What are childhood and adolescent psychological problems? - Chapter 16

What difficulties are associated with the identification and diagnosis of childhood and adolescent psychological problems?

There are some difficulties in psychopathology in childhood and adolescence that are not present in adults. First, behavioural and psychological problems must be seen in the context of the child as a developing organism. Bedwetting is normal up to a certain age, but it is from about 5 years old. Second, children have weak self-knowledge due to their immaturity. They can sense that something is not right, but not name it.

The psychological problems in children can be divided into two domains: externalizing disorders and internalizing disorders. Externalizing disorders are characterized by outward behaviour problems, such as aggressiveness, hyperactivity, or impulsiveness. Internalizing disorders are characterized by inward-looking and withdrawn behaviours and may represent depression, anxiety, and active attempts at social withdrawal.

It is important to consider what is normal at a given age when determining clinically relevant behavior in children. Diagnosis often depends on the individual's ability to communicate problems and their consequences to the counsellor. Children often find it difficult to communicate feelings and often have weak self-knowledge. Differences in cultural norms also influence whether behaviors are seen as problematic or not. In childhood and early adolescence, developments are very fast, which means that psychological problems can escalate quickly and dramatically. Therefore, problems should be identified as soon and early as possible to minimize psychological damage.

How is childhood psychopathology a precursor to adolescence psychopathology?

In many adult psychological disorders, childhood experiences are important in the aetiology. Developmental psychopathology describes how early childhood experiences may act as risk factors for later diagnosable psychological disorders. In addition, it seeks to describe pathways along which these experiences generate psychological problems in adulthood.

There are several ways in which psychopathology in childhood may be linked to psychopathology in adulthood. First, a childhood disorder may persist into adulthood in the same form. Second, psychopathology in childhood may adversely affect subsequent development and thus indirectly lead to various forms of maladaptive behavior later in life. Third, psychopathology in childhood may represent a less cognitive precursor to a related disorder in adulthood. Fourth, a childhood disorder may leave an individual vulnerable to later life stressors.

What is the prevalence of childhood and adolescent psychological disorders?

Estimates are that 10% to 20% of children and adolescents have a diagnosable psychological disorder. Disorders are more common in men than in women, but this is reversed in adulthood. Early developmental problems and specific fears (such as potty-training delays) often resolve themselves as childhood progresses, but other problems (such as disruptive behaviors) seem more permanent.

Comorbidity is common, about 2% of children have more than one diagnosis. In addition, psychopathology in childhood is associated with physical health problems and poor academic performance. Risk factors include having one parent, parental psychopathology, repeated early parental divorce, harsh or inadequate parenting, exposure to abuse or neglect, and negative peer influence.

What is Attention Deficit Hyperactivity Disorder (ADHD)?

Attention deficit hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity-impulsivity to a greater degree than would be expected based on age or stage of development. Hyperactivity is a higher level of activity than normal. Impulsivity is reacting to a situation without thinking about the consequences.

How Is ADHD Diagnosed?

Most children show both inattention and hyperactivity (combined presentation), but sometimes one is dominant. Therefore, there are two diagnostic subtypes, namely ADHD-predominantly inattentive and ADHD-predominantly hyperactivity/impulsivity. The DSM-5 criteria for ADHD are:

A persistent pattern of inattention and/or hyperactivity and impulsivity, interfering with normal functioning or development. For inattention, at least six of the following are present for at least six months: (1) not paying careful attention to details or carelessly making mistakes, (2) difficulty sustaining attention in activities, (3) not listening when spoken to becomes, (4) ignores instructions, (5) has difficulty organizing, (6) dislikes or avoids tasks that require sustained effort, (7) loses things necessary to complete tasks, (8) is easily distracted , (9) is forgetful in daily activities. For hyperactivity and impulsivity, at least six of the following have been present for at least six months: (1) high level of agitation,

• The symptoms were present before age 12
• The symptoms are present in at least two situations
• The symptoms reduce the quality of educational, social, or occupational skills
• The symptoms do not occur during schizophrenia or any other psychotic disorder and are not better explained by another mental disorder
• ADHD has a high comorbidity with oppositional defiant disorder and conduct disorder

What is the prevalence of ADHD?

About 5% of children are diagnosed with ADHD. Half of these carry this diagnosis into adulthood.

What are the consequences of ADHD?

First, the inattention and hyperactivity can predispose the child to anger outbursts, frustration, and stubbornness, among other things. This often leads to reduced learning performance and conflicts with teachers and family. Children with mostly inattentive symptoms suffer the most in terms of learning performance and children with mostly hyperactivity symptoms in terms of peer rejection and injuries. In addition, they generally have difficulty making friends because their behavior is aggressive and disruptive.

Adults with ADHD have less success and security at work, poorer interpersonal relationships, poorer academic performance, and poorer overall life satisfaction.

What does the aetiology of ADHD look like?

There are several biological factors in the aetiology of ADHD, including heredity, brain factors, prenatal factors, and nutrients. The heritability of ADHD is about 76%, according to twin studies. In addition, several genes have been identified that contribute to the development of ADHD. Studies show that it is very likely that there is a gene-environment interaction, with vulnerability to ADHD only manifested by certain environmental influences.

MRI studies show that there are differences between the brains of individuals with ADHD and those without ADHD. The brains of children with ADHD are smaller and develop less quickly. Brain volumes of several specific brain regions are inversely related to different ADHD symptoms. For example, problems in executive functioning are related to reduced volume of the frontal lobes. Prenatal factors that interact with genetic predisposition include maternal smoking and drinking during pregnancy and birth complications such as low birth weight, respiratory problems and suffocation.

In addition, there are studies that state that hyperactivity is due to biochemical imbalances from food additives, refined sugars and lead poisoning. There are also several psychological factors in the aetiology of ADHD, including parent-child interactions and theory of mind impairments. Children with ADHD are more likely to have been raised by parents who also have ADHD, which can exacerbate symptoms caused by the genetic component alone. Psychodynamic theories also point to the possible role of inconsistent or ineffective parenting. Learning theory suggests that parental responses to disruptive and impulsive behaviors may be rewarding or reinforcing for children with ADHD.

Children with ADHD often fail to understand their peers' intentions in social situations, suggesting problems with theory of mind. There is inconsistency in finding a relationship between ADHD and poor performance on theory of mind tasks. There is, however, consistency regarding the relationship between ADHD and limited performance on tasks that require executive functioning. Therefore, it is argued that ADHD symptoms are directly linked to impairments in executive rather than social functioning.

What is Conduct Disorder?

Conduct disorder is a pattern of behavior in which the child shows various behavior problems, including fighting, lying, running away from home, vandalism and truancy.

How is conduct disorder diagnosed?

The DSM-5 criteria for conduct disorder are:

A persistent pattern of behavior that violates other people's rights or social norms, manifested by at least three of the following for at least 12 months:

• Bullying or threatening others
• Starting a fight
• Using of a weapon to inflict serious physical harm
• Physical cruelty to others
• Physical cruelty to animals
• Robbing or other similar offenses
• Forcing others to engage in sexual activity
• Setting fire to destroying or seriously damaging property
• Intentionally destroying another's property
• Breaking into cars or houses
• Lying to get things
• Shoplifting or similar
• Staying out at night despite parental intervention, which starts before the age of 13
• Running away from home at least twice or once for a longer period of time, (15) often misses school starting before age 13
• The disruptions cause significant impairment in social, academic, and occupational functioning
• If the patient is over 18: the condition is not better explained by antisocial personality disorder

There are two subtypes of conduct disorder, childhood and adolescence-onset conduct disorder. Childhood-onset conduct disorder is defined by the onset of at least one characteristic of conduct disorder before age 10. Adolescent-onset conduct disorder is defined by the onset of conduct disorder symptoms after age 10.

There are three considerations in diagnosing conduct disorder. First, individuals are normally under the age of 18 and are only diagnosed with conduct disorder later in life if they do not meet the criteria for an antisocial PS. Second, the clinician must consider the social context in which the behaviors occur. In some environments, these can have a protective function. Third, there is a related category of disordered behavior called oppositional defiant disorder (ODD). This diagnosis is made when children do not meet the full criteria for conduct disorder.

What is the prevalence and course of conduct disorder?

For boys, the prevalence of conduct disorder is between 4% and 16%, for girls between 1.2% and 9%. The disorder also manifests itself differently in boys (aggression, violent behavior) than in girls (lying, running away from home). The lifetime prevalence is around 9.5%. Symptoms usually appear between mid-childhood and mid-adolescence and most resolve in adulthood, but some eventually meet the criteria for antisocial PD.

What is the aetiology of conduct disorder?

There are several biological factors in the development of conduct disorder, namely genetic, neuropsychological and prenatal factors. Twin studies show that the hereditary component is between 45% and 67%. These studies also show that the behaviors such as aggression and violent behavior are hereditary and that environmental factors probably play an important role.

Neuropsychological impairments in cognitive functioning include impairments in executive functioning, verbal IQ, and memory. However, the association between antisocial behavior and weak executive functioning appears to be mainly driven by relations between weak executive functioning and criminal behavior and externalizing behavior, rather than by specific conduct disorder. Prenatal factors in the aetiology of conduct disorder include maternal smoking and drinking during pregnancy and maternal malnutrition during and after pregnancy.

In addition, there are several psychological factors in the development of conduct disorder, namely influences from family and peers, cognitive factors and socio-economic factors. Family and parent-child relationships are important factors involved. Risk factors for developing ODD and conduct disorder include parental unemployment, having a parent with an antisocial PD, impaired care for the child, and abuse or maltreatment during childhood. Family environments that are less close-knit, have few intellectual/cultural pursuits, have a lot of conflict, and are more stressful are associated with the development of conduct disorder in the child.

Many children develop antisocial and aggressive behavior because they imitate the violent activities they see in the media and among their peers. Violent behavior can thus be facilitated, as it can become the norm if seen regularly. However, children affected by the media are often already emotionally and psychologically disturbed.

Conduct disorder is associated with the development of deviant moral consciousness. This may be because they develop highly distorted ways of interpreting the world. Dodge developed the social information processing model for antisocial and aggressive behavior, in which he argues that trauma, abuse, neglect, and insecure attachment can create specific information processing biases. For example, there is a tendency to interpret cues as malicious, even though there may be good intentions behind them, this is called the hostile attributional bias. This often results in an aggressive response. Socio-economic factors that can cause conduct disorder are poverty, low socio-economic status, unemployment, living in the city and poor educational achievement.

What is childhood anxiety?

Childhood anxiety manifests itself as withdrawn behavior. Many anxiety disorders are similar to those seen in adults, but some are specific to children, such as separation anxiety.

What are the characteristics of anxiety problems?

Separation anxiety is the intense fear of being separated from parents or caregivers. The prevalence is about 4% for children aged 6-12 months and has a 12-month prevalence of 1.6% for adolescents. The DSM-5 criteria for separation anxiety are:

Excessive fear of separation from those to whom the individual is attached, manifested by at least three of the following:

• Disproportionate distress when separation from home or attachment figures is experienced or anticipated
• Ongoing and unnecessary care about losing attachment figures or possible things that could happen to them
• Persistent and unnecessary worry about unexpected events that may cause separation from attachment figures
• Persistent aversion to going out or going far away from home because of fear of separation
• Persistent and unnecessary fear of being left alone or without the attachment figures
• Persistent aversion to sleeping alone or sleeping far away from home
• Repeated nightmares about separation
• Complaints about physical symptoms such as headaches or nausea upon separation from attachment figures or in anticipation thereof.
• The fear is present for at least four weeks in children and six months in adults
• The disruption causes significant impairment in key areas of functionality
• The disturbance is not better explained by another mental disorder.

OCD in childhood is very similar to OCD in adulthood. The characteristics are intrusive, repetitive thoughts, obsessions and compulsions. The manifestations of the disorder are slightly different in children than in adolescents. For example, obsessions in children include symmetry and contamination, but in adolescents religious and sexual obsessions. OCD in childhood is comorbid with a variety of disorders such as tic disorders, Tourette's syndrome, other anxiety disorders and eating disorders. Tic disorders are uncontrollable physical movements such as facial and mouth twitching and rapid blinking. Tourette's syndrome is a disorder in which motor and vocal tics occur frequently during the day for at least a year.

Generalized anxiety disorder in children and adolescents often takes the form of anticipatory anxiety, with chronic worry about potential problems and threats. Pathological worry is the persistent worry that is perceived by the individual as uncontrollable. The number of concerns increases with age.

Specific phobias are common in normal development. However, if a fear persists and becomes more problematic, it can affect daily life. An example of this is a social phobia, which starts with a fear of strangers and can grow into a fear of social situations and strangers.

Tics often begin in childhood and diminish in adolescence. Simple tics are short-lived, such as blinking, shrugging, sniffing, and grunting. Complex motor tics are of longer duration and may consist of combinations of simple tics. Tourette's syndrome and behavioral tics are often comorbid with OCD. Treatments used for OCD can also be effective for behavioral tics.

What is the aetiology of anxiety problems?

Twin and family studies show that there is a combination of hereditary and environmental factors. Trauma and stress in childhood are risk factors for a variety of psychological disorders in adulthood. These experiences cause psychological stress and anxiety. In addition, illnesses such as asthma and the death of a pet can cause anxiety and depression. Also, children are very bombarded with information about possible dangers and threats. If negative information is given by an authority figure, it can lead to changes in fear beliefs and avoidance. Because children depend on their parents or caregivers for guidance and emotional support, it is not surprising that dysfunctional forms of parenting can cause problems in childhood. Both overprotective and avoidant parenting styles have negative effects and facilitate anxiety.

What is Childhood and Adolescent Depression?

In childhood, depression manifests as clingy behavior, not wanting to go to school, and exaggerated fears. In addition, there is a greater degree of somatic problems. In adolescence, depression manifests as sulking, withdrawal from family activities, weight disturbances, loss of energy, feelings of worthlessness and guilt, and in extreme cases suicidal thoughts.

How is depression diagnosed in childhood and adolescence?

The diagnostic criteria are essentially the same as for adults. However, some symptoms change with age. Certain complaints are more prominent in younger children than in adolescents. Depression occurs in less than 1% of pre-school children. Prevalence is between 2% and 3% for school-age children and between 4% and 8% for adolescents. Depression is comorbid with other anxiety and substance use disorders. This has negative consequences for learning performance, social functioning and is associated with an increased risk of suicide, among other things.

What is the aetiology of depression in childhood and adolescence?

There are several risk factors for developing depression:

• Dispositional factors and existing psychological problems
• Stressful experiences
• Weak coping skills
• Weak social support
• Problems in physical health
• Weak learning performance

There appears to be a genetic component to childhood depression, but studies differ in their findings. Studies suggest that genetic influences are indirect and have their effect in combination with environmental factors. There is a strong link between child depression and parental depression, which may indicate heredity on the one hand, but parental depression may also create negative early experiences that may precede child depression.

Psychological factors include the parent-child relationship and the development of dysfunctional cognitions that shape depressive thinking. Depressed parents can transfer their negative mood to their child through interactions with the child. In addition, depressed parents may not be able to respond appropriately to their child's emotional experiences, which may leave the child feeling helpless or unable to learn how to regulate emotions. Children of depressed mothers have more interpersonal limitations and a risk of interpersonal dysfunction, which can then exacerbate and perpetuate depression in the child. Research on cognitive factors has mainly focused on the role of a pessimistic inferential style, in which negative events are attributed to stable causes. Children with this style are more likely to have an increase in depressive symptoms due to negative events than children who do not have this style. In addition, this style interacts with daily hassles in predicting an increase in depressive symptoms.

The prototype adolescent most at risk for depression is a 16-year-old female with early or late puberty. She experiences low self-confidence, negative body image, feelings of worthlessness, pessimism and self-blame. She is self-conscious and very dependent on others, but she says she receives little support from family. She experiences major and mild stressors, such as conflict with parents and poor school performance, and she has a weak coping style. Other forms of psychopathology are present, including anxiety disorders, smoking, and past suicidality.

What drug treatments are there?

SSRIs were first used to treat depression, but this has been shown to increase the risk of suicide. However, new studies call for this to be reconsidered, as the benefits would outweigh the risks. Fluoxetine is used in the treatment of anxiety disorders. However, there are several reasons why drug treatment in children should be treated with caution:

• Complete resolution of symptoms is rarely achieved, especially in the treatment of depression with SSRIs
• SSRIs have unpleasant side effects, such as nausea, headache and insomnia
• Safety and effectiveness have not been proven, as studies vary widely in methodology
• Doubts about the safety of various antidepressant drugs in children exist in both the US and the UK, to the extent that official warnings have been issued against their use.

With regard to ADHD, more is known about drug treatments. Ritalin (methylphenidate) is the most commonly used form of stimulant medication to treat hyperactive children. The exact effect is not known, but it probably acts on the neurotransmitters noradrenaline and dopamine in areas of the brain that regulate attention and behavior. Disadvantages of Ritalin are that the long-term effects are not known that there are various side effects (such as sleeping problems and memory loss), and that it is an amphetamine, which means that it can also be abused.

How can Behaviour Therapy be used?

A commonly used classical conditioning method to treat nocturnal enuresis is the bell-and-battery technique. A sensor is placed in the underwear of the child and if it detects urine, an alarm will sound. As a result, the child learns to associate a full bladder with waking up.

Specific behavioral therapy techniques such as systematic desensitization can also be used to treat anxiety problems. Selective reinforcement techniques are used to improve learning performance in children with ADHD and conduct disorder. Desired behaviour is rewarded, and disruptive behaviour is ignored. Time-out (TO) is a means of reducing disruptive behavior (aggression, breaking things, not listening) by taking the child out of the situation and, for example, having him/her sit in a specific TO chair for a period of 5 to 15 minutes.

Behavior management techniques are treatment methods that can be used in a variety of settings and can even be taught to parents as a tool to monitor and respond appropriately to their children at home.

What family interventions are there?

Systematic family therapy is based on the view that childhood problems stem from inappropriate family structure and organization. The therapist focuses on the boundaries between parents and children and how they communicate. Parent management training seeks to teach parents how to adjust their responses to their children so that acceptable behavior, not antisocial behavior, is rewarded. This is used in families with children with conduct disorder. Functional family therapy (FFT) combines elements of systematic family therapy and CBT. The treatment focuses on strengthening family relationships by opening up communication between parents and children.

These forms of therapy are used for conduct disorder, ADHD, depression, anxiety and eating disorders and are more useful than no treatment or alternative treatments.

How can Cognitive Behaviour Therapy (CBT) be used?

CBT is mainly used to treat depression in adolescents. The individual is then made aware of pessimistic and negative thoughts, depressive beliefs and erroneous attributions. The individual is then taught to replace these with more realistic and constructive cognitions. CBT has been successful in treating anxiety disorders such as OCD, generalized anxiety disorder, specific phobias, social phobia and separation anxiety. Family interventions can be successful by teaching parents how to apply basic CBT procedures to their child's anxiety.

What is Play Therapy?

Play therapy includes a variety of play-based therapeutic and assessment techniques that can be used with younger children who are less able to communicate and express their emotions. It also allows children to develop a positive relationship with the therapist, learn to communicate, express feelings, modify behavior, and develop problem-solving skills. This form of therapy appears to be effective and also has positive effects on behavior in general, social adjustment and personality.