Disorders of Childhood & Adolescence Part I

  • typically diagnoses in childhood + adolescence but may be diagnosed later in life

  • internalizing disorders

    • separation anxiety disorder

    • selective mutism

    • reactive attachment disorder

    • disinhibited social engagement disorder

  • mood disorders early in life

    • disruptive mood dysregulation disorder

  • externalizing disorders

    • “disruptive, impulse control, and conduct disorders”

    • intermittent explosive disorder

    • oppositional defiant disorder

    • conduct disorder

  • neurodevelopmental disorders

    • tic disorder

    • attention-deficit/hyperactivity disorder

    • autism spectrum disorder

    • intellectual disability

    • learning disorder

Intermittent Explosive Disorder DSM-5-TR

  • A) recurrent behavior outbursts representing a failure to control aggressive impulses as manifested by either of the following:

    • low intensity/high frequency: verbal aggression (e.g. temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring 2x a week, on average, for 3 months

      • aggression does not result in physical harm to people or animals or the destruction of property

    • high intensity/low frequency: 3 behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period

  • B) the magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors

  • C) the recurrent aggressive outbursts are not premeditated (they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (money, power, intimidation)

  • D) the recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences

  • E) chronological age is at least 6 years old (or equivalent developmental level)

  • F) not better explained by something else

    • for children 6-18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis

Intermittent Explosive Disorder (IED) Etiology

  • genetics related to aggression, less research on IED specifically

  • serotonin

  • early exposure to familial aggression, violence, interpersonal trauma

Intermittent Explosive Disorder (IED) Treatments

  • SSRIs (Prozac)

  • CBT - cognitive restructuring, relaxation techniques, role playing scenarios, implementing coping skills

Oppositional Defiant Disorder (DSM-5-TR)

  • A) a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting for at least 6 months as evidenced by at least 4 symptoms from any category below, and exhibited with at least one individual who is not a sibling

    • 9 total possible symptoms

    • angry/irritable mood (1-3)

      • often loses temper

      • is touchy or easily annoyed

      • is often angry or resentful

    • argumentative (4-7)

      • often argues with authority figures, or, for children + adolescence, with adults

      • often actively defies or refused to comply with requests from authority figures or with rules

      • often deliberately annoys others

      • often blames others for their mistakes or misbehavior

    • vindictiveness (8)

      • has been spiteful or vindictive at least 2x within the past 6 months

  • B) disturbance in behavior is associated with distress in individual or others in their immediate social context, or it negatively impacts social, educational, occupational, or other areas of functioning

  • C) behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder

ODD specify current severity

  • mild - symptoms only confined to one setting

  • moderate - some symptoms are present in at least 2 settings

  • severe - some symptoms are present in 3+ settings

ODD Note: persistence + frequency of behaviors should be considered within appropriate developmental parameters

  • younger than 5: most days for 6 months

  • 5 or older: 1x a week for 6 months

  • consider whether behaviors are outside the realm of developmental level of individual

ODD Etiology + Treatment

  • symptoms normally resolve or turn into another disorder

    • negative affect (angry/irritable mood) → anxiety or depressive disorder

    • oppositional behaviors (e.g. vindictiveness) → conduct disorder

  • etiology

    • emotion regulation difficulties (emotional reactivity, poor frustration tolerance)

    • parenting behaviors (inconsistent discipline, harsh punishments)

    • maternal smoking while pregnant

  • treatment

    • CBT - learning strategies to regulate emotion; identifying outburst triggers and consequences, etc.

    • parent management training

      • increase positive reinforcements for intended behavior; reduce accidentally positively reinforcing oppositional behavior

      • use consistent punishment for undesired behavior

      • use predictable and immediate parenting responses

      • modeling positive interactions in the household

Conduct Disorder (DSM-5-TR)

  • A) a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms or rules are violated, as manifested by the presence of 3 (or more) of the following 15 criteria in the past 12 months from any of the categories below, with at least 1 criterion present in the past 6 months

    • aggression to people and animals

      • often bullies, threatens, or intimates others

      • often initiates physical fights

      • has used a weapon that can cause serious physical harm to others (a bat, brick, broken bottle, knife gun)

      • has been physically cruel to people has been physically cruel to animals

      • has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, armed robbery)

      • has forced someone into sexual activity

    • destruction of property

      • has deliberately engaged in fire setting with the intention of causing serious damage

      • has deliberately destroyed others’ property (other than by fire setting)

    • deceitfulness or theft

      • has broken into someone else’s house, building, or car

      • often lies to obtain goods or favors or to avoid obligations (“cons” others)

      • has stolen items of nontrivial value without confronting a victim (e.g. shoplifting, but without breaking and entering; forgery)

    • serious violation of rules

      • often stays out at night despite parental prohibitions, beginning before age 13 years

      • has run away from home overnight at least 2x while living in parental or parental surrogate home (or once without returning for a lengthy period)

      • is often truant from school, beginning before age 13 years

  • B) the disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning

  • C) if the individual is age 18 years or older, criteria are not met for antisocial personality disorder

  • Note: there are many specifiers, but we won’t cover most of them

Conduct Disorder Callous-Unemotional (CU) specifier

  • persistent lack of empathy & indifference to the feelings and well-being of others

  • there are other specifies, but we won’t cover them

Conduct Disorder Etiology

  • biological - low MAOA activity, especially when combined with childhood maltreatment

    • MAOA = monoamine oxidase A

  • psychological - moral disengagement

Conduct Disorder Treatment

  • difficult to treat, especially when CU traits are present

  • best outcomes with early intervention

  • parent management training (consistent discipline, reinforcing positive behaviors, promote prosocial behaviors)

  • use self-talk to control impulses