Child and Adolescent Psychopathology

1
Child and Adolescent Psychopathology

• David Axelson, M.D.
• Assistant Professor of Psychiatry
• Western Psychiatric Institute Clinic - UPMC

2
Child vs. Adult Psychopathology

• 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 occur in all ages but
  symptoms/presentation is different in kids

3
Why disorders may appear differently in children?

• Neurodevelopmental factors (certain neurocircuits
  not fully developed yet synaptic pruning)
  
• Cognitive maturity
• Social Context

4
Major classes of childhood psychiatric disorders

• Developmental Disorders
• Autism Pervasive Developmental Disorders
• Language and Learning Disorders
• Disruptive Behavior Disorders (externalizing)
• Attention Deficit Hyperactivity Disorder
• Oppositional Defiant Disorder Conduct Disorder
• Affective Disorders (internalizing)
• Anxiety Disorders
• Depression Bipolar Disorder
• Other disorders
• Tourettes Disorder Eating Disorders Substance
  Use D/Os
  

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Epidemiology

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

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Issues in Making Psychiatric Diagnoses in Kids

• 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/os, rule out abuse
  
• Need to evaluate whether symptoms are
  inappropriate for developmental level, and
  whether they cause functional impairment or
  clinically significant distress

7
Anxiety Disorders

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

8
Separation Anxiety Disorder

• 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 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.
  
• 75 of children with separation anxiety disorder
  manifest school refusal

9
Depression

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

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Attention-Deficit Hyperactivity Disorder (ADHD)

• Hyperactivity
• Inattention/Distractibility
• Impulsivity

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ADHD - Epidemiology

• Prevalence rates vary among studies from 3 8
  of school-age children
  
• Ratio of male to female generally ranges from 31
  to 81.
  
• Age of onset prior to age seven
• Slightly more prevalent in lower socioeconomic
  groups

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Manifestations of Hyperactivity

• 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
  
• Always on the go driven by a motor
• Talks excessively

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ADHD - Inattention

• Cannot sustain attention compared to peers, esp.
  at long, boring, or monotonous tasks
  
• Disorganized often loses things
• Distractible
• Cannot follow through on instructions
• Doesnt seem to be listening when spoken to

14
ADHD - Impulsivity

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

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ADHD Associated Symptoms

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

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ADHD Clinical Course

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

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Other disruptive behavior disorders

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

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Pervasive Developmental Disorders (PDD)

• Autism
• Impairment in Language
• Deficits in social functioning
• Abnormally restricted activities and interests
• Likely a spectrum of PDDs
• Profound autism to milder PDD NOS or Aspergers
  syndrome
  

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Autism - Epidemiology

• Prevalence rate 1-2 in 1000 (may be rising)
• Age of onset before age 3 in 94 cases
• Ratio of malefemale 4 - 51
• Evenly distributed across socioeconomic and
  ethnic groups

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Autism Impairment of Social Interactions

• 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
  
• Absence of sharing experiences with others
  (bring to show)
  
• Absent or abnormal social play
• Gross impairment in ability to make peer
  friendships

21
Impairment of Communication/Language Abnormalities

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

22
Impaired Repertoire of Activities/Interests

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

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Autism Associated symptoms

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

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Other Pervasive Developmental Disorders

• Aspergers Disorder
• Normal early language development and
  intelligence
  
• Impairment in social functioning and restriction
  in interests like autism
  
• PDD NOS
• Most common (1 in 200-500)
• Meets some but not all criteria for autism

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Tourettes Syndrome

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

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Tourettes - Epidemiology

• Prevalence rate at least 0.09
• Ratio of malefemale 31
• Median age of onset is 6 years (range 1-17)

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Tics

• Motor Tics
• Simple motor tics (single muscle group) e.g.
  eye blinking
  
• Complex motor tics (multiple muscle groups)
  e.g. kicking
  
• Vocal Tics
• Simple vocal tics (noises) e.g. clicking
• 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)

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Tourettes Clinical Course

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

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Tourettes Associated Symptoms

• Attention Deficit Hyperactivity Disorder and
  other behavior disorders
  
• Obsessive-Compulsive Disorder
• Depression
• Substance Abuse