Disorders first observed in childhood can be much harder to diagnose than adult disorders for several reasons:
Traits that would be considered abnormal in adulthood can often be considered normal developmental behaviors in a child, including grandiosity and egocentrism.
Characteristics of adult disorders can appear different in children. For example, depression often exhibits in children as agitation or aggression, but it is more likely to exhibit in adulthood as lethargy.
Many times childhood disorders are not diagnosed until the person has reached adulthood, so information necessary for meeting diagnostic criteria must be gathered from friends’ and family’s memories, as opposed to currently observable behaviors or self-reports.
One of the major changes that came with the DSM-5 is the removal of the mulitaxial system of diagnosis. In its place, consideration was given to gender and cultural considerations as well as developmental and life-span considerations. The life-span consideration is important to consider in the change in diagnostic criteria when it comes to mental disorders diagnosed in children. Many mental disorders now have specific criteria particular for childhood onset. The following disorders are a specific set of disorders that begin in childhood (American Psychiatric Association, 2013b):
Intellectual disabilities
Communication disorders
Language disorder
Autism spectrum disorder
Attention-deficit/hyperactivity disorder (ADHD)
Specific learning disorder
Motor disorders
Developmental coordination disorder
Stereotypic movement disorder
Tic disorders
Tourette’s disorder
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Disorders Of children
Other neurodevelopmental disorders
It is important to remember that children can suffer from the same disorders (with the exception of personality disorders) as adults. However, this lecture focuses on disorders in which the symptoms must be present in childhood to have been diagnosed. In addition, remember that children often exhibit behavioral and emotional problems that don’t necessarily meet formal diagnostic criteria yet are troubling to parents and teachers. For example, children may have nightmares or normal enuresis or exhibit lying or noncompliance.
Let’s focus on what is arguably one of the most hotly debated disorders in the DSM: ADHD.
ADHD
ADHD centers on chronic inattention. It is a good example of a disorder that is often diagnosed for the first time in adulthood. It is very common to find college students whose ADHD is undetected until they are in college because they are so intelligent. In college, when they are required to manage their time and be
self-disciplined, their symptoms of ADHD are suddenly quite distressing. Sometimes, they go to the counseling center not understanding why they are not succeeding in school. The clinician must ascertain from the college student and parents or guardians whether or not there were symptoms of ADHD present earlier in the student’s life.
People with ADHD can appear very different from one another depending on the symptoms that accompany the inattention. The following graphic describes the symptoms of ADHD:
ADHD Diagnosis and Treatment
Issues Surrounding Diagnosis and Treatment of ADHD
Before discussing issues surrounding ADHD treatment, keep in mind that many scientists and clinicians disagree on the usefulness of labeling children as having any disorders. Research and debate on ADHD have truly brought this disagreement to the forefront of the media. Arguments abound as to whether or not ADHD exists as a disorder or whether it is a label for children that previous generations would have called active or undisciplined. Some of this debate has been settled by very recent brain imaging studies, which have identified brain processing differences between those diagnosed with ADHD and those not.
Another debate has centered on the psychopharmacology of ADHD: Are physicians overeager to medicate children and adults with ADHD? Is ADHD truly as prevalent in our schools as it seems? Although the DSM reports that the prevalence rate for ADHD hovers between 1 and 7 percent of all children, there are theorists who believe that there are much higher rates of students who are taking medications or receiving accommodations for ADHD.
The affect of ADHD on children or adults can be mediated with behavioral strategies. However, medication seems to be the more effective yet controversial treatment. Most of the medications are stimulant-based. (There is an exception, but the therapeutic efficacy of the non stimulant-based medications seems to be much lower than that of the stimulant-based medications.) The use of a stimulant to treat a disorder centered on distractibility and hyperactivity seems counterintuitive to many people. However, if you understand the biology of ADHD, it makes perfect sense.
The brain requires a minimum level of stimulation in order to function optimally. For individuals with ADHD, their brains are actually producing a less-than-minimum amount of stimulation—they are under-stimulated. Their distractibility or hyperactivity is their brains’ way of compensating by seeking out additional stimulation (either from the environment or through motor movement) to obtain that minimum level necessary for functioning. Therefore, when given stimulant medications, their brains get what they need. The brain no longer needs to compensate, so the individual is actually able to relax. Therefore, a person who legitimately has ADHD will seem calmer, better able to concentrate, or better able to sleep after taking a stimulant. However, the person without ADHD will have more energy, have less need for sleep, or be more agitated after taking a stimulant. Therefore, you can use a person’s response to stimulant medications as a discriminator between those with ADHD and those without ADHD.
Two important notes to keep in mind as we conclude this discussion:
Stimulant medications are highly addictive and are often sought by non-ADHD individuals who desire their side-effects (such as weight loss or ability to “pull all-nighters” or a single night of total sleep deprivation). For this reason, they are classified as Schedule II drugs (which are drugs having a high potential for abuse) and prescriptions for them must be renewed monthly in attempts to limit abuse.
Some clinicians currently hypothesize that there is a second type of ADHD—an adult onset type. This is a relatively new area of research.
Autism Spectrum Disorder
For the DSM-5, there were significant changes to pervasive developmental disorders (PDDs). PDDs were a set of disorders that occur due to delays in development. Prior to DSM-5, the different PDDs included autism, Asperger’s syndrome, Rett syndrome, childhood disintegrative disorder, and PDD Not Otherwise Specified (NOS). According to the American Psychiatric Association (2013a), research has shown that the different diagnoses weren’t applied consistently and many of the symptoms were similar. Several disorders were eliminated and merged into one called autism spectrum disorder.
The main features of autism spectrum disorder include (American Psychiatric Association, 2013b):
Deficits in social communication
Social interactions
Non-verbal communication skills
Understanding relationships
Restrictive repetitive behaviors
Repetitive motor movements
Ritualized behaviors
Strong interests in unusual objects
Heightened sensitivity to sensory stimulation.
Intellectual Developmental Disorder
In 2010, President Obama signed into law Public Law 111–256, which changed a reference from mental retardation to intellectual disability. The law is also known as Rosa’s Law due to a family’s advocacy to change the way in which a person with intellectual disabilities is viewed. The terms mental retardation and “retarded” are viewed as a derogatory labels that are often stigmatizing. When DSM-5 was published, the term mental retardation was removed and replaced with intellectual disabilities. One of the other major changes in the diagnosis of intellectual disabilities was the discontinued use of an intelligence quotient (IQ) alone to establish the level of disability.
Intellectual Developmental Disorder (IDD) main characteristics include the following domains (American Psychiatric Association, 2013c):
Conceptual domain
Reading/Writing
Reasoning
Knowledge
Memory
Social domain
Social judgment
Interpersonal communication skills
Empathy
Practical domain
Personal care
Job responsibilities
Money management
Recreation
Organizing school and work tasks
The severity level (e.g., deficits in the domains above) is mild, moderate, severe, or profound. DSM-5 doesn’t provide a specific age of onset but does describe that IDD is diagnosed only during the developmental period of the individual.
Neurocognitive Disorders
The cognitive disorders focus on disturbances in the individual’s ability to function cognitively, including thinking, reasoning, or memory. There are two primary concepts that underline cognitive disorders:
Delirium: It is a lapse in consciousness and impairment in the thought process.
Dementia: It is significant memory loss along with a loss of multiple cognitive processes such as abstract thinking or language.
The movies would have us believe that amnesia (loss of memory), a type of delirium, is a relatively common occurrence. The hero or heroine has a shock and loses his or her memory. Usually in these plotlines, the individual suffers anterograde amnesia—the individual forgets everything leading up to his or her shock. However, in reality, retrograde amnesia is much more common. This type of amnesia produces an inability or impairment in forming new memories. For example, an individual suffers a brain trauma. The individual would be able to remember his or her past, but would have difficulty forming new memories, as described in the following case:
