What is the Epidemiology of Child Psychiatric Disorders?

Introduction

The epidemiology of child psychiatric disorders is the study of the incidence, prevalence, and distribution of conditions in child and adolescent psychiatry.

Subfields of paediatric psychiatric epidemiology include developmental epidemiology, which focuses on the genetic and environmental causes of child psychiatric disorders. The field of paediatric psychiatric epidemiology finds widely varying rates of childhood psychiatric disorders, depending on study population, diagnostic method, and cultural setting.

Prevalence of Mental Illness

Epidemiological research has shown that between 3% and 18% of children have a psychiatric disorder causing significant functional impairment (reasons for these widely divergent prevalence rates are discussed below) and Costello and colleagues have proposed a median prevalence estimate of 12%. Using a different statistical method, Waddell and colleagues propose a prevalence rate for all mental disorders in children of 14.2%.

Developmental Epidemiology

Developmental epidemiology seeks to “disentangle how the trajectories of symptoms, environment, and individual development intertwine to produce psychopathology”.

Socio-Economic Influences

Mental illness in childhood and adolescence is associated with parental unemployment, low family income, being on family income assistance, lower parental educational level, and single-parent, blended or stepparent families.

Methodological Issues

Epidemiological research has produced widely divergent estimates, depending on the nature of the diagnostic method (e.g. structured clinical interview, unstructured clinical interview, self-report or parent-report questionnaire), but more recent studies using DSM-IV-based structured interviews produce more reliable estimates of clinical “caseness”. Past research has also been limited by inconsistent definitions of clinical disorders, and differing upper and lower age limits of the study population. Changing definitions over time have given rise to spurious evidence of changing prevalence of disorders. Furthermore, almost all epidemiological surveys have been carried out in Europe, North America and Australia, and the cross-cultural validity of DSM criteria have been questioned, so it is not clear to what extent the published data can be generalised to developing countries.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Epidemiology_of_child_psychiatric_disorders >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What are Adverse Childhood Experiences?

Introduction

Adverse childhood experiences (ACEs) encompass various forms of physical and emotional abuse, neglect, and household dysfunction experienced in childhood.

ACEs have been linked to premature death as well as to various health conditions, including those of mental disorders. Toxic stress linked to childhood maltreatment is related to a number of neurological changes in the structure of the brain and its function. The Adverse Childhood Experiences Study, published in 1998, was the first large scale study to look at the relationship between ten categories of adversity in childhood and health outcomes in adulthood. Subsequent research is beginning to identify specific biomarkers associated with different kinds of ACEs.

Long Term Effects

According to the Centre for Youth Wellness website:

“Exposure without a positive buffer, such as a nurturing parent or caregiver, can lead to a Toxic Stress Response in children, which can, in turn, lead to health problems like asthma, poor growth and frequent infections, as well as learning difficulties and behavioral issues. In the long term, exposure to ACEs can also lead to serious health conditions like heart disease, stroke, and cancer later in life.”

Adverse childhood experiences can alter the structural development of neural networks and the biochemistry of neuroendocrine systems (i.e. how the brain regulates the hormonal activity in the body) and may have long-term effects on the body, including speeding up the processes of disease and aging and compromising immune systems.

Adverse childhood experiences are equal to various stresses, and a serious adversity is defined as a trauma. The World Health Organisation (WHO) recognises that prolonged stress in childhood can have life-long implications for the development of many diseases. Moreover, ACEs can disrupt early brain development leading to the possible development of several disorders. WHO has designed a screening questionnaire to be used internationally in order to list adverse effects, and relate them to future developments.

The effects of ACEs goes beyond health and risk taking behaviours with studies reporting that people with high ACEs scores showed less trust in government COVID-19 information and polices.

Health Outcomes in Adulthood

Physical Health

ACEs have been linked to numerous negative health and lifestyle issues into adulthood across multiple countries and regions including the United States, the European Union, South Africa, and Asia. Across all these groups researchers have reported seeing the adoption of higher rates of unhealthy lifestyle behaviour including sexual risk taking, smoking, heavy drinking, and obesity. The associations between these lifestyle issues and ACEs shows a dose response relationship with people having four or more ACEs have significantly more of these lifestyle problems. Physical health problems arise in people with ACEs with a similar dose response relationship. Chronic illnesses such as asthma, arthritis, cardiovascular disease, cancer, diabetes, stroke, and migraines show increased symptom severity in step was exposure to ACEs.

Mental Health

Mental health issues have been well know in the face of childhood trauma. Exposure to ACEs is no different with multiple mental health conditions found to have a dose response relationship with symptom severity and prevalence – including depression, attention-deficit hyperactivity disorder (ADHD), anxiety, suicidality, bipolar disorder and schizophrenia.

Special Populations

Additionally, epigenetic transmission may occur due to stress during pregnancy or during interactions between mother and newborns. Maternal stress, depression, and exposure to partner violence have all been shown to have epigenetic effects on infants.

Implementing Practices

Globally knowledge about the prevalence and consequences of adverse childhood experiences has shifted policy makers and mental health practitioners towards increasing, trauma-informed and resilience-building practices. This work has been over 20 years in the making bringing together research are implemented in communities, education settings, public health departments, social services, faith-based organisations and criminal justice.

Communities

As knowledge about the prevalence and consequences of ACEs increases, more communities seek to integrate trauma-informed and resilience-building practices into their agencies and systems. Indigenous populations show similar patterns of mental and physical health challenges as other minority groups. Interventions have been developed in American Indian tribal communities and have demonstrated that social support and cultural involvement can ameliorate the negative physical health effects of ACEs.

There is a paucity of empirical research documenting the experiences of communities who have attempted to implement information about ACEs and trauma-informed practice into widespread public action. The Matlin et al. (2019) article on Pottstown, Pennsylvania’s process demonstrated the challenges associated with community implementation. The Pottstown Trauma-Informed Community Connection (PTICC) initiative evolved from a series of prior collectives that all had similar goals of creating community resilience in order to prevent and treat ACEs. Over the course of the two-year study, over 230 individuals from nearly 100 organisations attended one training offered by the PTICC, raising the number of engaged public sectors from 2 to 14. Participation in training and events was fairly steady and this was largely due to community networking.

However, the PTICC faced several challenges similar to those predicted by the Building Community Resilience model. These barriers included availability of resources over time, competition for power within the group, and the lack of systemic change needed to support long-term goals. Still, Pottstown has built a trauma-informed community foundation and offers lessons to other communities who have similar goals: start with a dedicated small team, identify community connectors, secure long-term financial backing, and conduct data-informed evaluations throughout.

Other community examples exist, such as Tarpon Springs, Florida which became the first trauma-informed community in 2011. Trauma-informed initiatives in Tarpon Springs include trauma-awareness training for the local housing authority, changes in programs for ex-offenders, and new approaches to educating students with learning difficulties.

Education

ACEs exposure is widespread globally, one study from the National Survey of Children’s Health in the United States reported that approximately 68% of children 0-17 years old had experienced one or more ACEs. The impact of ACEs on children can manifest in difficulties focusing, self regulating, trusting others, and can lead to negative cognitive effects. One study found that a child with 4 or more ACEs was 32 times more likely to be labelled with a behavioural or cognitive problem than a child with no ACEs. Another study by the Area Health Education Centre of Washington State University found that students with at least three ACEs are three times as likely to experience academic failure, six times as likely to have behavioural problems, and five times as likely to have attendance problems. The trauma-informed school movement aims to train teachers and staff to help children self-regulate, and to help families that are having problems that result in children’s normal response to trauma. It also seeks to provide behavioural consequences that will not re-traumatize a child.

Trauma-informed education refers to the specific use of knowledge about trauma and its expression to modify support for children to improve their developmental success. The National Child Traumatic Stress Network (NCTSN) describes a trauma-informed school system as a place where school community members work to provide trauma awareness, knowledge and skills to respond to potentially negative outcomes following traumatic stress. The NCTSN published a study that discussed the ARC (attachment, regulation and competency) model, which other researchers have based their subsequent studies of trauma-informed education practices on. Trauma-sensitive or trauma-informed schooling has become increasingly popular in Washington, Massachusetts, and California in the last 10 years.

Social Services

Social service providers – including welfare systems, housing authorities, homeless shelters, and domestic violence centres – are adopting trauma-informed approaches that help to prevent ACEs or minimize their impact. Utilising tools that screen for trauma can help a social service worker direct their clients to interventions that meet their specific needs. Trauma-informed practices can also help social service providers look at how trauma impacts the whole family.

Trauma-informed approaches can improve child welfare services by:

  • Openly discussing trauma; and
  • Addressing parental trauma.

The New Hampshire Division for Children Youth and Families (DCYF) is taking a trauma-informed approach to their foster care services by educating staff about childhood trauma, screening children entering foster care for trauma, using trauma-informed language to mitigate further traumatisation, mentoring birth parents and involving them in collaborative parenting, and training foster parents to be trauma-informed.

Housing authorities are also becoming trauma-informed. Supportive housing can sometimes recreate control and power dynamics associated with clients’ early trauma. This can be reduced through trauma-informed practices, such as training staff to be respectful of clients’ space by scheduling appointments and not letting themselves into clients’ private spaces, and also understanding that an aggressive response may be trauma-related coping strategies. Up to 50% of people with housing insecurity experienced at least four ACEs.

Health Care Services

Screening for or talking about ACEs with parents and children can help to foster healthy physical and psychological development and can help doctors understand the circumstances that children and their parents are facing. By screening for ACEs in children, paediatric doctors and nurses can better understand behavioural problems. Some doctors have questioned whether some behaviours resulting in ADHD diagnoses are in fact reactions to trauma. Children who have experienced four or more ACEs are three times as likely to take ADHD medication when compared with children with less than four ACEs. Screening parents for their ACEs allows doctors to provide the appropriate support to parents who have experienced trauma, helping them to build resilience, foster attachment with their children, and prevent a family cycle of ACEs.

Public Health

Objections to screening for ACEs include the lack of randomised controlled trials that show that such measures can be used to actually improve health outcomes, the scale collapses items and has limited item coverage, there are no standard protocols for how to use the information gathered, and that revisiting negative childhood experiences could be emotionally traumatic. Other obstacles to adoption include that the technique is not taught in medical schools, is not billable, and the nature of the conversation makes some doctors personally uncomfortable. Some public health centres see ACEs as an important way (especially for mothers and children) to target health interventions for individuals during sensitive periods of development early in their life, or even in utero.

Resilience and Resources

Resilience is the ability to adapt or cope in the face of significant adversity and threats such as health problems, stressors experienced in the workplace or home. Resiliency can moderate the relationship of the effects of ACEs and health problem in adulthood. Being able use emotion regulation resources such as cognitive reappraisal and mindfulness people are able to protect themselves from the potential negative effects of stressors, these skills can be taught to people but people living with ACEs score lower on measures of resilience and emotion regulation.

Resilience and access to other resources are protective factors against the effects of exposure to ACEs. Increasing resilience in children can help provide a buffer for those who have been exposed to trauma and have a higher ACE score. People and children who have fostered resiliency have the skills and abilities to embrace behaviours that can foster growth. In childhood, resiliency and attachment security can be fostered from having a caring adult in a child’s life.

Adverse Childhood Experiences Study

The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by the US health maintenance organisation Kaiser Permanente and the Centres for Disease Control and Prevention that was originally published in the American Journal of Preventive Medicine. Participants were recruited to the study between 1995 and 1997 and have since been in long-term follow up for health outcomes. The study has demonstrated an association of ACEs with health and social problems across the lifespan. The study has produced many scientific articles and conference and workshop presentations that examine ACEs.

In the 1980s, the dropout rate of participants at Kaiser Permanente’s obesity clinic in San Diego, California, was about 50%; despite all of the dropouts successfully losing weight under the program. Vincent Felitti, head of Kaiser Permanente’s Department of Preventive Medicine in San Diego, conducted interviews with people who had left the programme, and discovered that a majority of 286 people he interviewed had experienced childhood sexual abuse. The interview findings suggested to Felitti that weight gain might be a coping mechanism for depression, anxiety, and fear.

Felitti and Robert Anda from the Centres for Disease Control and Prevention (CDC) went on to survey childhood trauma experiences of over 17,000 Kaiser Permanente patient volunteers. The 17,337 participants were volunteers from approximately 26,000 consecutive Kaiser Permanente members. About half were female; 74.8% were white; the average age was 57; 75.2% had attended college; all had jobs and good health care, because they were members of the Kaiser health maintenance organisation. Participants were asked about different types of adverse childhood experiences that had been identified in earlier research literature:

  • Physical abuse.
  • Sexual abuse.
  • Emotional abuse.
  • Physical neglect.
  • Emotional neglect.
  • Exposure to domestic violence.
  • Household substance abuse.
  • Household mental illness.
  • Parental separation or divorce.
  • Incarcerated household member.

Findings

According to the United States’ Substance Abuse and Mental Health Services Administration, the ACE study found that:

  • Adverse childhood experiences are common.
    • For example, 28% of study participants reported physical abuse and 21% reported sexual abuse.
    • Many also reported experiencing a divorce or parental separation, or having a parent with a mental and/or substance use disorder.
  • Adverse childhood experiences often occur together.
    • Almost 40% of the original sample reported two or more ACEs and 12.5% experienced four or more.
    • Because ACEs occur in clusters, many subsequent studies have examined the cumulative effects of ACEs rather than the individual effects of each.
  • Adverse childhood experiences have a dose-response relationship with many health problems.
    • As researchers followed participants over time, they discovered that a person’s cumulative ACEs score has a strong, graded relationship to numerous health, social, and behavioural problems throughout their lifespan, including substance use disorders.
    • Furthermore, many problems related to ACEs tend to be comorbid, or co-occurring.
ACE Pyramid
The ACE Pyramid represents the conceptual framework for the ACE Study, which has uncovered how adverse childhood experiences are strongly related to various risk factors for disease throughout the lifespan, according to the CDC.

About two-thirds of individuals reported at least one adverse childhood experience; 87% of individuals who reported one ACE reported at least one additional ACE. The number of ACEs was strongly associated with adulthood high-risk health behaviours such as smoking, alcohol and drug abuse, promiscuity, and severe obesity, and correlated with ill-health including depression, heart disease, cancer, chronic lung disease and shortened lifespan. Compared to an ACE score of zero, having four adverse childhood experiences was associated with a seven-fold (700%) increase in alcoholism, a doubling of risk of being diagnosed with cancer, and a four-fold increase in emphysema; an ACE score above six was associated with a 30-fold (3000%) increase in attempted suicide.

The ACE study’s results suggest that maltreatment and household dysfunction in childhood contribute to health problems decades later. These include chronic diseases – such as heart disease, cancer, stroke, and diabetes – that are the most common causes of death and disability in the United States. These findings are important because they provided a link between the effects of child maltreatment and negative effects later in life which had not been established as clearly before this study.

Subsequent Surveys

The ACE Study has produced more than 50 articles that look at the prevalence and consequences of ACEs. It has been influential in several areas. Subsequent studies have confirmed the high frequency of adverse childhood experiences.

The original study questions have been used to develop a 10-item screening questionnaire. Numerous subsequent surveys have confirmed that adverse childhood experiences are frequent.

The Behavioural Risk Factor Surveillance System (BRFSS) which is ran by the CDC, is an annual survey conducted in waves by groups of individual state and territory health departments.. An expanded ACE survey instrument was included in several US states found each state. Adverse childhood experiences were even more frequent in studies in urban Philadelphia and in a survey of young mothers (mostly younger than 19). Surveys of adverse childhood experiences have been conducted in multiple EU member countries.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Adverse_childhood_experiences >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is the Adverse Childhood Experiences International Questionnaire?

Introduction

Adverse Childhood Experiences International Questionnaire (ACE-IQ) is a World Health Organisation (WHO), 43-item screening questionnaire.

Purpose

It is intended to measure:

  • Types of child abuse or trauma;
  • Neglect;
  • Household dysfunction;
  • Peer violence;
  • Sexual and emotional abuse; and
  • Exposure to community and collective violence.

Who is it For?

ACE-IQ is meant to be administered to people 18 years or older in all countries, and is currently undergoing validation testing.

What is Parentification?

Introduction

Parentification is the process of role reversal whereby a child is obliged to act as parent to their own parent or sibling. In extreme cases, the child is used to fill the void of the alienating parent’s emotional life.

Two distinct types of parentification have been identified technically: instrumental parentification and emotional parentification.

  • Instrumental parentification involves the child completing physical tasks for the family, such as looking after a sick relative, paying bills, interpreting foreign language, or providing assistance to younger siblings that would normally be provided by a parent.
  • Emotional parentification occurs when a child or adolescent must take on the role of a confidante or mediator for (or between) parents or family members.

Background

Melitta Schmideberg noted in 1948 how emotional deprivation could lead parents to treat their children (unconsciously) as substitute parent figures. “Spousification” and “parental child” (Minuchin) offered alternative concepts exploring the same phenomenon; while the theme of intergenerational continuity in such violations of personal boundaries was further examined. Eric Berne touched on the dangers of parents and children having a symmetrical, rather than asymmetrical relationship, as when an absent spouse is replaced by the eldest child; and Virginia Satir wrote of “the role-function discrepancy…where the son gets into a head-of-the-family role, commonly that of the father”.

Object relations theory highlighted how the child’s false self is called into being when it is forced prematurely to take excessive care of the parental object; and John Bowlby looked at what he called “compulsive caregiving” among the anxiously attached, as a result of a parent inverting the normal relationship and pressuring the child to be an attachment figure for them.

All such aspects of disturbed and inverted parenting patterns have been drawn under the umbrella of the wider phenomenon of parentification – with the result (critics suggest) that on occasion “ironically the concept of parentification has…been as over-burdened as the child it often describes”

Choice of Child

For practical reasons, elder children are generally chosen for the familial “parental” role – very often the first-born children who were put in the anomalous role. However, gender considerations mean that sometimes the eldest boy or eldest girl was selected, even if they are not the oldest child overall, for such reasons as the preference to match the sex of the missing parent.

Thus where there is a disabled child in the family to be cared for, “older siblings, especially girls, are at the greatest risk of parentification”; where a father-figure is missing, it may be the eldest son who is forced to take on his father’s responsibilities, without ever obtaining the autonomy that normally accompanies such adult roles.

Alternatively a widower may put a daughter into the social and emotional role of his deceased wife – “spousification”; or a mother can oblige her daughter to play the caring role, in a betrayal of the child’s normal expectation of love and care

Narcissistic

Narcissistic parentification occurs when a child is forced to take on the parent’s idealised projection, something which encourages a compulsive perfectionism in the child at the expense of their natural development. In a kind of pseudo-identification, the child is induced by any and all means to take on the characteristics of the parental ego ideal – a pattern that has been detected in western culture since Homer’s description of the character of Achilles.

Disadvantages

The almost inevitable byproduct of parentification is losing one’s own childhood. In destructive parentification, the child in question takes on excessive responsibility in the family, without their caretaking being acknowledged and supported by others: by adopting the role of parental care-giver, the child loses their real place in the family unit and is left lonely and unsure. In extreme instances, there may be what has been called a kind of disembodiment, a narcissistic wound that threatens one’s basic self-identity.

In later life, parentified children often experience anxiety over abandonment and loss, and demonstrate difficulty handling rejection and disappointment within interpersonal relationships.

Case Studies

  • Carl Jung in his late autobiography reports that his mother always spoke to him as an adult, confiding in him what she could not share with her husband. Laurens van der Post commented on the grown-up atmosphere surrounding the young Jung, and considered that “this activation of the pattern of the “old man” within himself…was all a consequence of the extent to which his father and mother failed each other”.
  • Patrick Casement reports on a patient – Mr T – whose mother was distressed at any and all his feelings, and who therefore protected her from them – mothering her himself.

Literary Examples

The Tale of Genji tells that for “Kaoru’s mother…her son’s visits were her chief pleasure. Sometimes he almost seemed more like a father than a son – a fact which he was aware of and thought rather sad”.

Charles Dickens’ “Angel in the house” characters, particularly Agnes Wickfield in David Copperfield, are parentified children. Agnes is forced to be the parent of her alcoholic father and seems to strive for perfection as a means of reaching the “ego ideal” of her deceased mother (who died upon child-birth). Agnes marries late, has relationship and intimacy problems (she has a hard time expressing her love for David until he reveals his own love for her), and has some self-defeating attitudes; in one scene she blames her own father’s misfortunes on herself. However, she proves to be resilient, resourceful, responsible and even potentially career-driven (she forms her own school). She also manages to marry the protagonist David and the two live happily together for 10 years with children by the end of the novel.

The theme of parentification has also been explored in the Twilight series, with particular but not exclusive reference to the character of Bella Swan.

An Overview of Bipolar Disorder in Children

Introduction

Bipolar disorder in children, or paediatric bipolar disorder (PBD), is a controversial mental disorder in children and adolescents that is mainly diagnosed in the United States, and is hypothesized to be like bipolar disorder (BD) in adults, thus is proposed as an explanation for extreme changes in mood and behaviour accompanying periods of depressed or irritable moods and periods of elevated moods so called manic or hypomanic episodes.

These shifts are sometimes quick, but usually are gradual. The average age of onset of paediatric bipolar disorder is unclear, but the risk increases with the onset of puberty. Bipolar disorder is rare in childhood. Paediatric bipolar disorder is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

The DSM has specified that the criteria for bipolar disorder can be applied to children since 1980. However, the exact criteria for diagnosing paediatric bipolar disorder remains controversial and heavily debated. There are big differences in how commonly it is diagnosed across clinics and in different countries. There has been a rapid increase in research on the topic, but training and clinical practice lag behind.

Identifying bipolar disorder in youth is challenging. Children often exhibit chronic rather than episodic mania periods. Almost always, these chronic problems have causes other than bipolar disorder. The criteria for paediatric bipolar disorder can also often be masked by developmental differences. Comorbid disorders make determining what symptoms are signs of bipolar disorder and which are due to other disorders (e.g. OCD, ADHD, disruptive behaviour problems) difficult, leading to complications in treatment. For example, a common treatment for OCD are serotonin re-uptake inhibitors (SRIs), however, SRIs can lead to mood instability and worsening bipolar disorder.[5] The most common misdiagnosis for ADHD in the USA is paediatric bipolar disorder due to hyperactivity being described as prolonged periods of mania. Empirical research conducted in 2004 found that “bipolar disorder (in preadolescence) was initially misdiagnosed in 12 out of 24 youths” (Mahoney, 2004). This is a dangerous misdiagnosis due to the vastly different treatment forms. Firstly, ADHD does not require mood stabilisers like paediatric bipolar disorder. Secondly, the stimulants given to treat ADHD have been shown to cause psychosis and exacerbate mania in paediatric bipolar disorder (Wendling, 2009). This misuse of medication can lead to mood episodes, suicidality, and hospitalisation.

Brief History

Descriptions of children with symptoms similar to contemporary concepts of mania date back to the 18th century. In 1898, a detailed psychiatric case history was published about a 13-year-old that met Jean-Pierre Falret and Jules Baillarger’s criteria for folie circulaire, which is congruent to the modern conception of bipolar I disorder.

In Emil Kraepelin’s descriptions of bipolar disorder in the 1920s, which he called “manic depressive insanity”, he noted the rare possibility that it could occur in children. In addition to Kraepelin, Adolf Meyer, Karl Abraham, and Melanie Klein were some of the first to document bipolar disorder symptoms in children in the first half of the 20th century. It was not mentioned much in English literature until the 1970s when interest in researching the subject increased. It became more accepted as a diagnosis in children in the 1980s after the DSM-III (1980) specified that the same criteria for diagnosing bipolar disorder in adults could also be applied to children.

Recognition came twenty years after, with epidemiological studies showing that approximately 20% of adults with bipolar disorder already had symptoms in childhood or adolescence. Nevertheless, onset before age 10 was thought to be rare, below 0.5% of the cases. During the second half of the century misdiagnosis with schizophrenia was not rare in the non-adult population due to common co-occurrence of psychosis and mania, this issue diminishing with an increased following of the DSM criteria in the last part of the 20th century.

Epidemiology

The prevalence of bipolar in youth is estimated at 2%.

Diagnosis

Diagnosis is made based on a clinical interview by a psychiatrist or other licensed mental health practitioner. There are no blood tests or brain scans to diagnose bipolar disorder. Obtaining information on family history and the use of questionnaires and checklists are helpful in making an accurate diagnosis. Commonly used assessment tools include the:

Signs and Symptoms

In both the American Psychiatric Association’s DSM-5 and the World Health Organisation’s ICD-10, the same criteria used to diagnose bipolar disorder in adults are used to make the diagnosis in children with some adjustments to account for differences in age and developmental stage. For example, the DSM-5 specifies that in children, depressive episodes can manifest as persistently irritable moods.

In diagnosing manic episodes, it is important to compare the changes in mood and behaviour to the child’s normal mood and behaviours at baseline instead of to other children or adults. For example, grandiosity (i.e. unrealistic overestimation of one’s intelligence, talent, or abilities) is normal at varying degrees during childhood and adolescence. Therefore, grandiosity is only considered symptomatic of mania in children when the beliefs are held despite being presented with concrete evidence otherwise or when they lead to a child attempting activities that are clearly dangerous, and most importantly, when the grandiose beliefs are an obvious change from that particular child’s normal self-view in between episodes.

Controversy

The diagnosis of childhood bipolar disorder is controversial, although it is recognised that bipolar disorder typical symptoms are dysfunctional and have negative consequences for minors suffering them. Main discussion is centred on whether what is called bipolar disorder in children refers to the same disorder than when diagnosing adults, and the related question on whether adults’ criteria for diagnosis are useful and accurate when applied to children. More specifically, main discussion over diagnosis in children circles around mania symptomatology and its differences between children and adults.

Diagnostic criteria may not correctly separate children with bipolar disorder from other problems such as ADHD, and emphasize fast mood cycles.

Treatment

Medications can produce important side effects, so interventions have been recommended to be closely monitored and families of patients to be informed of the different possible problems that can arise. Atypical antipsychotics are more effective than mood stabilizers, but have more side effects. Typical antipsychotics may produce weight gains as well as other metabolic problems, including diabetes mellitus type 2 and hyperlipidaemia. Extrapyramidal secondary effects may appear with these medications. These include tardive dyskinesia, a difficult-to-treat movement disorder (dyskinesia) that can appear after long-term use of antipsychotics. Liver and kidney damage are a possibility with mood stabilisers.

Psychological treatment usually includes some combination of education on the disease, group therapy and cognitive behavioural therapy (CBT). Children with bipolar disorder and their families are informed, in ways accordingly to their age and family role, about the different aspects of bipolar disorder and its management including causes, signs and symptoms and treatments. Group therapy aims to improve social skills and manage group conflicts, with role-playing as a critical tool. Finally, cognitive-behavioural training is directed towards the participants having a better understanding and control over their emotions and behaviours.

  • BPD I, manic or mixed, without psychosis:
    • Stage 1: Monotherapy with a mood stabiliser (lithium, Divalproex, or carbamazepine), or atypical antipsychotic (olanzapine, quetiapine, or risperidone).
      • Lithium or Divalproex is recommended for first-line treatment.
      • Partial (minimal to moderate) improvement with monotherapy, augment with another of the first-line recommendations.
    • Stage 2: Monotherapy with an alternative drug, then augmentation.
    • Stage 3: Possible medication combinations – lithium plus Divalproex, lithium plus atypical, or Divalproex plus atypical.
    • Stage 4: Combination of 2-3 mood stabilisers.
    • Stage 5: Alternate monotherapy with oxcarbazepine, ziprasidone, or aripiprazole (all Level D).
    • Stage 6: For nonresponse or intolerable side effects – clozapine for children or adolescents, or electroconvulsive therapy (ECT) for adolescents only.
  • BPD I, manic or mixed, with psychosis:
    • Stage 1: Same as BPD I without psychosis except for first-line treatment warrants a combination of mood stabiliser and an atypical antipsychotic.
    • Stages 2-4: Varying combinations and augmentations.
    • Stage 5: Alternate monotherapy (oxcarbazepine) plus an atypical antipsychotic.

Prognosis

Chronic medication is often needed, with relapses of individuals reaching rates over 90% in those not following medication indications and almost to 40% in those complying with medication regimens in some studies. Compared to adults, a juvenile onset has in general a similar or worse course, although age of onset predicts the duration of the episodes more than the prognosis. A risk factor for a worse outcome is the existence of additional (comorbid) pathologies.

Children with bipolar disorder are more likely to suicide than other children.

What is the Behaviour Analysis of Child Development?

Introduction

The behavioural analysis of child development originates from John B. Watson’s behaviourism.

Brief History

In 1948, Sidney Bijou took a position as associate professor of psychology at the University of Washington and served as director of the university’s Institute of Child Development. Under his leadership, the Institute added a child development clinic and nursery school classrooms where they conducted research that would later accumulate into the are that would be called “Behaviour Analysis of Child Development”. Skinner’s behavioural approach and Kantor’s interbehavioural approach were adopted in Bijou and Baer’s model. They created a three-stage model of development (basic, foundational, and societal). Bijou and Baer looked at these socially determined stages, as opposed to organising behaviour into change points or cusps (behavioural cusp). In the behavioural model, development is considered a behavioural change. It is dependent on the kind of stimulus and the person’s behavioural and learning function. Behaviour analysis in child development takes a mechanistic, contextual, and pragmatic approach.

From its inception, the behavioural model has focused on prediction and control of the developmental process. The model focuses on the analysis of a behaviour and then synthesizes the action to support the original behaviour. The model was changed after Richard J. Herrnstein studied the matching law of choice behaviour developed by studying of reinforcement in the natural environment. More recently, the model has focused more on behaviour over time and the way that behavioural responses become repetitive. it has become concerned with how behaviour is selected over time and forms into stable patterns of responding. A detailed history of this model was written by Pelaez. In 1995, Henry D. Schlinger, Jr. provided the first behaviour analytic text since Bijou and Baer comprehensively showed how behaviour analysis – a natural science approach to human behaviour – could be used to understand existing research in child development. In addition, the quantitative behavioural developmental model by Commons and Miller is the first behavioural theory and research to address notion similar to stage.

Research Methods

The methods used to analyse behaviour in child development are based on several types of measurements. Single-subject research with a longitudinal study follow-up is a commonly-used approach. Current research is focused on integrating single-subject designs through meta-analysis to determine the effect sizes of behavioural factors in development. Lag sequential analysis has become popular for tracking the stream of behaviour during observations. Group designs are increasingly being used. Model construction research involves latent growth modelling to determine developmental trajectories and structural equation modelling. Rasch analysis is now widely used to show sequentially within a developmental trajectory.

A recent methodological change in the behavioural analytic theory is the use of observational methods combined with lag sequential analysis can determine reinforcement in the natural setting.

Quantitative Behavioural Development

The model of hierarchical complexity is a quantitative analytic theory of development. This model offers an explanation for why certain tasks are acquired earlier than others through developmental sequences and gives an explanation of the biological, cultural, organisational, and individual principles of performance. It quantifies the order of hierarchical complexity of a task based on explicit and mathematical measurements of behaviour.

Research

Contingencies, Uncertainty, and Attachment

The behavioural model of attachment recognises the role of uncertainty in an infant and the child’s limited communication abilities. Contingent relationships are instrumental in the behaviour analytic theory, because much emphasis is put on those actions that produce parents’ responses.

The importance of contingency appears to be highlighted in other developmental theories, but the behavioural model recognises that contingency must be determined by two factors:

  • The efficiency of the action; and
  • That efficiency compared to other tasks that the infant might perform at that point.

Both infants and adults function in their environments by understanding these contingent relationships. Research has shown that contingent relationships lead to emotionally satisfying relationships.

Since 1961, behavioural research has shown that there is relationship between the parents’ responses to separation from the infant and outcomes of a “stranger situation.”. In a study done in 2000, six infants participated in a classic reversal design (refer to single-subject research) study that assessed infant approach rate to a stranger. If attention was based on stranger avoidance, the infant avoided the stranger. If attention was placed on infant approach, the infant approached the stranger.

Recent meta-analytic studies of this model of attachment based on contingency found a moderate effect of contingency on attachment, which increased to a large effect size when the quality of reinforcement was considered. Other research on contingency highlights its effect on the development of both pro-social and anti-social behaviour. These effects can also be furthered by training parents to become more sensitive to children’s behaviours, Meta-analytic research supports the notion that attachment is operant-based learning.

An infant’s sensitivity to contingencies can be affected by biological factors and environment changes. Studies show that being placed in erratic environments with few contingencies may cause a child to have conduct problems and may lead to depression (see Behavioural Development and Depression below). Research continues to look at the effects of learning-based attachment on moral development. Some studies have shown that erratic use of contingencies by parents early in life can produce devastating long-term effects for the child.

Motor Development

Since Watson developed the theory of behaviourism, behaviour analysts have held that motor development represents a conditioning process. This holds that crawling, climbing, and walking displayed by infants represents conditioning of biologically innate reflexes. In this case, the reflex of stepping is the respondent behaviour and these reflexes are environmentally conditioned through experience and practice. This position was criticised by maturation theorists. They believed that the stepping reflex for infants actually disappeared over time and was not “continuous”. By working with a slightly different theoretical model, while still using operant conditioning, Esther Thelen was able to show that children’s stepping reflex disappears as a function of increased physical weight. However, when infants were placed in water, that same stepping reflex returned. This offered a model for the continuity of the stepping reflex and the progressive stimulation model for behaviour analysts.

Infants deprived of physical stimulation or the opportunity to respond were found to have delayed motor development. Under conditions of extra stimulation, the motor behaviour of these children rapidly improved. Some research has shown that the use of a treadmill can be beneficial to children with motor delays including Down syndrome and cerebral palsy. Research on opportunity to respond and the building of motor development continues today.

The behavioural development model of motor activity has produced a number of techniques, including operant-based biofeedback to facilitate development with success. Some of the stimulation methods such as operant-based biofeedback have been applied as treatment to children with cerebral palsy and even spinal injury successfully. Brucker’s group demonstrated that specific operant conditioning-based biofeedback procedures can be effective in establishing more efficient use of remaining and surviving central nervous system cells after injury or after birth complications (like cerebral palsy). While such methods are not a cure and gains tend to be in the moderate range, they do show ability to enhance functioning.

Imitation and Verbal Behavior

Behaviourists have studied verbal behaviour since the 1920s. E.A. Esper (1920) studied associative models of language, which has evolved into the current language interventions of matrix training and recombinative generalisation. Skinner (1957) created a comprehensive taxonomy of language for speakers. Baer, along with Zettle and Haynes (1989), provided a developmental analysis of rule-governed behaviour for the listener. and for the listener Zettle and Hayes (1989) with Don Baer providing a developmental analysis of rule-governed behaviour. According to Skinner, language learning depends on environmental variables, which can be mastered by a child through imitation, practice, and selective reinforcement including automatic reinforcement.

B.F. Skinner was one of the first psychologists to take the role of imitation in verbal behaviour as a serious mechanism for acquisition. He identified echoic behaviour as one of his basic verbal operants, postulating that verbal behaviour was learned by an infant from a verbal community. Skinner’s account takes verbal behaviour beyond an intra-individual process to an inter-individual process. He defined verbal behaviour as “behaviour reinforced through the mediation of others”. Noam Chomsky refuted Skinner’s assumptions.

In the behavioural model, the child is prepared to contact the contingencies to “join” the listener and speaker. At the very core, verbal episodes involve the rotation of the roles as speaker and listener. These kinds of exchanges are called conversational units and have been the focus of research at Columbia’s communication disorders department.

Conversational units is a measure of socialisation because they consist of verbal interactions in which the exchange is reinforced by both the speaker and the listener. H.C. Chu (1998) demonstrated contextual conditions for inducing and expanding conversational units between children with autism and non-handicapped siblings in two separate experiments. The acquisition of conversational units and the expansion of verbal behaviour decrease incidences of physical “aggression” in the Chu study and several other reviews suggest similar effects. The joining of the listener and speaker progresses from listener speaker rotations with others as a likely precedent for the three major components of speaker-as-own listener – say so correspondence, self-talk conversational units, and naming.

Development of Self

Robert Kohelenberg and Mavis Tsai (1991) created a behaviour analytic model accounting for the development of one’s “self”. Their model proposes that verbal processes can be used to form a stable sense of who we are through behavioural processes such as stimulus control. Kohlenberg and Tsai developed functional analytic psychotherapy to treat psychopathological disorders arising from the frequent invalidations of a child’s statements such that “I” does not emerge. Other behaviour analytic models for personality disorders exist. They trace out the complex biological-environmental interaction for the development of avoidant and borderline personality disorders. They focus on Reinforcement sensitivity theory, which states that some individuals are more or less sensitive to reinforcement than others. Nelson-Grey views problematic response classes as being maintained by reinforcing consequences or through rule governance.

Socialisation

Over the last few decades, studies have supported the idea that contingent use of reinforcement and punishment over extended periods of time lead to the development of both pro-social and anti-social behaviours. However research has shown that reinforcement is more effective than punishment when teaching behaviour to a child. It has also been shown that modelling is more effective than “preaching” in developing pro-social behaviour in children. Rewards have also been closely studied in relation to the development of social behaviours in children. The building of self-control, empathy, and cooperation has all implicated rewards as a successful tactic, while sharing has been strongly linked with reinforcement.

The development of social skills in children is largely affected in that classroom setting by both teachers and peers. Reinforcement and punishment play major roles here as well. Peers frequently reinforce each other’s behaviour. One of the major areas that teachers and peers influence is sex-typed behaviour, while peers also largely influence modes of initiating interaction, and aggression. Peers are more likely to punish cross-gender play while at the same time reinforcing play specific to gender. Some studies found that teachers were more likely to reinforce dependent behaviour in females.

Behavioural principles have also been researched in emerging peer groups, focusing on status. Research shows that it takes different social skills to enter groups than it does to maintain or build one’s status in groups. Research also suggests that neglected children are the least interactive and aversive, yet remain relatively unknown in groups. Children suffering from social problems do see an improvement in social skills after behaviour therapy and behaviour modification (refer to applied behaviour analysis). Modelling has been successfully used to increase participation by shy and withdrawn children. Shaping of socially desirable behaviour through positive reinforcement seems to have some of the most positive effects in children experiencing social problems.

Anti-Social Behaviour

In the development of anti-social behaviour, aetiological models for anti-social behaviour show considerable correlation with negative reinforcement and response matching (refer to matching law). Escape conditioning, through the use of coercive behaviour, has a powerful effect on the development and use of future anti-social tactics. The use of anti-social tactics during conflicts can be negatively reinforced and eventually seen as functional for the child in moment to moment interactions. Anti-social behaviours will also develop in children when imitation is reinforced by social approval. If approval is not given by teachers or parents, it can often be given by peers. An example of this is swearing. Imitating a parent, brother, peer, or a character on TV, a child may engage in the anti-social behaviour of swearing. Upon saying it they may be reinforced by those around them which will lead to an increase in the anti-social behaviour. The role of stimulus control has also been extensively explored in the development of anti-social behaviour. Recent behavioural focus in the study of anti-social behaviour has been a focus on rule-governed behaviour. While correspondence for saying and doing has long been an interest for behaviour analysts in normal development and typical socialisation, recent conceptualisations have been built around families that actively train children in anti-social rules, as well as children who fail to develop rule control.

Developmental Depression with Origins in Childhood

Behavioural theory of depression was outlined by Charles Ferster. A later revision was provided by Peter Lewisohn and Hyman Hops. Hops continued the work on the role of negative reinforcement in maintaining depression with Anthony Biglan. Additional factors such as the role of loss of contingent relations through extinction and punishment were taken from early work of Martin Seligman. The most recent summary and conceptual revisions of the behavioural model was provided by Johnathan Kanter. The standard model is that depression has multiple paths to develop. It can be generated by five basic processes, including: lack or loss of positive reinforcement, direct positive or negative reinforcement for depressive behaviour, lack of rule-governed behaviour or too much rule-governed behaviour, and/or too much environmental punishment. For children, some of these variables could set the pattern for lifelong problems. For example, a child whose depressive behaviour functions for negative reinforcement by stopping fighting between parents could develop a lifelong pattern of depressive behaviour in the case of conflicts. Two paths that are particularly important are:

  1. Lack or loss of reinforcement because of missing necessary skills at a developmental cusp point; or
  2. The failure to develop adequate rule-governed behaviour.

For the latter, the child could develop a pattern of always choosing the short-term small immediate reward (i.e. escaping studying for a test) at the expense of the long-term larger reward (passing courses in middle school). The treatment approach that emerged from this research is called behavioural activation.

In addition, use of positive reinforcement has been shown to improve symptoms of depression in children. Reinforcement has also been shown to improve the self-concept in children with depression comorbid with learning difficulties. Rawson and Tabb (1993) used reinforcement with 99 students (90 males and 9 females) aged from 8 to 12 with behaviour disorders in a residential treatment program and showed significant reduction in depression symptoms compared to the control group.

Cognitive Behaviour

As children get older, direct control of contingencies is modified by the presence of rule-governed behaviour. Rules serve as an establishing operation and set a motivational stage as well as a discrimintative stage for behaviour. While the size of the effects on intellectual development are less clear, it appears that stimulation does have a facilitative effect on intellectual ability. However, it is important to be sure not to confuse the enhancing effect with the initial causal effect. Some data exists to show that children with developmental delays take more learning trials to acquire in material.

Learned Units and Developmental Retardation

Behaviour analysts have spent considerable time measuring learning in both the classroom and at home. In these settings, the role of a lack of stimulation has often been evidenced in the development of mild and moderate mental retardation. Recent work has focused on a model of “developmental retardation,”. an area that emphasizes cumulative environmental effects and their role in developmental delays. To measure these developmental delays, subjects are given the opportunity to respond, defined as the instructional antecedent, and success is signified by the appropriate response and/or fluency in responses. Consequently, the learned unit is identified by the opportunity to respond in addition to given reinforcement.

One study employed this model by comparing students’ time of instruction was in affluent schools to time of instruction in lower income schools. Results showed that lower income schools displayed approximately 15 minutes less instruction than more affluent schools due to disruptions in classroom management and behaviour management. Altogether, these disruptions culminated into two years worth of lost instructional time by grade 10. The goal of behaviour analytic research is to provide methods for reducing the overall number of children who fall into the retardation range of development by behavioural engineering.

Hart and Risely (1995, 1999) have completed extensive research on this topic as well. These researchers measured the rates of parent communication with children of the ages of 2-4 years and correlated this information with the IQ scores of the children at age 9. Their analyses revealed that higher parental communication with younger children was positively correlated with higher IQ in older children, even after controlling for race, class, and socio-economic status. Additionally, they concluded a significant change in IQ scores required intervention with at-risk children for approximately 40 hours per week.

Class Formation

The formation of class-like behaviour has also been a significant aspect in the behavioural analysis of development. This research has provided multiple explanations to the development and formation of class-like behaviour, including primary stimulus generalisation, an analysis of abstraction, relational frame theory, stimulus class analysis (sometimes referred to as recombinative generalisation), stimulus equivalence, and response class analysis. Multiple processes for class-like formation provide behaviour analysts with relatively pragmatic explanations for common issues of novelty and generalisation.

Responses are organised based upon the particular form needed to fit the current environmental challenges as well as the functional consequences. An example of large response classes lies in contingency adduction, which is an area that needs much further research, especially with a focus on how large classes of concepts shift. For example, as Piaget observed, individuals have a tendency at the pre-operational stage to have limits in their ability to preserve information. While children’s training in the development of conservation skills has been generally successful, complications have been noted. Behaviour analysts argue that this is largely due to the number of tool skills that need to be developed and integrated. Contingency adduction offers a process by which such skills can be synthesized and which shows why it deserves further attention, particularly by early childhood interventionists.

Autism

Ferster (1961) was the first researcher to posit a behaviour analytic theory for autism. Ferster’s model saw autism as a by-product of social interactions between parent and child. Ferster presented an analysis of how a variety of contingencies of reinforcement between parent and child during early childhood might establish and strengthen a repertoire of behaviours typically seen in children diagnosed with autism. A similar model was proposed by Drash and Tutor (1993), who developed the contingency-shaped or behavioural incompatibility theory of autism. They identified at least six reinforcement paradigms that may contribute to significant deficiencies in verbal behaviour typically characteristic of children diagnosed as autistic. They proposed that each of these paradigms may also create a repertoire of avoidance responses that could contribute to the establishment of a repertoire of behaviour that would be incompatible with the acquisition of age-appropriate verbal behaviour. More recent models attribute autism to neurological and sensory models that are overly worked and subsequently produce the autistic repertoire. Lovaas and Smith (1989) proposed that children with autism have a mismatch between their nervous systems and the environment, while Bijou and Ghezzi (1999) proposed a behavioural interference theory. However, both the environmental mismatch model and the inference model were recently reviewed, and new evidence shows support for the notion that the development of autistic behaviours are due to escape and avoidance of certain types of sensory stimuli. However, most behavioural models of autism remain largely speculative due to limited research efforts.

Role in Education

One of the largest impacts of behaviour analysis of child development is its role in the field of education. In 1968, Siegfried Englemann used operant conditioning techniques in a combination with rule learning to produce the direct instruction curriculum. In addition, Fred S. Keller used similar techniques to develop programmed instruction. B.F. Skinner developed a programmed instruction curriculum for teaching handwriting. One of Skinner’s students, Ogden Lindsley, developed a standardized semilogrithmic chart, the “Standard Behaviour Chart,” now “Standard Celeration Chart,” used to record frequencies of behaviour, and to allow direct visual comparisons of both frequencies and changes in those frequencies (termed “celeration”). The use of this charting tool for analysis of instructional effects or other environmental variables through the direct measurement of learner performance has become known as precision teaching.

Behaviour analysts with a focus on behavioural development form the basis of a movement called positive behaviour support (PBS). PBS has focused on building safe schools.

In education, there are many different kinds of learning that are implemented to improve skills needed for interactions later in life. Examples of this differential learning include social and language skills. According to the NWREL (Northwest Regional Educational Laboratory), too much interaction with technology will hinder a child’s social interactions with others due to its potential to become an addiction and subsequently lead to anti-social behaviour. In terms of language development, children will start to learn and know about 5-20 different words by 18 months old.

Critiques of Behavioural Approach and New Developments

Behaviour analytic theories have been criticized for their focus on the explanation of the acquisition of relatively simple behaviour (i.e. the behaviour of nonhuman species, of infants, and of individuals who are intellectually disabled or autistic) rather than of complex behaviour. Michael Commons continued behaviour analysis’s rejection of mentalism and the substitution of a task analysis of the particular skills to be learned. In his new model, Commons has created a behaviour analytic model of more complex behaviour in line with more contemporary quantitative behaviour analytic models called the model of hierarchical complexity. Commons constructed the model of hierarchical complexity of tasks and their corresponding stages of performance using just three main axioms.

In the study of development, recent work has been generated regarding the combination of behaviour analytic views with dynamical systems theory. The added benefit of this approach is its portrayal of how small patterns of changes in behaviour in terms of principles and mechanisms over time can produce substantial changes in development.

Current research in behaviour analysis attempts to extend the patterns learned in childhood and to determine their impact on adult development.

Professional Organisations

The Association for Behaviour Analysis International has a special interest group for the behaviour analysis of child development.

Doctoral level behaviour analysts who are psychologists belong to American Psychological Association’s division 25: behaviour analysis.

The World Association for Behaviour Analysis has a certification in behaviour therapy. The exam draws questions on behavioural theories of child development as well as behavioural theories of child psychopathology.

What is Oppositional Defiant Disorder?

Introduction

Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as “a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness” in children and adolescents.

This behaviour is usually targeted toward peers, parents, teachers, and other authority figures. Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit. It has certain links to Attention Deficit Hyperactivity Disorder (ADHD) and as much as one half of children with ODD will also diagnose as having ADHD as well.

Brief History

Oppositional defiant disorder was first defined in the DSM-III (1980). Since the introduction of ODD as an independent disorder, the field trials to inform the definition of this disorder have included predominantly male subjects. Some clinicians have debated whether the diagnostic criteria presented above would be clinically relevant for use with females. Furthermore, some have questioned whether gender-specific criteria and thresholds should be included. Additionally, some clinicians have questioned the preclusion of ODD when conduct disorder is present. According to Dickstein, the DSM-5 attempts to:

“redefine ODD by emphasizing a ‘persistent pattern of angry and irritable mood along with vindictive behavior,’ rather than DSM-IV’s focus exclusively on negativistic, hostile, and defiant behavior.’ Although DSM-IV implied, but did not mention, irritability, DSM-5 now includes three symptom clusters, one of which is ‘angry/irritable mood’—defined as ‘loses temper, is touchy/easily annoyed by others, and is angry/resentful.’ This suggests that the process of clinically relevant research driving nosology, and vice versa, has ensured that the future will bring greater understanding of ODD”.

Epidemiology

ODD, is a pattern of negativistic, defiant, disobedient and hostile behaviour, and is one of the most prevalent disorders from preschool age to adulthood. ODD is marked by defiant and disobedient behaviour towards authority figures. This can include: frequent temper tantrums, excessive arguing with adults, refusing to follow rules, acting in a way to purposely upset others, getting easily irked, having an angry attitude, and acting vindictive. Children with ODD usually begin showing symptoms around 6 to 8, although the disorder can emerge in younger children, too. Symptoms can last throughout the teen years. The pooled prevalence is approximately 3.6% up to age 18. There has been research to support that ODD is more common in boys than girls with a 2:1 ratio.

ODD has a prevalence of 1% to 11%. The average prevalence is approximately 3.3%. Gender and age play an important role in the rate of the disorder. In fact, ODD gradually develops and becomes apparent in preschool years; often before the age of eight years old. However, it is very unlikely to emerge following early adolescence. There is difference in prevalence between boys and girls. The ratio of this prevalence is 1.4 to 1 with it being more prevalent in boys than in girls, before adolescence. On the other hand, girls’ prevalence tends to increase after puberty. When researchers observed the general prevalence of oppositional defiant disorder throughout cultures, they noticed that it remained constant. However, the sex difference in ODD prevalence is only significant in Western cultures. There are two possible explanations for this difference which are that in non-Western cultures there is a decreased prevalence of ODD in boys or an increased prevalence of ODD in girls. Other factors can influence the prevalence of the disorder. One of these factors is the socioeconomic status. Youths living in families of low socioeconomic status have a higher prevalence. Another factor is based on the criteria used to diagnose an individual. When the disorder was first included in the DSM-III, the prevalence was 25% higher than when the DSM-IV revised the criteria of diagnosis. The DSM-V made more changes to the criteria grouping certain characteristics together in order to demonstrate that ODD display both emotional and behavioural symptomatology. In addition, criteria were added to help guide clinicians in diagnosis because of the difficulty found in identifying whether the behaviours or symptoms are directly related to the disorder or simply a phase in a child’s life. Consequently, future studies may obtain results indicating a decline in prevalence between the DSM-IV and the DSM-V due to these changes.

Signs and Symptoms

DSM-IV-TR) (now replaced by DSM-5) stated that a child must exhibit four out of the eight signs and symptoms to meet the diagnostic threshold for oppositional defiant disorder. These symptoms include:

  1. Often loses temper.
  2. Is often touchy or easily annoyed.
  3. Is often angry and resentful.
  4. Often argues with authority figures or for children and adolescents, with adults.
  5. Often actively defies or refuses to comply with requests from authority figures or with rules.
  6. Often deliberately annoys others.
  7. Often blames others for his or her mistakes or misbehaviour.
  8. Has been spiteful or vindictive at least twice within the past 6 months.

These behaviours are mostly directed towards an authority figure such as a teacher or a parent. Although these behaviours can be typical among siblings, they must be observed with individuals other than siblings for an ODD diagnosis. Children with ODD can be verbally aggressive. However, they do not display physical aggressiveness, a behaviour observed in conduct disorder. Furthermore, they must be perpetuated for longer than six months and must be considered beyond a normal child’s age, gender and culture to fit the diagnosis. For children under 5 years of age, they occur on most days over a period of 6 months. For children over 5 years of age they occur at least once a week for at least 6 months. It is possible to observe these symptoms in only one setting, most commonly home. Thus the severity would be mild. If it is observed in two settings then it would be characterised as moderate and if the symptoms are observed in 3 or more settings then it would be considered severe.

These patterns of behaviour result in impairment at school and/or other social venues.

Aetiology

There is no specific element that has yet been identified as directly causing ODD. Researchers looking precisely at the etiological factors linked with ODD are limited. The literature often examines common risk factors linked with all disruptive behaviours, rather than specifically about ODD. Symptoms of ODD are also often believed to be the same as CD even though the disorders have their own respective set of symptoms. When looking at disruptive behaviours such as ODD, research has shown that the causes of behaviours are multifactorial. However, disruptive behaviours have been identified as being mostly due either to biological or environmental factors.

Genetic Influences

Research indicates that parents pass on a tendency for externalising disorders to their children that may be displayed in multiple ways, such as inattention, hyperactivity, or oppositional and conduct problems. Research has also shown that there is a genetic overlap between ODD and other externalising disorders. Heritability can vary by age, age of onset, and other factors. Adoption and twin studies indicate that 50% or more of the variance causing antisocial behaviour is attributable to heredity for both males and females. ODD also tends to occur in families with a history of ADHD, substance use disorders, or mood disorders, suggesting that a vulnerability to develop ODD may be inherited. A difficult temperament, impulsivity, and a tendency to seek rewards can also increase the risk of developing ODD. New studies into gene variants have also identified possible gene-environment (G x E) interactions, specifically in the development of conduct problems. A variant of the gene that encodes the neurotransmitter metabolising enzyme monoamine oxidase-A (MAOA), which relates to neural systems involved in aggression, plays a key role in regulating behaviour following threatening events. Brain imaging studies show patterns of arousal in areas of the brain that are associated with aggression in response to emotion-provoking stimuli.

Prenatal Factors and Birth Complications

Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning or exposure to lead, and mother’s use of alcohol or other substances during pregnancy may increase the risk of developing ODD. In numerous research, substance use prior to birth has also been associated with developing disruptive behaviours such as ODD. Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.

Neurobiological Factors

Deficits and injuries to certain areas of the brain can lead to serious behavioural problems in children. Brain imaging studies have suggested that children with ODD may have hypofunction in the part of the brain responsible for reasoning, judgment, and impulse control. Children with ODD are thought to have an overactive behavioural activation system (BAS) and an underactive behavioural inhibition system (BIS) (both discussed here). The BAS stimulates behaviour in response to signals of reward or non-punishment. The BIS produces anxiety and inhibits ongoing behaviour in the presence of novel events, innate fear stimuli, and signals of non-reward or punishment. Neuroimaging studies have also identified structural and functional brain abnormalities in several brain regions in youths with conduct disorders. These brain regions are the amygdala, prefrontal cortex, anterior cingulate, and insula, as well as interconnected regions.

Social-Cognitive Factors

As many as 40% of boys and 25% of girls with persistent conduct problems display significant social-cognitive impairments. Some of these deficits include immature forms of thinking (such as egocentrism), failure to use verbal mediators to regulate his or her behaviour, and cognitive distortions, such as interpreting a neutral event as an intentional hostile act. Children with ODD have difficulty controlling their emotions or behaviours. In fact, students with ODD have limited social knowledge that is based only on individual experiences, which shapes how they process information and solve problems cognitively. This information can be linked with the social information processing model (SIP) that describes how children process information to respond appropriately or inappropriately in social settings. This model explains that children will go through five stages before displaying behaviours: encoding, mental representations, response accessing, evaluation, and enactment. However, children with ODD have cognitive distortions and impaired cognitive processes. This will therefore directly impact their interactions and relationship negatively. It has been shown that social and cognitive impairments result in negative peer relationships, loss of friendship, and an interruption in socially engaging in activities. Children learn through observational learning and social learning. Therefore, observations of models have a direct impact and greatly influence children’s behaviours and decision-making processes. Children often learn through modelling behaviour. Modelling can act as a powerful tool to modify children’s cognition and behaviours.

Environmental Factors

Negative parenting practices and parent-child conflict may lead to antisocial behaviour, but they may also be a reaction to the oppositional and aggressive behaviours of children. Factors such as a family history of mental illnesses and/or substance use disorders as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behaviour disorders. Parenting practices not providing adequate or appropriate adjustment to situations as well as a high ratio of conflicting events within a family are causal factors of risk for developing ODD.

Insecure parent-child attachments can also contribute to ODD. Often little internalisation of parent and societal standards exists in children with conduct problems. These weak bonds with their parents may lead children to associate with delinquency and substance use. Family instability and stress can also contribute to the development of ODD. Although the association between family factors and conduct problems is well established, the nature of this association and the possible causal role of family factors continues to be debated.

In a number of studies, low socioeconomic status has also been associated with disruptive behaviors such as ODD.

Other social factors such as neglect, abuse, parents that are not involved, and lack of supervision can also contribute to ODD.

Externalising problems are reported to be more frequent among minority-status youth, a finding that is likely related to economic hardship, limited employment opportunities, and living in high-risk urban neighbourhoods. Studies have also found that the state of being exposed to violence was also a contribution factor for externalizing behaviours to occur.

Diagnosis

For a child or adolescent to qualify for a diagnosis of ODD, behaviours must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends or placing him or her in harmful situations. These behaviours must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.

Management

Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioural therapy, and social skills training. According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents.

Children with oppositional defiant disorder tend to exhibit problematic behaviour that can be very difficult to control. An occupational therapist can recommend family based education referred to as Parent Management Training (PMT) in order to encourage positive parents and child relationships and reduce the child’s tantrums and other disruptive behaviours. Since ODD is a neurological disorder that has biological correlates, an occupational therapist can also provide problem solving training to encourage positive coping skills when difficult situations arise, as well as offer cognitive behavioural therapy (CBT).

Psychopharmacological Treatment

Psychopharmacological treatment is the use of prescribed medication in managing oppositional defiant disorder. Prescribed medications to control ODD include mood stabilisers, anti-psychotics, and stimulants. In two controlled randomised trials, it was found that between administered lithium and the placebo group, administering lithium decreased aggression in children with conduct disorder in a safe manner. However, a third study found the treatment of lithium over a period of two weeks invalid. Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.

The effectiveness of drug and medication treatment is not well established. Effects that can result in taking these medications include hypotension, extrapyramidal symptoms, tardive dyskinesia, obesity, and increase in weight. Psychopharmacological treatment is found to be most effective when paired with another treatment plan, such as individual intervention or multimodal intervention.

In one case, a 16-year-old boy was given oestrogen at an L.A. juvenile jail due to allegedly having ODD due to somewhat elevated testosterone levels, developing gynecomastia and requiring breast reduction surgery as a result.

Individual Interventions

Individual interventions are focused on child-specific individualised plans. These interventions include anger control/stress inoculation, assertiveness training, and child-focused problem-solving skills training programme, and self-monitoring skills.

Anger control and stress inoculation help prepare the child for possible upsetting situations or events that may cause anger and stress. It includes a process of steps they may go through.

Assertiveness training educates individuals in keeping a balance between passivity and aggression. It is about creating a response that is controlled, and fair.

A child-focused problem-solving skills training programme aims to teach the child new skills and cognitive processes that teach how to deal with negative thoughts, feelings, and actions.

Parent and Family Treatment

According to randomised trials evidence shows that parent management training is most effective. It has strong influences over a longer period of time and in various environments.

Parent-child interaction training is intended to coach the parents while involving the child. This training has two phases. The first phase being child-directed interaction, whereby it is focused on teaching the child non-directive play skills. The second phase is parent-directed interaction, where the parents are coached on aspects including clear instruction, praise for compliance, and time-out for noncompliance. The parent-child interaction training is best suited for elementary-aged children.

Parent and family treatment has a low financial cost, which can yield an increase in beneficial results.

Multimodal Intervention

Multimodal intervention is an effective treatment that looks at different levels including family, peers, school, and neighbourhood. It is an intervention that concentrates on multiple risk factors. The focus is on parent training, classroom social skills, and playground behaviour programmes. The intervention is intensive and addresses barriers to individuals’ improvement such as parental substance use or parental marital conflict.

An impediment to treatment includes the nature of the disorder itself, whereby treatment is often not complied with and is not continued or stuck with for adequate periods of time.

Comorbidity

ODD can be described as a term or disorder with a variety of pathways in regard to comorbidity. High importance must be given to the representation of ODD as a distinct psychiatric disorder independent of conduct disorder.

In the context of oppositional defiant disorder and comorbidity with other disorders, researchers often conclude that ODD co-occurs with an ADHD, anxiety disorders, emotional disorders as well as mood disorders. Those mood disorders can be linked to major depression or bipolar disorder. Indirect consequences of ODD can also be related or associated with a later mental disorder. For instance, conduct disorder is often studied in connection with ODD. Strong comorbidity can be observed within those two disorders, but an even higher connection with ADHD in relation to ODD can be seen. For instance, children or adolescents who have ODD with coexisting ADHD will usually be more aggressive, will have more of the negative behavioural symptoms of ODD and thus, inhibit them from having a successful academic life. This will be reflected in their academic path as students.

Other conditions that can be predicted in children or people with ODD are learning disorders in which the person has significant impairments with academics and language disorders in which problems can be observed related to language production and/or comprehension.

What is Resignation Syndrome?

Introduction

Resignation syndrome (also called traumatic withdrawal syndrome or traumatic refusal; Swedish: uppgivenhetssyndrom) is a possibly factitious, dissociative syndrome that induces a catatonic state, first described in Sweden in the 1990s. The condition affects predominately psychologically traumatised children and adolescents in the midst of a strenuous and lengthy migration process.

Refer to Pervasive Refusal Syndrome (PRS).

Young people reportedly develop depressive symptoms, become socially withdrawn, and become motionless and speechless as a reaction to stress and hopelessness. In the worst cases, children reject any food or drink and have to be fed by feeding tube; the condition can persist for years. Recovery ensues within months to years and is claimed to be dependent on the restoration of hope to the family.

More recently, this phenomenon has been called into question, with two children witnessing that they were forced by their parents to act apathetic in order to increase chances of being granted residence permits. As evidenced by medical records, healthcare professionals were aware of this scam, and witnessed parents who actively refused aid for their children but remained silent at the time. Later Sveriges Television, Sweden’s national public television broadcaster, were severely critiqued by investigative journalist Janne Josefsson for failing to uncover the truth. In March 2020, a report citing the Swedish Agency for Medical and Social Evaluation, SBU, said “There are no scientific studies that answer how to diagnose abandonment syndrome, nor what treatment works.”

Signs and Symptoms

Affected individuals (predominantly children and adolescents) first exhibit symptoms of anxiety and depression (in particular apathy, lethargy), then withdraw from others and care for themselves. Eventually their condition might progress to stupor, i.e. they stop walking, eating, talking, and grow incontinent. In this stage patients are seemingly unconscious and tube feeding is life-sustaining. The condition could persist for months or even years. Remission happens after life circumstances improve and ensues with gradual return to what appears to be normal function.

Nosology

Refusal syndrome and pervasive refusal syndrome shares common features and etiologic factors; however, the former is more clearly associated with trauma and adverse life circumstances. Neither is included in the standard psychiatric classification systems.

Pervasive refusal syndrome (also called pervasive arousal withdrawal syndrome) has been conceptualised in a variety of ways, including a form of post-traumatic stress disorder, learned helplessness, ‘lethal mothering’, loss of the internal parent, apathy or the ‘giving-up’ syndrome, depressive devitalisation, primitive ‘freeze’, severe loss of activities of daily living and ‘manipulative’ illness. It was also suggested to be on the ‘refusal-withdrawal-regression spectrum’.

Acknowledging its social importance and relevance, the Swedish National Board of Health and Welfare recognised the novel diagnostic entity resignation syndrome in 2014. While others argue that already-existing diagnostic entities should be used and are sufficient in the majority of cases, i.e. severe major depressive disorder with psychotic symptoms or catatonia, or conversion/dissociation disorder.

Currently, diagnostic criteria are undetermined, pathogenesis is uncertain, and effective treatment is lacking.

Causes

Resignation syndrome appears to be a very specialised response to the trauma of refugee limbo, in which families, many of whom have escaped dangerous circumstances in their home countries, wait to be granted legal permission to stay in their new country, often undergoing numerous refusals and appeals over a period of years.

Experts proposed multifactorial explanatory models involving individual vulnerability, traumatisation, migration, culturally conditioned reaction patterns and parental dysfunction or pathological adaption to a caregiver’s expectations to interplay in pathogenesis. Severe depression or conversion/dissociation disorder has been also suggested (as best diagnostic alternatives).

However, the currently prevailing stress hypothesis fails to account for the regional distribution (see Epidemiology) and contributes little to treatment. An asserted “questioning attitude”, in particular within the health care system, it has been claimed, may constitute a “perpetuating retraumatization possibly explaining the endemic” distribution. Furthermore, Sweden’s experience raises concerns about “contagion”. Researchers argue that culture-bound psychogenesis can accommodate the endemic distribution because children may learn that dissociation is a way to deal with trauma.

A proposed neurobiological model of the disorder suggests that the impact of overwhelming negative expectations are directly causative of the down-regulation of higher order and lower order behavioural systems in particularly vulnerable individuals.

Epidemiology

Depicted as a culture-bound syndrome, it was first observed and described in Sweden among children of asylum seekers from former Soviet and Yugoslav countries. In Sweden, hundreds of migrant children, facing the possibility of deportation, have been diagnosed since the 1990s. For example, 424 cases were reported between 2003 and 2005; and 2.8% of all 6547 asylum applications submitted for children were diagnosed in 2004.

It has also been observed in refugee children transferred from Australia to the Nauru Regional Processing Centre. The Economist wrote in 2018 that Doctors without Borders (MSF) refused to say how many of the children on Nauru may be suffering from traumatic withdrawal syndrome. A report published in August 2018 suggested there were at least 30. The National Justice Project, a legal centre, has brought 35 children from Nauru this year. It estimates that seven were suffering from refusal syndrome, and three were psychotic.

What is Pervasive Refusal Syndrome?

Introduction

Pervasive refusal syndrome (PRS), also known as pervasive arousal withdrawal syndrome (PAWS) is a rare hypothesized paediatric mental disorder. PRS is not included in the standard psychiatric classification systems; that is, PRS is not a recognised mental disorder in the World Health Organisation’s current (ICD-10) and upcoming (ICD-11) International Classification of Diseases and the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Refer to Resignation Syndrome.

Purported Signs and Symptoms

According to some authors, PRS symptoms have common characteristics with other psychiatric disorders, but (according to these authors), current psychiatric classification schemes, such as the DSM cannot account for the full scope of symptoms seen in PRS. Purported symptoms include partial or complete refusal to eat, move, talk, or care for oneself; active and angry resistance to acts of help and support; social withdrawal; and school refusal.

Hypothesized Causes

Trauma might be a causal factor because PRS is repeatedly seen in refugees and witnesses to violence. Viral infections might be a risk factor for PRS.

Mechanism

Some authors hypothesize that learned helplessness is one of the mechanisms involved in PRS. A number of cases have been reported in the context of eating disorders.

Hypothesized Epidemiology

Epidemiological studies are lacking. Pervasive refusal syndrome is reportedly more frequent in girls than boys. The average age of onset is purported to be 7-15.