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SERIOUS DISORDERS OF CHILDREN & ADOLESCENTS 


Some psychiatric disorders such as autism typically start in childhood, while others such as mood disorders may first be diagnosed adolescents, or adulthood.  Although there is still much to learn about childhood disorders, it is generally accepted that many, if not most, of the disorders listed below are primarily biological in nature, that is, based on structural and / or chemical abnormalities in the brain.  They are sometimes referred to as neurological disorders. 


Autism and other pervasive developmental disorders, schizophrenia, and schizoaffective disorder are clearly biologically based, resulting from a malfunction of the brain.  Other disorders, including attention deficit hyperactivity disorder, anxiety disorder, and mood disorders may also be primarily biologically based and generally respond to drug therapy.  For neurobiological disorders, appropriate medical diagnosis and treatment are essential.  If a child cannot process information or is not in control of his emotions, psychosocial and educational strategies alone are not likely to be effective.   


Professionals have long been reluctant to “label” children with a mental illness diagnosis given the uncertainties about behavior that may be due to developmental problems, the impact of illegal drugs or alcohol, and the ordinary emotional turmoil that accompanies the passage from adolescence to adulthood.  However families need to know what is wrong with their child.  A diagnosis is essential to the task of designating an effective treatment and educational approach. 


AUTISTIC DISORDER


The child fails to relate normally to parents and other people and has play, which is ridged, repetitive, and lacks variety.  Seventy-five percent of children with autistic disorder also have mental retardation.  Once present, autism typically affects the person for life, although about one-third of affected individuals will be able to attain some degree of independence.   


ANXIETY DISORDER


Anxiety may or may not be associated with a specific situation.  Anxiety and worry may be far out of proportion to the actual likelihood or impact of a featured event.  Included among the anxiety disorder are panic attacks, social phobia, obsessive-compulsive disorder, and post-traumatic stress disorder. 


BIPOLAR DISORDERS & DEPRESSION


In children, aggressive or hostile behaviors may mask underlying depression.  Parents should consider the possibility of depression when there are unexplained physical complaints, a drop in school performance, social withdrawal, apathy, increased irritability, tearfulness, sleep or appetite changes, and suicidal behavior or symptoms. 


SCHIZOPHRENIA


Schizophrenia usually starts in the late teens or 20’s, and seldom occurs before adolescence, but some cases at age five or six have been reported/  there is evidence, however, that certain structural changes in the brain are present at birth in individuals who later develop schizophrenia.  The essential features are the same for childhood and adults but it may be difficult to diagnose in children.  


TOURETTE’S DISORDER


Tourette’s Disorder often begins when a child, age five to seven, begins to have tics such as eye blinking, grimacing, or shoulder jerks.  Sudden vocalizations (barks, clicks, yelps) may appear later, and still later the person may involuntarily say words or phrases.  Uttering obscene words out of context occurs in less then 10% of patients. 


ATTENTION DEFICIT HYPERACTIVITY DISORDER


One of the may prevalent and serious disorders affecting children and adolescents is Attention Deficit Hyperactivity Disorder (ADHD).  ADHD has serious impact on the lives of many children and adolescents, and is frequently misunderstood. 

ADHD is generally categorized into four sub-groups.  The first two-groups reflect the major characteristics associated with ADHD: inattention, high activity level, and impulsivity.


The first group is where the primary characteristics are inattentiveness and disorganization.  This is called ADHA predominantly inattentive type.  The second condition is where hyperactivity and impulsivity are the striking features.  This is called ADHD predominantly hyperactive-impulsive type.  The third condition is a combination of the first two while the fourth is considered ADHD not otherwise specified.   


The U.S. Department of Education uses the term ADD (Attention Deficit Disorder) for the type of ADHD characterized by inattentiveness and disorganization and reserves the term ADHD for the type in which hyperactivity and impulsivity predominate. 


ADHD is a complex neurobiological disorder and researchers believe that chemicals in the brain that are not working properly cause the symptoms of ADHD.  More specifically, it is believed that the neurotransmitters, the chemical messengers of the brain, do not work properly in individuals with ADHD.  As a result, many children with ADHD have difficulties in several spheres of functioning that may cause significant problems at home, at school, and in the community.  Although children may be inattentive and impulsive at times, youngsters with ADHD behave this way more frequently and are more likely to cause problems at home and at school. 


For the diagnosis of ADHD to be given, the symptoms need to have been present before the age of seven, and there must be impairment in two or more settings (such as home and school).  It is often the case that diagnosis is first made after children start school, and begin to underachieve academically.  While ADHD is typically thought of as a disorder of young children, in fact it frequently continues into adolescence and often into adulthood.  Researchers have estimated that ADHD affects three to five percent of all children.  ADHD is anywhere from three to six times more common in boys than girls. 


ADHD often occurs with other conditions.  According to information from a major study at the National Institute of Mental Health, two-thirds of children with ADHD have at least one other coexisting condition.  Some of the most common co-occurring conditions are oppositional defiant disorder, anxiety, learning disabilities, and depression. 


Common Features of Children & Adolescents with ADHD


One of the primary complaints from parents and teachers is that children and adolescents with ADHD have difficulty following rules and instructions.  The two core characteristics of ADD, inattention and impulsivity, are largely to blame.  Parents often complain that their child doesn’t complete his chores.  He or she may start a job but somehow never get it finished. 


Impulsivity is the second primary characteristic of ADD.  Specific examples include: responds quickly without waiting for instructions, makes careless errors, doesn’t consider consequences, takes risks, carelessly damages possessions, has difficulty delaying gratification, and takes short cuts in work. 


Both inattention and impulsivity contribute to disorganization, difficulty getting started, and failure to complete homework.  As a result, children with ADHD may have lower self-esteem as early as first or second grade.  Many children with ADD are less mature and may be developmentally behind their peers by as much as three or four years.  


One way of characterizing the deficiencies of many children with ADHD is to indicate that they have “executive functioning” difficulties.  Deficits in key executive function skills that interfere with the ability to do well academically include such things as: holding facts in your head and manipulating them; getting started on tasks, staying alert, and finishing work. 


The challenges facing teenagers and ADD are more complex.  The risk of school failure, school suspension or expulsion, dropping out of school, substance abuse, pregnancy, speeding tickets, car wrecks, and suicide are greater for them.  


Parents have observed that teenagers with ADHD are more difficult to discipline.  On a more positive note, children with ADHD can be very engaging, enthusiastic, and certainly energetic.


If a parent thinks his or her child may be exhibiting behavior reflective of ADHD, then he or she should seek the opinion of a mental health professional or pediatrician who specializes in ADHD.  The parent may also want to gather information from the school about the child’s behavior.  A diagnosis should be based upon a comprehensive evaluation, including interviews, tests and questionnaires, and direct observation.  Interventions typically include psychosocial and behavioral components as well as medication. 


Parents with children with ADHD can find support groups to be an invaluable aid.  In addition to parent organizations that deal with a variety of mental disorders such as the National Alliance on Mental Illness, and the Federation of Families for Children’s Mental Health, parents can contact CHADD (Children and Adults with Attention Deficit Disorder). 


It is important to keep in mind that ADHD is not just a passing phase for children. It is a long-term, sometimes life-long condition.  Many children receive effective intervention and family support, make great progress, and learn how to put their attributes to best use, especially in their adult years.  Without effective intervention and family support, however, ADHD can significantly impair functioning for many years and help bring on other serious emotional and behavioral conditions. 


Summarized from an article by Dan Casseday and Bob Friedman, University of South Florida. 


Substance Use Disorders


According to the 2007 Monitoring the Future study, about half of all adolescents (49.1%) have used illicit drugs by 12th grade, and 72% have tried alcohol.  While national trends show an overall decline in adolescent substance use, the rates of new users of prescription opiates, which are perceived by most teens as less harmful and are readily available, are now comparable to the rates of new users of marijuana. 


The National Survey on Drug Use and Health reports that ages 14-17, the high school years, are still the highest risk time for starting to use of alcohol and drugs.  The most commonly abused substances for teens are alcohol and marijuana, but in 2006, more youths initiated non-medical use of prescription drugs than started using marijuana. 


Most adolescents engage in either experimental or social use; that is, using substances out of curiosity, or to be part of the crowd.  However, research indicates that by age 18, about one in four adolescents will meet criteria for substance abuse, and one in 5 for substance dependence (see page 9 for a more detailed description of the differences between substance abuse and dependence). 


Sometimes parents may minimize the behavior, particularly with alcohol or marijuana, or may rationalize that “All kids try it, so did I.”  However, recent research suggests that alcohol has significantly greater impacts on learning and memory in adolescents than adults, but that adolescents experience less sedation and motor coordination effects so may not accurately perceive their levels of impairment.  The common adolescent pattern of binge drinking followed by withdrawal seems to carry a higher risk of long-term impairment in memory, cognitive functioning, and attention, which are essential for successful development to adulthood.  


It can be difficult for parents to distinguish between experimental use and abuse.  The best indicator is observing how much the substance use is affecting the teen’s life, including academic achievement, physical health, social activities, and choice of friends.  A substance abuse evaluation, including drug testing, can help determine whether or not treatment is necessary.  Many adolescents do not see their substance use as a problem; most teens enter treatment because of juvenile justice mandates. 


Family therapy appears to be an important component of successful treatment for teens.  However, in some cases families are not willing to participate, or family members may use substances themselves, and adolescents rarely have the options adults do to leave environments that put their recovery at risk.  Teens also may feel uncomfortable in traditional 12-step programs due to age differences or difficulty speaking up in groups. 

Youths who are in the process of discovering their identity may resist what they see as pressure to label themselves as alcoholics or addicts 


Co-Occurring Disorders


Data from the Substance Abuse and Mental Health Services Administration and the U.S. Department of Health and Human Services indicates that almost half of youths with a mental health diagnosis have a co-occurring substance use disorder, while about 21% of youths admitted to substance abuse treatment have a co-occurring mental health disorder.   The most common diagnosis is conduct disorder, followed by mood disorders.  Research also supports an association between post traumatic stress disorder and substance use disorders, especially for girls. 


Internalizing” mental health disorders such as anxiety or depression seem somewhat more likely to precede substance abuse, while “externalizing” disorders, i.e., conduct disorder or oppositional defiant disorder, may start simultaneously with substance use.  Co-occurring disorders also seem to correlate with a higher risk of relapse within the first six months after treatment. 


Just as with adults, adolescents may experience parallel or sequential rather than integrated treatment, shifting between the substance abuse and mental health service systems depending on which disorder is most acute at any given time.  Adolescents also face other challenges in getting appropriate help for co-occurring disorders, including the lack of research about psychiatric medications and teens, and the importance of finding treatment that is tailored to the youth’s developmental stage.  These adolescents often are involved with many other systems and need case management to reduce conflicts and promote effective cooperation.