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ANXIETY DISORDERS

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ESSENTIALS OF DIAGNOSIS AND TYPICAL FEATURES

  • Fear or anxiety that is excessive or persisting beyond developmentally appropriate period.

  • Fear or anxiety is accompanied by behavioral disturbances or physical manifestations.

  • Symptoms cause functional impairment or significant distress.

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Anxiety is described as the anticipation of future threat and fear is described as the emotional response to real or perceived imminent threat. Both are protective emotions, part of the normal repertoire of children. Distinguishing developmentally appropriate fears and anxiety from those associated with anxiety disorders can be challenging and requires knowledge of normative development. Generally, fears or anxiety that persists beyond the expected developmental period, or cause significant distress or impairment suggest an anxiety disorder. Some anxiety disorders are more likely to be precipitated by stress, but many are not. An anxious temperament can be identified as early as infancy, and children with such temperaments are more likely to develop anxiety disorders, especially if they are living with anxious parents. Community-based studies of school-aged children and adolescents suggest that nearly 10% of children have some type of anxiety disorder. Anxiety disorders are important to identify and treat early as untreated disorders often persist or evolve into other anxiety disorders.

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Identification & Diagnosis

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Comorbidity is common with anxiety disorders: Children with one anxiety disorder are likely to have another anxiety disorder and have increased risk for other psychiatric disorders such as depression. It is therefore important to carefully screen children with an anxiety disorder to insure that another disorder is not missed. In addition, children with anxiety, presenting to a pediatrician, are more likely to present with a physical complaint, such as headaches or abdominal pain than with identified anxiety (see Table 7-7). While medical causes of anxiety are rare, it is important not to misdiagnose a physical symptom as anxiety; for example, to ascribe the gastrointestinal (GI) upset of inflammatory bowel disease, to anxiety. Screening should also assess for medications and substances that can cause anxiety. Substances include caffeine, marijuana, amphetamines, cocaine, and alcohol during withdrawal. Medications that have been associated with anxiety include steroids, tacrolimus, angiotensin-converting enzyme inhibitors, anticholinergics, dopamine agonists, β-adrenergic agonists, serotonin selective reuptake inhibitors, thyroid medications, and procaine derivatives. Medical illnesses that can lead to symptoms suggestive of anxiety include those associated with hyperthyroid states, hypoglycemia, hypoxia, and more rarely, pheochromocytoma.

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Table Graphic Jump Location
Table 7-7.Signs and symptoms of anxiety in children.
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Treatment

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Treatment must be tailored to the developmental age of the child. Treatment of younger children focuses on helping parents understand their child's symptoms, developing skills to help their child manage distress, while also helping parents tolerate their child's distress. As soon as children have the developmental capacity to engage in assessing their own anxiety and in learning coping strategies, they are incorporated into therapy.

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Cognitive behavioral therapy (CBT) with exposure has the most evidence regarding the successful treatment of anxiety. Exposure refers to planned progressive presentation of low- to mid-level anxiety provoking stimulus. The aim is to desensitize the child to the stimulus. Cognitive behavioral therapy can be delivered in group settings, or with an individual child and parents. The basic goals include helping children identify and quantify anxiety symptoms, identify maladaptive cognitions, learn cognitive, and behavioral coping strategies to begin exposures to situations or items associated with medium- to low-level anxieties. Parents or caregivers also learn these skills in order to help children or youth practice in settings outside the therapy office. The ultimate goal is to enable the child to face the particular anxiety or set of anxieties that are causing distress or dysfunction, experience a decrease in anxiety, and resume normal functioning.

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When anxiety symptoms do not remit with cognitive, behavioral, and environmental interventions, and continue to significantly affect life functioning, psychopharmacologic agents may be helpful. There is evidence that SSRIs are effective in treating anxiety disorders in children as young as 6 years of age, but these medications do not have FDA approval for this indication. The anxiolytic effect of SSRIs can be as rapid as a few days, whereas the effects of benzodiazepines are immediate. Pediatricians are aware of this immediate effect, but the use of benzodiazepines while waiting for the anxiolytic effects of SSRIs is discouraged with youth because the developing brain is at increased risk for dependency and iatrogenic substance abuse. Alpha agonists are an alternative that can be used on a scheduled or as-needed based, and usually are better tolerated without concern for physiologic dependence. Please refer to medication used for treatment of depressive disorders (Table 7-8) as they are commonly used in the treatment for anxiety as well.

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Table Graphic Jump Location
Table 7-8.Common medications used for the treatment of depression in children and adolescents.
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Prognosis

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Early treatment of anxiety disorders can be very effective and decrease the risk for negative impact on developmental trajectories or the development of other psychiatric disorders. The standard of care is CBT for milder cases and a combination of CBT/antidepressant for more severe cases or cases that do not respond to CBT alone.

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The life course of anxiety disorders is as follows. Anxiety disorders that present in childhood tend to wax and wane during childhood, but patients who present with more severe symptoms often develop several anxiety disorders during adolescence and are at risk for depression, substance abuse and other negative developmental outcomes. Parenting style may contribute to anxiety; specifically, autonomy granting is more likely to result in less anxious children, whereas harsh or rejecting parenting results in more anxious children. Treatment of parental anxiety disorders when present improves the outcome of the child's anxiety disorder.

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As mentioned earlier, the PAL Washington is a great resource for primary care providers. The site includes treatment algorithms and related information for the diagnosis and treatment of commonly encountered mental health disorders. To illustrate this point, the treatment algorithm for anxiety disorders is included in Figure 7-1.

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Figure 7-1.

Treatment algorithm for children and adolescents with anxiety. (Reproduced with permission from Hilt R: Primary Care Principles for Child Mental Health, summer 2015. version 6.1. Seattle Children's Hospital.

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1. Separation Anxiety

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ESSENTIALS OF DIAGNOSIS AND TYPICAL FEATURES

  • Persistent excessive worry about losing or being separated from attachment figures, due to harm, illness, or death befalling either the attachment figure or the patient.

  • Reluctance or refusal to leave the attachment figure or sleep away from the attachment figure.

  • Fear of being home without attachment figure.

  • Physical complaints when separation occurs or is anticipated.

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General Considerations

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Younger children may not be symptomatic until the separation is imminent, and may not experience explicit fears related to separation. As children get older, they may experience specific fears such as fears of kidnapping, parents getting into car accidents, being separated due to natural disasters, etc. Behaviors associated with separation anxiety also vary by age; young children are more likely to present with difficulties around the separation of sleep and for older children other separations, such as school, sleep overs, and camp, may be the focus of anxiety. In addition to appearing anxious, children with separation anxiety can appear sad, aggressive, or experience physical symptoms when facing the anxiety provoking separation. Separation anxiety disorder is more prevalent in younger children (4% 6-month prevalence compared with 1.6% 6-month prevalence in adolescence).

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Identification & Diagnosis

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Anxiety about separation from attachment figures is part of early normative development. Separation anxiety disorder must be distinguished from normal development, must occur for more than 4 weeks for children, and lead to impairment or significant distress.

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Treatment

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Parents are often try to alleviate symptoms caused by separation anxiety and are important to include in treatment. Treatment of separation anxiety includes CBT that is modified to address the developmental level of the child. Children who do not respond to therapy may require medication such as an SSRI. Children younger than school age are generally not treated with medication.

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Other Considerations

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The differential for separation anxiety is broad and includes other anxiety disorders, mood disorders, oppositional defiant disorder, conduct disorder, psychotic disorder, and personality disorders. Pediatricians are likely to encounter children with school refusal, a common behavioral manifestation of separation anxiety. It is important to recognize and intervene early with school refusal as the longer a child is out of school, the more difficult it is to help the child return to school. Symptoms of school refusal often include physical symptoms and or behavioral outbursts as school time approaches. Parents often notice symptoms abate on the weekend, vacations, or if the child is no longer expected to attend school. Mild cases may be handled with the help of the pediatrician's office, but more severe cases may need the help of a mental health specialist.

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School refusal can also be related to other anxiety disorders, learning disorders, mood disorders, psychotic disorders, oppositional defiant disorder, conduct disorder and environmental stressors such as bullying or poor student teacher fit. Identifying the etiology of school refusal helps providers appropriately target the level and type of intervention.

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Prognosis

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Separation anxiety often abates by adolescence, but adolescents who experienced separation anxiety disorder in childhood are at increased risk to develop other disorders.

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2. Selective Mutism Disorder

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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Consistent failure to speak in social settings (such as school) where this is expected, despite speaking in other settings

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General Considerations
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Selective mutism is more frequent in younger children, symptoms may be present before 5, but usually do not lead to problems until the child enters school. Immigrant children or other children who initially learned one language and are expected to function in the school setting in a second language may present with selective mutism.

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Identification & Diagnosis
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Children with selective mutism usually speak with close family members and may also speak with a “best” friend. They may be quite outgoing within this comfortable setting, but are often shy outside of this setting, and can be comfortable with social roles that do not require verbal communication. Children with selective mutism can become angry and aggressive when facing a demand to speak. Screening for selective mutism is useful as families may not be aware of the problem, or may not appreciate that it is interfering with function at school. To meet criteria for selective mutism, symptoms must interfere with function in school, work, or social communication, and must last longer than 1 month, not including the first month of school. Symptoms cannot be due to autism, a communication disorder or psychotic disorders.

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Treatment
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This disorder can be perplexing for parents and teachers as the child's engagement in speaking can vary significantly across settings. Treatment therefore usually begins with psychoeducation. Children with selective mutism can be difficult to engage due to their shyness, so clinicians must be adept at using both verbal and nonverbal methods to form an alliance with the child. CBT with exposure aimed at increasing verbal interactions can be very successful. Patients with more severe symptoms, or symptoms that do not respond to therapy, may benefit from an SSRI.

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Other Considerations
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The differential diagnosis includes other disorders that can interfere with speech, such as autism, communication disorders, and psychotic disorders. Children with selective mutism can have other comorbid anxiety disorders, such as social anxiety disorder, separation anxiety, and specific phobia.

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Recognition and treatment of selective mutism is critical as the longer a child avoids verbal communication in settings outside of the family, the more entrenched this behavior becomes. Children with untreated selective mutism are at risk for depression, and social anxiety disorder and substance abuse as adolescents.

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3. Specific Phobias
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Excessive fear or worry about a certain thing, experience, or situation.

  • The thought about or exposure to this trigger causes excessive anxiety.

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General Considerations
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Specific phobias are common, impacting 5% of children and 16% of adolescents. Simple phobias often lessen over time, but more severe, persistent forms can be debilitating.

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Identification & Diagnosis
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Specific phobia is an intense fear of a particular thing, experience, or situation that lasts for at least 6 months. This object or situation is a cause of great distress nearly every time the individual anticipates or is exposed to the stimulus. The perceived harm or threat is well out of proportion to the actual stimulus. To handle the distress, the child avoids the object or situation, therefore reinforcing the anxiety. The distress caused by the stimulus can also present as a panic attack, fainting, or irritability. Young children may present with increased clinginess.

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Treatment
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The mainstay of treatment for specific phobias is CBT aimed at reducing anxiety or fear of the phobic stimulus.

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Other Considerations
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Children commonly experience more than one specific phobia and as the number of phobias increases, so does the degree of impairment. The differential diagnosis includes other anxiety disorders, trauma, and stress-related disorders, eating disorders, schizophrenia, and other psychotic disorders.

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Significant childhood separation events are associated with later onset of phobia. Addressing specific phobia is important as untreated specific phobia have one of the higher rates of stability over time among childhood anxiety disorders.

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4. Panic Disorder
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Recurrent, unexpected panic attacks, described as an abrupt onset of intense fear, that crescendos over the course of minutes and is accompanied by physical symptoms

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General Considerations
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Panic disorder is more likely to present after the onset of puberty with a prevalence rate of 2%–3% during adolescence. Unlike many other anxiety disorders, there is more likely to be a stressor preceding the onset of panic disorder. Children who experience separation anxiety disorder are at increased risk to develop panic disorder.

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Identification & Diagnosis
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The physical symptoms of panic disorder are symptoms of a surge in the adrenergic system and include palpitations, sweating, shortness of breath, choking, chest pain or tightness, GI distress, dizziness or associated feelings, chills or heat, numbness, or tingling. Cognitive symptoms can include feelings of unreality, fear of going crazy, or of dying. To meet criteria for a panic attack, at least four of the above symptoms must be present, and individuals with panic disorder experience a fear of or related to future attacks that leads to maladaptive behavior. Youth with panic disorder are most likely to present to the pediatrician with fears related to physical symptoms of autonomic arousal, such as a fear that there is something wrong with their heart. Adolescents are less likely than adults to report panic attacks and thus specific questions questionnaires should be used when adolescents present with anxiety.

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Although over time, individuals with panic disorder can come to expect panic attacks tied to certain cues, they must experience at least some unexpected panic attacks that seem to come out of the blue.

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Treatment
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Cognitive behavioral therapy for youth with panic disorder focuses on the cognitions associated with the panic attack as well as the physiologic distressing symptoms. Exposure targets may include situations that trigger panic attacks, or some of the physiologic symptoms experienced during an attack. The frequency of treatment can vary depending on the acuity of the patient, with lower levels of care provided during weekly outpatient therapy and higher levels provided several times a week through intensive outpatient treatment programs or daily in day treatment programs. Patients who do not respond to therapy alone may benefit from an SSRI. Benzodiazepines have been used with adults but are discouraged for use with youth in the primary care setting.

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Other Considerations
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The differential diagnosis of panic attacks includes a physical cause of panic symptoms. This must be ruled out when appropriate. Panic disorder can be debilitating as youth can go to extensive lengths to avoid cues. Youth who avoid going out in public by themselves, should be diagnosed with agoraphobia in addition to panic disorder. Although panic disorder increases the risk of developing a substance abuse disorder, withdrawal of some substances can also lead to panic symptoms. For adolescents who are actively using, this can difficult to distinguish. Panic attacks can present as part of other anxiety disorders, but the panic attacks in other disorders are cued by the underlying fear or anxiety, such as public performance in social anxiety disorder, or anticipation of an event in generalized anxiety disorder. Panic disorder is higher among individuals with other anxiety disorders, depression, and bipolar disorder.

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Prognosis
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Panic symptoms and panic disorder are both important to recognize and treat. Untreated panic disorder has the highest rate of stability over time among childhood anxiety disorders. Individuals with panic symptoms that occur in the context of another disorder at increased risk to develop depression.

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5. Agoraphobia
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • An excessive fear of being in a situation where panic-like symptoms might occur, leading to avoidance of these situations.

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General Considerations
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Agoraphobia can be debilitating. In children and adolescents, it is more likely to present as school refusal than fear of the other situations listed below. Children and adolescents may be reluctant to report symptoms, so a careful screening is warranted for anxious children, or children who are refusing to attend school. In community samples, agoraphobia is more likely to occur in later adolescence; 1.7% of adolescents suffer from agoraphobia, but this may be an underestimate because of the difficulty of assessing youth. Similar to panic disorder, initial symptoms often are triggered by a stressful event.

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Identification & Diagnosis
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The most well-known fear associated with agoraphobia is fear of open spaces, including the market place. For individuals with agoraphobia, other situations can also trigger intense fear, such as using public transportation, standing in line or being in a crowd, being in an enclosed space, or outside the home alone. Individuals with agoraphobia experience two or more of these fears that last for over 6 months and lead to distress or impairment. Full panic disorder symptoms do not have to be present to meet criteria for agoraphobia.

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Treatment
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Treatment of individuals with agoraphobia can be very challenging, as treatment typically requires leaving home. Online treatments are available with limited data on efficacy. The current standard remains CBT with exposure, and SSRI for individuals who do not respond to treatment or are severely impacted by agoraphobia.

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Other Considerations
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The differential diagnosis includes other anxiety disorders, PTSD, depression, and medical conditions. For example, adolescents with postural orthostatic tachycardia syndrome (POTS) may fear leaving the house, due to a fear of fainting, or individuals with inflammatory bowel disease may fear diarrhea.

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Prognosis
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Individuals with agoraphobia are at risk for co-morbid disorders including other anxiety disorders and depression, and males have a high incidence of substance abuse.

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6. Generalized Anxiety Disorder (GAD)
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Multiple, intense, disproportionate, or irrational worries, often about future events.

  • Worry is accompanied by other symptoms

  • The worry is difficult to control.

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General Considerations
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Individuals with generalized anxiety disorder often recall a lifetime of anxiety, but community samples find GAD rarely presents before adolescence; the prevalence of GAD in adolescence is 0.9%. Potential reasons for this discrepancy include that the symptoms of anxiety may not meet full criteria for GAD at an earlier age, or symptoms may be underestimated by parents or guardians. Individuals who develop GAD at an early age are more likely to have greater impairment.

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GAD is highly heritable, overlapping with the risk for depression and neuroticism. In addition anxious overprotective parenting increases the risk of GAD, but is not necessary for the development of the disorder.

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The differential diagnosis of symptoms of anxiety is presented in Table 7-9.

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Table Graphic Jump Location
Table 7-9.Differential diagnosis of symptoms of anxiety.
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Identification & Diagnosis
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Young children with generalized anxiety often worry about their competence or performance while older youth may worry about additional issues such as family finances or being on time. Worry and anxiety that is not pathological must be distinguished from the worries or anxieties of GAD. In addition, children with GAD experience at least one symptom of fatigue, restlessness or poor concentration, irritability, feeling on edge, or sleep disturbance. GAD can also be accompanied by other somatic symptoms and the pediatrician is more likely to encounter children with GAD who present with symptoms of GI difficulties or headaches. To meet criteria for GAD, the symptoms must cause significant distress or disturbance of function and be present for at least 6 months.

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Treatment
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As with other anxiety disorders psychotherapy is the first-line treatment, with the possible addition of an SSRI if the response is insufficient.

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Other Considerations
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It can be challenging to distinguish GAD from other anxiety disorders. Substance induced anxiety should be considered with adolescents who experience a sudden onset of anxiety. Individuals with GAD are at increased risk to experience depression.

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Prognosis
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The combination of medication and therapy can be very effective for treating youth with GAD. Individuals with GAD are at increased risk for depression.

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7. Social Anxiety Disorder
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Excessive worrying in social settings.

  • Inability to perform in front of others as expected for age.

  • Avoidance of events or settings that are social in nature or involve large groups.

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General Considerations
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Social anxiety disorder is characterized by significant, persistent fear in social settings, or performance situations. The disorder results in overwhelming anxiety and inability to function when exposed to unfamiliar people and/or scrutiny. This is usually a problem of older children and adolescents.

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Identification & Diagnosis
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Anxiety symptoms in children with social anxiety disorder are related specifically to the social setting and not better explained by another anxiety disorder. Common manifestations of this disorder include consistent avoidance of social functions, and persistent somatic complaints that occur in a social setting and resolve in the absence of social exposure. The symptoms significantly disrupt the child's—and frequently the family's—life, and parents often describe a pattern of overly accommodating their child's avoidance and/or incentivizing their child to attend routine social, extracurricular, or family functions.

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Treatment
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Similar to the other anxiety categories, the mainstay of treatment for social anxiety disorder is CBT therapy. The goal is to modify behavior and diminish the anxiety in social settings through the use of specific cognitive and behavioral techniques. As with other anxiety disorders, if ongoing CBT therapy is not effective at mitigating the anxiety, then psychopharmacologic agents may be helpful. SSRIs are the only class of medication to have demonstrated efficacy for children with social anxiety disorder.

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Other Considerations
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Children with social anxiety disorder are at increased risk for depression and school avoidance. They can also experience panic attacks, and there is high comorbidity between substance use disorders and anxiety disorders, especially social anxiety disorder.

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Prognosis
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Early age of onset, more severe avoidance and the presences of panic symptoms are all predictors of persistence over time. Treatment with CBT or a combination of CBT and medication can be very effective for the majority of youth with social anxiety disorder.

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Obsessive-Compulsive Disorder
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Recurrent obsessive thoughts, impulses, or images that are experienced as intrusive at times.

  • Repetitive compulsive behaviors or mental acts are performed to prevent or reduce distress stemming from obsessive thoughts.

  • Obsessions and compulsions cause marked distress, are time-consuming, and interfere with normal routines.

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General Considerations
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Obsessive-compulsive disorder (OCD) is related to anxiety disorders, but tends to cluster genetically with other compulsive disorders such as compulsive skin picking, and hoarding. Onset often occurs during childhood, and untreated OCD can have a lifelong course. Males have an earlier age of onset, with childhood cases usually occurring before the age of 10 years. OCD often leads to avoidance of situations that trigger obsessions, and for children and adolescents, this can interfere with development.

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Identification & Diagnosis
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The obsessions that lead to OCD are defined as recurrent, persistent, intrusive thoughts, urges, or images that cause significant distress. The individual tries to avoid, suppress, or ignore the obsessions or to mitigate them through action or thought. The obsessions and compulsions of OCD consume more than an hour per day. Obsessions vary by individuals, but tend to cluster into the following groups: intrusive “forbidden” images such as sexual, aggressive or religiously taboo images, thoughts of contamination, need for symmetry, fears of harming others, fears of harm to oneself or loved ones. Individuals often experience more than one cluster and types of obsessions can change over time. In addition to compulsive symptoms, youth who are experiencing obsessions may also experience panic, depressive, irritable, and suicidal symptoms. Sudden onset of symptoms should alert pediatricians to screen for Group A streptococcal infections, as pediatric autoimmune disorders associated with these infections have been implicated in the development of OCD for some children.

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Caretakers can often identify children who have compulsions, but obsessions can be difficult to recognize because they are experienced internally. Youth who recognize that obsessions and compulsions are strange may not spontaneously reveal symptoms unless specifically asked.

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Treatment
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Many individuals with OCD feel that their symptoms are “crazy” or alternatively, they do not want to consider giving up their compulsions as they feel these will lead to intense distress. Psychoeducation is an important first step in treatment of OCD to help put symptoms in perspective and outline treatment progression. OCD is best treated with a combination of CBT specific to OCD, with use of medications in more severe cases. SSRIs are effective in diminishing OCD symptoms, but higher doses may be needed than those used to treat anxiety disorders or depression. Fluvoxamine and sertraline have FDA approval for the treatment of pediatric OCD. The tricyclic antidepressant clomipramine has FDA approval for the treatment of OCD in adults. Severe cases have been treated with gamma knife brain surgery interrupting the circuit involved in OCD.

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Other Considerations
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OCD often occurs with other compulsive disorders such as trichotillomania (the recurrent pulling out of hair), compulsive skin picking, body dysmorphic disorder, or hoarding. Youth with OCD are at increased risk to have comorbid ADHD, depression, and tics. The differential diagnosis includes all of the above as well as psychotic disorders and obsessive compulsive personality disorder.

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Prognosis
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The combination of CBT plus medication is most effective for patients who do not respond to either treatment alone. It is important to recognize and treat OCD early, as early age of onset and greater impairment are predictors of poor prognosis. Hoarding is particularly difficulty to treat.

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Franklin  ME  et al: Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA 2011;306(11):1224–1232 PMID:
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Post-Traumatic Stress Disorder
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Signs and symptoms of hyperarousal and reactivity.

  • Avoidant behaviors and numbing of responsiveness.

  • Flashbacks to a traumatic event such as nightmares, intrusive thoughts, or repetitive play.

  • Follows traumatic events such as exposure to violence, physical or sexual abuse, natural disasters, car accidents, dog bites, and unexpected personal tragedies.

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General Considerations
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Factors that predispose individuals to the development of post-traumatic stress disorder (PTSD) include proximity to the traumatic event or loss, a history of exposure to trauma, preexisting depression or anxiety disorder, being abused by a caregiver, or witnessing a threat to a caregiver. PTSD can develop in response to natural disasters, terrorism, motor vehicle crashes, and significant personal injury, in addition to physical, sexual, and emotional abuse. Natural disasters such as hurricanes, fires, flooding, and earthquakes, create situations in which large numbers of affected individuals are at heightened risk for PTSD. Individuals who have a previous history of trauma, or an unstable social situation are at greatest risk of PTSD.

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Long overdue, attention is now being paid to the substantial effects of family and community violence on the psychological development of children and adolescents. Abused children are especially likely to develop PTSD and to suffer wide-ranging symptoms and impaired functioning. As many as 25% of young people exposed to violence develop symptoms of PTSD and children with some symptoms of PTSD can suffer significant distress and functional impairment, even when not meeting full criteria for PTSD.

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Identification & Diagnosis
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Children and adolescents with PTSD show persistent fear, anxiety, and hypervigilance. They may regress developmentally and experience fears of strangers, the dark, and being alone, and avoid reminders of the traumatic event. For young children with magical thinking, this can involve avoiding objects or events that may not be obviously linked to the traumatic event. Children with PTSD re-experience elements of the events in the form of nightmares and flashbacks. In their symbolic play, one can often notice repetition of some aspect of the traumatic event. Children with a history of traumatic experiences or neglect in infancy and early childhood are likely to show signs of reactive attachment disorder and have difficulty forming relationships with caregivers.

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Treatment
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Before considering treatment, it is critical to ensure that the child is living in a safe environment. If there is concern regarding current or past abuse, this must be reported to social services. The cornerstone of treatment for PTSD is education of the child and family regarding the nature of the disorder so that the child's emotional reactions and regressive behavior are not mistakenly viewed as volitional. The child needs support, reassurance, and empathy. Treatment also includes building a developmentally appropriate narrative of the event to help the child understand their experience. Efforts should be made to establish or maintain daily routines as much as possible, especially after a trauma or disaster that interrupts the family's environment. In the case of media coverage of a disaster or event, children's viewing should be avoided or limited. Individual and family psychotherapy are central features of treatment interventions. Specific fears usually wane with time, and behavioral desensitization may help. Trauma-focused CBT is considered first-line treatment for PTSD. There is preliminary evidence that eye movement desensitization and reprocessing (EMDR) may also be useful.

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For children with more severe and persistent symptoms, assessment for treatment with medication is indicated. Children who have lived for an extended time in abusive environments or who have been exposed to multiple traumas are more likely to require treatment with medications. Currently, there is not a medication that has FDA approval for treating PTSD for children. Child psychiatrists may choose medications to target specific symptoms (eg, anxiety, depression, nightmares, and aggression). Some of the medications used to treat children with PTSD include clonidine or guanfacine (Tenex), mood stabilizers, antidepressants, and neuroleptics.

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Other Considerations
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Evidence is growing to support a connection between victimization in childhood and problems in adulthood, including health problems, substance abuse, unstable personality and mood disorders. It is important to treat PTSD not only to relieve the suffering of youth with PTSD, but also to mitigate long-term negative sequelae.

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Prognosis
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The best prognostic indicator for children exposed to trauma is a supportive relationship with a caregiving adult. Frequently caregivers exposed to trauma also have PTSD and need referral for treatment so that they can also assist in their child's recovery. Timely access to therapy enhances prognosis. Children with more severe PTSD may require intermittent therapy to identify and treat symptoms that emerge during different stages of development.

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Cohen  JA, Kelleher  KJ, Mannarino  AP: Identifying, treating, and referring traumatized children: the role of pediatric providers. Arch Pediatr Adolesc Med 2008 May;162(5):447–452 PMID:
[PubMed: 18458191]
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Cohen  JA, Scheeringa  MS: Post-traumatic stress disorder diagnosis in children: challenges and promises. Dialogues Clin Neurosci 2009;11(1):91–99 PMID:
[PubMed: 19432391]
+
Dulcan  MK, Martini  DR: Concise Guide to Child & Adolescent Psychiatry, 2nd ed. Washington, DC: American Psychiatric Association; 1999.
+
Kirsch  V, Wilhelm  FH, Goldbeck  L: Psychophysiological characteristics of PTSD in children and adolescents: a review of the literature. J Trauma Stress 2011 Apr;24(2):146–154. doi: 10.1002/jts.20620 [Epub 2011 Mar 24] [Review] Erratum in: J Trauma Stress. 2011 Jun;24(3):370–372 PMID:
[PubMed: 21438015]
+
National Child Traumatic Stress Network. Multiple invaluable resources available at: http://www.nctsn.org. Accessed September 27, 2015.
+
Scheeringa  MS, Zeanah  CH: Reconsideration of harm's way: onsets and comorbidity patterns of disorders in preschool children and their caregivers following Hurricane Katrina. J Clin Child Adolesc Psychol 2008 Jul;37(3):508–518 PMID:
[PubMed: 18645742]

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ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

++
Inattentive, Hyperactive, & Combined Type
++

ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Significant impairment in attention or concentration.

  • Significant hyperactivity and energy in excess of that expected for age.

  • Must be present in two or more settings.

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General Considerations
++

Attention-deficit/hyperactivity disorder (ADHD) is one of the most commonly seen and treated psychiatric conditions in children and adolescents. Although there is no definitive cause or cure for this disorder, with adequate screening and monitoring, it can be identified and effectively treated.

++
Identification & Diagnosis
++

Symptoms of ADHD fall into two categories: hyperactive and impulsive or inattentive. If a child has a significant number of symptoms in both categories, a diagnosis of ADHD, combined type is given. As with all psychiatric diagnoses, functional impairment is a required feature, as is presentation across multiple settings and relationships (eg, home and school). It is important to keep in mind that intermittent symptoms of hyperactivity and/or inattention without functional impairment do not warrant a diagnosis of ADHD.

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Treatment
++

Medication is a primary treatment for ADHD. Stimulants are the most effective and most commonly prescribed medications. Approximately 75% of children with ADHD experience improved attention span, decreased hyperactivity, and decreased impulsivity when given stimulant medications. Children with ADHD who do not respond favorably to one stimulant may respond to another. Children and adolescents with ADHD without prominent hyperactivity (ADHD, predominantly inattentive type) are also likely to be responsive to stimulant medications. When stimulants are not well tolerated or effective, nonstimulants may be used as an alternative. Among nonstimulant medications, atomoxetine, a selective noradrenergic reuptake inhibitor and guanfacine ER, a central α2A-adrenergic receptor agonist, both have FDA approval for the treatment of ADHD in children. Please refer to tables of stimulants and nonstimulants when considering which medication to use (Tables 7–10 and 7–11).

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Table Graphic Jump Location
Table 7-10.Stimulant medication used for treatment of ADHD.a
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Table Graphic Jump Location
Table 7-11.Nonstimulant medication used for treatment of ADHD.
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Other Considerations
++

As discussed later in this chapter, not all hyperactivity and/or inattention can be attributed to ADHD. Some of the most common psychiatric conditions that have similar presenting problems to ADHD include mood disorder (ie, bipolar and depression), anxiety disorders, oppositional defiant disorder, adjustment disorder, PTSD, and learning disorders. There are also a number of medical diagnoses with presenting problems similar to ADHD, including head injury, hyperthyroidism, fetal alcohol syndrome, and lead toxicity. Inadequate nutrition and sleep deprivation, including poor quality of sleep, can also cause inattention. It is important to have the correct diagnosis prior to initiating treatment for ADHD.

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ADHD comorbidities are common and include anxiety disorders, mood disorders, oppositional defiant disorder, and conduct disorder. While stimulant medication, the first-line treatment for ADHD, has the potential for abuse, individuals who are treated for ADHD are significantly less likely to abuse substances compared to those who have not been treated. Also, a large majority of children and adolescents with ADHD are not formally diagnosed, and of those who are diagnosed, only 55% actually receive ongoing treatment.

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Special Considerations Regarding the Use of Stimulant Medication
++

Common adverse events include anorexia, weight loss, abdominal distress, headache, insomnia, dysphoria and tearfulness, irritability, lethargy, mild tachycardia, and mild elevation in blood pressure. Less common side effects include interdose rebound of ADHD symptoms, emergence of motor tics or Tourette syndrome, behavioral stereotypy, tachycardia, hypertension, depression, mania, and psychotic symptoms. Reduced growth velocity can occur, however, for individual patient's ultimate height is not usually compromised. Treatment with stimulant medications does not predispose to future substance abuse. Young children are at increased risk for side effects from stimulant medications. Additive stimulant effects are seen with sympathomimetic amines (ephedrine and pseudoephedrine).

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Reports of sudden death and serious cardiovascular adverse events among children taking stimulant medication raised concerns about their safety. The labels for methylphenidate and amphetamine medications were changed in 2006 to note reports of stimulant-related deaths in patients with heart problems and advised against using these products in individuals with known serious structural abnormalities of the heart, cardiomyopathy, or serious heart rhythm abnormalities. There continues to be insufficient data to confirm whether taking stimulant medication causes cardiac problems or sudden death. The FDA is advising providers to conduct a thorough physical examination, paying close attention to the cardiovascular system, and to collect information about the patient's history and any family history of cardiac problems. If this scrutiny suggests a problem, providers should consider a screening electrocardiogram or an echocardiogram. In addition, stimulants should also be used cautiously in individuals with a personal or family history of motor tics or Tourette syndrome, as these medications may cause or worsen motor tics. Caution should also be taken if there is a personal or family history of substance abuse or addictive disorders, as these medications can be abused. Students attending college/university may be at increased risk to divert their stimulants to peers. Stimulants should be used with caution in individuals with psychotic disorders, as they can significantly worsen psychotic symptoms. Likewise stimulants should be used with caution in individuals with bipolar affective disorder as they can worsen mood dysregulation.

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Initial medical screening should include observation for involuntary movements and measurement of height, weight, pulse, and blood pressure. (See also Chapter 3.) Pulse, blood pressure, height, and weight should be recorded every 3–4 months and at times of dosage increases and abnormal movements such as motor tics should be assessed at each visit.

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Prognosis
++

Research indicates that 60%–85% of those diagnosed with ADHD in childhood continue to carry the diagnosis into adolescence. The literature varies greatly about progression of ADHD into adulthood. Most studies show that in adulthood, a majority of adolescents diagnosed with ADHD in adolescence continue to have functional impairment, whether or not they meet full criteria for the disorder. While many have devised ways to cope with their symptoms in a manner that does not require medication, about one-third of adults previously diagnosed with ADHD in childhood require ongoing medication management.

+
Biederman  J  et al: Treatment of ADHD with stimulant medications: response to Nissen perspective in the New England Journal of Medicine. J Am Acad Child Adolesc Psychiatry 2006 Oct;45(10):1147–1150 PMID:
[PubMed: 16840880]
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Correll  CU, Kratochvil  CJ, March  JS: Developments in pediatric psychopharmacology: focus on stimulants, antidepressants, and antipsychotics. J Clin Psychiatry 2011 May;72(5):655–670 PMID:
[PubMed: 21658348]
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Daughton  JM, Kratochvil  CJ: Review of ADHD pharmacotherapies: advantages, disadvantages, and clinical pearls. J Am Acad Child Adolesc Psychiatry 2009 Mar;48(3):240–248 PMID:
[PubMed: 19242289]
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McVoy  M, Findling  R: Child and adolescent psychopharmacology update. Psychiatr Clin North Am 2009 Mar;32(1):111–133 PMID:
[PubMed: 19248920]
+
National Institute of Mental Health, Attention Deficit Hyperactivity Disorder: http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/index.shtml. Accessed September 27, 2015.

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MOOD DISORDERS

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1. Depression
++

ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Dysphoric mood, mood lability, irritability, or depressed appearance, persisting for weeks to months at a time.

  • Characteristic neurovegetative signs and symptoms (eg, changes in sleep, appetite, concentration, and activity levels).

  • Suicidal ideation, feeling of hopelessness.

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General Considerations
++

The incidence of depression in children increases with age, from 1% to 3% before puberty to around 8% for adolescents. The rate of depression in females approaches adult levels by age 15. The lifetime risk of depression ranges from 10% to 25% for women and 5% to 12% for men. The incidence of depression in children is higher when other family members have been affected by depressive disorders. The sex incidence is equal in childhood, but with the onset of puberty the rates of depression for females begin to exceed those for males by 5:1.

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Identification & Diagnosis
++

Clinical depression can be defined as a persistent state of unhappiness or misery that interferes with pleasure or productivity. Depression in children and adolescents is as likely to be characterized by an irritable mood state accompanied by tantrums or verbal outbursts as it is to be a sad mood. Typically, a child or adolescent with depression begins to look unhappy and may make comments such as “I have no friends,” “life is boring,” “there is nothing I can do to make things better,” or “I wish I were dead.” Behavior patterns change from baseline and can include social isolation, deterioration in schoolwork, loss of interest in usual activities, anger, and irritability. Sleep and appetite patterns commonly change, and the child may complain of tiredness and nonspecific pain such as headaches or stomach aches (Table 7-12).

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Table Graphic Jump Location
Table 7-12.Clinical manifestations of depression in children and adolescents.
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Clinical depression is typically identified by asking about the symptoms. Children are often more accurate than their caregivers in describing their own mood state. When several depressive symptoms cluster together over time, are persistent (2 weeks or more), and cause impairment, a major depressive disorder may be present. When depressive symptoms are of lesser severity but have persisted for 1 year or more, a diagnosis of dysthymic disorder should be considered. Milder symptoms of short duration in response to some stressful life event may be consistent with a diagnosis of adjustment disorder with depressed mood.

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The American Academy of Pediatrics recommends annual screening for depression in children age 12 and older using a standardized measure. The Center for Epidemiologic Study of Depression–Child Version (CESD-C), Child Depression Inventory (CDI), Beck Depression Rating Scale, and Reynolds Adolescent Depression Scale and Patient Health Questionnaire-9 modified for teens (PHQ-9) are self-report rating scales that are easily used in primary care to assist in assessment and monitoring response to treatment. Several are available in the public domain.

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Treatment
++

Treatment includes developing a comprehensive plan to treat the depressive episode and help the family to respond more effectively to the patient's emotional needs. Referrals should be considered for individual and possibly adjunctive family therapy. CBT improves depressive symptoms in children and adolescents. This includes a focus on building coping skills to change negative thought patterns that predominate in depressive conditions. It also helps identify, label, and verbalize feelings and misperceptions. In therapy, efforts are also made to resolve conflicts between family members and improve communication skills within the family.

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Mild to moderate depressive symptoms often improve with psychotherapy alone. When the symptoms of depression are moderate and persistent, or severe, antidepressant medications may be indicated (see Table 7-8). A positive family history of depression increases the risk of early-onset depression in children and adolescents and the chances of a positive response to antidepressant medication. Depression in toddlers and young children is best approached with parent-child relational therapies.

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The carefully conducted Treatment of Adolescent Depression Study (TADS) is a major source of evidence for clinic guidelines regarding the treatment of depression in children and adolescents. This study found that CBT combined with fluoxetine led to the best outcomes in the treatment of pediatric depression during the first 12 weeks of treatment. Although our knowledge is still evolving, these findings suggest that when recommending or prescribing an antidepressant, the provider should consider concurrently recommending cognitive-behavioral or interpersonal therapy. Providers should discuss the options for medication treatment, including which medications have FDA approval for pediatric indications (see Table 7-6). Target symptoms should be carefully monitored for improvement or worsening, and it is important to ask and document the responses about any suicidal thinking and self-injurious behaviors.

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Special Considerations Regarding the Use of Antidepressant Medication
++

There are some special considerations when prescribing the various classes of antidepressant medication. Table 7-8 outlines the distinct differences between some of the most commonly used antidepressant medications.

++
A. Selective Serotonin Reuptake Inhibitors (SSRI)
++

Each SSRI has different FDA indications. Providers can choose to treat with an SSRI that has not received FDA approval for a specific indication or age group. Typical considerations for using a medication without FDA approval include the side-effect profile and/or whether another family member has responded to a specific medication. In these instances, providers should inform the patient and family that they are using a medication off-label.

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The therapeutic response for SSRIs should be expected 4–6 weeks after a therapeutic dose has been reached. The starting dose for a child younger than 12 years is generally half the starting dose for an adolescent. SSRIs are usually given once a day, in the morning with breakfast. One in ten individuals may experience sedation and prefer to take the medication at bedtime. Caution should be used in cases of known liver disease or chronic or severe illness where multiple medications may be prescribed, because all SSRIs are metabolized in the liver. In addition, caution should be used when prescribing for an individual with a family history of bipolar disorder, or when the differential diagnosis includes bipolar disorder, because antidepressants can induce manic or hypomanic symptoms.

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Adverse effects of SSRIs are often dose-related and time-limited: GI distress and nausea (can be minimized by taking medication with food), headache, tremulousness, decreased appetite, weight loss, insomnia, sedation (10%), and sexual dysfunction (25%). Irritability, social disinhibition, restlessness, and emotional excitability can occur in approximately 20% of children taking SSRIs. It is important to systematically monitor for side effects. SSRIs other than fluoxetine should be discontinued slowly to minimize withdrawal symptoms including flu-like symptoms, dizziness, headaches, paresthesias, and emotional lability.

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All SSRIs inhibit the hepatic microsomal enzyme system. The order of inhibition is: fluoxetine > fluvoxamine > paroxetine > sertraline > citalopram > escitalopram. This can lead to higher-than-expected blood levels of concomitant medications. Taking tryptophan while on an SSRI may result in a serotonergic syndrome of psychomotor agitation and GI distress. A potentially fatal interaction that clinically resembles neuroleptic malignant syndrome may occur when SSRIs are administered concomitantly with monoamine oxidase inhibitors (MAOIs). Fluoxetine has the longest half-life of the SSRIs and should not be initiated within 14 days of the discontinuation of a monoamine oxidase inhibitor, or a monoamine oxidase inhibitor initiated within at least 5 weeks of the discontinuation of fluoxetine. One should be cautious of prescribing SSRIs in conjunction with ibuprofen and other NSAIDs for concerns of GI bleeding.

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B. Serotonin Norepinephrine Reuptake Inhibitors
++

Serotonin norepinephrine reuptake inhibitors (SNRIs), which include venlafaxine, duloxetine, desvenlafaxine, and milnacipran, are antidepressants that primarily inhibit reuptake of serotonin and norepinephrine. Desvenlafaxine is the major active metabolite of the antidepressant venlafaxine. It is approved for the treatment of major depression in adults. Contraindications for this class of medication include hypertension, which is typically dose related. The most common adverse effects are nausea, nervousness, and sweating. SNRIs should be discontinued slowly to minimize withdrawal symptoms: including flu-like symptoms, dizziness, headaches, paresthesias, and emotional lability.

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C. Other Antidepressants
++

Bupropion is an antidepressant that inhibits reuptake of primarily serotonin, but also norepinephrine and dopamine. It is approved for treatment of major depression in adults. Like the SSRIs, bupropion has very few anticholinergic or cardiotoxic effects. The medication has three different formulations, and consideration for use is based on tolerability and compliance. Bupropion can interfere with sleep, so dosing earlier in the day is paramount to adherence and decreasing side effects. Contraindications of this medication include history of seizure disorder or bulimia nervosa. The most common adverse effects include psychomotor activation (agitation or restlessness), headache, GI distress, nausea, anorexia with weight loss, insomnia, tremulousness, precipitation of mania, and induction of seizures with doses above 450 mg/d.

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Mirtazapine is an α2-antagonist that enhances central noradrenergic and serotonergic activity. It is approved for the treatment of major depression in adults. Mirtazapine should not be given in combination with monoamine oxidase inhibitors. Very rare side effects are acute liver failure (1 case per 250,000–300,000), neutropenia, and agranulocytosis. More common adverse effects include dry mouth, increased appetite, constipation, weight gain, and increased sedation.

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Tricyclic antidepressants (TCAs) are an older class of antidepressants, which include imipramine, desipramine, clomipramine, nortriptyline, and amitriptyline. With the introduction of the SSRIs and alternative antidepressants, use of the TCAs has become uncommon for the treatment of depression and anxiety disorders. The TCAs have more significant side-effect profiles and require substantial medical monitoring, including the possibility of cardiac arrhythmias. Overdose can be lethal. TCAs are still used to treat medical and psychiatric issues, such as chronic pain syndromes, headache, or enuresis as well as depression, anxiety, bulimia nervosa, OCD, and PTSD. Imipramine and desipramine are FDA approved for the treatment of major depression in adults and for enuresis in children age 6 years and older. Contraindications include cardiac disease or arrhythmia, unexplained syncope, seizure disorder, family history of sudden cardiac death or cardiomyopathy, and known electrolyte abnormality (with bingeing and purging). Initial medical screening includes taking a thorough family history for sudden cardiac death and the patient's history for cardiac disease, arrhythmias, syncope, seizure disorder, or congenital hearing loss (associated with prolonged QT interval). Other screening procedures include serum electrolytes and blood urea nitrogen in patients who have eating disorders, cardiac examination, and a baseline ECG. Ongoing medical follow-up includes monitoring pulse and blood pressure (ie, screening for tachycardia and orthostatic hypotension) with each dosage increase, and obtaining an ECG to monitor for atrioventricular block with each dosage increase. After reaching steady state, record pulse, blood pressure, and ECG every 3–4 months. TCAs may potentiate the effects of central nervous system depressants and stimulants. Barbiturates and cigarette smoking may decrease plasma levels while phenothiazines, methylphenidate, and oral contraceptives may increase plasma levels. SSRIs given in combination with TCAs will result in higher TCA blood levels. Please refer to Table 7-13 on upper limits of cardiovascular parameters with tricyclic antidepressants.

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Table Graphic Jump Location
Table 7-13.Upper limits of cardiovascular parameters with tricyclic antidepressants.
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Other Considerations
++

The risk of suicide is the most significant risk associated with depressive episodes. In addition, adolescents are likely to self-medicate their feelings through substance abuse, or indulge in self-injurious behaviors such as cutting or burning themselves (without suicidal intent). School performance usually suffers during a depressive episode, as children are unable to concentrate or motivate themselves to complete homework or projects. The irritability, isolation, and withdrawal that often result from the depressive episode can lead to loss of peer relationships and tense dynamics within the family. Please refer to section on identifying and addressing suicide risk for additional information.

++

Depression often coexists with other mental illnesses such as ADHD, oppositional defiant disorder, conduct disorder, anxiety disorders, eating disorders, and substance abuse disorders. Medically ill patients also have an increased incidence of depression. Every child and adolescent with a depressed mood state should be asked directly about suicidal ideation and physical and sexual abuse. Depressed adolescents should also be screened for hypothyroidism and substance abuse.

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In 2005, the FDA issued a “black box warning” regarding suicidal thinking and behavior for all antidepressants prescribed for children and adolescents. The FDA compiled data from 24 short-term trials of 4–16 weeks that included the use of antidepressants for major depressive disorder and obsessive compulsive disorder. Across these studies, the average risk of suicidal thinking and behavior during the first few months of treatment was 4% or twice the placebo risk of 2%. No suicides occurred in these trials. Although children face an initial increased risk of suicidal thinking and behaviors during the first few months of treatment, there is now substantial evidence that antidepressant treatment, over time, is protective against suicide. For example, following the addition of the “black box warning” for all antidepressants in October 2005, a 20% decrease in prescriptions for those younger than age 20 occurred. During the same time period, there was an 18% increase in suicides. Furthermore, the suicide rates in children and adolescents were lowest in areas of the country that had the highest rate of SSRI prescriptions. This suggests best practice is to educate the family regarding both the risks and benefits of antidepressant treatment and monitor carefully for any increase in suicidal ideation or self-injurious urges, as well as improvement in target symptoms of depression, especially in the first 4 weeks and subsequent 3 months after beginning their use.

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Prognosis
++

A comprehensive treatment intervention, including psychoeducation for the family, individual and family psychotherapy, medication assessment, and evaluation of school and home environments, often leads to complete remission of depressive symptoms over a 1- to 2-month period. If medications are started and prove effective, they should be continued for 6–12 months after remission of symptoms to prevent relapse. Early-onset depression (before age 15) is associated with increased risk of recurrent episodes and the potential need for longer-term treatment with antidepressants. Education of the family and child/or adolescent will help them identify depressive symptoms sooner and decrease the severity of future episodes with earlier interventions. Some studies suggest that up to 30% of preadolescents with major depression manifest bipolar disorder at 2-year follow-up. It is important to reassess the child or adolescent with depressive symptoms regularly for at least 6 months and to maintain awareness of the depressive episode in caring for this child in the future.

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Cheung  AH  et al: GLAD PC Steering Committee Expert survey for the management of adolescent depression in primary care. Pediatrics 2008 Jan;121(1):e101–e107 PMID:
[PubMed: 18166529]
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Cheung  AH  et al: GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management. Pediatrics 2007 Nov;120(5):e1313–e1326. Erratum in: Pediatrics 2008 Jan; 121(1):227 PMID:
[PubMed: 17974724]
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Richardson  L, McCauley  E, Katon  W: Collaborative care for adolescent depression: a pilot study. Gen Hosp Psychiatry 2009 Jan–Feb;31(1):36–45 [Epub 2008 Nov 18] PMID:
[PubMed: 19134509]
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Richardson  LP  et al: Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics 2010 Dec;126(6):1117–1123 [Epub 2010 Nov 1] PMID:
[PubMed: 21041282]
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The REACH Institute, Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Toolkit: http://www.thereachinstitute.org/guidelines-for-adolescent-depression-primary-care.
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US Preventive Services Task Force Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics 2009 Apr;123(4):1223–1228. Erratum in: Pediatrics. 2009 Jun;123(6):1611 PMID:
[PubMed: 19336383]
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Williams  SB  et al: Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics 2009 Apr;123(4):e716–e735 [Review] PMID:
[PubMed: 19336361]
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Zuckerbrot  RA, Cheung  AH, Jensen  PS, Stein  REK, Laraque  D, and the GLAD-PC Steering Group: Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007 Nov;120(5):e1299–e1312 PMID:
[PubMed: 17974723]

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2. Bipolar Disorder
++

ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Periods of abnormally and persistently elevated, expansive, or irritable mood, and heightened levels of energy and activity.

  • Associated symptoms: grandiosity, diminished need for sleep, pressured speech, racing thoughts, impaired judgment.

  • Not caused by prescribed or illicit drugs.

  • The symptoms most commonly reported first are depressive symptoms.

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General Considerations
++

Bipolar disorder (previously referred to as manic-depressive disorder) is an episodic mood disorder manifested by alternating periods of mania and major depressive episodes or, less commonly, manic episodes alone. Children and adolescents often exhibit a variable course of mood instability combined with aggressive behavior and impulsivity. At least 20% of bipolar adults experience onset of symptoms before age 20 years. Onset of bipolar disorder before puberty is uncommon; however, symptoms often begin to develop and may be initially diagnosed as ADHD or other disruptive behavior disorders. The lifetime prevalence of bipolar disorder in middle to late adolescence approaches 1%.

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Identification & Diagnosis
++

In about 70% of patients, the first symptoms are primarily those of depression. In the remainder, manic, hypomanic, or mixed states dominate the presentation. Patients with mania display a variable pattern of elevated, expansive, or irritable mood along with rapid speech, high energy levels, difficulty in sustaining concentration, and a decreased need for sleep. The child or adolescent may also have hypersexual behavior. It is critical to rule out abuse, or be aware of abuse factors contributing to the clinical presentation. Patients often do not acknowledge any problem with their mood or behavior. The clinical picture can be quite dramatic, with florid psychotic symptoms of delusions and hallucinations accompanying extreme hyperactivity and impulsivity. Other illnesses on the bipolar spectrum are bipolar type II, which is characterized by recurrent major depressive episodes alternating with hypomanic episodes (lower intensity manic episodes that do not cause social impairment and do not typically last as long as manic episodes) and cyclothymic disorder, which is diagnosed when the child or adolescent has had 1 year of hypomanic symptoms alternating with depressive symptoms that do not meet criteria for major depression.

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It is also common for individuals diagnosed with bipolar spectrum disorders to have a history of inattention and hyperactivity problems in childhood, with some having a comorbid diagnosis of ADHD. While ADHD and bipolar disorder are highly comorbid, inattention and hyperactivity symptoms accompanied by mood swings can be an early sign of bipolar disorder before full criteria for the disorder have emerged and clustered together in a specific pattern.

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Differentiating ADHD, bipolar disorder, and major depressive disorder can be a challenge, and confusion about the validity of the disorder in younger children still exists. The situation is further complicated by the potential for the coexistence of ADHD and mood disorders in the same patient.

++

A history of the temporal course of symptoms can be most helpful. ADHD is typically a chronic disorder of lifelong duration. However, it may not be a problem until the patient enters the classroom setting. Mood disorders are typically characterized by a normal baseline followed by an acute onset of symptoms usually associated with acute sleep, appetite, and behavior changes. If inattentive, hyperactive, or impulsive behavior was not a problem in the previous year, it is unlikely to be ADHD. Typically, all these disorders are often heritable, so a positive family history can be informative in formulating a diagnosis. Successful treatment of relatives can offer guidance for appropriate treatment.

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In prepubescent children, mania may be difficult to differentiate from ADHD and other disruptive behavior disorders. In both children and adolescents, preoccupation with violence, decreased need for sleep, impulsivity, poor judgment, intense and prolonged rages or dysphoria, hypersexuality, and some cycling of symptoms suggest bipolar disorder. Table 7-14 further defines points of differentiation between ADHD, conduct disorder, and bipolar disorder.

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Table Graphic Jump Location
Table 7-14.Differentiating behavior disorders.
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The Young Mania Rating Scale and The Child Mania Rating Scale may be helpful in eliciting concerning symptoms and educating families and patients, and in aiding timely referral to local mental health resources.

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Children and adolescents with bipolar disorder are more likely to be inappropriate or aggressive toward peers and family members. Their symptoms almost always create significant interference with academic learning and peer relationships. The poor judgment associated with manic episodes predisposes individuals to dangerous, impulsive, and sometimes criminal activity. Legal difficulties can arise from impulsive acts, such as excessive spending, and acts of vandalism, theft, or aggression, that are associated with grandiose thoughts. Affective disorders are associated with a 30-fold greater incidence of successful suicide. Substance abuse may be a further complication, often representing an attempt at self-medication for the mood problem.

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Treatment
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Most patients with bipolar disorder respond to pharmacotherapy with either mood stabilizers, such as lithium, atypical antipsychotics, or antiepileptic drugs. Other mood stabilizers, carbamazepine and valproate, are less effective. Lithium, risperidone, aripiprazole, quetiapine, asenapine, and olanzapine have been approved by the FDA for the treatment of acute and mixed manic episodes in adolescents. In addition, lithium and aripiprazole are approved for preventing recurrence. It is recommended that primary care providers refer all patients with suspected bipolar mood disorder to a mental health provider for diagnostic clarification and treatment. In situations where bipolar mood disorder is evident, a referral to a psychiatrist is recommended. In cases of severe impairment, hospitalization is required to maintain safety and initiate treatment. Supportive psychotherapy for the patient and family and education about the recurrent nature of the illness are critical. Family therapy should also include improving skills for conflict management and appropriate expression of emotion.

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In addition to prescribing medications that have FDA approval for use in children with bipolar disorder (lithium and the atypical antipsychotic medications), providers may choose to use other medications off-label after nonresponse to first-line treatment or because of side-effect profiles. In these cases, it is recommended that a psychiatrist initiate and monitor early treatment. Once the goal of stabilization has been attained, it is reasonable for a primary care provider to provide maintenance therapy.

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Other Considerations
++

Physical or sexual abuse and exposure to domestic violence can also cause children to be mood labile, hyperactive, and aggressive, and PTSD should be considered by reviewing the history for traumatic life events in children with these symptoms. Diagnostic considerations should also include substance abuse disorders, and an acute organic process, especially if the change in personality has been relatively sudden, or is accompanied by other neurologic changes. Individuals with manic psychosis may resemble those with schizophrenia. Psychotic symptoms associated with bipolar disorder should clear with resolution of the mood symptoms, which should also be prominent. Hyperthyroidism should be ruled out.

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Prognosis
++

It is not uncommon for the patient to need lifelong medication. In its adult form, bipolar disorder is an illness with a remitting course of alternating depressive and manic episodes. The time span between episodes can be years or months depending on the severity of illness and ability to comply with medication interventions. In childhood, the symptoms may be more pervasive and not fall into the intermittent episodic pattern until after puberty.

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3. Disruptive Mood Dysregulation Disorder (DMDD)
++

ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Persistent irritability and severe behavioral outbursts at least three times a week for 1 year or more

  • The mood in between these symptoms is persistently negative (i.e., irritable, angry or sad), which is observable by others

  • The tantrums and negative moods are present in at least two settings

  • Onset of illness prior to 10 years old

  • Chronological or developmental age of at least 6 years old

  • A disruption in functioning in more than one setting (e.g., home, school and/or socially)

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General Considerations
++

DMDD is a new diagnosis in the DSM-5. Historically, many of these children would have previously been diagnosed with some variation of bipolar mood disorder. The addition of DMDD allows for an additional diagnosis in which the mainstay of treatment is not necessarily a mood stabilizer.

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Identification & Diagnosis
++

The diagnosis is based on clinical findings and there is no screening tool for this disorder. Refer to essentials of diagnosis and typical features above. In cases where symptoms overlap between DMDD and ODD, DMDD supersedes ODD.

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Treatment
++

There are no approved medications for DMDD and psychotherapy is the mainstay of treatment. Some off-label pharmacological considerations include α-agonists, medication(s) used for depression and/or bipolar mood disorder, and/or stimulants if ADHD is present.

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Other Considerations
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The differential diagnosis for DMDD is similar to other mood disorders. In addition, special attention and consideration should include screening for ADHD, anxiety, trauma, and significant interpersonal and relational deficits. Those with DMDD are at a higher risk than the general population to develop major depressive disorder and generalized anxiety disorder. With the addition of this diagnosis, researchers are now able to gather data to aid with the diagnosis, treatment, and outcome measures.

+
AACAP Facts for Families Disruptive Mood Dysregulation Disorder: http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Disruptive_Mood_Dysregulation_Disorder_DMDD_110.aspx. Accessed September 27, 2015.
+
Chang  K: Challenges in the diagnosis and treatment of pediatric bipolar depression. Dialogues Clin Neurosci 2009;11(1):73–80 PMID:
[PubMed: 19432389]
+
Cummings  CM, Fristad  MA: Pediatric bipolar disorder: recognition in primary care. Curr Opin Pediatr 2008 Oct;20(5):560–565 PMID:
[PubMed: 18781119]
+
Demeter  CA  et al: Current research in child and adolescent bipolar disorder. Dialogues Clin Neurosci 2008;10(2):215–228 PMID:
[PubMed: 18689291]
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DSM-5, 5th ed, American Psychiatric Association, May 2013.
+
Miklowitz  DJ, Chang  KD: Prevention of bipolar disorder in at-risk children: theoretical assumptions and empirical foundations. Dev Psychopathol 2008 Summer;20(3):881–897 PMID:
[PubMed: 18606036]
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Miklowitz  DJ  et al: Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry 2008 Sep;65(9):1053–1061 PMID:
[PubMed: 18762591]
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Youngstrom  EA, Birmaher  B, Findling  RL: Pediatric bipolar disorder: validity, phenomenology, and recommendations for diagnosis. Bipolar Disord 2008 Feb;10(1 Pt 2):194–214 PMID:
[PubMed: 18199237]

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SUICIDE IN CHILDREN & ADOLESCENTS

++

The suicide rate in young people has remained high for several decades. In 2007, suicide was the third leading cause of death among children and adolescents aged 10–24 years in the United States. The suicide rate among adolescents aged 15–19 years quadrupled from approximately 2.7 to 11.3 per 100,000 since the 1960s. It is estimated that each year, approximately 2 million US adolescents attempt suicide, yet only 700,000 receive medical attention for their attempt. Suicide and homicide rates for children in the United States are two to five times higher than those for the other 25 industrialized countries combined, primarily due to the prevalence of firearms in the United States. For children younger than 10 years, the rate of completed suicide is low, but from 1980 to 1992, it increased by 120%, from 0.8 to 1.7 per 100,000. Adolescent girls make three to four times as many suicide attempts as boys of the same age, but the number of completed suicides is three to four times greater in boys. Firearms are the most commonly used method in successful suicides, accounting for 40%–60% of cases; hanging, carbon monoxide poisoning, and drug overdoses each account for approximately 10%–15% of cases.

++

Suicide is almost always associated with a psychiatric disorder and should not be viewed as a philosophic choice about life or death or as a predictable response to overwhelming stress. Most commonly it is associated with a mood disorder and the hopelessness that accompanies a severe depressive episode. Suicide rates are higher for Native American and Native Alaskan populations than for white, black, and Latino/Hispanic populations. Although suicide attempts are more common in individuals with a history of behavior problems and academic difficulties, other suicide victims are high achievers who are temperamentally anxious and perfectionistic and who commit suicide impulsively after a failure or rejection, either real or perceived. Mood disorders (in both sexes, but especially in females), substance abuse disorders (especially in males), and conduct disorders are commonly diagnosed at psychological autopsy in adolescent suicide victims. Some adolescent suicides reflect an underlying psychotic disorder, with the young person usually committing suicide in response to auditory hallucinations or psychotic delusions.

++

The vast majority of young people who attempt suicide give some clue to their distress or their tentative plans to commit suicide. Most show signs of dysphoric mood (anger, irritability, anxiety, or depression). Over 60% make comments such as “I wish I were dead” or “I just can't deal with this any longer” within the 24 hours prior to death. In one study, nearly 70% of subjects experienced a crisis event such as a loss (eg, rejection by a girlfriend or boyfriend), public shaming, a failure, or an arrest prior to completed suicide. With ubiquitous social networking technologies and the presence of digital profiles, posting distress messages electronically and aggression in the form of cyber-bullying are important to identify and discuss when conducting risk assessments and gathering information about relationships, supports, and sources of stress.

++
Assessment of Suicide Risk
++

Any clinical assessment for depression must include questions about suicidal ideation. If a child or adolescent expresses suicidal thinking, the treating provider must ask if he or she has an active plan, intends to complete that plan, and has made previous attempts. Suicidal ideation accompanied by any plan warrants immediate referral for a psychiatric crisis assessment. This can usually be accomplished at the nearest emergency department (ED).

++

Assessment of suicide risk calls for a high index of suspicion and a direct interview with the patient and his or her parents or guardians. The highest risk of suicide is among white, adolescent boys. High-risk factors include previous suicide attempts, a suicide note, and a viable plan for suicide with the availability of lethal means, close personal exposure to suicide, conduct disorder, and substance abuse. Other risk factors are signs and symptoms of major depression or dysthymia, a family history of suicide, a recent death in the family, and a view of death as a relief from the pain in the patient's life.

++
Intervention
++

Suicidal ideation and any suicide attempt must be considered a serious matter. The patient should not be left alone, and the treating provider should express concern and convey a desire to help. The provider should meet with the patient and the family, both alone and together, and listen carefully to their problems and perceptions. It is helpful to explicitly state that with the assistance of mental health professionals solutions can be found.

++

The majority of patients who express suicidal ideation and all who have made a suicide attempt should be referred for psychiatric evaluation and possible hospitalization. Most providers feel uncomfortable and have little experience in evaluating suicidal risk. In addition, this evaluation frequently takes considerable time and requires contact with multiple informants for information gathering and treatment planning. The provider should err on the side of caution, as referral for further assessment is always appropriate when there is concern about suicidal thinking and behavior.

++

An evaluation in a psychiatrist's office or the ED will help determine level of risk and disposition. If the patient has suicidal ideation without a plan, has a therapist he or she can see the same or next day, is able to “contract for safety,” and the family is able to provide supervision and support, then the evaluating provider can consider sending the patient and family home that day from the office or ED without need for immediate hospitalization. If there is potential for suicide as determined by suicidal ideation with a plan, there are no available resources for therapy, and the patient is not able to cooperate with a plan to ensure safety; if the patient is severely depressed or intoxicated; if the family does not appear to be appropriately concerned; or if there are practical limitations on providing supervision and support to ensure safety, the individual should be hospitalized on an inpatient psychiatric unit. Any decision to send the patient home from the ED without hospitalization should be made only after consultation with a mental health professional. The decision should be based on lessening of the risk of suicide and assurance of the family's ability to follow through with outpatient therapy and provide appropriate support and supervision. As part of safety planning for discharge, guns, knives, and razor blades should be removed from the home, and, to the extent possible, access to them outside the home should be prohibited. Medications and over-the-counter drugs should be kept locked in a safe place with minimal opportunity of patient access (eg, key kept with a parent, or use of combination lock on the medicine chest). The patient should be restricted from driving for at least the first 24 hours or longer to lessen the chance of impulsive motor vehicle crashes. Instructions and phone numbers for crisis services should be given, and the family must be committed to a plan for mental health treatment.

++

Suicide prevention efforts include heightened awareness in the community and schools to identify at-risk individuals and increase access to services, including hotlines and counseling services. Restricting young people's access to firearms is a critical factor, as firearms are responsible for 85% of deaths due to suicide or homicide in youth in the United States.

++

Finally, the treating provider should be aware of his or her own emotional reactions to dealing with suicidal adolescents and their families. Because the assessment can require considerable time and energy, the provider should be on guard against becoming tired, irritable, or angry. Although understandable, provider fears about precipitating suicide by direct and frank discussions of suicidal risk are unfounded. Reviewing difficult cases with colleagues, developing formal or informal relationships with psychiatrists, and attending workshops on assessment and management of depression and suicidal ideation can decrease the anxiety and improve competence for primary care providers.

+
Bursztein  C, Apter  A: Adolescent suicide. Curr Opin Psychiatry 2009 Jan;22(1):1–6 PMID:
[PubMed: 19122527] .
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Carballo  JJ  et al: The role of the pediatrician in preventing suicide in adolescents with alcohol use disorders. Int J Adolesc Med Health 2007 Jan–Mar;19(1):61–65 PMID:
[PubMed: 17458325] .
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Dervic  K, Brent  DA, Oquendo  MA: Completed suicide in childhood. Psychiatr Clin North Am 2008 Jun;31(2):271–291 PMID:
[PubMed: 18439449] .
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Dudley  M  et al: New-generation antidepressants, suicide and depressed adolescents: how should clinicians respond to changing evidence? Aust N Z J Psychiatry 2008 Jun;42(6):456–466 PMID:
[PubMed: 18465372] .
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Gardner  W  et al: Screening, triage, and referral of patients who report suicidal thought during a primary care visit. Pediatrics 2010 May;125(5):945–952 [Epub 2010 Apr 12] PMID:
[PubMed: 20385642] .
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Goldstein  TR: Suicidality in pediatric bipolar disorder. Child Adolesc Psychiatr Clin N Am 2009 Apr;18(2):339–352, viii PMID:
[PubMed: 19264267] .
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Greydanus  D, Patel  D, Pratt  H: Suicide risk in adolescents with chronic illness: implications for primary care and specialty pediatric practice: a review. Dev Med Child Neurol 2010 Dec;52(12):1083–1087 [Epub 2010 Aug 31] PMID:
[PubMed: 20813018] .
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Kim  YS, Leventhal  B: Bullying and suicide. Int J Adolesc Med Health 2008 Apr–Jun;20(2):133–154 PMID:
[PubMed: 18714552]
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Prager  LM: Depression and suicide in children and adolescents. Pediatr Rev 2009 Jun;30(6):199–205; quiz 206 PMID:
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Steele  MM, Doey  T: Suicidal behaviour in children and adolescents. Part 1: etiology and risk factors. Can J Psychiatry 2007 Jun;52(6 Suppl 1):S21–S33 PMID:
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Steele  MM, Doey  T: Suicidal behaviour in children and adolescents. Part 2: treatment and prevention. Can J Psychiatry 2007 Jun;52(6 Suppl 1):S35–S45 PMID:
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Wintersteen  MB, Diamond  GS, Fein  JA: Screening for suicide risk in the pediatric emergency and acute care setting. Curr Opin Pediatr 2007 Aug;19(4):398–404 PMID:
[PubMed: 17630602] .

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CONDUCT DISORDERS

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1. Oppositional Defiant Disorder
++

ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months.

  • Loses temper, argues with adults, defies rules.

  • Blames others for own mistakes and misbehavior.

  • Angry, easily annoyed, vindictive.

  • Does not meet criteria for conduct disorder.

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General Considerations
++

Oppositional defiant disorder is more common in families where caregiver dysfunction (eg, substance abuse, parental psychopathology, significant psychosocial stress) is present. It is also more prevalent in children with a history of multiple changes in caregivers, inconsistent, harsh, or neglectful parenting, or serious marital discord.

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Identification & Diagnosis
++

Oppositional defiant disorder usually is evident before 8 years of age and may be an antecedent to the development of conduct disorder. The symptoms usually first emerge at home, but then extend to school and peer relationships. The disruptive behaviors of oppositional defiant disorder are generally less severe than those associated with conduct disorder and do not include hurting other individuals or animals, destruction of property, or theft.

++
Treatment
++

Interventions include careful assessment of the psychosocial situation and recommendations to support parenting skills and optimal caregiver functioning. Assessment for comorbid psychiatric diagnoses such as learning disabilities, depression, and ADHD should be pursued and appropriate interventions recommended.

++
2. Conduct Disorder
++

ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • A persistent pattern of behavior that includes the following:

    • Defiance of authority.

    • Violating the rights of others or society's norms.

    • Aggressive behavior toward persons, animals, or property.

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General Considerations
++

Disorders of conduct affect approximately 9% of males and 2% of females younger than 18 years. This is a very heterogeneous population, and overlap occurs with ADHD, substance abuse, learning disabilities, neuropsychiatric disorders, mood disorders, and family dysfunction. Many of these individuals come from homes where domestic violence, child abuse, drug abuse, shifting parental figures, and poverty are environmental risk factors. Although social learning partly explains this correlation, the genetic heritability of aggressive conduct and antisocial behaviors is currently under investigation.

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Identification & Diagnosis
++

The typical child with conduct disorder is a boy with a turbulent home life and academic difficulties. Defiance of authority, fighting, tantrums, running away, school failure, and destruction of property are common symptoms. With increasing age, fire-setting and theft may occur, followed in adolescence by truancy, vandalism, and substance abuse. Sexual promiscuity, sexual perpetration, and other criminal behaviors may develop. Hyperactive, aggressive, and uncooperative behavior patterns in the preschool and early school years tend to predict conduct disorder in adolescence with a high degree of accuracy, especially when ADHD goes untreated. A history of reactive attachment disorder is an additional childhood risk factor. The risk for conduct disorder increases with inconsistent and severe parental disciplinary techniques, parental alcoholism, and parental antisocial behavior.

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Treatment
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Effective treatment can be complicated by the psychosocial problems often found in the lives of children and adolescents with conduct disorders. These problems may also interfere with achieving compliance with treatment recommendations. Efforts should be made to stabilize the environment and improve functioning within the home, particularly as it relates to parental functioning and disciplinary techniques. Identification of learning disabilities and placement in an optimal school environment is critical. Any associated neurologic and psychiatric disorders should be addressed.

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Residential treatment may be necessary for individuals whose symptoms do not respond to lower level interventions, or whose environment is not able to meet their needs for supervision and structure. Juvenile justice system involvement is common in cases where conduct disorder behaviors lead to illegal activities, theft, or assault.

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Medications such as mood stabilizers, neuroleptics, stimulants, and antidepressants have all been studied in youth with conduct disorders, yet none has been found to be consistently effective. Each patient suspected of conduct disorder should be screened for other common psychiatric disorders and a history of trauma prior to the initiation of medication. Providers should use caution when prescribing various medications off-label for disruptive behavior. Early involvement in programs, such as Big Brothers, Big Sisters, scouts, and team sports, in which consistent adult mentors and role models interact with youth, decreases the chances that the youth will develop antisocial personality disorder. Multisystemic therapy (MST) is being used increasingly as an intervention for youth with conduct disorders and involvement with the legal system. MST is an intensive home-based model of care that seeks to stabilize and improve the home environment and to strengthen the support system and coping skills of the individual and family.

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Other Considerations
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Young people with conduct disorders, especially those with more violent histories, have an increased incidence of neurologic signs and symptoms, psychomotor seizures, psychotic symptoms, mood disorders, ADHD, and learning disabilities. Efforts should be made to identify these associated disorders because they may require specific therapeutic interventions. Conduct disorder is best conceptualized as a final common pathway emerging from a variety of underlying psychosocial, genetic, environmental, and neuropsychiatric conditions.

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Prognosis
++

The prognosis is based on the ability of the child's support system to mount an effective treatment intervention consistently over time. The prognosis is generally worse for children in whom the disorder presents before age 10 years; those who display a diversity of antisocial behaviors across multiple settings; and those who are raised in an environment characterized by parental antisocial behavior, alcoholism or other substance abuse, and conflict. Nearly half of individuals with a childhood diagnosis of conduct disorder develop antisocial personality disorder as adults.

++

HIGH-RISK PATIENTS AND HOMICIDE

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Aggression & Violent Behavior in Youth
++

The tragic increase in teenage violence, including school shootings, is of particular concern to health professionals, as well as to society at large. There is strong evidence that screening and initiation of interventions by primary care providers can make a significant difference in violent behavior in youth. Although the prediction of violent behavior remains a difficult and imprecise endeavor, providers can support and encourage several important prevention efforts.

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The vast majority of the increase in youth violence, including suicides and homicides, involves the use of firearms. Thus, the presence of firearms in the home, the method of storage and safety measures taken when present, and access to firearms outside the home should be explored regularly with all adolescents as part of their routine medical care.

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It is important to note that violent behavior is often associated with suicidal impulses. In the process of screening for violent behavior, suicidal ideation should not be overlooked. Any comment about wishes to be dead, or hopelessness, should be taken seriously and assessed immediately.

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Interventions for parents include encouraging parents and guardians to be aware of their child's school attendance and performance. Parents should be encouraged to take an active role and learn about their children's friends, be aware of who they are going out with, where they will be, what they will be doing, and when they will be home. Most students involved in school violence might have been identified earlier and potentially may have benefited from interventions to address problems in social and educational functioning in the school environment. Communities and school districts nationwide have increased their efforts to identify and intervene with students whom teachers, peers, or parents recognize as having difficulty.

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Threats & Warning Signs Requiring Immediate Consultation
++

Any and all threats that children make can be alarming. However, it is important to respond to the more serious and potentially lethal threats. These threats should be taken with the utmost seriousness and parents/guardians should see a mental health provider immediately. Such threats include threats/warnings about hurting or killing someone or oneself, threats to run away from home and/or threats to damage or destroy property.

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Factors Associated With Increased Risk of Violent and/or Dangerous Behavior
++

Not all threats signify imminent danger. There are several potential predictors to consider when assessing the dangers of a child or adolescent, such as past history of violence or aggressive behavior, including uncontrollable angry outbursts; access to guns or other weapons; history of getting caught with a weapon in school; and family history of violent behaviors. These are likely predictors of future violent behavior. In addition, children who witness abuse and violence at home and/or have a preoccupation with themes and acts of violence (eg, TV shows, movies, music, violent video games, etc) are also at high risk of such behavior. Victims of abuse (ie, physical, sexual, and/or emotional) are more susceptible to feeling shame, loss, and rejection. The difficulty of dealing with abuse can further exacerbate an underlying mood, anxiety, or conduct disorder. Children who have been abused are more likely to be perpetrators of bullying and engage in verbal and physical intimidation toward peers. They also may be much more prone to blame others and are unwilling to accept responsibility for their own actions. Substance use is another major factor frequently associated with violent, aggressive, and/or dangerous behavior, particularly because it impacts judgment and is often associated with decreased inhibition and increased impulsivity. Socially isolated children also carry a high risk for violent and dangerous behavior. These include children with little to no adult supervision, poor connection with peers, and little to no involvement in extracurricular activities. These individuals may be more likely to seek out deviant peer groups for a sense of belonging.

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How Providers & Parents Can Respond to Concerns of Violence and/or Dangerous Behavior
++

If a provider or parent suspects that a child is at risk for violent and/or dangerous behavior, the most important intervention is to talk with the child immediately about alleged threat and/or behavior. One should consider the child's past behavior, personality, and current stressors when evaluating the seriousness and likelihood of them engaging in a destructive or dangerous behavior. If the child already has a mental health provider, he/she should be contacted immediately. If they are not reachable, the parent(s)/guardian(s) should take the child to the closest ED for a crisis evaluation. It is always acceptable to contact local police for assistance, especially if harm to others is suspected. Another indication that warrants a crisis evaluation is if a child refuses to talk, is argumentative, responds defensively, or continues to express violent or dangerous thoughts/plans. Continuous, face-to-face adult supervision is essential while awaiting professional intervention. After evaluation, it is imperative to follow up with recommendations from mental health provider(s) to ensure safety and ongoing management.

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Barker  ED, Maughan  B: Differentiating early-onset persistent versus childhood-limited conduct problem youth. Am J Psychiatry 2009 Aug;166(8):900–908 [Epub 2009 Jul 1] PMID:
[PubMed: 19570930] .
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Boylan  K  et al: Comorbidity of internalizing disorders in children with oppositional defiant disorder. Eur Child Adolesc Psychiatry 2007 Dec;16(8):484–494 [Epub 2007 Sep 24] PMID:
[PubMed: 17896121] .
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Eyberg  SM, Nelson  MM, Boggs  SR: Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. J Clin Child Adolesc Psychol 2008 Jan;37(1):215–237 PMID:
[PubMed: 18444059] .
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Fazel  S, Doll  H, Långström  N: Mental disorders among adolescents in juvenile detention and correctional facilities: a systematic review and metaregression analysis of 25 surveys. J Am Acad Child Adolesc Psychiatry 2008 Sep;47(9):1010–1019 PMID:
[PubMed: 18664994] .
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Hamilton  SS, Armando  J: Oppositional defiant disorder. Am Fam Physician 2008 Oct 1;78(7):861–866 PMID:
[PubMed: 18841736] .
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Jensen  PS: The role of psychosocial therapies in managing aggression in children and adolescents. J Clin Psychiatry 2008;69(Suppl 4):37–42 PMID:
[PubMed: 18533767]
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Loeber  R, Burke  J, Pardini  DA: Perspectives on oppositional defiant disorder, conduct disorder, and psychopathic features. J Child Psychol Psychiatry 2009 Jan;50(1–2):13342 PMID:
[PubMed: 19220596] .
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Turgay  A: Psychopharmacological treatment of oppositional defiant disorder. CNS Drugs 2009;23(1):1–17 PMID:
[PubMed: 19062772]

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SOMATOFORM DISORDERS

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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • A symptom suggesting physical dysfunction.

  • No physical disorder accounting for the symptom.

  • Symptoms causing distress, dysfunction, or both.

  • Symptoms not voluntarily created or maintained, as in malingering.

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General Considerations
++

Conversion symptoms most often occur in school-aged children and adolescents. The exact incidence is unclear, but in pediatric practice they are probably seen more often as transient symptoms than as chronic disorders requiring help from mental health practitioners. A conversion symptom is thought to be an expression of underlying psychological conflict. The specific symptom may be symbolically determined by the underlying conflict and may resolve the dilemma created by the underlying wish or fear (eg, a seemingly paralyzed child need not fear expressing his or her underlying rage or aggressive retaliatory impulses). Hypochondriasis, somatization, and conversion disorders involve an unhealthy overemphasis and preoccupation with somatic experiences and symptoms.

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Identification & Diagnosis
++

Somatoform disorders are defined by the presence of physical illness or disability for which no organic cause can be identified, although neither the patient nor the caregiver is consciously fabricating the symptoms. The category includes body dysmorphic disorder, conversion disorder, hypochondriasis, somatization disorder, and somatoform pain disorder (Table 7-15).

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Table Graphic Jump Location
Table 7-15.Somatoform disorders in children and adolescents.
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Although children can present with a variety of symptoms, the most common include neurologic and GI complaints. Children with conversion disorder may be surprisingly unconcerned about the substantial disability deriving from their symptoms. Symptoms include unusual sensory phenomena, paralysis, vomiting, abdominal pain, intractable headaches, and movement or seizure-like disorders.

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In the classic case of conversion disorder, the child's symptoms and examination findings are not consistent with the clinical manifestations of any organic disease process. The physical symptoms often begin within the context of a family experiencing stress, such as serious illness, a death, or family discord. On closer examination, the child's symptoms are often found to resemble symptoms present in other family members.

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Treatment
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In most cases, conversion symptoms resolve quickly when the child and family are reassured that the symptom is a way of reacting to stress. The child is encouraged to continue with normal daily activities, knowing that the symptom will abate when the stress is resolved. Treatment of conversion disorders includes acknowledging the symptom rather than telling the child that the symptom is not medically justified and responding with noninvasive interventions such as physical therapy while continuing to encourage normalization of the symptoms. If the symptom does not resolve with reassurance, further investigation by a mental health professional is indicated. Comorbid diagnoses such as depression and anxiety disorders should be addressed, and treatment with psychopharmacologic agents may be helpful.

++

Somatoform disorder is not associated with the increased morbidity and mortality associated with other psychiatric disorders such as mood disorders or psychotic illness. Somatoform patients are best treated with regular, short, scheduled medical appointments to address the complaints at hand. In this way they do not need to precipitate emergencies to elicit medical attention. The medical provider should avoid invasive procedures unless clearly indicated and offer sincere concern and reassurance. The provider should also avoid telling the patient “it's all in your head” and should not abandon or avoid the patient, as somatoform patients are at great risk of seeking multiple alternative treatment providers and potentially unnecessary treatments.

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Other Considerations
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It is sometimes not possible to rule out medical disease as a source of the symptoms. Medical follow-up is required to monitor for changes in symptoms and response to recommended interventions. Somatic symptoms are often associated with anxiety and depressive disorders (see Tables 7–7 and 7–15). Occasionally, psychotic children have somatic preoccupations and even somatic delusions.

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Children with conversion disorder may have some secondary gain associated with their symptoms. Several reports have pointed to the increased association of conversion disorder with sexual overstimulation or sexual abuse. As with other emotional and behavioral problems, health care providers should always screen for physical and sexual abuse.

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Prognosis
++

Patients presenting with somatoform disorders are often resistant to mental health treatment, in part fearing that any distraction from their vigilance will put them at greater risk of succumbing to a medical illness. Psychiatric consultation is often helpful, and for severely incapacitated patients, referral psychiatric consultation is always indicated.

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Andresen  JM  et al: Physical symptoms and psychosocial correlates of somatization in pediatric primary care. Clin Pediatr (Phila) 2011 Oct;50(10):904–909 PMID:
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Campo  JV  et al: Physical and emotional health of mothers of youth with functional abdominal pain. Arch Pediatr Adolesc Med 2007 Feb;161(2):131–137 PMID:
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Ginsburg  GS, Riddle  MA, Davies  M: Somatic symptoms in children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 2006 Oct;45(10):1179–1187 PMID:
[PubMed: 17003663] .
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Goldbeck  L, Bundschuh  S: Illness perception in pediatric somatization and asthma: complaints and health locus of control beliefs. Child Adolesc Psychiatry Ment Health 2007 Jul 16;1(1):5 PMID:
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Kozlowska  K  et al: A conceptual model and practice framework for managing chronic pain in children and adolescents. Harv Rev Psychiatry 2008;16(2):136–150 PMID:
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Kozlowska  K  et al: Conversion disorder in Australian pediatric practice. J Am Acad Child Adolesc Psychiatry 2007 Jan;46(1):68–75 PMID:
[PubMed: 17195731] .
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Masia  WC  et al: CBT for anxiety and associated somatic complaints in pediatric medical settings: an open pilot study. J Clin Psychol Med Settings 2009 Jun;16(2):169–177 PMID:
[PubMed: 19152057] .
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Mulvaney  S  et al: Trajectories of symptoms and impairment for pediatric patients with functional abdominal pain: a 5-year longitudinal study. J Am Acad Child Adolesc Psychiatry 2006 Jun;45(6):737–744 PMID:
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Plioplys  S  et al: Multidisciplinary management of pediatric non-epileptic seizures. J Am Acad Child Adolesc Psychiatry 2007 Nov;46(11):1491–1495 PMID:
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Seshia  SS, Phillips  DF, von Baeyer  CL: Childhood chronic daily headache: a biopsychosocial perspective. Dev Med Child Neurol 2008 Jul;50(7):541–545 PMID:
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Walker  LS  et al: Appraisal and coping with daily stressors by pediatric patients with chronic abdominal pain. J Pediatr Psychol 2007 Mar;32(2):206–216 PMID:
[PubMed: 16717138] .

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ADJUSTMENT DISORDERS

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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • The precipitating event or circumstance is identifiable.

  • The symptoms have appeared within 3 months after the occurrence of the stressful event.

  • Although the child experiences distress or some functional impairment, the reaction is not severe or disabling.

  • The reaction does not persist more than 6 months after the stressor has terminated.

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General Considerations
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The most common and most disturbing stressors in the lives of children and adolescents are the death of a loved one, marital discord, separation and divorce, family illness, a change of residence or school setting, experiencing a traumatic event, and, for adolescents, peer-relationship problems. These stressors naturally have a significant impact on children and adolescents.

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Identification & Diagnosis
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When faced with stress, children can experience many different symptoms, including changes in mood, changes in behavior, anxiety symptoms, and physical complaints. When the reaction is significantly out of proportion to the stressor and a decline in functioning is noted, a diagnosis of adjustment disorder is highly suspected. The two main categories of adjustment disorders include disturbance in emotions (ie, depression and anxiety) and/or conduct.

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Treatment
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The mainstay of treatment involves genuine empathy and assurance to the parents and the patient that the emotional or behavioral change is a predictable consequence of the stressful event. This validates the child's reaction and encourages the child to talk about the stressful occurrence and its aftermath. Parents are encouraged to help the child with appropriate expression of feelings, while defining boundaries for behavior that prevent the child from feeling out of control and ensure safety of self and others. Maintaining or reestablishing routines can also alleviate distress and help children and adolescents adjust to changing circumstances by increasing predictability and decreasing distress about the unknown.

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Other Considerations
++

When symptoms emerge in reaction to an identifiable stressor but are severe, persistent, or disabling, depressive disorder, anxiety disorder, and conduct disorders must be considered.

++
Prognosis
++

The duration of symptoms in adjustment reactions depends on the severity of the stress; the child's personal sensitivity to stress and vulnerability to anxiety, depression, and other psychiatric disorders; and the available support system.

++

PSYCHOTIC DISORDERS

++

ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Delusional thoughts

  • Disorganized speech (rambling or illogical speech patterns)

  • Disorganized or bizarre behavior

  • Hallucinations (auditory, visual, tactile, olfactory)

  • Paranoia, ideas of reference

  • Negative symptoms (ie, flat affect, avolition, alogia)

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General Considerations
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The incidence of schizophrenia is about 1 per 10,000 per year. The onset of schizophrenia is typically between the middle to late teenage and early 30s. Symptoms usually begin after puberty, although a full “psychotic break” may not occur until the young adult years. Childhood onset (before puberty) of psychotic symptoms due to schizophrenia is uncommon and usually indicates a more severe form of the spectrum of schizophrenic disorders. Childhood-onset schizophrenia is more likely to be found in boys.

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Schizophrenia has a strong genetic component. Other psychotic disorders that may be encountered in childhood or adolescence include schizoaffective disorder and psychosis not otherwise specified (psychosis NOS). Psychosis NOS may be used as a differential diagnosis when psychotic symptoms are present, but the cluster of symptoms is not consistent with a schizophrenia diagnosis.

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Identification & Diagnosis
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Children and adolescents display many of the symptoms of adult schizophrenia. Hallucinations or delusions, bizarre and morbid thought content, and rambling and illogical speech are typical. Affected individuals tend to withdraw into an internal world of fantasy and may then equate fantasy with external reality. They generally have difficulty with schoolwork and with family and peer relationships. Adolescents may have a prodromal period of depression prior to the onset of psychotic symptoms. The majority of patients with childhood-onset schizophrenia have had nonspecific psychiatric symptoms or symptoms of delayed development for months or years prior to the onset of their overtly psychotic symptoms.

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Obtaining a family history of mental illness is critical when assessing children and adolescents with psychotic symptoms. Psychological testing, particularly the use of projective measures, is often helpful in identifying or ruling out psychotic thought processes. Psychotic symptoms in children younger than age 8 years must be differentiated from manifestations of normal vivid fantasy life or abuse-related symptoms. Children with psychotic disorders often have learning and attention disabilities in addition to disorganized thoughts, delusions, and hallucinations. In psychotic adolescents, mania is differentiated by high levels of energy, excitement, and irritability. Any child or adolescent exhibiting new psychotic symptoms requires a medical evaluation that includes physical and neurologic examinations (including consideration of magnetic resonance imaging and electroencephalogram), drug screening, and metabolic screening for endocrinopathies, Wilson disease, and delirium.

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Treatment
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The treatment of childhood and adolescent schizophrenia focuses on four main areas: (1) decreasing active psychotic symptoms, (2) supporting development of social and cognitive skills, (3) reducing the risk of relapse of psychotic symptoms, and (4) providing support and education to parents and family members. Antipsychotic medications (neuroleptics) are the primary psychopharmacologic intervention. In addition, a supportive, reality-oriented focus in relationships can help to reduce hallucinations, delusions, and frightening thoughts. In situations where psychosis is evident, a referral to a psychiatrist is recommended. In cases of severe impairment, hospitalization is required to maintain safety and initiate treatment. A special school or day treatment environment may be necessary, depending on the child's or adolescent's ability to tolerate the school day and classroom activities. Support for the family emphasizes the importance of clear, focused communication and an emotionally calm climate in preventing recurrences of overtly psychotic symptoms.

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Special Considerations Regarding the Use of Antipsychotic Medication
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While it is the expected that a psychiatrist initiate treatment, primary care providers undoubtedly treat children on antipsychotics and should become familiar with management and potential common and severe side effects of this class of medication. The “atypical antipsychotics” differ from conventional antipsychotics in their receptor specificity and effect on serotonin receptors. Conventional antipsychotics are associated with a higher incidence of movement disorders and extrapyramidal symptoms due to their wider effect on dopamine receptors. The atypical antipsychotics have a better side-effect profile for most individuals and comparable efficacy for the treatment of psychotic symptoms and aggression. Because of their increased use over conventional antipsychotics, the information that follows primarily focuses on safe use of atypical antipsychotics.

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Common adverse effects of the atypical antipsychotics are cognitive slowing, sedation, orthostasis, and weight gain. Most side effects tend to be dose related. Less frequent, but important side effects are development of type 2 diabetes and change in lipid and cholesterol profile. The risk-benefit ratio of the medication for the identified target symptom should be carefully considered and reviewed with the parent or guardian. Providers should obtain baseline height, weight, and waist circumference, observe and examine for tremors and other abnormal involuntary movements, and establish baseline values for CBC and LFTs, lipid profile, and cholesterol. Antipsychotics can cause QT prolongation leading to ventricular arrhythmias. Therefore, it is important to obtain an ECG if there is a history of cardiac disease or arrhythmia. Medications that affect the cytochrome P-450 isoenzyme pathway (including SSRIs) may increase the neuroleptic plasma concentration and increase risk of QTc prolongation.

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In addition to the above concerns, postmarketing clinical use has demonstrated significant reports of hyperglycemia, and diabetes mellitus. Table 7-16 presents the currently recommended monitoring calendar. Baseline and ongoing evaluations of significant markers are considered standard clinical practice. It is important to mention other side effects, which include irregular menses, gynecomastia, and galactorrhea due to increased prolactin, sexual dysfunction, photosensitivity, rashes, lowered seizure threshold, hepatic dysfunction, and blood dyscrasias.

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Table Graphic Jump Location
Table 7-16.Health monitoring and antipsychotics.
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Other troublesome side effects of antipsychotics include dystonia, akathisia (characterized by an urge to be in constant motion and difficulty sitting still), pseudoparkinsonism, and tardive dyskinesia (TD). These side effects typically occur in a stepwise fashion and are also dose related. The first three are reversible and typically are relieved by anticholinergic agents, such as benztropine (Cogentin) and diphenhydramine, or β-blockers, specifically for akathisia. The risk of TD is small in patients on atypical antipsychotics, and those on conventional antipsychotics for less than 6 months. There is no universally effective treatment. Withdrawal dyskinesias are reversible movement disorders that appear following withdrawal of neuroleptic medications. Dyskinetic movements develop within 1–4 weeks after withdrawal of the drug and may persist for months.

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A severe side effect of antipsychotics is neuroleptic malignant syndrome (NMS). NMS is a very rare medical emergency associated primarily with the conventional antipsychotics, although it has also been reported with atypical antipsychotics. It is manifested by severe muscular rigidity, mental status changes, fever, autonomic lability, and myoglobinemia. NMS can occur without muscle rigidity in patients taking atypical antipsychotics and should be considered in the differential diagnosis of any patient on antipsychotics who presents with high fever and altered mental status. Mortality as high as 30% has been reported. Treatment includes immediate medical assessment and withdrawal of the neuroleptic and may require transfer to an intensive care unit.

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The patient should be examined at least every 3 months for side effects, including observation for TD using the Abnormal Involuntary Movement Scale quarterly monitoring of blood pressure, weight gain, abdominal circumference, dietary and exercise habits, and, if indicated, fasting blood glucose and lipid panels. In cases of significant weight gain or abnormal laboratory values, patients should either be switched to an agent with a decreased risk for these adverse events or should receive specific treatments for the adverse events when discontinuation of the offending agent is not possible. In general, a child and adolescent psychiatrist should evaluate children with psychosis, initiate treatment and refer back to the pediatrician once symptoms are adequate control.

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Other Considerations
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Antipsychotics are also used for acute mania and as adjuncts to antidepressants in the treatment of psychotic depression (with delusions or hallucinations). Antipsychotics may also be used cautiously in refractory PTSD, in refractory OCD, and in individuals with markedly aggressive behavioral problems unresponsive to other interventions. In some instances, they may be useful for the body image distortion and irrational fears about food and weight gain associated with anorexia nervosa.

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Prognosis
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Schizophrenia is a chronic disorder with exacerbations and remissions of psychotic symptoms. Generally, earlier onset (prior to age 13 years), poor premorbid functioning (oddness or eccentricity), and predominance of negative symptoms (withdrawal, apathy, or flat affect) over positive symptoms (hallucinations or paranoia) predict more severe disability, while later age of onset, normal social and school functioning prior to onset, and predominance of positive symptoms are associated with better outcomes and life adjustment to the illness.

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There is a handout for monitoring the side effects of atypical antipsychotics available at: http://webspace.psychiatry.wisc.edu/walaszek/geropsych/docs/atypical-antipsychotic.doc.

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OTHER PSYCHIATRIC CONDITIONS

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Several psychiatric conditions are covered elsewhere in this book. Refer to the following chapters for detailed discussion:

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  • Attention-deficit/hyperactivity disorder (ADHD): see Chapter 3.

  • Autism and pervasive developmental disorders: see Chapter 3.

  • Enuresis and encopresis: see Chapter 3.

  • Eating disorders: see Chapter 6.

  • Intellectual disability/mental retardation: see Chapter 3.

  • Substance abuse: see Chapter 5.

  • Sleep disorders: see Chapter 3.

  • Tourette syndrome and tic disorders: see Chapter 25.

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