Overview of Mental Disorders in Children
A consideration of developmental principles enhances understanding of mental illness in children and adolescents by reconciling the concept of mental disorder as a stable state or condition with the ongoing development of the child. According to these principles, a mental disorder results from the interaction of a child and his or her environment. Thus, mental illness often does not lie within the child alone. Within the conceptual framework and language of integrative neuroscience, the mental disorder is an"emergent property" of the transaction with the environment. Proper assessment of a child’s mood, thought, and behaviors demands a simultaneous consideration of nature and nurture, genes and environment, and biology and psychosocial influences. These relationships are reciprocal. The brain shapes behavior, and learning shapes the brain.
Mental disorders must be considered within the context of the family and peers, school, home, and community. Taking the social-cultural environment into consideration is essential to understanding mental disorders in children and adolescents, as it is in adults. However, the changing nature of these environments, coupled with the progressively unfolding processes of brain development, makes the emphasis on context, as well as development, more complex and more central in child mental health (Jensen & Hoagwood, 1997).
Thus, developmental psychopathology encourages consideration of the transactions between the individual and the social and physical environment at the same time that signs and symptoms of mental disorder are considered. Moreover, focusing on diagnostic labels alone provides too limited a view of mental disorders in children and adolescents.
General Categories of Mental Disorders of Children
Mental disorders with onset in childhood and adolescence are listed in Table 3-2 as they appear in DSM-IV. These disorders fall into a number of broad categories, most of which apply not just to children but across the entire life span: anxiety disorders; attention-deficit and disruptive behavior disorders; autism and other pervasive developmental disorders; eating disorders (e.g., anorexia nervosa); elimination disorders
Table 3-2. Selected mental disorders of childhood and adolescence from the DSM-IV
Attention-Deficit and Disruptive Behavior Disorders
Autism and Other Pervasive Developmental Disorders
Learning and Communication Disorders
Mood Disorders (e.g., Depressive Disorders)
(e.g., enuresis, encopresis); learning and communication disorders; mood disorders (e.g., major depressive disorder, bipolar disorder); schizophrenia; and tic disorders (Tourette’s disorder). Several of the more common childhood conditions are described below.
Disorders of anxiety and mood are characterized by the repeated experience of intense internal or emotional distress over a period of months or years. Feelings associated with these conditions may be those of unreasonable fear and anxiety, lasting depression, low self-esteem, or worthlessness. Syndromes of depression and anxiety very commonly co-occur in children. The disorders in this broad group include separation anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder, obsessive-compulsive disorder, major depressive disorder, dysthymia, and bipolar disorder (DSM-IV).
Children who suffer from attention-deficit disorder, disruptive disorder, and oppositional defiant disorder may be inattentive, hyperactive, aggressive, and/or defiant; they may repeatedly defy the societal rules of the child’s own cultural group or disrupt a well-ordered environment such as a school classroom.
Children with autism and other pervasive developmental disorders often suffer from disordered cognition or thinking and have difficulty understanding and using language, understanding the feelings of others, or, more generally, understanding the world around them. Such disorders are often associated with severe learning difficulties and impaired intelligence. The disorders in this category include the pervasive developmental disorders, autism, Asperger’s disorder, and Rett’s disorder (DSM-IV).
It is not uncommon for a child to have more than one disorder or to have disorders from more than one of these groups. Thus, children with pervasive developmental disorders often suffer from ADHD. Children with a conduct disorder are often depressed, and the various anxiety disorders may co-occur with mood disorders. Learning disorders are common in all these conditions, as are alcohol and other substance use disorders (DSM-IV).
Assessment and Diagnosis
As with adults, assessment of the mental function of children has several important goals: to learn the unique functional characteristics of each individual (sometimes called formulation) and to diagnose signs and symptoms that suggest the presence of a mental disorder. Case formulation helps the clinician understand the child in the context of family and community. Diagnosis helps identify children who may have a mental disorder with an expected pattern of distress and limitation, course, and recovery. Both processes are useful in planning for treatment and supportive care. Both are helpful in developing a treatment plan.
Even with the aid of widely used diagnostic classification systems such as DSM-IV (see Chapter 2), diagnosis and diagnostic classification present a greater challenge with children than with adults for several reasons. Children are often unable to verbalize thoughts and feelings. Clinicians by necessity become more reliant on parents, teachers, and other professionals, who may be unable to assess these mental processes in children. Children’s normal development also presents an ever-changing backdrop that complicates clinical presentation. As previously noted, some behaviors may be quite normal at one age but suggest mental illness at another age. Finally, the criteria for diagnosing most mental disorders in children are derived from those for adults, even though relatively little research attention has been paid to the validity of these criteria in children. Expression, manifestation, and course of a disorder in children might be very different from those in adults. The bound!
aries between normal and abnormal are less distinct and those between one diagnosis and another are fluid.
Thus, the field of childhood mental health historically downplayed diagnosis. This trend began to change in the 1980s, in part as a result of developing practice guidelines and tougher reimbursement standards (Lonigan et al., 1998) and more appropriate diagnostic categories and criteria (DSM III, III-R, and IV). The body of accumulated research on treatment and services referred to throughout this chapter reflects the past emphasis on the efficacy of treatments, sometimes with and sometimes independently of diagnosis.
Most disorders are diagnosed by their manifestations, that is, by symptoms and signs, as well as functional impairment (see Chapter 2). A diagnosis is made when the combination and intensity of symptoms and signs meet the criteria for a disorder listed in DSM-IV. However, diagnosis of childhood mental disorders, as noted earlier, is rarely an easy task. Many of the symptoms, such as outbursts of aggression, difficulty in paying attention, fearfulness or shyness, difficulties in understanding language, food fads, or distress of a child when habitual behaviors are interfered with, are normal in young children and may occur sporadically throughout childhood. Well-trained clinicians overcome this problem by determining whether a given symptom is occurring with an unexpected frequency, lasting for an unexpected length of time, or is occurring at an unexpected point in development. Clinicians with less experience may either overdiagnose normal behavior as a disorder or miss a diagno!
sis by failing to recognize abnormal behavior. Inaccurate diagnoses are more likely in children with mild forms of a disorder.
When conducted by a mental health professional, the evaluation process usually consists of gathering information from several sources: the child, parents,
teachers, pediatricians, and hospital records. The mental health professional also makes observations of the child’s or teenager’s behavior and patterns of speech. Very often, additional testing is requested to assess the child’s or youth’s intelligence and learning abilities. Information about symptoms can be obtained more reliably by direct questioning (Gittelman-Klein, 1978; Gittelman, 1985).
A full evaluation may take several hours. By that time, the professional should have a good understanding of how the child is functioning at home, at school, and in society and some understanding of the family’s characteristics. With this information, the child or adolescent psychiatrist, clinical psychologist, or social worker can suggest further investigations and, if needed, initiate treatment of the child and provide counseling to parents and teachers on how to best assist the child or teenager to overcome problems.
There is a dearth of child psychiatrists, appropriately trained clinical child psychologists, or social workers (Thomas & Holzer, 1999). Furthermore, many barriers remain that prevent children, teenagers, and their parents from seeking help from the small number of specially trained professionals who are available. This places a burden on pediatricians, family physicians, and other gatekeepers (such as school counselors and primary child care workers) to identify children for referral and treatment decisions. These gatekeepers are unlikely to have the time and specialized training to do an evaluation requiring several hours. Their responsibility often is to"triage" cases, that is, refer children who need further evaluation to specialists. Many, however, are involved in treating children and adolescents. They may be greatly aided by various diagnostic aids such as brief questionnaires that can be completed in the waiting room of the pediatrician, the school counseling office, or some other community setting. Ideally, these screening questionnaires would be accompanied by a clear guide on interpreting results and identifying what kind of score or behavior would normally indicate a need for referral to a professional.
Some of the questionnaires that specifically address mood disorders are shown in Figure 3-1. Other questionnaires, such as the Adolescent Antisocial Self-Report Behavior Checklist (Kulik et al., 1968), the Eyberg Child Behavior Inventory (Eyberg & Robinson, 1983), and the Family Interaction Coding Pattern (Patterson, 1982), assess antisocial behavior. Adults and teachers can use instruments such as the Child Behavior Checklist (Achenbach & Edelbrock, 1983) to assess a relatively full range of behavioral and emotional symptoms and disorders from the perspective of adult informants. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Hathaway & McKinley, 1989) and the Millon Adolescent Personality Inventory (MAPI) (Millon et al., 1982) questionnaires may be used with adolescents to assess normal and abnormal personality function.
The advent of highly structured, computer-driven assessment tools, such as the NIMH Diagnostic Interview Schedule for Children, which comes in a spoken version that can be given through headphones to children and/or their parents (Shaffer et al., 1996a), promises to greatly improve the ability of professionals outside of the mental health field to obtain robust diagnostic information, which can guide them in decisions about further referral or treatment.
Figure 3-1. Questionnaires used to assess childhood mood disorders
The Children's Depression Inventory (CDI) Kovacs, 1985
Beck Depression Inventory (BDI) Beck, Ward, Mendelson, Mock & Erbaugh, 1961
Reynolds Adolescent Depression Scale (RADS) Reynolds, 1986
Children's Depression Scale (CDS) Tisher & Lang, 1983
Center for Epidemiological Studies of Depression (CES-D) Radloff, 1977
Kandel Depression Scale (KDS) Kandel & Davies, 1982
Zung Self-Rating Depression Scale (SDS) Zung, 1965
Diagnostic Interview Schedule for Children (DISC) Shaffer & Fisher, 1998
Children and adolescents receive most of the traditional treatments described in Chapter 2, particularly psychosocial treatments, such as psychotherapies, and various medications. Specific psychosocial and pharmacological treatment approaches are described in subsequent sections on specific mental disorders. Much of the research, however, has been conducted on adults, with results extrapolated to children. Some of the treatments, such as interactive or play therapy with young children, are unique to clinical work with this group, while others, such as individual psychotherapy with adolescents, are similar to clinical work with adults. Many of the treatment interventions have been"packaged" together in particular arrangements for delivery in specific clinical settings.
More attention is being paid to the value of multimodal therapies, that is, the combination of pharmacological and psychosocial therapies. While research is limited, multimodal studies have shown benefits for treatment of ADHD (see later section), anxiety (Kearney & Silverman, 1998), and depression. Tempering the value of psychotherapy as well as pharmacotherapy, which is discussed below, is that the efficacy of these therapies in the research setting is greater than that in the real world. The problem of the gap between research and clinical practice is discussed in greater depth elsewhere in this chapter and in Chapter 2.
The major types of psychotherapy for children are supportive, psychodynamic, cognitive-behavioral, interpersonal, and family systemic. With the exception of the latter, these therapies originally were developed for adults and then tailored for use in children.
Most psychotherapies are deemed effective for children and adolescents because they improve more than with no treatment, as discussed later in this chapter under Treatment Interventions (Casey & Berman, 1985; Hazelrigg et al., 1987; Weisz et al., 1987; Kazdin et al., 1990; Baer & Nietzel, 1991; Grossman & Hughes, 1992; Shadish et al., 1993; Weisz & Weiss, 1993; Weisz et al., 1995). But despite this strong body of research on children comparing treatment with no treatment, far less attention has been paid to, and guidance provided about, the efficacy of a given psychotherapy for a specific diagnosis (Lonigan et al., 1998). In other words, it is not clear which therapies are best for which conditions. The American Psychological Association sought to rectify this problem by convening two task forces, the second of which exhaustively reviewed the professional literature to evaluate the strength of the evidence for treating individual disorders in children. The second task force re!
fined two sets of criteria against which to evaluate the evidence: the first, and more rigorous, set of criteria was for Well-Established Psychosocial Interventions, while the other was for Probably Efficacious Psychosocial Interventions (Lonigan et al., 1998). The findings of the task force’s comprehensive evaluation were published, disorder by disorder, in an entire issue of the Journal of Clinical Child Psychology in June 1998. While findings relating to individual disorders are presented in the next section of this chapter, this was the overarching conclusion: ". . . the majority of these [psychosocial] interventions do not meet criteria for the highest level of empirical support, the well-established criteria" (Lonigan et al., 1998). The problem, according to these authors, is that too few well-controlled studies have been performed for each disorder. To meet the criteria for a Well-Established Psychosocial Intervention, there must be at least two well-conducted group-design studies conducted by different teams of researchers, among other criteria. Hereafter, these criteria4 are referred to as the American Psychological Association Task Force Criteria.
Some other general points are warranted about the value of psychotherapies for children. Psychotherapies are especially important alternatives for those children who are unable to tolerate, or whose parents prefer them not to take, medications. They also are important for conditions for which there are no medications with well-documented efficacy. They also are pivotal for families under stress from a child’s mental disorder. Therapies can serve to reduce stress in parents and siblings and teach parents strategies for managing symptoms of the mental disorder in their child (see later sections on Disruptive Disorders and Home-Based Services).
Dramatic increases have occurred over the past decade in the use of pharmacological therapies for children and adolescents with mental disorders, but research has lagged behind the surge in their use (Jensen et al., 1999). Our gaps in knowledge span three areas in particular. First, for most prescribed medications, there are no studies of safety and efficacy for children and adolescents. This is true for medications for mental disorders as well as for somatic disorders. Depending on the specific medication, evidence may be lacking for short-term, or most commonly, for long-term safety and efficacy. The problem is even more pronounced with newer medications, most of which have been introduced into the market for adults. Only in the case of psychostimulants for ADHD is there an adequate body of research on their safety and efficacy in children and adolescents, albeit short-term information only (Greenhill et al., 1998) (see later section on ADHD). Second, there is often limited information about pharmacokinetics, that is, drug concentrations in body fluids and tissues over time (Clein & Riddle, 1996). Most of what is known about pharmacokinetics comes from studies of adults. But pediatric pharmacokinetic studies are crucial to identifying the appropriate dose and dose frequency for children of different ages and body sizes. Third, the combined effectiveness of pharmacological and psychosocial treatments, that is, multimodal treatments, is seldom studied. Multimodal treatments have the potential to yield dose reductions in pharmacological treatments, thereby improving the side-effect profile, parental acceptance, and patient compliance.
The dearth of research on children and adolescents has allowed for widespread "off-label" use of medications. This means that, for this population, physicians who are prescribing a given drug do not have the benefit of research and drug labeling information developed by the sponsor and approved by the Food and Drug Administration (FDA). Under U.S. food and drug law, a drug is approved by the FDA only for a defined population. Yet after its approval and market availability, physicians are at liberty to prescribe it for anyone, even though the sponsor only is allowed to market the drug for the approved population (which typically is adults) (FDA, 1998). Fortunately, there is a large body of clinical experience with children and adolescents to guide prescribing practices, despite few controlled studies (Green, 1996).
There are several reasons for the paucity of research on medications for children and adolescents. One is greater caution on the part of both the medical profession and parents to experiment with children or to prescribe drugs with potentially serious side effects. Another reason is the need for compliance with dosing requirements of the clinical trial protocol. When children are research subjects, enforcing compliance is generally perceived to be more difficult. Researchers must rely on parents to assess the degree of compliance. A final reason is the cost of research. Once drugs have reached the market for adults, pharmaceutical companies have fewer financial incentives to conduct expensive and methodologically demanding studies with children, to whom drugs may be given through off-label prescribing. The problem has been significant enough to have galvanized Congress into passing legislation, the FDA Modernization Act of 1997, to create financial incentives for drug sponsors to conduct research with pediatric subjects [FDA, 1999 Title 21 USC 505A(g)]. The FDA Modernization Act may help alleviate this problem, but it is too early to tell.
Despite the relative lack of information concerning safety and efficacy of psychotropic agents in children, six scientific reviews have been completed recently; these reviews comprehensively surveyed all available published research concerning the safety and efficacy of psychotropic medication, focusing on six general classes of medication: the psychostimulants (Greenhill et al., 1998), the mood stabilizers and antimanic agents (Ryan et al., 1999), the selective serotonin reuptake inhibitors (SSRIs) (Emslie et al., 1999), antidepressants (Geller et al., 1998), antipsychotic agents (Campbell et al., 1999), and other miscellaneous agents (Riddle et al., 1998).
Review of this comprehensive body of research evidence indicates strong support for the safety and efficacy of several classes of agents for several conditions, specifically, SSRIs for childhood/adolescent obsessive-compulsive disorder, and the psychostimulants for ADHD. For many other disorders and medications, however, information from rigorously controlled trials is sparse or altogether absent (see Figure 3-2). Further, only in the area of ADHD is information now emerging on longer term safety and efficacy, as well as on the merits of combining psychopharmacologic and psychotherapeutic treatments.
Given the inadequacy of efficacy data for most nonstimulant psychotropics, studies are needed for the majority of agents. However, efficacy data appear to be most urgently needed for SSRIs, mood stabilizers, and novel antipsychotics, since the level of usage of these medications appears to be highest among the growing list of psychotropic medications used in youth (Fisher & Fisher, 1996). In contrast to adult psychopharmacology that is focusing on differential efficacy and speed of onset of these categories of psychotropics, pediatric psychopharmacology needs basic studies of efficacy.
Additional information on specific medication treatment is presented in the succeeding sections, providing more detailed discussion of particular disorders. In-depth information is presented on two disorders where a great deal of research has been done, namely, ADHD and major depressive disorder, followed by briefer discussions of other childhood mental disorders.