Child and Adolescent Psychopathology Tomàs, J.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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