents with PTSD, no current laboratory tests can help in
making this diagnosis.
DIFFERENTIAL DIAGNOSIS
A number of overlapping symptoms are seen between childhood PTSD and presentations
of childhood anxiety disorders, such as separation anxiety disorder, obsessive-compulsive
disorder (OCD) or social phobia, in which recurrent intrusive thoughts or avoidant
behaviors occur. Children with depressive disorders often exhibit withdrawal and a sense
of isolation from peers as well as guilt about life events over which they realistically
have no control. Irritability, poor concentration, sleep disturbance, and decreased
interest in usual activities can also be observed in both PTSD and major depressive
disorder.
Children who have lost a loved one in a traumatic event may go on to experience
both PTSD and a major depressive disorder when bereavement persists beyond its
expected course. Children with PTSD may also be confused with children who have
disruptive behavior disorders, because they often show poor concentration, inattention,
and irritability. It is critical to elicit a history of traumatic exposure and evaluate the
chronology of the trauma and the onset of the symptoms to make an accurate diagnosis
of PTSD.
COURSE AND PROGNOSIS
For some children and adolescents with milder forms of PTSD, symptoms may persist for
one to two years, after which they diminish and attenuate. In more severe
circumstances, however, PTSD syndromes persist for many years or decades in children
and adolescents, with spontaneous remission in only a portion of them.
The prognosis of untreated PTSD has become an issue of growing concern for
researchers and clinicians who have documented a variety of serious comorbidities and
psychobiological abnormalities associated with PTSD. In one study, children and
adolescents with severe PTSD were at risk for decreased intracranial volume, diminished
corpus callosum area, and lower IQs compared to children without PTSD. Children and
adolescents with histories of physical and sexual abuse have been found to exhibit higher
rates of depression and suicidality themselves and in their offspring as well. This
highlights the importance of early recognition and treatment of PTSD that may
significantly improve the long-term outcome among youth.
TREATMENT
Trauma-Focused Cognitive-Behavior Therapy
Randomized clinical trials have provided evidence for the efficacy of trauma-focused
cognitive-behavior therapy (CBT) in the treatment of PTSD in children and adolescents.
This treatment is generally administered over 10 to 16 treatment sessions, including
nine components itemized in the acronym PRACTICE. Trauma-focused CBT as detailed
by Cohen, Mannarino, and Deblinger in their text Treating Trauma and Traumatic Grief in
Children and Adolescents entails the inclusion of gradual exposure to feared stimuli as a
critical element. Such stimuli encompass places, people, sounds, and situations. The first
component of trauma-focused CBT is psychoeducation regarding the nature of typical
emotional and physiological reactions to traumatic events and PTSD. Next, Parenting
Skills involve sessions focused on guiding parents on providing praise, administering a
time out, contingency reinforcement programs, and troubleshooting for specific
symptoms in a given child. Component 3 is Relaxation, in which children are taught to
utilize muscle relaxation, focused breathing, affective modulation, thought-stopping, and
other cognitive techniques to diminish feelings of helplessness and distress. Component
4 is Affective Expression and Modulation, geared to help children and their parents to
identify their feelings, interrupt disturbing thoughts with positive imagery, and teach
positive self-talk and social skills building. Component 5 is Cognitive coping and
processing, which deals specifically with reviewing the Cognitive Triangle, in which the
relationship between thoughts, feelings, and behaviors is explored. Unhelpful thoughts
are challenged with practice. In Component 6, Trauma narrative, the story of the
traumatic event and its sequelae are developed over time by the child, with the
therapist’s support, using a depiction of words, art, or other creative form. Eventually
this is shared with the parent. Component 7, In Vivo Exposure and Mastery of Trauma
Reminders, is a session that reviews with the child how to deal with situations that are a
reminder of the trauma and how to maintain control over distressing feelings associated
with it. Component 8 is Conjoint Child-Parent Sessions; this component may involve
several sessions in which the child and parent share their understanding of the process
of the therapy and the gains that they have made. Finally, Component 10, Enhancing
future safety, involves sessions that focus on the changes made in the family to ensure
the safety of the child. These final sessions also promote healthy communication
between the child and the parents.
A variant of trauma-focused CBT for PTSD is called eye movement desensitization and
reprocessing (EMDR), in which an exposure and cognitive reprocessing interventions are
paired with directed eye movements. This technique is not as well accepted as the more
extensive trauma-focused CBT detailed above.
Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
CBITS is an intervention that administers treatment in the school setting for children
who screen positive for PTSD and whose parents agree to treatment in school. It consists
of ten weekly group sessions, one to three individual imaginal exposure sessions, two to
four optional sessions with parents, and one parent education session. Similar to
trauma-focused CBT (TF-CBT), CBITS incorporates psychoeducation, relaxation training,
cognitive coping skills, gradual exposure to traumatic memories through a narrative, in
vivo exposure, and affect modulation, cognitive restructuring, and social problem
solving. In one randomized controlled trial, 86% of students in the CBITS group
reported significantly decreased PTSD symptoms compared to the waitlist controls.
Students who received CBITS also reported lower depression scores. Among parents
whose children received CBITS treatment, 78% reported decreased psychosocial
problems in their children. After CBITS treatment, the improvements in both the PTSD
and depression symptoms were sustained at 6 months.
Structured Psychotherapy for Adolescents Responding to Chronic Stress
(SPARCS)
SPARCS consists of a group intervention, generally administered in 16 sessions, with a
focus on the needs of adolescents between the ages of 12 and 19 years who have lived
with chronic trauma and may also carry a diagnosis of PTSD. SPARCS was tested in a
trial of multicultural teens and young adults with moderate or severe trauma exposure.
Most of the participants were female, and comprised multiple ethnic groups: 67%
African American; 12% Latino; 21% Caucasian. SPARCS demonstrated efficacy in
reducing traumatic stress symptoms, mainly in the largest group, the African American
group. SPARCS utilizes cognitive behavioral techniques, and also incorporates many of
the components of TF-CBT. In addition, SPARCS includes mindfulness techniques and
relaxation.
Trauma Affect Regulation: Guide for Education and Therapy (TARGET)
TARGET, an affect regulation therapy, combines CBT components, such as cognitive
processing, with affect modulation. It is administered to adolescents between the ages of
13 and 19 who have been exposed to maltreatment and/or chronic traumatic exposure
to such things as community violence or domestic violence. It is generally administered
in 12 sessions, which focus on past or current situations. As with SPARCS treatment,
gradual exposure may occur in the context of recounting past trauma but is not a core
component of the treatment. A randomized trial with 59 delinquent girls aged 13 to 17
years who met full or partial criteria for PTSD found that TARGET reduced anxiety,
anger, depression, and PTSD cognitions. TARGET is a promising treatment for girls with
histories of delinquency, especially to reduce anger and to enhance optimism and selfefficacy.
Crisis Intervention/Psychological Debriefing
Crisis intervention/psychological debriefing typically consists of several sessions
immediately after an exposure to a traumatic event in which a traumatized child or
adolescent is encouraged to describe the traumatic event in the context of a supportive
environment. Psychoeducation is provided and guidance about the management of
initial emotional reactions may be provided. Anecdotal reports suggest that this
intervention may be helpful, but no controlled studies have yet provided evidence that
this intervention leads to a more positive outcome.
Psychopharmacological Treatment
Several pharmacologic agents have been utilized to treat children and adolescents with
PTSD, often focused on diminishing intrusive thoughts, hyperarousal, and avoidance,
with some success and mixed results. Given the frequent comorbidity of depressive
disorder, anxiety disorders, and behavioral problems associated with PTSD, a multitude
of psychopharmacological agents have been utilized to ameliorate symptoms associated
with PTSD in youth. Antidepressant agents have been used as adjuncts to psychosocial
treatments in youth with PTSD. Despite the fact that sertraline and paroxetine are
approved by the Food and Drug Administration (FDA) in the treatment of PTSD in
adults, there is scant evidence to support its use for the core symptoms of PTSD in youth.
A randomized controlled trial of TF-CBT plus sertraline compared to TF-CBT plus
placebo in 24 children with PTSD found that both groups had significant reduction in
PTSD symptoms, with no significant difference between the groups. A multicenter study
of 131 children aged 6 to 17 years with PTSD were treated with 10 weeks of sertraline
or placebo. Results showed sertraline to be a safe treatment; however, it was not
demonstrated to have efficacy compared to placebo. A randomized controlled trial using
citalopram did not show superiority of citalopram over placebo in treatment of core
PTSD symptoms. There is, however, evidence suggesting that the use of selective
serotonin reuptake inhibitors (SSRIs) in traumatized children with burns may be
preventive regarding the development of PTSD. Published literature demonstrates that
up to 50 percent of children with moderate to severe burns develop PTSD, thus
preventive strategies are important. A randomized controlled study of sertraline to
prevent PTSD found that children who received sertraline, flexibly dosed between 25 mg
and 150 mg per day, had a decrease in parent-reported symptoms of PTSD over 8 weeks
compared to a placebo group. Among the child-reported symptoms, however, there was
no significant difference between the two groups.
Antiadrenergic agents have been tried to treat dysregulation of the noradrenergic
system in adults and youth with PTSD. α-2-agonists such as clonidine and guanfacine,
for example, have been used to decrease norepinephrine release, whereas centrally
acting β-antagonists such as propranolol, and α-1-antagonists such as prazosin, are
hypothesized to improve hyperarousal and intrusive thoughts through attenuation of
norepinephrine postsynaptically. In adults, clonidine (Catapres) and propranolol
(Inderal) have been used to treat PTSD, especially nightmares and exaggerated startle
response, with evidence of improvement. Although there are some data in adults with
PTSD to support the use of these agents, data in youth are limited largely to case
reports. There is a suggestion that guanfacine may reduce nightmares in children with
PTSD and that clonidine may diminish symptoms of reenactment of traumatic events in
children. One report of propranolol treatment in 11 pediatric patients with PTSD from
sexual or physical abuse with a mean age of 8.5 years, who exhibited agitation and
hyperarousal, indicated some decrease in symptoms in 8 of the 11 children studied.
Another open study of transdermal clonidine treatment of preschoolers with PTSD
suggests that clonidine may be efficacious in this population in decreasing activation
and hyperarousal. An additional open trial of oral clonidine with dosage ranges of 0.05
to 0.1 mg twice daily similarly suggests that this medication may provide some relief for
the symptoms of hyperarousal, impulsivity, and agitation in young children with PTSD.
Second-generation antipsychotics such as risperidone, olanzapine, quetiapine,
ziprasidone, and aripiprazole have been studied in adults with PTSD with mixed results.
Risperidone and aripiprazole have both been given FDA approval for use in children
and adolescents with aggression, severe behavioral dyscontrol, and severe psychiatric
disorders; however, controlled trials have not been done with children with PTSD. A
report of three preschool-aged children who exhibited symptoms of acute stress disorder
and who had severe thermal burns were reported to improve after being treated with
risperidone.
Mood-stabilizing agents including divalproex, carbamazepine, topiramate, and
gabapentin have been utilized for adults with PTSD with modest improvement. In
children and adolescents with PTSD, one open-label trial of carbamazepine and one trial
of divalproex have been undertaken. In the carbamazepine trial, all 28 patients were
reported to be either asymptomatic or improved at blood levels of the agent of 10 to
11.5 micrograms/ml. In the divalproex trial, 12 males who carried diagnoses of conduct
disorder comorbid with PTSD were randomly assigned to high- or low-dose divalproex
with reported improvement in those receiving the higher doses. Benzodiazepines are
often prescribed to treat anxiety symptoms in patients with PTSD, although there are no
controlled trials to support their use in youth with PTSD at this time.
Given that many children and adolescents with PTSD have comorbid depressive and
anxiety disorders, SSRIs are recommended in the treatment of these coexisting disorders.
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28 - 31.12 Mood Disorders and Suicide in Children
31.12 Mood Disorders and Suicide in Children and Adolescents

29 - 31.12a Depressive Disorders and Suicide in Ch
31.12a Depressive Disorders and Suicide in Children and Adolescents
manual, lesson plans and lesson materials and worksheets. Santa Monica, CA: RAND Health. 2009.
Meighen KG, Hines LA, Lagges AM. Risperidone treatment of preschool children with thermal burns and acute stress
disorder. J Child Adolesc Psychopharmacol. 2007;17:223–232.
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disorder: A double-blind placebo-controlled trial. J Child Adolesc Psychopharmacol. 2010;20:463–471.
Rynn M, Puliafico A, Heleniak C, Rikhi P, Ghalib K, Vidair H. Advances in pharmacotherapy for pediatric anxiety
disorders. Depress Anxiety. 2011;28:76–87.
31.12 Mood Disorders and Suicide in Children and
Adolescents
31.12a Depressive Disorders and Suicide in Children and
Adolescents
Depressive disorders in youth represent a significant public health concern, in that they
are prevalent and result in long-term adverse effects on the individual’s cognitive,
social, and psychological development. These disorders affect approximately 2 to 3
percent of children and up to 8 percent of adolescents, so the need for early
identification and access to evidence-based interventions such as cognitive-behavioral
therapies (CBTs) and antidepressant agents, is essential. Although major depression runs
in families, with the highest risk in children whose parents experienced early onset
depression, twin studies have demonstrated that major depression is only moderately
heritable, approximately 40 to 50%, highlighting environmental stressors and adverse
events as major contributors to major depressive disorder in youth. The core features of
major depression in children, adolescents, and adults bear a striking resemblance;
however, clinical presentation is strongly influenced by the developmental level of the
child or adolescent. The American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) utilizes the same criteria for major
depressive disorder in youth as in adults, except that for children and adolescents,
irritable mood may replace a depressed mood in the diagnostic criteria.
Most children and adolescents with depressive disorders neither attempt nor complete
suicide; however, severely depressed youth often have suicidal ideation, and suicide
remains the most serious risk of major depression. Nevertheless, many depressed youth
do not ever have suicidal ideation, and many children and adolescents who engage in
suicidal behavior do not have a depressive disorder. There is epidemiological evidence to
suggest that depressed youth with recurrent active suicidal ideation, including a plan,
and who have made prior attempts, are at higher risk to complete suicide, compared to
youth who express only passive suicidal ideation.
Mood disorders in children and adolescents have been studied increasingly over the
last two decades, culminating in large sample multisite randomized controlled trials
such as the Treatment of Adolescent Depression (TADS) study, which provides evidence
of the efficacy of both cognitive-behavioral therapy as well as selective serotonin
reuptake inhibitors (SSRIs). Furthermore, when the preceding modalities are combined,
the greatest efficacy is achieved. Increased recognition of depressive disorders in
preschool populations has sparked clinicians and researchers to develop psychosocial
interventions such as the Parent-Child Interaction Therapy Emotion Development (PCITED), which target treatment specifically for this age group. The expression of disturbed
and depressed mood appears to vary with developmental stage. Very young children
with major depression are often observed to be sad, listless, or apathetic, even though
they may not articulate these feelings verbally. Perhaps surprisingly, mood-congruent
auditory hallucinations are not infrequently observed in young children with major
depression. Somatic complaints such as headaches and stomachaches, withdrawn and
sad appearance, and poor self-esteem are more universal symptoms. Patients in late
adolescence with more severe forms of depression often display pervasive anhedonia,
severe psychomotor retardation, delusions, and a sense of hopelessness. Symptoms that
appear with the same frequency, regardless of age and developmental status, include
suicidal ideation, depressed or irritable mood, insomnia, and diminished ability to
concentrate.
Developmental issues, however, influence the expression of depressive symptoms. For
example, unhappy young children who exhibit recurrent suicidal ideation are rarely able
to propose a realistic suicide plan or to carry out such a plan. Children’s moods are
especially vulnerable to the influences of severe social stressors, such as chronic family
discord, abuse and neglect, and academic failure. Many young children with major
depressive disorder have histories of abuse, neglect, and families with significant
psychosocial burdens such as parental mental illness, substance abuse, or poverty.
Children who develop depressive disorders in the midst of acute toxic family stressors
may have remission of depressive symptoms when the stressors diminish or when a
more nurturing family environment is introduced. Depressive disorders are generally
episodic, albeit typically lasting close to a year; however, their onset may be insidious
and remain unidentified until significant impairment in peer relationships, deterioration
in
academic
function,
or
withdrawal
from
activities
emerges.
Attentiondeficit/hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct
disorder are not infrequently comorbid with a major depressive episode. In some cases,
conduct disturbances or disorders occur in the context of a major depressive episode and
resolve with the resolution of the depressive episode. Clinicians must clarify the
chronology of the symptoms to determine whether a given behavior (e.g., poor
concentration, defiance, or temper tantrums) was present before the depressive episode
and is unrelated to it or whether the behavior is occurring for the first time and is
related to the depressive episode.
EPIDEMIOLOGY
Depressive disorders increase in frequency with increasing age in the general
population. Mood disorders among preschool-age children are estimated to occur in
about 0.3 percent of community samples, and 0.9 percent in clinic settings. The
prevalence of major depression in school age children is 2 to 3 percent. Depression in
referred samples of school-age children is found to be the same frequency in boys as in
girls, with some surveys indicating a slightly increased rate among boys. In adolescents,
prevalence rate of major depression is from 4 to 8 percent and two to three times more
likely in females than males. By age 18 years, the cumulative incidence of major
depression is 20 percent. Children with a family history of major depression in a firstdegree relative are about three times more likely to develop the disorder than in those
without family histories of affective disorders. The prevalence of persistent depressive
disorder in children ranges from 0.6 to 4.6 percent and in adolescence increases to 1.6
to 8 percent. Children and adolescents with persistent depressive disorder have a high
likelihood of developing major depressive disorder at some point after 1 year of the
persistent depressive disorder. The rate of developing a major depression on top of
persistent depressive disorder (double depression) within a 6-month period of persistent
depressive disorder is estimated to be about 9.9 percent.
Among psychiatrically hospitalized children and adolescents, the rates of major
depressive disorder have been estimated to be close to 20 percent for children and 40
percent for adolescents.
ETIOLOGY
Considerable evidence indicates that major depression in youth is the same fundamental
disorder experienced by adults, and that its neurobiology is likely to be an interaction of
genetic vulnerability and environmental stressors.
Genetic Studies
Converging evidence suggests that an interaction between genetic susceptibility and
environmental stressors contributes to an emerging major depression and is associated
with brain volume, especially in the hippocampal region. The serotonin transporter
gene and, in particular, the serotonin transporter promoter polymorphism (5-HTTLPR)
have become a focus of investigation. Patients with the short S-allele of the serotonin
polymorphism who also experienced a significant environmental adverse event such as
neglect, developed smaller hippocampal volumes compared to patients with only one of
the above risk factors. The S-allele of the polymorphism leads to decreased serotonin (5HT) reuptake and thus potentially to decreased uptake of serotonin into the brain. A
large longitudinal study in New Zealand found that the S-allele of the serotonin
transporter gene was associated with early environmental stress and subsequent
depression. This study demonstrated a relationship between early environmental stress
and subsequent depression in children with one or two short alleles, but not in children
with two long alleles. Because the short alleles are less efficient in transcription, this
finding suggests that the availability of the transporter gene may provide a marker for
vulnerability to depression. The findings that the combination of a decreased volume in
the hippocampus is associated with the S-allele of the serotonin transporter gene
polymorphism and early adverse events in depression, may represent a mechanism by
which the risk of major depression is mediated by both genetics and environmental
stressors.
Familiality
Twin studies have demonstrated that major depression is approximately 40 to 50
percent heritable. There is an increased risk of depression in the children of parents with
the disorder, and this risk is further increased for the child when the parents developed
depressive disorders at an early age. Studies suggest age-related differences in the
heritability of major depression such that in younger children, environmental influences
appear to be more dominant and in first episodes in adolescence, heritability may play
a larger role. Family studies suggest that for children with a parent with a history of
major depressive disorder, the risk of developing an episode of major depressive
disorder is doubled, whereas with two depressed parents, the risk of an episode of major
depressive disorder quadruples in the offspring before age 18 years. Similarly, children
with the largest number of severe episodes starting at younger ages exhibit the densest
family histories of major depressive disorder.
Neurobiology
Neuroendocrine studies have examined the hypothalamic-pituitary-adrenal axis, the
hypothalamic
growth
hormone,
the
hypothalamic-pituitary-thyroid,
and
the
hypothalamic-pituitary-gonadal axes, seeking to demonstrate consistent markers in
depressed youth. These studies have yielded inconsistent results. For example, depressed
prepubertal children secrete significantly more growth hormone during sleep than
nondepressed children or youth with other psychiatric disorders. In addition, depressed
children secrete significantly less growth hormone in response to insulin-induced
hypoglycemia than do nondepressed patients. Both findings appear to persist for
months after partial or full remission. Thyroid hormone studies have found lower free
total thyroxine (FT4) levels in depressed adolescents than in a matched control group.
These values were associated with normal thyroid-stimulating hormone (TSH). This
finding suggests that, although values of thyroid function remain in the normative
range, FT4 levels have shifted downward. These downward shifts in thyroid hormone
possibly contribute to the clinical manifestations of depression.
Sleep studies are also inconclusive in depressed children and adolescents.
Polysomnography in depressed children have only occasionally shown characteristic
sleep markers of adults with major depressive disorder: reduced rapid eye movement
(REM) latency and an increased number of REM periods.
Magnetic Resonance Imaging
Neuroimaging studies of depressed youth demonstrate smaller frontal white matter
volumes, larger frontal gray matter volumes, and larger lateral ventricle volumes.
Depressed youth have been found to have a blunted amygdala response to fearful faces
compared to non-depressed children and depressed children have been found to have
smaller amygdale volumes compared to healthy controls.
Because twin studies and adoption studies have demonstrated that depression appears
to be only 40 to 50 percent heritable, with environmental contributions more
predominant in younger children, family and environmental contributions must be
examined. Adverse events during childhood such as maltreatment, abuse or neglect,
parental death, parental psychiatric illness, substance abuse, parent–child conflict, and
lack of family cohesion are all risk factors for childhood depression. Data from twin and
genetic studies support the conclusion that the interaction of genetic and environmental
factors plays a critical role in depressive disorders, since correlation of adverse life
events and depression is stronger in children and adolescents with known genetic
susceptibility.
Once a child or adolescent has experienced one major depressive episode, the
psychosocial “scars” increase his or her vulnerability for a subsequent episode. The
psychosocial impairments in depressed children remain far after recovery from the
episode. Among depressed preschoolers, the sooner that adverse life events promoting
the depression are identified, the more rapidly interventions may be administered to
treat the depression.
DIAGNOSIS AND CLINICAL FEATURES
Major Depressive Disorder
Major depressive disorder in children is diagnosed most easily when it is acute and
occurs in a child without previous psychiatric symptoms. Often, however, the onset is
insidious, and the disorder occurs in a child who has had several years of difficulties with
hyperactivity, separation anxiety disorder, or intermittent depressive symptoms.
According to the DSM-5, diagnostic criteria for a major depressive episode consist of
at least five symptoms, for a period of 2 weeks, including either (1) depressed or
irritable mood, or (2) a loss of interest or pleasure. Additional symptoms may include
failure to make expected weight gains, daily insomnia or hypersomnia, psychomotor
agitation or retardation, daily fatigue or loss of energy, feelings of worthlessness or
inappropriate guilt, diminished ability to think or concentrate, and recurrent thoughts of
death. These symptoms must produce social or academic impairment. To meet the
diagnostic criteria for major depressive disorder, the symptoms cannot be due to the
direct effects of a substance (e.g., alcohol) or a general medical condition. In contrast to
the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR), in which a diagnosis of major depressive disorder was not made within 2
months of the loss of a loved one, except when marked functional impairment, morbid
preoccupation
with
worthlessness,
suicidal
ideation,
psychotic
symptoms,
or
psychomotor retardation was present, in DSM-5, a diagnosis of major depressive
disorder can be made at any time following a loss, even without the preceding
symptoms. This change reflects the understanding that grief typically lasts 1 to 2 years,
rather than 2 months, and that major depressive disorder may occur in the presence of
grief at any time after a loss.
A major depressive episode in a prepubertal child is likely to be manifest by somatic
complaints, psychomotor agitation, and mood-congruent hallucinations. Anhedonia is
also frequent, but anhedonia, as well as hopelessness, psychomotor retardation, and
delusions, are more common in adolescent and adult major depressive episodes than in
those of young children. Adults have more problems than depressed children and
adolescents with sleep and appetite. In adolescence, negativistic or frankly antisocial
behavior and the use of alcohol or illicit substances can occur and may justify the
additional diagnoses of oppositional defiant disorder, conduct disorder, and substance
abuse or dependence. Feelings of restlessness, irritability, aggression, reluctance to
cooperate in family ventures, withdrawal from social activities, and isolation from peers
often occur in adolescents. School difficulties are likely. Depressed adolescents may
become less attentive to personal appearance and show increased sensitivity to rejection
by peers, and in romantic relationships.
Children can be reliable reporters about their emotions, relationships, and difficulties
in psychosocial functions. They may, however, refer to depressive feelings in terms of
anger, or feeling “mad” rather than sad. Clinicians should assess the duration and
periodicity of the depressive mood to differentiate relatively universal, short-lived, and
sometimes frequent periods of sadness, usually after a frustrating event, from a true,
persistent depressive mood. The younger the child, the more imprecise his or her time
estimates are likely to be.
Mood disorders tend to be chronic if they begin early. Childhood onset may be the
most severe form of mood disorder and tends to appear in families with a high incidence
of mood disorders and alcohol abuse. The children are likely to have such secondary
complications as conduct disorder, alcohol and other substance abuse, and antisocial
behavior. Functional impairment associated with a depressive disorder in childhood
extends to practically all areas of a child’s psychosocial world; school performance and
behavior, peer relationships, and family relationships all suffer. Only highly intelligent
and academically oriented children with no more than a moderate depression can
compensate for their difficulties in learning by substantially increasing their time and
effort. Otherwise, school performance is invariably affected by a combination of
difficulty concentrating, slowed thinking, lack of interest and motivation, fatigue,
sleepiness, depressive ruminations, and preoccupations. Depression in a child may be
misdiagnosed as a learning disorder. Learning problems secondary to depression, even
when long-standing, are corrected rapidly after a child’s recovery from the depressive
episode.
Children and adolescents with severe forms of major depressive disorder may have
hallucinations and/or delusions. Usually, these psychotic symptoms are thematically
consistent with the depressed mood, occur with the depressive episode (usually at its
worst), and do not include certain types of hallucinations (such as conversing voices and
a commenting voice, which are specific to schizophrenia). Depressive hallucinations
usually consist of a single voice speaking to the person from outside his or her head,
with derogatory or suicidal content. Depressive delusions center on themes of guilt,
physical disease, death, nihilism, deserved punishment, personal inadequacy, and
(sometimes) persecution. These delusions are rare in prepuberty, probably because of
cognitive immaturity, but are present in about half of psychotically depressed
adolescents.
Adolescent onset of a mood disorder can be complicated by use of alcohol or drugs.
One study found that up to 17 percent of adolescents with depressive disorder received
an initial evaluation due to substance abuse.
Persistent Depressive Disorder (Dysthymia)
Persistent depressive disorder, in DSM-5, represents a consolidation of chronic major
depressive disorder and what DSM-IV-TR termed dysthymic disorder. In children and
adolescents it consists of a depressed or irritable mood for most of the day, for more
days than not, over a period of at least 1 year. DSM-5 notes that in children and
adolescents, irritable mood can replace the depressed mood criterion for adults and that
the duration criterion is not 2 years but 1 year for children and adolescents. According
to the DSM-5 diagnostic criteria, two or more of the following symptoms must
accompany the depressed or irritable mood: low self-esteem, hopelessness, poor appetite
or overeating, insomnia or hypersomnia, low energy or fatigue, or poor concentration
or difficulty making decisions. During the year of the disturbance, these symptoms do
not resolve for more than 2 months at a time. In addition, the diagnostic criteria for
dysthymic disorder specify that during the first year, no major depressive episode
emerges. To meet the DSM-5 diagnostic criteria for persistent depressive disorder, a
child must not have a history of a manic or hypomanic episode. Persistent depressive
disorder is also not diagnosed if the symptoms occur exclusively during a chronic
psychotic disorder or if they are the direct effects of a substance or a general medical
condition. DSM-5 provides specifiers for early onset (before 21 years of age) or late
onset (after 21 years of age).
A child or adolescent with persistent depressive disorder may have had a major
depressive episode before developing persistent depressive disorder; however, it is much
more common for a child with persistent depressive disorder for more than 1 year to
develop a concurrent episode of major depressive disorder. In this case, both depressive
diagnoses apply (double depression). Persistent depressive disorder in youth is known to
have an average age of onset that is several years earlier than the typical onset of major
depressive disorder. Occasionally, youth fulfill the criteria for persistent depressive
disorder, except that their episode does not last for a whole year, or they experience
remission from symptoms for more than a 2-month period. These mood presentations in
youth may predict additional mood disorder episodes in the future. Current knowledge
suggests that the longer, more recurrent, and less directly related to social stress these
episodes are, the greater the likelihood of future severe mood disorder. When minor
depressive episodes follow a significant stressful life event by less than 3 months, it may
be classified as an adjustment disorder.
Cyclothymic Disorder
Cyclothymia is a chronic and fluctuating mood disturbance of hypomanic symptoms and
periods of depressive symptoms that do not meet diagnostic criteria for major depressive
disorder. The difference in the DSM-5 diagnostic criteria for youth with cyclothymic
disorder compared to adults is that a period of 1 year, rather than 2 years, of numerous
mood swings is applied. Bipolar II disorder is distinguished from cyclothymia by a
history of episodes of major depressive disorder. When an episode of major depressive
disorder occurs after a diagnosis of cyclothymia has been present for at least 2 years, a
concurrent diagnosis of Bipolar II disorder is made.
Bereavement
Bereavement is a state of grief related to the death of a loved one, which presents with
an overlap of symptoms characteristic of a major depressive episode. Typical depressive
symptoms associated with bereavement include feelings of sadness, insomnia,
diminished appetite, and, in some cases, weight loss. Grieving children may become
withdrawn and appear sad, and they are not easily drawn into even favorite activities.
In DSM-5, bereavement is not a mental disorder; however, uncomplicated
bereavement is included as a category documented with a v code, indicating that a
normal grief reaction to the loss of a loved one has become a focus of clinical attention.
Children in the midst of a typical bereavement period may also meet the criteria for
major depressive disorder. Symptoms indicating major depressive disorder exceeding
typical bereavement include intense guilt related to issues beyond those surrounding the
death of the loved one, preoccupation with death other than thoughts about being dead
to be with the deceased person, morbid preoccupation with worthlessness, marked
psychomotor retardation, prolonged serious functional impairment, and hallucinations
other than transient perceptions of the voice of the deceased person.
The duration of bereavement varies; in children, the duration may depend partly on
the support system in place. For example, a child who must be removed from home
because of the death of the only parent in the home may feel devastated and abandoned
for a long period. Children who lose loved ones may feel a sense of guilt, that the death
may have occurred because they were “bad” or did not perform as expected.
Ryan was a 12-year-old 7th grader in middle school who was brought to the
emergency room in handcuffs by police after walking into oncoming traffic right after
school. Ryan walked in front of a city bus; the driver began honking at the boy who
kept walking slowly into the traffic. Two police stationed in their car across the street
from the school heard the bus honking and noticed Ryan and confronted him. The
police were about to issue the boy a citation for crossing against the red light;
however, when they inquired as to why he had crossed against the traffic light he
informed them that he was trying to kill himself. The police handcuffed Ryan, placed
him in the police car without a struggle and brought him to the local hospital’s
emergency room. Ryan’s mother was contacted and met her son in the emergency
room. Ryan was found to be physically intact, without injury, by the emergency room
doctors, and psychiatric evaluation was initiated by a team of child psychiatrists
including an attending child psychiatrist and two child and adolescent psychiatry
residents. Ryan became tearful when asked what had happened, and reported that he
had purposefully walked in front of the bus in the hope of being hit by the bus in
order to die. Ryan reported that he has been bullied by numerous peers over the last 2
years and is picked on because he is short and overweight. Ryan reported that on this
day, a girl in his class had pushed him down and started hitting him and laughing at
him. Ryan reported that he had been teased and physically assaulted repeatedly by
peers in his grade and that they call him stupid and fat. Ryan has some friends, who
usually defend him, but on this day, his friends were not close by and he became
desperate. Ryan disclosed, however, that even before this day, he has been
consistently sad in school for the past year, and that he has thought about suicide
recurrently over the last year, mainly due to feeling ostracized and worthless after
being picked on and bullied. Ryan continues to be actively suicidal, disclosing his
strong feeling that for him, life is not worth living. Ryan is a relatively good student,
earning good grades, especially in math, although he is currently failing history. Upon
separate interview with Ryan’s mother, she reports that she has no knowledge of any
problems that Ryan has been struggling with, and that she feels that Ryan is not
depressed, not severely bullied, or seriously unhappy in school, and reports that this
must have been a mistake and that she is ready to take him home. Ryan reported that
he had previously seen a counselor in school a few times last year when he was
bullied, but that he has received no intervention for his depression or his suicidality
and that he has not shared these feeling with his family and that he is generally
content at home. Ryan has an older brother and a younger brother who are well
adjusted. When Ryan and his mother were interviewed together, Ryan was able with
some encouragement to let his mother know how depressed, hopeless, and suicidal he
feels, and why. Ryan’s mother burst into tears and Ryan tried to comfort his mother,
although he was crying as well. Ryan was placed on a 72-hour hold for “danger to
self,” and referred to a children’s psychiatric inpatient unit for further evaluation and
treatment. A trial of an SSRI antidepressant was recommended as well as
psychoeducation and family sessions so that Ryan and his family would reach an
understanding about his current psychiatric disorder, and that together they could
work on a safe and productive plan for Ryan. Ongoing psychosocial intervention was
recommended for Ryan and his family after hospitalization.
PATHOLOGY AND LABORATORY EXAMINATION
No laboratory test is useful in making a diagnosis of a major depression. If a child or
adolescent also complains of symptoms of hypothyroidism, that is, dry skin, coldness,
lethargy, and so on, then a screening test for thyroid function may be indicated.
Rating scales for depressive symptoms administered by the clinician to the child and
parent may be helpful in the evaluation. The Children’s Depression Rating Scale-Revised
(CDRS-R) is a 17-item instrument administered by the clinician separately to the parent
and child or adolescent. The clinician scores a rating for each item using the information
from both the parent and the child. The scale assesses affective, somatic, cognitive, and
psychomotor symptoms. A cumulative score of 40 is a marker for moderate depression
and a score of 45 or greater for significant depression.
DIFFERENTIAL DIAGNOSIS
Substance-induced mood disorder may be difficult to differentiate from other mood
disorders until detoxification occurs. Anxiety symptoms and disorders often coexist with
depressive disorders. Of particular importance in the differential diagnosis is the
distinction between agitated depressive or manic episodes and ADHD, in which the
persistent excessive activity and restlessness can cause confusion. Prepubertal children
generally do not show classic forms of agitated depression, such as hand-wringing and
pacing. Instead, an inability to sit still, irritability, and frequent temper tantrums are
the most common symptoms. Sometimes, the correct diagnosis becomes evident only
after remission of the depressive episode.
COURSE AND PROGNOSIS
The course and prognosis of major depression in children and adolescents depends on
the severity of illness, the rapidity of interventions, and the degree of response to the
interventions. In general, 90 percent of youth recover from a first episode of moderate
to severe major depressive disorder within 1 to 2 years. The age of onset, episode
severity, and the presence of comorbid disorders also influence course and prognosis. In
general, the younger the age of onset, the greater the recurrence of multiple episodes,
and the presence of comorbid disorders predict a poorer prognosis. The mean length of
an untreated episode of major depression in children and adolescents is about 8 to 12
months; the cumulative probability of recurrence is 20 to 60 percent within 2 years and
70 percent by 5 years. The greatest risk for relapse is in the 6 months to 1 year after
treatment is discontinued. Depressed children who live in families with high levels of
chronic conflict are more likely to have relapses. The relapse rates for childhood major
depression into adulthood are also high. In a community sample, 45 percent of
adolescents with a history of major depression developed another episode of major
depression in early adulthood.
Youth with major depression are at higher risk for the development of future bipolar
disorder, compared to adults. Overall estimates of children with an episode of major
depression developing bipolar disorder are about 20 to 40 percent. Clinical
characteristics of a depressive episode in youth, suggesting the highest risk of
developing bipolar I disorder include hallucinations and delusions, psychomotor
retardation, and a family history of bipolar illness. In a longitudinal study of
prepubertal children with major depression, 33 percent developed bipolar I disorder,
whereas 48 percent went on to develop bipolar II or bipolar disorder not otherwise
specified by early adulthood.
Depressive disorders are associated with short-term and long-term peer relationship
difficulties and complications, compromised academic achievement, and persistently low
self-esteem. Persistent depressive disorder has an even more protracted recovery than
major depressive disorder; the mean episode length is about 4 years. Early onset
persistent depressive disorder is associated with significant risks of comorbidity with
major depressive disorder (70 percent), bipolar disorder (13 percent), and future
substance abuse (15 percent). The risk of suicide, which accounts for about 12 percent of
adolescent mortalities, is significant among adolescents with depressive disorders.
TREATMENT
The American Academy of Child and Adolescent Psychiatry practice parameters, as well
as a consensus of experts who developed the Texas Children’s Medication Algorithm
Project (TMAP) made evidence-based recommendations for the treatment of children
and adolescents with depressive disorders. These include psychoeducation and
supportive interventions for youth with mild forms of depression. For youth with
moderate to severe depression or recurrent episodes of major depression, with
significant impairment and with active suicidal thoughts or behaviors, or psychosis,
optimal intervention includes both psychopharmacological and CBT. CBT or
interpersonal therapy (IPT) alone may be effective for moderate depression, especially
when treatment is continued for 6 months or longer.
Psychiatric Hospitalization
Assessment of suicidal thoughts, behaviors, and past history of suicidal behavior is
indicated in evaluating every child or adolescent with major depression. Safety is the
most immediate consideration in assessing depression in youth, that is, a determination
as to whether immediate psychiatric hospitalization is necessary. Depressed children and
adolescents who express suicidal thoughts or behaviors most often require some
extended evaluation in the safety of the psychiatric hospital to provide maximal
protection from self-destructive impulses and behaviors.
EVIDENCE-BASED TREATMENT STUDIES
The Treatment for Adolescents with Depression Study (TADS) divided 439 adolescents
between 12 years and 17 years of age into three treatment groups of 12 weeks,
composed of either fluoxetine (Prozac) alone (10 to 40 mg per day), fluoxetine with the
same dose range in combination with CBT, or CBT alone. Based on ratings of the
Children’s Depression Rating Scale-Revised (CDRS-R) combination treatment had
significantly superior response rates compared with either treatment alone. Based on
CGI scores, at 12 weeks, rates of much or very much improved were 71 percent for the
combined treatment group, 60.6 percent for the fluoxetine group, and 43.2 percent for
the CBT alone group; and 34.4 percent for the placebo group. At 12 weeks, combination
treatment was rated the optimal strategy in the treatment of adolescent depression. By
the end of 9 months of treatment, however, response rates for each group had
converged so that response for the combination group was 86 percent, fluoxetine group
response was about 81 percent, and CBT-alone group response rate was 81 percent. The
long-term effectiveness of treatments for adolescent depression demonstrates that for
moderately ill adolescents, fluoxetine, CBT, or the combination is efficacious. However,
the addition of CBT to fluoxetine decreased persistent suicidal ideation and potential
treatment-related emergence of suicidal ideation.
A second large multicenter randomized placebo controlled trial, Treatment of SSRIResistant Depression in Adolescents (TORDIA), included adolescents with major
depression, who had not responded to a 2-month trial with an SSRI antidepressant. In
this study, 334 adolescents between 12 and 18 years of age were randomly assigned to a
different SSRI agent (either citalopram, paroxetine, citalopram, or another
antidepressant class, venlafaxine) with or without concurrent CBT. The SSRI plus CBT
group and the venlafaxine plus CBT group had higher response rates of improvement
(54.8 percent) than the group on medications alone (40.5 percent). There were no
differences found in the response rates between antidepressant agents.
Psychosocial Interventions
CBT is widely recognized as an efficacious intervention for the treatment of moderately
severe depression in children and adolescents. CBT aims to challenge maladaptive
beliefs and enhance problem-solving abilities and social competence. A review of
controlled cognitive-behavioral studies in children and adolescents revealed that, as with
adults, both children and adolescents showed consistent improvement with these
methods. Other “active” treatments, including relaxation techniques, were also shown to
be helpful as adjunctive treatment for mild to moderate depression. Findings from one
large controlled study comparing cognitive-behavioral interventions with nondirective
supportive psychotherapy and systemic behavioral family therapy showed that 70
percent of adolescents had some improvement with each of the interventions; cognitivebehavioral intervention had the most rapid effect. Another controlled study comparing a
brief course of CBT with relaxation therapy favored the cognitive-behavioral
intervention. At a 3- to 6-month follow-up, however, no significant differences existed
between the two treatment groups. This effect resulted from relapse in the cognitivebehavioral group, along with continued recovery in some patients in the relaxation
group. Factors that seem to interfere with treatment responsiveness include the presence
of comorbid anxiety disorder that probably was present before the depressive episode. It
has been shown, however, that longer term CBT is efficacious in the treatment of
depression, and has the advantage of mitigating suicidal ideation.
Interpersonal psychotherapy (IPT) focuses on improving depression through a focus
on ways in which depression interferes with interpersonal relationships and overcoming
these challenges. The four main areas of focus with interpersonal psychotherapy include
loss, interpersonal disputes, role transition, and interpersonal deficits. A modification of
interpersonal therapy to more specifically address depression for adolescents (IPT-A)
includes a focus on separation from parents, authority figures, peer pressures, and
dyadic relationships. IPT-A has been studied on an outpatient basis as well as in a
school-based clinic setting. A 12-week study of 48 adolescents with major depression
randomly assigned to IPT-A or clinical monitoring found that the group receiving IPT-A
showed decreased depressive symptoms, increased social functioning, and improved
problem solving compared to the other group. In the school-based health clinic,
depressed adolescents were randomly assigned to IPT-A or treatment as usual for a
period of 16 weeks. Clinic staff were trained and administered the treatment. At the end
of 16 weeks, those adolescents receiving IPT-A had greater symptom reduction and
improved overall functioning; especially older and more severely depressed adolescents
seemed to benefit most significantly.
Parent-Child Interaction Therapy Emotion Development (PCIT-ED) for preschool
depression, a modification of Parent-Child Interaction Therapy (PCIT) historically used
in the treatment of disruptive disorders for children, was piloted in a randomized
controlled trial for 54 depressed preschoolers. Fifty-four depressed young children from
age 3 to 7 years were randomly assigned to either PCIT-ED or psych-education with
their caregivers. PCIT-ED was manualized and consists of three modules conducted over
14 sessions in 12 weeks. The core modules of PCIT—Child-Directed Interaction (CDI)
and Parent-Directed Interaction (PDI)—were utilized and limited to four sessions each.
The focus of these modules is to strengthen the parent–child relationship by coaching
parents in positive play techniques, giving effective directives to the child, and
responding to disruptive behavior in firm but not punitive ways. The novel portion of
the treatment targeting the preschool depression consisted of a 6-week Emotion
Development (ED) module, which focused on helping the parent to be a more effective
emotion guide and affect regulator for the child. As part of the ED module, the parent
learned to accurately recognize his or her own emotions as well as the child’s and serves
to help regulate the child’s emotions. A psychoeducation control condition,
Developmental Education and Parenting Intervention (DEPI) was developed and
administered to parents in small group sessions. The DEPI condition was designed to
educate parents about child development and emphasized emotional and social
development without individual coaching or practice with behavioral techniques as
provided in the PCIT-ED group. Primary outcome measures included parent’s report of
the child’s symptoms of depression using a structured instrument, the Preschool Age
Psychiatric Assessment (PAPA), and depression severity was measured pretreatment and
posttreatment using parent ratings on the Preschool Reelings Checklist Scale Version
(PFC-S) a 20-item checklist. Results revealed that both groups showed significant
improvement with particular improvement in the PCIT-ED group with respect to
emotion recognition, child executive functioning, and parenting stress. This pilot study
indicates that PCIT-ED is a promising novel intervention for preschool depression that
deserves further investigation.
Pharmacotherapy
Fluoxetine (Prozac) and escitalopram (Lexapro) have Food and Drug Administration
(FDA) approval in the treatment of major depression in adolescents. Three randomized
controlled trials (RCTs) using fluoxetine with depressed children and adolescents
demonstrate its efficacy. Common side effects observed with fluoxetine include
headache, gastrointestinal symptoms, sedation, and insomnia.
Short-term randomized clinical trials have demonstrated efficacy of citalopram
(Celexa), and sertraline (Zoloft) compared with placebo in the treatment of major
depression in children and adolescents.
Sertraline has been shown to provide efficacy in two multicenter, double-blind,
placebo-controlled trials of 376 children and adolescents who were treated with
sertraline at doses ranging from 50 mg to 200 mg a day, or placebo. greater than 40
percent decrease in depression rating scale scores were found in nearly 70 percent of
the patients treated with sertraline, compared with 56 percent in the placebo group.
Most common side effects are anorexia, vomiting, diarrhea, and agitation.
Citalopram has been demonstrated in one RCT in the United States to be efficacious in
174 children and adolescents treated with citalopram at doses of 20 to 40 mg a day or
placebo for 8 weeks. Significantly more of the group on citalopram showed
improvement compared with placebo on the depression rating scale (CDRS-R). A
significantly increased response rate (response defined as less than 28 on CDRS-R) of 35
percent was found in the citalopram group, compared with 24 percent of the placebo
group. Common side effects that emerged included headache, nausea, insomnia, rhinitis,
abdominal pain, dizziness fatigue, and flu-like symptoms.
Similar to the literature for adult depression, as many negative as positive study
findings have emerged in RCTs of the treatment of childhood and adolescent depression.
RCTs to date that have not shown efficacy on primary outcome measures include those
using mirtazapine (Remeron), and tricyclic antidepressants. A meta-analysis of SSRI
trials in depressed children and adolescents found efficacy of SSRIs compared to placebo
with an average response rate of 60 percent for the SSRI compared to 49 percent for
placebo.
Starting doses of SSRIs for prepubertal children are lower than doses recommended
for adults, and adolescents are generally treated at the same doses recommended for
adults.
Venlafaxine (Effexor), which blocks both serotonin and norepinephrine uptake, has
been found to be effective in the TORDIA study; however, adverse effects including
increased blood pressure have made this agent a second-line choice compared to the
SSRIs. Tricyclic antidepressants are not generally recommended for the treatment of
depression in children and adolescents due to a lack of proved efficacy along with the
potential risk of cardiac arrhythmia associated with their use.
A potential side effect of selective serotonin reuptake inhibitors (SSRIs) in depressed
children is behavioral activation, or induction of hypomanic symptoms. In such
situations, the medication should be discontinued to determine whether the activation
resolves with discontinuation of the medication, or evolves into a hypomanic or manic
episode. Activation due to SSRIs, however, do not necessarily predict a diagnosis of
bipolar disorder.
FDA Warning and Suicidality
In September 2004, the FDA received information from their Psychopharmacologic Drug
and Pediatric Advisory Committee indicating, based on their review of reported suicidal
thoughts and behavior among depressed children and adolescents who participated in
randomized clinical trials with nine different antidepressants, an increased risk of
suicidality in those children who were on active antidepressant medications. Although
no suicides were reported, the rates of suicidal thinking and behaviors were 2 percent
for patients on placebo, versus 4 percent among patients on antidepressant
medications. The FDA, in accordance with the recommendation of their advisory
committees, instituted a “black-box” warning to the health professional label of all
antidepressant medication indicating the increased risk of suicidal thoughts and
behaviors in children and adolescents being treated with antidepressant medications,
and the need for close monitoring for these symptoms. Several reviews since 2004,
however, concluded that the data do not indicate a significant increase in the risk of
suicide or serious suicide attempts after starting treatment with antidepressant drugs.
Duration of Treatment
Based on available longitudinal data and the natural history of major depression in
children and adolescents, current recommendations include maintaining antidepressant
treatment for 1 year in a depressed child who has achieved a good response, and to then
discontinue the medication at a time of relatively low stress for a medication-free
period.
Pharmacologic Treatment Strategies for Resistant Depression
Pharmacological recommendations, in accordance with an expert consensus panel that
developed the Texas Children’s Medication Algorithm Project (TMAP), as well as the
Treatment of SSRI-resistant Adolescents with Depression study (TORDIA) in the
treatment of children or adolescents who have not responded to treatment with an SSRI
agent is to change to another SSRI medication. If a child is not responsive to the second
SSRI medication, then either a combination of antidepressants or augmentation
strategies may be reasonable choices as well as an antidepressant from another class of
medications.
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) has been used for a variety of psychiatric illnesses in
adults, primarily severe depressive and manic mood disorders and catatonia. ECT is
used rarely for adolescents, although published case reports indicate its efficacy in
adolescents with depression and mania. Currently case reports suggest that ECT may be
a relatively safe and useful treatment for adolescents who have persistent severe
affective disorders, particularly with psychotic features, catatonic symptoms, or
persistent suicidality.
SUICIDE
In the United States, suicide is the third leading cause of death among adolescents, after
accidental death and homicide. Throughout the world, suicide rarely occurs in children
who have not reached puberty. In the last 15 years, the rates of both completed suicide
and suicidal ideation rates have decreased among adolescents. This decrease appears to
coincide with the increase in SSRI medications prescribed to adolescents with mood and
behavioral disturbance.
Suicidal Ideation and Behavior
Suicidal ideation, gestures, and attempts are frequently, but not always, associated with
depressive disorders. Reports indicate that as many as half of suicidal individuals
express suicidal intentions to a friend or a relative within 24 hours before enacting
suicidal behavior.
Suicidal ideation occurs in all age groups and with greatest frequency in children and
adolescents with severe mood disorders. More than 12,000 children and adolescents are
hospitalized in the United States each year because of suicidal threats or behavior, but
completed suicide is rare in children younger than 12 years of age. A young child is
hardly capable of designing and carrying out a realistic suicide plan. Cognitive
immaturity seems to play a protective role in preventing even children who wish they
were dead from committing suicide. Completed suicide occurs about five times more
often in adolescent boys than in girls, although the rate of suicide attempts is at least
three times higher among adolescent girls than among boys. Suicidal ideation is not a
static phenomenon; it can wax and wane with time. The decision to engage in suicidal
behavior may be made impulsively without much forethought, or the decision may be
the culmination of prolonged rumination.
The method of the suicide attempt influences the morbidity and completion rates,
independent of the severity of the intent to die at the time of the suicidal behavior. The
most common method of completed suicide in children and adolescents is the use of
firearms, which accounts for about two thirds of all suicides in boys and almost one half
of suicides in girls. The second most common method of suicide in boys, occurring in
about one fourth of all cases, is hanging; in girls, about one fourth commit suicide
through ingestion of toxic substances. Carbon monoxide poisoning is the next most
common method of suicide in boys, but it occurs in less than 10 percent; suicide by
hanging and carbon monoxide poisoning are equally frequent among girls and account
for about 10 percent each. Additional risk factors in suicide include a family history of
suicidal behavior, exposure to family violence, impulsivity, substance abuse, and
availability of lethal methods. Gender differences in nonfatal suicidal behavior among
9th grade adolescents in a recent survey of students in 100 high schools found that
serious suicidal thoughts were reported in 19.8 percent of female students and 10.8
percent of females had made an attempt. In male students, 9.3 percent had a history of
suicidal thoughts and 4.9 percent had made an attempt. In this study, female students
showed evidence of higher levels of mood and anxiety problems, whereas males had a
slightly higher level of disruptive behavior problems. Female students reported higher
levels of depression, anxiety, somatic complaints, and increased levels of emotional and
behavioral problems than males. In young adolescents, even without meeting full
criteria for psychiatric disorders, females report more psychopathology along with
higher likelihood of nonfatal suicidal behavior.
Epidemiology
In a study of 9- to 16-year-olds in a 3-month period. passive suicidal thoughts were
approximately 1 percent, suicidal ideation with a plan was 0.3 percent, and suicide
attempt was 0.25 percent. In adolescents 14 to 18 years, the current rate of suicidal
ideation was found to be 2.7 percent and annual incidence was 4.3 percent. Among this
population of adolescents, lifetime prevalence of suicide attempt was 7.1 percent with a
much higher rate of suicidal behavior for girls than for boys: 10.1 percent compared to
3.8 percent. Completed suicide rates in youth are much less common in children and
younger teens 10 to 14 years, with a slighter lower rate of 0.95 per 100,000 for females
compared to 1.71 per 100,000 for males. In older adolescents 15 to 19 years of age,
completed suicide is considerably lower for females, 3.52 per 100,000 compared to
males, 12.65 per 100,000 in the United States in 2004.
Etiology
Universal features in adolescents who resort to suicidal behaviors are the inability to
synthesize viable solutions to ongoing problems and the lack of coping strategies to deal
with immediate crises. Therefore, a narrow view of the options available to deal with
recurrent family discord, rejection, or failure contributes to a decision to commit suicide.
Genetic Factors.
Completed suicide and suicidal behavior is two to four times more
likely to occur in individuals with a first-degree family member with similar behavior.
Evidence of a genetic contribution to suicidal behavior is based on family suicide risk
studies and the higher concordance for suicide among monozygotic twins compared to
dizygotic twins. Recent studies have investigated the possible contributions of the short
allele of the serotonin transporter promoter polymorphism (5-HTTLPT) to suicidal
behaviors, although to date, the evidence has not been consistent. Current studies are
seeking to investigate correlations between genetic vulnerability and environment and
timing interactions as multiple variables that may interact to increase the risk of
suicidal behavior.
Biological Factors.
A relationship between altered central serotonin with suicide
as well as impulsive aggression has been found in children and adolescents, and has
been demonstrated in adults. Studies have documented a reduction in the density of
serotonin transporter receptors in the prefrontal cortex, and serotonin receptors among
individuals with suicidal behaviors. Postmortem studies in adolescents who have
completed suicide show the most significant alterations in the prefrontal cortex and
hippocampus, brain regions that are also associated with emotion regulation and
problem solving. These studies have found altered serotonin metabolites, alteration in 5HT2a binding and decreased activity of protein kinase A and C. Decreased levels of
serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) have also been found in the
cerebrospinal fluid of depressed adults who attempted suicide by violent methods. Metaanalyses suggest an association between the short S-allele of the serotonin transporter
promoter gene and depression as well as suicidal behavior, particularly when combined
with adverse life events.
Psychosocial Factors.
Although severe major depressive illness is the most
significant risk factor for suicide, increasing its risk by 20 percent, many severely
depressed individuals are not suicidal. A sense of hopelessness, impulsivity, recurrent
substance use, and a history of aggressive behavior, have been associated with an
increased risk of suicide. A wide range of psychopathological symptoms are associated
with exposure to violent and abusive homes. Aggressive, self-destructive, and suicidal
behaviors seem to occur with greatest frequency among youth who have endured
chronically stressful family lives. The most significant family risk factor for suicidal
behavior is maltreatment, including physical and sexual abuse and neglect. The single
largest association is between sexual abuse and suicidal behavior. Large community
studies have provided data suggesting that youth at risk for suicidal behavior include
those who feel disconnected, isolated, or alienated from peers. Sexual orientation is a
risk factor, with increased rates of suicidal behavior of two to six times among youth
who identify themselves as gay, lesbian, or bisexual. Protective factors mitigating the
risk of suicidal behavior are youth who have a strong connection to school and peers
even in the face of other risk factors.
Diagnosis and Clinical Features
The characteristics of adolescents who attempt suicide and those who complete suicide
are similar and up to 40 percent of suicidal persons have made a previous attempt.
Direct questioning of children and adolescents about suicidal thoughts is necessary,
because studies have consistently shown that caregivers are frequently unaware of these
ideas in their children. Suicidal thoughts (i.e., children talking about wanting to harm
themselves) and suicidal threats (e.g., children stating that they want to jump in front of
a car) are more common than suicide completion.
Most older adolescents with suicidal behavior meet criteria for one or more psychiatric
disorders, often including major depressive disorder, bipolar disorder, and psychotic
disorders. Youth with mood disorders in combination with substance abuse and a history
of aggressive behavior are at particularly high risk for suicide. The most common
precipitating factors in younger adolescent suicide completers appear to be impending
disciplinary actions, impulsive behavioral histories, and access to loaded guns,
particularly in the home. Adolescents without mood disorders with histories of disruptive
and violent, aggressive, and impulsive behavior may be susceptible to suicide during
family or peer conflicts. High levels of hopelessness, poor problem-solving skills, and a
history of aggressive behavior are risk factors for suicide. A less common profile of an
adolescent who completes suicide is one of high achievement and perfectionistic
character traits facing a perceived failure, such an academically proficient adolescent
humiliated by a poor grade on an exam.
Findings from a World Health Organization mental health survey reveals that a range
of psychiatric disorders increase the risk of suicidal ideation across the lifespan. Youth
with psychiatric disorders characterized by severe anxiety and poor impulse control are
at higher risk to act on suicidal ideation. In psychiatrically disturbed and vulnerable
adolescents, suicide behavior may represent impulsive responses to recent stressors.
Typical precipitants of suicidal behavior include conflicts and arguments with family
members and boyfriends or girlfriends. Alcohol and other substance use can further
predispose an already vulnerable adolescent to suicidal behavior. In other cases, an
adolescent attempts suicide in anticipation of punishment after being caught by the
police or other authority figures for a forbidden behavior.
About 40 percent of youth who complete suicide had previous psychiatric treatment,
and about 40 percent had made a previous suicide attempt. A child who has lost a
parent by any means before age 13 is at higher risk for mood disorders and suicide. The
precipitating factors include loss of face with peers, a broken romance, school
difficulties, unemployment, bereavement, separation, and rejection. Clusters of suicides
among adolescents who know one another and go to the same school have been
reported. Suicidal behavior can precipitate other such attempts within a peer group
through identification—so-called copycat suicides. Some studies have found a transient
increase in adolescent suicides after television programs in which the main theme was
the suicide of a teenager.
The tendency of disturbed young persons to imitate highly publicized suicides has been referred to as Werther syndrome,
after the protagonist in Johann Wolfgang von Goethe’s novel, The Sorrows of Young Werther. The novel, in which the hero
kills himself, was banned in some European countries after its publication more than 200 years ago because of a rash of
suicides by young men who read it; some dressed like Werther before killing themselves or left the book open at the
passage describing his death. In general, although imitation may play a role in the timing of suicide attempts by vulnerable
adolescents, the overall suicide rate does not seem to increase when media exposure increases. In contrast, direct exposure
to peer suicide is associated with increased risk of depression and posttraumatic stress disorder rather than suicide.
Treatment
The prognostic significance of suicidal ideation and behaviors in adolescents ranges
from relatively low lethality, to high risk for completion. One of the challenges in
addressing suicide is to identify children and adolescents with suicidal ideation, and
particularly to treat those who have untreated psychiatric disorders, as the risk of
completed suicide increases with age, as does the onset of an untreated psychiatric
disorder. Adolescents who come to medical attention because of suicidal attempts must
be evaluated before determining whether hospitalization is necessary. Pediatric patients
who present to the emergency room with suicidal ideation benefit from an intervention
that occurs in the emergency room to ensure that the patient is transitioned to
outpatient care when hospitalization is not necessary. Those who fall into high-risk
groups should be hospitalized until the acute suicidality is no longer present. Adolescents
at higher risk include those who have made previous suicide attempts, especially with a
lethal method, males older than 12 years of age with histories of aggressive behavior or
substance abuse, use of a lethal method, and severe major depressive disorder with
social withdrawal, hopelessness, and persistent suicidal ideation.
Relatively few adolescents evaluated for suicidal behavior in a hospital emergency
room subsequently receive ongoing psychiatric treatment. Factors that may increase the
probability of psychiatric treatment include psychoeducation for the family in the
emergency room, diffusing acute family conflict, and setting up an outpatient follow-up
during the emergency room visit. Emergency room discharge plans often include
providing an alternative if suicidal ideation reoccurs, and a telephone hot-line number
provided to the adolescent and the family in case suicidal ideation reappears.
Scant data exist to evaluate the efficacy of various interventions in reducing suicidal
behavior among adolescents. CBT alone and in combination with SSRIs have been
shown to decrease suicidal ideation in depressed adolescents over time in the Treatment
of Adolescent Depression (TADS) study, a large multisite study; however, these
interventions do not work immediately, so safety precautions must be taken for highrisk situations. Dialectical behavior therapy (DBT), a long-term behavioral intervention
that can be applied to individuals or groups of patients, has been shown to reduce
suicidal behavior in adults, but has yet to be investigated in adolescents. Components of
DBT include mindfulness training to improve self-acceptance, assertiveness training,
instruction on avoiding situations that may trigger self-destructive behavior, and
increasing the ability to tolerate psychological distress. This approach warrants
investigation among adolescents.
Given the reduction in completed suicide among adolescents over the last decade,
during the same period in which SSRI treatment in the adolescent population has
markedly risen, it is possible that SSRIs have been instrumental in this effect. Given the
risk of increased rate of suicidal thoughts and behaviors among depressed children and
adolescents (indicated in randomized clinical trials with antidepressant medications and
leading to the “black-box” warning for all antidepressants for depressed youth), close
monitoring for suicidality is mandatory for any child or adolescent being treated with
antidepressants.
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30 - 31.12b Early Onset Bipolar Disorder
31.12b Early-Onset Bipolar Disorder
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31.12b Early-Onset Bipolar Disorder
Early onset bipolar disorder has been recognized in children as a rare disorder with
greater continuity with its adult counterpart when it occurs in adolescents than in
prepubertal children. Over the last decade there has been a significant increase in the
diagnosis of bipolar I disorder made in youth referred to psychiatric outpatient clinics
and inpatient units. Questions have arisen regarding the phenotype of bipolar disorder
in youth, particularly in view of the continuous irritability and mood dysregulation and
lack of discrete mood episodes in most prepubertal children who have received the
diagnosis. The “atypical” bipolar symptoms among prepubertal children often include
extreme mood dysregulation, severe temper tantrums, intermittent aggressive or
explosive behavior, and high levels of distractibility and inattention. This constellation
of mood and behavior disturbance in the majority of prepubertal children with a current
diagnosis of bipolar disorder is nonepisodic, although some fluctuation in mood may
occur. The high frequency of the above symptoms in combination with chronic
irritability has led to the inclusion of a new mood disorder in youth in the Fifth Edition
of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) called Disruptive Mood Dysregulation Disorder, which is discussed in the
next section (31.12c). Many children with nonepisodic mood disorders often have past
histories of severe attention-deficit/hyperactivity disorder (ADHD), making the
diagnosis of bipolar disorder even more complicated. Family studies of children with
ADHD have not revealed an increased rate of bipolar I disorder. Children with
“atypical” bipolar disorders, however, are frequently seriously impaired, are difficult to
manage in school and at home, and often require psychiatric hospitalization.
Longitudinal follow-up studies are under way with groups of children diagnosed with
subthreshold bipolar disorders and nonepisodic mood disorders, to determine how many
will develop classic bipolar disorder. In one recent study of 140 children with bipolar
disorder not otherwise specified (that is, the presence of distinct manic symptoms but
subthreshold for manic episodes), 45 percent developed bipolar I or bipolar II illness
over a follow-up period of 5 years. In another study, 84 children who were labeled with
“severe mood dysregulation” (that is, a persistent nonepisodic negative mood along
with severe anger outbursts) who also exhibited at least three manic symptoms (either
pressured speech, agitation, insomnia, or flight of ideas) plus distractibility (also
common to ADHD), followed for approximately 2 years, found that only one child
experienced a hypomanic or mixed episode. Although childhood severe mood
dysregulation has been found to be common in community samples—one study reported
a lifetime prevalence of 3.3 percent in youth 9 to 19 years of age—its relationship to
future bipolar disorder remains questionable. A longitudinal community-based study that
followed children and adolescents with nonepisodic irritability over a 20-year period,
found that these children were at higher risk to develop depressive disorders and
generalized anxiety disorder, rather than bipolar disorders over time.
Among adults and older adolescents with bipolar disorder who present with classic
manic episodes, a major depressive episode typically precedes a manic episode. A classic
manic episode in an adolescent, similar to in a young adult, may emerge as a distinct
departure from a preexisting state often characterized by grandiose and paranoid
delusions and hallucinatory phenomena. According to DSM-5, the diagnostic criteria for
a manic episode are the same for children and adolescents as for adults (see Table 8.16). The diagnostic criteria for a manic episode include a distinct period of an
abnormally elevated, expansive, or irritable mood that lasts at least 1 week or for any
duration if hospitalization is necessary. In addition, during periods of mood disturbance,
at least three of the following significant and persistent symptoms must be present:
inflated self-esteem or grandiosity, decreased need for sleep, pressure to talk, flight of
ideas or racing thoughts, distractibility, an increase in goal-directed activity, and
excessive involvement in pleasurable activities that may result in painful consequences.
According to the DSM-5, in contrast to DSM-IV-TR, diagnostic criteria for bipolar disorder now include changes in both
mood and activity or energy level. Furthermore, whereas previously, full criteria for both mania or hypomania and major
depressive disorder were required to make a diagnosis of a mixed episode, in DSM-5, this requirement no longer applies;
instead a specifier, “with mixed features,” has been added. This specifier can be applied to a current manic episode,
hypomanic episode, or depressive episode. Thus, for example, in order to add the “mixed features” specifier to a manic or
hypomanic episode, three of the following symptoms must be present during the majority of days of the current or most
recent episode of mania or hypomania: prominent depressed mood, diminished interest in most activities, psychomotor
retardation nearly every day, fatigue or loss of energy, feelings of excessive guilt or worthlessness, or recurrent thoughts of
death. To apply the “with mixed features” specifier to a full major depressive episode, three of the following
hypomanic/manic symptoms must be present: elevated or expansive mood, grandiosity, pressured speech or increased
speech, flight of ideas, increased energy, or decreased need for sleep.
When mania appears in an adolescent, there is a high incidence of psychotic features
including both delusions and hallucinations, which most typically involve grandiose
notions about their power, worth, and relationships. Persecutory delusions and flight of
ideas are also common. Overall, gross impairment of reality testing is common in
adolescent manic episodes. In adolescents with major depressive disorder destined for
bipolar I disorder, those at highest risk have family histories of bipolar I disorder and
exhibit acute, severe depressive episodes with psychosis, hypersomnia, and psychomotor
retardation.
EPIDEMIOLOGY
The prevalence rates of bipolar disorder among youth vary depending on the age group
studied, and on whether the diagnostic criteria are applied narrowly, restricting it to
discrete mood episodes or more broadly, to include nonepisodic mood and behavioral
states. In younger children, bipolar disorder is extremely rare, with no cases of bipolar I
disorder identified in children between the ages of 9 years and 13 years by the Great
Smokey Mountain Study. However, severe mood dysregulation, often a prominent
feature in prepubertal children receiving a diagnosis of bipolar disorder, was found in
3.3 percent of an epidemiological sample. In adolescents, bipolar disorder is more
frequent, found to range from 0.06 to 0.1 percent of the general population of 16-yearolds in studies using a narrow definition of bipolar I disorder. Prevalence of
subthreshold symptoms of bipolar illness was found to be 5.7 percent in one study to at
least 10 percent in another. Follow-up studies into adulthood revealed that the
subthreshold manic symptoms predicted high levels of impairment with progression to
depression and anxiety disorders, not bipolar I or II disorders.
Community use of the diagnosis of bipolar disorder in youth has increased markedly
over the last 15 years in both outpatient and inpatient psychiatric settings. A recent
survey indicated a 40-fold increase in the diagnosis of bipolar disorder in youth being
treated at outpatient clinics from the mid-1990s to the mid-2000s. Furthermore, from
2000 through 2006, the rate of youth hospitalized with a primary diagnosis of bipolar
disorder increased from 3.3 per 10,000 to 5.7 per 10,000.
ETIOLOGY
Genetic Factors
Estimates of the heritability of bipolar disorder based on adult twin studies range from
approximately 60 to 90 percent, with shared environmental variables accounting for 30
to 40 percent and the nonshared environmental factors accounting for approximately
10 to 20 percent. High rates of bipolar disorder have been reported in the relatives of
the narrow phenotype of early onset bipolar disorder compared to young adult-onset of
bipolar disorder. The high rates of comorbid ADHD among children with early onset
bipolar disorder has led to questions regarding the co-transmission of these disorders in
family members. However, children with the broader phenotype of bipolar disorder, that
is, severe mood dysregulation without episodes of mania, have not been found to have
higher rates of bipolar disorder in family members, which suggests that the narrow and
broad phenotypes of bipolar disorder may be distinct and separate entities. Nearly 25
percent of adolescent offspring of families with probands with bipolar disorder
experienced a mood disorder by the age of 17 years old, compared to 4 percent of
controls, with approximately 8 percent representing bipolar I, bipolar II, or bipolar
disorder not otherwise specified. Most of the risk in the offspring, therefore, is for
unipolar major depressive disorder. Disruptive behavior disorders were not found to be
increased, in a longitudinal study, in the offspring of families with a bipolar proband,
compared to controls. The combination of ADHD and bipolar disorder is not found as
frequently in relatives of children with only ADHD compared with first-degree relatives
of children with the combination.
Although bipolar disorder appears to have a significant heritable component, its mode
of inheritance remains unknown. A number of research groups have concluded that
early onset bipolar disorder is a more severe form of the illness, characterized by more
mixed episodes, greater psychiatric comorbidity, more lifetime psychotic symptoms,
poorer response to prophylactic lithium treatment, and a greater heritability. The
European collaborative study of early-onset bipolar disorder (France, Germany, Ireland,
Scotland, Switzerland, England, and Slovenia) carried out a genome-wide linkage
analysis of both the narrow and the broad early onset bipolar disorder. This group
concluded that a genetic factor located in the 2q14 region is either specifically involved
in the etiology of early onset bipolar disorder, or that a gene in this region exerts
influence as a modifier of other genes in the development of bipolar disorder in this age
group. Other linkage regions that were found by this collaborative did not find specific
genome regions that pertained only to the early onset group of bipolar disorder,
suggesting that there may be some genetic factors common to early-onset and adultonset bipolar disorder. This is consistent with the increased incidence of adult-onset
bipolar disorder among siblings of early onset disease. Further genome-wide studies are
needed to elucidate the genetic etiology of early onset bipolar disorder.
Neurobiological Factors
Converging data suggest that early-onset bipolar disorder is associated with both
structural and functional brain alterations in prefrontal cortical and subcortical regions
associated with the processing and regulation of emotional stimuli. Structural magnetic
resonance imaging (MRI) studies suggest that altered development of white matter and
a decreased amygdalar volume are found more frequently in this population than in the
general population. Functional MRI (fMRI) studies are important in that they can
identify altered brain function in vulnerable populations such as youth with early-onset
bipolar disorder at baseline, and can also be utilized to elucidate functional changes
toward normalization in brain functioning after various treatments, and potentially
identify pretreatment neural predictors of good response to various treatments.
A recent fMRI study of pediatric bipolar patients documented pretreatment brain activity and posttreatment effects of a
trial of risperidone versus divalproex. This double-blind study included 24 unmedicated manic patients with a mean age of
13 years, randomized to either risperidone or divalproex treatment, and 14 healthy controls examined over a 6-week
period. Prior to treatment, the patient group showed increased amygdala activity compared to healthy controls, which was
poorly controlled by the higher ventrolateral prefrontal cortex (VLPFC) and the dorsolateral prefrontal cortex (DLPFC),
which are believed to exert influence on the amygdala to control emotional regulation and processing. Increased amygdala
activity at baseline predicted a poorer treatment response to both the risperidone and the divalproex in the patient group.
Patients were given an affective color-matching word task involving matching positive words (i.e., happiness,
achievement, success), negative words (i.e., disappointment, depression, or rejection), or neutral words, with one of two
colored circles displayed on a screen while fMRI was administered. Greater pretreatment right amygdala activity during a
word task with positive and negative words in the risperidone group, and greater pretreatment left amygdala activity with
a positive word task in the divalproex group, predicted poor response on the Young Mania Rating Scale. Increased
amygdala activity in early-onset bipolar patients is hypothesized to be a potential biomarker predicting resistance and poor
treatment response to both risperidone and divalproex.
Neuropsychological Studies
Impairments in verbal memory, processing speed, executive function, working memory,
and attention are commonly found in early-onset bipolar disorder. Data suggest that on
tasks of working memory, processing speed, and attention, children and adolescents
with comorbid bipolar disorder and ADHD demonstrate more pronounced impairments
compared with those without ADHD. Other studies found that children with bipolar
disorder make a greater number of emotion recognition errors compared with controls.
They more frequently identified faces as “angry” when presented with adult faces;
however, these errors did not occur when children’s faces were shown. Impaired
perception of facial expression has also been reported in studies of adults with bipolar
disorder.
DIAGNOSIS AND CLINICAL FEATURES
Early onset bipolar disorder is often characterized by extreme irritability that is severe
and persistent, and may include aggressive outbursts and violent behavior. In between
outbursts, children with the broad diagnosis may continue to be angry or dysphoric. It is
rare for a prepubertal child to exhibit grandiose thoughts or euphoric mood; for the most
part, children diagnosed with early onset bipolar disorder are intensely emotional with
a fluctuating but overriding negative mood. Current diagnostic criteria for bipolar
disorders in children and adolescents in DSM-5 are the same as those used in adults (see
Tables 8.1-6 and 31.12b-1). The clinical picture of early-onset bipolar disorder, however,
is complicated by the prevalence of comorbid psychiatric disorders.
Table 31.12b-1
DSM-5 Diagnostic Criteria for Bipolar II Disorder
Comorbidity with ADHD
ADHD is the most common comorbid condition among youth with early onset bipolar
disorder and has been reported in up to 90 percent of prepubertal children and up to 50
percent of adolescents diagnosed with bipolar disorder. One of the main sources of
diagnostic confusion regarding children with early onset bipolar disorder is the
comorbid ADHD, since the two disorders share many diagnostic criteria, including
distractibility, hyperactivity, and talkativeness. Even when the overlapping symptoms
are removed from the diagnostic count, a significant percentage of children with bipolar
disorder continued to meet the full criteria for ADHD. This implies that both disorders
with their own distinct features are present in many cases.
Comorbidity with Anxiety Disorders
Children and adolescents with bipolar disorder have been reported to have higher than
expected rates of panic and other anxiety disorders. In youth with the narrow
phenotype of bipolar disorders, up to 77 percent have been reported to exhibit an
anxiety disorder. Lifetime prevalence of panic disorder was found to be 21 percent
among subjects with the broader phenotype of bipolar disorder compared with 0.8
percent in those without mood disorders. Patients diagnosed with bipolar disorder who
have comorbid high levels of anxiety symptoms are reported as adults to have higher
risks of alcohol abuse and suicidal behavior. On the other hand, children who exhibit the
broader phenotype of bipolar disorder are at higher risk to go on to have anxiety
disorders as well as depressive disorders.
Jeanie is a 13-year-old adopted teen who was admitted to the hospital after
assaulting her adoptive mother, causing bruises on her arms and legs from Jeanie’s
kicks and punches. Jeanie has had a long history of excessively severe tantrums,
which include assaultive and self-injurious behavior since before she was adopted at
the age of 3 years. Jeanie had always been a child who was irritable and explosive,
with a short fuse, who could blow up with very little provocation, even when things
were going her way. Jeanie had become increasingly hard to manage at home,
refused to go to school, yelled and screamed for hours on a daily basis, and often hit
and kicked her adoptive parents by the time she was 10 years old. Jeannie had been
placed in residential treatment for about a year and a half from age 11 and a half to
almost 13, where she had been given a diagnosis of bipolar disorder and placed on
lithium and citalopram. She was doing so well there after a year that Jeanie’s
adoptive mother decided to take her home. After a few weeks at home, however,
Jeanie began to decompensate, having daily explosive tantrums during which she
became aggressive and out of control. On multiple occasions she had hurt herself and
her adoptive mother and father. Upon arriving at the hospital, Jeanie was calm by
the time she was brought to her hospital room; however, her adoptive mother refused
to consider taking her home until she had received a full psychiatric evaluation and
something new was done to control Jeanie’s unsafe behaviors. Jeanie was initially
evaluated by the child and adolescent psychiatrist on-call, after which she was
admitted to a pediatric inpatient unit, where she awaited a bed on a psychiatric
adolescent inpatient unit. The psychiatrist learned that Jeanie had been born
prematurely to a teenage mother and placed in multiple foster homes until she was
adopted. Jeanie was a small girl who appeared younger than her stated age, although
her demeanor was bossy and pedantic. Jeanie’s biological family history was
unknown, and although she had at least one stigmata of fetal alcohol syndrome, her
IQ was in the average range and there was no other evidence to corroborate this
possibility. On mental status examination in the hospital, Jeanie reported that things
were fine, that she was not depressed, and that she did not get along with kids her
own age but that she had a few friends. Jeanie admitted that she had a bad temper
and that she did not remember what she did after she was in a rage. Jeanie’s affect
was odd, and she seemed to like having the psychiatrist as her audience. Jeanie
denied suicidal ideation or past attempts, and she denied having been a danger to
herself or her adoptive parents. Jeanie seemed annoyed when she was asked about
the reasons for her placement in a residential facility, and she became irritable when
questioned about the reasons for her current admission. Jeanie was referred for
admission to an adolescent psychiatric inpatient unit with the following
recommendations: Jeanie was referred for a trial of an atypical antipsychotic, such as
risperidone or olanzapine, and a reconsideration of a return to a more structured
school program, either a day program or residential facility. The diagnosis of bipolar
disorder remained in question, as she did not meet the narrow phenotype for this
disorder.
PATHOLOGY AND LABORATORY EXAMINATION
No specific laboratory indices are currently helpful in making the diagnosis of bipolar
disorders among children and adolescents.
DIFFERENTIAL DIAGNOSIS
The most important clinical entities to distinguish from early onset bipolar disorder are
also the disorders with which it is most frequently comorbid. Included are ADHD,
oppositional defiant disorder, conduct disorder, anxiety disorders, and depressive
disorders.
Although childhood ADHD tends to have its onset earlier than pediatric mania, current
evidence from family studies supports the presence of ADHD and bipolar disorders as
highly comorbid in children, and the concurrence is not because of the overlapping
symptoms that the two disorders share. In a recent study of more than 300 children and
adolescents who attended a psychopharmacology clinic and received a diagnosis of
ADHD, bipolar disorder was also evident in almost one third of those children with
ADHD who had combined–type and hyperactive-types, and occurred with much less
frequency (i.e., in less than 10 percent) in children with ADHD, inattentive-type.
COURSE AND PROGNOSIS
There are several pathways regarding the course and prognosis of children diagnosed
with early onset bipolar disorder. Those who present with severe mood dysregulation at
an early age, without discrete mood cycles, are most likely to develop anxiety and
depressive disorders as they mature. Youth who present in adolescence with a
recognizable manic episode are most likely to continue to meet criteria for bipolar I
disorder in adulthood. In both cases, the long-term impairment is considerable.
A longitudinal study of 263 child and adolescent inpatients and outpatients with bipolar disorder followed for an average
of 2 years found that approximately 70 percent recovered from their index episode within that period. Half of these
patients had at least one recurrence of a mood disorder during this time, more frequently a depressive episode than a
mania. No differences were found in the rates of recovery for children and adolescents whose diagnosis was bipolar I
disorder, bipolar II disorder, or bipolar disorder not otherwise specified; however, those youth whose diagnosis was
bipolar disorder not otherwise specified had a significant longer duration of illness before recovery, with less frequent
recurrences once they recovered. About 19 percent of patients changed polarity once per year or less, 61 percent shifted
five or more times per year, about half cycled more than ten times per year, and about one third cycled more than 20 times
per year. Predictors of more rapid cycling included lower socioeconomic status (SES), presence of lifetime psychosis, and
bipolar disorder not otherwise specified diagnosis. Over the follow-up period, about 20 percent of subjects who were
diagnosed with bipolar II disorder converted to bipolar I disorder, and 25 percent of the bipolar disorder not otherwise
specified subjects developed bipolar I disorder or bipolar II disorder during the follow-up period.
Similar to the natural history of bipolar disorders in adults, children have a wide
range of symptom severity in manic and depressed episodes. The more frequent
diagnostic conversions from bipolar II disorder to bipolar I disorder among children and
adolescents, compared with adults, highlight the lack of stability of the bipolar II
disorder diagnosis in youth. This is also the case with respect to conversion from bipolar
disorder not otherwise specified to other bipolar disorders. When bipolar disorder occurs
in young children, recovery rates are lower. In addition, a greater likelihood is seen of
mixed states and rapid cycling, and higher rates of polarity changes compared with
those who develop bipolar disorders in late adolescence or early adulthood.
TREATMENT
Treatment of early onset bipolar disorder incorporates multimodal interventions
including pharmacotherapy, psychoeducation, psychosocial intervention with the family
and the child, and school interventions to optimize a child’s school adjustment and
achievement.
Pharmacotherapy
Two classes of medications—atypical antipsychotics and mood stabilizing agents—are
the most well-studied agents that provide efficacy in the treatment of early-onset bipolar
disorders. Eight randomized controlled trials have shown efficacy of atypical
antipsychotic agents in the treatment of bipolar disorder in youth between the ages of
10 and 17 years. These studies compared an atypical antipsychotic to placebo, or
compared an atypical antipsychotic to a mood stabilizer, or added an antipsychotic to a
mood-stabilizing agent. The atypical antipsychotics included olanzapine, quetiapine,
risperidone, aripiprazole, and ziprasidone. All five of the atypical antipsychotic studies
demonstrated significant efficacy in the treatment of early onset bipolar manic or mixed
states. A recent trial comparing quetiapine and valproate found that both were
efficacious, but the quetiapine was superior in the speed of its effect. In another trial
comparing risperidone and divalproex treatment for bipolar disorder in youth,
risperidone was found to have a more rapid improvement and a greater final reduction
in manic symptoms compared to divalproex.
Mood-stabilizing agents have been used in open trials and anecdotally with early
onset bipolar illness with little evidence of efficacy at this time. In trials using lithium or
divalproex for treatment of early onset bipolar disorder, responses were less robust
compared to results with atypical antipsychotics. Controlled trials have provided some
evidence suggesting that lithium is efficacious in the management of aggression
behavior disorders. Although lithium has been approved for use in adolescent mania,
more research is needed to know if lithium is effective for more classic forms of mania
in adolescents. The Collaborative Lithium Trials (CoLT) established a set of protocols to
establish the safety and potential efficacy of lithium in youth, and to develop studies to
provide evidence-based dosing of lithium for youth. A group of researchers recently
studied the first-dose pharmacokinetics of lithium carbonate in youth and found that
clearance and volume are correlated with total body weight in youth, and particularly
with fat-free mass. Difference in body size was consistent with the pharmacokinetics of
lithium metabolism in children and adults. An open-label trial of lamotrigine (Lamictal)
in the treatment of bipolar depression among youth provides possible support for its use
in children and adolescents.
Current evidence suggests a faster response and more robust effect with atypical
antipsychotics compared to mood-stabilizing agents in the treatment of early-onset
bipolar disorder. However, given the severity and impairment of bipolar disorder in
youth, when only partial recovery is achieved, consideration of adding an additional
agent may be necessary.
Psychosocial Treatment
Psychosocial treatment interventions for early onset bipolar illness have included a
family-focused treatment. This treatment consists of several sessions of psychoeducation,
then sessions focusing on current stressors and mood management plan, and then
several sessions of communication enhancement training and problem-solving skills
training. The use of this type of intervention for youth diagnosed with bipolar disorder
as well as youth at risk for the disorder by virtue of their family history or subthreshold
conditions has been of value. Adjunctive family-focused psychoeducational treatment
modified for children and adolescents has been shown to reduce relapse rate. Children
and adolescents treated with mood-stabilizing agents in addition to a psychosocial
intervention showed improvement in depressive symptoms, manic symptoms, and
behavioral disturbance over 1 year.
A year-long trial of a modified Family Focused Treatment-High Risk in youth with
bipolar disorder showed significant improvement in mood disturbance, especially
depressive mood and hypomania, and improved psychosocial functioning. Familyfocused treatment for high-risk youth is a promising intervention that deserves further
investigation as a longitudinal follow-up to determine the course of youth at risk to
develop bipolar disorder.
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31.12c Disruptive Mood Dysregulation Disorder
Disruptive mood dysregulation disorder, a new inclusion in the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is
characterized by severe, developmentally inappropriate, and recurrent temper outbursts
at least three times per week, along with a persistently irritable or angry mood between
temper outbursts. In order to meet diagnostic criteria, the symptoms must be present for
at least a year, and the onset of symptoms must be present by the age of 10 years old.
Children with these symptoms have typically been diagnosed with bipolar disorder, or a
combination of oppositional defiant disorder, ADHD and intermittent explosive disorder.
Recent longitudinal data suggest, however, that these children do not typically develop
classic bipolar disorder in late adolescence or early adulthood. Instead, studies suggest
that youth with chronic irritability and severe mood dysregulation are at higher risk for
future unipolar depressive disorders and anxiety disorders. Although the initial studies of
children and adolescents with severe mood dysregulation included several symptoms of
hyperarousal (such as distractibility, physical restlessness, insomnia, racing thoughts,
flight of ideas, pressured speech, or intrusiveness), the current DSM-5 diagnostic criteria
for disruptive mood dysregulation do not include any hyperarousal criteria. Youths
diagnosed with mood dysregulation disorder who also exhibit multiple symptoms of
hyperarousal may be comorbid for ADHD.
EPIDEMIOLOGY
Most of the epidemiological data applied to disruptive mood dysregulation disorder was
gathered from children and adolescents with severe mood dysregulation, which includes
hyperarousal symptoms. Because disruptive mood dysregulation disorder differs from
severe mood dysregulation disorder only in the absence of hyperarousal symptoms, the
epidemiological data from the severe mood dysregulation disorder studies can be viewed
as a useful proxy for disruptive mood dysregulation disorder. Severe mood dysregulation
has a lifetime prevalence of 3 percent in children age 9 to 19 years. Within that
percentage, males (78 percent) are more prevalent than females (22 percent). The mean
age of onset is 5 to 11 years of age.
COMORBIDITY
Disruptive mood dysregulation disorder often co-occurs with other psychiatric disorders.
The most common comorbidities are ADHD (94 percent), oppositional defiant disorder
(84 percent), anxiety disorders (47 percent), and major depressive disorder (20
percent). The relationship of severe mood dysregulation and disruptive mood
dysregulation disorder to bipolar disorder has been a topic of clinical investigation.
Youth with severe mood dysregulation and hyperarousal symptoms have been
conceptualized as a “broad phenotype” of pediatric bipolar disorder, however, the term
“severe mood dysregulation” was utilized by researchers for these youth because it
remains unclear whether these youth go on to meet criteria for a bipolar disorder.
Disruptive mood dysregulation disorder is conceptualized as a disorder that is not
episodic, and may coexist with ADHD. However, current evidence does not support its
continuity with an emerging bipolar disorder.
DIAGNOSIS AND CLINICAL FEATURES
The DSM-5 diagnostic criteria for disruptive mood dysregulation disorder (Table. 31.12c1) requires outbursts that are grossly out of proportion to the situation. These temper
outbursts present with verbal rages and/or physical aggression toward people or
property, and are inappropriate for the child’s developmental level. Temper outbursts
occur, on average, three or more times per week, with variations in mood between
outbursts. Symptoms must exhibit before age 10 years, be present for at least 12 months,
and be present within at least two settings (i.e., home and school). The diagnosis is not
made for the first time in youth younger than 6 years or older than 18 years. In between
temper outbursts, the child’s mood is persistently irritable and angry, and this mood is
observable by others such as parents, teachers, or peers. There has never been period
lasting more than one day in which full criteria for a manic or hypomanic episode
(except for duration) are fulfilled. The above behaviors do not occur exclusively in the
context of an episode of major depression and are not better accounted for by another
psychiatric disorder. The DSM-5 diagnostic criteria for disruptive mood dysregulation
disorder are found in Table 31.12c-1.
Table 31.12c-1
DSM-5 Diagnostic Criteria for Disruptive Mood Dysregulation Disorder
Daniel, a 12-year-old 7th grade boy was brought to his pediatrician by his mother,
who was exasperated with Daniel’s rages and inappropriate tantrums. Daniel was on
the floor in the waiting room, pounding his hands on the floor, yelling at his mother
“get me out of here!” and crying. His mother had bruises on both legs from Dylan’s
kicks, and she appeared distressed. Daniel’s mother walked into the office, leaving
Daniel on the floor in the waiting room and burst into tears. “I can’t deal with him
anymore.” She recounted the problems that Daniel had been having for the last 2
years: Severe recurrent tantrums four to five times/week. “He tantrums like a 6-yearold, and even when he is not having a tantrum, he is perpetually angry and irritable.”
She reported that Daniel had lost all of his friends due to his short fuse and frequent
verbal and physical outbursts. He was almost always irritable, even on his birthday.
Daniel’s mother wonders whether there is anything physical wrong with him, but
physical examination and routine blood tests reveal no abnormalities. Daniel’s
tantrums had lessened somewhat last summer during the 2-month summer vacation;
however, as soon as school resumed, he was back to consistent irritability. After an
interview with Daniel, his pediatrician determined that he was not acutely suicidal;
however, he required urgent psychotherapeutic intervention. Daniel was referred to a
clinical psychologist for cognitive-behavioral treatment, and a child and adolescent
psychiatrist for a medication evaluation. Daniel resisted psychotherapy; however,
after several sessions, Daniel’s parents felt more hopeful than they had in a long time,
and learned that Daniel’s problems were not “all their fault.” Daniel agreed to begin a
trial of fluoxetine, which was titrated up to 30 mg over several weeks, and after about
a month, it became clear that his irritability had diminished noticeably. Daniel still
had many problems with peers, and he still had one or two tantrums per week;
however, the tantrums were becoming less prolonged and less intense. Daniel seemed
genuinely happy when he was invited to a classmate’s birthday party, and he was
able to interact successfully with his peers during the party without any conflicts.
Daniel continues to benefit from CBT, and he remains on fluoxetine 40 mg a day.
Daniel is still described as a “temperamental” boy, but he is doing well in school, has
rekindled several friendships, and is able to participate in family gatherings without a
major tantrum.
DIFFERENTIAL DIAGNOSIS
Bipolar Disorder
Disruptive mood dysregulation disorder closely resembles the “broad phenotype” of
bipolar disorder. Although not episodic, it has been theorized by some clinicians and
researchers that the chronic and persistent symptoms of mood disturbance and
irritability may be an early developmental presentation of bipolar disorder. Disruptive
mood dysregulation, however, does not meet formal diagnostic criteria for mania in
bipolar disorder, because irritability in disruptive mood dysregulation disorder is chronic
and nonepisodic.
Oppositional Defiant Disorder
Disruptive mood dysregulation disorder is similar to oppositional defiant disorder in that
they both include irritability, temper outbursts, and anger. Many patients with
disruptive mood dysregulation disorder meet the criteria for oppositional defiant
disorder; however, most patients with oppositional defiant disorder do not meet the
criteria for disruptive mood dysregulation disorder. Oppositional defiant disorder
includes symptoms of annoyance and defiance that are not found in disruptive mood
dysregulation disorder. Disruptive mood dysregulation disorder requires that irritable
outbursts be present in at least two settings, whereas oppositional defiant disorder
requires that they be present in only one setting.
COURSE AND PROGNOSIS
Disruptive mood dysregulation disorder is a chronic disorder. Longitudinal studies thus
far have shown that patients with disruptive mood dysregulation disorder in childhood
have a high risk of progressing to major depressive disorder, dysthymic disorder, and
anxiety disorders over time.
TREATMENT
The current treatment of disruptive mood dysregulation is based on symptomatic
interventions, in view of the fact that its etiology is not well understood at this time. If
disruptive mood dysregulation disorder is confirmed to resemble unipolar depression
and anxiety disorders in its pathophysiology, and it is often comorbid with ADHD, then
SSRIs and stimulants would likely be the pharmacological agents of first choice.
However, if the pathophysiology of disruptive mood dysregulation disorder is similar to
that of bipolar disorder, then first-line treatments for youth would include atypical
antipsychotic agents and mood stabilizers. There are scant treatment studies of
disruptive mood dysregulation disorder in the current literature. One controlled trial of
youths with symptoms of severe mood dysregulation and ADHD symptoms who did not
respond to stimulants, responded to divalproex (Depakote) combined with behavioral
psychotherapy compared to placebo and behavioral psychotherapy. There are treatment
studies underway of youth who exhibit symptoms of severe mood dysregulation utilizing
an SSRI plus a stimulant compared to a stimulant and placebo.
Psychosocial interventions such as cognitive-behavioral psychotherapy are likely to be
an essential component of treatment for youth with disruptive dysregulation disorder,
and psychosocial interventions targeting children diagnosed with bipolar disorder may
be beneficial.
REFERENCES
Blader JC, Schooler NR, Jensen PS, Pliszka SR, Kafantaris V. Adjunctive divalproex versus placebo for children with ADHD
and aggression refractory to stimulant monotherapy. Am J Psychiatry. 2009;166:1392–1401.
Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, Leibenluft E.
Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biol Psychiatry.
2006;60:991–997.
Copeland WE, Angold A, Costello J, Egger H. Prevalence, comorbidity, and correlates of DSM-5 proposed disruptive mood
dysregulation disorder. Am J Psychiatry. 2013;170:173.
Fristad MA, Verducci JS. Walters K, Young ME. Impact of multifamily psychoeducational psychotherapy in treating
children aged 8 to 12 years with mood disorder. Arch Gen Psychiatry. 2009;66:1013–1021.
Leibenluft E. Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. Am J
Psychiatry. 2011;168:129.

32 - 31.12d Oppositional Defiant Disorder
31.12d Oppositional Defiant Disorder
Leibenluft E, Cohen P, Gorrindo T, Brook JS, Pine DS. Chronic versus episodic irritability in youth: A community based
longitudinal study of clinical and diagnostic associations. J Child Adolesc Psychopharmacol. 2006;16:456–466.
Margulies DM, Weintraub S, Basile J, Grover PJ, Carlson GA. Will disruptive mood dysregulation disorder reduce false
diagnosis of bipolar disorder in children? Bipolar Disord. 2012;14:488.
Stringaris A, Barona A, Haimm C, Brotman MA, Lowe CH, Myers F, Rustgi E, Wheeler W, Kayser R, Towbin K, Leibenluft
E. Pediatric bipolar disorder versus severe mood dysregulation: Risk for manic episodes on follow-up. J Am Acad Child
Adolesc Psychiatry. 2010;49:397.
Yearwood EL, Meadows-Oliver M. Mood dysregulation disorders. In: Yearwood EL, Pearson GS, Newland JA, eds. Child and
Adolescent Behavioral Health: A Resource for Advance Practice Psychiatric and Primary Care Practitioners in Nursing.
Hoboken, NJ: John Wiley & Sons Inc.; 2012:165.
West Ae, Pavuluri MN. Psychosocial treatments for childhood and adolescent bipolar disorder. Child Adolesc Psychiatr Clin
N Am. 2009;18:471–482.
Yearwood EL, Meadows-Oliver M. Mood dysregulation disorders. In: Yearwood EL, Pearson GS, Newland JA, eds. Child and
Adolescent Behavioral Health: A Resource for Advance Practice Psychiatric and Primary Care Practitioners in Nursing.
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disorder in middle childhood on substance use and delinquent behavior. J Am Acad Child Adolesc Psychiatry. 2007;46:33.
31.12d Oppositional Defiant Disorder
Disruptive behaviors, especially oppositional patterns and aggressive behaviors, are
among the most frequent reasons for children and adolescents to be referred for
psychiatric evaluation. Demonstration of impulsive and oppositional behaviors are
developmentally normative in young children; many youth who continue to display
excessive patterns in middle childhood will find other forms of expression as they
mature and will no longer demonstrate these behaviors in adolescence or adulthood. The
origin of stable patterns of oppositional defiant behavior is widely accepted as a
convergence of multiple contributing factors, including biological, temperamental,
learned, and psychological conditions. Risk factors for the development of aggressive
behavior in youth include childhood maltreatment such as physical or sexual abuse,
neglect, emotional abuse, and overly harsh and punitive parenting. The American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5), has divided oppositional defiant disorder into three types: Angry/Irritable
Mood, Argumentative/Defiant Behavior, and Vindictiveness. A child may meet
diagnostic criteria for oppositional defiant disorder with a 6-month pattern of at least
four symptoms from the three types above. Angry/Irritable children with oppositional
defiant disorder often lose their tempers, are easily annoyed, and feel irritable much of
the time. Argumentative/Defiant children display a pattern of arguing with authority
figures, and adults such as parents, teachers, and relatives. Children with this type of
oppositional defiant disorder actively refuse to comply with requests, deliberately break
rules, and purposely annoy others. These children often do not take responsibility for
their actions, and often blame others for their misbehavior. Children with the Vindictive
type of oppositional defiant disorder are spiteful, and have shown vindictive or spiteful
actions at least twice in 6 months to meet diagnostic criteria.
Oppositional defiant disorder is characterized by enduring patterns of negativistic,
disobedient, and hostile behavior toward authority figures, as well as an inability to
take responsibility for mistakes, leading to placing blame on others. Children with
oppositional defiant disorder frequently argue with adults and become easily annoyed
by others, leading to a state of anger and resentment. Children with oppositional
defiant disorder may have difficulty in the classroom and with peer relationships, but
generally do not resort to physical aggression or significantly destructive behavior.
In contrast, children with conduct disorder engage in severe repeated acts of
aggression that can cause physical harm to themselves and others and frequently violate
the rights of others.
In oppositional defiant disorder, a child’s temper outbursts, active refusal to comply
with rules, and annoying behaviors exceed expectations for these behaviors for children
of the same age. The disorder is an enduring pattern of negativistic, hostile, and defiant
behaviors in the absence of serious violations of the rights of others.
EPIDEMIOLOGY
Oppositional and negativistic behavior, in moderation, is developmentally normal in
early childhood and adolescence. Epidemiological studies of negativistic traits in
nonclinical populations found such behavior in 16 to 22 percent of school-age children.
Although oppositional defiant disorder can begin as early as 3 years of age, it typically
is noted by 8 years of age and usually not later than early adolescence. Oppositional
defiant disorder has been reported to occur at rates ranging from 2 to 16 percent with
increased rates reported in boys before puberty, and an equal sex ratio reported after
puberty. The prevalence of oppositional defiant behavior in males and females
diminishes in youth older than 12 years of age.
ETIOLOGY
The most dramatic example of normal oppositional behavior peaks between 18 and 24
months, the “terrible twos,” when toddlers behave negativistically as an expression of
growing autonomy. Pathology begins when this developmental phase persists
abnormally, authority figures overreact, or oppositional behavior recurs considerably
more frequently than in most children of the same mental age. Among the criteria
included in oppositional defiant disorder, irritability appears to be the one most
predictive of later psychiatric disorders, whereas the other elements may be considered
components of temperament.
Children exhibit a range of temperamental predispositions to strong will, strong
preferences, or great assertiveness. Parents who model more extreme ways of expressing
and enforcing their own will may contribute to the development of chronic struggles
with their children that are then reenacted with other authority figures. What begins for
an infant as an effort to establish self-determination may become transformed into an
exaggerated behavioral pattern. In late childhood, environmental trauma, illness, or
chronic incapacity, such as mental retardation, can trigger oppositionality as a defense
against helplessness, anxiety, and loss of self-esteem. Another normative oppositional
stage occurs in adolescence as an expression of the need to separate from the parents
and to establish an autonomous identity.
Classic psychoanalytic theory implicates unresolved conflicts as fueling defiant
behaviors targeting authority figures. Behaviorists have observed that in children,
oppositionality may be a reinforced, learned behavior through which a child exerts
control over authority figures; for example, if having a temper tantrum when a request
or demand is made of the child coerces the parents to withdraw their request, then
tantrum behavior becomes strongly reinforced. In addition, increased parental attention
during a tantrum can reinforce the behavior.
DIAGNOSIS AND CLINICAL FEATURES
Children with oppositional defiant disorder often argue with adults, lose their temper,
and are angry, resentful, and easily annoyed by others at a level and frequency that is
outside of the expected range for their age and developmental level. Frequently, youth
with oppositional defiant disorder actively defy adults’ requests or rules and deliberately
annoy other persons. They tend to blame others for their own mistakes and
misbehavior, more often than is appropriate for their developmental age.
Manifestations of the disorder are almost invariably present in the home, but they may
not be present at school or with other adults or peers. In some cases, features of the
disorder from the beginning of the disturbance are displayed outside the home; in other
cases, the behavior starts in the home, but is later displayed outside. Typically,
symptoms of the disorder are most evident in interactions with adults or peers whom the
child knows well. Thus, a child with oppositional defiant disorder may not show signs of
the disorder when examined clinically. Although children with oppositional defiant
disorder may be aware that others disapprove of their behavior, they may still justify it
as a response to unfair or unreasonable circumstances. The disorder appears to cause
more distress to those around the child than to the child.
Chronic oppositional defiant disorder or irritability almost always interferes with
interpersonal relationships and school performance. These children are often rejected by
peers, and may become isolated and lonely. Despite adequate intelligence, they may do
poorly or fail in school, due to their lack of cooperation, poor participation, and
inability to accept help. Secondary to these difficulties are low self-esteem, poor
frustration tolerance, depressed mood, and temper outbursts. Adolescents who are
ostracized may turn to alcohol and illegal substances as a modality to fit in with peers.
Children who are chronically irritable often develop mood disorders in adolescence or
adulthood.
Pathology and Laboratory Examination
No specific laboratory tests or pathological findings help diagnose oppositional defiant
disorder. Because some children with oppositional defiant disorder become physically
aggressive and violate the rights of others as they get older, they may share some
characteristics with people with high levels of aggression, such as low central nervous
system serotonin.
DIFFERENTIAL DIAGNOSIS
Oppositional behaviors are both normal and adaptive within an expected range at
specific developmental stages. Periods of normative negativism must be distinguished
from oppositional defiant disorder. Developmentally appropriate oppositional behavior
is neither considerably more frequent nor more intense than that seen in other children
of the same mental age. Oppositional defiant disorder must be distinguished from
Disruptive Mood Dysregulation Disorder in so far as they are both characterized by
chronic irritability and inappropriate temper outbursts. According to the DSM-5,
oppositional defiant disorder cannot be diagnosed in the presence of disruptive mood
dysregulation disorder. (See Section 31.12c for a further discussion of disruptive mood
dysregulation disorder.)
Oppositional defiant behavior occurring temporarily in reaction to a stressor should
be diagnosed as an adjustment disorder. When features of oppositional defiant disorder
appear during the course of conduct disorder, schizophrenia, or a mood disorder, the
diagnosis of oppositional defiant disorder should not be made. Oppositional and
negativistic behaviors can also be present in ADHD, cognitive disorders, and mental
retardation. Whether a concomitant diagnosis of oppositional defiant disorder should be
made depends on the severity, pervasiveness, and duration of such behavior. Some
young children who receive a diagnosis of oppositional defiant disorder go on in several
years to meet the criteria for conduct disorder. Some investigators believe that the two
disorders may be developmental variants of each other, with conduct disorder being the
natural progression of oppositional defiant behavior when a child matures. Most
children with oppositional defiant disorder, however, do not later meet the criteria for
conduct disorder, and up to one fourth of children with oppositional defiant disorder
may not meet the diagnosis several years later.
The subtype of oppositional defiant disorder that tends to progress to conduct disorder
is one in which aggression is prominent, for example, the Angry/Irritable type and the
Vindictive type. Many children who have ADHD and oppositional defiant disorder
develop conduct disorder before the age of 12 years. Many children who develop
conduct disorder have a history of oppositional defiant disorder. Overall, the current
consensus is that two subtypes of oppositional defiant disorder may exist. One type,
which is likely to progress to conduct disorder, includes certain symptoms of conduct
disorder (e.g., fighting, bullying). The other type, which is characterized by less
aggression and fewer antisocial traits, does not progress to conduct disorder. However,
in either case, when both oppositional defiant disorder and conduct disorder are
present, according to DSM-5, they may be diagnosed concurrently.
Jackson, age 8 years, was brought to the clinic for evaluation of irritability,
negativity and defiant behavior by his mother. She complained that he had frequent
prolonged tantrums, triggered by not “getting his way.” Jackson’s mother described
the tantrums as consisting of shouting, cursing, crying, slamming doors, and
sometimes throwing books or objects on the floor. Jackson had been having troubles
in school as well and his teacher had reported to the family that he seemed to have a
habit of provoking other students as well as the teacher by making noises, rocking in
his seat, and whistling in class. Recently, at home, Jackson was kicking his foot
against his mother’s chair and she asked him to stop. He looked at her and continued
to kick her chair until she became angry and sent him to his room. He then started
yelling and stated that he wasn’t doing anything and that his mother was just picking
on him. Jackson’s mother reports that she has given up on asking him to help with
chores, because it inevitably results in an argument. Jackson appears sullen and
irritable on interview. He insists that his problems are all his mother’s fault and she is
always nagging him unfairly. During the interview with his mother, he interrupted
her several times, to say that she was lying and to contradict her story. Despite
Jackson’s behavioral problem he has been able to succeed academically and scores
highly on standardized tests. His mother reports that Jackson used to have some
friends in kindergarten, but as he has gotten older, he has lost almost all of his friends
because he has difficulty sharing his things and tends to be bossy. Jackson’s mother
reports that ever since his sister was born when he was 2 years old, he has been
aggressive and rivalrous toward her. Jackson’s parents separated and divorced when
he was 3. He has had no contact with his father since then. Jackson’s mother was
depressed for a year after the divorce until she sought treatment. She has always felt
guilty that his father is not in his life, and Jackson blames her for not having his
father around. She believes his behaviors have become worse since she recently
started dating again.
COURSE AND PROGNOSIS
The course of oppositional defiant disorder depends on the severity of the symptoms and
the ability of the child to develop more adaptive responses to authority. The stability of
oppositional defiant disorder varies over time, with approximately 25 percent of
children with the disorder no longer meeting diagnostic criteria. Persistence of
oppositional defiant symptoms poses an increased risk of additional disorders, such as
mood disorders, conduct disorder and substance use disorders. Positive outcomes are
more likely for intact families who can modify their own expression of demands and
give less attention to the child’s argumentative behaviors.
An association exists between oppositional defiant disorder and ADHD, as well as
with mood disorders. In children who have a long history of aggression and oppositional
defiant disorder, there is a greater risk of the development of conduct disorder and later
substance use disorders. Parental psychopathology, such as antisocial personality
disorder and substance abuse, appears to be more common in families with children who
have oppositional defiant disorder than in the general population, which creates
additional risks for chaotic and troubled home environments. The prognosis for
oppositional defiant disorder in a child depends somewhat on family functioning and
the development of comorbid psychopathology.
TREATMENT
The primary treatment of oppositional defiant disorder is family intervention using both
direct training of the parents in child management skills and careful assessment of
family interactions. The goals of this intervention are to reinforce more prosocial
behaviors and to diminish undesired behaviors at the same time. Cognitive behavioral
therapists emphasize teaching parents how to alter their behavior to discourage the
child’s oppositional behavior by diminishing attention to it, and encourage appropriate
therapy focuses on selectively reinforcing and praising appropriate behavior and
ignoring or not reinforcing undesired behavior.
Children with oppositional defiant behavior may also benefit from individual
psychotherapy in which they role play and “practice” more adaptive responses. In the
therapeutic relationship, the child can learn new strategies to develop a sense of
mastery and success in social situations with peers and families. In the safety of a more
“neutral” relationship, children may discover that they are capable of less provocative
behavior. Often, self-esteem must be restored before a child with oppositional defiant
disorder can make more positive responses to external control. Parent–child conflict
strongly predicts conduct problems; patterns of harsh physical and verbal punishment
particularly evoke the emergence of aggression in children. Replacing harsh, punitive
parenting and increasing positive parent–child interactions may positively influence the
course of oppositional and defiant behaviors.
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33 - 31.12e Conduct Disorder
31.12e Conduct Disorder
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31.12e Conduct Disorder
Aggressive patterns of behavior are among the most frequent reasons for children and
adolescents to be referred for psychiatric intervention. Although demonstration of
impulsive behaviors is developmentally normative in children, many youth who
continue to display excessive patterns of aggression in middle childhood generally
require intervention. Children who develop enduring patterns of aggressive behaviors
that begin in early childhood and violate the basic rights of peers and family members,
however, may be destined for an entrenched pattern of conduct disordered behaviors
over time. Controversy remains as to whether a set of “voluntary” behaviors can
constitute a valid psychiatric disorder, or may be better accounted for as maladaptive
responses to adverse events, harsh or punitive parenting, or a threatening environment.
Longitudinal studies have demonstrated that, for some youth, early patterns of
disruptive behavior may become a lifelong pervasive repertoire culminating in adult
antisocial personality disorder. The etiology of enduring patterns of aggressive behavior
is widely accepted as a convergence of multiple contributing factors, including
biological, temperamental, learned, and psychological conditions. Risk factors for the
development of aggressive behavior in youth include childhood maltreatment such as
physical or sexual abuse, neglect, emotional abuse, and overly harsh and punitive
parenting. Chronic exposure to violence in the media including television, video games,
and music videos has been shown to promote lower levels of empathy in children, which
may add a risk factor for the development of aggressive behavior.
Conduct disorder is an enduring set of behaviors in a child or adolescent that evolves
over time, usually characterized by aggression and violation of the rights of others.
Youth with conduct disorder often demonstrate behaviors in the following four
categories: physical aggression or threats of harm to people, destruction of their own
property or that of others, theft or acts of deceit, and frequent violation of ageappropriate rules. Conduct disorder is associated with many other psychiatric disorders
including ADHD, depression, and learning disorders. It is also associated with certain
psychosocial factors, including childhood maltreatment, harsh or punitive parenting,
family discord, lack of appropriate parental supervision, lack of social competence, and
low socioeconomic level. The American Psychiatric Association’s DSM-5 criteria require
three persistent specific behaviors of 15 conduct disorder symptoms listed, over the past
12 months, with at least one of them present in the past 6 months (Table 31.12e-1).
Conduct disorder symptoms include bullying, threatening, or intimidating others, and
staying out at night despite parental prohibition. DSM-5 also specifies that when
truancy from school is a symptom, it begins before 13 years of age. The disorder may be
diagnosed in a person older than 18 years only if the criteria for antisocial personality
disorder are not met. DSM-5 includes specifiers denoting the severity of the disorder,
including “mild” in which there are few conduct problems in excess of those needed to
make the diagnosis and behaviors cause only minor harm to others. In “moderate” cases,
symptoms exceed the minimum; however, there is less confrontation that may cause
harm to individuals than in “severe” cases. According to DSM-5, the “severe” level shows
many conduct problems in excess of the minimal diagnostic criteria or conduct problems
that cause considerable harm to others. DSM-5 has also added the following specifier:
“With limited prosocial emotions.” To qualify for this specifier, the individual must show
a persistent interpersonal and emotional pattern that can be characterized by at least
two of the following: (1) Lack of remorse or guilt, (2) callous lack of empathy, (3)
unconcerned about performance, (4) shallow or deficient affect. Individuals with
conduct disorder who qualify for this specifier are more likely to have childhood-onset
type and meet the criteria for a “severe” disorder. Children with conduct disorder
engage in severe repeated acts of aggression that can cause physical harm to themselves
and others and frequently violate the rights of others. Children with conduct disorder
usually have behaviors characterized by aggression to persons or animals, destruction of
property, deceitfulness or theft, and multiple violations of rules, such as truancy from
school. These behavior patterns cause distinct difficulties in school life as well as in peer
relationships. Conduct disorder has been divided into three subtypes, based on the age
of onset of the disorder. Childhood-onset subtype, in which at least one symptom has
emerged repeatedly before age 10 years; Adolescent-onset type, in which no
characteristic persistent symptoms were seen until after age 10 years; and Unspecifiedonset, in which age of onset is unknown. Although some young children show persistent
patterns of behavior consistent with violating the rights of others or destroying
property, the diagnosis of conduct disorder in children appears to increase with age.
Epidemiological surveys indicate that geographic locations representing a broad range
of different cultures are not associated with significant variability in prevalence rates of
either oppositional defiant disorder or conduct disorder. A longitudinal study of
population density and antisocial behaviors in youth found no relationship in children 4
to 13 years of age between conduct problems and density of living area. However,
higher rates of conduct problems were self-reported by youth 10 years to 17 years who
lived in higher-density communities.
Table 31.12e-1
DSM-5 Diagnostic Criteria for Conduct Disorder
EPIDEMIOLOGY
Estimated prevalence rates of conduct disorder in the United States range from 6 to 16
percent for males, and from 2 to 9 percent for females. Ratio of conduct disorder in
males compared to females ranges from 4:1 to as much as 12:1. Conduct disorder occurs
with greater frequency in the children of parents with antisocial personality disorder
and alcohol dependence than in the general population. The prevalence of conduct
disorder and antisocial behavior is associated with socioeconomic factors, as well as
parental psychopathology.
ETIOLOGY
A meta-analysis of longitudinal studies indicates that the most important risk factors
that predict conduct disorder include impulsivity, physical or sexual abuse or neglect,
poor parental supervision and harsh and punitive parental discipline, low intelligence
quotient (IQ), and poor school achievement.
Parental Factors
Harsh, punitive parenting characterized by severe physical and verbal aggression is
associated with the development of children’s maladaptive aggressive behaviors. Chaotic
home conditions are associated with conduct disorder and delinquency. Divorce itself is
not necessarily a risk factor, but the persistence of hostility, resentment, and bitterness
between divorced parents may be the more important contributor to maladaptive
behavior. Parental psychopathology, child abuse, and negligence often contribute to
conduct disorder. Sociopathy, alcohol dependence, and substance abuse in the parents
are associated with conduct disorder in their children. Parents may be so negligent that
a child’s care is shared by relatives or assumed by foster parents. Many such parents
were scarred by their own upbringing and tend to be abusive, negligent, or engrossed in
getting their own personal needs met.
Studies indicate that parents of children with conduct disorder have high rates of
serious psychopathology, including psychotic disorders. Data shows that children who
exhibit a pattern of aggressive behavior have frequently been exposed to physically or
emotionally harsh parenting.
Genetic Factors
A study of more than 6,000 male, female, and opposite sex twins found that genetic and
environmental factors accounted for proportionally the same amount of variance in
males and females. Genetic, and/or shared environmental factors exert different effects
on males and females in childhood conduct disorder, but by adulthood, the genderspecific influences on antisocial behavior are no longer apparent. The sex-specific
effects on antisocial behavior in youth along with the replicated finding of a potential
role for the X-linked monoamine oxidase A gene in the etiology of antisocial behavior
leads to the need for further genetic investigation of conduct disorder on the X
chromosome and for analyses of these behaviors to be done separately by gender.
Sociocultural Factors
Youth residing in geographic areas with greater population density report increased
rates of aggression and delinquency. Unemployed parents, lack of a supportive social
network, and lack of positive participation in community activities seem to predict
conduct disorder. Associated findings that may influence the development of conduct
disorder in urban areas are increased exposure to and prevalence of substance use. A
survey of alcohol use and mental health in adolescents found that weekly alcohol use
among adolescents is associated with increased delinquent and aggressive behavior.
Significant interactions between frequent alcohol use and age indicated that those
adolescents with weekly alcohol use at younger ages were most likely to exhibit
aggressive behaviors and mood disorders. Although drug and alcohol use does not cause
conduct disorder, it increases the risks associated with it. Drug intoxication itself can
also aggravate the symptoms. Thus, all factors that increase the likelihood of regular
substance use may, in fact, promote and expand the disorder.
Psychological Factors
Poor emotion regulation among youth is associated with higher rates of aggression and
conduct disorder. Emotion regulation is associated with social competence and can be
observed even in children of preschool age. Those children with greater degrees of
emotion dysregulation exhibit higher levels of aggression. Poor modeling of impulse
control and the chronic lack of having their own needs met leads to a less welldeveloped sense of empathy.
Neurobiological Factors
Neuroimaging studies utilizing MRI have used voxel-based morphometry methods to
compare structural brain differences between children with conduct disorder compared
to normal controls. Studies have reported that children with conduct disorder had
decreased gray matter in limbic brain structures, and in the bilateral anterior insula and
left amygdala compared to healthy controls. A study investigated structural brain
differences in children comorbid for oppositional defiant disorder or conduct disorder
and ADHD compared to those with ADHD alone, and normal controls. Findings included
decreased gray matter in ADHD and ADHD comorbid for oppositional defiant disorder
or conduct disorder compared to controls in regions including bilateral temporal and
occipital cortices, and the left amygdala.
Neurotransmitter studies in children with conduct disorder, suggest low level of
plasma dopamine β-hydroxylase, an enzyme that converts dopamine to norepinephrine,
leading to a hypothesis of decreased noradrenergic functioning in conduct disorder.
Other studies of conduct-disordered juvenile offenders have found high plasma serotonin
levels in blood. Evidence indicates that blood serotonin levels correlate inversely with
levels of 5-HIAA in the cerebrospinal fluid (CSF) and that low 5-HIAA levels in CSF
correlate with aggression and violence.
Neurologic Factors
An electroencephalography (EEG) study investigating resting frontal brain electrical
activity, emotional intelligence, aggression, and rule breaking in 10-year-old children
found that aggressive children had significantly greater relative right frontal brain
activity at rest compared with nonaggressive children. Frontal resting brain electrical
activity has been hypothesized to reflect the ability to regulate emotion. Boys tended to
show lower emotional intelligence than girls and greater aggressive behavior than girls.
No relationship, however, was found between emotional intelligence and pattern of
frontal EEG activation.
Child Abuse and Maltreatment
Evidence shows that children chronically exposed to violence, physical or sexual abuse,
and neglect, particularly at a young age, are at high risk for demonstrating aggression.
A study of female caregivers exposed to intimate partner violence revealed a strong
association with offspring aggression and mood disturbance. Severely abused children
and adolescents tend to be hypervigilant; in some cases, they misperceive benign
situations as directly threatening and respond defensively with violence. Not all
expressed aggressive behavior in adolescents is synonymous with conduct disorder;
however, youth with a repetitive pattern of hypervigilance and violent responses are
likely to violate the rights of others.
Comorbid Factors
ADHD and conduct disorder are often found to coexist, with ADHD often predating the
development of conduct disorder, and not infrequently substance abuse. Central nervous
system injury, dysfunction, or damage predispose a child to impulsivity and behavioral
disturbances, which sometimes evolve into conduct disorder.
DIAGNOSIS AND CLINICAL FEATURES
Conduct disorder does not develop overnight, instead, many symptoms evolve over time
until a consistent pattern develops that involves violating the rights of others. Very
young children are unlikely to meet the criteria for the disorder, because they are not
developmentally able to exhibit the symptoms typical of older children with conduct
disorder. A 3-year-old does not break into someone’s home, steal with confrontation,
force someone into sexual activity, or deliberately use a weapon that can cause serious
harm. School-age children, however, can become bullies, initiate physical fights, destroy
property, or set fires. The DSM-5 diagnostic criteria for conduct disorder are given in
Table 31.12e-1.
The average age of onset of conduct disorder is younger in boys than in girls. Boys
most commonly meet the diagnostic criteria by 10 to 12 years of age, whereas girls
often reach 14 to 16 years of age before the criteria are met.
Children who meet the criteria for conduct disorder express their overt aggressive
behavior in various forms. Aggressive antisocial behavior can take the form of bullying,
physical aggression, and cruel behavior toward peers. Children may be hostile, verbally
abusive, impudent, defiant, and negativistic toward adults. Persistent lying, frequent
truancy, and vandalism are common. In severe cases, destructiveness, stealing, and
physical violence often occur. Some adolescents with conduct disorder make little
attempt to conceal their antisocial behavior. Sexual behavior and regular use of tobacco,
liquor, or illicit psychoactive substances begin unusually early for such children and
adolescents. Suicidal thoughts, gestures, and acts are frequent in children and
adolescents with conduct disorder who are in conflict with peers, family members, or the
law and are unable to problem solve their difficulties.
Some children with aggressive behavioral patterns have impaired social attachments,
as evinced by their difficulties with peer relationships. Some may befriend a much older
or younger person or have superficial relationships with other antisocial youngsters.
Many children with conduct problems have poor self-esteem, although they may project
an image of toughness. They may lack the skills to communicate in socially acceptable
ways and appear to have little regard for the feelings, wishes, and welfare of others.
Children and adolescents with conduct disorders often feel guilt or remorse for some of
their behaviors, but try to blame others to stay out of trouble.
Many children and adolescents with conduct disorder suffer from the deprivation of
having few of their dependency needs met and may have had either overly harsh
parenting or a lack of appropriate supervision. The deficient socialization of many
children and adolescents with conduct disorder can be expressed in physical violation of
others and, for some, in sexual violation of others. Severe punishments for behavior in
children with conduct disorder almost invariably increases their maladaptive expression
of rage and frustration rather than ameliorating the problem.
In evaluation interviews, children with aggressive conduct disorders are typically
uncooperative, hostile, and provocative. Some have a superficial charm and compliance
until they are urged to talk about their problem behaviors. Then, they often deny any
problems. If the interviewer persists, the child may attempt to justify misbehavior or
become suspicious and angry about the source of the examiner’s information and
perhaps bolt from the room. Most often, the child becomes angry with the examiner and
expresses resentment of the examination with open belligerence or sullen withdrawal.
Their hostility is not limited to adult authority figures, but is expressed with equal
venom toward their age-mates and younger children. In fact, they often bully those who
are smaller and weaker. By boasting, lying, and expressing little interest in a listener’s
responses, such children reveal their lack of trust in adults to understand their position.
Evaluation of the family situation often reveals severe marital disharmony, which
initially may center on disagreements about management of the child. Because of a
tendency toward family instability, parent surrogates are often in the picture. Children
with conduct disorder are more likely to be unplanned or unwanted babies. The parents
of children with conduct disorder, especially the father, have higher rates of antisocial
personality disorder or alcohol dependence. Aggressive children and their family show a
stereotyped pattern of impulsive and unpredictable verbal and physical hostility. A
child’s aggressive behavior rarely seems directed toward any definable goal and offers
little pleasure, success, or even sustained advantages with peers or authority figures.
In other cases, conduct disorder includes repeated truancy, vandalism, and serious
physical aggression or assault against others by a gang, such as mugging, gang fighting,
and beating. Children who become part of a gang usually have the skills for ageappropriate friendships. They are likely to show concern for the welfare of their friends
or their own gang members and are unlikely to blame them or inform on them. In most
cases, gang members have a history of adequate or even excessive conformity during
early childhood that ended when the youngster became a member of the delinquent peer
group, usually in preadolescence or during adolescence. Also present in the history is
some evidence of early problems, such as marginal or poor school performance, mild
behavior problems, anxiety, and depressive symptoms. Some family social or
psychological pathology is usually evident. Patterns of paternal discipline are rarely
ideal and can vary from harshness and excessive strictness to inconsistency or relative
absence of supervision and control. The mother has often protected the child from the
consequences of early mild misbehavior, but does not seem to encourage delinquency
actively. Delinquency, also called juvenile delinquency, is most often associated with
conduct disorder but can also result from other psychological or neurological disorders.
Violent Video Games and Violent Behavior
Longitudinal studies corroborate the contribution of media violence including video
gaming in middle-school children with the expression of aggression in those adolescents.
A review of the literature of the effect of violent video games on children and
adolescents revealed that violent video game playing is related to aggressive affect,
physiologic arousal, and aggressive behaviors. It stands to reason that the degree of
exposure to violent games and the more restriction of activity would be related to a
greater preoccupation with violent themes.
PATHOLOGY AND LABORATORY EXAMINATION
No specific laboratory test or neurological pathology helps make the diagnosis of
conduct disorder. Some evidence indicates that amounts of certain neurotransmitters,
such as serotonin in the CNS, are low in some persons with a history of violent or
aggressive behavior toward others or themselves. Whether this association is related to
the cause, or is the effect, of violence or is unrelated to the violence is not clear.
DIFFERENTIAL DIAGNOSIS
Disturbances of conduct, including impulsivity and aggression, may occur in many
childhood psychiatric disorders, ranging from ADHD, to oppositional defiant disorder, to
disruptive mood dysregulation disorder mood disorder, to major depression, to bipolar
disorder, specific learning disorders, and psychotic disorders. Therefore, clinicians must
obtain a comprehensive history of the chronology of the symptoms to determine
whether the conduct disturbance is a transient or an enduring pattern. Isolated acts of
aggressive behavior do not justify a diagnosis of conduct disorder; an entrenched
pattern must be present. The relationship of conduct disorder to oppositional defiant
disorder is still under debate. Historically, oppositional defiant disorder has been
conceptualized as a mild precursor of conduct disorder, without the violation of rights,
likely to be diagnosed in younger children who may be at risk for conduct disorder.
Children who progress from oppositional defiant disorder to conduct disorder over time,
maintain their oppositional characteristics, and some evidence indicates that the two
disorders are independent. Currently, in the DSM-5, oppositional defiant disorder and
conduct disorder are considered distinct, and they may be diagnosed comorbidly. Many
children with oppositional defiant disorder do not develop conduct disorder, and
conduct disorder emerging in adolescence is not necessarily preceded by oppositional
defiant disorder. The main distinguishing clinical feature between these two disorders is
that in conduct disorder, the basic rights of others are violated, whereas in oppositional
defiant disorder, hostility and negativism fall short of seriously violating the rights of
others.
Mood disorders are often present in children who exhibit irritability and aggressive
behavior. Both major depressive disorder and bipolar disorders must be ruled out, but
the full syndrome of conduct disorder can occur and be diagnosed during the onset of a
mood disorder. Substantial comorbidity exists of conduct disorder and depressive
disorders. A recent report concludes that the high correlation between the two disorders
arises from shared risk factors for both disorders rather than a causal relation. Thus, a
series of factors, including family conflict, negative life events, early history of conduct
disturbance, level of parental involvement, and affiliation with delinquent peers,
contribute to the development of affective disorders and conduct disorder. This is not the
case with oppositional defiant disorder, which cannot be diagnosed if it occurs
exclusively during a mood disorder.
ADHD and learning disorders are commonly associated with conduct disorder.
Usually, the symptoms of these disorders predate the diagnosis of conduct disorder.
Substance abuse disorders are also more common in adolescents with conduct disorder
than in the general population. Evidence indicates an association between fighting
behaviors as a child and substance use as an adolescent. Once a pattern of drug use is
formed, this pattern may interfere with the development of positive mediators, such as
social skills and problem-solving, which could enhance remission of the conduct
disorder. Thus, once substance abuse develops, it may promote continuation of the
conduct disorder. Obsessive-compulsive disorder also frequently seems to coexist with
disruptive behavior disorders. All the disorders described here should be noted when they
co-occur. Children with ADHD often exhibit impulsive and aggressive behaviors that
may not meet the full criteria for conduct disorder.
Damien, age 12 years, was referred for psychiatric evaluation after being picked up
by police for truancy, and running away from home. Damien explained that he just
wanted to get out of his house and go see his friends. He doesn’t like to be at home
because his mother tries to tell him what to do. Damien’s mother says that he left and
stayed out overnight multiple times in the past year, but that he usually returns the
next morning. She complains that he is constantly in trouble. He has shoplifted on
several occasions that she knows of, the first time at age 8 years. She suspects that he
also steals from neighbors or school. The police have been involved on many
occasions including truancy, staying out all night, stealing from a neighborhood store,
and smoking marijuana. Damien has a quick temper, and his mother knows he was
involved in several fights over the past year in the neighborhood. Damien is
particularly cruel to his younger brother, constantly taunting and teasing him.
Damien’s mother stated that he lies constantly, sometimes for no apparent reason.
When he was 6 years of age, he was fascinated with fire and set several small fires at
home, fortunately with no serious injury or damage. Damien’s mother was tearful
when she disclosed that Damien is just like his no-good father and that she wished she
never had him. Damien initially refused to answer questions, and turned away
scowling, but gradually began to talk. Damien presented a tough image with an
indifferent attitude toward the interviewer. Damien denied any abuse at home, saying
that he ran off because he was bored. However, upon further questioning, Damien
admitted that his mother’s previous boyfriend who was in the home when Damien was
between 6 and 8 years of age used to hit him with a belt when he got out of line.
Damien justified his own behaviors as just having fun. He explained the fights as
being provoked by the others and denied the use of any weapons, although he
bragged about breaking the nose of another youth. Damien’s school records indicate
that an Individualized Educational Plan (IEP) was required when he was in the 2nd
grade, and he was evaluated for symptoms of ADHD when he was in 1st grade.
Methylphenidate (Ritalin) was prescribed; however, the family did not continue with
treatment, and he is currently on no medication. Damien is currently in 6th grade
special education classes, having failed and repeated 5th grade. Damien’s grades are
failing, and he may have to repeat 6th grade. Damien admits to truancy on several
occasions this year in addition to his problems with completing schoolwork. His
previous evaluation indicates that child protective services evaluated the family for
possible neglect when he was 5 years of age after he and his brother were found
barefoot on the street late one evening without his mother in sight. Apparently,
Damien’s family was referred for counseling and never attended. Both of Damien’s
parents have a history of drug and alcohol abuse. Damien’s birth was unplanned, and
his mother used drugs during pregnancy. His parents separated soon after his birth,
and his mother returned to live with her parents briefly. Damien and his mother
moved to live with her boyfriend when Damien was 1 year of age after she became
pregnant with his younger sister. Damien’s mother’s relationship ended within a year,
and only Damien, his mother, and his sister live in their apartment. Damien’s mother
has worked several different jobs, and Damien wonders if she has a drinking problem.
COURSE AND PROGNOSIS
The course and prognosis for children with conduct disorder is most guarded in those
who have symptoms at a young age, exhibit the greatest number of symptoms, and the
most severe, and express them most frequently. This finding is true partly because those
with severe conduct disorder seem to be most vulnerable to comorbid disorders later in
life, such as mood disorders and substance use disorders. A longitudinal study found
that, although assaultive behavior in childhood and parental criminality predict a high
risk for incarceration later in life, the diagnosis of conduct disorder per se was not
correlated with imprisonment. The best prognosis is predicted for mild conduct disorder
in the absence of coexisting psychopathology and the presence of normal intellectual
functioning.
TREATMENT
Psychosocial Interventions
Early sustained preventive interventions can significantly alter the course and prognosis
of aggressive behavior when it is administered starting at kindergarten age. A screening
program used with kindergarteners predicted lifetime disruptive behavior disorder by
age 18 years, with the highest risk group demonstrating an 82 percent chance of a
disruptive behavior diagnosis without intervention. A prevention program, the Fast
Track Preventive Intervention, randomized 891 kindergarteners to either a 10-year
prevention program or a control condition. The 10-year intervention included parent
behavior management, child social cognitive skills, reading, home visiting, mentoring,
and classroom curricula. The children in the Fast Track Intervention were substantially
prevented from the development of conduct disorder during the 10-year period and for 2
years thereafter.
A meta-analysis of controlled trials of CBT programs indicates that CBT can result in
significant reductions in conduct-disordered symptoms in children and adolescents. CBT
treatment interventions that are proven to be efficacious include the following.
Kazdin’s Problem-Solving Skills Training (PSST) in which a 12-week sequential
program helps children develop problem-solving solutions when faced with conflictual
situations. Assignments called “supersolvers” provide vignette situations in which
children can practice these techniques. A companion program, Parent Management
Training (PMT) can be added to the intervention, but PSST can be effective even
without the parent component. Another CBT-based intervention, the Incredible Years
(IY), targeting young children from 3 to 8 years, is administered over 22 weeks and
delivers sessions to the child and has a parent training component and a teacher
training. Another CBT-based intervention is the Anger Coping Program, an 18-session
intervention for school-aged children in the grades 4 to 6 focused on a child’s increased
development of emotion recognition and regulation, and managing anger. Anger coping
strategies include distraction, self-talk, perspective taking, goal setting, and problem
solving.
Overall, treatment programs have been more successful in decreasing overt symptoms
of conduct, such as aggression, than the covert symptoms, such as lying or stealing.
Treatment strategies for young children that focus on increasing social behavior and
social competence are believed to reduce aggressive behavior. A study of 548 third
graders administered a school-based intervention instead of a regular health curriculum
in several public schools in North Carolina, called Making Choices: Social Problem Solving
Skills for Children (MC) program along with supplemental teacher and parent
components. Compared with third graders receiving the routine health curriculum,
children exposed to the MC program were rated lower on the posttest social and overt
aggression, and higher on social competence. In addition, they scored higher on an
information-processing skills posttest. These findings support the notion that schoolbased prevention programs have the potential to strengthen social and emotional skills
and diminish aggressive behavior among normal populations of school-age children.
School settings can also use behavioral techniques to promote socially acceptable
behavior toward peers and to discourage covert antisocial incidents.
Psychopharmacologic Interventions
Efficacy of psychopharmacologic interventions includes several placebo-controlled
studies of risperidone for aggression in youth associated with disruptive behavior
disorders, and/or mental retardation. In addition, risperidone has been found to be
superior to placebo in reducing aggressive behavior in a large 6-month placebosubstitution study. One randomized double-blind placebo-controlled trial with quetiapine
also showed efficacy for aggressive behavior. Early studies of antipsychotics, most
notably haloperidol (Haldol), reported decreased aggressive and assaultive behaviors in
children with a variety of psychiatric disorders. Atypical antipsychotics risperidone
(Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and
aripiprazole (Abilify) have generally replaced the older antipsychotics in clinical
practice due to their comparable efficacy and improved side effect profiles. Side effects
of second-generation antipsychotics include sedation, increased prolactin levels, (with
risperidone use) and extrapyramidal symptoms, including akathisia. In general,
however, the atypical antipsychotics appear to be well tolerated. A study of divalproex
in youth with conduct disorder showed that those who responded most robustly exhibited
aggression characterized by agitation, dysphoria, and distress. Although early trials
suggested that carbamazepine (Tegretol) was useful to control aggression, a doubleblind, placebo-controlled study did not show superiority of carbamazepine over placebo
in decreasing aggression. A pilot study found that clonidine (Catapres) may decrease
aggression. The SSRIs, including fluoxetine (Prozac), sertraline (Zoloft), paroxetine
(Paxil), and citalopram (Celexa), are used clinically to target symptoms of impulsivity,
irritability, and mood lability, which frequently accompany conduct disorder. Conduct
disorder often coexists with ADHD, learning disorders, and, over time, mood disorders
and substance-related disorders; thus, the treatment of concurrent disorders must also be
addressed.

34 - 31.13 Anxiety Disorders of Infancy, Childhood
31.13 Anxiety Disorders of Infancy, Childhood, and Adolescence
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31.13 Anxiety Disorders of Infancy, Childhood, and
Adolescence
Anxiety disorders are among the most common disorders in youth, affecting 10 to 20
percent of children and adolescents. Although observable anxiety behaviors mark

35 - 31.13a Separation Anxiety Disorder, Generaliz
31.13a Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder (Social Phobia)
normative development in infants, anxiety disorders in childhood predict a wide range
of psychological difficulties in adolescence including additional anxiety disorders, panic
attacks, and depressive disorders. Fear is an expected response to real or perceived
threat; however, anxiety is the anticipation of future danger. Anxiety disorders are
characterized by recurrent emotional and physiological arousal in response to excessive
perceptions of perceived threat or danger. Anxiety disorders commonly found in youth
include separation anxiety disorder, generalized anxiety disorder, social anxiety
disorder, and selective mutism. Anxiety is classified into disorders based on how it is
experienced, the situations that trigger it, and the course that it tends to follow.
31.13a Separation Anxiety Disorder, Generalized Anxiety
Disorder, and Social Anxiety Disorder (Social Phobia)
Separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder in
children are often considered together in the evaluation process and differential
diagnosis, and in developing treatment strategies, because they are highly comorbid and
have overlapping symptoms. A child with separation anxiety disorder, generalized
anxiety disorder, or social anxiety disorder has a 60 percent chance of having at least
one of the other two disorders as well. Of children with one of the above anxiety
disorders, 30 percent have all three of them. Children and adolescents may also have
additional comorbid anxiety disorders such as specific phobia or panic disorder.
Separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder
are distinguished from each other by the types of situations that elicit the excessive
anxiety and avoidance behaviors.
SEPARATION ANXIETY DISORDER
Separation anxiety is a universal human developmental phenomenon emerging in
infants younger than 1 year of age and marking a child’s awareness of a separation
from his or her mother or primary caregiver. Normative separation anxiety peaks
between 9 months and 18 months and diminishes by about 2½ years of age, enabling
young children to develop a sense of comfort away from their parents in preschool.
Separation anxiety or stranger anxiety most likely evolved as a human response that
has survival value. The expression of transient separation anxiety is also normal in
young children entering school for the first time. Approximately 15 percent of young
children display intense and persistent fear, shyness, and social withdrawal when faced
with unfamiliar settings and people. Young children with this pattern of significant
behavioral inhibition are at higher risk for the development of separation anxiety
disorder, generalized anxiety disorder, and social phobia. Behaviorally inhibited
children, as a group, exhibit characteristic physiological traits, including higher than
average resting heart rates, higher morning cortisol levels than average, and low heart
rate variability. Separation anxiety disorder is diagnosed when developmentally
inappropriate and excessive anxiety emerges related to separation from the major
attachment figure. According to the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), separation anxiety disorder is
characterized by a level of fear or anxiety regarding separation from their parents or
primary caregiver, which is beyond developmental expectations. Furthermore, there
may be a pervasive worry that harm will come to a parent upon separation, which leads
to extreme distress, and sometimes nightmares. The DSM-5 requires the presence of at
least three symptoms related to excessive worry about separation from a major
attachment figure for a period of at least 4 weeks. The worries often take the form of
refusal to go to school, fears and distress on separation, repeated complaints of physical
symptoms such as headaches and stomachaches when separation is anticipated, and
nightmares related to separation issues.
GENERALIZED ANXIETY DISORDER
Children with generalized anxiety disorder have significant distress in activities of daily
life often focused on the child’s fears of incompetence in many areas, including school
performance and in social settings. In addition, children with generalized anxiety
disorder, according to DSM-5, experience at least one of the following symptoms:
restlessness, being easily fatigued, “mind going blank,” irritability, muscle tension, or
sleep disturbance. Children with generalized anxiety disorder tend to feel fearful in
multiple settings and expect more negative outcomes when faced with academic or
social challenges, compared with peers. Children and adolescents with generalized
anxiety disorder may experience symptoms of autonomic hyperarousal such as
tachycardia, shortness of breath, or dizziness, and are more likely than nonanxious
youth to experience sweating, nausea, or diarrhea when they become anxious. Children
and adolescents with generalized anxiety disorder tend to be overly concerned about
potential natural disasters such as earthquakes or floods, and these worries can interfere
with their daily activities. Finally, children and adolescents with generalized anxiety
disorder are continuously worried about the quality of their performance in academics,
sports, and other activities, and often seek excessive reassurance about their
performance.
SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
Children who experience intense discomfort and distress in social situations and are
impaired by their fear of scrutiny or humiliation are given the diagnosis of social
anxiety disorder. Their distress may be expressed in the form of crying, tantrums,
avoidance, freezing, or even becoming “mute” in these situations. According to DSM-5,
this disorder is characterized by consistent anxiety and distress in almost all social
situations. Any situation in which the child feels exposed to possible scrutiny by others
can provoke fear or anxiety, and the child will often try to avoid these feared social
situations. Children must experience the anxiety in the presence of peers, not only with
adults, in order to receive the diagnosis. A child or adolescent with social anxiety
disorder may exhibit the performance only type, which targets a specific type of
performing, such as fear of public speaking. The performance only type typically
manifests in school or academic settings in which public presentations must be
performed, such as in front of classmates in school.
Social anxiety disorder has significant implications for future accomplishments, since
it is associated with lower levels of satisfaction in leisure activities, increased rates of
school dropout, less productivity in the workplace as adults, and increased rates of
remaining single. Despite the significant impairment caused by social anxiety disorder,
up to half of individuals with the disorder do not receive treatment.
EPIDEMIOLOGY
The prevalence of anxiety disorders has varied with the age group of the children
surveyed and the diagnostic instruments used. Lifetime prevalence of any anxiety
disorder in children and adolescents ranges from 10 percent to 27 percent. Anxiety
disorders are common in preschoolers as well, and follow a similar epidemiologic profile
as in older children. An epidemiologic survey using the Preschool Age Psychiatric
Assessment (PAPA) found that 9.5 percent of preschoolers met criteria for any anxiety
disorder, with 6.5 percent exhibiting generalized anxiety disorder, 2.4 percent meeting
criteria for separation anxiety disorder, and 2.2 percent meeting criteria for social
phobia. Separation anxiety disorder is estimated to be about 4 percent in children and
young adolescents. Separation anxiety disorder is more common in young children than
in adolescents and has been reported to occur equally in boys and girls. The onset may
occur during preschool years, but is most common in children 7 to 8 years of age. The
rate of generalized anxiety disorder in school-age children is estimated to be
approximately 3 percent, the rate of social phobia is 1 percent, and the rate of simple
phobias is 2.4 percent. In adolescents, lifetime prevalence for panic disorder was found
to be 0.6 percent; the prevalence for generalized anxiety disorder was 3.7 percent.
ETIOLOGY
Biopsychosocial Factors
Evidence for the influences of parental psychopathology and parenting styles on the
emergence of anxiety disorders in childhood has been found in multiple investigations.
Longitudinal studies have found that parental overprotection has been associated with
an increased risk of the development of anxiety disorders in children, and insecure
parent–child attachment is associated with higher than expected rates of anxiety
disorders in childhood. It is also well known that maternal depression and anxiety have
led to an increased risk for anxiety and depression in children. Psychosocial factors in
conjunction with a child’s temperament influences the degree of separation anxiety
evoked in situations of brief separation and exposure to unfamiliar environments. The
temperamental trait of shyness and withdrawal in unfamiliar situations has been shown
to be associated with a higher risk of developing separation anxiety disorder,
generalized anxiety disorder, social anxiety disorder, or all three during childhood and
adolescence.
External life stresses often coincide with development of the disorder. The death of a
relative, a child’s illness, a change in a child’s environment, or a move to a new
neighborhood or school is frequently noted in the histories of children with separation
anxiety disorder. In a vulnerable child, these changes probably intensify anxiety.
Neurophysiological correlations are found with behavioral inhibition (extreme
shyness); children with this constellation are shown to have a higher resting heart rate
and an acceleration of heart rate with tasks requiring cognitive concentration.
Additional physiological correlates of behavioral inhibition include elevated salivary
cortisol levels, elevated urinary catecholamine levels, and greater papillary dilation
during cognitive tasks.
Neuroimaging studies of adolescents with anxiety show an increased activation of the
amygdala compared to non-anxious adolescents when presented with anxiety-provoking
stimuli. Furthermore, anxious adolescents maintain the hyperactivation of the amygdala
over time, rather than showing an attenuation of the effect as in nonanxious
adolescents. Structural studies of the amygdala in adolescents with anxiety have led to
conflicting results, some studies finding increased amygdala volumes, whereas other
studies finding decreased amygdala volumes.
Social Learning Factors
Fear, in response to a variety of unfamiliar or unexpected situations, may be
unwittingly communicated from parents to children by direct modeling. If a parent is
fearful, the child will probably have a phobic adaptation to new situations, especially to
a school environment. There are much data to suggest that overprotective parenting
promotes increased interpersonal sensitivity in healthy children, and increases the risk
of social anxiety disorder in children with behavioral inhibition or other anxiety
disorders such as separation anxiety disorder. Some parents appear to teach their
children to be anxious by overprotecting them from expected dangers or by
exaggerating the dangers. For example, a parent who cringes in a room during a
lightning storm teaches a child to do the same. A parent who is afraid of mice or insects
conveys the affect of fright to a child. Conversely, a parent who becomes angry with a
child when the child expresses fear of a given situation, for example, when exposed to
animals, may promote a phobic concern in the child by exposing the child to the
intensity of the anger expressed by the parent. Social learning factors in the
development of anxiety reactions are magnified when parents have anxiety disorders
themselves. These factors may be pertinent in the development of separation anxiety
disorder as well as in generalized anxiety disorder and social phobia. A recent study
found no association between psychosocial hardships, such as ongoing family conflict,
and behavioral inhibition among young children. It appears that temperamental
predisposition to anxiety disorders emerges as a highly heritable constellation of traits,
and is not created by psychosocial stressor.
Genetic Factors
Genetic studies suggest that genes account for at least one third of the variance in the
development of anxiety disorders. Heritability for anxiety disorders in children and
adolescents ranges from 36 percent to 65 percent, with the highest estimates found in
younger children with anxiety disorders. Two heritable characteristics—behavioral
inhibition (the tendency toward fear and withdrawal in new situations) and
physiological hyperarousal—have both been found to impart significant risk factors for
future development of an anxiety disorder. However, although the temperamental
constellation of behavioral inhibition, excessive shyness, the tendency to withdraw from
unfamiliar situations, and the eventual emergence of anxiety disorders have a genetic
contribution, one third to two thirds of young children with behavioral inhibition do not
appear to go on to develop anxiety disorders.
Family studies have shown that the offspring of adults with anxiety disorders are at
an increased risk of having an anxiety disorder themselves. Separation anxiety disorder
and depression in children overlap, and the presence of an anxiety disorder increases
the risk of a future episode of a depressive disorder. Current consensus on the genetics
of anxiety disorders suggests that what is inherited is a general predisposition toward
anxiety, causing heightened levels of arousal, emotional reactivity, and increased
negative affect, all of which increase the risk of developing separation anxiety disorder,
generalized anxiety disorder, and social phobia.
DIAGNOSIS AND CLINICAL FEATURES
Separation anxiety disorder, generalized anxiety disorder, and social phobia are highly
related in children and adolescence because, in most children, overlapping symptoms as
well as comorbid disorders emerge. Generalized anxiety disorder is the most common
anxiety disorder among youth, more common in adolescents than in younger children;
in almost one third of these cases, a child with generalized anxiety disorder also exhibits
separation anxiety disorder and social anxiety disorder.
Diagnostic criteria for separation anxiety disorder, according to the DSM-5, include
three of the following symptoms for at least 4 weeks: persistent and excessive worry
about losing, or possible harm befalling, major attachment figures; persistent and
excessive worry that an untoward event can lead to separation from a major attachment
figure; persistent reluctance or refusal to go to school or elsewhere because of fear of
separation; persistent and excessive fear or reluctance to be alone or without major
attachment figures at home or without significant adults in other settings; persistent
reluctance or refusal to go to sleep without being near a major attachment figure or to
sleep away from home; repeated nightmares involving the theme of separation;
repeated complaints of physical symptoms, including headaches and stomachaches,
when separation from major attachment figures is anticipated; and recurrent excessive
distress when separation from home or major attachment figures is anticipated or
involved. The following case history demonstrates separation anxiety disorder along
with autonomic arousal symptoms.
Jake was a 9-year-old boy who was referred for outpatient evaluation by his family
physician. He refused to sleep in his room alone at night and exhibited violent
tantrums each morning in order to avoid going to school. Jake expressed recurrent
fears that something bad would happen to his mother. He worried that she would get
into a car accident or that there would be a fire at home and his mother would be
killed. Developmental history revealed that Jake was anxious and irritable as an
infant and toddler. He had trouble adjusting to babysitters in the preschool years.
There was a history of panic disorder, with agoraphobia in the mother and major
depression in his father. Jake became more concerned and territorial over his mother
when his father left the family, and his mother became depressed. Jake always kept
track of his mother’s whereabouts and insisted that she stay at home.
Nighttime was a particularly difficult time at home. When Jake’s mother tried to get
Jake to remain in his room, Jake would whine and cry and insist that his mother lie in
bed with him until he fell asleep. He also expected his mother to be in the master
bedroom across the hall from his room throughout the evening. Jake’s mother
reported that that each evening her son would get up and peek through the crack in
the master bedroom door, as frequently as every 10 minutes, to be certain that she
was still there. Jake reported frequent nightmares that his mother was killed and that
monsters prevented him from rescuing his mother, taking him away from his family
forever.
During the daytime, Jake would shadow his mother around the house. Jake would
agree to play a game with his sister in the lower level of the house only if his mother
was close by. When Jake’s mother went upstairs, he would interrupt the game and
follow her upstairs. He refused to sleep at a friend’s house. Frequently, at home as the
evening progressed, Jake described a queasy sensation in his stomach mixed with
feelings of sadness.
On school days, Jake usually complained of stomachaches and tried to stay home.
Jake appeared distressed and panicky and would become violent when his mother
attempted to drop him off at school. Once at school, he seemed calmer and less
distressed, but frequently was seen in the nurse’s office, complaining of nausea and
seeking to be sent home. (Adapted from case material from Gail A. Bernstein, M.D.
and Anne E. Layne, Ph.D.)
The essential feature of separation anxiety disorder is extreme anxiety precipitated by
separation from parents, home, or other familiar surroundings, whereas in generalized
anxiety disorder, fears are extended to negative outcomes for all kinds of events,
including academic, peer relationship, and family activities. In generalized anxiety
disorder, a child or adolescent experiences at least one recurrent physiological symptom,
such as restlessness, poor concentration, irritability, or muscle tension. In social phobia,
the child’s fears peak during performance situations involving exposure to unfamiliar
people or situations. Children and adolescents with social phobia have extreme concerns
about being embarrassed, humiliated, or negatively judged. In each of the preceding
anxiety disorders, the child’s experience can approach terror or panic. The distress is
greater than that normally expected for the child’s developmental level and cannot be
explained by any other disorder. Morbid fears, preoccupations, and ruminations
characterize separation anxiety disorder. Children with anxiety disorders overestimate
the probability of danger and the likelihood of negative outcome. Children with
separation anxiety disorder and generalized anxiety disorder become overly fearful that
someone close to them will be hurt or that something terrible will happen to them or
their families, especially when they are away from important caring figures. Many
children with anxiety disorders are preoccupied with health and worry that their
families or friends will become ill. Fears of getting lost, being kidnapped, and losing the
ability to be in contact with their families is predominant among children with
separation anxiety disorder.
Adolescents with anxiety disorders may not directly express their worries; however,
their behavior patterns often reflect either separation anxiety or other anxiety if they
exhibit discomfort about leaving home, engage in solitary activities because of fears
about how they will perform in front of peers, or have distress when away from their
families. Separation anxiety disorder in children is often manifested at the thought of
travel or in the course of travel away from home. Children may refuse to go to camp, a
new school, or even a friend’s house. Frequently, a continuum exists between mild
anticipatory anxiety before separation from an important figure and pervasive anxiety
after the separation has occurred. Premonitory signs include irritability, difficulty
eating, whining, staying in a room alone, clinging to parents, and following a parent
everywhere. Often, when a family moves, a child displays separation anxiety by intense
clinging to the mother figure. Sometimes, geographical relocation anxiety is expressed
in feelings of acute homesickness or psychophysiological symptoms that break out when
the child is away from home or is going to a new country. The child yearns to return
home and becomes preoccupied with fantasies of how much better the old home was.
Integration into the new life situation may become extremely difficult. Children with
anxiety disorders may retreat from social or group activities and express feelings of
loneliness because of their self-imposed isolation.
Sleep difficulties are frequent in children and adolescents with any anxiety disorder or
in severe separation anxiety; a child or adolescent may require having someone remain
with him or her until he or she falls asleep. An anxious child may awaken and go to a
parent’s bed or even sleep at the parents’ door in an effort to diminish anxiety.
Nightmares and morbid fears may be expressions of anxiety (Fig. 31.13a-1).
FIGURE 31.13a-1
This surrealistic photograph symbolically represents the anxiety in a childhood
nightmare. (Courtesy of Arthur Tress for Magnum Photos, Inc.)
Associated features of most anxiety disorders include fear of the dark and imaginary
worries. Children may have the feeling that eyes are staring at them and monsters are
reaching out for them in their bedrooms. Children with separation anxiety disorder,
generalized anxiety disorder, and social anxiety disorder often complain of somatic
symptoms and may be more sensitive to changes in their bodies compared to youth
without anxiety disorders. Children with separation anxiety disorder, generalized
anxiety disorder, or social anxiety disorder are often more emotionally sensitive than
peers and more easily brought to tears. Frequent somatic complaints accompanying
anxiety
disorders
include
gastrointestinal
symptoms,
nausea,
vomiting,
and
stomachaches; unexplained pain in various parts of the body; sore throats; and flu-like
symptoms. Older children and adolescents typically complain of somatic experiences
classically reported by adults with anxiety, such as cardiovascular and respiratory
symptoms—palpitations,
dizziness,
faintness,
and
feelings
of
strangulation.
Physiological signs of anxiety are a part of the diagnostic criteria for generalized
anxiety disorder, but they are more often also experienced by children with separation
anxiety and social phobia than the general population. The following case history
demonstrates a young adolescent with generalized anxiety disorder.
Rachel was a 13-year-old girl referred for an evaluation by her pediatrician based
on her chronic gastrointestinal complaints without any organic illness. On interview,
Rachel appeared withdrawn and meek but responsive to questions. She endorsed a
number of worries that included concerns about her health, her parents’ safety, her
school performance, and her peer relationships. Rachel’s greatest worries were related
to her health and safety. Rachel’s mother reported that Julie had recently been very
reluctant to play outside, because she feared she would contract Lyme disease from a
tick bite or West Nile virus from a mosquito bite. Rachel was also very distressed by
news reports about catastrophic events locally and around the world (e.g.,
kidnapping, crime, terrorism). Rachel was described by her family and teachers as
overly conscientious about her schoolwork and as often being concerned about adult
matters (e.g., finances, parents’ job security). Symptoms that accompanied Rachel’s
worries primarily involved stomach pain and problems falling asleep. Rachel tended
to be quite perseverative; repetitively verbalizing her worries even after reassurance
was given. Rachel admitted that she worried for hours each day and could not “turn
off” her worried thoughts.
Rachel was the product of a normal pregnancy and delivery. Her medical history
was unremarkable, with the exception of frequent gastrointestinal pain since
kindergarten. Julie was described as irritable and difficult to soothe as an infant.
Developmental milestones were met within normal limits. She was described as very
obedient and had no history of externalizing behavior problems. She was very
concerned about her academic performance from an early age and earned A’s with an
occasional B. Rachel was somewhat shy in social situations but well-liked by her
peers. Family history included depression in her maternal grandmother and a
maternal history of generalized anxiety disorder, social anxiety, and separation
anxiety disorder as a child. Rachel had two younger siblings who were high achievers
and without notable problems. (Adapted from case material from Gail A. Bernstein,
M.D., and Ann E. Layne, Ph.D.)
The next case history demonstrates an adolescent with multiple anxiety and
depressive disorders.
Kate is a 15-year-old 10th grader who lives with her biological parents and two
sisters, age 9 and 14 years. Kate is a very articulate teen who has always been a good
student, although she never volunteers answers in school unless she is called on by her
teachers. She gets along well with her sisters when at home, but ever since she entered
high school in the 9th grade year, she declines invitations to go to friends’ homes, has
turned down opportunities to go to parties, and has even stopped going on outings
with her sisters to the neighborhood mall and the movies. Kate reports that she gets
too nervous, and blushes when she is with friends outside of the classroom at school
because she can’t think of anything to say to them. She reports that she is embarrassed
to go shopping or to the movies with her sisters because they often run into
neighborhood peers along the way, stop to chat, and this makes her feel “stupid,”
because even though she is the oldest, she does not say anything, and believes that her
sisters’ friends will laugh at her shyness. Recently, one of her former best friends
confronted her about why she had stopped “hanging out” with her friends. Kate had
stopped eating lunch with her friends in school because she felt humiliated when they
would talk about their weekend plans and even when they invited her to join, she
would just look the other way and ignore the conversation. Kate had become isolated,
even in school, and admitted to her sister that she was lonely. Kate was brought for
an evaluation after her younger sister commented to her mother that Kate spent all of
her time alone whenever her sisters saw their friends, and that she looked sad and
stressed out whenever she was around peers. Kate was down, always in poor spirits
and had stopped interacting with her sisters even at home, and her sisters were often
out with their own friends. On rare occasions Kate’s younger sister had invited Kate to
parties or to friend’s homes, but Kate had declined and burst into tears.
Kate was evaluated by a child psychiatrist who made the diagnoses of social anxiety
disorder, generalized anxiety disorder, and major depression and recommended a
combination of treatment options, including cognitive-behavioral therapy (CBT) and
a trial of a selective serotonin reuptake inhibitor (SSRI), fluoxetine. Kate and her
family decided to try the medication first. Kate was started on 10 mg of fluoxetine and
over the next month was titrated to a dose of 20 mg. By the third week of the
medication trial, Kate was noticeably less resistant to going out with her sisters to
places where they were likely to encounter peers. Her sisters noticed that she did not
seem as stressed and started to occasionally sit with peers at lunch in the school
cafeteria. She stated that she did not feel as self-conscious as she used to in class and
was willing to go to a friend’s house. She still declined to go to a birthday party of a
peer that she didn’t know very well. Kate continued on the same medication and
within 2 months, she was significantly less anxious in social situations. She
complained occasionally of a stomachache, but tolerated the medication well. Her
family was impressed when she requested they plan a birthday party for her 16th
birthday and decided to invite 10 friends.
Pathology and Laboratory Examination
No specific laboratory measures help in the diagnosis of separation anxiety disorder,
generalized anxiety disorder, or social anxiety disorder.
DIFFERENTIAL DIAGNOSIS
The presence of separation anxiety is a developmentally expected feature in a young
child and often does not represent an impairing condition, thus clinical judgment must
be used in distinguishing normal anxiety from separation anxiety disorder in this age
group. In older school-age children, a child experiencing more than normal distress is
apparent when school is refused on a regular basis. For children who resist school, it is
important to distinguish whether fear of separation, general worry about performance,
or more specific fears of humiliation in front of peers or the teacher are driving the
resistance. In many cases in which anxiety is the primary symptom, all three of the
above-feared scenarios come into play. In generalized anxiety disorder, anxiety is not
primarily focused on separation.
When depressive disorders occur in children, possible comorbidities such as separation
anxiety disorder should be evaluated as well. A comorbid diagnosis of separation
anxiety disorder and depressive disorder should be made when the criteria for both
disorders are met; the two diagnoses often coexist. Panic disorder with agoraphobia is
uncommon before 18 years of age; the fear is of being incapacitated by a panic attack
rather than of separation from parental figures. School refusal is a frequent symptom in
separation anxiety disorder, but is not pathognomonic of it. Children with other
diagnoses, such as specific phobias, or social anxiety disorder, or fear of failure in school
because of learning disorder, may also lead to school refusal. When school refusal occurs
in an adolescent, the severity of the dysfunction is generally greater than when it
emerges in a young child. Similar and distinguishing characteristics of childhood
separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder
are presented in Table 31.13a-1.
Table 31.13a-1
Common Characteristics in Childhood Anxiety Disorders
COURSE AND PROGNOSIS
The course and the prognosis of separation anxiety disorder, generalized anxiety
disorder, and social anxiety disorder are varied and are related to the age of onset, the
duration of the symptoms, and the development of comorbid anxiety and depressive
disorders. Young children who can maintain attendance in school, after-school activities,
and peer relationships generally have a better prognosis than children or adolescents
who refuse to attend school and withdraw from social activities. The large multisite
randomized clinical trial Child/Adolescent Anxiety Multimodal Study (CAMS) provided
acute treatment for children and adolescents with one or more anxiety disorders with
sertraline medication alone, cognitive-behavior therapy (CBT) alone, or both together,
and found that predictors of future remission included younger age of initiation of
treatment, lower severity of anxiety, absence of a comorbid depressive or anxiety
disorder, and the absence of social anxiety disorder as the primary anxiety disorder
being treated. A follow-up study of children and adolescents with mixed anxiety
disorders over a 3-year period reported that up to 82 percent no longer met criteria for
the anxiety disorder at follow-up. Of the group followed, 96 percent of those with
separation anxiety disorder were remitted at follow-up. Most children who recovered did
so within the first year. Early age of onset and later age at diagnosis were factors in this
study that predicted slower recovery. Close to one third of the group studied, however,
had developed another psychiatric disorder within the follow-up period, and 50 percent
of these children developed another anxiety disorder. Studies have shown a significant
overlap between separation anxiety disorder and depressive disorders. In cases with
multiple comorbidities, the prognosis is more guarded. Longitudinal data indicate that
some children with severe school refusal continue to resist attending school into
adolescence and remain impaired for many years.
TREATMENT
The treatment of child and adolescent separation anxiety disorder, generalized anxiety
disorder, and social anxiety disorder are often considered together, given the frequent
comorbidity and overlapping symptomatology of these disorders. A multimodal
comprehensive treatment approach usually includes psychotherapy, most often CBT,
family education, family psychosocial intervention, and pharmacological interventions,
such as SSRIs. The best evidence-based treatments for childhood anxiety disorders
include CBT and SSRIs. The comparative efficacy of CBT, SSRI medication, and their
combination (CBT + SSRI) in the treatment of childhood anxiety disorders was
investigated in the National Institute of Mental Health (NIMH)–funded Child/Adolescent
Anxiety Multimodal Study (CAMS). This double-blind, placebo-controlled, multi-site
study included 488 children and adolescents with separation anxiety disorder,
generalized anxiety disorder, or social anxiety disorder, who were randomly assigned to
be treated with either CBT alone, SSRI medication (sertraline) alone, both CBT and
sertraline, or placebo. After an acute treatment phase of 12 weeks, those in the
combined CBT + sertraline group had an 80.7 percent response rate of much or very
much improved on the clinical global improvement (CGI) rating. Response rates for the
CBT–only and sertraline-only groups were 59.7 percent and 54.9 percent, respectively.
Placebo response was 23.7 percent. Over time, during open follow-up, the combination
of CBT plus sertraline continued to provide the most efficacy. All three treatments—
CBT, sertraline, and their combination—were superior to placebo, and thus effective
treatments in childhood anxiety, but combined treatment was most likely to help
children and adolescents with anxiety disorders. A trial of CBT may be applied first, if
available, when a child is able to function sufficiently to engage in daily activities while
obtaining this treatment. For a child with severe impairment, however, a combination
of treatments is recommended. BT is widely accepted as first-line evidence-based
treatment for childhood anxiety disorders. A meta-analysis reviewed 16 randomized
controlled trials of CBT for childhood anxiety disorders and found CBT to be consistently
superior to a wait-list control group or a psychological placebo group. Exposure-based
CBT has received the most empiric support among psychotherapeutic interventions for
anxiety disorders in youth and has been shown to be superior to wait-list control groups
in reducing impairment and symptoms of anxiety.
Several psychosocial interventions have been designed specifically for anxiety
disorders in young children. A randomized clinical trial of CBT for 4- to 7-year-old
children was administered via a manualized intervention called “Being Brave: A
Program for Coping with Anxiety for Young Children and their Parents.” This manual
was loosely modeled after the manualized Coping Cat program. The intervention
utilized a combination of parent-only sessions and child-and-parent sessions. Response
rate, measured as much or very much improved on the Clinical Global Improvement
Scale for Anxiety, was 69 percent among completers versus 32 percent of the wait-list
controls. The treated children showed significantly better CGI improvement on social
anxiety disorder, separation anxiety disorder, and specific phobia, but not on
generalized anxiety disorder. This treatment, a developmentally modified parent–child
CBT, shows promise in young children.
Coaching Approach behavior and Leading by Modeling (the CALM program) is an
intervention aimed at treating anxiety disorders in children younger than 7 years of
age, who are too young to effectively engage in traditional CBT. The CALM program
draws on previous work with children aged 2 to 7 years through interventions that
target a child’s undesired behavior by modifying parents’ behavior, called Parent-Child
Interaction Therapy (PCIT). The CALM program is a 12-session manual-based
intervention that provides live, individualized coaching via a bug-in-the-ear receiver
worn by the parent during sessions. It incorporates exposure tasks and promotes
“brave” behavior with parent coaching. A pilot study using the CALM program with
nine patients with a mean age of 5.4 years found that all treatment completers (seven
patients and families) were rated as global responders, and all but one showed
functional improvement. Adapting the PCIT model for anxiety disorders in young
children appears to be a promising approach to treating anxiety in early childhood.
A meta-analysis of randomized controlled trials of antidepressant agents for childhood
anxiety provides evidence that multiple SSRIs, including fluvoxamine (Luvox),
fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are efficacious in the
treatment of childhood anxiety. Based on this evidence, SSRIs are the first choice of
medication in the treatment of anxiety disorders in children and adolescents.
A large, multisite investigation by the National Institute of Mental Health (Research
Units in Pediatric Psychopharmacology [RUPP]) confirmed the safety and efficacy of
fluvoxamine in the treatment of childhood separation anxiety disorder, generalized
anxiety disorder, and social phobia. This double-blind, placebo controlled study of 128
children and adolescents revealed that 76 percent of children in the group treated with
fluvoxamine showed significant improvement compared with 29 percent of those in the
placebo group. Response to medication was noticeable after only two weeks of
treatment. Fluvoxamine dosages ranged from 50 mg to 250 mg per day in children and
up to 300 mg per day in adolescents. Children and adolescents with less comorbid
depressive symptoms had the best response. Children and adolescents who responded to
this medication were continued on fluvoxamine for a period of 6 months, and almost all
of them continued to be responders at the 6-month mark.
Several other randomized clinical trials have also supported the efficacy of SSRIs in
the treatment of child and adolescent anxiety disorders. A randomized, controlled trial
found fluoxetine, at a dose of 20 mg per day, to be safe and effective for children with
these disorders, with minor side effects including gastrointestinal distress, headache, and
drowsiness. In addition, a randomized clinical trial for the treatment of generalized
anxiety disorder in children lends support for the efficacy of sertraline (Zoloft). Finally,
a large industry randomized clinical trial of paroxetine (Paxil) in the treatment of
children with social phobia found that paroxetine was associated with response in 78
percent of children treated. Paroxetine was utilized at a dosage range of 10 to 50 mg
per day.
The Food and Drug Administration (FDA) has placed a “black box” warning on
antidepressants, including all of the SSRI agents, used in the treatment of any childhood
disorder, because of concerns about increased suicidality; however, no individual
childhood anxiety study has found a statistically significant increase in suicidal thoughts
or behaviors.
Tricyclic drugs are not currently recommended due to their potentially serious cardiac
adverse effects. β-Adrenergic receptor antagonists, such as propranolol (Inderal), and
buspirone (BuSpar) have been used clinically in children with anxiety disorders, but
currently no data support their efficacy. Diphenhydramine (Benadryl) may be used in
the short term to control sleep disturbances in children with anxiety disorders. Open
trials and one double-blind, placebo-controlled study suggested that alprazolam
(Xanax), a benzodiazepine, may help to control anxiety symptoms in separation anxiety
disorder. Clonazepam (Klonopin) has been studied in open trials and may be useful in
controlling symptoms of panic and other anxiety symptoms.
Although SSRIs and CBT alone and in combination have demonstrated efficacy in the
treatment of anxiety disorders in youth, approximately 20 to 35 percent of children and
adolescents with anxiety disorders do not appear to benefit. Several novel agents have
been suggested as potential treatments, some based on their effect on the N-methyl-daspartate (NMDA) system. For example, d-cycloserine (DCS), currently FDA approved in
the treatment of pediatric tuberculosis, is a partial receptor agonist of the NMDA system
and is hypothesized to augment the benefits of exposure treatment for phobias. Some
evidence suggests that DCS may increase the speed of exposure interventions; however,
long-term gains have not been proven. Riluzole is an antiglutamatergic agent that
decreases glutamatergic transmission by inhibiting glutamate release and inactivation of
sodium channels in cortical neurons, and blocking γ-aminobutyric acid (GABA)
reuptake. Due to its antiglutamatergic effects, Riluzole has been postulated to provide
augmentation in the treatment of obsessive-compulsive disorder and generalized anxiety
disorder. Another agent, memantine, an NMDA receptor antagonist, with FDA approval
in the treatment of Alzheimer’s disease, has been hypothesized to decrease anxiety due
to its influence on the glutamatergic system. Published case reports have provided mixed
results.
Although most childhood anxiety disorders wax and wane over time, school refusal
associated with separation anxiety disorder can be viewed as a psychiatric emergency. A
comprehensive treatment plan involves the child, the parents, and the child’s peers and
school. Family interventions are critical in the management of separation anxiety
disorder, especially in children who refuse to attend school, so that firm encouragement
of school attendance is maintained while appropriate support is also provided. When a
return to a full school day is overwhelming, a program should be arranged so the child
can progressively increase the time spent at school. Graded contact with an object of
anxiety is a form of behavior modification that can be applied to any type of separation
anxiety. Some severe cases of school refusal require hospitalization. Cognitivebehavioral modalities include exposure to feared separations and cognitive strategies,
such as coping self-statements aimed at increasing a sense of autonomy and mastery.
In summary, evidence-based treatments for anxiety disorders have focused SSRIs and
CBT. SSRIs have been shown to be both safe and efficacious in the treatment of
childhood anxiety disorders; however, in severe disorders, the evidence suggests that
optimal treatment is to provide both CBT and SSRI antidepressant agents
simultaneously.
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the CALM Program for anxiety disorders in early childhood. J Anxiety Disord. 2012;26:40–49.
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Ginsburg GS, Kendall PC, Sakolsky D, Compton SN, Piacentini J, Albano AM, Walkup JT, Sherrill J, Coffey KA, Rynn MA,
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36 - 31.13b Selective Mutism
31.13b Selective Mutism
Hanna GL, Fischer DJ, Fluent TE. Separation anxiety disorder and school refusal in children and adolescents. Pediatr Rev.
2006;27:56–63.
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TH, Rosenbaum JF, Biederman J. Cognitive behavioral therapy for 4- to 7-year-old children with anxiety disorders: A
randomized clinical trial. J Consult Clin Psychol. 2010;78:498–510.
Otani K, Suzuki A, Matsumoto Y, Kamata. Parental overprotection increases interpersonal sensitivity in healthy subjects.
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Reinblatt SP, Walkup JT. Psychopharmacologic treatment of pediatric anxiety disorders. Child Adolesc Psychiatric Clin N
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Rockhill C, Kodish I, DiBassisto C, Macias M, Varley C, Ryan S. Anxiety disorders in children and adolescents. Curr Prob
Pediatr Adolesc Health Care. 2010;0:66–99.
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disorders. Depress Anxiety. 2011;28:76–87.
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Walkup JT, Albano AM, Piacentini J. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N
Engl J Med. 2008;359:2753–2766.
31.13b Selective Mutism
Selective mutism, believed to be related to social anxiety disorder, although an
independent disorder, is characterized in a child by persistent lack of speaking in one or
more specific social situations, most typically, the school setting. A child with selective
mutism may remain completely silent or near silent, in some cases only whispering in a
school setting. Although selective mutism often begins before age 5 years, it may not be
apparent until the child is expected to speak or read aloud in school. Current
conceptualization of selective mutism highlights a convergence of underlying social
anxiety, along with an increased likelihood of speech and language problems leading to
the failure to speak in certain situations. Typically, children with the disorder are silent
during stressful situations, whereas some may verbalize almost inaudibly single-syllable
words. Despite an increased risk for delayed speech and language acquisition in children
with selective mutism, children with this disorder are fully capable of speaking
competently when not in a socially anxiety-producing situation. Some children with the
disorder will communicate with eye contact or nonverbal gestures but not verbally when
at school. Otherwise, children with selective mutism speak fluently at home and in many
familiar settings. Selective mutism is believed to be related to social anxiety disorder
because of its expression primarily in selective social situations.
EPIDEMIOLOGY
The prevalence of selective mutism varies with age, with younger children at increased
risk for the disorder. According to the DSM-5, the point prevalence of selective mutism
using clinic or school samples has been found to range between 0.03 percent and 1
percent, depending on whether a clinical or community sample is studied. A large
epidemiologic survey in the United Kingdom reported a prevalence rate of selective
mutism to be 0.69 percent in children 4 to 5 years of age, which dropped to 0.8 percent
near the end of the same academic year. Another survey in the United Kingdom
identified 0.06 percent of 7-year-olds as having selective mutism. Young children are
more vulnerable to the disorder than older ones. Selective mutism appears to be more
common in girls than in boys. Clinical reports suggest that many young children
spontaneously “outgrow” this disorder as they get older; the longitudinal course of the
disorder remains to be studied.
ETIOLOGY
Genetic Contribution
Selective mutism may have many of the same etiologic factors leading to the emergence
of social anxiety disorder. In contrast to other childhood anxiety disorders, however,
children with selective mutism are at greater risk for delayed onset of speech or speech
abnormalities that may be contributory. However, in addition to the speech and
language factor, one survey found that 90 percent of children with selective mutism met
diagnostic criteria for social phobia. These children showed high levels of social anxiety
without notable psychopathology in other areas, according to parent and teacher
ratings. Thus, selective mutism may not represent a distinct disorder, but may be better
conceptualized as a subtype of social phobia. Maternal anxiety, depression, and
heightened dependence needs are often noted in families of children with selective
mutism, similar to families with children who exhibit other anxiety disorders.
Parental Interactions
Maternal overprotection and anxiety disorders in parents may exacerbate interactions
that unwittingly reinforce selective mutism behaviors. Children with selective mutism
usually speak freely at home, and only exhibit symptoms when under social pressure
either in school or other social situations. Some children seem predisposed to selective
mutism after early emotional or physical trauma; thus, some clinicians refer to the
phenomenon as traumatic mutism rather than selective mutism.
Speech and Language Factors
Selective mutism is conceptualized as an anxiety-based refusal to speak; however, a
higher than expected proportion of children with the disorder have a history of speech
delay. An interesting finding suggests that children with selective mutism are at higher
risk for a disturbance in auditory processing, which may interfere with efficient
processing of incoming sounds. For the most part, however, speech and language
problems in children with selective mutism are subtle and cannot account for the
diagnosis of selective mutism.
DIAGNOSIS AND CLINICAL FEATURES
The diagnosis of selective mutism is not difficult to make after it is clear that a child has
adequate language skills in some environments but not in others. The mutism may have
developed gradually or suddenly after a disturbing experience. The age of onset can
range from 4 to 8 years. Mute periods are most commonly manifested in school or
outside the home; in rare cases, a child is mute at home but not in school. Children who
exhibit selective mutism may also have symptoms of separation anxiety disorder, school
refusal, and delayed language acquisition. Because social anxiety is almost always
present in children with selective mutism, behavioral disturbances, such as temper
tantrums and oppositional behaviors, may also occur in the home. Compared to children
with other anxiety disorders, except social anxiety disorder, children with selective
mutism tend to have less social competence and more social anxiety.
Janine is a 6-year-old Chinese-American first-grade girl who lives with her
biological mother, father, and siblings. Janine’s parents reported a 2-year history of
not speaking at school, beginning in kindergarten, or to any children or adults outside
of her family, despite speaking normally at home. At home, she reportedly is
animated and quite talkative with her immediate family and a few young cousins as
well. Although she speaks to adult relatives outside of her immediate family, her
communication is often limited to one-word responses to their questions. By her
parents’ report, Janine also exhibits extreme social anxiety, to the point of “freezing”
in certain situations when attention is focused on her. At the time of her evaluation,
Janine had not received prior treatment. Janine speaks fluent English, as well as
Mandarin, and, according to her parents, met all developmental milestones on time
and appears to have above-average intelligence. They also reported that Janine
enjoys dancing, singing, and imaginative play with her sisters.
During initial evaluation, Janine failed to make eye contact or respond verbally to
the intake clinician. Janine’s parents reported that this behavior is typical of her
when in a new situation but that she communicates nonverbally and makes eye
contact with most people once she “gets to know them.” On request, Janine’s parents
provided a videotaped recording of Janine playing at home with her sisters. In the
video, Janine was animated and was speaking spontaneously and fluently without
obvious impairment. Janine received diagnoses of selective mutism and social anxiety
disorder. CBT was recommended at this time.
CBT was initiated and the therapist instructed Janine and her mother to come up
with lists of easy, medium, and most difficult “speaking” situations and lists of small,
medium, and large rewards. These lists then became the basis for assignments for
exposures and reinforcement for speaking tasks that gradually increased in difficulty.
BT sessions included time with Janine and her mother together to review past and
future assignments and time with Janine and the therapist alone.
When treatment began, Janine did not communicate at all verbally or nonverbally
with the therapist. The therapist gradually developed a rapport with Janine utilizing
less stressful tasks such as whispering to her mother with the therapist in the corner,
then nodding yes or no, pointing, whispering to a stuffed animal, whispering to her
mother while facing the therapist, and eventually responding to the therapist directly.
The therapist used animal puppets to enable Janine to “warm up” without talking
directly to the therapist. After three sessions, Janine began to speak to the therapist in
a quiet whisper. Janine received stickers for completing each speaking assignment,
and, after filling up the sticker charts, she received rewards (a small toy or treat from
reward list).
Janine was also given assignments that involved her teacher and classmates. These
were implemented in gradual fashion and included waving to the teacher, playing an
audiotape of her saying “hello” to the teacher, whispering “hello” to the teacher,
speaking “hello” to the teacher in a regular voice, and so on. After approximately 14
sessions, Janine succeeded in speaking a complete sentence in front of the class when
called on and spoke to her teacher in front of several other students.
During the last few sessions, Janine’s mother took an increasingly active role in
assigning and following up on speaking assignments. When Janine entered the 2nd
grade it took only a few days for her to speak to her teacher and to most peers in
class. After completion of therapy, Janine’s mother continued to monitor Janine’s
speaking behaviors and to promote speaking in new situations by encouraging (and
rewarding) Janine’s gradual successes with novel people and situations. (Adapted
from case material from. Lindsey Bergman, Ph.D. and John Piacentini, Ph.D.)
Pathology and Laboratory Examination
No specific laboratory measures are useful in the diagnosis or treatment of selective
mutism.
DIFFERENTIAL DIAGNOSIS
Differential diagnosis of children who are silent in social situations emphasizes ruling
out communications disorder, autism spectrum disorder, and social anxiety disorder,
which may be diagnosed comorbidly. Once it is confirmed that the child is fully capable
of speaking in certain situations, which are comfortable, but not in school and other
social situations, an anxiety-related disorder comes to mind. Shy children may exhibit a
transient muteness in new, anxiety-provoking situations. These children often have
histories of not speaking in the presence of strangers and of clinging to their mothers.
Most children who are mute on entering school improve spontaneously and may be
described as having transient adaptation shyness. Selective mutism must also be
distinguished from mental retardation, pervasive developmental disorders, and
expressive language disorder. In these disorders, the symptoms are widespread, and no
one situation exists in which the child communicates normally; the child may have an
inability, rather than a refusal, to speak. In mutism secondary to conversion disorder,
the mutism is pervasive. Children introduced into an environment in which a different
language is spoken may be reticent to begin using the new language. Selective mutism
should be diagnosed only when children also refuse to converse in their native language
and when they have gained communicative competence in the new language but refuse
to speak it.
COURSE AND PROGNOSIS
Children with selective mutism are often excessively shy during preschool years, but the
onset of the full disorder is usually not evident until age 5 or 6 years. Many very young
children with early symptoms of selective mutism in a transitional period when entering
preschool have a spontaneous improvement over a number of months and never fulfill
criteria for the disorder. A common pattern for a child with selective mutism is to speak
almost exclusively at home with the nuclear family but not elsewhere, especially not at
school. Consequently, a child with selective mutism may have academic difficulties, or
even failure due to a lack of participation. Children with selective mutism are typically
shy, anxious, and at increased risk for a depressive disorder. Many children with early
onset selective mutism remit with or without treatment. Recent data suggest that
fluoxetine (Prozac) may influence the course of selective mutism, and treatment
enhances recovery. Children in whom the disorder persists often have difficulty forming
social relationships. Teasing and scapegoating by peers may cause them to refuse to go
to school. Some children with any form of severe social anxiety are characterized by
rigidity, compulsive traits, negativism, temper tantrums, and oppositional and
aggressive behavior at home. Other children with the disorder tolerate the feared
situation by communicating with gestures, such as nodding, shaking the head, and
saying “Uh-huh” or “No.” In one follow-up study, about one half of children with
selective mutism improved within 5 to 10 years. Children who do not improve by age 10
years appear to have a long-term course and a worse prognosis. As many as one third of
children with selective mutism, with or without treatment, may develop other
psychiatric disorders, particularly other anxiety disorders and depression.
TREATMENT
A multimodal approach using psychoeducation for the family, CBT, and SSRIs as needed
is recommended. Preschool children may also benefit from a therapeutic nursery. For
school-age children, individual CBT is recommended as a first-line treatment. Family
education and cooperation are beneficial. Published data on the successful treatment of
children with selective mutism is scant, yet solid evidence indicates that children with
social anxiety disorder respond to various SSRIs and, currently, CBT treatments are
under investigation in a multisite, randomized placebo-controlled trial of children with

37 - 31.14 Obsessive Compulsive Disorder in Childh
31.14 Obsessive-Compulsive Disorder in Childhood and Adolescence
anxiety disorders.
A recent report of 21 children with selective mutism treated in an open trial with
fluoxetine suggested that this medication may be effective for childhood selective
mutism. Reports have confirmed the efficacy of fluoxetine in the treatment of adult
social phobia and in at least one double-blind, placebo-controlled study using fluoxetine
with children with mutism. A large NIMH-funded study of anxiety disorders in children
and adolescents called Research Units in Pediatric Psychopharmacology (RUPP), has
shown distinct superiority of fluvoxamine over placebo in the treatment of a variety of
childhood anxiety disorders. Children with selective mutism may benefit similarly to
those with social phobia given the current belief that it is a subgroup of social phobia.
SSRI medications that have been shown in randomized, placebo-controlled trials to have
benefit in the treatment of children with social phobia include fluoxetine (20 mg to 60
mg per day), fluvoxamine (Luvox; 50 mg to 300 mg per day), sertraline (Zoloft; 25 mg
to 200 mg per day), and paroxetine (Paxil; 10 mg to 50 mg per day).
REFERENCES
Bergman RL, Lee JC. Selective mutism. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook
of Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:3694.
Carbone D, Schmidt LA, Cunningham CC, McHolm AE, Edison S, St. Pierre J, Boyle JH. Behavioral and socio-emotional
functioning in children with selective mutism: A comparison with anxious and typically developing children across
multiple informants. J Abnorm Child Psychol. 2010;38:1057–1067.
Davis TE III, May A, Whiting SE. Evidence-based treatment of anxiety and phobia in children and adolescents: Current
status and effects on the emotional response. Clin Psychol Rev. 2011;31:592–602.
Kehle TJ, Bray MA, Theodore LA. Selective mutism. In: Bear GG, Minke KM, eds. Children’s Needs III: Development,
Prevention, and Intervention. Washington DC: National Association of School Psychologists; 2006:293.
Rynn M, Puliafico A, Heleniak C, Rikhi P, Ghalib K, Vidair H. Advances in pharmacotherapy for pediatric anxiety
disorder. Depress Anxiety. 2011;28:76–87.
Schwartz RH, Freedy AS, Sheridan MJ. Selective mutism: Are primary care physicians missing the silence? Clin Pediatr
(Phila). 2006;45:43–48.
Scott S, Beidel DC. Selective mutism: An update and suggestions for future research. Curr Psychiatry Rep. 2011;13:251–257.
Toppelberg CO, Tabors P, Coggins A, Lum K, Burger C. Differential diagnosis of selective mutism in bilingual children. J
Am Acad Child Adolesc Psychiatry. 2005;44(6):592–595.
Wagner KD, Berard R, Stein MB, Wetherhold E, Carpenter DJ, Perera P, Gee M, Davy K, Machin A. A multicenter,
randomized, double-blind, placebo controlled trial of paroxetine in children and adolescents with social anxiety disorder.
Arch Gen Psychiatry. 2004;61:1153.
Waslick B. Psychopharmacology intervention for pediatric anxiety disorders: A research update. Child Adolesc Psychiatr
Clin N Am. 2006;1:51.
Yeganeh R, Beidel DC, Turner SM. Selective mutism: More than social anxiety? Depress Anxiety. 2006;23(3):117.
31.14 Obsessive-Compulsive Disorder in Childhood and
Adolescence
Childhood obsessive-compulsive disorder (OCD) is characterized by recurrent intrusive
thoughts associated with anxiety or fear and/or repetitive purposeful mental or
behavioral actions aimed at reducing fears and tensions caused by obsessions. Data
suggest that up to 25 percent of cases of OCD have their onset by 14 years of age. The
overall clinical presentation of OCD in youth is similar to that in adults; however,
compared to adults, children and adolescents with OCD more often do not consider their
obsessional thoughts or repetitive behaviors to be unreasonable. In milder cases of OCD,
a trial of cognitive-behavioral therapy (CBT) is recommended as an initial intervention.
OCD in youth is often treated successfully with selective serotonin reuptake inhibitors
(SSRIs) or CBT alone, or in combination. The results of a large-scale, randomized,
placebo-controlled study called the Pediatric OCD Treatment Study (POTS),
demonstrated that the greatest rates of remission in pediatric OCD are achieved with a
combination of both serotonergic agents and CBT treatment.
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) removed OCD from its former category of Anxiety
Disorders and placed it in a new category called Obsessive-Compulsive and Related
Disorders, with related disorders such as trichotillomania (hair pulling disorder),
hoarding disorder, body dysmorphic disorder, and excoriation (skin picking) disorder.
Nevertheless the relationship between OCD and other anxiety disorders remains
significant and supported by research.
EPIDEMIOLOGY
OCD is common among children and adolescents, with a point prevalence of about 0.5
percent and a lifetime prevalence of 2 to 4 percent. The rate of OCD among youth rises
exponentially with increasing age, with rates of 0.3 percent in children between the
ages of 5 and 7 years, rising to rates between 0.6 percent and 1 percent among teens.
According to the DSM-5, the prevalence of OCD in the United States is 1.2 percent, with
a slightly higher rate in females. Rates of OCD among adolescents are greater than those
for schizophrenia or bipolar disorder. Among young children with OCD there appears to
be a slight male predominance, which diminishes with age.
ETIOLOGY
Genetic Factors
Genetic factors have been estimated to contribute significantly to the development of
OCD in early onset illness. The rate of OCD among first-degree relatives of children and
adolescents who develop OCD is ten times greater than for the general population. Twin
studies have shown that the concordance rates for OCD is higher for monozygotic twins
(0.57) than for dizygotic twins (0.22); however, nongenetic factors play a role that may
be equal to or greater than genetic contributions in some cases. OCD is a heterogeneous
disorder that has been recognized for decades to run in families. In addition, the
presence of subclinical symptom constellations in family members appears to breed
true. Genetic linkage studies have revealed evidence of susceptibility loci on
chromosomes 1q, 3q, 6q, 7p, 9p, 10p, and 15q. The OCD collaborative genetics study
found that the Sapap3 gene was associated with grooming disorders and may be a
promising candidate gene for OCD. There is evidence that the glutamate receptor–
modulating genes may also be associated with and play a role in the emergence of OCD.
Family studies have suggested a relationship between OCD and tic disorders such as
Tourette’s syndrome. OCD and tic disorders are believed to share susceptibility factors,
which may include both genetic and nongenetic factors.
Neuroimmunology
Immunological contributions to the emergence of OCD have been hypothesized to be
related to an inflammatory process in the basal ganglia associated with an immune
response to a systemic infection that may trigger OCD and tics. A prototype of this
hypothesis has been the controversial association of OCD symptoms in a small subgroup
of children and adolescents following documented exposure to or infection with group A
β-hemolytic streptococcus (GABHS). Under this hypothesis, cases of infection-triggered
OCD have been termed Pediatric Autoimmune Neuropsychiatric Disorders Associated
with Streptococcus (PANDAS), and are believed to parallel an autoimmune process
leading to a movement disorder much like Sydenham’s chorea following rheumatic
fever. Some evidence from magnetic resonance imaging (MRI) studies has documented a
proportional relationship between the size of the basal ganglia and the severity of OCD
symptoms in a small sample. GABHS may be one of many physiological stressors that
can lead to an increase or emergence of OCD or tics; however, a prospective
longitudinal study of youth with PANDAS followed over a 2-year period found no
evidence of a temporal association between GABHS infections and OCD symptom
exacerbations in children who met the criteria for PANDAS. The presentation of OCD in
children and adolescents due to acute exposure to GABHS represents a minority of OCD
cases in youth and remains controversial.
Neurochemistry
The evidence that SSRIs diminish symptoms of OCD, along with findings of altered
sensitivity to the acute administration of 5-hydroxytryptamine (5-HT) agonists in
individuals with OCD, supports the probability of serotonin’s role in OCD. In addition,
the dopamine system is believed to be influential in OCD, especially in light of the
frequent comorbidity of OCD with tic disorders in childhood. Clinical observations have
indicated that obsessions and compulsions may be exacerbated during treatment of
ADHD (another frequent OCD comorbidity) with stimulant agents. Dopamine
antagonists administered along with SSRIs may augment effectiveness of SSRIs in the
treatment of OCD. Evidence suggests that multiple neurotransmitter systems may play a
role in OCD.
Neuroimaging
Both computed tomography (CT) and MRI of untreated children and adults with OCD
have revealed smaller volumes of basal ganglia segments compared to normal controls.
A meta-analysis of voxel-based morphometry (VBM) to assess gray matter density
compared 343 OCD patients with 318 healthy controls, and found that gray matter
density in OCD patients was smaller in parietofrontal cortical regions (including the
supramarginal gyrus, the dorsolateral prefrontal cortex, and the orbitofrontal cortex),
but larger in the basal ganglia (the putamen) and anterior prefrontal cortex compared
to healthy controls. Increased gray matter volume in the basal ganglia of patients with
OCD has been reported in other studies as well. These structural abnormalities in the
prefrontal-basal ganglia are likely to be integrally involved in the pathophysiology of
OCD. It is not clear whether the increases in gray matter in individuals with OCD occur
before or after the symptoms emerge. In children, evidence suggests that thalamic
volume is increased. Adult studies have provided evidence of hypermetabolism of frontal
cortical-striatal-thalamocortical networks in untreated individuals with OCD. Of interest,
imaging studies of before and after treatment have revealed that both medication and
behavioral interventions lead to a reduction of orbit frontal and caudate metabolic rates
in children and adults with OCD.
DIAGNOSIS AND CLINICAL FEATURES
Children and adolescents with obsessions or compulsions are often referred for
treatment due to the excessive time that they devote to their intrusive thoughts and
repetitive rituals. For some children, their compulsive rituals are perceived as
reasonable responses to their extreme fears and anxieties. Nevertheless, they are aware
of their discomfort and inability to carry out usual daily activities in a timely manner
due to the compulsions, such as getting ready to leave their homes to go to school each
morning.
The most commonly reported obsessions in children and adolescents include extreme
fears of contamination—exposure to dirt, germs, or disease—followed by worries related
to harm befalling themselves, family members, or fear of harming others due to losing
control over aggressive impulses. Also commonly reported are obsessional needs for
symmetry or exactness, hoarding, and excessive religious or moral concerns. Typical
compulsive rituals among children and adolescents involve cleaning, checking,
counting, repeating behaviors, or arranging items. Associated features in children and
adolescents with OCD include avoidance, indecision, doubt, and a slowness to complete
tasks. In most cases of OCD among youth, obsessions and compulsions are present.
According to the DSM-5, diagnosis of OCD is identical to that of adults, with the note
that young children may not be able to articulate the aims of their compulsions in
diminishing their anxiety. The DSM-5 has also added the following specifiers: with good,
fair, poor, or absent insight; that is, the greater the belief in the OCD obsessions and
compulsions, the poorer the insight. An additional specifier indicates whether the
individual has a current or past history of a tic disorder. Table 10.1-1 designates the
DSM-5 diagnostic criteria for OCD.
Many children and adolescents who develop OCD have an insidious onset and may
hide their symptoms as long as possible so that their rituals will not be challenged or
disrupted. A minority of children, particularly males with early onset may have a rapid
unfolding of multiple symptoms within a few months. OCD is commonly found to be
comorbid with anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and
tic disorders, especially Tourette’s syndrome. Children with comorbid OCD and tic
disorders are more likely to exhibit counting, arranging, or ordering compulsions and
less likely to manifest excessive washing and cleaning compulsions. The high
comorbidity of OCD, Tourette’s syndrome, and ADHD has led investigators to postulate
a common genetic vulnerability to all three of these disorders. It is important to search
for comorbidity in children and adolescents with OCD so that optimal treatments can be
administered.
Jason, a 12-year-old boy in the sixth grade, was brought for evaluation by his
parents, who expressed concerns over his repeated questions and anxiety regarding
developing acquired immunodeficiency syndrome (AIDS). Jason was a highfunctioning and well-adjusted boy who abruptly began to exhibit extremely disruptive
behaviors related to his fears of AIDS approximately 2 to 3 months before the
evaluation. Jason’s new behaviors included relentless concerns about contracting
illness, washing rituals, repeated expressions of uncertainty over his own behavior,
seeking reassurance, repeating rituals, and avoidance.
Specifically, Jason repeatedly expressed his fear and belief that he was exposed to
human immunodeficiency virus (HIV) through exposure to multiple strangers who
were infected. For example, while riding in the car, if Jason saw a stranger from the
window who appeared to him to be poor or ill kempt, he experienced a surge of
extreme anxiety and obsessively agonized about whether the stranger could have AIDS
and had exposed him to it. Despite his parents’ reassurances about his safety and lack
of exposure to illness, Jason insisted on vigorously washing himself for approximately
one hour each time he reached home after being out. Jason continually expressed
doubts about his own behavior. He often asked his parents, “Did I use the s___ word?
Did I use the f___ word?” Reassurance was only slightly calming. Jason, previously an
excellent student, began to lose the ability to focus on schoolwork. While reading
passages from assigned materials, Jason frequently experienced severe anxiety,
wondering if he had missed a word or misunderstood the sentence, and proceeded to
reread the material. Completing a page of written material began to take Jason 30 to
60 minutes. Over several weeks, he was less and less able to complete assignments,
following which, he became very distressed over his deteriorating grades.
During Jason’s evaluation, his family history suggested that Jason’s older sister had
experienced a period in which she too had similar but milder anxieties, with less
interference in functioning, and she had never received any treatment for those
symptoms.
At the intake interview, Jason presented as a preoccupied and sad boy who was
cooperative with questioning. He did not volunteer much information, and he allowed
his parents to recount the extent of his symptoms. Jason believed that his relentless
concerns were well founded, and that he required repeated reassurance from his
parents in order to continue his daily activities. Jason met full diagnostic criteria for
OCD. Symptoms of depression were present but not sufficient for major depressive
disorder.
CBT was initiated; however, Jason was so fearful of deviating from his rituals that
he was unable to participate fully in his treatment, and he became despondent about
his future. Jason refused to go to school due to his increasing distress associated with
reading and his shame regarding his diminishing academic performance. Given his
limited progress during the first 2 months of CBT, fluoxetine (Prozac) was added and
increased up to 40 mg per day. Over a 3-week period some improvement was noted,
and Jason was more amenable to cooperating with his CBT treatment. CBT and SSRI
treatment was continued over the next 3 months on a regular basis. Over time, Jason
finally began to show some flexibility with his rituals, and he was able to decrease the
amount of time he spent with rituals. Once he had found some relief from his
symptoms, Jason was able to focus more on his schoolwork and his family life.
Follow-up over the next year was positive; Jason had maintained his gains from
treatment, with only minimal interference from residual OCD symptoms. Jason’s
academic achievement improved, he was able to engage in activities with friends, and
he spent almost no time preoccupied with obsessional thoughts of illness and
cleansing rituals. (Adapted from a case courtesy of James T. McCracken, M.D.)
Pathology and Laboratory Examination
No specific laboratory measures are useful in the diagnosis of obsessive-compulsive
disorder.
Even when the onset of obsessions or compulsions appears to be associated with a
recent infection with GABHS, antigens and antibodies to the bacteria do not indicate a
causal relationship between GABHS and OCD.
DIFFERENTIAL DIAGNOSIS
Developmentally appropriate rituals in the play and behavior of young children should
not be confused with OCD in that age group. Preschoolers often engage in ritualistic
play and request a predictable routine such as bathing, reading stories, or selecting the
same stuffed animal at bedtime, to promote a sense of security and comfort. These
routines allay developmentally normal fears and lead to reasonable completion of daily
activities. On the other hand, obsessions or compulsions are driven by extreme fears,
and they significantly interfere with daily function because of the excessive time that
they consume and the extreme distress that ensues when they are interrupted. The
rituals of preschoolers generally become less rigid by the time they enter grade school,
and school-age children do not typically experience a surge of anxiety when they
encounter small changes in their routine.
Children and adolescents with generalized anxiety disorder, separation anxiety
disorder, and social phobia experience intense worries that are often expressed
repeatedly; however, these are mundane compared to obsessions, which are often so
extreme that they appear bizarre. A child with generalized anxiety disorder typically
worries repeatedly about performance on academic examinations, whereas a child with
OCD may experience repeated intrusive thoughts that he may harm someone he loves.
The compulsions of OCD are not present in other anxiety disorders; however, children
with autism spectrum disorders often display repetitive behaviors that may resemble
OCD. In contrast with the rituals of OCD, children with autism spectrum disorder are not
responding to anxiety, but are more often exhibiting stereotyped behaviors that are selfstimulating or self-comforting.
Children and adolescents with tic disorders such as Tourette’s syndrome may display
complex repetitive compulsive behaviors similar to the compulsions seen in OCD.
Children and adolescents with tic disorders, in fact, are at higher risk for the
development of concurrent OCD.
Severe OCD symptoms may be difficult to distinguish from delusional symptoms,
especially when the obsessions and compulsions are bizarre in nature. In most adults,
and often in youth with OCD, despite an inability to control their obsessions or resist
completing compulsions, insight into their lack of reasonableness is preserved. That is,
an individual’s conviction in their beliefs often does not reach delusional intensity.
When insight is present, and underlying anxiety can be described, even in the face of
significant dysfunction due to bizarre obsessions and compulsion, the diagnosis of OCD
is suspect.
COURSE AND PROGNOSIS
OCD with an onset in childhood and adolescence is most often a chronic, waxing and
waning disorder with variability in severity and outcome. Follow-up studies suggest that
up to 40 to 50 percent of children and adolescents recover from OCD with minimal
residual symptoms. A study of childhood OCD treatment with sertraline resulted in close
to 50 percent of participants experiencing complete remission, and partial remission in
another 25 percent with a follow-up time of one year. Predictors of the best outcome
were in those children and adolescents without comorbid disorders, including tic
disorders and ADHD. A study of 142 children and adolescents with OCD followed over a
period of 9 years at the Maudsley Hospital in England found 41 percent to have a
persistence of OCD, with 40 percent exhibiting an additional psychiatric diagnosis at
follow-up. The main predictor for persistent OCD was duration of illness at the time of
initial assessment. Approximately half of the follow-up group was still receiving
treatment, and half believed that they needed continued treatment.
Neuropsychological functioning may also play a role in outcome and prognosis. A
study of 63 youth with OCD who completed the Rey-Osterrieth Complex Figure (ROCF)
along with specific subtests of the Wechsler Intelligence Scale for Children, Third Edition
(WISC-III), found that 5-minute recall accuracy from the ROCF was positively correlated
with response to treatment, particularly CBT. These findings imply that poorer
performance on the ROCF and poor response to CFBT may be in part due to executive
functioning difficulties and that treatment may need to be modified to account for these
obstacles.
Overall, the prognosis is hopeful for most children and adolescents with mild to
moderate OCD. In about 10 percent of cases, OCD may represent a prodrome of a
psychotic disorder in children and adolescents. In youth with subthreshold OCD
symptoms, there is a high risk of developing of the full OCD disorder within a period of
2 years. Childhood OCD has been shown to be responsive to available treatments,
resulting in improvement, if not complete remission, in the majority of cases.
TREATMENT
CBT and SSRIs have both been shown to be efficacious treatments for OCD in youth.
CBT geared toward children of varying ages is based on the principle of
developmentally appropriate exposure to the feared stimuli coupled with response
prevention, leading to diminishing anxiety over time on exposure to feared situations.
CBT manuals have been developed to ensure that developmentally appropriate
interventions are made and that comprehensive education is provided to the child and
parents.
Treatment guidelines for children and adolescents with mild to moderate OCD
recommend a trial of CBT prior to initiating medication. However, the Pediatric OCD
Treatment Study (POTS), a multi-site National Institute of Health (NIH)–funded
investigation of sertraline and CBT each alone, and in combination, for the treatment of
childhood-onset OCD, revealed that the combination was superior to either treatment
alone. Each treatment alone also provided encouraging levels of response. Mean daily
dose of sertraline was 133 mg/day in the group administered the combination
treatment, and 170 mg/day for the sertraline alone group. Improvement with
pharmacologic intervention of childhood OCD usually occurs within 8 to 12 weeks of
treatment. Most children and adolescents who experienced a remission with acute
treatment using SSRIs were still responsive over a period of a year. Among youth with
OCD who obtain partial response to a therapeutic trial of SSRI treatment, augmentation
with a short-term OCD-specific CBT leads to a significantly greater response. Evidence
shows that higher treatment expectations by patients and families are linked to better
treatment response, greater compliance with home-based CBT assignments, less drop
out of treatment, and reduced impairment.
In addition to individual CBT, both family and group CBT interventions have been
shown to be efficacious in the treatment of childhood OCD. Family CBT (FCBT)
intervention in the treatment of OCD in youth has been shown to increase response
rates. A controlled comparison of family CBT and psychoeducation and relaxation (PRT)
in 71 families of children with OCD showed that clinical remission rates in the FCBT
group were significantly higher than those in the PRT group. The FCBT treatment
reduced parent involvement and accommodation in their affected child’s symptoms,
which led to decreased symptomatology.
A randomized controlled study investigating web-camera delivered FCBT (W-CBT)
compared to a waitlist condition assigned 31 families to one of the above conditions.
Assessments were conducted immediately before and after treatment and at 3-month
follow-up for the W-CBT group. The W-CBT group was superior to the waitlist control
group on all primary outcome measures, with large effect sizes. Eighty-one percent of
the W-CBT group responded compared to 13% of the waitlist group. The gains were
maintained at the 3-month follow-up assessment. The authors conclude that W-CBT may
be efficacious in the treatment of OCD in youth and may be a promising tool for future
dissemination.
Exposure and response prevention (ERP), a common strategy within CBT already
shown to be effective on an individual basis for OCD, was studied in a group format in
youth with OCD in a community-based program. Group-based ERP was found to be
effective in reducing OCD symptom severity and depressive symptoms, but not anxiety
symptoms, in a naturalistic treatment setting for children with OCD and comorbid
anxiety and/or depressive features.
Robust evidence of SSRI efficacy for OCD in youth has been shown through multiple
randomized clinical trials. A meta-analysis of 13 studies of SSRIs, including sertraline,
fluvoxamine, fluoxetine, and paroxetine have provided evidence of efficacy of SSRIs
with a moderate effect size. A randomized controlled clinical trial of citalopram versus
fluoxetine in youth with OCD found that citalopram was as safe and effective as
fluoxetine for the treatment of OCD in children and adolescents. There have been no
apparent differences in the rate of response for the individual SSRIs.
Currently, three SSRIs: sertraline (at least 6 years), fluoxetine (at least 7 years), and
fluvoxamine (at least 8 years), as well another as clomipramine (at least 10 years), have
received Food and Drug Administration (FDA) approval for the treatment of OCD in
youth. The black box warning for antidepressants used in children for any disorder,
including OCD is applicable, so that close monitoring for suicidal ideation or behavior is
mandated when these agents are used in the treatment of childhood OCD.
Typical side effects that emerge with the use of SSRIs include insomnia, nausea,
agitation, tremor, and fatigue. Dosage ranges for the various SSRIs found to have
efficacy in randomized clinical trials are the following: fluoxetine (20 mg to 60 mg),
sertraline (50 mg to 200 mg), fluvoxamine (up to 200 mg), and paroxetine (up to 50
mg).
Clomipramine was the first antidepressant studied in the treatment of OCD in
childhood and the only tricyclic antidepressant that has FDA approval for the treatment
of anxiety disorders in childhood. Clomipramine was found to be efficacious in doses up
to 200 mg, or 3 mg/kg, whichever is less, and may be chosen for children or adolescents
who cannot tolerate other SSRIs due to insomnia, significant appetite suppression, or
activation. Nevertheless, clomipramine is not recommended as a first-line treatment due
to its greater potential risks compared to other SSRIs, including cardiovascular risk of
hypotension and arrhythmia, and seizure risk.
Pediatric patients with OCD who respond only partially to medications tend to have
at least moderate to severe OCD symptoms, high ratings of global impairment and
significant comorbidity even after their partial response to an adequate trial of
medication. Augmentation strategies with medications to enhance serotonergic effects,
such as with atypical antipsychotics (e.g., risperidone) have demonstrated increased
response when partial response has been achieved with SSRIs. Aripiprazole
augmentation in 39 adolescents with OCD who did not respond to two trials of
monotherapy with SSRIs led to 59 percent of patients being rated as improved or very
much improved. Patients who responded to aripiprazole were less impaired at baseline
in functional impairment but not in clinical severity of their OCD. Aripiprazole final
mean dose was 12.2 mg per day. This agent may be effective for pediatric OCD and
warrants further controlled trials.
Given the lack of data on discontinuation, recommendations for maintaining
medication such as stabilization, education about relapse risk, and tapering medication
during the summer are likely in order to minimize academic compromise in case of
relapse. For children and adolescents with more severe or multiple episodes of
significant exacerbation of symptoms, treatment for more than a year is recommended.
Overall, efficacy of treatment for children and adolescents with OCD is high with choices
of SSRIs and CBT.
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31.15 Early-Onset Schizophrenia
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31.15 Early-Onset Schizophrenia
Early-onset
schizophrenia
comprises
childhood-onset
and
adolescent-onset
schizophrenia. Childhood-onset schizophrenia is a very rare and virulent form of
schizophrenia now recognized as a progressive neurodevelopmental disorder. Childhood
onset is characterized by a more chronic course, with severe social and cognitive
consequences and increased negative symptoms compared to adult-onset schizophrenia.
Childhood-onset schizophrenia is defined by an onset of psychotic symptoms before the
age of 13 years, believed to represent a subgroup of patients with schizophrenia with an
increased heritable etiology, and evidence of widespread abnormalities in the
development of brain structures including the cerebral cortex, white matter,
hippocampus and cerebellum. Children diagnosed with childhood-onset schizophrenia
have higher than normal rates of premorbid developmental abnormalities that appear
to be nonspecific markers of abnormal brain development. Early-onset schizophrenia is
defined as an onset of disease before the age of 18 years, including childhood-onset as
well as adolescent-onset schizophrenia. Early-onset schizophrenia is associated with
severe clinical course, poor psychosocial functioning, and increased severity of brain
abnormality. Despite the more severe course, current evidence supports the efficacy of
both psychosocial and pharmacological interventions in the management of childhoodonset and, particularly, adolescent-onset schizophrenia.
Children with childhood-onset schizophrenia have been shown to have more
significant deficits in measures of intelligence quotient (IQ), memory, and tests of
perceptuomotor skills compared with adolescent-onset schizophrenia. Increased
impairment in childhood-onset schizophrenia of cognitive measures such as IQ, working
memory, and perceptuomotor skills such deficits may be premorbid markers of illness,
rather than sequelae, of the disorder. Although cognitive impairments are greater in
younger patients with schizophrenia, clinical presentation of schizophrenia remains
remarkably similar across the ages, and the diagnosis of childhood-onset schizophrenia
is continuous with that in adolescents and adults, with one exception: in childhood-onset
schizophrenia a failure to achieve expected social and academic functioning may replace
a deterioration in functioning. According to the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the diagnosis of
schizophrenia includes an “active phase” of the illness, consisting of at least one of the
following three symptoms: delusions, hallucinations, or disorganized speech, and at
least one additional symptom present most of the time for a month. The additional
symptom may be another one of the preceding three, or one of the following two
symptoms: grossly disorganized or catatonic behavior, or negative symptoms (i.e.,
diminished emotional expression or avolition). In the active phase, symptoms are
present for a significant amount of time during a single month and cause impairment.
To meet full criteria for schizophrenia, continuous signs of disturbance must persist for
at least 6 months. Social, academic, or occupational impairment must be present. In
contrast to previous diagnostic criteria, the subtypes of schizophrenia (paranoid,
disorganized, catatonic, undifferentiated, and residual) have been eliminated due to
their lack of diagnostic validity and reliability. Instead, an eight-symptom “ClinicianRated Dimensions of Psychosis Symptom Severity” scale for determining severity of
psychosis across many psychotic illnesses is included in Section III of the DSM-5.
Symptom domains rated in this scale include the following: hallucinations, delusions,
disorganized speech, abnormal psychomotor behavior, negative symptoms (restricted
emotional expression or avolition), impaired cognition, depression, and mania.
HISTORICAL PERSPECTIVE
Before the 1960s, the term childhood psychosis was applied to a heterogeneous group of
children, many of whom exhibited autism spectrum disorder symptoms without
hallucinations and delusions. In the late 1960s and 1970s, reports of children with
evidence of a profound psychotic disturbance very early in life included observations of
intellectual disabilities, social deficits, and severe communication and language
impairments, and no family history of schizophrenia. Children whose psychoses emerged
after the age of 5 years, however, more often exhibited auditory hallucinations,
delusions, inappropriate affect, thought disorder, normal intellectual function, and a
positive family history of schizophrenia.
In the 1980s, schizophrenia with childhood onset was formally separated from what
was then termed autistic disorder, and currently termed autism spectrum disorder. The
distinction of childhood schizophrenia from autism spectrum disorder reflected evidence
accrued during the 1960s and 1970s showing a divergent clinical picture, family history,
age of onset, and course between the two disorders. However, even after the separation
of the disorders, controversy and confusion remained as to the distinctiveness in the
long-term courses of these disorders. First, research documented a small group of
children with autism spectrum disorder who developed schizophrenia in later childhood
or adolescence. Second, many children with childhood-onset schizophrenia exhibit
neurodevelopmental abnormalities, some of which are also evident in children with
autism spectrum disorder. Children with autism spectrum disorder and those with
childhood-onset schizophrenia are typically impaired in multiple areas of adaptive
functioning from relatively early in life. However, in autism spectrum disorder, the
onset is almost always before 3 years of age, whereas the onset of childhood-onset
schizophrenia occurs before the age of 13 years, but most often is not recognizable in
children until after the age of 3 years. Childhood-onset schizophrenia is significantly less
frequent than adolescent-onset or onset in young adulthood, and few reports document
cases of schizophrenia onset before 5 years of age. According to the DSM-5,
schizophrenia can be diagnosed in the presence of autism spectrum disorder, provided
that the diagnosis of schizophrenia is specifically differentiated from autism spectrum
disorder.
EPIDEMIOLOGY
The frequency of childhood-onset schizophrenia is reported to be less than one case in
about 40,000 children, whereas among adolescents between the ages of 13 and 18 years,
the frequency of schizophrenia is increased by a factor of at least 50. Schizophrenia with
childhood onset resembles the more severe, chronic, and treatment-refractory adultonset schizophrenic subgroups, in that the same core phenomenological features are
present; however, in childhood-onset schizophrenia, extremely high rates of
comorbidities are present, including attention-deficit/hyperactivity disorder (ADHD),
depressive disorders, anxiety disorders, speech and language disorders, and motor
disturbances. In adolescents, the prevalence of schizophrenia is estimated to be 50 times
that in younger children, with probable rates of 1 to 2 per 1,000. Boys seem to have a
slight preponderance among children diagnosed with schizophrenia, with an estimated
ratio of about 1.67 boys to 1 girl. Boys often become identified at a younger age than
girls do. Schizophrenia rarely is diagnosed in children younger than 5 years of age. The
prevalence of schizophrenia among the parents of children with schizophrenia is about 8
percent, which is about twice the prevalence in the parents of patients with adult-onset
schizophrenia.
ETIOLOGY
Childhood-onset schizophrenia is a neurodevelopmental disorder in which complex
interactions between genes and the environment are presumed to result in abnormal
early brain development. The consequences of the aberrant brain development in
schizophrenia may not be fully evident until adolescence or early adulthood; however,
data support the hypothesis that white matter abnormalities and disturbances in
myelination in childhood, lead to abnormal connectivity between brain regions. The
aberrant connectivity in various regions of the brain is believed to be an important
contributing factor in the psychotic symptoms and cognitive deficits in childhood-onset
schizophrenia.
Genetic Factors
Estimates of heritability for childhood-onset schizophrenia have been as high as 80
percent. The precise mechanisms of transmission of schizophrenia are still not well
understood. Schizophrenia is known to be up to eight times more prevalent among firstdegree relatives of those with schizophrenia than in the general population. Adoption
studies of patients with adult-onset schizophrenia have shown that schizophrenia occurs
in the biological relatives, not the adoptive relatives. Additional genetic evidence is
supported by higher concordance rates for schizophrenia in monozygotic twins than in
dizygotic twins. Higher rates of schizophrenia have been established among relatives of
those with childhood-onset schizophrenia than in the relatives of those with adult-onset
schizophrenia.
Endophenotype Markers for Childhood-Onset Schizophrenia.
Currently,
no reliable method can identify persons at the highest risk for schizophrenia in a given
family. Neurodevelopmental abnormalities and higher-than-expected rates of
neurological soft signs and impairments in sustaining attention and in strategies for
information processing appear among children at high risk. Increased rates of disturbed
communication styles are found in family members of individuals with schizophrenia.
Reports have documented higher than expected neuropsychological deficits in attention,
working memory, and premorbid IQ among children who later develop schizophrenia
and its spectrum disorders.
Magnetic Resonance Imaging (MRI) Studies
A National Institute of Mental Health (NIMH) prospective study of more than 100
patients with childhood-onset schizophrenia and their typically developing siblings has
demonstrated progressive loss of gray matter, delayed and disrupted white matter
growth, and a decline in cerebellar volume in those with childhood-onset schizophrenia.
Although siblings of children with childhood-onset schizophrenia also showed some of
these brain disruptions, the gray matter abnormalities were normalized over time in the
siblings, indicating a protective mechanism in siblings that was not present in those
children with childhood-onset schizophrenia. Furthermore, the hippocampal volume loss
across the age span appears to be static among children with childhood-onset
schizophrenia. An MRI NIMH study of more than 100 children with childhood-onset
schizophrenia and their typically developing siblings, studied for about two decades,
documented that in childhood-onset schizophrenia, progressive brain gray matter loss
occurs continuously over time. This gray matter shrinkage occurs with ventricular
increases, with a pattern of loss originating in the parietal region and proceeding
frontally to dorsolateral prefrontal and temporal cortices, including superior temporal
gyri. Studies of childhood-onset schizophrenia at the NIMH provided evidence that early
loss of parietal gray matter followed by frontal and parietal gray matter loss is more
pronounced in childhood-onset schizophrenia than in schizophrenia with later onset.
Other research utilized diffusion tensor images from children with childhood-onset
schizophrenia versus controls and found increased diffusivities in the posterior corona
radiata in children with childhood-onset schizophrenia, which implicated abnormal
connectivity with the parietal lobes. These results contrasted with findings among
subjects with later onset of schizophrenia in whom there were more abnormalities in the
frontal lobes.
DIAGNOSIS AND CLINICAL FEATURES
All of the symptoms included in adult-onset schizophrenia may be manifest in children
and adolescents with the disorder. However, youth with schizophrenia are more likely to
have a premorbid history of social rejection, poor peer relationships, clingy withdrawn
behavior, and academic trouble than those with adult-onset schizophrenia. Some
children with schizophrenia evaluated in middle childhood have early histories of
delayed motor milestones and language acquisition similar to some symptoms of autism
spectrum disorder.
The onset of schizophrenia in childhood is frequently insidious, starting with
inappropriate affect or unusual behavior; it may take months or years for a child to
meet all of the diagnostic criteria for schizophrenia.
Auditory hallucinations commonly occur in children with schizophrenia. The voices
may reflect an ongoing critical commentary, or command hallucinations may instruct
children to harm or kill themselves or others. Hallucinatory voices may sound human or
animal, or “bizarre,” for example, identified as “a computer in my head,” martians, or
the voice of someone familiar, such as a relative. The childhood-onset schizophrenia
project at the NIMH found high rates across all hallucination modalities. However, there
were unexpectedly high rates of tactile, olfactory, and visual hallucinations among this
study group of patients with childhood-onset schizophrenia. Visual hallucinations were
associated with lower IQ and earlier age at onset of disease. Visual hallucinations are
often frightening; affected children may “see” images of the devil, skeletons, scary faces,
or space creatures. Transient phobic visual hallucinations occur in severely anxious or
traumatized children who do not develop major psychotic disorders. Visual, tactile, and
olfactory hallucinations may be a marker of more severe psychosis.
Delusions occur in up to half of children and adolescents with schizophrenia, in
various forms, including persecutory, grandiose, and religious. Delusions increase in
frequency with increased age. Blunted or inappropriate affect appears almost
universally in children with schizophrenia. Children with schizophrenia may giggle
inappropriately or cry without being able to explain why. Formal thought disorders,
including loosening of associations and thought blocking, are common features among
youth with schizophrenia. Illogical thinking and poverty of thought are also often
present. Unlike adults with schizophrenia, children with schizophrenia do not have
poverty of speech content, but they speak less than other children of the same
intelligence and are ambiguous in the way they refer to persons, objects, and events.
The communication deficits observable in children with schizophrenia include
unpredictably changing the topic of conversation without introducing the new topic to
the listener (loose associations). Children with schizophrenia also exhibit illogical
thinking and speaking and tend to underuse self-initiated repair strategies to aid in their
communication. When an utterance is unclear or vague, normal children attempt to
clarify their communication with repetitions, revision, and more detail. Children with
schizophrenia, on the other hand, fail to aid communication with revision, fillers, or
starting over. These deficits may be conceptualized as negative symptoms in childhood
schizophrenia.
Although core phenomena for schizophrenia seem to be universal across the age span,
a child’s developmental level significantly influences the presentation of the symptoms.
Delusions of young children are less complex, therefore, than those of older children, for
example, age-appropriate content, such as animal imagery and monsters, is likely to be
a source of delusional fear in young children. According to the DSM-5, a child with
schizophrenia may experience deterioration of function, along with the emergence of
psychotic symptoms, or the child may never achieve the expected level of functioning.
A 12-year-old 6th grade boy named Ian, with a longstanding history of social
isolation, academic problems, and temper outbursts began to develop concerns that
his parents might be poisoning his food. Over the next year, his symptoms progressed
with increased suspiciousness and fearfulness, preoccupation with food, and beliefs
that Satan was trying to communicate with him. Ian also appeared to be responding
to auditory hallucinations that he believed were coming from the radio and television,
which he found frightening and commanded him to harm his parents. Ian had also
been informing his mother that their food had a strange smell and that’s why he
thought it was poisoned, and at night, he would see frightening figures in his room.
During this time, his parents also observed bizarre behaviors, including talking and
yelling to himself, perseverating about devils and demons, and finally, assaulting
family members because he thought they were evil. On one occasion, Ian was found to
be scratching himself with a kitchen knife in an effort to “please God.” No
predominant mood symptoms emerged, and there was no history of substance abuse
found.
Developmentally, Ian was the product of a full-term pregnancy complicated by a
difficult labor and forceps delivery. His early motor and speech milestones were each
delayed by about 6 months; however, his pediatrician reassured his parents that this
was within the limits of normal development. As a younger child, Ian tended to be
quiet and socially awkward. His intellectual function was tested and was found to be
in the average range; however, academic achievement testing was consistently below
grade level. Ian remained lonely and isolated, and he had great difficulty making
friends.
Ian has had no medical problems and his immunizations were up to date.
Ian’s family psychiatric history was significant for depression in a maternal aunt
and a completed suicide in a maternal great-grandparent.
Ian was sent by ambulance to the hospital for the first time from school when he
tried to jump off a balcony on the second story of his school, in response to auditory
hallucinations commanding him to kill himself. During his hospitalization his parents
reluctantly consented to a trial of risperidone for him, and he was titrated up to 3 mg
per day. His auditory hallucinations were moderately improved after 2 weeks of
treatment; however, he continued to be suspicious and mistrustful of his physicians
and family. Ian’s family was very confused as to what had caused Ian’s serious
symptoms, and the hospital treatment team met with his parents multiple times
during his hospitalization to reassure them that they had not caused his illness and
that; their continued support might improve his chances of improvement. After
discharge from the hospital, 30 days later, Ian was placed in a special education
program, in a nonpublic school, and he was assigned a psychotherapist who met
regularly with him individually and with his family. At the time of discharge from the
hospital, Ian’s symptoms had moderately improved, although he still had auditory
hallucinations intermittently. Over the next 5 years subsequent to the onset of his
illness, Ian had many exacerbations of his psychosis and he was hospitalized nine
times, including placement in a long-term residential program. Ian had received trials
of olanzapine, quetiapine, and aripiprazole, each of which seemed to lead to
improvement for a period of time, after which he was no longer responsive to the
medications. Ian continued to receive individual cognitive behavioral therapy and
family therapy, and his family was very supportive. Even with these interventions,
Ian’s mental status continued to display tangential and disorganized thinking,
paranoid delusions, loose associations, perseverative speech patterns, and a flat, at
times inappropriate, affect. He had periods of time in which he resorted to pacing and
muttering to himself, with no social interaction with others unless initiated by adults.
Finally, Ian achieved significant improvement after being placed on clozapine
(Clozaril) therapy, although he remained mildly symptomatic. (Adapted from a case
by Jon M. McClellan, M.D.)
PATHOLOGY AND LABORATORY EXAMINATIONS
No specific laboratory tests are diagnostically specific for childhood-onset schizophrenia.
Electroencephalography (EEG) studies have not been helpful in distinguishing children
with schizophrenia from other children. Although data exist to suggest that
hypoprolinemia is associated with the risk of schizoaffective disorder due to an
alteration on chromosome 22q11, no association of hyperprolinemia with childhoodonset schizophrenia has been identified.
DIFFERENTIAL DIAGNOSIS
One of the significant challenges in making a diagnosis of childhood-onset schizophrenia
is that very young children who report hallucinations, apparent thought disorders,
language delays, and poor ability to differentiate reality from fantasy may be
manifesting phenomena better accounted for by other disorders such as posttraumatic
stress disorder, or sometimes developmental immaturity, none of which evolve into a
major psychotic illness.
Nevertheless, the differential diagnosis of childhood-onset schizophrenia includes
autism
spectrum
disorder,
bipolar
disorders,
depressive
psychotic
disorders,
multicomplex developmental syndromes, drug-induced psychosis, and psychosis caused
by organic disease states. Children with childhood-onset schizophrenia have been shown
to have frequent comorbidities, including ADHD, oppositional defiant disorder, and
major depression. Children with schizotypal personality disorder have some traits in
common with children who meet diagnostic criteria for schizophrenia. Blunted affect,
social isolation, eccentric thoughts, ideas of reference, and bizarre behavior can be seen
in both disorders; however, in schizophrenia, overt psychotic symptoms, such as
hallucinations, delusions, and incoherence, must be present at some point.
Hallucinations alone, however, are not evidence of schizophrenia; patients must show
either a deterioration of function or an inability to meet an expected developmental
level to warrant the diagnosis of schizophrenia. Auditory and visual hallucinations can
appear as self-limited events in nonpsychotic young children who are experiencing
extreme stress or anxiety related to unstable home lives, abuse, or neglect or in children
experiencing a major loss.
Psychotic phenomena are common among children with major depressive disorder, in
which both hallucinations and, less commonly, delusions may occur. The congruence of
mood with psychotic features is most pronounced in depressed children, although
children with schizophrenia may also seem sad. The hallucinations and delusions of
schizophrenia are more likely to have a bizarre quality than those of children with
depressive disorders. In children and adolescents with bipolar I disorder, it often is
difficult to distinguish a first episode of mania with psychotic features from
schizophrenia if the child has no history of previous depressions. Grandiose delusions
and hallucinations are typical of manic episodes, but clinicians often must follow the
natural history of the disorder to confirm the presence of a mood disorder. Autism
spectrum disorders share some features with schizophrenia, most notably, difficulty with
social relationships, an early history of delayed language acquisition, and ongoing
communication deficits. However, hallucinations, delusions, and formal thought disorder
are core features of schizophrenia and are not expected features of autism spectrum
disorder. Autism spectrum disorder is usually diagnosed by 3 years of age, whereas
schizophrenia with childhood onset can rarely be diagnosed before 5 years of age.
Among adolescents, alcohol and other substance abuse sometimes can result in a
deterioration of function, psychotic symptoms, and paranoid delusions. Amphetamines,
lysergic acid diethylamide (LSD), and phencyclidine (PCP) may lead to a psychotic state.
A sudden, flagrant onset of paranoid psychosis may suggest substance-induced psychotic
disorder. Medical conditions that can induce psychotic features include thyroid disease,
systemic lupus erythematosus, and temporal lobe disease.
COURSE AND PROGNOSIS
Important predictors of the course and outcome of childhood and early-onset
schizophrenia include the child’s premorbid level of functioning, the age of onset, IQ,
response to psychosocial and pharmacological interventions, degree of remission after
the first psychotic episode, and degree of family support. Early age at onset, and
children with comorbid developmental delays, learning disorders, lower IQ, and
premorbid behavioral disorders, such as ADHD and conduct disorder, are less treatment
responsive and likely to have the most guarded prognoses. Predictors of a poorer course
of childhood-onset schizophrenia include family history of schizophrenia, young age and
insidious onset, developmental delays and lower level of premorbid function, and
chronic or length of first psychotic episode. Psychosocial and family stressors are known
to influence the relapse rate in adults with schizophrenia, and high expression of
negative emotion (EE) likely affects children with childhood-onset schizophrenia as well.
An important factor in outcome is the accuracy and stability of the diagnosis of
schizophrenia. One study reported that one third of children who received an initial
diagnosis of schizophrenia were later diagnosed with bipolar disorder in adolescence.
Children and adolescents with bipolar I disorder may have a better long-term prognosis
than those with schizophrenia. The NIMH-funded Treatment of Early-Onset
Schizophrenia reported outcome of neurocognitive functioning in 8- to 19-year-old youth
with schizophrenia or schizoaffective disorders, who participated in a randomized
double-blind clinical trial comparing molindone, olanzapine, and risperidone. The three
medication groups yielded no group differences in neurocognitive functioning over a
year; however, when data from the three groups were combined, a significant modest
improvement was observed in several domains of neurocognitive functioning. The
authors concluded that antipsychotic intervention in youth with early-onset
schizophrenia spectrum disorders led to modest improvement in neurocognitive
function.
TREATMENT
The treatment of childhood-onset schizophrenia requires a multimodal approach,
including
psychoeducation
for
families,
pharmacological
interventions,
psychotherapeutic interventions, social skills interventions, and appropriate educational
placement. A recent randomized controlled trial investigated the effectiveness of several
psychosocial interventions on youth in an early prodromal stage, characterized by
changes in cognitive and social behavior. The interventions, termed integrated
psychological interventions, specifically included cognitive-behavioral therapy, group
skills training, cognitive remediation therapy, multifamily psychoeducation, and
supportive counseling on the prevention of psychosis. Of interest, the integrated
psychological intervention was shown to be more effective than standard treatments in
delaying the onset of psychosis over a 2-year follow-up period. These results sparked
interest in the potential utility of psychosocial interventions to mediate psychosis, and
to alter relapse rate and severity of illness over time. Children with childhood-onset
schizophrenia may have less robust responses to antipsychotic medications than
adolescents and adults. Family education and ongoing therapeutic family interventions
are critical to maintain the maximum level of support for the patient. Monitoring the
most appropriate educational setting for a child with childhood-onset schizophrenia is
essential, especially in view of the frequent social skill deficits, attention deficits, and
academic difficulties that often accompany childhood-onset schizophrenia.
Pharmacotherapy
Second-generation
antipsychotics,
serotonin-dopamine
antagonists,
are
current
mainstay pharmacological treatments for children and adolescents with schizophrenia,
having largely replaced the conventional antipsychotics, that is, dopamine receptor
antagonists, due to their more favorable side-effect profiles. Current data include six
randomized clinical trials in youth investigating the efficacy of second-generation
antipsychotics for early-onset schizophrenia, with limited support for one agent over the
others. Although clozapine, a serotonin receptor antagonist with some dopamine (D2)
antagonism, which is hypothesized to be more effective in reducing positive and
negative symptoms, has been shown to be highly effective in adults with treatmentrefractory schizophrenia, it remains a choice of last resort in youth, based on its serious
side effects. To date, however, evidence from multisite randomized clinical trials
supports some efficacy of risperidone, olanzapine, aripiprazole, and clozapine in the
treatment of childhood- and adolescent-onset schizophrenia. Two randomized clinical
trials using risperidone in adolescents with schizophrenia found risperidone at doses up
to 3 mg per day to be superior to placebo. A multisite randomized 6-week controlled
trial of olanzapine in adolescents with schizophrenia found that it was more efficacious
than placebo. A randomized controlled trial of aripiprazole at two fixed doses found that
it was superior to placebo in the treatment of positive symptoms of adolescent
schizophrenia; however, more than 40 percent of subjects in the active medication
group did not achieve remission. Finally, clozapine has been demonstrated to be more
effective than haloperidol in improving both positive and negative symptoms in
treatment-resistant schizophrenia in youth. More recently, a study compared clozapine
to high doses of olanzapine and found that response rates were about twice as great for
clozapine as olanzapine (66% vs. 33%) when response was defined by a 30% or greater
reduction in symptoms on the Brief Psychiatric Rating Scale and improvement on the
Clinical Global Impression Scale. The Treatment of Early Onset Schizophrenia Spectrum
Disorders Study compared the efficacy of risperidone and olanzapine with those of
molindone, a mid-potency conventional antipsychotic. In this study, lacking a placebo
group, each of these agents provided a similar therapeutic effect; however, fewer than
half of the patients responded optimally. Despite the limited randomized controlled
studies of second-generation antipsychotics for the treatment of schizophrenia in youth,
the Food and Drug Administration (FDA) is progressively approving the use of these
agents for pediatric schizophrenia and bipolar illness. In 2007, the FDA approved the
use of risperidone and aripiprazole for the treatment of schizophrenia in 13- to 17-yearolds. The use of olanzapine and quetiapine were approved by the FDA in 2009 in the
treatment of schizophrenia in 13 to 17 year olds.
A double-blind, randomized 8-week controlled trial compared the efficacy and safety
of olanzapine to clozapine in childhood-onset schizophrenia. Children with childhoodonset schizophrenia who were resistant to at least two previous treatments with
antipsychotics were randomized to treatment for 8 weeks with either olanzapine or
clozapine followed by a 2-year open-label follow-up. Using the Clinical Global Impression
of Severity of Symptoms Scale and Schedule for the Assessment of Negative/Positive
Symptoms, clozapine was found to be associated with a significant reduction in all
outcome measures, whereas olanzapine showed improvement on some measures but not
on all. The only statistically significant measure in which clozapine was superior to
olanzapine was in alleviating negative symptoms, compared with baseline. Clozapine
was associated with more adverse events, such as lipid abnormalities and a seizure in
one patient.
Several studies have provided evidence that risperidone, a benzisoxazole derivative, is
as effective as the older high-potency conventional antipsychotics, such as haloperidol
(Haldol), and causes less frequent severe side effects, in the treatment of schizophrenia
in older adolescents and adults. Published case reports and limited larger controlled
studies have supported the efficacy of risperidone in the treatment of psyhosis in
children and adolescents. Risperidone has been reported to cause weight gain and
dystonic reactions and other extrapyramidal adverse effects in children and adolescents.
Olanzapine is generally well tolerated with respect to extrapyramidal adverse effects
compared with conventional antipsychotics and risperidone, but it is associated with
moderate sedation and significant weight gain.
Psychosocial Interventions
Psychosocial interventions aimed at family education and patient and family support
are recognized as critical components of the treatment plan for childhood-onset
schizophrenia. Although there are not yet randomized controlled trials of psychosocial
interventions in children and adolescents with schizophrenia, family therapy,
psychoeducation, and social skills training have been shown to lead to improved clinical
symptoms in young adults with a first episode of schizophrenia, and reviews of the adult
literature support the benefit of cognitive behavioral therapy, and cognitive remediation
as adjunctive treatments to pharmacologic agents in adults. Psychotherapists who work
with children with schizophrenia must take into account a child’s developmental level in
order to support the child’s reality testing and be sensitive to the child’s sense of self.
Long-term supportive family interventions and cognitive behavioral and remediation
interventions combined with pharmacotherapy are likely to be the most effective
approach to early-onset schizophrenia.
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31.16 Adolescent Substance Abuse
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31.16 Adolescent Substance Abuse
Substance use is a public health concern among American youth. The most common
substances used by adolescents in the United States are tobacco, alcohol, and marijuana.
Adolescent substance use and abuse, however, includes a wider range of substances,
including cocaine, heroin, inhalants, phencyclidine (PCP), lysergic acid diethylamide
(LSD),
dextromorphan,
anabolic
steroids
and
various
club
drugs,
3,4methylenedioxymethamphetamine (MDMA or Ecstasy), flunitrazepam (Rohypnol),
gamma-hydroxybutyrate (GHB), and ketamine (Ketalar). It is estimated that
approximately 20 percent of 8th graders in the United States have tried illicit drugs and
about 30 percent of 10th through 12th graders have used an illicit substance. Alcohol
remains the most common substance used and abused by adolescents. Binge drinking
occurs in about 6 percent of adolescents, and teens with alcohol use disorders are at
greater risk of problems with other substances as well.
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), in contrast to the previous Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), does not separate
the diagnoses of substance abuse from substance dependence. Instead, the DSM-5
provides criteria for substance use disorder, accompanied by criteria for intoxication,
withdrawal, and substance-induced disorders. The previous DSM-IV-TR criterion of
recurrent substance-related legal problems has been deleted in the DSM-5, and a new
criterion, craving, or a strong desire or urge to use a substance, has been added. In the
DSM-5, a threshold of two or more criteria must be present. Cannabis withdrawal and
caffeine withdrawal are new disorders in the DSM-5. The combined substance use
criteria including both abuse and withdrawal phenomena may strengthen the validity of
the disorder in adolescents, and the elimination of the criterion for “legal problems” is
also an appropriate change for adolescents, since this is less common for younger
adolescents and for adolescent females who use substances. Two recent commentaries
raise concerns regarding the application of DSM-5 criteria to adolescents with respect to
the symptom of tolerance, particularly to alcohol, that may occur across the board, and
may be developmentally normal for adolescents who use alcohol but for whom there is
no clinical impairment, and for withdrawal symptoms, which may have clinical
significance but is only moderately associated with level of severity of substance use.
Many risk and protective factors influence the age of onset and severity of substance
use among adolescents. Psychosocial risk factors mediating the development of
substance use disorders include parent modeling of substance use, family conflict, lack
of parental supervision, peer relationships, and individual stressful life events.
Protective factors that mitigate substance use among adolescents include variables such
as a stable family life, strong parent–child bond, consistent parental supervision,
investment in academic achievement, and a peer group that models prosocial family
and school behaviors. Interventions that diminish risk factors are likely to mitigate
substance use.
Approximately one of five adolescents has used marijuana or hashish. Approximately
one third of adolescents have used cigarettes by age 17 years. Studies of alcohol use
among adolescents in the United States have shown that by 13 years of age, one third of
boys and almost one fourth of girls have tried alcohol. By 18 years of age, 92 percent of
males and 73 percent of females reported trying alcohol, and 4 percent reported using
alcohol daily. Of high school seniors, 41 percent reported using marijuana; 2 percent
reported using the drug daily.
Drinking among adolescents follows adult demographic drinking patterns: The highest
proportion of alcohol use occurs among adolescents in the northeast; whites are more
likely to drink than are other groups; among whites, Roman Catholics are the least
likely nondrinkers. The four most common causes of death in persons between the ages
of 10 and 24 years are motor vehicle accidents (37 percent), homicide (14 percent),
suicide (12 percent), and other injuries or accidents (12 percent). Of adolescents treated
in pediatric trauma centers, more than one third are treated for alcohol or drug use.
Studies considering alcohol and illicit drug use by adolescents as psychiatric disorders
have demonstrated a greater prevalence of substance use, particularly alcoholism,
among biological children of alcoholics than among adopted youth. This finding is
supported by family studies of genetic contributions, by adoption studies, and by
observing children of substance users reared outside the biological home.
Numerous risk factors influence the emergence of adolescent substance abuse. These
include parental belief in the harmlessness of substances, lack of anger control in
families of substance abusers, lack of closeness and involvement of parents with
children’s activities, maternal passivity, academic difficulties, comorbid psychiatric
disorders such as conduct disorder and depression, parental and peer substance use,
impulsivity, and early onset of cigarette smoking. The greater the number of risk
factors, the more likely it is that an adolescent will be a substance user.
EPIDEMIOLOGY
Alcohol
The Centers for Disease Control and Prevention Youth Risk Behavior Survey found that
72.5 percent of high school students had tried at least one alcoholic drink, and 24.2
percent reported an episode of heavy drinking in the month preceding the survey.
Findings from the Monitoring the Future Survey suggest that about 39 percent of
adolescents have used alcohol before the 8th grade. Another survey found that drinking
was a significant problem for 10 to 20 percent of adolescents. Drinking was reported by
70 percent of 8th grade students: 54 percent reported drinking within the past year, 27
percent reported having gotten drunk at least once, and 13 percent reported binge
drinking in the 2 weeks before the survey. By the 12th grade, 88 percent of high school
students reported drinking, and 77 percent drank within the past year; 5 percent of 8th
grade students, 1.3 percent of 10th grade students, and 3.6 percent of 12th grade
students reported daily alcohol use. In the age range of 13 to 17 years, in the United
States, reports indicate there are 3 million problem drinkers and 300,000 adolescents
with alcohol dependence. The gap between male and female alcohol consumers is
narrowing.
Marijuana
For the last two decades, marijuana has been one of the most widely used drugs by
young people in developed countries, and recently it has become highly used globally.
The United Nations Office on Drugs and Crime estimated that marijuana was used by
3.9 percent of people worldwide between ages 15 years and 64 years. Marijuana is the
most commonly used illicit drug among high school students in the United States. It is
estimated that about 10 percent of those who try marijuana become daily users, and 20
to 30 percent become weekly users. Marijuana has been termed a “gateway drug,”
because the strongest predictor of future cocaine use is frequent marijuana use during
adolescence. Of 8th grade, 10th grade, and 12th grade students, 10, 23, and 36 percent,
respectively, report using marijuana, a slight decrease from the year preceding the
survey. Of 8th grade, 10th grade, and 12th grade students, 0.2, 0.8, and 2 percent,
respectively, report daily marijuana use. Prevalence rates for marijuana are highest
among Native American males and females; these rates are nearly as high in white
males and females and Mexican American males. The lowest annual rates are reported
by Latin American females, African American females, and Asian American males and
females.
Cocaine
The annual cocaine use reported by high school seniors decreased more than 30 percent
between 1990 and 2000. Currently, about 0.5 percent of 8th grade students, 1 percent of
10th grade students, and 2 percent of 12th grade students are estimated to have used
cocaine. The prevalence rates for crack cocaine use, however, is increasing and is most
common among those between the ages of 18 and 25.
Crystal Methamphetamine
Crystal methamphetamine, or “ice,” was at a relative low level of use in adolescence
about one decade ago of 0.5 percent, and has steadily increased to a recent rate of 1.5
percent among 12th graders.
Opioids
A survey of 7,374 high school seniors found that 12.9 percent reported nonmedical use
of opioids. Of users, more than 37 percent reported intranasal administration of
prescription opioids.
Lysergic Acid Diethylamide (LSD)
Lysergic acid diethylamide is reportedly used by 2.7 percent of 8th grade students, 5.6
percent of 10th grade students, and 8.8 percent of 12th grade students. Of 12th grade
students, 0.1 percent report daily use. The current LSD rates are lower than rates of LSD
use during the past two decades.
3,4-Methylenedioxymethamphetamine (MDMA)
The popularity of MDMA has increased over the last decade, and current rates of use in
the United States are in the range of about 5 percent for 10th graders and 8 percent of
12th graders, despite that the perceived harmfulness of this drug has increased over the
last decade to almost 50 percent among 12th graders. Accidental adolescent deaths have
been associated with the use of MDMA.
Gamma-Hydroxybutyrate (GHB)
Gamma-hydroxybutyrate, a club drug, has been found in surveys to have an annual
prevalence rate of 1.1 percent for 8th graders, 1.0 percent rate for 10th graders, and a
1.6 percent rate of use for 12th graders.
Ketamine (Ketalar)
Ketamine, another club drug, was found recently to have a rate of 1.3 percent annual
prevalence for 8th graders, 2.1 percent for 10th graders, and 2.5 percent rate for 12th
graders.
Flunitrazepam (Rohypnol)
Flunitrazepam (Rohypnol), a third club drug, has been found to have an annual
prevalence rate of about 1 percent for all high school grades combined.
Anabolic Steroids
Despite reported knowledge of the risks of anabolic steroids among high school students,
surveys over the last 5 years found rates of anabolic steroid use to be 1.6 percent among
8th graders and 2.1 percent among 10th graders. Up to 45 percent of 10th and 12th
graders reported knowledge of the risks of anabolic steroids; however, over the last
decade it appears that high school seniors reported less disapproval of their use.
Inhalants
The use of inhalants in the form of glue, aerosols, and gasoline is relatively more
common among younger than older adolescents. Among 8th grade, 10th grade, and 12th
grade students, 17.6, 15.7, and 17.6 percent, respectively, report using inhalants; 0.2
percent of 8th grade students, 0.1 percent of 10th grade students, and 0.2 percent of 12th
grade students report daily use of inhalants.
Multiple Substance Use
Among adolescents enrolled in substance abuse treatment programs, 96 percent are
polydrug users; 97 percent of adolescents who abuse drugs also use alcohol.
ETIOLOGY
Genetic Factors
The concordance for alcoholism is reportedly higher among monozygotic than dizygotic
twins. Considerably fewer studies have been conducted of families of drug abusers. One
twin study of drug users showed that the drug abuse concordance for male monozygotic
twins was twice that for dizygotic twins. Studies of children of alcoholics reared away
from their biological homes have shown that these children have about a 25 percent
chance of becoming alcoholics.
Psychosocial Factors
Among adolescents, substance use, particularly marijuana use, is strongly influenced by
peers, and especially for those adolescents who report using marijuana for relaxation,
the drug is used to escape from stress, and as a social activity. There are data to suggest,
however, that marijuana use is also associated with both social anxiety disorder and
depressive symptoms. Among young adolescents who start using alcohol, tobacco, and
marijuana at an early age, data suggest that they often come from families with low
parental supervision. The risk of early initiation of substances is greatest for children
below 11 years of age. Increased parental supervision during middle childhood years
may diminish drug and alcohol sampling and ultimately diminish the risk of using
marijuana, cocaine, or inhalants in the future.
Comorbidity
Rates of alcohol and marijuana use are reportedly higher in relatives of youth with
depression and anxiety disorders. On the other hand, mood disorders are common
among those with alcoholism. Evidence indicates another strong link between early
antisocial behavior, conduct disorder, and substance abuse. Substance abuse can be
viewed as one form of behavioral deviance that, unsurprisingly, is associated with other
forms of social and behavioral deviance. Early intervention with children who show
early signs of social deviance and antisocial behavior may conceivably impede the
processes that contribute to later substance abuse.
Comorbidity, the occurrence of more than one substance use disorder or the
combination of a substance use disorder and another psychiatric disorder, is common. It
is important to know about all comorbid disorders, which may show differential
responses to treatment. Surveys of adolescents with alcoholism show rates of 50 percent
or higher for additional psychiatric disorders, especially mood disorders. A recent survey
of adolescents who used alcohol found that more than 80 percent met criteria for
another disorder. The disorders most frequently present were depressive disorders,
disruptive behavior disorders, and drug use disorders. These rates of comorbidity are
even higher than those for adults. The diagnosis of alcohol abuse or dependence was
likely to follow, rather than precede, other disorders; that a large proportion of
adolescents with alcoholism have a previous childhood disorder may have both
etiological and treatment implications. In this survey, the onset of alcohol disorders did
not systematically precede drug abuse or dependence. In 50 percent of cases, alcohol use
followed drug use. Alcohol use may be a gateway to drug use, but is not in most cases.
The presence of other psychiatric disorders was associated with an earlier onset of
alcohol disorder, but it did not seem to indicate a more protracted course of alcoholism.
DIAGNOSIS AND CLINICAL FEATURES
According to the DSM-5, substance-related disorders include the following three
categories: substance use, substance intoxication, and substance withdrawal disorder.
Whereas in DSM-IV-TR, substance abuse and dependence were two separate categories,
in DSM-5, they are combined in one diagnosis called substance use disorder.
Substance use refers to a maladaptive pattern of substance use leading to clinically
significant impairment or distress, manifest by one or more of the following symptoms
within a 12-month period: recurrent substance use in situations that causes physical
danger to the user, recurrent substance use in the face of obvious impairment in school
or work situations, recurrent substance use despite resulting legal problems, or recurrent
substance use despite social or interpersonal problems.
Substance intoxication refers to the development of a reversible, substance-specific
syndrome caused by use of a substance. Clinically significant maladaptive behavioral or
psychological changes must be present.
Substance withdrawal refers to a substance-specific syndrome caused by the cessation
of, or reduction in, prolonged substance use. The substance-specific syndrome causes
clinically significant distress or impairs social or occupational functioning.
Two new disorders in DSM-5 include Cannabis withdrawal disorder and caffeine
withdrawal disorder.
The diagnosis of alcohol or drug use in adolescents is made through careful interview,
observations, laboratory findings, and history provided by reliable sources. Many
nonspecific signs may point to alcohol or drug use, and clinicians must be careful to
corroborate hunches before jumping to conclusions. Substance use can be viewed on a
continuum with experimentation (the mildest use), regular use without obvious
impairment, abuse, and finally, dependence. Changes in academic performance,
nonspecific physical ailments, and changes in relationships with family members,
changes in peer group, unexplained phone calls, or changes in personal hygiene may
indicate substance use in an adolescent. Many of these indicators, however, also can be
consistent with the onset of depression, adjustment to school, or the prodrome of a
psychotic illness. It is important, therefore, to keep the channels of communication with
an adolescent open when substance use is suspected.
Nicotine
Nicotine is one of the most addictive substances known; it involves cholinergic
receptors, and enhancing acetylcholine, serotonin, and β-endorphin release. Young
teens who smoke cigarettes are also exposed to other drugs more frequently than
nonsmoking peers.
Alcohol
Alcohol use in adolescents rarely results in the sequelae observed in adults with chronic
use of alcohol, such as withdrawal seizures, Korsakoff’s syndrome, Wernicke’s aphasia,
or cirrhosis of the liver. One report, however, has stated that adolescent exposure to
alcohol may result in diminished hippocampal brain volume. Because the hippocampus
is involved with attention, it is conceivable that adolescent alcohol use could result in
compromised cognitive function, especially with respect to attention.
Marijuana
The short-term effects of the active ingredient in marijuana, tetrahydrocannabinol
(THC), include impairment in memory and learning, distorted perception, diminished
problem-solving ability, loss of coordination, increased heart rate, anxiety, and panic
attacks. Abrupt cessation of heavy marijuana use by adolescents has been reported to
result in a withdrawal syndrome characterized by insomnia, irritability, restlessness,
drug craving, depressed mood, and nervousness followed by anxiety, tremors, nausea,
muscle twitches, increased sweating, myalgia, and general malaise. Typically, the
withdrawal syndrome begins 24 hours after the last use, peaks at 2 to 4 days, and
diminishes after 2 weeks. Marijuana use has been associated with increased risk of
psychiatric disorders. Poor cognitive functioning has been associated with chronic
marijuana use, although it is not clear whether marijuana impairs cognitive function.
Deficits in verbal learning, memory, and attention have been reported in chronic
marijuana users, and both acute and chronic marijuana use is associated with changes in
cerebral blood flow to certain brain regions, which can be detected by positron emission
tomography. Functional imaging studies suggest that there is less activity in brain
regions involved with attention and memory in chronic marijuana users. A 15-year
follow-up of 50,465 Swedish males in the military reported that participants who had
used marijuana by 18 years of age were 2.4 times more likely to develop schizophrenia.
Risks associated with chronic marijuana use include higher rates of motor vehicle
accidents, impaired respiratory function, increased risk of cardiovascular disease, and
potential increased risk for psychotic symptoms and disorders.
Cocaine
Cocaine can be sniffed or snorted, injected, or smoked. Crack is the term given to
cocaine after it has been changed to a free base for smoking. Cocaine’s effects include
constriction of peripheral blood vessels, dilated pupils, hyperthermia, increased heart
rate, and hypertension. High doses or prolonged use of cocaine can induce paranoid
thinking. There is immediate risk of death secondary to cardiac arrest or from seizures
followed by respiratory arrest. In contrast to stimulants used to treat attentiondeficit/hyperactivity disorder (ADHD), such as methylphenidate, cocaine quickly crosses
the blood–brain barrier and moves off the dopamine transporter within 20 minutes;
methylphenidate remains bound to dopamine for long periods.
Heroin
Heroin, a derivative of morphine, is produced from a poppy plant. Heroin usually
appears as a white or brown powder that can be snorted, but more commonly, it is used
intravenously. Withdrawal symptoms include restlessness, muscle and bone pain,
insomnia, diarrhea and vomiting, cold flashes with goose bumps, and kicking
movements. Withdrawal occurs within a few hours after use; symptoms peak between
48 and 72 hours later and remit within about a week.
Club Drugs
Adolescents who frequent nightclubs, raves, bars, or music clubs also frequently use
MDMA, GHB, Rohypnol, and ketamine. GHB, Rohypnol (a benzodiazepine), and
ketamine (an anesthetic) are primarily depressants and can be added to drinks without
detection because they are often colorless, tasteless, and odorless. The Drug-Induced
Rape Prevention and Punishment Act was passed after these drugs were found to be
associated with date rape. MDMA is a derivative of methamphetamine, a synthetic with
both stimulant and hallucinogenic properties. MDMA can inhibit serotonin and
dopamine reuptake. MDMA can result in dry mouth, increased heart rate, fatigue,
muscle spasm, and hyperthermia.
Lysergic Acid Diethylamide
LSD is odorless, colorless, and has a slightly bitter taste. Higher doses of LSD can
produce visual hallucinations and delusions and, in some cases, panic. The sensations
experienced after ingestion of LSD usually diminish after 12 hours. Flashbacks can occur
up to 1 year after use. LSD can produce tolerance; that is, after multiple uses, more is
needed to provide the same degree of intoxication.
Substance use is related to a variety of high-risk behaviors, including early sexual
experimentation, risky driving, destruction of property, stealing, “heavy metal” or
alternative music, and, occasionally, preoccupation with cults or Satanism. Although
none of these behaviors necessarily predicts substance use, at the extreme, these
behaviors reflect alienation from the mainstream of developmentally expected social
behavior. Adolescents with inadequate social skills may use a substance as a modality to
join a peer group. In some cases, adolescents begin their substance use at home with
their parents, who also use substances to enhance their social interactions. Although no
evidence indicates what determines a typical adolescent user of alcohol or drugs, many
substance users seem to have underlying social skills deficits, academic difficulties, and
less than optimal peer relationships.
TREATMENT
Interventions for substance use disorders in adolescents first require effective screening
and identification of those teens in need of treatment. Once a substance use disorder has
been identified in a teen, a variety of treatment options can be sought.
In accordance with the goals of the U.S Substance Abuse Mental Health Services
Administration (SAMHSA), a school-based alcohol and drug Screening, Brief
Intervention, and Referral to Treatment (SBIRT) has been initiated in a study with 629
adolescents ages 14 to 17 years in 13 participating high schools in New Mexico.
Initially, school-based health centers provided substance use screenings for all students
who were seen in the clinic for any reason. Once identified, substance using adolescents
were offered either brief intervention by clinic staff (85.1 percent of those identified),
whereas 14.9 percent received brief treatment or referral to treatment. The brief
intervention was based on motivational interviewing, with the goal of helping the
student to gain motivation for behavioral change, and being referred for more intensive
treatment if needed. Students who received the intervention, regardless of the severity
of their substance use, reported decreases in self-reported drinking to intoxication at the
6-month follow-up. Furthermore, students who reported drug use, self-reported
decreased use at follow-up. Alcohol use was reported by 42 percent of the student
participants, and alcohol intoxication was reported by 37 percent. Eighty-five percent of
study participants who reported drug use, reported only marijuana use in the month
prior to entering the study. The frequency of alcohol and marijuana as the most
predominant substances in this age group is consistent with epidemiological data.
Overall, this school-based intervention had the advantage of being easily accessible to
adolescents and provided a graded option for treatment according to the severity of the
substance use. This study suggests that school-based programs for identifying and
providing brief interventions for high school students is viable and merits further study.
Treatment of substance use disorders in adolescents is designed to directly prevent the
substance use behaviors and to provide education for the patient and family and to
address cognitive, emotional, and psychiatric factors that influence the substance use in
a variety of settings such as a residential milieu, group, and individual psychosocial
session.
One validated instrument used as a guide for clinicians in the treatment of adolescent
substance use designates levels of care appropriate for the symptoms. This instrument
called the Child and Adolescent Levels of Care Utilization Services (CALOCUS) outlines six
levels of care:
Level 0: Basic services (prevention)
Level 1: Recovery maintenance (relapse prevention)
Level 2: Outpatient (once per week visits)
Level 3: Intensive outpatient (2 or more visits per week)
Level 4: Intensive integrated services (day treatment, partial hospitalization,
wraparound services)
Level 5: Nonsecure, 24-hour medically monitored service (group home, residential
treatment facility)
Level 6: Secure 24-hour medical management (inpatient psychiatric or highly
programmed residential facility)
Treatment settings that serve adolescents with alcohol or drug use disorders include
inpatient units, residential treatment facilities, halfway houses, group homes, partial
hospital programs, and outpatient settings. Basic components of adolescent alcohol or
drug use treatment include individual psychotherapy, drug-specific counseling, self-help
groups (Alcoholics Anonymous [AA], Narcotics Anonymous [NA], Alateen, Al-Anon),
substance abuse education and relapse prevention programs, and random urine drug
testing. Family therapy and psychopharmacological intervention may be added.
Before deciding on the most appropriate treatment setting for a particular adolescent,
a screening process must take place in which structured and unstructured interviews
help to determine the types of substances being used and their quantities and
frequencies. Determining coexisting psychiatric disorders is also critical. Rating scales
are typically used to document pretreatment and posttreatment severity of abuse. The
Teen Addiction Severity Index (T-ASI), the Adolescent Drug and Alcohol Diagnostic
Assessment (ADAD), and the Adolescent Problem Severity Index (APSI) are several
severity-oriented rating scales. The T-ASI is broken down into dimensions that include a
family function, school or employment status, psychiatric status, peer social
relationships, and legal status.
After most of the information about substance use and the patient’s overall psychiatric
status has been obtained, a treatment strategy must be chosen and an appropriate
setting must be determined. Two very different approaches to the treatment of
substance abuse are embodied in the Minnesota model and the multidisciplinary
professional model. The Minnesota model is based on the premise of AA; it is an
intensive 12-step program with a counselor who functions as the primary therapist. The
program uses self-help participation and group processes. Inherent in this treatment
strategy is the need for adolescents to admit that substance use is problematic and that
help is necessary. Furthermore, they must be willing to work toward altering their
lifestyle to eradicate substance use. The multidisciplinary professional model consists of
a team of mental health professionals that usually is led by a physician. Following a
case-management model, each member of the team has specific areas of treatment for
which he or she is responsible. Interventions may include cognitive-behavioral therapy,
family therapy, and pharmacological intervention. This approach usually is suited for
adolescents with comorbid psychiatric diagnoses.
Cognitive-behavioral approaches to psychotherapy for adolescents with substance use
generally require that adolescents be motivated to participate in treatment and refrain
from further substance use. The therapy focuses on relapse prevention and maintaining
abstinence.
Psychopharmacological interventions for adolescent alcohol and drug users are still in
their early stages. The presence of mood disorders clearly indicates the need for
antidepressants, and generally, the selective serotonin reuptake inhibitors are the first
line of treatment. Occasionally, an intervention is made to substitute the illicit drug with
another drug that is more amenable to the treatment situation; for example, using
methadone instead of heroin. Adolescents are required to have documented attempts at
detoxification and consent from an adult before they can enter such a treatment
program.
Peter, a 16-year-old 11th grader, was admitted to substance abuse treatment for the
second time, following a relapse and threats of suicide. He was initially admitted to
an adolescent psychiatric inpatient unit following a serious suicide attempt. Peter
reported a longstanding history of ADHD, but he had been a good student and not had
any difficulties until middle school. Peter reported an onset of substance use at age 13
years, rapid progression in substance involvement since age 14 years, and then
current use of marijuana on a daily basis, drinking alcohol up to five times each week,
and experimentation with a variety of substances, such as LSD and Ecstasy. After
being discharged from the psychiatric hospital, Peter attended teen group sessions
focusing on his substance use problems. Family sessions led to the realization that
Peter’s mother had been depressed for some time, and she entered into her own
treatment. Peter was improving with respect to his substance use; however, his
depressive symptoms increased following 4 weeks of abstinence. Peter was started on
fluoxetine (Prozac). After the medication was titrated to 30 mg, he remained on it for
a month at which time he showed improvement in mood and treatment compliance.
Peter continued to attend the teen AA meetings and outpatient therapy. Family
conflict soon recurred, however, and Peter became noncompliant with outpatient
treatment, medication, and meetings. He resumed old relationships with substance
using peers and relapsed into daily marijuana use and occasional alcohol use.
(Courtesy of Oscar G. Bukstein, M.D.)
Efficacious treatments for cigarette smoking cessation include nicotine-containing
gum, patches, or nasal spray or inhaler. Bupropion (Zyban) aids in diminishing cravings
for nicotine and is beneficial in the treatment of smoking cessation.
Because comorbidity influences treatment outcome, it is important to pay attention to
other disorders, such as mood disorders, anxiety disorders, conduct disorder, or ADHD
during the treatment of substance use disorders.
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social anxiety disorder in the National Epidemiologic Study of Alcohol and Related Conditions (NESARC). Drug Alcohol
Depend. 2012;124:128–134.
Bukstein O. Adolescent substance abuse. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive
Textbook of Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins; 2009:3818.
Centers for Disease Control and Prevention, 2009. Youth Risk Behavior Survey. Updated February 22, 2011.
Fiorentini A, Volunteri LS, Draogna F, Rovera C, Maffini M, et al. Substance-induced psychoses: A critical review of the
literature. Curr Drug Abuse Rev. 2011;4:228–240.
Fraser S, Hides L, Philips L, Proctor D, Lubman DI. Differentiating first episode substance induced primary psychotic
disorders with concurrent substance use in young people. Schizophr Res. 2012;136:110–115.
Giedd J, Stocvkman M Weele C. Anatomic magnetic resonance imaging of the developing child and adolescent brain. In:
Reyna VF; Chapman SB, Dougherty MR, Copnfrey J., eds. The Adolescent Brain: Learning, Reasoning, and Decision
Making. Washington, D.C: American Psychological Association; 2012.
Harrow BS, Tompkins CP, Mitchell PD, Smith KW, Soldz S, Kasten L, Fleming K. The impact of publicly funded managed
care on adolescent substance abuse treatment outcomes. Am J Drug Alcohol Abuse. 2006;32(3):379.
Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future: National Survey Results on Drug Use.
1975–2007. Vol 3 Secondary School Students. Bethesda, MD. National Institute on Drug Abuse; 2008.
Kaminer Y, Winters KC. Proposed DSM-5 substance use disorders for adolescents: If you build it, will they come? Am J
Addict. 2012;21:280–281.
Lenk KM, Erickson DJ, Wonters KC, Nelson TF, Toomey TL. Screening services for alcohol misuse and abuse at four-year
colleges in the U.S. J Subst Abuse Treat. 2012;43:352–358.
McCabe SE, West BT, Teter CJ, Boyd CJ. Medical and nonmedical use of prescription opioids among high school seniors in
the United States. Arch Pediatr Adolesc Med. 2012;166:797–802.
Mitchell SG, Gryczynski J, Gonzales A, Moseley A, Peterson T, et al. Screening, brief intervention, and referral to treatment
(SBIRT) for substance use in a school-based program: Services and outcomes. Am J Addict. 2010;21:S5–S13.
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40 - 31.17 Child Psychiatry Other Conditions
31.17 Child Psychiatry: Other Conditions

41 - 31.17a Attenuated Psychosis Syndrome
31.17a Attenuated Psychosis Syndrome
Pub Health. 2013;13:724–732.
Winters K. Advances in the science of adolescent drug involvement: Implications for assessment and diagnosis. Curr Opin
Psychiatry. 2012;318–324.
Winters KC, Martim CS, Chung T. Substance use disorders in DSM-V. When applied to adolescents. Addiction.
2011;106:882–884.
Yuma-Guerrero PJ, Lawson KA, Velasquez MM, von Sternberg K, Maxson T, et al. Screening, brief intervention, and referral
for alcohol use in adolescents: A systematic review. Pediatrics. 2012;130:115–122.
31.17 Child Psychiatry: Other Conditions
31.17a Attenuated Psychosis Syndrome
Attenuated Psychosis Syndrome (APS) is a new diagnostic category included in the
American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) as a condition for further study. It is a syndrome characterized by
subthreshold psychotic symptoms, less severe than those found in psychotic disorders,
but which are often present in prodromal psychotic states.
Debate and controversy among clinicians and researchers have surrounded the
inclusion of APS in the DSM-5. There are those who believe that the identification and
treatment of a prodromal syndrome of a psychotic disorder would either delay or
diminish the severity of the future psychotic illness. And, there are others who believe
that identification of a prodromal syndrome, which may rarely if ever progress to a full
psychotic illness, would lead to unnecessary exposure to antipsychotic agents with
unpredictable and possibly harmful effects. There is agreement, however, that patients
with subthreshold prodromal psychotic symptoms are often impaired and are in need of
psychological and psychiatric intervention.
A recent meta-analysis reported that the rate of onset of psychotic disorders in those
patients with prodromal psychotic symptoms was 18 percent at 6 months, 22 percent at
1 year, 29 percent at 2 years, and 36 percent at 3 years. In a follow up study it was
found that of those with prodromal symptoms who went on to develop a threshold
psychotic illness, 73 percent met criteria for schizophrenia.
In children and adolescents psychotic symptoms are not necessarily a hallmark of a
threshold psychotic disorder compared to adults. For example, in 50 percent of children
with major depressive episodes, psychotic symptoms were present. In addition,
epidemiological studies have found that globally, auditory hallucinations occur in 9
percent to 21 percent of children and in 8.4 percent of adolescents. Thus, in youth, the
association between subthreshold psychotic symptoms and the emergence of future
psychotic illness may not be a reliable predictor. Nevertheless, identification and follow
up of youth with APS may provide an increased understanding of the longitudinal
significance of these symptoms.
ETIOLOGY
Genetic Factors
Family studies have demonstrated that genetic factors influence vulnerability for
schizophrenia spectrum disorders and other psychotic disorders. To the extent that APS
and schizophrenia are related, genetic contributions are likely to be significant.
Adoption and twin studies have confirmed that monozygotic twins have about a 50
percent concordance rate for schizophrenia compared to dizygotic twins who have a
concordance rate of about 10 percent. In addition, adopted children of parents with
schizophrenia do not have higher rates of schizophrenia; but biological children of
schizophrenic parents do. However, genetic factors do not account fully for the
emergence of schizophrenia spectrum disorders, since there is only a 50 percent
concordance of exhibiting these disorders among monozygotic twins. Environmental
factors also play an important role.
Environmental Factors
Early environmental factors that increase the risk of developing schizophrenia include
fetal malnutrition, hypoxia at birth, and possibly prenatal infections. Other
environmental factors include trauma, stress, social adversity and isolation. Finally,
gene–environment interactions may influence an individual’s sensitivity to adverse
environmental events.
DIAGNOSIS
Attenuated psychosis syndrome, according to DSM-5, is based on the presence of at least
one of the following: delusions, hallucinations, or disorganized speech, which causes
functional impairment. Although the symptoms may not have progressed to full
psychotic severity, they must have been present at least once per week for one month,
and must have emerged or worsened in the past year. The symptoms must cause
impairment and warrant clinical attention.
Attenuated delusions are described as either suspiciousness, persecutory, or grandiose,
resulting in a lack of trust in others, and a sense of danger. Attenuated delusions, in
contrast to delusions of threshold illness, may lead to loosely organized beliefs about
hostile intentions of others, or danger; however, the delusions are not as fixed as they
become in full blown psychotic illness. Attenuated hallucinations include altered sensory
perceptions such as perception of murmurs, rumblings, or shadows that are disturbing;
but they can be challenged, and skepticism about their reality is likely to be present.
Disorganized communication or speech may be displayed as vague, or confused
explanations, or circumstantial or tangential communication. When severe, but still in
the attenuated range, thought blocking or loose associations may emerge; however, in
contrast to psychotic illness, redirection is possible, and a logical conversation is
typically achieved. Although impairment is present in APS, the individual retains an
awareness and insight into the mental changes that are occurring.
TREATMENT
A recent review of the literature on treatment trials with patients at ultra-high-risk for
psychosis found that early intervention with both psychological interventions and
pharmacological agents can reduce symptoms and either delay or prevent the onset of a
full psychotic illness. Other studies, however, found mixed results for early psychological
or pharmacological interventions to prevent the onset of psychotic illness. One study
found that most patients who became frankly psychotic did so within a few months after
joining the study, making it difficult to determine if these patients were already
exhibiting early signs of onset of schizophrenia when identified as prodromal.
A variety of treatment approaches have been used including treatment with
risperidone, olanzapine, omega-3 polyunsaturated fatty acid (w-3PUFA), cognitivebehavioral therapy (CBT), cognitive therapy (CT), and one using an integrated
psychological intervention (IPI) including cognitive approaches, psychoeducation, and
social skills intervention. A review of treatment effectiveness in APS found that
receiving treatment was associated with lower risk of psychotic illness at 1 year, 2
years, and 3 years. Given the limited data, however, it is not clear which interventions
are most efficacious. Therefore, until additional treatment trials provide efficacy data,
the safest choices for treatment of APS includes psychological interventions rather than
the use of antipsychotic agents. In summary, APS identifies a group of patients with
psychotic-like phenomena that warrant interventions in order to improve their distress
and functional levels. Further study is needed, however, to determine the relationship
between APS and the development of schizophrenia and other psychotic illnesses.
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psychotic disorder: A randomized placebo-controlled trial. Arch Gen Psychiatry. 2010;67:146–14.
Addington J, Epstein I, Liu L, French P, Boydell KM. A randomized controlled trial of cognitive behavioral therapy for
individuals at clinical high risk of psychosis. Schizophr Res. 2011;125:54–61.
Arango C. Attenuated psychotic symptoms syndrome: How it may affect child and adolescent psychiatry. Eur Child Adolesc
Psychiatry. 2011;20:67–70.
Bechdolf A, Wagner M, Ruhrman S, Harrigan S, Veith V, et al. Preventing progression to first episode psychosis in early
initial prodromal states. Br J Psychiatry. 2012;200:22–29.
Fusar-Poli P, Borgwardt S, Bechdolf A, Addington J, Riecher-Rossler A, et al. The psychosis high-risk state. A
comprehensive state-of-the-art review. JAMA. 2013;70:107–120.
Fusar-Poli P, Bechdolf A, Taylor M, Carpenter W, Yung A, McGuire P. At risk for schizophrenia or affective psychosis? A
meta-analysis of DSM/ICD diagnostic outcomes in individuals at high clinical risk. [Published online May 15, 2012].
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clinical risk. Arch Gen Psychiatry. 2012;69:220–229.
Jacobs E, Kline E, Schiffman J. Defining treatment as usual for attenuated psychosis syndrome: A survey of community
practitioners. Psychiatr Serv. 2012;63:1252–1256.
McGlashan TH, Zipursky RB, Perkins D, Addington J, Miller T, et al. Randomized, double-blind trial of olanzapine versus

42 - 31.17b Academic Problem
31.17b Academic Problem
placebo in patients prodromally symptomatic for psychosis. Am J Psychiatry. 2006;163:790–799.
McGorry PD, Nelson B, Amminger GP, Bechdolf A, Francey SM, et al. Intervention in individuals at ultra-high risk for
psychosis: A review and future directions. J Clin Psychiatry. 2009;70:1206–1212.
McGorry PD, Yung AR, Phillips LJ, Yuen HP, Francey S, et al. Randomized controlled trial of interventions designed to
reduce the risk of progression to first episode psychosis in a clinical sample with subthreshold symptoms. Arch Gen
Psychiatry. 2002;59:921–928.
Morrison A, French P, Walford L, Lewis SW, Kilcommons A, et al. Cognitive therapy for the prevention of psychosis in
people at ultra-high risk: Randomised controlled trial. Br J Psychiatry. 2004;185:291–297.
Phillips LJ, Nelson B, Yuen HP, Francey SM, Simmons M. Randomized controlled trial of interventions for young people at
ultra-high risk of psychosis; study design and baseline characteristics. Aust N Z J Psychiatry. 2009;43:818–829.
Preti A. Cella M. Randomized-controlled trails in people at ultra high risk of psychosis: A review of treatment
effectiveness. Schizophr Res. 2010;123:30–36.
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syndrome of psychosis, diagnosis in DSM-V: The debate. Indian J Psychiatry. 2011;53:57–65.
Yung AR, Woods SW, Ruhrmann S, Addington J, Schultze-Lutter F. Wither the attenuated psychosis syndrome? Schizophr
Bull. 2012;38:1130–1134.
Yung AR, Phillips JL, Nelson B, Francey S, Panyuen H, et al. Randomized controlled trial of interventions for young people
at ultra-high risk for psychosis: 6-month analysis. J Clin Psychiatry. 2011;72:430–440.
31.17b Academic Problem
Academic underachievement or failure is a major public health concern in youth,
affecting between 10 percent and 20 percent of youth, with long-ranging associations
with high-risk behaviors and poorer adjustment in early adulthood. The DSM-5 includes
the category Academic or Educational Problem in the section “other conditions that may
be a focus of clinical attention,” since school failure requires clinical intervention and
influences a child’s level of overall functioning.
An investigation of the effects of students’ perception of support from parents,
teachers, and peers showed a correlation with adolescent academic achievement. That
is, adolescents’ perception of support from their teachers and parents was directly
related to their academic achievement, whereas perceived peer support was indirectly
related to actual academic achievement, it contributed to an adolescent’s overall
perception of support, which was correlated to achievement.
Academic difficulties and externalizing behavior problems have been found to coexist
at higher rates than would be expected by chance. This association has been found in
both clinical and epidemiological samples. A longitudinal study of academic
underachievement and behavior problems in school-aged children from 1st grade to 6th
grade found that the combination of academic and behavior problems in the 1st grade
predicted continued academic difficulties and behavioral problems 5 years later. This
combination was more frequently seen in boys than in girls, beginning with the 1st
grade. This is also true for children with reading difficulties, attentional problems, and
behavioral problems.
Behavioral choices and life events can exacerbate academic problems in the absence
of learning disorder and can interfere with lessening academic failures. For example,
once a student perceives that he or she is falling behind academically, a greater
temptation is to replace academic pursuits with other activities, such as drug use. A
recent study assessed the level of, and deterioration in, academic achievement in
relation to initiation of marijuana use among young teens. In a sample of rural teens,
36 percent of boys and 23 percent of girls initiated use of marijuana by the end of the
9th grade and that deteriorating academic performance was a significant predictor of
initiating marijuana use. The hypothesis remaining to be tested is whether timely
intervention to improve academic standing would lower the risk of beginning drug use.
The DSM-5 Academic and Educational problem category is used when a child or
adolescent is having significant academic difficulties that are not caused by a specific
learning disorder or communication disorder or directly related to a psychiatric disorder.
Nevertheless, intervention is necessary because the child’s achievement in school is
significantly impaired, and this has an impact on the well-being of the child and may
negatively influence concurrent psychiatric disorders.
ETIOLOGY
Many risk factors may play a role in academic underachievement or failure, including
genetic factors, and developmental factors such as premature birth, as well as
environmental factors such as level of maternal education. Very preterm children exhibit
difficulties in working memory, which is a crucial ability and skill in learning new
information and developing academic skills.
Children and adolescents troubled by social isolation, identity issues, or extreme
shyness may withdraw from full participation in academic activities. Academic problems
may be the result of a confluence of multiple contributing factors and may occur in
adolescents who were previously high academic achievers. School is the main social and
educational venue for children and adolescents. Success and acceptance in the school
setting depend on children’s physical, cognitive, social, and emotional adjustment.
Children and adolescents’ competency in general coping with developmental tasks are
reflected in their academic and social success in school.
Anxiety can play a major role in interfering with children’s academic performance.
Anxiety can hamper their ability to perform well on tests, to speak in public, and to ask
questions when they do not understand something. Depressed youth also may withdraw
from academic pursuits; they require specific interventions to improve their academic
performance and to treat their depression. Youth consumed by family problems, such as
financial troubles, marital discord in their parents, and mental illness in family
members, may be distracted and unable to attend to academic tasks.
Cultural and economic background can play a role in how well accepted a child feels
in school and can affect the child’s academic achievement. Familial socioeconomic level,
parental education, race, religion, and family functioning can influence a child’s sense
of fitting in and can affect preparation to meet school demands.
Schools, teachers, and clinicians can share insights about how to foster productive and
cooperative environments for all students in a classroom. Teachers’ expectations about
their students’ performance influence these performances. Teachers serve as agents
whose varying expectations can shape the differential development of students’ skills
and abilities. Such conditioning early in school, especially when negative, can disturb
academic performance. A teacher’s affective response to a child, therefore, can prompt
the appearance of an academic problem. Most important is a teacher’s humane
approach to students at all levels of education, including medical school.
DIAGNOSIS
The DSM-5 contains the following statement about academic or educational problem:
This category can be used when an academic or educational problem is the focus of
clinical attention or has an impact on the individual’s diagnosis, treatment, or
prognosis. Problems to be considered include illiteracy or low-level literacy; lack of
access to schooling owing to unavailability or unattainability; problems with academic
performance (e.g., failing school examinations, receiving failing marks, or grades) or
underachievement (below what would be expected given the individual’s intellectual
capacity); discord with teachers, school staff, or other students; and any other problems
related to education and/or literacy.
A 15-year-old 10th grade boy, Greg, with a history of prematurity and ADHD, was
called to a meeting with his parents and school counselor due to his 12-week report
card reflecting failure in two classes, and Cs and Ds in the rest. Until the end of 9th
grade, Greg was a B and C student, and he had been stabilized for many years on his
treatment for ADHD. In the 10th grade, however, since the beginning of the semester,
Greg had not been able to keep up. His counselor had also noticed insidiously
increasing isolative behavior for the past 2 months; previous evaluation of ADHD had
included a full intellectual evaluation, which showed his full-scale intelligence
quotient (IQ) to be 100 and revealed no specific areas of academic weakness.
Discussion with his parents and school counselor revealed that Greg had become upset
when his parents had announced that they would be separating. Greg had not been
doing his homework, and felt that school was no longer relevant for his social life or
future. After getting behind in his classes in the first 6 weeks of the semester, Greg
stopped trying, feeling overwhelmed and demoralized. It was decided that Greg would
given accommodations from his teachers so that he could pass his classes without
having to hand in every assignment that had long passed. Greg would receive daily
tutoring, and was referred for a psychiatric evaluation to determine the severity of his
mood disorder.
TREATMENT
The initial step in determining a useful intervention for an academic problem is an
evaluation of educational problems and psychosocial issues. Identifying and addressing
family-, school-, and peer-related stressors are critical. An individualized evaluation may
be indicated so that specific educational accommodations can be applied.
In children with poor working memory, that is, a poor ability to store and retrieve
information, learning and academic achievement is often impeded. Children with
attention-deficit/hyperactivity disorder, as well as children born prematurely, often
exhibit difficulties in working memory. In an effort to improve working memory in very
preterm children, a computerized working memory training program (Cogmed) is being
evaluated, consisting of 25 sessions of 35 minutes each, to be administered at home.
Participants will undergo a baseline cognitive assessment, and then be randomized to
either an adaptive or placebo version of Cogmed.
Psychosocial intervention may be applied successfully for scholastic difficulties related
to poor motivation, poor self-concept, and underachievement. In some cases, on the
other hand, excessive hours spent in extracurricular activities, such as mandatory
practices for multiple high school sports can result in compromised academic
achievement. Early efforts to relieve academic problems are critical: Sustained problems
in learning and school performance frequently are compounded and precipitate severe
difficulties. Feelings of anger, frustration, shame, loss of self-respect, and helplessness—
emotions that most often accompany school failures—damage self-esteem emotionally
and cognitively, disabling future performance and clouding expectations for success.
Generally, children with academic problems require either school-based intervention or
individual attention.
Tutoring on an individual and frequent basis is an effective technique for increasing
academic production and is typically included in a comprehensive educational program.
Tutoring has proved of value in preparing for standardized multiple choice
examinations, such as the Scholastic Aptitude Test (SAT), as well as for increasing
academic achievement in daily school subjects. Taking examinations, either school-based
or standardized exams repetitively and using relaxation skills are techniques of great
value in diminishing interference of test anxiety.
REFERENCES
Chen JJ. Relation of academic support from parents, teachers and peers to Hong Kong adolescents’ academic achievement:
The mediating role of academic engagement. Genet Soc Gen Psychol Monogr. 2005;131:77.
Henry KL, Smith EA, Caldwell LL. Deterioration of academic achievement and marijuana use onset among rural
adolescents. Health Educ Res. 2007;22:372–384.
Ingesson SG. Stability of IQ measures in teenagers and young adults with developmental dyslexia. Dyslexia. 2006;12:81.
Ivanovic DM, Leiva BP, Perez HT, Olivares MG, Diaz NS, Urrutia MS, Almagia AF, Toro TD, Miller PT, Bosch EO, Larrain
CG. Head size and intelligence, learning, nutritional status and brain development. Head, IQ, learning, nutrition and
brain. Neuropsychologica. 2004;42:1118.
Kempe C, Gustafson S, Samuelsson S. A longitudinal study of early reading difficulties and subsequent problem behaviors.
Scand J Psychol. 2011;52:242–250.
Knifsend CA, Graham S. Too much of a good thing? How breadth of extracurricular participation relates to school-related

43 - 31.17c Identity Problem
31.17c Identity Problem
affect and academic outcomes during adolescence. J Youth Adolescence. 2012;41:379–389.
Lucio R, Hunt E, Bornovalova M. Identifying the necessary and sufficient number of risk factors for predicting academic
failure. Dev Psychol. 2012;48:422–428.
Pascoe L, Roberts G, Doyle LW, Lee KJ, Thompson DK, et al. Preventing academic difficulties in preterm children: A
randomised controlled trial of an adaptive working memory training intervention-IMPRINT study. BMC Pediatr.
2013;13:144–156.
Reinke WM, Herman KC, Petras H, Ialongo NS. Empirically derived subtypes of child academic and behavior problems: Cooccurrence and distal outcomes. J Abnorm Psychol. 2008;36:759–770.
Roberts G, Quach J, Gold L, Anderson P, Richards F, Mensah F, et al. Can improving working memory prevent academic
difficulties? A school-based randomised controlled trial. BMC Pediatr. 2011;11:57–66.
Williams BL, Dunlop AL, Kramer M, Dever BV, Hogue C, et al. Perinatal origins of first-grade academic failure: Role of
prematurity and maternal factors. Pediatrics. 2013;131:693–700.
31.17c Identity Problem
The normative developmental process for an adolescent was conceptualized by the
developmentalist Erik Erikson as an adolescent “crisis of identity.” The transition
between a childhood identity and the process of accepting a more mature sense of self is
the resolution of the “crisis.” Consolidation of identity encompasses cognitive,
psychodynamic, psychosexual, neurobiological, and cultural development. As identity is
confirmed in adolescence, a sense of self-sameness and continuity over time unfolds. The
notion of an identity crisis in adolescence gained widespread attention by clinicians and
the popular media during the late 1960s and early 1970s, when many adolescents
displayed rejection of mainstream cultural values and ideas and demonstrated
alternative lifestyles. The concept of identity disorder as a psychiatric diagnosis was
embraced in the 1980s when the DMS-III was devised, as a disorder usually first evident
in childhood. It was meant to include adolescents who presented with “severe subjective
distress regarding uncertainty about a variety of issues relating to identity” to the point
where they became impaired.
Identity problem is not currently conceptualized as a psychiatric disorder, rather it
refers to uncertainty about issues, such as goals, career choice, friendships, sexual
behavior, moral values, and group loyalties. An identity problem can cause severe
distress for a young person and can lead a person to seek psychotherapy or guidance;
however, it is not included in the DSM-5. It sometimes occurs in the context of such
mental disorders as mood disorders, psychotic disorders, and borderline personality
disorder. A study examining Intolerance of Uncertainty (IU), that is, the tendency to
react negatively to uncertain situations, in 191 adolescents found that IU is correlated
with adolescent social anxiety, worry, and to a lesser extent, depression.
EPIDEMIOLOGY
No reliable information is available regarding overall prevalence; however, factors
increasing risk for identity problems include psychiatric disorders, psychosocial
difficulties, and the pressures of assimilation as an ethnic minority into mainstream
society.
ETIOLOGY
The causes of identity problems often are multifactorial and include the pressures of a
dysfunctional families, the influences of coexisting mental disorders, and the degree to
which adolescents feel integrated into their school and family environments. In general,
adolescents with social skills deficits, major depressive disorder, psychotic disorders, and
other mental disorders report feeling alienated from their peer group and family
members, and experience some turmoil. Children who have had difficulty mastering
expected developmental tasks all along are likely to have difficulty with the pressure to
establish a well-defined identity during adolescence. Erikson used the term identity versus
role diffusion to describe the developmental and psychosocial tasks challenging
adolescents to incorporate past experiences and present goals into a coherent sense of
self.
CLINICAL FEATURES
The essential features of identity problem seem to revolve around the question, “Who
am I?” Conflicts are experienced as irreconcilable aspects of the self that the adolescent
cannot integrate into a coherent identity. As Erikson described identity problem, youth
manifests severe doubting and an inability to make decisions, a sense of isolation, inner
emptiness, a growing inability to relate to others, disturbed sexual functioning, a
distorted time perspective, a sense of urgency, and the assumption of a negative
identity. The associated features frequently include marked discrepancy between the
adolescent’s self-perception and the views that others have of the adolescent; moderate
anxiety and depression that are usually related to inner preoccupation, rather than
external realities; and self-doubt and uncertainty about the future, with either difficulty
making choices or impulsive experiments in an attempt to establish an independent
identity. Adolescents with identity problem may join “outcast” cult-like groups. A study
examining relationships of social context and identity of high-risk Hispanic adolescents
found that school problems and identity confusion among these adolescents were related
to behavioral problems and risk-taking behaviors including alcohol use, illicit drug use,
and sexual risk-taking behaviors.
DIFFERENTIAL DIAGNOSIS
Identity problems must be differentiated from sequelae of a mental disorder (e.g.,
borderline personality disorder, schizophreniform disorder, schizophrenia, or a mood
disorder). At times, what initially seems to be an identity problem may be the
prodromal manifestations of one of these disorders. Intense, but normal, conflicts
associated with maturing, such as adolescent turmoil and midlife crisis, may be
confusing, but they usually are not associated with marked deterioration in school, in
vocational or social functioning, or with severe subjective distress. Considerable
evidence indicates that adolescent turmoil often is not a phase that is outgrown but an
indication of true psychopathology.
COURSE AND PROGNOSIS
The onset of identity problem most frequently occurs in late adolescence, as teenagers
separate from the nuclear family and attempt to establish an independent identity and
value system. The onset usually is characterized by a gradual increase in anxiety,
depression, regressive phenomena (e.g., loss of interest in friends, school, and
activities), irritability, sleep difficulties, and changes in eating habits. The course usually
is relatively brief, as developmental lags respond to support, acceptance, and the
provision of a psychosocial moratorium.
Extensive prolongation of adolescence with continued identity problem can lead to
the chronic state of role diffusion, which may indicate a disturbance of early
developmental stages and the presence of borderline personality disorder, a mood
disorder, or schizophrenia. An identity problem usually resolves by the mid-20s. If it
persists, the person with the identity problem may have difficulty with career
commitments and lasting attachments.
Jenna, an 8-year-old girl, was adopted in Taiwan at 10 months of age by a white
midwestern couple. As she grew, her vulnerability to separations became increasingly
more pronounced. Jenna developed school refusal, and would exhibit outbursts of
rage and misbehavior when she was forced to go to school. She pleaded with her
mother to care for the many aches and pains that plagued her.
By the time she reached adolescence, Jenna had an entrenched habit of cutting and
self-mutilating. She responded to frustration, separations, or perceived threats of
abandonment by cutting herself or burning herself with cigarette lighters. Eventually,
she was able to verbalize the multiple functions that self-injury served for her. She
noted that she was able to stay home from school, be in the company of her mother,
and avoided the stresses of peer interactions. Jenna and her mother began a course of
psychotherapy in which Jenna learned that she would still need to attend school,
regardless of her cutting behavior, and her mother learned to provide incentives for
Jenna to diminish her maladaptive behaviors. Over time, Jenna became more flexible
and realized that she was harming herself, and not others around her. Jenna was able
to return to school, and with the help of her therapist, she was able to discontinue her
self-injurious behaviors and focus on succeeding in school and with her peers.
(Adapted from Efrain Bleiberg, M.D.)
TREATMENT
Considerable consensus exists among clinicians that adolescents experiencing identity

44 - 31.18 Psychiatric Treatment of Children and A
31.18 Psychiatric Treatment of Children and Adolescents

45 - 31.18a Individual Psychotherapy
31.18a Individual Psychotherapy
problems may respond to brief psychosocial intervention. Individual psychotherapy
directed toward encouraging growth and development usually is considered the therapy
of choice. Adolescents with identity problems often feel developmentally unprepared to
deal with the increasing demands for social, emotional, and sexual independence. Issues
of separation and individuation from their families can be challenging and
overwhelming. Enlisting the concepts outlined by Erikson with regard to adolescent
development, psychotherapy may include discussion of adolescent exploration (active
search among alternatives for activities and friendships that fit) and commitment
(demonstrated investment) in activities that promote independence and autonomy.
Treatment is aimed at helping these adolescents develop a sense of competence and
mastery about necessary social and vocational choices. A therapist’s empathic
acknowledgment of an adolescent’s struggle can be helpful in the process.
REFERENCES
Bleiberg E. Identity problem and borderline disorders in children and adolescents In: Sadock BJ, Sadock VA, eds. Kaplan &
Sadock’s Comprehensive Textbook of Psychiatry. 8th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2005:3457.
Boelen PA, Vrinssen I, van Tulder F. Intolerance of uncertainty in adolescents. J Nerv Ment Dis. 2010;198:194–200.
Chabrol H, Leichsenring F. Borderline personality organization and psychopathic traits in nonclinical adolescents:
Relationship of identity diffusion, primitive defense mechanism and reality testing with callousness and impulsivity
traits. Bull Menninger Clin. 2006;70:160.
Erikson EH. Identity and the life cycle: Selected papers. Psychol Issues. 1959;1:1.
Ivanovic DM, Leiva BP, Perez HT, Olivares MG, Diaz NS, Urrutia MS, Almagia AF, Toro TD, Miller PT, Bosch EO, Larrain
CG. Head size and intelligence, learning, nutritional status and brain development. Head, IQ, learning, nutrition and
brain. Neuropsychologica. 2004;42:1118.
Mackinnon SP, Nosko A, Pratt MW, Norris JE. Intimacy in young adults’ narratives of romance and friendship predicts
Eriksonian Generativity: A mixed method analysis. J Personality. 2011;79:3.
Marcia J, Jossleson R. Eriksonian personality research and its implications for psychotherapy. J Personality. 2012;81:617–
629.
Rossi NE, Mebert CJ. Does a quarterlife crisis exist? J Genet Psychol. 2011;172:141–161.
Schwartz SJ, Mason CA, Pantin H, Wang W, Brown CH, et al. Relationships of social context and identity to problem
behavior among high-risk Hispanic adolescents. Youth Sci. 2009;40:541–570.
Thomas JJ. Adolescents’ conceptions of the influence of romantic relationships on friendships. J Genet Psychol.
2012;173:198–207.
31.18 Psychiatric Treatment of Children and Adolescents
31.18a Individual Psychotherapy
Individual psychotherapy with children and adolescents generally begins by establishing
rapport through developmentally appropriate psychoeducation regarding the target
symptoms and disorders to be addressed. As a rule, the younger the child, the more
extensively family members participate in the treatment. Even among adolescents,
family members are often directly involved in some components of the treatment in
order to achieve the maximum benefit. In recent years, randomized clinical trials have
provided a body of literature to support the efficacy of cognitive-behavioral
psychotherapy for a wide range of childhood psychiatric disorders including obsessivecompulsive disorder (OCD), anxiety disorders, and depressive disorders. Additional
therapeutic approaches including supportive, psychodynamic, and more recently,
mindfulness-based stress reduction (MBSR), mindful meditation, and yoga are sometimes
incorporated into psychosocial treatments, creating an “eclectic” mixture. The initial
goal of any psychotherapeutic strategy is to establish a working relationship with the
child or adolescent. In general, successful individual psychotherapeutic interventions
with youth also necessitate establishing a therapeutic rapport with parents. To establish
a therapeutic relationship with a child of any age requires a knowledge of normal
development as well as an understanding of the context in which the symptoms
emerged. Individual psychotherapy with children focuses on improving adaptive skills
as well as diminishing specific symptomatology. Most children do not seek psychiatric
treatment; typically, they are brought to a psychotherapist due to symptoms noted by a
family member, schoolteacher, or, pediatrician. Children often believe that they are
being taken for treatment because of their misbehavior or as a punishment for
wrongdoing.
Children and adolescents are the most accurate informants of their own thoughts,
feelings, moods, and perceptual experiences; however, external behavior problems are
often more accurately identified by parents or teachers. Psychotherapists for children
frequently function as their advocates in interactions with schools, after-school
programs, and community organizations. Individual psychotherapy with a child often
takes place in conjunction with family therapy, group therapy, educational remediation,
and psychopharmacological interventions.
PSYCHOTHERAPEUTIC TECHNIQUES AND UNDERLYING THEORIES
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is an amalgam of behavioral therapy and cognitive
psychology. It emphasizes how children may use thinking processes and cognitive
modalities to reframe, restructure, and solve problems. A child’s distortions are
addressed by generating alternative ways of dealing with problematic situations.
Cognitive-behavioral strategies have been shown in multiple studies to be effective in
the treatment of child and adolescent mood disorders, OCD, and anxiety disorders. A
recent study compared a family-focused CBT, the “Building Confidence Program,” with
traditional child-focused CBT, with minimal family involvement for children with
anxiety disorders. Both interventions included coping skills training and in vivo
exposure, but the family CBT intervention also included parent communication training.
Compared with the child-focused CBT, family CBT was associated with greater
improvement on independent evaluators’ ratings and parent reports of child anxiety,
but not on children’s self-reports of improvement. Family-focused CBT has also been
used in the treatment of pediatric bipolar disorder with promising results.
One of the limiting factors in providing CBT to children with OCD, anxiety disorders,
and depressive disorders is the lack of sufficient numbers of trained child and adolescent
cognitive-behavioral therapists. A recent study addressed the feasibility of combining a
CBT via clinic-plus-Internet treatment. Children who received the clinic-plus-Internet
treatment showed significantly greater reductions in anxiety from pretreatment to
posttreatment, and maintained gains for a period of 12 months compared with children
who received no active treatment, but were on a wait-list. The Internet treatment was
acceptable to families and dropout rate was minimal.
Psychoanalysis and Psychoanalytic Therapy
Child Psychoanalysis.
Child psychoanalysis, an intensive, uncommon form of
psychoanalytic psychotherapy, involves three to four sessions a week and places an
emphasis on unconscious resistance and defenses. In this approach, therapists anticipate
unconscious resistance and allow transference manifestations to mature to a full
transference neurosis, through which neurotic conflicts are ultimately resolved.
Interpretations of dynamically relevant conflicts are emphasized in psychoanalytic
descriptions, and elements that are predominant in other types of psychotherapies are
included. In all psychotherapy, children should derive support from a consistently
understanding and accepting relationship with their therapists. Remedial educational
guidance is provided when necessary.
In classic psychoanalytic theory, exploratory psychotherapy is applicable to patients
of all ages and involves reversing the evolution of psychopathological processes. A
principal difference noted with advancing age is a sharpening distinction between
psychogenetic and psychodynamic factors. The younger the child, the more the genetic
and dynamic forces are intertwined. The development of pathological processes
generally is believed to begin with experiences that have proved to be particularly
significant to children and to have affected them adversely. Although in one sense the
experiences were real, in another sense, they may have been misinterpreted or
imagined. In any event, to children, these were traumatic experiences that caused
unconscious complexes. Being inaccessible to conscious awareness, the unconscious
elements readily escape rational adaptive maneuvers and are subject to pathological
misuse of adaptive and defensive mechanisms. The result is the development of conflicts
leading to distressing symptoms, character attitudes, or patterns of behavior that
constitute the emotional disturbance.
Psychoanalytic Psychotherapy.
Psychoanalytic psychotherapy, a modified form
of psychoanalysis, is expressive and exploratory and endeavors to reverse the evolution
of emotional disturbance through reenacting and desensitizing traumatic events. This is
achieved by having children freely express thoughts and feelings in an interview-play
situation. Ultimately, therapists help patients understand feelings that they may have
avoided, as well as fears and wishes that have been self-defeating.
Behavioral Therapy
All behavior, whether adaptive or maladaptive, is a consequence of the same basic
principles of behavior acquisition and maintenance. Behavior is either learned or
unlearned. What renders behavior abnormal or disturbed is its social significance.
Although theories and their derivative therapeutic intervention techniques have become
increasingly complex over the years, all learning can be subsumed in two global basic
mechanisms. One is classic respondent conditioning, akin to Ivan Pavlov’s famous
experiments, and the second is operant instrumental learning, which is associated with B.
F. Skinner; the latter is also basic to both Edward Thorndike’s law of effect, which is
about the influence of reinforcing consequences of behavior, and to Sigmund Freud’s
pain-pleasure principle. Behavior therapy assigns the highest priority to the immediate
precipitants of behavior and deemphasizes remote underlying causal determinants that
are important in the psychoanalytic tradition.
Respondent conditioning theory asserts that only two types of abnormal behavior
exist: behavioral deficits that result from a failure to learn, and deviant maladaptive
behavior that is a consequence of learning inappropriate things. Such concepts have
always been an implicit part of the rationale underlying all child psychotherapy.
Intervention strategies derive much of their success, particularly with children, from
rewarding previously unnoticed good behavior, thereby highlighting it, and making it
occur more frequently than in the past.
Family Therapy
Family therapies have been influenced by conceptual contributions from systems theory,
communications theory, object relations theory, social role theory, ethology, and
ecology. The core premise entails the idea of a family as a self-regulating, open system
that possesses its own unique history and structure. This structure is constantly evolving
as a consequence of dynamic interaction between the family’s mutually interdependent
systems and persons who share a complementarity of needs. From this conceptual
foundation, a wealth of ideas has emerged under rubrics such as family development,
life cycle, homeostasis, functions, identity, values, goals, congruence, symmetry, myths,
and rules; roles, such as spokesperson, symptoms-bearer, scapegoat, affect barometer,
pet, persecutor, victim, arbitrator, distractor, saboteur, rescuer, breadwinner,
disciplinarian, and nurturer; structure, such as boundaries, splits, pairings, alliances,
coalitions,
enmeshed,
and
disengaged;
and
double
bind,
scapegoating,
and
mystification. Increasingly, appreciation of the family system sometimes explains why a
minute therapeutic input at a critical junction may result in far-reaching changes.
Justin was a 14-year-old boy from a middle-class family enrolled in the 9th grade at
a public school. He was brought in by his parents for treatment of a long-standing
history of shyness and anxiety in social situations, which was more evident now that
most of his peers were getting together after school and he was spending his
weekends alone. Evaluation revealed social anxiety disorder as the primary disorder.
Justin was initially resistant to treatment despite his wish to feel more comfortable
with other people and in social situations with peers. After much discussion and some
pressure from his parents, Justin began to attend a cognitive-behavioral group
treatment for adolescents with social anxiety. Justin became mildly agitated each time
he was scheduled for a session; however, once he arrived, he was able to participate.
He began, a 16-session course of treatment combining education, cognitive
restructuring, behavioral exposure, relapse prevention, and four sessions of parent
involvement. As treatment progressed, Justin increased his visibility at school, and
even attended a school football game with a few peers. Justin told his therapist that
he wanted to go to the next school dance but was afraid that he would be embarrassed
and would have to go home before the dance was over. The therapists designed
several exposures whereby the various things that could happen at a dance were
presented to Justin, including being offered alcohol or drugs, having a good time
dancing, being left alone or ignored by his friends, or being turned down if he asked a
girl to dance with him. As it turned out, Justin’s few school acquaintances ignored him
and left him at the dance. Justin, prepared for this less-than-desired outcome in his
group experience, asked two girls to dance, and forced himself to interact with other
peers. To his surprise, despite his shyness, one girl agreed to dance with him. He
considered the evening a success. Justin subsequently went to another social event
with a new group of peers who seemed more accepting of him. In Justin’s case, the
importance of practicing responses to potential rejections in the safety of his
treatment group was crucial to his success at the dance, and it increased his
motivation to continue treatment. Through his treatment, Justin became more and
more appropriately prepared, through behavioral exposure and practice, to handle
what might previously have been awkward and discouraging situations. (Adapted
from a case contributed by Anne Marie Albano, Ph.D.)
Tim was a 3-year-old child, developing normally and quite verbal, until he started
preschool, at which time he suddenly refused to speak at all outside his home. Tim had
begun preschool shortly after his parents had separated and his father had left the
home. Prior to his parents’ separation, Tim was highly verbal and developmentally
ahead of many children his age in language skill. Although he was observed
constantly in preschool, he was never “caught” speaking to peers. He was described as
a compliant child who didn’t smile as easily as the other children, who played with
others and followed requests without problem but would not speak. During his
psychiatric evaluation, it was revealed that Tim enjoyed eating Froot Loops in a
favorite cup as a treat. Treatment was designed to provide incentive for speaking
through the delivery of a reinforcement of high value, the Froot Loops. Hence, Froot
Loops became available only in the preschool and the therapist’s office and,
temporarily, were not available in his home. The therapist enacted a process of
graduated shaping of communication behaviors—first nonverbal and then vocal
noises—and trained the preschool teacher to do the same. Froot Loop boxes were kept
in full view of Tim at all times during the initial phase of treatment and, when he was
“caught” gazing at the box, the therapist or teacher would prompt Tim for
acknowledgment that he wanted the treat. Pointing, looking, and nodding in their
direction resulted in receiving four Froot Loops. Next, Tim was asked to make a sound
or ask for the Froot Loop to receive the reward. This step was accomplished as he
grunted and eventually said, “Loop.” Finally, prompts to ask for the Froot Loops in a
sentence were enacted, and Tim complied with this demand. This phase of treatment
took 2 days at the preschool and 2 hours of therapy to accomplish. Eventually, the
boxes of Froot Loops were removed from the environments, but the teacher kept the
cereal with her to deliver four Loops whenever Tim made sounds or spoke in school.
This shaping procedure took an additional 3 days to result in Tim speaking to the
teacher and peers, albeit in short sentences. The treat was faded—that is, delivered on
a variable ratio schedule of every three to eight times that he spoke, to promote
further speaking and decrease the association with the treat. By the end of the second
week of training, Tim was speaking at the level he had achieved prior to his parents’
separation. Tim’s parents were cautioned to allow Tim to speak for himself in social
situations (e.g., order his own food at a restaurant, say hello to others, make his own
requests before providing a treat) as a way of relapse prevention. (Adapted from a
case contributed by Anne Marie Albano, Ph.D.)
Jenna was a 13-year-old teen with a family history of anxiety and depression. Her
parents brought her to treatment because of recurrent obsessions involving
contamination and germs, with corresponding compulsions during which she had
convinced her parents to check her food, while she washed her hands repeatedly until
they became raw and bleeding. Evaluation revealed a fear that, unless her parents
checked her food for bugs or germs, the meal was likely contaminated. Jenna’s
parents, attempting to ease her fear, would physically pull apart her food and
examine it to her satisfaction, often spending upward of 1 hour before each meal.
However, this process caused much distress and discord between Jenna and her
family. Jenna’s hand washing had generalized to almost every daily activity—after
opening a door, reading a book, using a pencil, or touching any object that she
deemed dirty. Jenna’s evaluation led to a recommendation of behavioral therapy
utilizing exposure and response prevention. This consisted of formulating a hierarchy
of her obsessions and compulsions, from the least upsetting (checking food prepared
by her mother) to the most upsetting (touching something that was wet or slimy and
then touching her mouth). Systematically, the therapist engaged Jenna first in a series
of imaginal exposures to a scene (e.g., you take a bite of hamburger and something
tastes gritty to you and you realize that your mom did not check the burger) until her
anxiety dropped to an acceptable level. The drop in anxiety typically took
approximately 25 minutes. Next, the scene was enacted in vivo, whereby foods were
introduced with “contaminants” in them (e.g., putting pieces of uncooked rice into the
burger to mimic “grit”), and Jenna ate the food without having her parents check. As
treatment progressed, Jenna learned that her chronic fear of becoming sick was not
likely to occur. Similarly, washing rituals were addressed by having her touch items
with various substances coating them and then touching her face and mouth. Jenna’s
treatment entailed a 14-session program during which her parents were taught to
assist her with these exposures in the home. Her parents were also instructed to
refrain from engaging in her rituals. Relapse prevention plans were added to expand
her range of food choices and situational contexts (cafeterias, food stands,
restaurants) for exposure. By the end of treatment, Jenna was eating without the need
for checking and with minimal anxiety. Moreover, she was engaging in a wide range
of activities without the need to wash after touching each object. (Adapted from a
case contributed by Anne Marie Albano, Ph.D.)
Supportive Psychotherapy
Supportive psychotherapy is particularly helpful in enabling a well-adjusted youngster
to cope with emotional turmoil engendered by a crisis. It also is used to treat
disturbances related to traumatic experiences, losses, mild mood disorders, and mild
forms of anxiety.
A 6-year-old boy was brought for treatment because of long-standing severe
aggression and destruction of property. In addition to an evaluation for medication,
the child was seen in twice-weekly psychoanalytically oriented psychotherapy. The
beginning sessions were marked by the repeated need to set limits and contain the
child’s aggressive behaviors. Two months into treatment, he began to pump himself
up, roar, and announce that he was “the Incredible Hulk.” He would then proceed to
stomp around the play therapy room, attempting to destroy the toys. The therapist
then suggested, “You know you can’t really be the Hulk. You can pretend that you are
the Hulk, and then maybe we can play this together.” After a number of similar
exchanges, the child gradually allowed the therapist to join in the game with him.
Over the next 6 months, the boy was able to modulate his behavior in that he was
able to “play the part” of the Hulk, but without destroying property, and limiting
himself to actions that were less aggressive. He was able to understand that he could
pretend to be the Hulk without literally trying to be the Hulk. (Adapted from a case
contributed by David L. Kaye, M.D.)
Combined Psychodynamic and Behavioral Therapy
Probably the most vivid examples of the integration of psychodynamic and behavioral
approaches are demonstrated in the milieu of child and adolescent inpatient, residential,
and partial hospital or intensive outpatient treatment programs. Behavioral change is
initiated in these settings, and its repercussions are explored concurrently in individual
psychotherapeutic sessions, so that the action in one arena and the information
stemming from it augment and illuminate what transpires in the other arena.
Alternative and Complementary Psychosocial interventions:
Mindfulness-Based Stress Reduction (MBSR), Mindfulness Meditation,
and Yoga
Mindfulness-Based Stress Reduction (MBSR), a psychoeducational training program
leading to applying the practice of mindfulness into everyday life was studied in
adolescent psychiatric outpatients. Mindfulness practices focus on paying sustained
attention to moment-to-moment stimuli without engaging in cognitive judgments or selfcriticism, and promoting an attitude of acceptance. In adults, this practice has been
shown to facilitate improved coping and decrease symptoms of anxiety, stress, and in
some cases, self-harming behaviors. The current study was a trial of approximately 100
adolescents aged 14 to 18, with heterogeneous diagnoses, who were randomized to a
waitlist control group receiving treatment as usual (TAU), which consisted of individual
or group therapy, or to manualized sessions of MBSR for 2 hours per week for 8 weeks.
The MBSR group was led by trained instructors who facilitated the use of mindfulness
practices by the participants during formal sessions and encouraged practice at home as
well. The participants were tested diagnostically at the end of the 8-week study period
and again at 3 months following the end of the study. The results found that both the
MBSR and the TAU groups reported significantly reduced anxiety, depressive, and
somatization symptoms, and improved self-esteem; but only the MBSR group reported
significant declines in perceived stress, obsessive symptoms, and interpersonal
problems. Furthermore, although more than 45 percent of the MBSR group showed
changes in diagnoses at the end of the study (such as no longer meeting criteria for a
mood disorder) none of the TAU group was found to have remitted from a diagnosis.
Mindfulness meditation practices have been applied in various forms to a multitude of
psychiatric conditions including mood disorders, chronic pain syndromes, anxiety
disorder, and ADHD. Mindfulness, according to Kabat-Zinn, is characterized by paying
complete attention to the present moment without judgment, with an ability to be
aware of inner and outer experiences in the present. There are many forms of
meditation which incorporate mindfulness, and both MBSR, and Mindfulness-Based
Cognitive Therapy (MBCT) developed by Teasdale, can be considered forms of
mindfulness meditation. There is evidence based on neuroimaging studies that
mindfulness meditation can induce specific brain states. One study indicated that
Vipassana meditation is associated with activation of the rostral anterior cingulate
cortex as well as the dorsal medial prefrontal cortex. There is evidence to suggest that
mindfulness meditations can improve attention, and that these changes may lead to
clinically important improvements.
Yoga originated in ancient India, and while there are many varieties, key components
include physical postures, controlled breathing, deep relaxation, and meditation.
Randomized controlled trials using yoga have provided evidence of its benefit as an
adjunctive intervention in mild depression, sleep disturbance, and attention problems.
Clinical trials comparing yoga to cooperative game playing or physical exercises in
children with ADHD found moderate improvements in ADHD symptoms when yoga was
added as an adjunct to medication. There is some evidence suggesting that yoga may be
beneficial as an adjunctive intervention for mild depression, even in the absence of
medication and potentially for schizophrenia, as an adjunct to medication.
THE ROLE OF PLAY
Observing play and engaging in play with children can be extremely informative in
assessing developmental abilities, and in understanding sensitive situations. This is
particularly relevant for young children, and for children who have experienced trauma,
which is difficult to describe in words.
Although the choices of play material vary among therapists, the following equipment
can constitute a well-balanced playroom or play area: multi-generational families of
dolls of various races; dolls representing special roles and feelings, such as police officer,
doctor, and soldier; dollhouse furnishings with or without a dollhouse; toy animals;
puppets; paper, crayons, paint, and blunt-ended scissors; a sponge-like ball; clay or
something comparable; tools such as rubber hammers, rubber knives, and guns; building
blocks, cars, trucks, and airplanes; and eating utensils. The toys should enable children
to communicate through play. Therapists should avoid fragile objects that can break
easily, that can result in physical injury to a child, or that can increase a child’s guilt.
Psychotherapy with children and adolescents generally is more directed and active
than it is with adults. Children usually cannot synthesize histories of their own lives, but
they are excellent reporters of their current internal states. Even with adolescents, a
therapist often takes an active role, is somewhat less open-ended than with adults, and
offers more direction and advocacy than with adults.
Nurturing and maintaining a therapeutic alliance may require educating children
about the process of therapy. Another educational intervention may entail assigning
labels to affects that have not been part of a youngster’s experience.
The temptation for therapists to offer themselves as a quasi-parent role model for
children may stem from helpful educational attitudes toward children. Although this
may sometimes be an appropriate therapeutic strategy, therapists should not lose sight
of the potential pitfalls of engaging in a highly parental role with their child and
adolescent patients.
PARENTS AND FAMILY MEMBERS
Parents and family members are involved in child psychotherapy to varying degrees.
For preschool-age children, the entire therapeutic effort may be directed toward the
parents, without any direct treatment of the child. At the other extreme, children can be
treated in psychotherapy without any parental involvement beyond the payment of fees
and transporting the child to the therapy sessions. Most practitioners, however, prefer
to maintain an alliance with parents to obtain additional information about the child.
Probably the most frequent parental arrangements are those developed in child
guidance clinics—that is, parent guidance focused on the child or the parent–child
interaction and therapy for the parents’ own individual needs concurrent with the
child’s therapy. Parents may be seen by their child’s therapist or by someone else.
Recently, increasing efforts have been made to shift the focus from the child as the
primary patient to the child as the family’s emissary to the clinic. In such family
therapy, all or selected members of the family are treated simultaneously as a family
group. Although the preferences of specific clinics and practitioners for either an
individual or a family therapeutic approach may be unavoidable, the final decision
regarding which therapeutic strategy or combination to use should be derived from the
clinical assessment.
CONFIDENTIALITY
The issue of confidentiality takes on greater meaning as children grow older. Very
young children are unlikely to be as concerned about this issue as are adolescents.
Confidentiality usually is preserved unless a child is believed to be in danger or to be a
danger to someone else. In other situations, a child’s permission usually is sought before
a specific issue is raised with parents. Advantages exist to creating an atmosphere in
which children can feel that all words and actions are viewed by therapists as
simultaneously both serious and tentative. In other words, children’s communications do
not bind therapists to a commitment; nevertheless, they are too important to be
communicated to a third party without a patient’s permission. Although such an attitude
may be implied, sometimes therapists should explicitly discuss confidentiality with
children. Most of what children do and say in psychotherapy is common knowledge to
the parents.
The therapist should try to enlist parents’ cooperation in respecting the privacy of
children’s therapeutic sessions. The respect is not always readily honored, because
parents are naturally curious about what transpires, and they may be threatened by a
therapist’s apparently privileged position.
Routinely reporting to a child the essence of communications with third parties about
the child underscores the therapist’s reliability and respect for the child’s autonomy. In
certain treatments, the report can be combined with soliciting the child’s guesses about
these transactions. A therapist also may find it fruitful to invite children, particularly
older children, to participate in discussions about them with third parties.
INDICATIONS
Psychotherapy usually is indicated for children with psychiatric symptoms or disorders
that interfere with their ability to function at home and in school, and causes significant
distress. A developmental perspective always informs psychosocial interventions with a
given child, so that it matches that child’s cognitive function and emotional maturity. If
a psychotherapy situation is not effective, it is important to determine whether the
therapist and patient are poorly matched, whether the type of psychotherapy is
inappropriate to the nature of the problems, and whether the child is cognitively

46 - 31.18b Group Psychotherapy
31.18b Group Psychotherapy
inappropriate for the treatment.
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Albano AM. Cognitive-behavioral psychotherapy for children and adolescents. In: Sadock BJ, Sadock VA, Ruiz P, eds.
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins;
2009:3721.
Balasubramaniam M, Telles S, Doraiswamy PM. Yoga on our minds: A systematic review of yoga for neuropsychiatric
disorders. Front Psychiatry. 2012;3:117.
Biegel GM, Brown KW, Shapiro SL, Schubert CM. Mindfulness-based stress reduction for the treatment of adolescent
outpatients: A randomized clinical trial. J Consult Clin Psychol. 2009;77:855–866.
Chiesa A, Serretti A. A systematic review of neurobiological and clinical features of mindfulness meditations. Psychol
Med.2010;40:1239–1252.
Kaye DL. Individual psychodynamic psychotherapy. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s
Comprehensive Textbook of Psychiatry. 9th ed. Vol. II Philadelphia: Lippincott Williams & Wilkins; 2009:3707.
Kober D, Martin A. Inpatient psychiatric, partial hospital, and residential treatment for children and adolescents. In: Sadock
BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II, Philadelphia:
Lippincott Williams & Wilkins; 2009:3766.
Kratochvil CJ, Wilens TE. Pediatric psychopharmacology. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s
Comprehensive Textbook of Psychiatry. 9th ed. Vol. II Philadelphia: Lippincott Williams & Wilkins; 2009:3756.
Pumariega A. Community-based treatment. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive
Textbook of Psychiatry. 9th ed. Vol. II, Philadelphia: Lippincott Williams & Wilkins; 2009:3772.
Rostain AL, Franklin ME. Brief psychotherapies for childhood and adolescence In: Sadock BJ, Sadock VA, Ruiz P, eds.
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins;
2009:3715.
Rubia K. The neurobiology of meditation and its clinical effectiveness in psychiatric disorders. Biol Psychiatry. 2009;82:1–
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Schlozman SC, Beresin EV. The treatment of adolescents. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s
Comprehensive Textbook of Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins; 2009:3777.
Siqueland L, Rynn M, Diamond GS. Cognitive behavioral and attachment based family therapy for anxious adolescents:
Phase I and II studies. J Anxiety Disord. 2005;19:361.
Spence SH, Holmes JM, March S, Lipp OV. The feasibility and outcome of clinic plus internet delivery of cognitivebehavior therapy for childhood anxiety. J Consult Clin Psychol. 2006;74:614.
Zylowska L, Ackerman DL, Yang MH, Futrell JL, Horton NL, Hale TS, Pataki C, Smalley SL. Mindfulness meditation training
in adults and adolescents with ADHD: A feasibility study. J Attention Dis. 2008;11:737–746.
31.18b Group Psychotherapy
Therapeutic groups for children and adolescents are varied in terms of problems
addressed, age of patients, group structure, and therapeutic approach implemented.
Group formats have been used to treat a broad range of clinical symptoms, including
anger-management for aggressive children and adolescents, social skills improvement,
support groups for survivors of childhood sexual abuse, and other traumatic events such
as the September 11th World Trade Center tragedy. In addition, groups have also been
settings for the treatment of adolescents with social anxiety and OCD, and youth with
depressive disorders. Groups have successfully used cognitive-behavioral techniques to
treat childhood anxiety disorders, adolescents with substance abuse, and youth with
specific learning disorders. Support groups for youth exposed to loss have provided
evidence of efficacy, including data from a study investigating the benefits of a
psychotherapy group for adolescent survivors of homicide victims. Group therapies can
be utilized with children of all ages using developmentally appropriate formats. The
groups can focus on behavioral, educational, and social skills and psychodynamic issues.
The mode in which the group functions depends on children’s developmental levels,
intelligence, and problems to be addressed. In behaviorally oriented and cognitivebehavioral groups, the group leader is a directive, active participant who facilitates
prosocial interactions and desired behaviors. In groups using psychodynamic
approaches, the leader may monitor interpersonal interactions less actively than in
behavior therapy groups.
Gathering children and adolescents into groups may lead to greater psychological
impact than treating them individually. A number of factors, described by Irving Yalom,
may contribute to the effectiveness of groups. These factors include the following
theoretical components:
Hope: Hope may be generated by gathering with others who are experiencing
similar difficulties and by observing others actively mastering the problems.
Universality: Children and adolescents with psychiatric disorders often feel isolated
and alienated from peers. Working together in groups may diffuse the isolation
and help children and adolescents view their disorder as only a small part of
their overall identity.
Imparting Information: Children and adolescents are familiar with a format of
gaining new information in a group setting, such as in school. The group therapy
format provides an opportunity to reinforce learning when the child or
adolescent “helps” or demonstrates what he or she has learned to peers.
Altruism: Helping other peers in a group setting by supporting them and
identifying with their struggles can improve a child or adolescent’s self-esteem
and help them gain a sense of mastery over their own issues.
Improved Social Skills: Group therapy is a safe format in which children and
adolescents with poor social skills can improve their interpersonal and
communication abilities under the supervision of a leader and with peers who
also benefit from the practice scenarios.
Groups can be highly effective modalities to provide peer feedback and support to
children who are either socially isolated or unaware of their effects on their peers.
Groups with very young children generally are highly structured by the leader and use
imagination and play to foster socially acceptable peer relationships and positive
behavior. Therapists must be keenly aware of the level of children’s attention span and
the need for consistency and limit setting. Leaders of preschool-age groups can model
supportive adult behavior in meaningful ways for children who have been deprived or
neglected. School-age children’s groups can be single sex or include both boys and girls.
School-age children are more sophisticated in verbalizing their feelings than
preschoolers, but they also benefit from structured therapeutic games. Children of school
age need frequent reminders about rules, and they are quick to point out infractions of
the rules to each other. Interpersonal skills can be addressed nicely in group settings
with school-age children.
Same-sex groups are often used among adolescents. Physiological changes in early
adolescence and the new demands of high school lead to stress that may be ameliorated
when groups of same-age peers compare and share. In older adolescence, groups more
often include both boys and girls. Even with older adolescents, the leader often uses
structure and direct intervention to maximize the therapeutic value of the group.
Adolescents who are feeling dejected or alienated may find a special sense of belonging
in a therapy group.
Keith was a high-functioning, 14-year-old boy diagnosed with autism spectrum
disorder. Keith was an awkward-looking adolescent who seemed younger than his
chronological age. His academic level was above average, but his social development
was odd. His pedantic speaking style contributed considerably to his social isolation,
particularly after starting 7th grade. He was referred to a group of adolescents with
social skills problems in order to improve his ability to make friends and have more
successful social interactions. Initially, Keith limited his participation to monosyllabic
answers to direct questions, and then he would go back to reading a book on the
history of Napoleon, his favorite subject and object of fascination. Group members
chose to ignore him after a while. Over a period of several weeks, his interest in the
book seemed to abate. Keith brought it, but it remained unopened on his lap. He
would make an occasional remark, which was often not related to the topic of
conversation. The other adolescents in the group seemed to respect his “differentness”;
however, it was still difficult to have successful social interactions. Two months later a
very shy 13-year-old boy joined the group. After a few sessions Keith developed an
unexpected interest in the newer member and sat near him and encouraged him to
interact with the group. Soon Keith was not bringing a book any longer and was more
involved with group members. In response to the group leader’s guidance and practice
exercises in the group, Keith learned to respond to social cues in a more appropriate
manner, and although he continued having morbid preoccupations with power and a
fascination with Napoleon, he was able to converse with group members about more
pertinent social topics. Keith’s increasing social skills and greater interest in people
was clinically evident. Social skills practice within the group became a most
significant tool to help Keith with his interpersonal interactions in school and with his
family. (Adapted from a case contributed by Alberto C. Serrano, M.D.)
PRESCHOOL-AGE AND EARLY SCHOOL-AGE GROUPS
Work with a preschool-age group usually is structured by a therapist through the use of
a particular technique, such as puppets or artwork. In therapy with puppets, children
project their fantasies onto the puppets in the same way as in ordinary play. Here, the
group aids the child less by interaction with other members than by action with the
puppets.
In play group therapy, the emphasis rests on children’s interactional qualities with
each other and with the therapist in the permissive playroom setting. A therapist should
be a person who can allow children to produce fantasies verbally and in play but who
can also use active restraint when children undergo excessive tension. The toys are the
traditional ones used in individual play therapy. The children use the toys to act out
aggressive impulses and to relive their home difficulties with group members and with
the therapist. The children selected for group treatment have a common social hunger
and need to be like their peers and be accepted by them. Selected children usually
include those with phobias, effeminate boys, shy and withdrawn children, and children
with disruptive behavior disorders.
Modifications of these criteria have been used in group psychotherapy for autistic
children, parent group therapy, and art therapy. A modification of group psychotherapy
has been used for toddlers with physical disabilities who show speech and language
delays. The experience of twice-weekly group activities involves mothers and children in
a mutual teaching–learning setting. This experience has proved effective for mothers
who received supportive psychotherapy in the group experience; their formerly hidden
fantasies about their children emerged and were dealt with therapeutically.
SCHOOL-AGE GROUPS
Activity group psychotherapy is based on the idea that corrective experiences in a
therapeutically conditioned environment may increase appropriate social interactions
between children and with adults. The format uses interview techniques, verbal
explanations of fantasies, group play, work, and other communications. In this type of
group psychotherapy, children verbalize in a problem-oriented manner, with the
awareness that problems brought them together and that the group aims to change
them. They report dreams, fantasies, daydreams, and unpleasant experiences.
Therapists vary in their use of time, co-therapists, food, and materials. Most groups
meet after school for at least 1 hour, although other group leaders prefer a 90-minute
session. Some therapists serve food during the last 10 minutes; others prefer serving
times when the children are together for talking. Food, however, does not become a
major feature and is never central to the group’s activities.
PUBERTAL AND ADOLESCENT GROUPS
Group therapy methods similar to those used in younger-age groups can be modified to
apply to pubertal children, who are often grouped monosexually. Their problems
resemble those of late latency-age children, but they (especially the girls) are also
beginning to feel the effects and pressures of early adolescence. Groups offer help
during a transitional period; they seem to satisfy the social appetite of preadolescents,
who compensate for feelings of inferiority and self-doubt by forming groups. This
therapy takes advantage of the influence of the socialization process during these years.
Because pubertal children experience difficulties in conceptualizing, pubertal therapy
groups tend to use play, drawing, psychodrama, and other nonverbal modes of
expression. The therapist’s role is active and directive.
Activity group psychotherapy has been the recommended group therapy for pubertal
children who do not have significantly disturbed personality patterns. The children,
usually of the same sex and in groups of not more than eight, freely engage in activities
in a setting especially designed and planned for its physical and environmental
characteristics. Samuel Slavson, a pioneer in group psychotherapy, pictured the group as
a substitute family in which the passive, neutral therapist becomes the surrogate for
parents. The therapist assumes various roles, mostly in a nonverbal manner, as each
child interacts with the therapist and other group members. Currently, however,
therapists tend to see the group as a form of peer group, with its attendant socializing
processes, rather than a reenactment of the family.
Late adolescents, 16 years of age and older, often may be included in groups of
adults. Group therapy has been useful in the treatment of substance-related disorders.
Combined therapy (the use of group and individual therapy) also has been used
successfully with adolescents.
OTHER GROUP SITUATIONS
Groups are also helpful in more focused treatments, such as specific social skills training
for children with ADHD, cognitive-behavioral group interventions for depressed children
and for children with bereavement problems or eating disorders. In these more
specialized groups, the issues are more specific, and actual tasks (as in social skills
groups) can be practiced within the group. Some residential and day treatment units use
group psychotherapy techniques. Group psychotherapy in schools for underachievers
and children from low socioeconomic levels has relied on reinforcement and on
modeling theory, in addition to traditional techniques, and has been supplemented by
parent groups.
In controlled conditions, residential treatment units have been used for specific studies
in group psychotherapy, such as behavioral contracting. Behavioral contracting with
reward–punishment
reinforcement
provides
positive
reinforcements
among
preadolescent boys with severe concerns in basic trust, low self-esteem, and dependence
conflicts. Somewhat akin to formal residential treatment units are social group work
homes. For children who undergo many psychological assaults before placement,
supportive group psychotherapy offers ventilation and catharsis, but more often it
succeeds in letting children become aware of the enjoyment of sharing activities and
developing skills.
Public schools—also a structured environment, although not usually considered the
best site for group psychotherapy—have been used by several workers. Group
psychotherapy as group counseling readily lends itself to school settings. One such
group used gender- and problem-homogeneous selection for groups of six to eight
students, who met once a week during school hours over 2 to 3 years.
INDICATIONS
Many indications exist for the use of group psychotherapy as a treatment modality.
Some indications are situational; a therapist may work in a reformatory setting, in
which group psychotherapy seems to reach adolescents better than individual treatment
does. Another indication is time economics; more patients can be reached in a given
time by the use of groups than by individual therapy. Group therapy best helps a child
at a given age and developmental stage and with a given type of problem. In young age
groups, children’s social hunger and their potential need for peer acceptance help
determine their suitability for group therapy. Criteria for unsuitability are controversial
and have been loosened progressively.
PARENT GROUPS
In group psychotherapy, as in most treatment procedures for children, parental
difficulties can present obstacles. Sometimes, uncooperative parents refuse to bring a
child or to participate in their own therapy. The extreme of this situation reveals itself
when severely disturbed parents use a child as their channel of communication to work
out their own needs. In such circumstances, a child is in the unfortunate position of
receiving positive group experiences that seem to create havoc at home.
Parent groups, therefore, can be a valuable aid to group psychotherapy for their
children. A recent study of a cognitive-behavioral group intervention for parents to
learn how to utilize therapeutic interventions with their anxiety disordered children
suggested that parent groups to teach these skills can be successfully utilized with their
children. Parents of children in therapy often have difficulty understanding their
children’s ailments, discerning the line of demarcation between normal and pathological
behavior, relating to the medical establishment, and coping with feelings of guilt.
Parent groups assist in these areas and help members formulate guidelines for action.
REFERENCES
Baer S, Garland EJ. Pilot study of community-based cognitive behavioral group therapy for adolescents with social phobia.
J Am Acad Child Adolesc Psychiatry. 2005;44:258.
Eggers CH. Treatment of acute and chronic psychoses in childhood and adolescence. MMW Fortschr Med. 2005;147:43.
Haen C. Rebuilding security: Group therapy with children affected by September 11. Int J Group Psychother. 2005;55:391.
Kreidler M. Group therapy for survivors of childhood sexual abuse who have chronic mental illness. Arch Psychiatr Nurs.
2005:19:176.

47 - 31.18c Residential, Day, and Hospital Treatme
31.18c Residential, Day, and Hospital Treatment
Laugeson EA, Frankel F, Gangman A, Dillon AR, Mogil C. Evidence-based social skills training for adolescents with autism
spectrum disorders: The UCLA PEERS Program. J Autism Dev Discord. 2012;42:1025–1036.
Laugeson EA, Frankel F. Social Skills for Teenagers with Developmental and Autism Spectrum Disorders: The PEERS
Treatment Manual. New York: Routledge; 2010.
Liddle HA, Rowe CL, Dakof GA, Ungaro RA, Henderson CE. Early intervention for adolescent substance abuse: Pretreatment
to posttreatment outcomes of a randomized clinical trial comparing multidimensional family therapy and peer group
treatment. J Psychoactive Drugs. 2004;36:49.
Manassis K, Mendlowitz SL, Scapillato D, Avery D, Fiksenbaum L, Freire M, Monga S, Owens M. Group and individual
cognitive-behavioral therapy for childhood anxiety disorders: A randomized trial. J Am Acad Child Adolesc Psychiatry.
2002:41:14243.
Mishna F, Muskat B. “I’m not the only one!” Group therapy with older children and adolescents who have learning
disabilities. Int J Group Psychother. 2004;54:455.
Muris P, Meesters C, van Melick M. Treatment of childhood anxiety disorders: A preliminary comparison between
cognitive-behavioral group therapy and a psychological placebo intervention. J Behav Ther Exp Psychiatry. 2002;33:143.
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intervention for children with prenatal alcohol exposure in a community mental health setting. Alcohol Clin Exp Res.
2012;36:141–152.
Stallard P, Sayal K, Phillips R, Tahylor JA, Spears M, Anderson R, Araya R, Lewis G, Millings A, Montgomery AA.
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31.18c Residential, Day, and Hospital Treatment
Inpatient, partial hospital, and residential treatment are designed for the management
of acute stabilization, stepdown care, and longer-term management of children and
adolescents with psychiatric disorders. Given the limited number of psychiatric inpatient
units for children and adolescents, however, intensive outpatient programs and partial
hospital treatment programs are often used for children with severe psychiatric
disorders. Partial hospital programs are increasingly being offered by managed care
companies as alternatives to hospitalization to contain treatment cost. These programs
are designed to serve the needs of children and adolescents with severe disorders who
require immediate psychosocial and/or pharmacological; interventions but who may not
meet the acuity criteria of “medical necessity” for hospitalization. Residential treatment
centers are appropriate settings for children and adolescents with psychiatric disorders
who require a highly structured and supervised setting for several months or longer.
Such settings provide a stable, consistent environment with a high level of psychiatric
monitoring that is less intensive than in a hospital. Children and adolescents with
serious psychiatric disturbances are sometimes admitted to residential facilities due to
family situations in which appropriate supervision and parenting are impossible.
Dan was a 16-year-old adolescent boy with a long history of depression and
multiple suicide attempts. He was admitted to a local adolescent psychiatric inpatient
unit after for a life-threatening suicide attempt. At the end of the first week of
hospitalization, Dan’s family’s managed care company refused continued coverage,
since they determined that he was no longer an acute suicide risk. Dan was remorseful
about his recent suicide attempt and was determined not to repeat his self-destructive
behavior. However, due to continued serious depressive symptoms and chronic family
dysfunction, the inpatient treatment team did not feel that Dan was ready to be
discharged to weekly outpatient treatment. Dan was transferred to a partial hospital
program affiliated with the inpatient unit. Over the course of Dan’s 8-week treatment,
he developed a strong therapeutic alliance with his individual therapist, and the
psychoeducation provided to the family resulted in the beginning of meaningful
changes. The partial hospital program child psychiatrist met with Dan regularly,
managed his medication, and collaborated with his therapist to manage his suicidal
ideation. At the end of 8 weeks, Dan’s depressive symptoms were decreased, and he
was safely transitioned to outpatient therapy and returned to school successfully. The
partial hospital program allowed for a safe transition from full hospitalization with
continued consolidation of progress in a highly structured system. (Adapted from case
material courtesy of Laurel J. Kiser, Ph.D., M.B.A., Jerry Heston M.D., and David
Pruitt, M.D.)
Mark was an 8-year-old boy referred to a rural community mental health center for
evaluation and treatment. Mark presented with extreme irritability, labile mood,
tantrums, and physical violence toward his peers and adults. Even when he was not
having a tantrum, he seemed discontent and irritated and had a short fuse. He had
received multiple school suspensions and was at risk for expulsion. His family
psychiatric history was positive for schizophrenia in his maternal grandmother. Upon
finishing
his
outpatient
psychiatric
evaluation,
the
clinician
recommended
participation in a newly established partial hospital/day treatment program that used
a behavioral management program close to Mark’s elementary school. The clinician
also recommended a trial of fluoxetine to determine whether Mark’s irritability would
be ameliorated, and individual therapy, social skills group, and family therapy.
During Mark’s 6-month participation in the day program, his behavioral
management program extended into the classroom setting as well as in therapeutic
activities. His daily goals included increasing compliance, decreasing anger outbursts,
and decreasing physical aggression. He was able to improve peer relations while
receiving immediate feedback and direct instruction on social skills in a group setting
and also in his individual therapy. Each staff member was able to consistently apply
behavior management principles in their domain areas. Mark’s parents actively
participated in family therapy sessions and parent conferences. Mark seemed to be
benefitting from the fluoxetine and was less irritable. Although he still had occasional
outbursts, they were milder and shorter. Mark was gradually transitioned to half a
day in a regular classroom setting, and he remained the other half day in the day
program. After 8 more weeks of this transition, he was able to return to his public
school. (Adapted from case material courtesy of Laurel J. Kiser, Ph.D., M.B.A., Jerry
Heston, M.D., and David Pruitt, M.D.)
HOSPITALIZATION
Psychiatric hospitalization is necessary when a child or adolescent is contemplating or
exhibiting dangerous behaviors directed at him or herself or toward others. The most
frequent reasons for psychiatric hospitalization among youth include suicidal thoughts
or behavior, and aggressive and assaultive behaviors. Safety, stabilization, and
initiation of effective treatment are the main goals of hospitalization. In some cases,
psychiatric hospitalization may be a given child’s first experience of a stable, safe
environment. Hospitals are often the most appropriate places to initiate a new
psychopharmacological agent, especially when side effects are prevalent, in order to
provide around-the-clock observations of a child’s behavior. Children who have been
maltreated often show remission of certain symptoms by virtue of being removed from a
stressful and abusive environment. Given the frequency of uncontrollable aggression as
the trigger for many psychiatric admissions among youth, inpatient units must provide
safe and effective ways to defuse and stabilize aggressive and violent acts. Placing a
child or adolescent on the verge of a violent act in a contained room away from the rest
of the milieu is one method of de-escalating a potentially violent situation. Both
restraint and seclusion have been considered therapeutic interventions for youth who
cannot control aggressive impulses, but given the rare but reported deaths of patients by
asphyxiation during restraint procedures, there have been efforts to reduce this
intervention. However, seclusion and restraint cannot be abandoned until another form
of intervention is found to be highly effective. In some cases, psychopharmacological
interventions, that is, “chemical restraint,” has been utilized to defuse acutely dangerous
situations on an inpatient unit. Optimally, identifying and recognizing antecedents of
aggressive behaviors and intervening before the aggression is enacted is the goal.
Inpatient care is a setting for stabilization and the initiation of treatment, with the
expectation that when a child or adolescent is discharged to a less restrictive
environment, the patient will no longer pose a danger to him or herself or others, and
that treatment and support services will be in place for continued care.
Partial Hospital
In most cases, children and adolescents who attend partial hospital, or day treatment
programs, have serious mental disorders and might warrant psychiatric hospitalization
without the program’s support. Family therapy, group and individual psychotherapy,
psychopharmacology, behavioral management programs, and special education are
integral parts of these programs. Partial hospital programs are excellent alternatives for
children and adolescents who require more intensive support, monitoring, and
supervision than is available in the community, but who can live successfully at home if
they receive the proper level of intervention.
The concept of daily comprehensive therapeutic experiences that do not require
removing children from their homes or families is derived partly from experiences with
a therapeutic nursery school. The main advantages of partial hospital programs are that
children remain with their families and the families can be more involved in day
treatment than they are in residential or hospital treatment. Partial hospital also is
much less expensive than residential treatment. At the same time, the risks of day
treatment include a child’s relative social isolation and confinement to a narrow band of
social contacts in the program’s disturbed peer population.
Indications.
The primary indication for a partial hospital plan is the need for a
more structured, intensive, and specialized treatment program than can be provided on
an outpatient basis. At the same time, the home in which the child is living should be
able to provide an environment that is at least not destructive to the child’s
development. Children who are likely to benefit from day treatment may have a wide
range of diagnoses, including autistic disorder, conduct disorder, ADHD, and mental
retardation. Exclusion symptoms include behavior that is likely to be destructive to the
children themselves or to others under the treatment conditions. Therefore, some
children who threaten to run away, set fires, attempt suicide, hurt others, or
significantly disrupt the lives of their families while they are at home are not suitable
for day treatment.
Programs.
Ingredients that lead to a successful partial hospital program include
clear administrative leadership, team collaboration, open communication, and an
understanding of children’s behavior.
A major function of child-care staff in partial hospital programs is to provide positive
experiences and a structure that enables the children and their families to internalize
controls and to function better than in the past. Because the ages, needs, and range of
diagnoses of children who may benefit from some form of day treatment vary, many
day treatment programs have been developed. Some programs specialize in the special
educational and structured environmental needs of mentally retarded children. Others
offer therapeutic efforts designed to treat children with autism and schizophrenia. Still
other programs provide the total spectrum of treatment usually found in full residential
treatment, of which they may be an extension. Children may move from one part of the
program to another and may be in residential treatment or partial hospital according to
their needs. A school program is always a major component of partial hospital
treatment. Attempts have been made to analyze the treatment outcome of partial
hospitalization. Many different dimensions exist to analyze the overall benefits of such
programs; assessment of level of improvement in clinical status, academic progress,
peer relationships, community interactions (legal difficulties), and family relationships
are some pertinent areas to measure. In a follow-up 1 year after discharge from a
partial hospital program, comparison of patients at admission and 1-year post-discharge
showed statistically significant improvement in clinical symptoms on each subscale of
the Child Behavior Checklist, except for sex problems. Improvements were found in mood,
somatic complaints, attention problems, thought problems, delinquent behavior, and
aggressive behavior. The assessment of long-term effectiveness of day treatment is
fraught with difficulties, and may differ when measuring a child’s maintenance of gains,
a therapist’s view of psychological gains, or cost-to-benefit ratios.
The lessons learned from day treatment programs have encouraged mental health
disciplines to have services follow children, rather than have separate programs, which
result in discontinuity of care. The experiences of partial hospital programs for
psychiatric conditions of children and adolescents have also encouraged pediatric
hospitals and departments to adopt models that promote continuity of care for children
with chronic physical illness.
RESIDENTIAL TREATMENT
Children in residential treatment often have combinations of severe psychiatric
disorders and severely troubled families who cannot adequately care for their children.
In some cases, a child or adolescent requires a more structured environment than is
possible at home. In other cases, a family is unable to oversee a child’s psychiatric
treatment due to their own psychiatric illness, substance abuse, or medical debilitation.
In cases of child abuse or neglect, a family does not provide a safe and nurturing
environment for a child. When families are available and motivated, their participation
is strongly encouraged while their children are in residential treatment. The aim is to
enable them to reunite with their children and care for them at home in the future.
Staff and Setting
Staffing patterns include various combinations of child-care workers, teachers, social
workers, psychiatrists, pediatricians, nurses, and psychologists; therefore, residential
treatment can be very expensive. The Joint Commission on the Mental Health of
Children made the following structural and setting recommendations:
In addition to space for therapy programs, there should be facilities for a first-rate school and a rich evening activity
program, and there should be ample space for play, both indoors and out. Facilities should be small, seldom exceeding 60
patients in capacity with a limit of 100 patients, and they should make provisions for children to live in small groups. The
centers should be located near the families they serve and should be readily accessible by public transportation. They should
be located for ready access to special medical and educational services and to various community resources, including
consultants. The centers should be open institutions whenever possible; locked buildings, wards, or rooms should be required
only rarely. In designing residential programs, the guiding principle should be that children should be removed from their
normal life settings the least possible distance in space, in time, and in the psychological texture of the experience.
Indications
Most children who are referred for residential treatment have had multiple evaluations
by professionals, such as school psychologists, outpatient psychotherapists, juvenile
court officials, or state welfare agency staff. Attempts at outpatient treatment and foster
home placement usually precede residential treatment. Sometimes, the severity of a
child’s problems or the inability of a family to provide for the child’s needs prohibits
sending a child home. Many children sent to residential treatment centers have
disruptive behavior problems in addition to other problems, including mood disorders
and psychotic disorders. In some cases, serious psychosocial problems, such as physical
or sexual abuse, neglect, indigence, or homelessness, necessitate out-of-home placement.
The age range of the children varies among institutions, but most children are between
5 and 15 years of age. Boys are referred more frequently than girls.
An initial review of data enables the intake staff to determine whether a particular
child is likely to benefit from the treatment program; often, for every child accepted for
admission, three are rejected. The next step usually is interviews with the child and the
parents by various staff members, such as a therapist, a group-living worker, and a
teacher. Psychological testing and neurological examinations are given, when indicated,
if they have not already been performed. The child and parents should be prepared for
these interviews.
Milieu
Most of a child’s time in a residential treatment setting is spent in the milieu. The staff
consists of clinicians and care workers who offer a structured environment that forms a
therapeutic milieu; the environment places boundaries and limitations on the children.
Tasks are defined within the limits of children’s abilities; incentives, such as additional
privileges, encourage them to progress rather than regress. In milieu therapy, the
environment is structured, limits are set, and a therapeutic atmosphere is maintained.
The children often select one or more staff members with whom to form a
relationship; through this relationship, they express, consciously and unconsciously,
many of their feelings about their parents. The child-care staff should be trained to
recognize such transference reactions and to respond to them in a way that differs from
the children’s expectations, which are based on their previous or even current
relationships with their parents. This requires an awareness of countertransference in
staff members.
To maintain consistency and balance, the group-living staff members must
communicate freely and regularly with each other and with the other professional and
administrative staff members of the residential setting, particularly the children’s
teachers and therapists. Behavior modification principles are typically embedded into
the daily program for children in residential settings. A recent study examined the
association between use of antipsychotic medication and seclusion/restraint (S/R)
frequency in the management of acute aggressive behavior in adolescents in residential
facilities. Adolescents who were in the moderate and high groups for having S/R were
significantly more likely to have changes in antipsychotic medication and receive higher
doses of medication. However, even with high doses, their rates of S/R continued to be
frequent. These findings bring into question the efficacy of antipsychotic agents for
managing acute aggression in residential settings.
Education
Children in residential treatment frequently have severe learning disorders, disruptive
behavior, and ADHD. Usually, the children cannot function in a regular community
school and consequently need a special on-grounds school. A major goal of the ongrounds school is to motivate children to learn. The educational process in residential
treatment is complex; Table 31.18c-1 shows its components.
Table 31.18c-1
Education Process in Residential Treatment
Therapy
Most residential facilities use a basic behavior modification program to set guidelines
and to give the residents a concrete sense of how to earn privileges. These behavioral
programs range in detail and intensity. Some programs operate with level systems that
are associated with privileges and responsibilities. Some programs use a token economy
system in which residents earn points for appropriate behavior and for meeting specific
goals. Most programs include basic tasks of living as well as specific therapeutic goals
for the residents.
Psychotherapy offered in these programs generally is supportive and oriented toward
reunion with the family when possible. Insight-oriented psychotherapy is included when
it can be used by a resident.
Parents
Concomitant work with parents is essential. Children usually have a strong tie to at
least one parent, no matter how disturbed the parent may be. Sometimes, a child
idealizes the parent, who repeatedly fails the child. Other times, the parent has an
ambivalent or unrealistic expectation that the child will return home. In some instances,
the parent must be helped to enable the child to live in another setting when it is in the
child’s best interest. Most residential treatment centers offer individual or group therapy
for parents, couples, or marital therapy, and in some cases, conjoint family therapy.
DAY TREATMENT
The concept of daily comprehensive therapeutic experiences that do not require
removing children from their homes or families is derived partly from experiences with
a therapeutic nursery school. Day hospital programs for children were then developed,
and the number of programs continues to grow. The main advantages of day treatment
are that children remain with their families and the families can be more involved in
day treatment than they are in residential or hospital treatment. Day treatment also is
much less expensive than residential treatment. At the same time, the risks of day
treatment are a child’s social isolation and confinement to a narrow band of social
contacts in the program’s disturbed peer population.
Indications
The primary indication for day treatment is the need for a more structured, intensive,
and specialized treatment program than can be provided on an outpatient basis. At the
same time, the home in which the child is living should be able to provide an
environment that is at least not destructive to the child’s development. Children who are
likely to benefit from day treatment may have a wide range of diagnoses, including
autistic disorder, conduct disorder, ADHD, and mental retardation. Exclusion symptoms
include behavior that is likely to be destructive to the children themselves or to others
under the treatment conditions. Therefore, some children who threaten to run away, set
fires, attempt suicide, hurt others, or significantly disrupt the lives of their families while
they are at home may not be suitable for day treatment.
Programs
The same ingredients that lead to a successful residential treatment program apply to
day treatment. These ingredients include clear administrative leadership, team
collaboration, open communication, and an understanding of children’s behavior.
Indeed, having a single agency offer both residential and day treatment has advantages.
A major function of child-care staff in day treatment for psychiatrically disturbed
children is to provide positive experiences and a structure that enables the children and
their families to internalize controls and to function better than in the past regarding
themselves and the outside world. Again, the methods used are essentially similar to
those in full residential treatment programs.
Because the ages, needs, and range of diagnoses of children who may benefit from
some form of day treatment vary, many day treatment programs have been developed.
Some programs specialize in special educational and structured environmental needs of
mentally retarded children. Others offer special therapeutic efforts required to treat
children with autism and schizophrenia. Still other programs provide the total spectrum
of treatment usually found in full residential treatment, of which they may be a part.
Children may move from one part of the program to another and may be in residential
treatment or day treatment according to their needs. The school program always is a
major component of day treatment, and psychiatric treatment varies according to a
child’s needs and diagnosis.
Results
Recently, attempts have been made to analyze the treatment outcome of day treatment
and partial hospitalization. Many different dimensions exist to analyzing overall
benefits of such programs. Assessment of level of improvement in clinical status,
academic progress, peer relationships, community interactions (legal difficulties), and
family relationships are some pertinent areas to measure. In a recent follow-up 1 year
after discharge from a partial hospital program, comparison of patients at admission
and 1-year post-discharge showed statistically significant improvement in clinical
symptoms on each subscale of the Child Behavior Checklist, except for sex problems.
These improvements were in mood symptoms, somatic complaints, attention problems,
thought problems, delinquent behavior, and aggressive behavior. The assessment of
long-term effectiveness of day treatment is fraught with difficulties, from the point of
view of a child’s maintenance of gains, a therapist’s view of psychological gains, or costto-benefit ratios.
At the same time, the advantage of day treatment has encouraged further
development of programs. Moreover, the lessons learned from day treatment programs
have moved mental health disciplines toward having services follow children, rather
than perpetuating discontinuities of care. The experiences of day treatment for
psychiatric conditions of children and adolescents have also encouraged pediatric
hospitals and departments to adopt a model that promotes continuity of care for the
medical treatment of children with chronic physical illnesses.
REFERENCES
Aarons GA, James S, Monn AR, Raghavan R, Wells RS, Leslie LK. Behavioral problems and placement change in a national
child welfare sample: A prospective study. J Am Acad Child Adolesc Psychiatry. 2010;49:70–80.
Baeza I, Correll CU, Saito E, Aranbekova D, Kapoor S, Chekuri R, De Hert M, Carbon M. Frequency, characteristics and
management of adolescent inpatient aggression. J Child Adolesc Psychopharmacol. 2013;23:271–281.
Damnjanovic M, Lakic A, Stevanovic ED, Jovanovic A. Effects of mental health on quality of life in children and adolescents
living in residential and foster care: a cross-sectional study. Epidemiol Psychiatr Sci. 2011;20:257–262.
Epstein RA Jr. Inpatient and residential treatment effects for children and adolescents: A review and critique. Child Adolesc
Psychiatr Clin N Am. 2004;13:411.
Geller JL, Biebel K. The premature demise of public child and adolescent inpatient beds: Part I: Overview and current
conditions. Psychiatric Q. 2006;77:251.
Geller JL, Biebel K. The premature demise of public child and adolescent inpatient beds: Part II: Challenges and
implications. Psychiatr Q. 2006;77(4):273–291.
Kober D, Martin A. Inpatient psychiatric, partial hospital and residential treatment for children and adolescents. In: Sadock
BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott
Williams & Wilkins; 2009:3766.
Miller L, Riddle MA, Pruitt D, Zachik A, DosReis S. Antipsychotic treatment patterns and aggressive behavior among

48 - 31.18d Pharmacotherapy
31.18d Pharmacotherapy
adolescents in residential facilities. J Behav Health Serv Res. 2013;40:97–110.
Noftle JW, Cook S, Leschied A, St Pierre J, Stewart SL, Johnson AM. The trajectory of change for children and youth in
residential treatment. Child Psychiatry Hum Dev. 2011;42:65–77.
31.18d Pharmacotherapy
Over the last decade, increasing evidence has emerged regarding the efficacy and safety
of psychopharmacological agents to treat child and adolescent psychiatric disorders.
Randomized placebo-controlled trials have confirmed the short-term efficacy of selective
serotonin reuptake inhibitors (SSRIs), for depressive disorders, anxiety, and OCD;
second-generation antipsychotics (SGAs) for psychosis and aggression; and multiple
central nervous system stimulants for ADHD. Published data support the short-term
efficacy and safety of fluoxetine, sertraline, fluvoxamine, and escitalopram in the
treatment of youth depression, anxiety disorders and OCD.
First-line evidence-based treatment for ADHD, has preferentially shifted toward longacting stimulant medications, including methylphenidate preparations (Concerta) and
amphetamine and amphetamine salt preparations (Adderall XR).
Significant progress in the field has been made through multi-site, National Institute
of Mental Health (NIMH)–funded research comparing types of treatment with treatment
combinations of pharmacological interventions and psychosocial treatments, for
disorders including OCD and major depressive disorders, and anxiety disorders. Studies
repeatedly found that cognitive-behavioral psychotherapy in combination with an SSRI
has advantages over either alone. Another area of progress has been evidence-based
treatment of ADHD in younger age groups. The NIMH Preschooler with ADHD
Treatment Study (PATS) was the first multisite study of ADHD preschool children,
treated first with a parent training component and followed, if necessary, by
administration of methylphenidate. This regimen was found to be effective and safe.
Double-blind, placebo-controlled studies have provided evidence for the efficacy of
fluoxetine, sertraline, and escitalopram treatment for depressive disorders in youth, and
the Food and Drug Administration (FDA) has approved both fluoxetine and escitalopram
in the treatment of adolescent depression. Fluoxetine, sertraline, and fluvoxamine have
been shown to have positive results based on randomized controlled trials (RCTs) in the
treatment of OCD in youth. Although the FDA has not yet approved SSRIs in the
treatment of child and adolescent anxiety, positive random-controlled trials (RCTs) exist
for fluoxetine, sertraline, paroxetine, and fluvoxamine in the treatment of youth
anxiety.
In 2004, the FDA released a statement on the recommendation of the
Psychopharmacologic Drugs and Pediatric Advisory Committees of a “black-box”
warning relating to an increased risk for suicidality in pediatric patients for all
antidepressant medications. The advisory committees came to the conclusion that an
increased risk of suicidal behaviors existed, although there were no suicides completed
among the data reviewed. All of the antidepressant medications must include the black
box warning for pediatric patients regardless of whether they have been studied in
pediatric populations. Currently, the SGAs, also known as serotonin-dopamine
antagonists (SDAs), have generally replaced the conventional antipsychotics (dopamine
receptor antagonists) in the treatment of psychotic disorders and for aggressive
behavior management.
THERAPEUTIC CONSIDERATIONS
As psychopharmacologic interventions for childhood psychiatric disorders have gained
an evidence base, establishing a therapeutic alliance, identifying and monitoring target
symptoms, and promoting medication compliance are important components of
successful clinical outcomes. Teamwork between the child, parents, and psychiatrist is
critical in successful treatment of childhood disorders with psychopharmacologic agents.
An evaluation for psychopharmacotherapy must first include an assessment of a
child’s psychopathology and physical condition to rule out any predisposition for side
effects (Table 31.18d-1). An assessment of the child’s caregivers focuses on their ability
to provide a safe, consistent environment in which a clinician can conduct a drug trial.
The physician must consider the risk-to-benefit ratio and must explain it to the patient,
if he or she is old enough, and to the child’s caregivers and others (e.g., child welfare
workers) who may be involved in the decision to medicate.
Table 31.18d-1
Diagnostic Processes of Biological Therapy
The clinician must obtain baseline ratings before medicating. Behavioral rating scales
help objectify the child’s response to medication. The physician generally starts at a low
dose and titrates upward on the basis of the child’s response and the appearance of
adverse effects. Optimal drug trials cannot be rushed (e.g., by insurance-imposed,
inadequately short hospital stays or by infrequent outpatient visits), nor can drug trials
be prolonged by the physician’s insufficient contact with the patient and the caregivers.
The success of drug trials often hinges on the physician’s daily accessibility.
CHILDHOOD PHARMACOKINETICS
Compared with adults, children have greater hepatic capacity, more glomerular
filtration, and less fatty tissue. Thus, stimulants, antipsychotics, and tricyclic drugs are
eliminated more rapidly by children than by adults; lithium (Eskalith) may also be
eliminated more rapidly, and children may be less able to store drugs in their fat.
Because of children’s quick elimination, the half-lives of many medications may be
shorter in children than in adults.
Little evidence indicates that clinicians can predict a child’s blood level from the
dosage or a treatment response from the plasma level. Relatively low serum levels of
haloperidol seem to be adequate to treat Tourette’s disorder in children. No correlation
is seen between the methylphenidate (Ritalin) serum level and a child’s response. The
data are incomplete and conflicting about major depressive disorder and serum levels of
tricyclic drugs. Serum level is related to response for tricyclic drugs in the treatment of
enuresis.
With lithium therapy, a ratio of lithium concentration in saliva to that in serum can
be established for a child by averaging three to four individual ratios. The average ratio
can then be used to convert subsequent saliva levels to serum levels and, thus, avoid
some venipuncture in children who are stressed by blood tests. As with serum levels,
regular clinical monitoring for adverse effects is necessary. Table 31.18d-2 lists
representative agents, their indications, dosages, adverse reactions, and monitoring
requirements.
Table 31.18d-2
Pharmacologic Agents for Psychiatric Disorders in Children Adolescents
STIMULANT AGENTS, ATOMOXETINE, AND α-AGONIST AGENTS
Stimulant pharmacologic agents remain the primary treatment for ADHD in children,
adolescents, and adults. Multiple studies support the efficacy of stimulant medications
for ADHD. Current practice is leaning toward more use of once-a-day, long-acting
preparations of stimulants such as methylphenidate, amphetamine and amphetamine
salts, and dex-methylphenidate (Focalin LA). The most frequently researched and used
stimulant is methylphenidate. Dextroamphetamine (Dexedrine) has comparable efficacy
and, unlike methylphenidate, is approved by the FDA for children 3 years of age and
older; the starting age for methylphenidate is 6 years. The amphetamine, Adderall,
combines
dextroamphetamine
and
amphetamine
salts.
The
extended-release
preparations, such as Concerta and Adderall XR, have the advantages of coverage of
symptoms throughout the school day without the necessity of taking another dose, as
well as a more continuous delivery of medication. Stimulants reduce hyperactivity,
inattentiveness, and impulsivity in about 75 percent of children with ADHD. The effects
are not paradoxical, because normal children respond similarly. The dose-related
adverse effects of stimulants are listed in Table 31.18d-3.
Table 31.18d-3
Common Dose-Related Side Effects of Stimulants
The methylphenidate transdermal patch (Daytrana) is approved by the FDA for the
treatment of ADHD in children age 6 to 12 years. Daytrana comes in patches that can
deliver 15 mg, 20 mg, and 30 mg when worn for 9 hours per day. The medication begins
to have its effects on the target symptoms of ADHD approximately 2 hours after the
patch is placed, and continues to deliver medication throughout the wear time. Given
that its active ingredient is methylphenidate, the side effects are generally the same as
those for methylphenidate, except for the potential skin irritation that may emerge from
wearing the patch. The patch should not be worn in the presence of a heating pad or
electric blanket because heat increases the rate of methylphenidate delivery into the
skin. Patients with glaucoma or known hypersensitivity to methylphenidate products
should not begin treatment with Daytrana. Daytrana has the advantages of being able
to deliver medication until the patch is removed and, for children who are unable to
swallow pills, Daytrana offers a unique administration option.
Lisdexamfetamine
dimesylate
(LDX),
sold
as
Vyvanse,
is
a
pro-drug
of
dextroamphetamine upon cleavage of the lysine portion of the molecule. LDX was
created to be longer lasting than dextroamphetamine and less likely to become a drug of
abuse because it requires enzymes to convert it to dextroamphetamine. LDX has been
approved by the FDA for the treatment of ADHD in children 6 to 12 years of age as well
as in adults with ADHD. In contrast to Adderall, which contains approximately 75
percent dextroamphetamine, LDX comprises the dextro enantiomer only. In trials, LDX
has also been shown to be effective and safe in the treatment of adolescents with ADHD.
Similar to other stimulant agents, the most common side effects of LDX were decreased
appetite, headache, insomnia, decreased weight, and irritability.
Recent studies support the use of atomoxetine (Strattera), a norepinephrine reuptake
inhibitor, as an efficacious nonstimulant treatment for ADHD in children and
adolescents. Atomoxetine is well absorbed after ingestion and reaches its maximal
plasma concentration after about 1 to 2 hours. Common side effects of atomoxetine
include abdominal discomfort, decreased appetite, dizziness, and irritability. Rarely,
minor increases in blood pressure and heart rate have been noted. Atomoxetine is
metabolized by the cytochrome P450 (CYP) 2D6 hepatic enzyme system, and a fraction
of the population (about 7 percent of Caucasians and 2 percent of African Americans)
are poor metabolizers, which may increase the plasma half-life by about fivefold. When
combined with other medications that inhibit CYP 2D6, such as fluoxetine and
paroxetine, diminished metabolism of atomoxetine can occur, and the dose may need to
be decreased. Atomoxetine is generally initiated at 0.5 mg/kg given once per day and
increased to a therapeutic dose ranging between 1.4 mg/kg and 1.8 mg/kg, either in
one dose or in two divided doses.
SECOND GENERATION ANTIPSYCHOTICS (SGAS) AND CONVENTIONAL
ANTIPSYCHOTIC AGENTS
The SGAs represent a major advance in the pharmacological treatment of schizophrenia
in children and adolescents, as well as in adults. The atypical antipsychotic agents have
largely replaced traditional antipsychotics because of their more favorable side-effect
profiles, greater effectiveness for negative symptomatology, and mood-stabilizing
effects. Although the SGAs are generally recommended currently as first-line agents in
the treatment of psychotic disorders in children and adolescents, only one controlled
NIMH trial has been conducted using an atypical agent in the treatment of
schizophrenia for youth. This study examined clozapine and found it to be superior to
haloperidol for treating positive and negative symptoms of schizophrenia in 21 youth.
The serious drawbacks of clozapine, however, limit it as a first-line agent for this
disorder. In the NIMH trial, five participants developed significant neutropenia, and
two experienced seizures. Clozapine is generally used only for treatment-resistant
schizophrenia.
Open label trials in youth with schizophrenia have suggested efficacy of other atypical
antipsychotic agents such as olanzapine, risperidone, and quetiapine. Case reports have
suggested that ziprasidone is effective. One of the main side effects of the atypical
antipsychotic agents is significant weight gain. A newer atypical agent, aripiprazole
awaits clinical trials to confirm its potential to be an efficacious and more weight
neutral agent for the treatment of childhood psychoses. Although conventional
antipsychotics, such as haloperidol, loxapine (Loxitane), and thioridazine (Mellaril)
have been shown to be significantly superior to placebo in the treatment of psychosis in
youth, given their side effect profiles they are typically chosen as first-line treatments.
Schizophrenia with onset in late adolescence is treated, as is adult-onset schizophrenia.
Aggressive, explosive, and assaultive behaviors associated with disruptive behavior
disorders, psychotic disorders, and posttraumatic stress disorders have been treated with
antipsychotic agents with varying reports of success. Randomized controlled trials with
several atypical antipsychotics, such as risperidone, olanzapine, quetiapine (Seroquel),
and aripiprazole (Abilify), have provided evidence of effectiveness for behavioral
improvement, with fewer long-term adverse effects than typical antipsychotics.
When conduct disorder is associated with ADHD, a trial of a stimulant is indicated;
stimulants are faster acting than atypical antipsychotics or mood-stabilizing agents used
in clinical practice to control dangerously aggressive behaviors.
The management of severe aggression, disruptive behavior, and ADHD remains a
challenge. Combinations of antipsychotics with mood-stabilizing agents or stimulants
are sometimes used in treatment-resistant cases, although few studies attest to the
efficacy or safety of drug combinations. Newer “atypical” antipsychotic medications—
SDAs—such as risperidone, olanzapine, clozapine (Clozaril), ziprasidone (Geodon), and
aripiprazole have enabled a wider range of treatment-resistant patients to benefit from
neuroleptic treatment. The SDAs are believed to relieve both the positive and negative
symptoms of schizophrenia and to produce less risk of extrapyramidal adverse effects
and less potential for the development of tardive dyskinesia. Nevertheless, all
antipsychotics pose some risk of extrapyramidal adverse effects and tardive dyskinesia.
One challenge in obtaining optimal pharmacological treatment for children is to
decrease maladaptive behaviors while promoting productive academic functioning. To
this end, clinicians must consider adverse effects of medication that result in cognitive
“dulling.” Certain pharmacological agents used in pediatric populations are associated
with a specific disorder or with target symptoms that appear in several disorders. For
example, haloperidol was shown in past studies to be effective in the treatment of
Tourette’s disorder, but it has also been used to control severe aggression. The highpotency antipsychotics haloperidol and pimozide (Orap) still have the greatest body of
evidence as effective medications for Tourette’s disorder, although they also have
considerable drawbacks. Pimozide prolongs the QT interval and, thus, requires
electrocardiography (ECG) monitoring. Clonidine, a presynaptic α-adrenergic blocking
agent, is less effective than either of the above-mentioned antipsychotics, but has the
advantage of avoiding the risk for tardive dyskinesia; sedation is a frequent side effect
of clonidine.
Tic disorders often coexist with ADHD in children and adolescents. Stimulant use is
controversial; it can precipitate tics and should be avoided in these patients, although
recent studies indicate that the prohibition may not be totally warranted. Clonidine
sometimes reduces tics in both ADHD and the comorbid cases.
SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRI)
ANTIDEPRESSANTS AND OTHER ANTIDEPRESSANTS
SSRI antidepressants have been found in randomized clinical trials to have efficacy in
the treatment of childhood anxiety disorders, depressive disorders, and OCD. A
substantial evidence base exists for the efficacy of SSRIs in the treatment of separation
anxiety, generalized anxiety disorder, and social phobia in children and adolescents.
Thus, SSRIs are currently recommended as first-line medications in the treatment of
childhood anxiety. Separation anxiety disorder, generalized anxiety disorder, and social
phobia are often studied together because they so commonly coexist. A given child with
one of the preceding anxiety disorders has a 60 percent chance of having a second one,
and in 30 percent of cases, all three are comorbid. Alprazolam (Xanax) may be helpful
in separation anxiety disorder, but randomized clinical trials are still needed.
The SSRIs currently are the drugs of choice in the pharmacological treatment of
depressive disorders in children and adolescents. Given the FDA placement of the “blackbox” warning on all antidepressants used in children and adolescents because of the
slightly increased risk of suicidal behaviors, close monitoring of suicidal ideation and
behavior is imperative. Although most side effects of SSRIs are tolerable, anecdotal
recent reports indicate occasional SSRI-induced apathy in children and adolescents.
Previously, clomipramine proved effective in diminishing obsessions and compulsions in
children and adolescents and was generally well tolerated. However, the SSRIs have a
more favorable adverse-effect profile and appear to be as effective as clomipramine.
MOOD-STABILIZING AGENTS
Classic mania in children and adolescents is treated as it is treated in adults. Use of
lithium in treating adolescent mania has been supported in many open trials.
Divalproex is used frequently to treat bipolar disorder in children and adolescents. A
recent double-blind, randomized pilot study comparing quetiapine (400 to 600 mg a
day) or divalproex (serum level 80 to 120 mg/mL) in a trial lasting approximately 1
month, found that quetiapine is at least as effective as divalproex in treating acute
manic symptoms. Reduction of symptoms occurred more quickly with quetiapine
compared with divalproex. Lithium has been shown in multiple investigations to reduce
aggression in conduct disorder, and propranolol (Inderal) has been chosen as an agent
to control aggression in open trials, although no evidence supports its use in children
and adolescents. Carbamazepine (Tegretol) has not been shown to be effective in
controlling aggression in child and adolescent conduct disorders.
Table 31.18d-4 summarizes the effects of drugs on cognitive tests of learning
functions. In children with learning disorders who have attention problems, even in the
absence of meeting full criteria for ADHD, methylphenidate facilitates performance on
several standard cognitive, psycholinguistic, memory, and vigilance tests, but does not
improve children’s academic achievement ratings or teacher ratings. Cognitive
impairment from psychotropic drugs, especially antipsychotics, may be an even greater
problem for persons who are mentally retarded than for those with learning disorders.
Table 31.18d-4
Effects of Psychotropic Drugs on Cognitive Tests of Learning Functionsa
BENZODIAZEPINES
Sleep terror disorder and sleepwalking disorder occur in the transition from deep deltawave sleep (stages 3 and 4) to light sleep. Benzodiazepines may be effective in these
disorders. They work by reducing both delta-wave sleep and arousals between sleep
stages. The medications should be used temporarily and only in severe cases, because
tolerance to the medications develops. Cessation of these medications can lead to severe
rebound worsening of the disorders, and reducing delta sleep in children may have
deleterious effects; thus, behavioral approaches are preferred for these disorders.
Patients with early-onset panic disorder and panic attacks have benefited from
clonazepam (Klonopin) in several open trials.
DESMOPRESSIN
Desmopressin (DDAVP) is effective in about 50 percent of patients with intractable
enuresis. Improvements with DDAVP range from diminished wetting with less urine
volume, to complete cessation of bedwetting. Desmopressin has been used intranasally
in dosages of 10 to 40 mg a day. When used over months, nasal discomfort can occur,
and water retention is potentially a problem. Patients who respond with full dryness
should continue to take the medication for several months to prevent relapses.
Desmopressin is now available in oral tablets, and a controlled multicenter study found
equal efficacy between intranasal and oral administration of desmopressin in the
treatment of enuresis. A dose of 400 mg of oral desmopressin was the study condition
associated with greater effectiveness than the lower 200 mg used.
ADVERSE EFFECTS AND COMPLICATIONS
Antidepressants
Adverse effects related to antidepressants have diminished significantly since SSRI
antidepressants have been widely accepted as first-line treatments for depressive
disorders in children and adolescents. Tricyclics are rarely recommended because of the
significant risks of dangerous adverse effects. The adverse effects of tricyclics for
children usually are similar to those for adults and result from the drugs’ anticholinergic
properties. These effects include dry mouth, constipation, palpitations, tachycardia, loss
of accommodation, and sweating. The most serious adverse effects in children are
cardiovascular; diastolic hypertension is more common and postural hypotension occurs
more rarely than in adults. ECG changes are most likely seen in children receiving high
doses. Slowed cardiac conduction (PR interval greater than 0.20 seconds or QRS interval
greater than 0.12) may necessitate lowering the dosage. FDA guidelines limit dosages to
a maximum of 5 mg/kg a day. The drugs can be toxic in an overdose, and in small
children, ingestion of 200 to 400 mg can be fatal. When the dosage is lowered too
rapidly, withdrawal effects occur, mainly gastrointestinal symptoms—cramping,
nausea, and vomiting—and sometimes apathy and weakness.
Antipsychotics
The SGAs have generally replaced the conventional antipsychotics as first-line agents in
the treatment of all psychotic disorders in children and adolescents. Historically, the
best-studied antipsychotics given to pediatric age groups are chlorpromazine
(Thorazine) and haloperidol. High-potency and low-potency antipsychotics are thought
to differ in their adverse-effect profiles. The phenothiazine derivatives (chlorpromazine
and thioridazine) have the most pronounced sedative and atropinic actions, whereas the
high-potency
antipsychotics
are
commonly
believed
to
be
associated
with
extrapyramidal reactions, such as parkinsonian symptoms, akathisia, and acute
dystonias. The risk of tardive dyskinesia in relation to antipsychotics leads to caution in
the use of drugs. Tardive dyskinesia, which is characterized by persistent abnormal
involuntary movements of the tongue, face, mouth, or jaw and sometimes the
extremities, is a known hazard when giving antipsychotics to patients of all age groups.
No known treatment is effective. Because transient choreiform movements of the
extremities and trunk are common after abrupt discontinuation of antipsychotics,
clinicians must distinguish these symptoms from persistent dyskinesia.
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Franklin ME, Sapyta J, Freeman JB, Khanna M, Compton S, Almirall D. Moore P, Choate-Summers M, Garcia A, Edson AL,
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Ginsburg GS, Kendall PC, Sakolsky D, Compton SN, Piacentini J, Albano AM, Walkup JT, Sherrill J, Coffey KA, Rynn MA,
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49 - 31.18e Psychiatric Treatment of Adolescents
31.18e Psychiatric Treatment of Adolescents
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31.18e Psychiatric Treatment of Adolescents
Adolescence, biologically beginning with puberty, is a period in which social,
intellectual, and sexual development take place alongside specific brain processes that
enhance teens’ abilities for increased abstract reasoning and greater sensitivity to social
nuances. However, the developmental brain processes are spread over many years, and
maturation is subject to individual variation. Inherent in development is continuing
change; however, most adolescents adapt to changes gradually, and their path toward
greater autonomy and independence is not characterized by perpetual crises and
struggle. Milestones achieved by adolescents during their developmental journey to
adulthood are typically reached without overwhelming strife or intervention. However,
psychiatric treatment is indicated for an adolescent who develops a disturbance of
thought, affect, or behavior that disrupts normal functioning. In adolescents, disruption
of functioning influences eating, sleeping, and school function, as well as relationships
with family and peers. A variety of serious psychiatric disorders, including
schizophrenia, bipolar disorder, eating disorders, and substance abuse typically have
their onset during adolescence. In addition, the risk for completed suicide drastically
increases in adolescence. Although some degree of stress is virtually universal in
adolescence, most teenagers who do not develop serious mental disorders cope well with
environmental demands. Teenagers with preexisting mental disorders often experience
exacerbations during adolescence and may become frustrated, alienated, and
demoralized.
Clinicians and parents seeking a window into an adolescent’s viewpoint should be
sensitive to their self-perceptions. A range of emotional maturity exists in teens of the
same chronological age. Issues characteristic of adolescence are related to new evolving
identities, the development of sexual activity, and developing plans to meet future life
goals.
DIAGNOSIS
Adolescents can be assessed with a focus on general progress in accomplishing the tasks
of individuating and developing a sense of autonomy. For many adolescents in today’s
culture, school performance and peer relationship successes are the primary barometers
of healthy functioning. Adolescents with normative intellectual function who are
deteriorating academically, or teens who become isolated from peers, are typically
experiencing significant psychological disturbance, which merits investigation.
Questions to be asked regarding adolescents’ stage-specific tasks are the following:
What degree of separation from their parents have they achieved? What sort of
identities are evolving? How do they perceive their past? Do they perceive themselves
as responsible for their own development or only the passive recipients of their parents’
influences? How do they perceive themselves with regard to the future, and how do they
anticipate their future responsibilities for themselves and others? Can they think about
the varying consequences of different ways of living? How do they express their sexual
and affectionate interests? These tasks occupy the lives of all adolescents and normally
are performed at different times.
Adolescents’ family and peer relationships must be evaluated. Do they perceive and
accept both “good and bad” qualities in their parents? Do they feel comfortable with
their peers and romantic partners as “separate persons” with needs that may not
completely match their own?
Respect and acceptance of an adolescent’s subcultural and ethnic background are
essential.
INTERVIEWS
Adolescent patients and their parents should be interviewed separately in a
comprehensive psychiatric evaluation. Other family members also may be included,
depending on their involvement in the teenager’s life and difficulties. Clinicians often
prefer to see the adolescent first, however; in order to develop a rapport with the
adolescent and promote being an advocate for the adolescent and avoid the appearance
of being the parents’ agent. In psychotherapy with an older adolescent, the therapist
and the parents usually have little contact after the initial part of the therapy, because
ongoing contact inhibits the adolescent’s desire to open up.
Interview Techniques
Adolescents may feel pressured by their parents to receive psychiatric treatment and
may at first be defensive, or appear guarded. Clinicians must establish themselves as
trustworthy and helpful adults to promote a therapeutic alliance. They should encourage
adolescents to tell their own stories, without interrupting to check discrepancies; such a
tactic may make the therapist seem correcting and disbelieving. Clinicians should ask
patients for explanations and theories about what happened. Why did these behaviors
or feelings occur? When did things change? What caused the identified problems to
begin when they did?
Sessions with adolescents generally follow the adult model; the therapist sits across
from the patient. In early adolescence, however, board games may help to stimulate
conversation in an otherwise quiet, anxious patient.
Language is crucial. Even when a teenager and a clinician come from the same
socioeconomic group, their language use is seldom the same. Psychiatrists should use
their own language, explain any specialized terms or concepts, and ask for an
explanation of unfamiliar in-group jargon or slang. Many adolescents do not talk
spontaneously about illicit substances and suicidal tendencies but do respond honestly to
a therapist’s questions. A therapist may need to ask specifically about each substance
and the amount and frequency of its use.
The sexual histories and current sexual activities of adolescents are increasingly
important pieces of information for adequate evaluation. The nature of adolescents’
sexual behavior often is a vignette of their whole personality structures and ego
development, but a long time may elapse in therapy before adolescents begin to talk
about their sexual behavior.
A 15-year-old adolescent male was referred for a psychiatric evaluation by his high
school counselor when he disclosed that he was late to school each day because it took
him 3 hours to get ready in the mornings. Even after he finally got to school, he often
missed classes and was found in the bathroom. In speaking to his counselor, he further
disclosed that he had developed a number of bedtime and morning rituals that took
longer and longer to complete because if he did them incorrectly, he had to repeat
them. They included checking the locks on the windows and doors, placing objects in
the “right” places on his dresser, and repeating a prayer 16 times. He also revealed
that when in the bathroom, he had to wash his hands a certain way and dry them
“just so,” or he feared something terrible would happen. He had not wanted his
parents to know about his difficulties, and he often told them that he had headaches
or stomachaches, which made him late. However, he did explain some of his
difficulties to his parents during the course of his psychiatric evaluation. His
evaluation revealed significant OCD and social phobia. Treatment was initiated,
including use of fluoxetine, an SSRI; CBT; and problem-solving family therapy. Over
the course of 6 months, his OCD responded well to the combination of medications
and CBT, and he was relieved that his family learned ways of helping him both at
home and in school. (Adapted from case material courtesy of Eugene V. Beresin, M.D.
and Steven C. Schlozman, M.D.)
A 14-year-old girl, one of the stars of her high school gymnastic team, began
increasing her daily exercise and restricting her diet after her coach indicated that she
should lose a few pounds. She became fixated on the size of her thighs and belly, and
once she started losing weight, she found that she was not satisfied and wanted to lose
a few more pounds. Over the next four months she lost so much weight that her coach
and pediatrician no longer allowed her to participate in athletics. Although she was
heartbroken about being restricted from gymnastics and planned to eat enough to be
able to participate again with her team, she was unable to gain weight, and continued
to lose more. She became increasingly terrified of getting fat and secretly exercised
any chance she could. She was a perfectionist in academics as well as in gymnastics.
She had started her menses 6 months previously, but after she lost a significant
amount of weight, her menses stopped. She was seen by a therapist and she and her
parents agreed to a meal plan that would result in weight gain, but her family was
baffled because she continued to lose more weight. Finally, when it became clear that
she was not able to be gain weight under the supervision of her family and her
outpatient therapist, she was hospitalized, and the diagnosis of anorexia nervosa, was
established. After a 30-day hospitalization with a modest weight gain, she was
stepped down to a partial hospital program in which she was supervised for all of her
meals, and went home at night. She remained in this program for 8 weeks, and was
able to gain 1 to 2 pounds per week. As part of this program, her weight was
monitored twice weekly, her vital signs were monitored, and she participated in
family therapy, individual psychodynamic psychotherapy, and weekly meetings with
a nutritionist. In her psychotherapy, over the course of the next year, she was able to
understand that her anorexia had served to prevent her from separating from her
parents and kept her close to home and isolated from her peers. She learned that she
was slower to mature than many of her peers and felt unable to cope with the social
pressures of being a high school student. Over time, she was able to maintain her
weight and begin to socialize with friends whom she hadn’t seen for many months.
When she was able to maintain an optimal weight she was thrilled to be able to
resume her athletics, and she began to develop closer friendships. (Adapted from case
material courtesy of Eugene V. Beresin, M.D., and Steven C. Schlozman, M.D.)
TREATMENT
Psychiatric treatment of an adolescent can occur in numerous venues and modalities.
Treatment can take place in individual or group settings, and can include interventions
that are pharmacological (when indicated), psychosocial, and from an environmental
perspective. The best choices for treatment must take into account the characteristics of
the individual adolescent and the family or social milieu. Adolescents’ striving for
autonomy may complicate problems of compliance with therapy and may result in the
need for stabilization in inpatient settings, whereas this level of care might not be
necessary at a different stage of life. The following discussion is less a set of guidelines
than a brief summary of what each treatment modality can or should offer.
Individual Psychotherapy
Individual psychosocial modalities with an evidence base for efficacy with adolescents
include cognitive-behavioral treatments for diagnoses of anxiety disorders, mood
disorders, and OCD. Interpersonal therapy is a technique that has been used to treat
mood disorders in adolescents. Few adolescent patients are trusting or open without
considerable time and testing of therapists, and it is helpful to anticipate the testing
period by letting patients know that it is expected and is natural and healthy. Pointing
out
the
likelihood
of
therapeutic
problems—for
instance,
impatience
and
disappointment with the psychiatrist, with the therapy, with the time required, and with
the often intangible results—may help keep problems under control. Therapeutic goals
should be stated in terms that adolescents understand and value. Although they may not
see the point in exercising self-control, enduring dysphoric emotions, or forgoing
impulsive gratification, they may value feeling more confident than in the past and
gaining more control over their lives and the events that affect them.
Typical adolescent patients need a relationship with a therapist they can perceive as a
real person, whom they feel respected by and they can trust. The therapist may seem
like another parent in some respects, since adolescents still need appropriate guidance,
especially in situations of high-risk behaviors. Thus, a professional who is impersonal
and anonymous is a less useful model than one who can accept and respond rationally
to an angry challenge or confrontation without fear or false conciliation—one that can
impose limits and controls when adolescents cannot, can admit mistakes and ignorance,
and can openly express the gamut of human emotions.
Combined Pharmacotherapy and Psychotherapy
Current evidence suggests that for many psychiatric disorders, optimal treatment
includes a combination of psychosocial and psychopharmacological interventions.
Randomized clinical trials have provided evidence of the superiority of CBT in
combination with SSRIs in the treatment of mood disorders, OCD, and anxiety disorders,
to name a few.
ADHD is often comorbid with additional disorders, thus, although the Multimodal
Treatment Study of Children with ADHD (MTA) found that psychosocial interventions
did not add to the efficacy of stimulant treatments for the core symptoms of ADHD, it is
important to consider that other concurrent disorders that affect overall functioning
often require psychosocial treatments. Advances in drug development have widened the
choice of medications to treat mood disorders (e.g., SSRIs) and schizophrenia (e.g.,
SGAs, including risperidone [Risperdal], olanzapine [Zyprexa], and clozapine
[Clozaril]). Although these medications have been used to treat psychiatric disorders in
adolescents, more research is required to determine their efficacy and safety profiles for
treatment of adolescent psychopathology.
A 17-year-old girl complained of recurrent episodes of rapid heartbeat, sweating,
trembling, and a fear that she was “going crazy.” Her first episode had occurred in her
high school cafeteria during a “college night” event, when multiple college
representatives were displaying their college’s information packets. After running out
of the cafeteria, she stood outside of her school and the episode gradually dissipated
over a period of about 15 minutes. Although she was a little nervous about going back
to school the next day, she did not have another episode. She had almost forgotten
about the episode, when it happened again, and even more intensely, when she was
shopping at the mall and talking about college applications with her friends. After
this episode, she became fearful of going out alone to the shopping mall. She was at
the beginning of her senior year in high school, considering her options for college
and was planning to take her SAT for the last time. Her parents wanted her to
maintain the family tradition and pressured her to try for the same college from which
her mother graduated. She was not opposed to applying to her mother’s alma mater,
but was very angry and upset about her parents’ pressure on her to make a
commitment to this school as her first choice. She became irritable and tearful, and
she was experiencing several panic attacks per week, all of which indicated that she
needed to get some help. She was evaluated by a psychiatrist and started on Lexapro
(escitalopram) to alleviate the panic disorder symptoms, as well as weekly
psychotherapy. The psychotherapy focused on the patient’s conflicts with her parents,
highlighting her chronic concern that she could not meet parental expectations and
fears of her independence. Medication appeared to reduce symptoms of tachycardia,
tremulousness, decreased her irritability, and diminished her preoccupation with lack
of competence. Psychotherapy and medication were both maintained for the next 8
months during her last year in high school. (Adapted from case material courtesy of
Cynthia R. Pfeffer, M.D.)
Group Psychotherapy
In many ways, group psychotherapy is a natural setting for adolescents. Most teenagers
are more comfortable with peers than with adults. A group diminishes the sense of
unequal power between the adult therapist and the adolescent patient. Participation
varies, depending on an adolescent’s readiness. Not all interpretations and
confrontations should come from the parent-figure therapist; group members often are
adept at noticing symptomatic behavior in each other, and adolescents may find it
easier to hear and consider critical or challenging comments from their peers.
Group psychotherapy usually addresses interpersonal and current life issues. Some
adolescents, however, are too fragile for group psychotherapy or have symptoms or
social traits that are too likely to elicit peer group ridicule; they need individual therapy
to attain sufficient ego strength to struggle with peer relationships. Conversely, other
adolescents must resolve interpersonal issues in a group before they can tackle
intrapsychic issues in the intensity of one-on-one therapy.
Family Therapy
Family therapy is the primary modality when adolescents’ difficulties mainly reflect a
dysfunctional family (e.g., teenagers with school refusal, runaways). The same may be
true when developmental issues, such as adolescent sexuality and striving for autonomy,
trigger family conflicts or when family pathology is severe, as in cases of incest and
child abuse. In these instances, adolescents usually need individual therapy as well, but
family therapy is mandatory if an adolescent is to remain in the home or return to it.
Serious character pathology, such as that underlying antisocial and borderline
personality disorders, often develops from highly pathogenic early parenting. Family
therapy is strongly indicated whenever possible for such disorders, but most authorities
consider it adjunctive to intensive individual psychotherapy when individual
psychopathology has become so internalized that it persists regardless of the current
family status.
Inpatient Treatment
Residential treatment schools often are preferable for long-term therapy, but hospitals
are more suitable for emergencies, although some adolescent inpatient hospital units
also provide educational, recreational, and occupational facilities for long-term
patients. Adolescents whose families are too disturbed or incompetent, who are
dangerous to themselves or others, who are out of control in ways that preclude further
healthy development, or who are seriously disorganized require, at least temporarily,
the external controls of a structured environment.
Long-term inpatient therapy is the treatment of choice for severe disorders that are
considered wholly or largely psychogenic in origin, such as major ego deficits that are
caused by early massive deprivation and that respond poorly or not at all to medication.
Severe borderline personality disorder, for example, regardless of the behavioral
symptoms, requires a full-time corrective environment in which regression is possible
and safe and in which ego development can take place. Psychotic disorders in
adolescence often require hospitalization; however, psychotic adolescents often respond
to appropriate medication well enough that therapy is feasible in an outpatient setting,
except during exacerbations. Adolescent patients with schizophrenia who exhibit a longterm deteriorating course may require hospitalization periodically.
Day Hospitals
In day hospitals, which have become increasingly popular, adolescents spend the day in
class, individual and group psychotherapy, and other programs, but they go home in the
evenings. Day hospitals are less expensive than full hospitalization and usually are
preferred by patients.
CLINICAL PROBLEMS
Atypical Puberty
Pubertal changes that occur 2.5 years earlier or later than the average age are within
the normal range. Body image is so important to adolescents, however, that extremes of
the norm may be distressing to some, either because markedly early maturation subjects
them to social and sexual pressures for which they are unready or because late
maturation makes them feel inferior and excludes them from some peer activities.
Medical reassurance, even if based on examination and testing to rule out
pathophysiology, may not suffice. An adolescent’s distress may show as sexual or
delinquent acting out, withdrawal, or problems at school that are sufficiently serious to
warrant therapeutic intervention. Therapy also may be prompted by similar
disturbances in some adolescents who fail to achieve peer-valued stereotypes of physical
development despite normal pubertal physiology.
Substance-Related Disorders
Some experimentation with psychoactive substances is almost ubiquitous among
adolescents, especially if this category of behavior includes alcohol use. Most
adolescents, however, do not become abusers, particularly of prescription drugs and
illegal substances. Any regular substance abuse represents disturbance. Substance abuse
sometimes is self-medication against depression or schizophrenic deterioration and
sometimes it signals a character disorder in teenagers whose ego deficits render them
unequal to the stresses of puberty and the tasks of adolescence. Some substances,
including cocaine, have a physiologically reinforcing action that acts independent of
preexisting psychopathology. When substance abuse covers an underlying illness or is a
maladaptive response to current stresses or disturbed family dynamics, treatment of the
underlying cause may diminish the substance use; in most cases of significant abuse,
however, the drug-taking behavior typically requires intervention. Substance abuse
treatments typically include a 12-step program with behavioral monitoring to
accomplish sobriety as well as the ability to verbalize regarding the motivations for
substance use. These philosophies are adapted to inpatient, intensive outpatient, and
once-a-week outpatient treatment.
Suicide
Suicide is the third leading cause of death among adolescents. Many hospital admissions
of adolescents result from suicidal ideation or behavior. Among adolescents who are not
psychotic, the highest suicidal risks occur in those who have a history of parental
suicide, who are unable to form stable attachments, who display impulsive behavior,
and who abuse alcohol or other substances. Many adolescents who complete suicide
have backgrounds that include long-standing family conflict and social problems since
early childhood and the escalation of subjective distress under the pressure of a sudden
perceived conflict or loss. Early childhood loss of parents also can increase the risk of
depression in adolescence. Adolescents who are susceptible to rapid and extreme mood
swings and a history of impulsive behavior are at greater risk of responding to despair
with impulsive suicide attempts. Abuse of alcohol and other substances are known added
risks for suicidal behavior in adolescents with suicidal ideations. The developmentally
predictable “omnipotent” attitudes of adolescents may cloud the immediate sense of
permanence of death and result in impulsive self-destructive behavior in adolescents.
During a psychiatric evaluation of an adolescent with suicidal thoughts, plans and
past attempts must be discussed directly when the concern arises and information is not
volunteered. Recurring suicidal thoughts should be taken seriously, and a clinician must
evaluate the imminent clinical danger requiring inpatient hospitalization versus an
adolescent’s ability to engage in an agreement or contract mandating that the
adolescent will seek help before engaging in self-destructive behavior. Adolescents
typically are honest in their refusal of such agreements, and, in such cases,
hospitalization is indicated. Hospitalization of a suicidal adolescent by a clinician is an
act of serious, protective concern.
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psychiatric outpatients: A randomized clinical trial. J Consult Clin Psychol. 2009;5:855–866.
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Scale (RCADS) measure anxiety symptoms consistently across adolescence? The TRAILS study. Int J Methods Psychiatric
Res. Mar 2013;22(1):27–35.
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interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 2004;61(6):577.
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primary neuropsychiatric disorders: A review of current and potentially promising treatment options. Exp Clin
Psychopharmacol. 2010;8:184–201.
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case-control study. Arch Gen Psychiatry. 2006;63:865.
Richardson T, Stallard P, Velleman S. Computerised cognitive behavioural therapy for the prevention and treatment of
depression and anxiety in children and adolescents: A systematic review. Clin Child Fam Psychol Rev. 2010;13:275–290.
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Am Acad Child Adolesc Psychiatry. 2006;45:329.
Seidman LJ. Neuropsychological functioning in people with ADHD across the lifespan. Clin Psychol Rev. 2006;26:466.
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symptoms of depression in high risk adolescents: pragmatic cluster randomised controlled trial. BMJ. 2012;345:e6058.

50 - 31.19 Child Psychiatry Special Areas of Inter
31.19 Child Psychiatry: Special Areas of Interest

51 - 31.19a Forensic Issues in Child Psychiatry
31.19a Forensic Issues in Child Psychiatry
31.19 Child Psychiatry: Special Areas of Interest
31.19a Forensic Issues in Child Psychiatry
Forensic evaluations of youth span a broad spectrum of situations and settings,
including child custody during a parental divorce, trauma and abuse situations, and
juvenile offender evaluations pertaining to juvenile and criminal court cases. Child and
adolescent psychiatrists are increasingly being sought out by patients and attorneys for
evaluations and expert opinions related to child sexual and physical abuse, to criminal
behaviors perpetrated by minors, and to evaluate the relations between traumatic life
events and the emergence of psychiatric symptoms in children and adolescents. As more
youth enter the juvenile justice system, an increasing need exists for forensic
psychiatrists with expertise in evaluation and treatment for detainees and committed
youths.
The specific tasks and role of a child and adolescent psychiatric forensic evaluator are
distinctly different from a child and adolescent psychiatrist doing a clinical evaluation
and clinical treatment intervention. In clinical settings, child mental health
professionals provide psychotherapy, medication evaluations, and advocacy for youth
with psychiatric diagnoses. As a forensic child psychiatric evaluator, however, the main
task is to be an expert, to report objective psychiatric findings related to the questions
asked. Two essential characteristics of a forensic evaluator, in contrast to a clinician are
(1) the relationship between the evaluator and the patient is not therapeutic, rather, it
is information seeking, and (2) there are clear limits of confidentiality in this situation,
that is, the information disclosed during a forensic evaluation may be brought to court,
or to an attorney, or to whomever initiated the evaluation.
Society’s view of children and their rights has evolved dramatically. In 1980, the
American Academy of Child and Adolescent Psychiatry (AACAP) published a code of
ethics that was developed to publicly endorse the ethical standards of this discipline. The
code is based on the assumption that children are vulnerable and unable to take
adequate care of themselves; as they mature, however, their capacity to make judgments
of, and choices about, their well-being develops as well. The code has several caveats:
From the standpoint of child and adolescent psychiatrists, issues of consent,
confidentiality, and professional responsibility must be seen in the context of
overlapping and potentially conflicting rights of children, parents, and society.
Confidentiality, or intensive trust, refers to the relationship between two persons with respect to the “entrustment of
secrets.” Until the 1970s, little attention was paid to issues of confidentiality pertaining to minors. In 1980, among the
items in the AACAP Code of Ethics, six principles were related to confidentiality. Breaches and limits of confidentiality can
be obtained in cases of child abuse or maltreatment or for purposes of appropriate education. Although unnecessary with a
child or adolescent, consent for disclosure should be obtained when possible. In 1979, the American Psychiatric
Association (APA) stated that a child 12 years of age could give consent for disclosure of confidential information and, with
the exception of safety issues, a minor’s consent is required for disclosure of information to others, including the child’s
parents. According to the AACAP Code of Ethics, the consent of a minor is not required for disclosure of confidential
information. Specific ages for consent are not addressed in the code. Child and adolescent psychiatrists often face the
dilemma of weighing the potential benefits and possible harm in sharing information obtained confidentially from a child
with the child’s parents. Although the smoothest transition occurs when the child and the physician agree that certain
information can be shared, in many situations that border on “dangerousness to the child or others,” the child or
adolescent does not agree to share the information with a parent or another responsible adult. Among adolescents, these
secrets that are sometimes shared with a psychiatrist may involve drug or alcohol use, unsafe sex practices, or a thrillseeking act that places the adolescent in danger. A psychiatrist may choose to work with the child or adolescent toward
agreeing to share confidential information when it is determined by the treating psychiatrist that the probable outcome
would be beneficial. The initial treatment contract, however, limits confidentiality to situations of “danger” to the child or
others.
CHILD CUSTODY
Child custody evaluations by child and adolescent psychiatrists may be initiated by
divorcing parents who cannot come to an agreement regarding custody of their
children, or can be requested by an attorney. Attorneys are most likely to seek child
custody evaluations when allegations are made of parental incompetence, or issues of
alleged physical or sexual abuse arise. Comprehensive custody evaluations by mental
health professionals may play a significant role in successful negotiations of custody by
parents without the necessity of proceeding to a trial.
The evolution of child custody decision-making has been influenced by increasing awareness and recognition of the
rights of children and women, as well as by a broadening perspective on the developmental and psychological needs of the
children involved. Historically, children were considered to be their fathers’ property. At the beginning of the 20th
century, the “tender years” doctrine became the standard for determining child custody. According to this doctrine, the
relationship between mother and infant, later generalized to mother and child, is responsible for the optimal emotional
development of the child; the doctrine thus supported custody decisions in the mother’s favor in most cases. With this
doctrine as its guide, psychological issues in developing children became an acceptable dimension to consider in the
determination of custody. In controversial and unclear cases, psychological expert testimony began to be accepted as a
valuable part of child custody decision-making.
The “best interest of the child” standard replaced the “tender years” doctrine and
expanded considerations of the optimal parent to include assessing issues of emotional
climate, safety, and educational and social opportunities for the children. The “best
interest of the child” grew from the movement to support legislation about the rights of
children in the areas of compulsory education, child labor laws, and child abuse and
neglect protection laws. Therefore, although “best interest” standards have broadened
the dimensions considered in evaluating which parent is best able to serve the best
interest of the child, how to measure these qualities in a parent remains vague. In view
of the lack of clarity regarding what specific parameters in a parent best correspond to
the interest of the child, child and adolescent psychiatrists have increasingly been asked
to help make decisions by defining relevant psychological conditions in parents and in
the relationships between parents and children.
Psychiatric evaluators may be asked to give an opinion about child custody at various points during the separation and
divorce process. Sometimes, a psychiatric evaluation is requested by the parents before any legal action occurs. When the
parents and an evaluator can agree on custody decisions before the legal process, a court is likely to go along with these
decisions rather than launch an additional investigation. A psychiatric evaluation may be ordered by the court or by the
attorneys representing the feuding parents. In such cases, an evaluator is faced with two disgruntled parents, who often are
consumed by their mutual conflict to the point that neither is willing to compromise, even in the child’s interest. The
advantage in such cases, however, is that evaluators represent the court and can act as advocate for the child without the
same pressures that an evaluator hired by only one parent faces. A psychiatric evaluation also may be initiated by a
guardian ad litem, an attorney who is appointed by the court to represent the child. Psychiatric evaluators also may be
requested to give an opinion about custody during a mediation process. Mediation is a legal process that usually involves
one attorney and one evaluator. Because mediation can occur outside the judicial system, some families may prefer it to
going through a trial. In addition to custody, psychiatric evaluators often are asked to give opinions about visitation.
In undertaking a custody evaluation, an evaluator is expected to determine the best interests of the child while keeping
in mind the standard elements that the court considers. These considerations include the wishes of the parents and the
child; relationships with significant others in the child’s life; the child’s adjustment to the current home, school, and
community; the psychiatric and physical health of all parties; and the level of conflict and potential danger to the child
under the care of either parent. A psychiatric evaluator must maintain his or her role as an advocate for the best interest of
the child and does not consider the fairest outcome for parents. The psychiatric evaluator conducts a series of interviews,
often including at least one separate interview with each parent and the child alone and one interview with the child and
both parents. The evaluator may obtain a written waiver of confidentiality from all parties because he or she may have
made disclosures to opposing attorneys and in court before the judge. The evaluator uses direct questioning as well as
observations of the relationships between the child and each parent. The age and developmental needs of the child are
considered in making a judgment regarding which parent may better serve the child’s interests. As part of the psychiatric
assessment of the child custody evaluation, the evaluator determines the need for psychiatric treatment of any of the
parties involved.
The child custody evaluation generally is provided in a written report. This document
is not confidential and can be used in court. The report contains a description of the
relationship between the child and parents, the capabilities of the parents, and finally,
the custody recommendations. In view of data supporting the importance of continuing
a relationship with both parents in most cases, it is recommended that joint custody be
considered before other options. When sufficient cooperation exists to negotiate for joint
custody, the best interests of the child often are served. Joint custody may not be the
best option for a child when the relationship of the child with either parent is
jeopardized and undermined by the other. The next most frequent choice when joint
custody is not advisable is full custody by one parent with visitation rights for the other
parent. The parent awarded full custody should be able to support the visitations and
relationship with the noncustodial parent. In custody disputes involving a biological
parent and a nonbiological parent, the biological parent generally has the right to
custody unless he or she is shown to be unable to provide for the child. After the custody
evaluation has been submitted in writing, the results must be communicated to the
parents, the child, and possibly their respective attorneys. The evaluator may be called
on to testify in court, and the parties can use the custody evaluation to mediate other
areas of their dispute.
Many complications can occur in an ongoing bitter dispute between divorcing or
divorced parents. Both true and false allegations of psychiatric illness, drug or alcohol
abuse, or sexual or physical abuse are not uncommon during custody battles. The
evaluator must be prepared to verify any allegations and to carefully discuss their
effects on custody and visitation. Evidence suggests that markedly elevated numbers of
unfounded allegations of child sexual abuse occur during the course of custody disputes.
Tremain, age 9 years, has been in a therapeutic foster home for 2 years, having
been removed from his home along with his younger sister, due to profound neglect,
as well as physical abuse. Although he is receiving cognitive-behavioral therapy,
medication, and a social skills group, he remains volatile, and typically becomes more
aggressive and regressed after weekly supervised visits with his mother. Tremain’s
sister has been reunited with their mother, and his guardian ad litem requests that a
child psychiatrist perform a forensic evaluation to determine whether visits should
continue. She reviews extensive records, evaluates each parent, obtains history from
them and the foster parent, and then observes a visit. Tremain’s little sister totally
dominates the visit, and her mother is at a loss to control her aggressive and
hyperactive behavior. Tremain is passive and clingy with his mother. According to the
social work supervisor, this is a fairly typical visit. When the child and adolescent
psychiatrist meets individually with Tremain, he expresses concern that his sister is
probably being abused at home, and he likes to check on her during these visits.
Tremain wants to go home, but he says that his mother has too many problems to
take care of him. Tremain has developed a positive relationship with his foster father
and, in contrast, has little to say about his biological mother. The child and adolescent
psychiatrist recommends a psychiatric evaluation of the sister, but Tremain’s mother
does not follow through. The child and adolescent psychiatrist recommends cutting
visits back to monthly, but Tremain’s anxiety and aggressive behavior persist around
these limited visits. It also becomes apparent that Tremain’s mother is not up to the
demands of caring for two special-needs children, as she is having difficulty
containing her little daughter. The child and adolescent psychiatrist recommends
delaying efforts at parental reunification however, maintaining contact between
Tremain, his mother, and his sister. (Adapted from case material from Diane H.
Schetky, M.D.)
JUVENILE OFFENDERS
According to the AACAP Practice Parameter for Child and Adolescent Forensic
Evaluations, at least 2.7 million youth younger than 18 years are arrested each year in
the U.S., and more than 1 million youth will have a formal interaction with the juvenile
justice system. Historically, a separate juvenile court system in the United States
occurred by statute in the state of Illinois in the late 1800s. Its mandate was to
rehabilitate rather than to punish. Despite the protective intentions of the legal system,
children and adolescents involved in the juvenile justice system are at high risk for
multiple psychiatric disorders and suicidal thoughts and behavior. The omission of
various constitutional safeguards, such as the rights to counsel, confrontation, and crossexamination of an accuser, eventually led to criticism and disillusionment with this
system. Juvenile offenders of small and significant crimes often were sent to state-run
residential programs that were criticized for being overcrowded, neglectful, and frankly
abusive. Despite the strong sentiment to increase due process protection for juveniles
rather than pretrial, trial, and sentencing, the juvenile court system includes intake,
adjudication, and disposition. The intake is a determination of whether probable cause
exists that the youth committed a crime. A youth who confesses may be diverted from
the court system altogether at this time, and appropriate plans for rehabilitation can be
made in a community setting. For more serious crimes or when juveniles deny
perpetrating a crime, the process continues. Juveniles must be represented by counsel,
and an attorney is provided if the family cannot afford to provide its own. Unlike adult
court, in juvenile court, guilt or innocence is determined by a judge, not a jury. The case
is argued by a prosecuting attorney and a defense attorney, and the judge is bound by
the same standards as in adult court; that is, a judgment of delinquency requires proof
beyond a reasonable doubt. When the charge is substantiated and the judgment is for
delinquency, the juvenile is an “adjudicated delinquent.” Disposition must next be
determined. Dispositions include a wide range of options, from placement in youth
correctional facilities, to residential treatment settings, to psychiatric hospitalizations
for further evaluation. Delinquent acts refer to ordinary crimes committed by juveniles;
status offenses refer to behaviors that would not be criminal if perpetrated by adults,
such as truancy, running away, or drinking alcohol. Sometimes, youths who are believed
to have committed a serious crime are turned over (receive a waiver) to adult criminal
court.
DEVELOPMENTAL IMMATURITY VERSUS JUVENILE COMPETENCE TO
STAND TRIAL
A growing body of research is elucidating the significance of “developmental
immaturity” on the capacity of children and young adolescents’ competency to stand
trial. Starting in the 1960s, the Supreme Court mandated a series of due process rights in
juvenile court proceedings including the rights to notice of charges, an adversarial
hearing with representation by counsel, the ability to cross-examine witnesses, and a
trial transcript. Furthermore, juveniles have the right to a hearing prior to being
transferred to adult court, and use of the standard of proof beyond a reasonable doubt
to sustain a delinquency petition; however, there is no mention of the right to be
competent to stand trial in delinquency proceedings. In the 1960 landmark case Dusky v.
United States, the Supreme Court established a minimum national standard for
competency in criminal proceedings for adults. This standard mandates that in order for
a defendant to be competent to stand trial, he or she must possess “sufficient present
ability to consult with his lawyer with a reasonable degree of rational understanding
and a rational as well as factual understanding of the proceedings against him.” Thus,
there is no legal requirement for juveniles to be competent to participate in delinquency
proceedings; however, many states have adopted their own competency standards for
their juvenile courts. This is critical insofar as research suggests that developmental level
has a definite impact on a child or early adolescent’s understanding of legal concepts,
and long-term implications of legal decisions, and thereby influences their competency
to stand trial. The following two U.S. Supreme Court rulings have provided legal
stipulations pertaining to the limitations of developmental immaturity and legal
culpability. (1) In the case, Roper v. Simmons (2005), a successful argument was made
that, among other reasons, but including a juvenile’s normative immaturity, including
impulsive decision making, susceptibility to peer pressure, and transitory behavior
patterns, youth younger than 18 years of age should be excluded from the death
penalty. (2) In 2010, in the case Graham v. Florida, using the developmental information
that fueled the exclusion of minors from the death penalty, the Court ruled that a life
sentence without parole for a juvenile offender, (with the exclusion of homicide cases),
constituted cruel and unusual punishment.
In one study using vignettes to elicit responses from children and adolescents
pertaining to competent participation in legal proceedings, findings included that
children 11 years to 13 years were less able to recognize risks and long-term
consequences associated with their decisions and were more likely than adults to accept
plea agreements; whereas youths up to 15 years also demonstrated greater compliance
with authority figures in their decision making, compared to adults. Researchers in this
field have concluded that due to developmental status alone, young juveniles are at
greater risk to make poor decisions on their own behalf in the context of working with
their own attorneys.
There are many factors that may influence a juvenile’s competency, and several are
essential in a competency evaluation of a juvenile, including: (1) age, with special
consideration in any child of 12 years or younger; (2) developmental stage with respect
to judgment, reasoning, responsibility, risk perception, suggestibility, temperance
(seeking advice rather than acting without the facts), and future orientation; (3)
assessment of mental disorder and intellectual level.
MENTAL HEALTH NEEDS OF YOUTH IN THE JUVENILE JUSTICE SYSTEM
Youth in the juvenile justice system are at extremely high risk for psychiatric
disturbance, and unmet mental health needs have reached such high proportions that
they are of public health concern. Adolescents in juvenile justice residential facilities not
only have higher rates of psychiatric disorders, including depression, substance use, and
suicidal behavior, but they are also significantly more likely to have been victims of
physical and sexual abuse, educational failure, and family conflict. A survey of 991
youth at an initial juvenile justice intake revealed high levels of suicidal ideation with
recent attempts more common in females, and youth with major depression or substance
use disorders, and those who were violent offenders. Few studies, however, have
documented the needs of juveniles in residential facilities and the medical and
psychiatric care available. A recent study collected data from the U.S. Department of
Justice censuses of all public and private juvenile justice facilities in the United States:
The Juvenile Residential Facilities Census (JRFC) and the Census of Juveniles in
Residential Placement (CJRP) investigated data on death rates of youth under the age of
21 years who had been charged with, or adjudicated for, an offense and are housed in
that facility because of the offense. In the 2-year period, a total of 62 deaths of youth
occurred. The leading cause of death was from suicide (20 cases), followed by accidents
(17 cases), illness (14 cases), and homicides by nonresidents (6 cases). No deaths
resulted from acquired immunodeficiency syndrome (AIDS), homicide by another
resident, or an injury that occurred before placement. The risk for death of youth in
juvenile justice facilities was found to be 8 percent higher than the death rate for the
general population of adolescents aged 15 to 19 years. Above all, the risk for suicide is
clearly increased in the juvenile justice facility compared with the general population,
indicating a significant need for increased mental health evaluation and treatment in
this population.
FORENSIC ASPECTS OF SCHOOL BULLYING
The forensic aspects of school bullying have increased over the last two decades,
particularly in the wake of the serious incidents of school violence that took place in the
mid-1990s such as the Columbine school shootings. The responsibilities of schools to
protect students and safeguard against injury have extended from a duty to care, to a
duty to protect. Bullying is typically observed in four different realms: physical,
relational, verbal, and cyberbullying. Forensic evaluations often begin with a referral
from an attorney, the court, or a family. After obtaining a comprehensive history of the
youths involved in a reported bullying incident, the evaluator is tasked with
determining if the alleged bullying has had a negative impact on the mental health and
well-being of the victim. In some cases, investigators have reported findings of increased
suicidality in the bully as well as the victim. One study reported that victims of
cyberbullying attempt suicide twice as often as other youth.
THE RELATIONSHIPS BETWEEN TRAUMA, ABUSE, AND VIOLENT
DELINQUENCY
Child and adolescent psychiatrists are frequently sought out to evaluate children or
adolescents who have been exposed to a traumatic or adverse life event and are
exhibiting a variety of violent and delinquent behaviors. The child and adolescent
psychiatrist may be asked to determine whether a child or adolescent is experiencing
posttraumatic stress disorder or whether a given set of symptoms is likely to have been
caused by exposure to the adverse life event. It is clear from surveys of delinquent
adolescents that there is a relationship between posttraumatic stress disorder, previous
histories of trauma and abuse, and aggressive behavior. Some researchers argue that
evidence supports a trauma-related psychopathology in youth that evolves into
aggressive behavior, and often into delinquency. It appears that brain circuits that
monitor “threat response,” that is, circuits that run from the medial nucleus of the
amygdala to the medial hypothalamus and to the periaqueductal gray matter, are overly
reactive in reactive/affective/defensive/impulsive aggression (RADI, also referred to as
“hot” aggression), as well as in planned or predatory aggression (PIP, also referred to as
“cold” aggression). Particularly in RADI, structures may have become dysregulated by
traumatic emotional activation, resulting in a lack of subtle differentiation between
emotions such as sadness, anger, and fear. The result is that any stress is perceived as a
threat, and activates the “defense” system, leading to the flight or fight decisions. The
final response seems to be “fight,” a response triggered during abusive or lifethreatening situations in which escape seems impossible.
In another study, a cognitive mechanism for the link between abusive parenting and
violent delinquency is offered. In this retrospective study of 112 adolescents (male 90;
female 22), ages 12 to 19 years who were incarcerated in a juvenile detention facility
pending criminal charges, participants completed questionnaires pertaining to exposure
to abusive and nonabusive discipline, expressed and converted shame, and violent
delinquency. The authors defined shame as a state in which negative attributions of the
self and self-blame are made as a result of perceived failure in meeting their own
expected standards. Higher levels of shame have been found among youth exposed to
trauma. Converted shame is an expression of externalizing blame to others so that
hostility is directed away from oneself, and decreases one’s own sense of responsibility
for something negative, such as abuse. Converted shame can serve as a self-protective
attribution. The findings of this study led to subjects’ responses, which fell into four
groups: (1) Low shame, and low blaming of others; (2) Converters: low shame and high
blaming of others, (3) Expressers: high shame, and low blaming of others, (4) High
shame and high blaming of others. Subjects who were in group 2 (low shame and high
blaming of others) had significantly more exposure to abusive parenting, and exhibited
significantly more violent delinquent behaviors than those in group 3 (high shame, low
blaming of others). Thus, although converting shame is “meant” to be self-protective,
and a potentially adaptive response to consistent abusive parenting, those adolescents
who strongly blamed others appeared to develop more violent delinquency. The authors
considered the violent delinquency a pathological response to trauma.
Dr. Sullivan is called by a defense attorney to review discovery material in a case
that alleges permanent harm and suffering in 6-year-old Travis, who is alleged to
have been sexually abused at age 3 in his day care center. Dr. Lane, the forensic
expert for the plaintiff, has evaluated the child and performed psychological testing of
him and concluded that the boy’s conduct problems are all related to the alleged
abuse, which the child has difficulty recalling. His early history on the boy is cursory,
however, and he has little information about the mother, who is a single parent, and
he did not review medical records. In her thorough review of discovery material, Dr.
Sullivan learns that Travis has witnessed extensive domestic violence and his mother’s
rape, shown signs of hyperactivity since age 2, and has exhibited much anxiety
related to his mother’s safety and several separations from her at times when she was
unable to care for him owing to depression. Travis also has had delayed language
development. Dr. Lane, at the time of his deposition, was asked why he had not asked
about these matters. He said he considered the mother’s personal life a private matter
and did not see its relevance to the litigation. Dr. Sullivan, when deposed, points out
that many other factors beside the alleged abuse might account for Tony’s behavioral
problems. (Adapted from case material from Diane H. Schetky, M.D.)
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52 - 31.19b Adoption and Foster Care
31.19b Adoption and Foster Care
children with autism spectrum disorders. J Dev Behav Pediatr. 2013;34(1):1–8.
31.19b Adoption and Foster Care
According to the U.S. Department of Health and Human Services, 408,425 children and
adolescents were in foster care in the United States in 2010. Most children entering
foster care have experienced multiple traumatic events including neglect, or abuse,
which are typically the precipitant for their removal from their biological parents. One
study estimated that 26 percent of children in the United States will experience a
traumatic event by the age of 4 years. Over the last decade, specifically between the
years of 2000 to 2010, the number of evaluations for suspected child maltreatment has
increased by 17 percent, according to another study.
Foster care is intended to be temporary out-of-home care, provided by the welfare
system, for children and adolescents whose immediate families are unable to care for
them. Given the severity of the pathology of vulnerable parents; however, care is often
needed for many months and years. In 1997, President Clinton signed the Adoption and
Safe Families Act, a law designed to improve provisions for child safety, to decrease the
length of time that a child remains in foster care without long-term planning, and to
limit the amount of time in which a biological parent has to undergo rehabilitation to 12
months. An additional law was added to allocate federal funds for independent living
assistance for adolescents and young adults aged 16 to 21 to assist them in transitioning
to independent living.
EPIDEMIOLOGY AND DEMOGRAPHICS OF FOSTER CARE
The number of children entering foster care due to maltreatment has risen in the last
decade by 19 percent. Of those children who entered foster care, there was an increase
of 60 percent in the number who were identified as emotionally disturbed. In the United
States, one of the most common scenarios of children being placed in foster care
involves parental substance abuse, which leads to inability of the parent to care for their
children. The National Center on Addiction and Substance Abuse of Columbia University
reported that seven of ten abused or neglected children had parents with substance
abuse. Furthermore, children in foster care were more often being raised by a single
mother prior to placement compared to children in the community.
Minority children are overrepresented in the foster care population. In a study
utilizing birth records and child protective service (CPS), black children were more than
twice as likely to be referred due to maltreatment, be substantiated as victims of
maltreatment, and enter the foster care system before age 5 years, compared to white
children. However, low socioeconomic black children had a lower rate of referral,
substantiation, and placement in foster care than socioeconomically similar white
children. Among Latinos, children of U.S.-born mothers were significantly more likely to
have involvement with CPS, compared to Latino children of foreign-born mothers.
However, after adjusting for socioeconomic factors, the relative risk of referral,
substantiation, and entry into the foster care system was significantly higher for all
Latino children than for white children. Approximately 38 percent of children in the
foster care system are African American, more than three times their representation in
the general population. Whites make up approximately 48 percent, and Hispanics make
up almost 15 percent of foster children; 55 to 69 percent are girls, and 83.4 percent
enter foster care at a mean age of 3 years. Children placed in care as infants are more
likely to stay in care. Those younger than 5 years of age currently comprise the fastest
growing segment of the foster care population. Studies reveal that up to 62 percent of
foster children had prenatal drug exposure.
NEEDS OF FOSTER CARE CHILDREN
Children entering foster care have enormous mental health needs; more than 80 percent
of them have developmental, emotional, or behavioral problems. It is estimated that up
to 70% of these children have diagnosable psychiatric disorders. In addition, according
to one study, quality of life (QOL) is significantly poorer among children in the foster
care system than children in the general community. Children and adolescents living in
residential care rated their QOL as poorer than those living with foster families. Up to
50 percent of foster care children exhibit depressive symptoms, and self-reports of
anxiety problems occur in about 36 percent. QOL is adversely affected by the presence
of mental health problems, and those youth with greater mental health difficulties rated
their QOL as poorer whether in residential facilities or foster placement. In a review of
the literature, psychiatric disorders found with increased frequency in foster youth were
attention-deficit/hyperactivity disorder (ADHD), posttraumatic stress disorder, conduct
disorders, attachment disorders, substance abuse, depression, and eating disorders.
In addition to high rates of psychiatric disorders, foster care youth are referred to
pediatric clinics more frequently due to multiple health problems compared to
community youth. Growth abnormalities (including failure to thrive), neurological
abnormalities, neuromuscular disorders, language disorders, cognitive delays, and
asthma are prevalent. Health care costs in foster care youth are six to ten times that of
matched non–foster-care peers. Among children 0 to 5 years of age, approximately 25
percent are seriously emotionally damaged; attachment disorders are increasingly
diagnosed. Foster care children use the full range of mental health services: outpatient,
acute inpatient, day treatment, partial hospitalization, and residential treatment.
Adolescents in foster care are at increased risk for substance abuse, teenage
pregnancies, and sexually transmitted diseases, including human immunodeficiency
virus (HIV). With public health care increasingly adopting a managed health care
system, which is designed to limit care, grave concern exists that the provision and
delivery of services to this medically and psychiatrically vulnerable population may be
seriously compromised.
KINSHIP CARE FOR FOSTER CHILDREN
More states are recognizing kinship care as an alternative placement option and are
authorizing licensing and reimbursement to kinship caregivers who are generally female
(mostly maternal grandmothers), of low income, of low education, and of minority
status. Currently, nationwide, approximately 23 percent of African American children
are in foster kinship care. It is unknown just how many children are in informal kinship
care within the African American population, which has had a long cultural tradition of
taking in children of family members who are unable to care for their offspring. The few
studies available indicate that outcomes, although mixed, are somewhat more positive
than for those children in nonkinship care. Children reportedly receive more positive
regard from caregivers in kinship care, and a consistent outcome, when it works, is that
it provides more stability than nonrelative foster care. Most foster children have
consistently said that they would rather be with a family member than stay in the
system. When foster children feel embraced by their families of origin, and the latter can
provide appropriate nurturance and access to good therapeutic services, the foster
children’s sense of identity and belonging is less disrupted. However, no demonstrable
difference is seen in the need for mental health, medical, and special educational
services for these children.
THERAPEUTIC FOSTER CARE
Therapeutic foster care (TFC) has emerged as a cost-effective alternative to the more
restrictive residential treatment center (RTC). Therapeutic effectiveness is mixed. TFC is
designed to provide nurturing family-based care with specialized treatment
interventions from an interdisciplinary treatment team. Therapeutic foster parents are
meant to be the agents of therapeutic change, functioning as extenders of the clinical
treatment team. Because of the children’s special needs, therapeutic foster parents must
have more extensive training than other foster parents, receive a higher reimbursement,
and receive more intensive monitoring, supervision, and support from the foster care
agency. Although the concept of TFC is promising, good outcome data do not show
consistent success. Several models exist, but implementation that shows fidelity to
empirically tested models is often spotty. Some models have proved too expensive and
complicated to implement in the real-world setting. The concept of professional
therapeutic parents, who are paid competitive full-time wages to care for special needs
foster children, holds promise as an alternative to current prevailing practice. Clinical
practice demonstrates that, when adequate and appropriate intensive in-home services
with good case management is provided in a well-managed foster care setting, children
can show significant gains.
CULTURAL COMPETENCE
Anna McPhatter defines cultural competence as the ability to use knowledge and cultural
awareness to design psychosocial interventions that support and sustain healthy client–
system functioning within a cultural context that is meaningful to the client. Because
American society is still significantly encumbered by racial conflicts, some children have
been denied placement with families of a different race, and have ended up in long-term
foster care rather than in a permanent adoption placement. The Association of Black
Social Workers went on record as opposing transracial placement of African American
children. In 1978, the Indian Child Welfare Act transferred to Tribal Courts the power to
make placement decisions about Native American children to reverse the practice of
placement in non–Native American homes. Adoption studies have shown that it is not
inherently harmful for children to be cross-racially adopted. Congress has passed
legislation, the Multiethnic Placement Act of 1994, facilitating transracial adoptions,
while maintaining the language of cultural awareness in placement decisions. The need
for cultural sensitivity, respect, and a capacity to facilitate a foster child’s cultural
development and identity are well acknowledged. These issues must be addressed in
training providers of foster care services.
PSYCHOLOGICAL ISSUES IN FOSTER CARE CHILDREN
Family risk factors including alcohol and drug abuse in parents, parental neglect and
abuse, and cognitive or mental or physical health problems in parents, as well as low
socioeconomic status and low social support, are strongly associated with a child being
placed out of the home. Psychiatric and behavior problems in the child may also
contribute to being placed out of the home. Among children who return home, 40
percent reenter the foster care system. These children struggle with issues of
abandonment, neglect, rejection, and physical, emotional, and sexual maltreatment.
The child’s age, home environment, and the specific reasons for going into placement
affect the emotional issues that the child must handle. Early abandonment and neglect
can lead to anaclitic depression. Attachment issues are prevalent in this young
population, because there has been no opportunity to form secure attachments with
consistent nurturing figures in early life.
Foster children are often unprepared for separations, which can be abrupt and
repeated in the current foster care climate. Early separation from the primary caretaker
is considered a major trauma for a child and sets the stage for vulnerability to
subsequent trauma. Those children who bounce from foster home to foster home have
their capacity to form enduring emotional attachments compromised; trust becomes a
lifelong challenge.
Children who have experienced traumatic physical and sexual abuse often become mistrustful, hypervigilant,
aggressive, impulsive, oppositional, and avoidant as they attempt to negotiate a world that they experience as threatening,
hostile, and uncaring. When a child’s early developmental period is spent in a psychosocial environment of trauma,
aggression, and lack of empathy from adults, the psychological seeds are sown for later violence against the self and others.
A wide range of behavior problems is likely to emerge in foster care children given their early family experiences. A
pervasive problem is one of dysregulation: dysregulation of behavior, emotions and affect, attention, and sleep. The
empirical data on the neurobiology of maltreatment on the developing brain reveals that stress hormones play an
important role in adaptation and coping, and that these capacities are compromised in varying degrees of severity in
abused and neglected children. The data also show that, because of the developmental plasticity of the brain, appropriate
early intervention can induce remediation and repair at the neurobiological level.
Nick, a 5-year-old, was placed in foster care because of maternal substance abuse
and inability to take care of her child. When seen for a psychiatric evaluation, it was
noted that all of his primary teeth were full of dental cavities. The foster mother was
asked about dental care, and she responded that the dentist had said that he would
wait until the teeth had fallen out, because they were his first set of teeth and did not
require intervention. This response aroused suspicion that neglect in the foster family
was exacerbating Nick’s hyperactive and aggressive behaviors. A neglect report was
made and the investigation revealed that Nick was not only neglected, but was also
being physically abused in that foster care placement. Subsequent to removal and
placement with a nurturing and responsible foster family, Nick has shown
considerable emotional stabilization, does well academically and socially, and is now
being adopted by that family. (Adapted from case material Marilyn B. Benoit, M.D.,
Steven L. Nickman, M.D., and Alvin Rosenfeld, M.D.)
FAMILY PRESERVATION
Family preservation has come under increasing scrutiny in the last decade. Estimates on
the percentage of children who are reportedly reunited vary from 66 to 90 percent.
Philosophically, family reunification appears to be the right thing to do, yet
approximately 40 percent of reunified children reenter out-of-home care. The field needs
discriminating criteria that would identify psychosocial profiles of families that could
best benefit from family preservation services. In 1996, the Child Welfare League of
America (CWLA) acknowledged the failure of family preservation efforts and requested
that child welfare policy makers rethink the current use of intensive family
preservation. Recent research has validated poor outcomes with family preservation.
Hopes are that the Adoption and Safe Families Act of 1997 will give child welfare
agencies the opportunity to step back from the myopic view of family preservation and
to consider the needs of the child as the major priority. The AACAP and the CWLA
jointly launched a national effort to address the mental health needs of children in
foster care. This effort is supported by a broad-based coalition of agencies that are all
stakeholders in foster care. The coalition proposes that the foster care system be child
focused, but inclusive of the biological and foster families in intervention planning on
the child’s behalf if families are to be preserved.
One case of a 7-year-old boy who was in foster care for 2 years is illustrative of why
some family preservation efforts fail. When James was returned to his biological
mother, she was in a new marriage with a new baby. Her husband was new to
parenting. The family was financially strapped and lived under harsh conditions.
James’ mother completed the required parenting course for resuming custody of her
child, and seemed pleased to have him back with her; however, no supports were put
in place to assist this young couple financially or with any family therapy,
psychoeducation, or case management interventions. Frequent and increasingly
urgent calls to the child welfare family reunification services were made to seek
respite and financial help, but this was not possible. The outcome for James was that
he was reabused and had to reenter the foster care system.
This outcome represents a failure of the system, but also translates into a debilitated
family, with a profound sense of failure. (Adapted from case material from Marilyn B.
Benoit, M.D., Steven L. Nickman, M.D., and Alvin Rosenfeld, M.D.)
FOSTER CARE OUTCOMES AND RESEARCH INITIATIVES
The overall quality of available outcome studies is poor. Some patterns, however, recur
across studies. Several studies reveal that 15 to 39 percent of the homeless are foster
care graduates, who are also overrepresented among adult substance abusers and clients
in the criminal justice system. It is likely that the reasons that initially precipitated the
child’s foster care placement contributed to the negative adult outcomes. Studies indicate
that children entering care who have been victimized, who have substance-abusing
parents or parents with major mental illness or high criminality, or both, and who come
from homes with a high degree of domestic violence are at greater risk of having poor
outcomes. Research on early maltreatment indicates that the influence of maltreatment
on brain development can be profound over the life span. Developmental disabilities
occur in more than 50 percent of the foster care population. Children returned to their
families of origin typically have fared worse than those who have remained in long-term
placement.
Several studies report findings indicating that multiple placements and poor parental involvement consistently lead to
negative outcomes. Federal mandate requires states to maintain a tracking system for children in foster care. New reporting
systems, the Adoption and Foster Care Analysis and Reporting System (AFCARS) and the Statewide Automated Child
Welfare Information System (SACWIS), are available nationwide. States are being monitored for compliance with their use,
and continued federal funds are contingent on the implementation of these information systems. Because foster care
placement is the result of psychosocial environmental failure, fixing the existing system requires more than good
information systems. Integration of sound, theory-driven, child-focused, family-centered services, collaboratively funded
by multiple governmental agencies, is essential. Through the use of longitudinal, research-based performance measures,
reliable data are emerging. The National Institutes of Mental Health (NIMH) has funded some research focusing on foster
care children and youth. The complexity of the impact of ever-changing psychosocial variables makes this type of research
challenging. Despite that, it must be done if welfare dollars are to be spent doing the right thing for needy children and
their families. In 2004, in a groundbreaking study, the Pew Commission on Children in Foster Care made sweeping
recommendations to overhaul the system, stating that “children deserve more from our child welfare system.”
HISTORY OF ADOPTION
Adoption has existed in different forms throughout history. In ancient Babylonia, it
provided for the transmission of property or artisan’s skills, whereas, in the Roman
Empire, it was often used to elevate the status of an adult protégé. In some Pacific
islands, adoption of young children formed part of an exchange system between related
clans. Concerns expressed by adopted persons about not knowing their roots are as
ancient as they are contemporary. Euripides’ Ion contains a touching dialogue between
a woman in search of the child she had given up years before and a young priest of
Apollo, who does not know that he is the woman’s son and says that the only mother he
knows is Apollo’s priestess.
Historically, closed adoptions were common practice. That was done to ensure the
sealed identities of birth and adoptive parents and was believed to be in the best
interests of adopted children. That practice is now considered flawed; contemporary,
although still controversial, thinking is that most adoptees should grow up knowing of
their adoption status, as well as the identities of their birth parents. Currently, adoptees,
as well as many birth parents and adoptive parents, increasingly have shared interests
in legislation that affects the open or closed status of birth records and the placement of
children in families. The phrase adoption triad has come to stand for these shared
interests. Several other organizations represent each of these three groups, and those
organizations often have divergent agendas. Since the 1980s, adoption practice has
been profoundly affected by federal legislation.
EPIDEMIOLOGY OF ADOPTION
Estimates suggest that between 2.5 and 3.5 percent of children in the United States are
adopted, with more than 2 percent adopted by nonrelatives, and about 1.5 percent in
relative adoptions, which include stepparents. Foster care children who are adopted
account for about 15 percent of all adopted children. Approximately 125,000 children
are adopted each year, in a variety of scenarios. Infants may be relinquished by their
biological parents at birth and adopted through private agencies. These adoptions are
increasingly “open,” with some continued contact with biological parents. About 50,000
babies are adopted in this manner each year. Another 50,000 children are adopted
through the child welfare system, and these children have often been exposed to
multiple foster home placements before they are adopted. These adoptees range in age,
with more than half of them being older than 6 years of age, and the majority of them
having experienced significant early abuse or neglect.
INTERNATIONAL ADOPTION
International adoptions have been growing over the last two decades. Each year more
than 20,000 children are adopted from overseas, and many of these are transracial
adoptions. More than 17,000 children were adopted from Guatemala, for example, in
the last two decades. In the Guatemalan adoptees, the mean age was 1.5 years and the
children had previously resided in orphanages, foster homes, or mixed-care settings.
Investigation of the health records of international adoptees who were evaluated in an
international adoption specialty clinic in the U.S. revealed that younger children at the
time of adoption have better growth, language development, cognitive skills, and
competence in activities of daily living compared to children who were older at time of
adoption. Among children matched for age, gender, and time from adoption to
evaluation, those who were previously living in foster care were observed to have
higher cognitive scores and improved growth compared to children who had resided in
orphanages. These findings support the priority of adoptive placement at younger ages
and that foster care has benefits over orphanage care.
EARLY CHILDHOOD VERSUS LATE ADOPTION
Data suggest that earlier age adoption predicts better outcome than adoption in middle
or late childhood. A recent prospective study examined factors related to successful
outcome in public adoption of children ranging in age from 5 to 11 years of age.
Prospective data were collected from domestic adoptions in the United Kingdom at the
1st year, and 6 years later on 108 adoptees who were placed primarily because of
situations involving childhood abuse and neglect. Outcome was assessed by the
disruption rate and measures of psychological adaptation. At the adolescent follow-up,
23 percent of the adoption placements had been disrupted, 49 percent were continuing
with positive adaptations, and 28 percent were ongoing but with significant conflicts.
Four factors contributed independently to the risk of disruptions: older age at
placement, report of being singled out and rejected by siblings, time in care, and greater
degree of behavioral problems. Given that almost half of the placements were ongoing,
it is apparent that later childhood age of adoption can also be successful; assessment of
the constellation of the adoptive families, and of the children’s behavioral problems,
may determine the likelihood of positive outcome for school-aged child adoptees.
BIRTH PARENTS: SEARCH AND REUNION
The increasing trend toward open adoption allows the opportunity for adoptees to more
easily search and successfully find their birth parents. Many adoptive parents choose
open adoptions in the belief that they can experience a greater connection with the
child if they have some relationship with the birth mother. Some adoptees want to
develop an ongoing relationship with birth parents, but many who search are satisfied
to meet birth parents without further correspondence. Outcomes of reunions with birth
parents vary widely. In some cases, especially when the birth parents are well
functioning and welcoming toward their child, the adoptee may experience a sense of
relief and joy in knowing that their birth mother is no longer vulnerable.
REFERENCES
Brenner E, Freundlich M. Enhancing the safety of children in foster care and family support programs: Automated critical
incident reporting. Child Welfare. 2006;85:611.
Briggs-Gowan MJ, Ford JD, Fraleigh L, McCarthy K, Carter AS. Prevalence of exposure to potentially traumatic events in a
healthy birth cohort of very young children in the northeastern United States. J Traum Stress. 2010;23:725–733.
Conn AM, Szilagyi MA, Franke TM, Albertin CS, Blumkin AK, Szilagyi PG. Trends in child protection and out-of-home care.
Pediatrics. 2013;132:712–719.
Carnochan S, Moore M, Austin MJ. Achieving timely adoption. Journal of Evidence-Based Social Work. 2012;10:210–219.

53 - 31.19c Child Maltreatment and Neglect
31.19c Child Maltreatment and Neglect
Damnjanovic M, Lakic A, Sevanovic D, Jovanovic A. Effects of mental health on quality of life in children and adolescents
living in residential and foster care: A cross-sectional study. Epidemiol and Psychiatr Sci. 2011;20:257–262.
Garcia AR, Pecora PJ, Aisenberg E. Institutional predictors of developmental outcomes among racially diverse foster care
alumni. Am J Orthopsychiatry. 2012;82:573–584.
Greeson JK, Briggs EC, Kisiel C, Layne CM, Ake III GS, Ko SJ, et al. Complex trauma and mental health in children and
adolescents placed in foster care: Findings from the National Child Traumatic Stress Network. Child Welfare.
2011;90:91–108.
Horowitz SM, Hurlburt MS, Cohen SD, Zhang J. Predictors of placement for children who initially remained in their
homes after an investigation for abuse or neglect. Child Abuse Neglect. 2011;35:188–198.
Lehmann S, Havik OE, Havik T, Heiervang. Mental disorders in foster children: A study of prevalence, comorbidity and risk
factors. Child Adolesc Psychiatry Ment Health. 2013;7:39.
McWey LM, Henderson TL, Tice SN. Mental health issues and the foster care system: An examination of the impact of the
Adoption and Safe Families Act. J Marital Fam Ther. 2006;32:195.
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examination of risk factors for involvement with child protective services. Child Abuse Neglect. 2013;37:33–46.
The Pew Commission on Children in Foster Care. Fostering the Future: Safety Permanence and Well-Being for Children in
Foster Care. Washington, DC; 2004.
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31.19c Child Maltreatment, Abuse and Neglect
Child maltreatment includes all types of abuse and neglect and is a major public health
concern in the United States. The Centers for Disease Control and Prevention (CDC)
estimate that one in every five children in the United States has been a victim of child
maltreatment. Among the CDC’s estimates of maltreated children, 9 percent were
victims of physical abuse, 1 percent were victims of sexual abuse, 4 percent were victims
of neglect, and 12 percent experienced emotional abuse. Estimates of children
maltreated in the United States each year are close to 1 million, and the annual number
of deaths caused by abuse or neglect is reported to be about 1,500. A majority of child
neglect and abuse occurs in infancy and early childhood, negatively impacting overall
brain development, and disrupting time-sensitive developmental brain processes. A
growing body of research suggests that child maltreatment potentially results in longterm damage in the neuroendocrine system, cell loss, and delays in myelination in the
hippocampus and prefrontal cortex, as well as a chronic inflammatory state
independent of clinical comorbidities.
The National Longitudinal Study on Adolescent Health investigated the prevalence,
risk factors, and health consequences of maltreatment in 12,118 adolescents. Maltreated
adolescents retrospectively reported the most common experiences were being left home
alone as a child, (reported by 41.5 percent of the sample), physical assault (reported by
28.4 percent), physical neglect (reported by 11.8 percent), and sexual abuse (reported
by 4.5 percent). Each type of maltreatment was associated with at least eight of the ten
adolescent health risks examined, including self-report of depression, regular alcohol
use, binge drinking, marijuana use, overweight status, generally “poor” health, inhalant
use, and aggressive behaviors, including fighting and hurting others. Clearly, the effects
of self-reported maltreatment had far ranging and long-lasting associations with
multiple detrimental consequences.
The identification, management, and treatment of child maltreatment require
cooperative efforts between professionals, including primary care physicians,
emergency room staff, law enforcement, attorneys, social service staff, and mental
health professionals. Perpetrators typically deny abuse or neglect and maltreated
children often fear disclosure of their abuse or neglect.
DEFINITIONS
DSM-5
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists Child
Maltreatment and Neglect in the section “Other Conditions That May Be a Focus of
Clinical Attention.” The presence of Child physical abuse, Child sexual abuse, Child
neglect, and Child psychological abuse can be coded as confirmed or suspected and as
an Initial encounter or a Subsequent encounter. Under a subcategory of “other
circumstances related to” each form of child maltreatment or neglect, five “V” coded
clinical situations related to maltreatment can be coded. These include the following (1)
Encounter for mental health services for victim of child maltreatment by parent, (2)
Encounter for mental health services for victim of nonparental child maltreatment, (3)
Personal history (past history) of childhood maltreatment, (4) Encounter for mental
health services for perpetrator of parental child maltreatment, (5) Encounter for mental
health services for perpetrator of nonparental child maltreatment.
Federal Law
The Child Abuse Prevention and Treatment Act was passed in 1974 and has been
amended several times, most recently in 2003. In federal law, child abuse and neglect
mean, at a minimum, any recent act or failure to act on the part of a parent or
caretaker that results in death, serious physical or emotional harm, or sexual abuse or
exploitation. It also includes an act or failure to act that presents an imminent risk of
serious harm. In federal law, sexual abuse means the employment, use, persuasion,
inducement, enticement, or coercion of any child to engage in or to assist any other
person to engage in any sexually explicit conduct (or simulation of such conduct for the
purpose of producing a visual depiction of such conduct) or the rape (and in cases of
caretaker or interfamilial relationships, statutory rape), molestation, prostitution, or
other forms of sexual exploitation of children or incest with children.
State Law
A large mass of legal definitions and guidelines exists at the state level. The legal
definitions of terms related to the maltreatment of children vary from one jurisdiction to
another, so clinicians should be aware of the definitions used in their own locale. The
following generic definitions are used in this section.
Neglect
Neglect, the most prevalent form of child maltreatment, is the failure to provide
adequate care and protection for children. Children can be harmed by malicious or
ignorant withholding of physical, emotional, and educational necessities. Neglect
includes failure to feed children adequately and to protect them from danger. Physical
neglect includes abandonment, expulsion from home, disruptive custodial care,
inadequate supervision, and reckless disregard for a child’s safety and welfare. Medical
neglect includes refusal, delay, or failure to provide medical care. Educational neglect
includes failure to enroll a child in school and allowing chronic truancy.
Physical Abuse
Physical abuse can be defined as any act that results in a nonaccidental physical injury,
such as beating, punching, kicking, biting, burning, and poisoning. Some physical abuse
is the result of unreasonably severe corporal punishment or unjustifiable punishment.
Physical abuse can be organized by damage to the site of injury: skin and surface tissue,
the head, internal organs, and skeletal.
Emotional Abuse
Emotional or psychological abuse occurs when a person conveys to children that they are
worthless, flawed, unloved, unwanted, or endangered. The perpetrator may spurn,
terrorize, ignore, isolate, or berate the child. Emotional abuse includes verbal assaults
(e.g., belittling, screaming, threats, blaming, or sarcasm), exposing the child to domestic
violence, overpressuring through excessively advanced expectations, and encouraging or
instructing the child to engage in antisocial activities. The severity of emotional abuse
depends on (1) whether the perpetrator actually intends to inflict harm on the child and
(2) whether the abusive behaviors are likely to cause harm to the child. Some authors
believe that the terms emotional or psychological abuse should not be used and that verbal
abuse more accurately describes the pathological behavior of the caregiver.
Sexual Abuse
Sexual abuse of children refers to sexual behavior between a child and an adult or
between two children when one of them is significantly older or uses coercion. The
perpetrator and the victim may be of the same sex or the opposite sex. The sexual
behaviors include touching breasts, buttocks, and genitals, whether the victim is dressed
or undressed; exhibitionism; fellatio; cunnilingus; and penetration of the vagina or anus
with sexual organs or objects. Sexual abuse can involve behavior over an extended time
or a single incident. Developmental factors must be considered in assessing whether
sexual activities between two children are abusive or normative. In addition to the
forms of inappropriate sexual touching, sexual abuse also refers to sexual exploitation of
children, for instance, conduct or activities related to pornography depicting minors and
promoting or trafficking in prostitution of minors.
Ritual Abuse
Cult-based ritual abuse, which includes satanic ritual abuse, is physical, sexual, or
psychological abuse that involves bizarre or ceremonial activity that is religiously or
spiritually motivated. Typically, multiple perpetrators abuse multiple victims over an
extended period. Ritual abuse is a controversial concept; some professionals believed in
the 1990s that ritual abuse was a common, horrible phenomenon in society, whereas
others were skeptical about most allegations and descriptions of ritual abuse.
Perpetrators of Abuse
Some lack of consistency is seen in who may be defined as an abuse perpetrator. Usually,
a person must be a parent or designated caregiver to be charged with neglect, physical
abuse, or emotional abuse. Another adult (e.g., a stranger) who injures a child would be
charged with battery, not with child abuse. On the other hand, a caretaker or any other
person could be charged with child sexual abuse. State laws vary in this regard.
ETIOLOGY
Physical Abuse
Although child abuse occurs at all socioeconomic levels, it is highly associated with
poverty and psychosocial stress, parental substance abuse, and mental illness. Child
maltreatment is strongly correlated with less parental education, underemployment,
poor housing, welfare reliance, and single parenting. Child abuse tends to occur more
often in families characterized by domestic violence, social isolation, parental mental
illness, and drug and alcohol abuse. The probability of maltreatment may be increased
by risk factors in the child such as prematurity, intellectual disability, and physical
handicap. In addition, the risk of child abuse increases in families with many children.
Sexual Abuse
Social, cultural, physiological, and psychological factors all contribute to the breakdown
of the incest taboo. Incestuous behavior has been associated with alcohol abuse,
overcrowding, increased physical proximity, and rural isolation that prevents adequate
extrafamilial contacts. Some communities may be more tolerant of incestuous behavior.
Major mental disorders and intellectual deficiency have been described in some
perpetrators of incest and sexual abuse.
CLINICAL FEATURES
Maltreated children manifest a variety of emotional, behavioral, and somatic reactions.
These psychological symptoms are neither specific nor pathognomonic: The same
symptoms can occur without any history of abuse. The psychological symptoms
manifested by abused children and the behaviors of abusive parents can be organized
into clinical patterns. Although it may be helpful to note whether a particular case falls
into one of these patterns, that in itself is not diagnostic of child abuse.
Physically Abused Children
In many cases, the physical examination and radiological evaluation show evidence of
repeated suspicious injuries. Abused children display behaviors that should arouse the
suspicions of the health professional. For example, these children may be unusually
fearful, docile, distrustful, and guarded. On the other hand, they may be disruptive and
aggressive. They may be wary of physical contact and show no expectation of being
comforted by adults, they may be on the alert for danger and continually size up the
environment, and they may be afraid to go home.
The literature regarding the psychological consequences of physical abuse and neglect
indicates a wide range of effects: affect dysregulation, insecure and atypical attachment
patterns, impaired peer relationships involving increased aggression or social
withdrawal, and academic underachievement. Physically abused children exhibit a range
of psychopathology, including depression, conduct disorder, ADHD, oppositional defiant
disorder, dissociation, and posttraumatic stress disorder (PTSD).
Physically Abusive Parents
Abusive parents often feel significant guilt, and may delay seeking help for the child’s
injuries, fearful that the child will be taken away. Often the history of how a child
sustained injuries given by the parents is implausible or incompatible with the physical
findings. Parents may blame a sibling or claim that the children injured themselves. The
characteristics of abusive parents often include a history of abuse in their own early
lives, a lack of empathy for the child, unrealistic expectations of the child, and an
impaired parent–child attachment.
Katie, 3 years of age, had been exhibiting new negative and aggressive behavior at
preschool beginning 3 months after the birth of her brother. Katie’s teacher observed
her increased irritability and aggression, at times pushing other children, and she had
recently hit a classmate with a wooden block, causing a laceration of the child’s lip.
When Katie’s teacher took her aside to talk about her behavior, she noticed several
bruises on Katie’s arms and face. When her teacher asked Katie how she had gotten
the bruises, Katie replied “my mommy’s boyfriend gets mad at me and hits me with
his belt.” The teacher reported suspected child abuse to Child Protective Services.
Katie’s teacher also called her mother to let her know what was happening, and
suggested that they take Katie for a psychiatric evaluation.
Katie’s baby brother was colicky and slept only for short periods of time throughout
the day and night. He stopped crying only when his mother held him. Her mother,
therefore, had little time for Katie, and the mother’s boyfriend was left to take care of
Katie on evenings after day care and on weekends. He began to drink more than
usual and became increasingly irritable. Katie’s mother and her boyfriend often
argued, and Katie had seen her mother physically pushed and threatened by her
boyfriend. Katie, who was a bright, curious, and talkative child, had tried to be
helpful by asking to hold the baby. When refused, however, Katie became upset and
would lie on the floor and have a tantrum. Katie began to have difficulty falling
asleep and awoke repeatedly during the night. Katie’s mother’s boyfriend would
become extremely angry when Katie would wake him up, and often told her to shut
up and slapped her when she told him that she couldn’t go back to sleep. On many
occasions, he responded to her tantrums or repeated demands for attention by hitting
her with his belt.
Child Protective Services suggested that mother’s boyfriend voluntarily move out,
and no longer spend time alone with Katie caring for her, which he did begrudgingly,
and Katie and her mother began a family therapy program that included parenting
training for Katie’s mother and, a behavioral program to help Katie with her
tantrums. Katie’s mother’s boyfriend attended Alcoholics Anonymous (AA) meetings
and stopped drinking. He was able to control his anger, and was allowed to visit the
home, as long as Katie’s mother was present. Within the next three months, Katie’s
aggressive behavior had ceased, and she was less irritable and was no longer having
tantrums. She was doing well with peers, was sleeping through the night, and was no
longer afraid to be at home. (Adapted from case material from William Bernet, M.D.)
Sexually Abused Children
A variety of symptoms, behavioral changes, and diagnoses sometimes occur in sexually
abused children: anxiety symptoms, dissociative reactions and hysterical symptoms,
depression, disturbances in sexual behaviors, and somatic complaints.
Anxiety Symptoms.
Anxiety symptoms include fearfulness, phobias, insomnia,
nightmares that directly portray the abuse, somatic complaints, and PTSD.
Dissociative Reactions and Hysterical Symptoms.
The child may exhibit
periods of amnesia, daydreaming, trance-like states, hysterical seizures, and symptoms
of dissociative identity disorder.
Depression.
Depression may be manifested by low self-esteem and suicidal and selfmutilative behaviors.
Disturbances in Sexual Behaviors.
Some sexual behaviors are particularly
suggestive of abuse, such as masturbating with an object, imitating intercourse, and
inserting objects into the vagina or anus. Sexually abused children may display sexually
aggressive behavior toward others. Other sexual behaviors are less specific, such as
showing genitals to other children and touching the genitals of others. A younger child
may manifest age-inappropriate sexual knowledge. In contrast to these overly
sexualized behaviors, the child may avoid sexual stimuli through phobias and
inhibitions.
Somatic Complaints.
Somatic complaints include enuresis, encopresis, anal and
vaginal itching, anorexia, bulimia, obesity, headache, and stomachache.
These symptoms are not pathognomonic. Nonabused children may exhibit any of these symptoms and behaviors. For
example, normal, nonabused children commonly exhibit sexual behaviors, such as masturbating, displaying their genitals,
and trying to look at people who are undressing.
Approximately one third of sexually abused children have no apparent symptoms. Many adults who were abused as
children have no significant abuse-related symptoms. On the other hand, the following factors tend to be associated with
more severe symptoms in the victims of sexual abuse: greater frequency and duration of abuse, sexual abuse that involved
force or penetration, and sexual abuse perpetrated by the child’s father or stepfather. Other factors associated with poorer
prognosis are the child’s perception of not being believed, family dysfunction, and lack of maternal support. Also, multiple
investigatory interviews appear to increase symptoms.
Intrafamilial Sexual Abuse
Incest can be defined strictly as sexual relations between close blood relatives, that is,
between a child and the father, uncle, or sibling. Because of increased reporting, sibling
incest is an area of growing concern. In its broader sense, incest includes sexual
intercourse between a child and a stepparent or stepsibling. Although father–daughter
incest is the most common form, incest can also involve father and son, mother and
daughter, and mother and son.
Intrafamilial sexual abuse and other sexual abuse that occurs over a period of time is
characterized by a particular pattern or sequence of steps. Victims of sexual abuse
recount a gradual progression of boundary violations by the perpetrator, starting with
tiny invasions and escalating to serious, overwhelming intrusions. Healthy, selfconfident children rebuff the intrusions directly (via temper tantrums and verbal
disagreements) or indirectly (through silence and distancing maneuvers) or by adopting
any strategy that causes the offender to refrain.
Sexual abuse that occurs over a period of time evolves through five phases:
engagement, sexual interaction, secrecy, disclosure, and suppression.
Engagement Phase.
The perpetrator induces the child into a special relationship.
The daughter in father–daughter incest has frequently had a close relationship with her
father throughout her childhood and may be pleased at first when he approaches her
sexually.
Sexual Interaction Phase.
The sexual behaviors progress from less to more
intrusive forms of abuse. As the behavior continues, the abused daughter becomes
confused and frightened, because she never knows whether her father will be parental
or sexual. If the victim tells her mother about the abuse, the mother may not be
supportive. The mother often refuses to believe her daughter’s reports or refuses to
confront her husband with her suspicions. Because the father provides special attention
to a particular daughter, her brothers and sisters may distance themselves from her.
Secrecy Phase.
The perpetrator threatens the victim not to tell. The father, fearful
that his daughter may expose their relationship and often jealously possessive of her,
interferes with the girl’s development of normal peer relationships.
Disclosure Phase.
The abuse is discovered accidentally (when another person
walks into the room and sees it), through the child’s reporting it to a responsible adult,
or when the child is brought for medical attention and an alert clinician asks the right
questions.
Suppression Phase.
The child often retracts the statements of the disclosure
because of family pressure or because of the child’s own mental processes. That is, the
child may perceive that violent or intrusive attention is synonymous with interest or
affection. Many incest survivors rally around their perpetrators, seeking to capture any
modicum of tenderness or interest. At times, affection for the perpetrator outweighs the
facts of abuse, and children recant their statements about sexual assault, regardless of
substantiated evidence of molestation.
A family with a comfortable financial situation lived in a pleasant, clean house in a
nice neighborhood, but they had no friends. Their four teenagers never had visitors.
One day, the oldest girl, 17 years of age, went to the police and told them that she
had a baby at home and that her own father was the father of the baby. The teen said
that her father had been having sexual relations with her for more than 4 years and
that he was now doing the same with her younger sisters. The mother admitted
suspecting the situation for years, but she had not reported it to the authorities for
fear of losing her husband and her children. (Courtesy of William Bernet, M.D.)
Extrafamilial Sexual Abuse
Of course, sexual abuse is not limited to incest. Children can be abducted and sexually
abused by strangers. A perpetrator may observe a playground and may identify a child
who is not closely supervised. A pedophile may molest this child and hundreds of other
children before he or she is apprehended. For the child, this is usually a single, isolated
experience.
On the other hand, children can be repeatedly abused by trusted adults, such as
teachers, counselors, family friends, and clergy. In this scenario, the pedophilic
perpetrator grooms the child over a period of time. He or she gains the friendship of
children through enjoyable activities and gifts, introduces sexual activities that may
seem innocent and even pleasurable, and progresses to more intrusive activities. The
pedophile encourages secrecy.
A solo sex ring is a form of child sexual abuse that involves one adult perpetrator and
multiple child victims, who may know about each other’s sexual activities with the
perpetrator. A sex ring may also involve multiple perpetrators and multiple victims.
Neurobiological and Health Consequences of Child Maltreatment
Current data document long-term physical and mental health consequences of child
physical abuse, sexual abuse, emotional abuse, and neglect. Severe physical abuse and
repeated sexual abuse cause changes in the child’s developing brain that persist into
adulthood. A review of 20 studies concluded that child maltreatment is associated with
future increased levels of inflammatory markers such as increased C-reactive protein
(CRP), fibrinogen, and proinflammatory cytokines. The association of child
maltreatment with an increased state of inflammatory markers in adulthood is a robust
finding. However, it is not clear how this occurs, and how it impacts functioning.
According to the CDC, and the Child Maltreatment report, long-term consequences of
child maltreatment lead to increased risk of multiple physical illnesses and high risk
behaviors such as alcoholism and drug abuse, which in turn can lead to depression,
unemployment, and unstable relationships. Physical abuse, emotional abuse, and
neglect are strongly related to future depressive disorders, anxiety disorders, eating
disorders, suicidal behaviors, drug use, and risky sexual behavior. Child maltreatment is
also associated with a host of physical conditions and illnesses, including ischemic heart
disease, liver disease, adolescent pregnancy, chronic obstructive pulmonary disease,
fetal death, and skeletal fractures. Studies have demonstrated that adults with childhood
histories of maltreatment are at higher risk for abnormalities on magnetic resonance
imaging (MRI) of the brain that indicate reduced size of the adult hippocampus. These
abnormalities are more pronounced on the left side of the brain. Deficient integration
exists between the left and right hemispheres, manifested by reduced size of the corpus
callosum. These neurobiological effects of child maltreatment probably mediate the
behavioral and psychological symptoms that follow abuse, such as increased
aggressiveness, heightened autonomic arousal, depression, and memory problems.
EVALUATION PROCESS
The evaluation of a child or adolescent who may have been physically or sexually
abused depends on its circumstances and context. Practitioners must consider whether
they are conducting a forensic evaluation, which has legal implications and may
ultimately be used in court, or a clinical evaluation, which is done for a therapeutic
purpose. A forensic evaluation emphasizes collecting accurate and complete data to
determine—as objectively as possible—what happened to the child. Was the injury an
accident, was it self-inflicted, or was it a result of parental abuse? Was the child actually
sexually abused, or was he or she indoctrinated to believe that he or she was abused?
The data collected in a forensic evaluation must be preserved in a reliable manner
through audiotape, videotape, or detailed notes. The results of the forensic evaluation
are organized into a report that is read by attorneys, a judge, and others. The emphasis
in a therapeutic evaluation is to assess psychological strengths and weaknesses, to make
a clinical diagnosis, to develop a treatment plan, and to lay the foundation for
continuing psychotherapy. The clinician is also interested in determining what
happened to the child, but it is not as essential to distinguish facts from fantasies.
Compared with the forensic evaluation, the psychotherapist does not need to keep such
detailed records and ordinarily does not prepare a report for court.
In addition to distinguishing a forensic examination from a therapeutic consultation, a
number of factors can affect the evaluation of a child who was abused or may have been
abused: whether one is a pediatrician in an emergency department or a child
psychiatrist in an office, whether a parent or another person is suspected of the abuse,
the severity of the abuse and the victim’s relationship to the perpetrator, whether
physical signs of abuse are obvious or absent, the age and gender of the child, and the
degree of anxiety, defensiveness, anger, or mental disorganization that the child
exhibits. Often, the examiner must be creative and persistent.
From the psychiatric perspective, the interview is usually the primary source of
information, and the physical examination is secondary. In practice, children who may
have been neglected or sexually abused are interviewed first and are later given a
physical examination and other tests. A child who has been physically abused is more
likely to have a physical examination that may be followed by a psychiatric interview.
When the child is brought to the emergency room, a detailed and spontaneous account
of the injury should be obtained promptly from parents or other caregivers before
secondary details and rationalizations cloud the information provided. The interviewer
should allow the caregiver to explain, to expound, to derail, or to detour the story line.
An abuser or codependent parent may claim to have happened on the injured child in a
coma or bleeding from some unknown trauma or to have noticed significant bruising,
burns, or a crooked extremity while bathing the child. Comparing the parents’ histories
can provide valuable insight into how power is wielded in the family unit.
A one-month-old baby girl was transferred from a rural hospital to a university
medical center because of a reported near sudden infant death syndrome (SIDS). The
child was unresponsive and required mechanical ventilation. A nuclear magnetic
resonance imaging (MRI) study revealed bilateral subdural hematomas, subarachnoid
hemorrhage, and hemorrhage in the parenchyma of the brain. An X-ray skeletal
survey showed two posterior rib fractures. An ophthalmologist observed extensive
retinal hemorrhages. After the child was admitted to the Pediatric Intensive Care Unit,
the child abuse consultant interviewed the parents separately. The mother, 28 years of
age, said that she had recently started a new job. The baby was perfectly fine when
she left her in the care of her live-in boyfriend, the child’s biological father. The
father, 24 years of age, said that when he checked on the baby, he found her not
breathing, blue, and unresponsive. He ran to report this to a neighbor and then called
911. The child abuse consultant suggested to the father that the baby must have been
injured in some way and asked whether the father had any explanation for this injury.
The father said, “I shook the baby after I found her not breathing.” The consultant
concluded that severe child abuse had occurred in the form of shaken baby syndrome.
The consultant notified child protective services and the local police department, so
that they could initiate and coordinate their investigation. (Courtesy of William
Bernet, M.D.)
Suspected Sexual Abuse.
The examiner should consider the possibility that the
parents are not telling the truth. This situation is more complex, however, than
suspected physical abuse. For example, the mother may wish to avoid the discovery of
father–daughter incest by blaming the child’s genital injury on another child or a
stranger. In another scenario, the mother may concoct an allegation of incest when the
child had never been abused at all. The first version protects a father who is guilty; the
second version implicates a father who is innocent.
The examiner should determine how the allegation originally arose and what
subsequent statements were made. Determine the emotional tone of the first disclosure
(e.g., whether the disclosure arose in the context of a high level of suspicion of abuse).
Determine the sequence of previous examinations, the techniques used, and what was
reported. Try to determine whether the previous interviews may have distorted the
child’s recollections. If possible, review transcripts, audiotapes, and videotapes of earlier
interviews. Seek a history of overstimulation, prior abuse, or other traumas. Consider
other stressors that could account for the child’s symptoms. The examiner should also ask
about exposure to other possible male and female perpetrators.
In Either Case.
Whether physical or sexual abuse is involved, a pertinent
psychosocial history should be collected and organized, including the following:
Symptoms and behavioral changes that sometimes occur in abused children
Confounding variables, such as psychiatric disorder or cognitive impairment, that
may need to be considered
Family’s attitude toward discipline, sex, and modesty
Developmental history from birth through periods of possible trauma to the present
Family history, such as earlier abuse of or by the parents, substance abuse by the
parents, spouse abuse, and psychiatric disorder in the parents
Underlying motivation and possible psychopathology of adults involved
Collateral Information
The evaluator should consider requesting collateral information from the following
people, after obtaining authorizations: protective services, school personnel, other
caregivers (e.g., babysitters), other family members (e.g., siblings), the pediatrician, and
police reports.
Child Interview
Several structured and semistructured interview protocols have been developed that
were designed to maximize the amount of accurate information and to minimize
mistaken or false information provided by children. These approaches include the
Cognitive Interview, which encourages witnesses to search their memories in various
ways, such as recalling events forward and then backward. The Step-Wise Interview is a
funnel approach that starts with open-ended questions and, if necessary, moves to more
specific questions. The interview protocol developed at the National Institute of Child
Health and Human Development (NICHD) includes a series of phases and makes use of
detailed interview scripts.
Although these protocols may be particularly important in a forensic context,
experienced clinicians endorse flexibility and consistent good-hearted behavior by the
interviewer. As with seeing any patient, the evaluator must size up the situation and use
techniques that are likely to help the youngster become comfortable and communicative.
One victim might need a favorite object (e.g., a teddy bear or a toy truck); another
might need to have a particular person included in the interview. Some children are
comfortable talking; others prefer to draw pictures. An unrelated joke, a shared cookie,
or a picture on the evaluator’s wall may lead to a disclosure of abuse. Important
comments might be made while chatting during the break time, instead of during the
structured interviews.
GENOTYPE AND MALTREATMENT: RISK AND PROTECTIVE FACTORS
Two studies of Caucasian males have provided evidence that particular genotypes with
high levels of monoamine oxidase A (MAOA) seem to protect against the malignant
impact of childhood maltreatment on the development of conduct disorder and
antisocial behavioral patterns. Subjects in a prospective cohort design involving courtsubstantiated cases of child abuse and neglect and matched comparison groups were
followed into adulthood. A composite index of violent and antisocial behavior (VASB)
was created based on arrest record, self-report, and diagnostic information. Genotypes
associated with high levels of MAOA activity were correlated with less risk of violent
and antisocial behavior in later life for Caucasians, but this effect was not found for
non-Caucasians. This result was not replicated in a group of adolescents with respect to
the development of adolescent conduct disorder. Further studies are needed to
understand the possible links between genotypes of high levels of MAOA and potential
behavioral outcomes.
TREATMENT AND PREVENTION STRATEGIES
The immediate strategic intervention is to ensure the child’s safety, which may require
the child’s removal from an abusive or neglectful home environment. Physicians are
among a group of professionals who are mandated by law to report suspected child
abuse or neglect to the local protective services agency.
Several evidence-based psychotherapies now exist in the treatment of childhood abuse
and neglect. These include Multisystemic Therapy for Child Abuse and Neglect (MSTCAN), Parent-Child Interaction Therapy (PCIT), adapted for children who have been
physically abused, and Combined Parent-Child Cognitive Behavioral Therapy (CPCCBT).
MST-CAN uses a home-based model in which therapists come to the home to involve
families in a highly monitored positive interactional approach toward their physically
abused children. Parents receive support and guidance to care for their children in a less
harsh, nonneglectful manner. This approach has been shown to reduce behavioral
problems in the children, while increasing parental understanding of meeting their
children’s needs in a safe environment.
PCIT consists of combined treatment for parents and children in which parenting is
coached directly by the therapist and practiced in sessions with parents and children
together. Typically, therapists observe parent–child interactions through a one-way
mirror and coach parents during the live interaction using a radio earphone. This model
is based on the premise that changing parent–child interaction patterns will break the
cycle of parent and child behaviors that maintain abusive behavior, and replace it with
more nurturing and supportive interactions. Although PCIT has been shown to be
effective, additional treatments are likely to be needed for parents with mental health
problems such as depression or substance use.
CPC-CBT is designed to help parents to develop more positive strategies with their
children and to help children to cope more effectively with their past abuse and to learn
more positive interactions with parents. Therapeutic techniques used with parents
include motivational interviewing, psychoeducation, adaptive coping skills, and better
problem solving when difficult situations arise. Therapeutic strategies used with children
focus on the development of positive coping, anger management, and gradual exposure
through the use of a developmentally appropriate trauma narrative. Parents and
children participate together in sessions in which the parent is able to convey complete
responsibility for their abusive behavior, and then, the parent and child collaborate on a
new joint family plan that promotes safety and more positive relationships. Therapeutic
sessions with the child and parent together appear to add to the effectiveness of
treatment.
Children who have been maltreated are at increased risk for further maltreatment
according to studies of child victims of abuse and maltreatment. Studies have shown that
four factors were most consistently identified as predictors of future maltreatment:
number of previous episodes of maltreatment; neglect as the form of maltreatment;
parental conflict; and parental psychiatric illness. Maltreated children were found to be
about six times more likely to experience recurrent maltreatment, and the risk of
recurrence was highest within 30 days of the index experience. This underscores the
importance of a careful examination of the protective factors in the home environment
and the early initiation of therapeutic sessions.
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31.19d Impact of Terrorism on Children
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31.19d Impact of Terrorism on Children
In recent years, exposure to mass trauma and terrorism has become an increasing
concern regarding the well-being of youth. Mass trauma has occurred directly and by
witness through highly publicized traumatic events globally and in the United States,
pertaining to terrorism, war, mass killings, and natural disasters.
On April 15, 2013, the first major terrorist attack in the United States since 9/11
occurred at the finish line of the Boston Marathon in the mid-afternoon. Two
“improvised explosive devices” (IEDs), that is, homemade bombs, detonated 8 minutes
apart in the middle of a densely packed crowd of thousands of marathon runners and
bystanders, killing three people and injuring about 264 others. Within moments after
the blasts, the crowd’s panic and chaos turned to purposeful attention to help others get
to emergency medical teams arriving on the scene. Courageously, bystanders ran
toward others to give aid rather than dispersing away from the scene in all directions.
Runners tore off their own shirts to apply pressure to fellow runners who were bleeding,
or to use them as tourniquets. Boston’s emergency response medical teams worked
quickly, efficiently, and tirelessly to transport injured runners to hospitals and into
operating rooms in order to save limbs, and stop bleeding. The fact that almost all the
injured were saved is a tribute to the emergency preparedness and collaboration of law
enforcement, medical, and surgical teams carrying out an emergency plan that they had
previously been briefed on, as a matter of course.
Additional situations in which youth are exposed to severe trauma and terror involve
armed conflict around the world, multiple mass school shootings that have taken place
across the United States in recent years, and hurricanes, devastating storms, and
tsunamis. Of course, more than a decade ago, the youth in the United States experienced
the large-scale domestic terrorist attack on September 11, 2001, on the World Trade
Center in New York City and the Pentagon in Washington, DC.
There is an increasing body of literature on the impact of terrorism on children as
well as a variety of other forms of trauma. One predominant and near universal
symptom in children in response to these stimuli is anxiety. Young children may cling
excessively to their parents, whereas older children may become preoccupied with fear
about unrelated issues. Some youth express overt anger, and others experience a sense
of hopelessness, lack of control, and/or depression. Severe traumas, such as
experiencing a terrorist event, may be more likely to result in posttraumatic stress
syndromes among exposed youth, compared to less severe forms of trauma. The number
of traumas experienced by a child, degree of family support provided after the exposure,
and the reactions of parents are all important factors in a child’s reaction.
According to a national survey after the terrorist attack of September 11th, stress
reactions to that disaster were increased by watching repeated media coverage of those
events. A similar study evaluating the impact of media versus direct exposure to
collective trauma, on acute stress response was undertaken 2 to 4 weeks after the
Boston Marathon bombings through surveying 846 people from Boston, 941 people
from New York City, and 2,888 people through Internet means. Direct exposure, defined
as being at or near the bombings, was compared to media exposure, including footage
on television and bombing related stories on the radio, in print, online, and other social
media coverage. Because acute stress responses appear within weeks of a traumatic
event, this study was able to capture acute stress difference between the two groups.
The study found that trauma related to media exposure was associated with acute stress
reactions in people from all over the United States who were not directly exposed to the
event in Boston. Furthermore, respondents reporting exposure to media coverage of the
bombings for six or more hours daily in the week following the bombings were nine
times more likely to report high acute stress than those who had minimal exposure to
media coverage of the events. In fact, the group who engaged in extensive media
coverage had higher levels of acute stress than respondents who had direct exposure in
Boston, but who had minimal exposure to media coverage of the bombings. These
findings suggest that prolonged media exposure to collective traumatic events may have
a strong negative impact on psychological symptoms and acute stress syndromes.
However, the study noted substantial resilience in the surveyed population. Researchers
have suggested that the effectiveness of Boston’s medical and law enforcement teams in
response to the terrorist bombings may have promoted some degree of resilience in the
population.
A unique aspect of exposure to terrorist-related trauma, as well as school shootings, is
the psychological effects of knowing that the trauma was both consciously and
purposely perpetrated, and yet also random. The random nature of terrorist attacks
appears to lead to especially adverse reactions in children. School shootings are among
the most tragic of traumatic events involving youth. On December 14, 2012, in the
village of Sandy Hook, in Newtown, Connecticut, a 20-year-old male in black clothing
carrying his mother’s rifle, shot his way through a glass window at the front of the
Sandy Hook Elementary School, rampaged the school, shooting and killing 20 first-grade
students from multiple classrooms and 6 school personnel, and then shot and killed
himself. He had shot and killed his mother before arriving at the school. The
psychological impact of this massacre on children who survived is moderated by age,
gender, and family reactions. Younger children appear to be at higher risk for
posttraumatic stress disorder, somatic symptoms, depression, and distress than older
children and adolescents. Gender also has been found to influence behavioral symptoms
after exposure to severe trauma or terrorism, with girls experiencing higher levels of
posttraumatic stress syndromes and depression, while boys exhibit more external
behavior problems.
Although the United States has launched a series of initiatives in response to the
threats and consequences of terrorism in the form of an act of Congress in 2002 called
the Public Health Security and Bioterrorism Preparedness and Response Act, children
and adolescents continue to view media exposure to terrorist events throughout the
world that reinforces a sense of danger.
The concept of terrorist acts is characterized by three distinct features: (1) They
produce a societal atmosphere of extreme danger and fear, (2) they inflict significant
personal harm and destruction, and (3) they undermine the expectation of citizens that
the state is able to protect them.
Child and adolescent reactions to exposure to terrorism are mediated by numerous
factors, including personal appraisal of persisting danger, the likelihood of recurrent
attack, and the perception of the relative safety of one’s family and close friends.
Children’s responses to terrorist exposure are influenced by how their parents cope with
the trauma and resulting turmoil and how well they understand the situation. PTSD has
been studied in adolescents, with and without learning disabilities, who have been
exposed to terror attacks. Findings from this study revealed that personal exposure to
terror, past personal life-threatening events, and history of anxiety all contributed to the
development of posttraumatic stress reactions. In addition, adolescents with learning
disabilities who had difficulties in cognitively processing the traumatic events were at
higher risk of developing PTSD when this was combined with the other high risk factors,
such as being personally exposed to the traumatic events.
Table 31.19d-1 identifies the relationship between objective features of danger and
subjective features related to exposure to terrorist acts.
Table 31.19d-1
Experience of Danger Consequent to Terrorist Acts
The following summarizes data collected after the terrorist attack of the World Trade
Center on September 11, 2001.
SEPTEMBER 11, 2001 ATTACKS
The U.S. Department of Education, through Project SERV, supported the New York City
Board of Education in conducting a needs assessment of New York City schoolchildren. A
total of 8,000 randomly selected students were surveyed 6 months after the September
11, 2001 attacks. Striking differences were seen among students in the vicinity of
Ground Zero as compared with students in the rest of the city, in exposure to smoke and
dust, fleeing for safety, problems getting home, and smelling smoke in the days and
weeks after September 11. Approximately 70 percent of all children, however, were
exposed to one of these factors. Interpersonal exposure through direct victimization of a
family member was greater among children attending schools outside the Ground Zero
vicinity as compared with those attending school in this area. Media exposure was
extensive and prolonged. Signs of heightened security were visible throughout the city.
The study used several scales of the Diagnostic Interview Schedule for Children (DISC).
Three sets of findings stand out from this study. First a significant degree of persistent
separation anxiety was seen, especially among school-age children, but also among
adolescents. Second, reflecting an age-related vulnerability to incident-specific new
fears (e.g., subways and buses) and avoidant behavior of school-age children, a nearly
25 percent rate of agoraphobia was reported among 4th- and 5th-graders. Care must be
taken, however, not to misrepresent incident-specific new fears as agoraphobia, because
the course of recovery and intervention strategies may differ. Third, an enormous
reservoir of prior traumatic experiences (more than one half of the total sample) was
associated with severity of current PTSD symptoms, emphasizing the need to attend to
prior trauma in conducting needs assessments, surveillance, and intervention strategies.
Other risk factors, in addition to younger age, included female gender and Hispanic
ethnicity. The finding of age-related increases in rates of conduct disorder also needs to
be interpreted in light of adolescent response to an ecology of danger in which overly
aggressive, reckless, and risk-taking behaviors are well documented and associated with
posttraumatic stress reactions. A major strength of this study was the inclusion of selfreported impairment as well as symptoms, setting an important standard for future
studies.
J. Stuber and colleagues conducted a telephone survey of a random sample of adult residents of Manhattan 1 to 2 months
after the September 11th attacks. The sample included more than 100 parents who were asked to describe the experiences
and reactions of their children. Not surprisingly, given the time of the incident, most children were at school or day care
when the disaster occurred. Many of the parents recalled concern about their children’s safety at the time, and most were
not reunited with their children for more than 4 hours. More than 20 percent of the parents studied reported that their
children had received counseling related to the disaster. Receiving counseling was associated with male gender, parental
posttraumatic stress, and having at least one sibling living in the household.
Also using parent report in a New York City telephone survey, researchers assessed predictors of posttraumatic stress
reactions in children between the ages of 4 and 17 years, 4 to 5 months after the attacks. Almost 20 percent of children
were reported by their parents to have experienced severe or very severe posttraumatic stress reactions, and
approximately two thirds had moderate posttraumatic stress reactions. Parental reactions and viewing three or more
graphic images of the disaster on television were associated with severe or very severe posttraumatic stress reactions in
children. Another study reported that 27 percent of children with severe or very severe posttraumatic stress reactions
received some mental health care 4 to 5 months after September 11th.
Two surveys of representative samples of adults were conducted after the September
11th attacks; the first between 4 and 5 months and the second between 6 and 9 months
after the attacks. Behavior problems were related to the child’s race or ethnicity, family
income, living in a single-parent household, disaster event experiences, and parental
reactions to the attacks. The results of these surveys were examined in light of findings
from a representative survey conducted before September 11th. The rate of behavior
problems was lower in the first post-September 11th survey (4 to 6 months after the
attacks) than rates in the pre-September 11th survey, but problems returned to preSeptember 11th levels by the second post-September 11th study (6 to 9 months after the
attacks). Consistent with findings in studies of Hurricane Andrew, these results suggest
that behavior problems may decrease in the months after a disaster or that parents may
be insensitive to them, but that they return to pre-disaster levels over time.
Media coverage of the September 11th attacks brought renewed debate about its
impact, especially on children, even children with no direct exposure. One study
reported extensive exposure to television coverage in children throughout the nation,
using a representative survey of adults conducted in the first days after the attacks.
Approximately one third of the parents surveyed attempted to limit or to prevent their
children’s viewing, but, among those whose parents made no attempt to restrict
viewing, the number of hours of disaster coverage watched was related to the number of
reported stress symptoms.
Using a Web-based, nationally representative sample of adults, another study
examined distress in children 1 to 2 months after the attacks by asking parents if their
children were upset by the events. Among the children perceived as most upset, 20
percent had trouble sleeping, 30 percent were irritable or easily upset, and 27 percent
feared separation from their parents. The mean age of children perceived as most upset
was 11 years, with no statistically significant gender differences. The proportion of
parents reporting at least one child upset did not differ by community in analysis of
data from the New York City metropolitan area, Washington, DC, other major
metropolitan areas, and the rest of the country.
A strength of these surveys was their examination of representative samples, but
earlier work points to concern about assessing children by interviewing their parents.
Furthermore, as with the Oklahoma City studies, the samples were composed mainly of
indirectly exposed children, and the clinical significance of the findings is unclear.
Nine-year-old Jason endured the traumatic loss of his father on the first plane into
the World Trade Center. Jason’s father was on board American Airlines Flight No. 11
on a business trip. Jason and his siblings were preparing to leave for school when he,
his mother and his siblings learned of the event. Jason watched his mother nearly
collapse when she confirmed the presence of his father aboard the aircraft. Jason
observed the recurring video segments of the second plane crashing into the second
tower several times that morning before his mother limited television access. Jason,
the oldest child in his family, had enjoyed an exceptionally close relationship with his
father.
Almost immediately after the terrorist attacks, Jason’s mother became worried that
he was despondent, suicidal and unable to function, just preoccupied with the grisly
nature of his father’s death. He was becoming increasingly agitated as he talked
constantly about the gruesome way that his father had died. Jason’s mother sought
immediate psychological treatment for him, during which he began to ask a continual
series of questions about his father’s death, including aspects of burning,
fragmentation, pain, blood, and the exact moment of his father’s deaths in
comparison with what he had initially observed on television. This became the main
theme of Jason’s early treatment, in which he ruminated (i.e., whether this father had
been “blown up in a thousand pieces” and the sequence of fire, burning, pain, and
death). Jason developed nightmares within days in which he awakened and called for
his mother at least three times a night. Jason was unwilling to discuss the content of
his dreams with his mother, given his observations of her own serious distress. Jason
began to express fears that the “hijackers” would hurt his mother and siblings. He
became focused on the concept that “half our freedom is gone,” and he was concerned
that one half of New York City was destroyed. He was preoccupied with enacting in
play, repetitive crashing down of creating the World Trade Center. Although after 3
months, he was able to resume sleeping through the night, he reported new troubling
dreams with themes of ghosts “popping out” and “everyone is killed, and then I’m
killed.” This worsened after the onset of the war in Afghanistan, and his mother had
to constantly reassure him that the war was not near their home.
Jason told his therapist of his wish that could find a time machine and be
transported back in time on board his father’s flight before it crashed. While his
therapist could fly the plane, he would overpower the “hijackers” and throw them off
the plane, and then the plane would land safely in Boston. Jason continued his wish
that after landing, his father and the other passengers tell him “thank you,” and be
very happy. After expressing his wish verbally, he appeared to be somewhat
comforted and he began to recall many positive activities with his father, and a series
of happy, highly detailed memories of his father, which then caused him to suddenly
become tearful with profound sadness at the realization that these would be no more.
In therapy, Jason alternately expressed rage and anger and confusion about the
actions of “Osama Bin Laden.” Over many months, Jason was able to remember and
speak about the good things he remembered about his father without immediately
breaking down in tears. Jason become a helpful big brother, who often tried to care
for his younger siblings, and his mother often told him how proud she was of him.
(Adapted from Robert S. Pynoos, M.D. M.P.H., Merritt D. Schreiber, Ph.D., Alan M.
Steinberg Ph.D., Betty Pfefferbaum, M.D., and J.D.)
To respond to the mental health needs of children and adolescents who have been
exposed to terrorism either through personal experience or through exposure to media
depicting world-wide terrorism, the adverse psychological reactions listed in Table
31.19d-2 must be considered.
Table 31.19d-2
Psychological Disorders Associated with Terrorism
COMPONENTS OF MECHANISMS FOR RECOVERY FROM EXPOSURE TO
TERRORISM
In order to begin the process of recovery from exposure to mass trauma, an assessment
of a child’s current coping must be done. Numerous instruments to measure coping exist.
These include COPE, a self-report questionnaire which has 52 items that can be used
with children, adolescents and adults; Children’s Coping Strategies Checklist (CCSC), a
self-report questionnaire with 45 general coping items used with children 9 to 13 years
of age; and How I Coped Under Pressure (HICIPS), which has 45 event specific
questions for children in the 4th to 6th grade. Once this assessment has been determined,
the next steps can be taken to begin the road to recovery.
Perception of Safety
The notion of perceived safety is an important protective factor as well as a component
of recovery for a child, adolescent, or adult who has been exposed to terrorism. A recent
report of symptoms of PTSD, depression, and perceived safety in disaster workers 2
weeks after the September 11th terrorist attacks found that lower perceived safety was
associated with increased symptoms of hyperarousal and intrusive fearful thoughts, but
not avoidance. An expected diminished sense of safety was found in those individuals
who had personally been in greater physical danger, or who had worked with dead
bodies compared with others who were physically less exposed. To regain a sense of
security, reestablishment of a perception of safety is a necessary first step.
Reestablishment or Maintenance of Daily Routines
Although it is clearly not always possible to maintain usual daily routines amidst war or
exposure to terrorism, a study of Israeli adolescents found that those whose families
were able to maintain their usual activities, such as attending school and family
functions, were at lower risk for the development of posttraumatic reactions.
Proactive Interventions to Enhance Resilience
Perceived personal resilience has been shown to be protective against symptoms of
posttraumatic stress development. Proactive interventions aimed at enhancing a sense
of personal resilience and an ability to cope with the stressful situation may serve to
decrease the risk of psychiatric symptoms after exposure to terrorism. Interventions may
include regaining a sense of perceived safety through reestablishing routines, altruistic
tasks, family preparedness planning, and parental expression of security.
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