Child and Adolescent Psychiatric Disorders dvmays@wisc

1. Child and Adolescent Psychiatric Disordersdvmays@wisc.edu

2. Kids and Mental Health • Principles: • Diagnosis is very complex!!! • Treatment is difficult and often unsatisfactory. • Families, schools, and social services are all extremely vulnerable to social, political, and financial pressures and emotions run high. • It is difficult to stay focused when there is a continual crisis.

3. Childhood Development • We currently believe that each child is born with an inborn temperament which is shaped and molded by the family, caretakers, and environmental experiences. In turn, the behavior of the infant effects the environment. Happy babies who like to be cuddled will elicit warmth and nurturance from the caretakers. Irritable, overly sensitive children may cause caregivers to be impatient and withdraw.

4. Theories of Personality: Trait Theories - Cloninger • Temperament and character: 50% of personality is attributed to temperament, 50% to character • Temperament: biologically based, quite stable • Novelty seeking • Harm avoidance • Reward dependence • Persistence • Character: psychosocially based, varies throughout adulthood • Self-directedness • Cooperativeness • Self-transcendence

5. Development of Disorders • Temperament to Trait to Disorder • Temperament, along with environmental influences, inclines people to develop certain traits. • Personality traits are emotional, cognitive, and behavioral tendencies in which individuals vary from each other. • When traits become maladaptive and dysfunctional, they lead to diagnosable personality disorders. Environmental stressors may amplify certain traits at certain times.

6. What Causes Pathology? • Nature and Nurture: Stress-Diathesis model • Most mental illnesses have their beginnings in childhood • Does a bad childhood cause mental illness? • The brain is an incredibly plastic organ. Early learning can be reversed by later learning. • Childhood experiences alone do not determine personality traits. • Adverse events in childhood do not regularly cause mental disorders. • Except for vision and language, the evidence for an invariable set of developmental stages that must be mastered at a certain time is slim.

7. Childhood Externalizing Disorders • Temperamentally extroverted and impulsive • In an unfavorable family environment, at risk for oppositional and conduct disorder • They effect peers, adults, and teachers quite negatively. • 33% will be diagnosed with antisocial personality disorder • Also at risk for substance abuse and mood disorders • ADHD with conduct disorder is risk for APD

8. Childhood Internalizing Disorders • Children with introverted temperaments who worry a lot and are overly dependent • Prone to depression and anxiety symptoms in certain environments

9. Childhood Cognitive Disorders • Odd affect, social isolation, poor interpersonal skills, cognitive difficulties • Clearly related to premorbid phase of schizophrenia • Children are at risk for schizophrenia, schizoaffective disorder

10. Environmental Data: Amplification Effects • Externalizing children may be in chronic conflict with peers, teachers, and other adults, and may respond to conflict with greater maladaptive behavior. • Shy children who are overly shy may be overly protected

11. Environmental Effects • There does not seem to be a one-to-one correspondence between particular stressors and particular disorders. • Abusive inconsistent parenting, sexual abuse, early loss, trauma, lack of social cohesion are all implicated.

12. Attention Deficit/ Hyperactivity Disorder • Current theories suggest that persons with ADHD actually have difficulty regulating their attention: difficulty inhibiting their attention to nonrelevant stimuli and/or focusing too intensely on specific stimuli to the exclusion of what is relevant. • A neurotransmitter imbalance connecting the frontal cortex with the basal ganglia results in distortion of six major aspects of executive functioning.

13. Executive Functions • Flexibility: shifting from one strategy or mindset to another • Organization: anticipating needs and problems • Planning: goal setting • Working memory: receiving, storing and retrieving information within short-term memory • Separating affect from cognition: detaching one’s emotions from one’s reason • Inhibiting and regulating verbal and motoric action: jumping to conclusions, difficulty waiting

14. ADHD • 3-7% incidence in many Western countries • 50-60% will have another condition, such as learning disorder, restless-legs syndrome, depression, anxiety, conduct disorder, obsessive-compulsive behavior • More frequently diagnosed in boys, but it is being recognized more in girls. • It is not clear how much is carried over into adulthood. Hyperactive symptoms may decrease with age because of increased self-control. Attention problems may continue.

15. ADHD • ADHD is the most common psychiatric disorder in childhood. Incidence of the different subtypes: the inattentive subtype - 4.7%, hyperactive - 3.4%, combined - 4.4%. • It is inheritable with concordance in monozygotic twins of 51%, dizygotic 33%. • Psychosocial factors do not appear to play an etiologic role, although they may contribute to oppositional and conduct disorders. • It has not been proven that environmental abnormalities contribute to ADHD.

16. Diagnosis • The diagnosis is made clinically using parent/child/teacher interviews and observations, behavior rating scales, physical and neurological examinations, cognitive testing. There is no laboratory test. • Important are past medical history including for other psychiatric disorders (anxiety, bipolar, conduct, depression, eating disorders, learning disability, pervasive developmental disorder, PTSD, psychosis, sleep disorder, AODA…)

17. Diagnosis • Social history • School performance • Social skills • Home and family interactions • Disorganization of personal space • Anger or rage reactions • Most awake in the late evening • Awakening child in the AM difficult • Unable to do chores • Homework organization and completion hard • Family dysfunction

18. Diagnosis • Medical exam • Laboratory work • Liver function tests possibly • Complete blood count • Drug screening if appropriate • Thyroid, glucose, other metabolic screen • Imaging - none presently • Physical • Other tests - impulsivity, attention deficit scales, IQ, learning disabilities, executive functions

19. Problems • “in vogue” diagnosis • Heavy pharmaceutical marketing • Those with diagnosis get special considerations • Primary care MD’s have difficult time with diagnosis - requires time and testing • Diagnosis is unusually dependent on social and educational circumstances • Diagnosis has high degree of subjectivity and testing is not specific

20. Treatment • Stimulant medication has become the mainstay of treatment. All of the medications seem to be equally effective with about a 70% response rate. • They have a positive effect on academic performance, classroom behavior, and academic productivity. • Side effects are the same: decreased appetite, initial sleep difficulty, headaches, stomachaches, tics, and irritability. Growth suppression, if at all, appears dose related. There is no evidence of tolerance or later substance abuse.

21. Treatment • Medication is useful for a large number of children, but not all. In addition, medication generally does not produce total remission of symptoms. • Psychosocial interventions such as parent support groups, parent management training, school based programs, behavior modification, special classes may be helpful.

22. Oppositional Defiant Disorder • A recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures • Losing one’s temper • Arguing with adults • Actively defying requests • Refusing to follow rules • Deliberately annoying other people • Blaming others for one’s own mistakes • Being resentful, irritable, spiteful, vindictive

23. ODD • Not diagnosed unless it occurs for at least 6 months and is much more frequent than in children of the same age. • Prevalence is 6-10%. More common in boys until puberty. • Lots of overlap with ADHD and CD. Some see ODD as a precursor for CD. • As with CD, temperament (irritability, impulsivity, and emotional intensity) contributes to a pattern of oppositional and defiant behaviors. Negative cycles result.

24. ODD • Milder forms may remit. More serious forms evolve into CD. • There is high comorbidity with ADHD, learning disorders, CD and internalizing disorders. A comprehensive evaluation is necessary, • Treatment involves PMT, medication if appropriate, social skills training, academic support, individual counseling if needed.

25. Conduct Disorder • One of the most difficult and intractable mental health problems in children. • Present in 2-9%, mostly boys • Behaviors: • Aggression toward people and animals • Destruction of property without aggression • Deceitfulness, lying, and theft • Serious violations of rules

26. Aggression • Bullies, threatens, or intimidates others • Initiates physical fights • Has used a weapon that could cause serious physical harm • Physically cruel to people or animals • Stolen while confronting a victim • Forced sexual activity

27. Property Destruction • Engaged in fire setting with the intention of causing damage • Deliberately destroyed others’ property

28. Deceitfulness or Theft • Has broken into someone’s house, building, or car • Often lies to obtain goods, favors, or avoid social obligations • Has stolen items of non-trivial value without confronting the victim

29. Serious Violations of Rules • Often stays out all night despite parental prohibitions, beginning before 13 years old • Has runaway from home overnight at least twice (or once for a lengthy period) • Is often truant from school, beginning before 13 years old

30. Subtypes of CD • Childhood onset • Presence of 1 criteria before age 10 • Typically boys exhibiting high levels of aggression • Often also have ADHD • Problems tend to persist to adulthood (APD) • Adolescent onset • No criteria met before age 10 • Less aggressive, more normal relationships • Most behaviors shown in conjunction with peers • Less ADHD. Equal gender distribution • Much better prognosis

31. Risks for Conduct Disorder • Individual • Perinatal toxicity • Difficult temperament • Poor social skills • Friends who engage in problem behavior • Innate predisposition for violence • Family • Poverty • Overcrowding • Poor housing • Parental drug abuse • Domestic violence

32. Risks for Conduct Disorder • Family (cont) • Inadequate, coercive parenting • Child abuse • Insufficient supervision • School • Disadvantaged school setting • Poor school performance beginning in elementary school

33. Natural History • Signs early as age 2 (irritable temperament, poor compliance, inattentiveness, impulsivity) • Early disturbances lead to diagnoses of ADHD or oppositional defiant disorder • For some children with severe temperament problems, even a stable home and excellent parenting does not prevent CD. However, more often children have unstable, stressed environments with ineffective or abusive parenting.

34. Natural History • Negative cycle: • Difficult temperament in the child • Children resist complying with parental requests • Parents either give in or become more punitive • Child either becomes more defiant or becomes physically aggressive • Parents become increasingly isolated from outside support. They are afraid to take the child out in public. • Child receives less and less parental interaction • Child does not have opportunities to learn more mature behaviors

35. Natural History • Elementary school • Children lack social skills, do not recognize social cues, cannot problem solve • Resort to aggression and intense anger rather than verbal problem solving • Blame others for their actions (no self-awareness) • Middle and high school • Noncompliance with commands • Emotional overreaction • Failure to take responsibility for their actions

36. Natural History • Middle and high school (cont) • Academic failure (poor cognitive development) • Peer group is other high risk children (other peers reject them at a time when friendships are critically important) • Depression often occurs as child is alienated from family, friends, school, other positive social groups • The deviant peer group provides training in criminal and delinquent behavior including substance abuse • If arrested and incarcerated, usually the behavior will worsen

37. Conduct Disorder • Co-occurrence with ADHD is at least 50%. It is almost impossible to distinguish these in young children. There is also high comorbidity with internalizing disorders and learning disabilities. • Children must be evaluated for academic difficulties as well as for comorbid mental illnesses.

38. Treatment • CD is highly resistant to treatment • Treatment must begin early and must include mental health, medical, educational and family components • Because of the high degree of overlap between CD and ADHD, stimulant medication is usually tried. In ADHD, stimulants control specific symptoms of inattention, impulsivity, and hyperactivity. They do not improve relationships with parents, teachers, or peers • No medication is proven helpful for conduct disorder without ADHD

39. Treatment • Parent Management Training has the strongest evidence base. • PMT offers parents training on how to become more effective in giving positive, specific feedback, how to employ the use of natural and logical consequences, and how to use brief, nonaversive punishments when appropriate.

40. Treatment • Individual psychotherapy as an individual treatment has not proven effective • Group therapy may have some benefit for younger children. For adolescents, group treatment often worsens behavior. • Best is a comprehensive model of treatment: behavioral PMT, social skills training, academic support, pharmacological treatment of ADHD or depression, individual counseling as needed.

41. Natural History • Physical aggression peaks around the age of two, then usually decreases as the child develops empathic attachment for others. • Adolescent risk taking is a normal transitional step to adulthood. • Risky behaviors include: • Alcohol: 40% of adult alcoholics report first having symptoms of alcoholism related behavior between 15-19. • Gambling: 10-14% of adolescents engage in problem gambling beginning at age 12.

42. Natural History • Risky behaviors: • Automobile accidents: drivers of both sexes between 16-20 are twice as likely to be in accidents than drivers between 20 and 50. It is the leading cause of death for teens. • Sexual activity: adolescents are more likely than adults to engage in impulsive sexual behavior, have multiple partners, and fail to use contraceptives. Younger teens (12-14) are more likely to engage in risky sexual behavior than older teens (16-19). 3 million adolescents a year contract an STD.

43. Risk Taking • Conventional wisdom states that teens take risks because they think they are invulnerable, and they don’t think before they act. Intervention programs have typically emphasized the importance of giving teens good information and then expecting them to make good choices. These programs have achieved only limited success.

44. Risk Taking • Recent studies demonstrate that teens: • Do not think they are invulnerable any more than adults think they are invulnerable • Tend to overestimate the true risks of potential behavior • After careful consideration, generally decide that the benefits usually outweigh the risks of a choice • Intervention programs do not address the allure of potential benefits. They emphasize dangers.

45. Risk Taking • Mature adults do not think logically in risky situations - they use intuitively based, bottom line thinking which yields a simple, black and white conclusion. This type of thinking increases with age, experience, and expertise. • Mature decision makers will not deliberate about risk versus benefits if there is a reasonable chance of a catastrophic outcome, e.g. playing Russian roulette.

46. Time to Decision:Is it a good idea to drink Drano?

47. Interventions • Consider that there are risky deliberators, and risky reactors who are too impulsive to deliberate. • For risky deliberators, focus on reducing the perceived benefits of risky behaviors. Encourage teens to develop rapid, unambiguous responses to risky situations (“I do not ride with a drinking driver.”) • For risky reactors, monitor and supervise as much as possible. Remove opportunities to engage in risky behavior. Do not rely solely on teaching them how to think.

48. The Teen Brain? • The myth: teens are inherently incompetent and irresponsible. • Peak age of arrest in the US for most crimes is 18. American parents and teens are in conflict with each other 20x/ month. • Research on 186 pre-industrialized societies: • 60% had no word for adolescence • Teens spent almost all their time with adults • Teens showed almost no signs of psychopathology • Antisocial behavior in teens was absent in >50%, or very mild when it did occur.

49. The Teen Brain? • Trouble begins to appear in other cultures soon after the introduction of Western-style schooling, television, and movies. • Until 100 years ago, teens were not trying to break away from adults, they were learning to become adults. • We have infantilized our teens, and isolated them from us. • Teens in the US are subjected to 10x as many restrictions as adults, twice as many as active duty marines and incarcerated felons.

50. Laws Restricting Behavior of Youth Under 18