ADHD Diagnosis

5 disorders of childhood and adolescence (neurodevelopmental disorders)

learning objectives 15

·  15.1 How does maladaptive behavior appear in different life periods?

·  15.2 What are the common disorders of childhood?

·  15.3 Do anxiety and depression appear in children and adolescents?

·  15.4 What are some specific disorders that occur in childhood?

·  15.5 What are intellectual disabilities?

·  15.6 How can we plan better programs to help children and adolescents?

A Case of Adolescent Depression and Attempted Suicide Emily is 15-year-old girl from a middle-class Caucasian background who had a history of depression during her childhood. She had periods of low mood, poor self-esteem, and social withdrawal. She also had symptoms of anxiety and was very reluctant to leave her home. During her year in the seventh grade, she became so fearful of going to school that she missed so many days she had to repeat the grade. She currently is in the eighth grade and has, to this point, missed a great deal of school. Her family became very concerned over Emily’s low mood and isolation, so they enrolled her in an out-patient treatment program for depression, anxiety episodes, and eating disorders. Her depression continued, and she became more isolated, lonely, and depressed and would not leave her room even for meals. One day her grandmother found her in their car in the garage with the engine running in an effort to end her life. Emily was admitted into an inpatient treatment program following her serious suicide attempt.

There is a history of psychiatric problems, particularly mood disorders, in her family. Her mother has been hospitalized on three occasions for depression. Her maternal grandfather, now deceased, was hospitalized at one time following a manic depressive episode.

In the early phases of her hospitalization, Emily underwent an extensive psychological and psychiatric evaluation. She was administered a battery of tests, including the Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A). She was cooperative with the evaluation and provided the assessment staff with sufficient information regarding her mood and attitudes to assist in developing a treatment program.

Emily showed many symptoms of a mood disorder in which both depression and anxiety were prominent features. The psychological evaluation indicated that she was depressed, anxious, and felt unable to deal with the school stress that her condition prompted. Moreover, her physical appearance and eating behavior suggested the strong likelihood of anorexia nervosa. Emily showed an extreme degree of social introversion on several measures and acknowledged her reticence at engaging in social interactions. The assessment psychologist concluded that her personality characteristics of social withdrawal, isolation, and difficult interpersonal relationships would likely result in her having problems in establishing a therapeutic relationship. Her treatment program involved supportive cognitive therapy along with antidepressant medication.

Although she endorsed a broad range of anxiety symptoms, in her testing and in the intake interview she endorsed few items regarding suicidal ideation. This was not sufficient evidence to support a conclusion that she was at less risk for suicide; however, it could simply reflect her unwillingness to openly discuss her recent attempt. Her past behavior and low mood indicated a need to consider the possibility of further suicide attempts.

She remained in inpatient treatment for 3 weeks and was discharged with the summary that she had shown substantial improvement. She was, however, referred for further psychological treatment on an outpatient basis.

Source: Adapted from Williams & Butcher,  2011 , pp. 151–63.

Until the twentieth century, little account was taken of the special characteristics of psychopathology in children; maladaptive patterns considered relatively specific to childhood, such as autism, received virtually no attention at all. Only since the advent of the mental health movement and the availability of child guidance facilities at the beginning of the twentieth century have marked strides been made in assessing, treating, and understanding the maladaptive behavior patterns of children and adolescents.

The problems of childhood were initially seen simply as downward extensions of adult-oriented diagnoses. The prevailing view was one of children as “miniature adults.” But this view failed to recognize special problems, such as those associated with the developmental changes that normally take place in childhood or adolescence. Only relatively recently have clinicians come to realize that they cannot fully understand childhood disorders without taking these developmental processes into account. Today, even though great progress has been made in providing treatment for disturbed children, facilities are still inadequate to the task, and most children with mental health problems do not receive psychological attention.

The number of children affected by psychological problems is considerable. Research studies in several countries have provided estimates of childhood disorders. Roberts, Roberts, et al. ( 2007 ) found that 17.1 percent of adolescents in large metropolitan areas of the United States meet the criteria for one or more DSM diagnoses. Verhulst ( 1995 ) conducted an evaluation of the overall prevalence of childhood disorder based on 49 studies involving over 240,000 children across many countries and found the average rate to be 12.3 percent. In most studies, maladjustment is found more commonly among boys than among girls; however, for some diagnostic problems, such as eating disorders (see  Chapter 8 ), rates are higher for girls than for boys. The most prevalent disorders are attention-deficit/hyperactivity disorder (ADHD) (Ryan-Krause et al.,  2010 ) and separation anxiety disorders (Cartwright-Hatton et al.,  2006 ). Some subgroups of the population—for example, Native Americans—tend to have higher rates of mental disorders. One study reported that 23 percent of the Native American children rated in the sample met criteria for 1 of the 11 mental disorders in the survey and 9 percent met criteria for 2 or more of the disorders (Whitbeck et al.,  2006 ).

Maladaptive Behavior in Different Life Periods

Several behaviors that characterize maladjustment or emotional disturbance are relatively common in childhood. Because of the manner in which personality develops, the various steps in growth and development, and the differing stressors people face in childhood, adolescence, and adulthood, we would expect to find some differences in maladaptive behavior in these periods. The fields of developmental science (Hetherington,  1998 ) and, more specifically,  developmental psychopathology  (Kim-Cohen,  2007 ) are devoted to studying the origins and course of individual maladaptation in the context of normal growth processes.

It is important to view a child’s behavior in the context of normal childhood development (Silk et al.,  2000 ). We cannot consider a child’s behavior abnormal without determining whether the behavior in question is appropriate for the child’s age. For example, temper tantrums and eating inedible objects might be viewed as abnormal behavior at age 10 but not at age 2. Despite the somewhat distinctive characteristics of childhood disturbances at different ages, there is no sharp line of demarcation between the maladaptive behavior patterns of childhood and those of adolescence, or between those of adolescence and those of adulthood. Thus, although our focus in this chapter will be on the behavior disorders of children and adolescents, we will find some inevitable carryover into later life periods.

Varying Clinical Pictures

The clinical picture of childhood disorders tends to be distinct from the clinical picture of disorders in other life periods. Some of the emotional disturbances of childhood may be relatively short lived and less specific than those occurring in adulthood. However, some childhood disorders severely affect future development. One study found that individuals who had been hospitalized as child psychiatric patients (between the ages of 5 and 17) died early in life due to unnatural causes (about twice the rate of the general population) when followed up from 4 to 15 years later (Kuperman et al.,  1988 ). The suicide risk among some disturbed adolescents is long-lasting and requires careful follow-up and attention (Fortune et al.,  2007 ). Suicidal thoughts are not uncommon in children. Riesch and colleagues ( 2008 ) report that 18 percent of sixth graders have thoughts of killing themselves. Two other recent studies have reported rates for children under age 15. Dervic, Brent, and Oquendo ( 2008 ) report that international suicide rates are 3.1 per million. Hawton and Harriss ( 2008 ) report that the long-term risk of suicide is 1.1 percent, with girls more likely than boys to commit suicide. Both studies report that difficult family relationships are the leading cause of suicidal behavior. Being bullied by another child is another factor that has been found to be associated with risk of suicide (Rivers & Noret,  2010 ).

Special Psychological Vulnerabilities of Young Children

Young children are especially vulnerable to psychological problems (Ingram & Price,  2001 ). In evaluating the presence or extent of mental health problems in children and adolescents, one needs to consider the following:

·  • They do not have as complex and realistic a view of themselves and their world as they will have later; they have less self- understanding; and they have not yet developed a stable sense of identity or a clear understanding of what is expected of them and what resources they might have to deal with problems.

·  • Immediately perceived threats are tempered less by considerations of the past or future and thus tend to be seen as disproportionately important. As a result, children often have more difficulty than adults in coping with stressful events (Mash & Barkley,  2006 ). For example, children are at risk for posttraumatic stress disorder after a disaster, especially if the family atmosphere is troubled—a circumstance that adds additional stress to the problems resulting from the natural disaster (Menaghan,  2010 ).

·  • Children’s limited perspectives, as might be expected, lead them to use unrealistic concepts to explain events. For young children, suicide or violence against another person may be undertaken without any real understanding of the finality of death.

·  • Children also are more dependent on other people than are adults. Although in some ways this dependency serves as a buffer against other dangers because the adults around him or her might “protect” a child against stressors in the environment, it also makes the child highly vulnerable to experiences of rejection, disappointment, and failure if these adults, because of their own problems, ignore the child (Lengua,  2006 ).

·  • Children’s lack of experience in dealing with adversity can make manageable problems seem insurmountable (Scott et al.,  2010 ). On the other hand, although their inexperience and lack of self-sufficiency make them easily upset by problems that seem minor to the average adult, children typically recover more rapidly from their hurts.

The Classification of Childhood and Adolescent Disorders

Until the 1950s no formal, specific system was available for classifying the emotional or behavioral problems of children and adolescents. Kraepelin’s ( 1883 ) classic textbook on the classification of mental disorders did not include childhood disorders. In 1952, the first formal psychiatric nomenclature (DSM-I) was published, and childhood disorders were included. This system was quite limited and included only two childhood emotional disorders: childhood schizophrenia and adjustment reaction of childhood. In 1966, the Group for the Advancement of Psychiatry provided a classification system for children that was detailed and comprehensive. Thus, in the 1968 revision of the DSM (DSM-II), several additional categories were added. However, growing concern remained—both among clinicians attempting to diagnose and treat childhood problems and among researchers attempting to broaden our understanding of childhood psycho-pathology—that the then-current ways of viewing psychological disorders in children and adolescents were inappropriate and inaccurate for several reasons. The greatest problem was that the same classification system that had been developed for adults was used for childhood problems even though many childhood disorders, such as autism, learning disabilities, and school phobias, have no counterpart in adult psychopathology. The early systems also ignored the fact that in childhood disorders, environmental factors play an important part in the expression of symptoms—that is, symptoms are highly influenced by a family’s acceptance or rejection of the behavior. In addition, symptoms were not considered with respect to a child’s developmental level. Some of the problem behaviors might be considered age appropriate, and troubling behaviors might simply be behaviors that the child will eventually outgrow. In the most recent revision of the diagnostic and statistical manual (DSM-5), efforts were made to provide diagnostic classification that is consistent with current research and contemporary clinical practice.

in review

·  • Define developmental psychopathology.

·  • Discuss the special psychological vulnerabilities of children.

Common Disorders of Childhood

At present the DSM-5 provides diagnoses for a large number of childhood and adolescent disorders or Neurodevelopmental Disorders. In addition, several disorders, involving intellectual disability (formerly referred to as mental retardation) are included. Space limitations do not allow us to explore fully the mental disorders of childhood and adolescence included in the DSM system, so we have selected several disorders to illustrate the broad range of problems that can occur in childhood and adolescence. Some of these disorders are more transient than many of the abnormal behavior patterns of adulthood discussed in earlier chapters—and also perhaps more amenable to treatment while others have a likelihood of persistence.

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) , often referred to as hyperactivity, is characterized by difficulties that interfere with effective task-oriented behavior in children—particularly impulsivity, excessive or exaggerated motor activity, such as aimless or haphazard running or fidgeting, and difficulties in sustaining attention (Nigg et al.,  2005 ; see DSM-5 Criteria for Attention-Deficit/Hyperactivity Disorder). The diagnostic criteria for ADHD remained relatively unchanged for children and adolescents in DSM-5.

Children with ADHD are highly distractible and often fail to follow instructions or respond to demands placed on them (Wender,  2000 ). Perhaps as a result of their behavioral problems, children with ADHD are often lower in intelligence, usually about 7 to 15 IQ points below average (Barkley,  1997 ). Children with ADHD also tend to talk incessantly and to be socially intrusive and immature. Recent research has shown that many children with ADHD show deficits on neuropsychological testing that are related to poor academic functioning (Biederman et al.,  2004 )  Watch the Video Jimmy: Attention-Deficit/Hyperactivity Disorder on MyPsychLab .

Children with ADHD generally have many social problems because of their impulsivity and overactivity. Hyperactive children usually have great difficulty in getting along with their parents because they do not obey rules. Their behavior problems also result in their being viewed negatively by their peers (Hoza et al.,  2005 ). In general, however, hyperactive children are not anxious, even though their overactivity, restlessness, and distractibility are frequently interpreted as indications of anxiety. They usually do poorly in school and often show specific learning disabilities such as difficulties in reading or in learning other basic school subjects. Hyperactive children also pose behavior problems in the elementary grades. The case study on page 513 reveals a typical clinical picture.

The symptoms of ADHD are relatively common among children seen at mental health facilities in the United States, with from 3 to 7 percent reported in the DSM and 8 percent reported in a recent study in the United Kingdom (Alloway et al.,  2010 ). In fact, hyperactivity is the most frequently diagnosed mental health condition in children in the United States (Ryan-Krause et al.,  2010 ). The disorder occurs most frequently among preadolescent boys—it is six to nine times more prevalent among boys than among girls. ADHD occurs with the greatest frequency before age 8 and tends to become less frequent and to involve briefer episodes thereafter. ADHD has also been found to be comorbid with other disorders such as oppositional defiant disorder (ODD) (Staller,  2006 ), which we discuss later. Some residual effects, such as attention difficulties, may persist into adolescence or adulthood (Odell et al.,  1997 ). ADHD is found in other cultures (Bauermeister et al.,  2010 )—for example, one study of 1,573 children from 10 European countries reported that ADHD symptoms are similarly recognized across all countries studied and that the children are significantly impaired across a wide range of domains.

DSM-5 criteria for: Attention-Deficit/Hyperactivity Disorder

·  A. A persistent pattern of inattention and/or hyperactivityimpulsivity that interferes with functioning or development, as characterized by (1) and/or (2):

·  1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

·  a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

·  b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

·  c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).