The history is the most important tool for identifying a psychiatric disorder. The initial focus in conducting the history is to establish rapport and to ensure the child’s safety with respect to the risk of suicide or physical or sexual abuse. After safety is ensured, the history should focus on delineating the specific behaviors of concern, on identifying any stressors that may be precipitating the behavior ( Table 27.1 ), and on recognizing any associated symptoms that may differentiate which disorder or disorders are causing the behavior. In addition to primary psychiatric diagnoses, the clinician should focus on possible medical causes of the behaviors in question, including medication side effects, substance abuse, and medical illnesses ( Tables 27.2 and 27.3 ). Comorbidity is common in children with psychiatric illnesses, and as such, the clinician should consider whether a combination of medical and psychiatric diagnoses may be producing the patient’s symptoms.
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|
| Category | Disorders |
|---|---|
| Head trauma | Traumatic brain injury |
| Subdural hematoma | |
| Infectious | Lyme disease |
| Prion diseases | |
| Neurosyphilis | |
| Viral infections/encephalitides (HIV infection/encephalopathy, herpes encephalitis, cytomegalovirus, Epstein-Barr virus) | |
| Whipple disease | |
| Cerebral malaria | |
| Systemic infection | |
| Inflammatory | Autoimmune encephalitis |
| Systemic lupus erythematosus | |
| Sjögren syndrome | |
| Temporal arteritis | |
| Hashimoto encephalopathy | |
| Sydenham chorea | |
| Sarcoidosis | |
| Neoplastic | Primary or secondary cerebral neoplasm |
| Systemic neoplasm | |
| Paraneoplastic encephalitis | |
| Endocrine/acquired metabolic | Hepatic encephalopathy |
| Uremic encephalopathy | |
| Dialysis dementia | |
| Hypo/hyperparathyroidism | |
| Hypo/hyperthyroidism | |
| Addison disease/Cushing disease | |
| Postpartum | |
| Vitamin deficiency: vitamin B 12 , folate, niacin, vitamin C, thiamine | |
| Gastric bypass–associated nutritional deficiencies | |
| Hypoglycemia | |
| Hyponatremia | |
| Vascular | Stroke |
| Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) | |
| Degenerative | Progressive supranuclear palsy |
| Huntington disease | |
| Corticobasal ganglionic degeneration | |
| Multisystem atrophy/striatonigral degeneration/olivopontocerebellar atrophy | |
| Idiopathic basal ganglia calcifications/Fahr disease | |
| Demyelinating/Dysmyelinating | Multiple sclerosis |
| Acute disseminated encephalomyelitis | |
| Adrenoleukodystrophy | |
| Metachromatic leukodystrophy | |
| Inherited metabolic | Wilson disease |
| Posterior horn syndrome | |
| Tay-Sachs disease | |
| Neuronal ceroid lipofuscinosis | |
| Niemann–Pick type C | |
| Acute intermittent porphyria | |
| Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) | |
| Cerebrotendinous xanthomatosis | |
| Homocystinuria | |
| Ornithine transcarbamylase deficiency | |
| Epilepsy | Ictal |
| Interictal | |
| Postictal | |
| Forced normalization | |
| Postepilepsy surgery | |
| Lafora progressive myoclonus epilepsy | |
| Medications | Analgesics |
| Androgens (anabolic steroids) | |
| Antiarrhythmics | |
| Anticonvulsants | |
| Anticholinergics | |
| Antibiotics | |
| Antihypertensives | |
| Antineoplastic agents | |
| Corticosteroids | |
| Dopamine agonists | |
| Oral contraceptives | |
| Sedatives/hypnotics | |
| Selective serotonin reuptake inhibitors (SSRIs) (serotonin syndrome) | |
| Drugs of abuse | Alcohol |
| Amphetamines | |
| Cocaine | |
| Hallucinogens | |
| Marijuana and synthetic cannabinoids | |
| Methylenedioxymethamphetamine (MDMA) (Ecstasy) | |
| Phencyclidine | |
| Drug withdrawal syndromes | Alcohol |
| Barbiturates | |
| Benzodiazepines | |
| Amphetamines | |
| SSRIs | |
| Toxins | Heavy metals |
| Inhalants | |
| Other | Normal-pressure hydrocephalus |
| Ionizing radiation | |
| Decompression sickness |
Information should be obtained from multiple sources whenever possible, including parents and any other adults who have spent a significant amount of time with the child, such as teachers. The child should be interviewed separately so as to provide a better chance of obtaining his or her perspective and of uncovering a history of abuse or destructive behaviors, such as substance abuse, self-harm, or high-risk sexual activity. As some psychiatric disorders demonstrate a strong genetic predisposition, a detailed psychiatric family history should be obtained. Psychiatric illness in family members may be undiagnosed; hence, the clinician should inquire about the presence of symptoms in addition to formal diagnoses in the family.
The following validated principles should guide history taking, particularly when discussing sensitive topics such as substance use, sexual abuse, and suicidal ideation or intent:
- 1.
Behavioral incident : The clinician should break down complex patterns of behavior into discrete incidents and focus on concrete details chronologically. Doing so allows the clinician to objectively establish the sequence of behaviors behind sensitive events, particularly when the patient’s subjective responses to the events may influence recall or reporting.
- 2.
Shame attenuation : The clinician should assume a stance of unconditional positive regard so as to minimize the influence of guilt or shame while discussing taboo subjects.
- 3.
Gentle assumption : By framing questions based on the assumption that a behavior exists, the clinician may overcome patient hesitation to acknowledge the presence of that behavior.
- 4.
Symptom amplification : Similar to gentle assumption, by assuming a high frequency of the behavior and inquiring in a concrete manner (e.g., “How many days a week do you drink? 5-6?”), the clinician may make the patient feel more at ease by acknowledging the existence of a particular behavior, particularly if a patient is troubled by the frequency of the behavior.
- 5.
Denial of the specific: By asking specific questions, the clinician may elicit more accurate information by prompting recollection of particular behaviors that may otherwise be denied when asked in general terms. For example, asking the patient whether they have ever used marijuana may be more likely to elicit a positive response than asking the patient whether they have ever used illegal drugs.
- 6.
Normalization: By simply describing common patterns of symptoms or behaviors, the clinician may help the patient feel more at ease by endorsing the presence of similar patterns in his or her behaviors.
The history allows the clinician to define patterns of behavior that suggest a differential diagnosis. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), contains descriptive diagnostic criteria based on the presence or absence of various symptoms and aids the clinician in assigning a specific diagnosis to these behavior patterns and symptom clusters. Terms frequently used in the diagnosis of psychotic illnesses are noted in Table 27.4 .
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Conditions Characterized by Disruptive Behaviors
Disruptive behaviors are broadly categorized by whether they violate the rights of others and are then further classified by whether there is associated difficulty in regulating emotions or behaviors ( Fig. 27.1 ).
Conditions That Do Not Violate the Rights of Others
Attention-deficit/hyperactivity disorder.
The cardinal features of attention-deficit/hyperactivity disorder (ADHD) are hyperactivity, distractibility, and impulsivity. Manifestations of these symptoms must be present in more than 1 setting (e.g., school and home) and must interfere with functioning or development. ADHD is more frequent in males than in females, with a ratio of about 2 : 1 in children. However, females may be underdiagnosed as they are more likely to present with inattention than with hyperactivity. The DSM-5 specifies that there must be a persistent pattern of inattention and/or hyperactivity–impulsivity with 6 or more symptoms in either category lasting at least 6 months. Adolescents 17 years of age or older require only 5 symptoms; however, symptoms should be present prior to 12 years of age.
Inattention
- 1.
Lack of attention to detail or inaccurate work
- 2.
Difficulty sustaining attention
- 3.
Failure to listen when spoken to directly
- 4.
Lack of follow-through
- 5.
Disorganization
- 6.
Avoidance of activities requiring sustained attention
- 7.
Frequent loss of items
- 8.
Easy distraction by extraneous stimuli
- 9.
Forgetfulness
Hyperactivity/Impulsivity
(See Nelson Textbook of Pediatrics, p. 200.)
- 1.
Frequent fidgeting or squirming
- 2.
Frequent need to walk around
- 3.
Restlessness or need to run around/climb
- 4.
Difficulty engaging in quiet activities
- 5.
Acting “on the go,” restlessness, or difficulty of caregivers to keep up with
- 6.
Talking excessively
- 7.
Frequently interrupting
- 8.
Difficulty waiting turn
- 9.
Intrusiveness
The chronicity of the hyperactivity in this disorder may be subtle. Although children with ADHD tend to move around more than other children, the hyperactivity may be of concern only in certain situations in which the child is expected to be quiet (e.g., in school or places of worship). Some children with ADHD can sit and be attentive in quiet and relaxed situations, whereas a noisy and active setting, such as an unstructured classroom, precipitates inappropriate behavior. As these children become older, they often become less overtly hyperactive. For instance, an adolescent may mostly feel restless without acting upon that feeling in a disruptive manner. This restlessness may contribute significantly to academic underachievement. Despite intentions for diligent studying, the restlessness may cause the affected teenager to feel the need to walk around, distracting from studying.
Impulsivity significantly contributes to morbidity. The impulsivity applies not only to actions but also to emotions. An impulsive child whose emotions change quickly is at risk for physically aggressive behaviors, such as hitting or biting. In school-aged children, the impulsive aggression is often manifested as explosive behavior. Because of their explosive behavior, inability to wait their turn in a game, and difficulty regulating emotions when interacting with teachers, these children have great difficulty with both peer and teacher relations. Impulsivity can also be potentially life threatening because the child may act before considering the consequences. Impulsivity may manifest as risk-taking behaviors in both children (e.g., running into the street after a ball without checking for traffic) and adolescents (e.g., high-risk sexual activity or substance abuse).
Hyperactivity and impulsivity in children are often readily apparent to adults; however, the manifestations of inattention and distractibility are often not as overt. In young children, inattentive behavior can consist of shifting from 1 activity to another and having difficulty finishing tasks. The parents may incorrectly consider these actions to represent lack of motivation. In adolescence, inattentive behavior may result in poor school performance. These children may forget to do homework or may need excessively long periods to complete assignments because of their inability to focus on their work and may be mislabeled as being lazy.
The challenge in diagnosing ADHD lies in defining when specific behaviors are abnormal, particularly when those behaviors may not be apparent in all situations or contexts. The clinician should not rely solely on observations obtained in the clinic setting, but should instead gather information from multiple sources, including parents, teachers, daycare workers, and even a direct classroom observation from a trained health care professional. The classroom teacher represents an excellent resource for determining whether the patient’s level of activity and degree of impulsivity are abnormal. Standardized behavioral checklists filled out by the parents and teachers quantify the degree of abnormal behaviors with regard to an age-specific reference population.
Before establishing a diagnosis of ADHD, the clinician must rule out other psychiatric and medical causes of the patient’s symptoms. With respect to psychiatric conditions, the differential diagnosis of ADHD includes learning disorders, oppositional behavior, mood disorders, anxiety disorders, and substance abuse. Because of the high association of learning disorders with ADHD, each evaluation should include an assessment for learning problems .
With respect to medical conditions, the differential diagnosis of ADHD includes iron deficiency, lead toxicity, thyroid disorders, seizures, hearing loss, and substance abuse. Screening for symptoms of sleep-disordered breathing is essential because chronically ineffective or inefficient sleep can produce symptoms of inattention and hyperactivity.
Tic disorders.
Tics are motor movements or vocalizations that are sudden, rapid, recurrent, nonrhythmic, and involuntary. Tics often become worse during stress but may improve during activities requiring moderate physical or mental activity. Tics need to be differentiated from other abnormal movements, such as chorea, athetosis, dystonia, myoclonus, and hemiballismus, which may be associated with an underlying neurologic condition or may be medication-induced. Simple motor tics are defined as repetitive movements of single muscle groups. They may consist of eye blinking, neck jerking, or shoulder shrugging. Complex motor tics are repetitive movements of several muscle groups in coordination, such as repetitive grooming behaviors, deep knee bends, or smelling of objects. Simple vocal tics are defined as nonverbal noises, such as throat clearing or grunting sounds, whereas complex vocal tics are intelligible words. Complex vocal tics may manifest as coprolalia , the repetitive, stereotyped vocalization of obscenities.
The DSM-5 categorizes tic disorders as follows:
- 1.
Provisional tic disorder: motor and/or vocal tics lasting less than a year
- 2.
Chronic motor or vocal tic disorder: either motor or vocal tics lasting longer than a year
- 3.
Tourette disorder: both motor and vocal tics lasting longer than a year
Tourette disorder consists of multiple motor and vocal tics of at least 1 year in duration. The incidence of this condition is 4-5 per 10,000. In some families, this illness is inherited as an autosomal dominant condition, with 70% penetrance in females and near complete penetrance in males. Because of this difference in penetrance, Tourette disorder is 1.5-3 times more common in males than in females. The median age at presentation is 7 years, though some children may present as early as 2 years. While coprolalia is popularly thought to be a common feature of Tourette disorder, fewer than 10% of affected patients have this form of complex vocal tics.
The DSM-5 criteria for Tourette disorder are as follows:
- 1.
Multiple motor and vocal tics lasting longer than a year with no tic-free intervals longer than 3 months
- 2.
Symptom onset before age 18 years
- 3.
No medical cause for the tics
Tics may lead to the patient being socially ostracized. Children with chronic tic disorders frequently have other psychologic conditions, such as ADHD or obsessive-compulsive disorder (OCD), which may lead to further difficulties in peer interactions and frequent frustration of teachers and family members. Such stressors can worsen the tics, which can further compound the problem.
Disruptive mood dysregulation disorder.
While the predominant characteristic of disruptive mood dysregulation disorder (DMDD) is chronic, persistent, and severe irritability, it is often the behavioral issues that prompt presentation to a clinician. DMDD often manifests as irritable, depressed mood and temper tantrums with a low frustration tolerance. The DSM-5 requires the following for diagnosis:
- 1.
Severe recurrent temper outbursts that manifest with verbal or behavioral aggression out of proportion to the situation in intensity or duration
- 2.
Behavior is inconsistent with developmental level
- 3.
Behavior occurs on average 3 or more times per week
- 4.
The mood between outbursts is persistently irritable or angry
- 5.
Symptoms present for 12 or more months
- 6.
Symptoms present in at least 2 settings
- 7.
Age of onset of symptoms must be before age 10 years, but diagnosis should not be made before age 6 years or after age 18 years
The overall prevalence of DMDD among children and adolescents is as high as 5%. Rates are higher in males and school-aged children than in females and adolescents. DMDD can cause significant difficulties with school performance and family/peer relationships. Many children with DMDD will also meet criteria for ADHD, oppositional defiant disorder (ODD), or anxiety disorders. The diagnosis of DMDD should be distinguished from bipolar disorder, which must have distinct episodes of mania or hypomania ( Table 27.5 ). The age of the patient can also help differentiate DMDD and bipolar disorders because bipolar disorders rarely present prior to adolescence.
The following conditions require clinically significant distress or impairment in social or occupational functioning:
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Substance Use Disorder.
Substance use can lead to a wide range of disturbances in mood and behavior. The hallmark of a substance use disorder is the continued use of a substance despite it causing ongoing negative cognitive, behavioral, and physiologic symptoms. The other hallmark of substance use disorder is the significance of the negative behaviors, such as verbal or physical aggression, defiance, lying, or stealing. Sometimes these behaviors will reach the point of violating family and friends.
Conditions That Violate the Rights of Others
Oppositional defiant disorder.
The characteristic feature of ODD is a persistent pattern of both defiant behavior and an angry or irritable mood. Affected individuals exhibit at least 4 of the following behaviors in a consistent manner over a 6-month period:
- 1.
Frequently losing temper
- 2.
Often arguing with authority figures
- 3.
Defying rules
- 4.
Deliberately annoying adults
- 5.
Blaming others for his or her actions
- 6.
Becoming easily annoyed by others
- 7.
Being angry
- 8.
Being vindictive
ODD should not be diagnosed if the patient meets the DSM-5 criteria for conduct disorder or if the symptoms occur in the context of a mood, anxiety, or psychotic disorder, in which children exhibit oppositional behavior as a reaction to their illness.
Prevalence ranges from 1-11%, depending on the population. In prepubertal children, it occurs more frequently in boys; however, in adolescents, its incidence is equal in both sexes. Most children present before 8 years of age. Affected preschool-aged children sometimes exhibit increased motor activity, difficulty being comforted, and overreacting to situations. Affected school-aged children have low self-esteem and a low tolerance for frustration. The disorder commonly occurs in families with a history of mood or psychotic disorders—particularly maternal depression—and with chronic disruptive behaviors, such as ADHD or conduct disorder.
Children with this disorder are at marked risk for other psychologic disorders, such as ADHD. In addition, these patients may be at increased risk for conduct disorder, antisocial personality disorder as adults, substance abuse, major depressive disorder, and suicide.
Conduct disorder.
A child has conduct disorder if he or she has repetitively violated the rights of others and of society. Children with this diagnosis have performed 3 or more of the following behaviors within the past year and with at least 1 occurring in the previous 6 months:
- 1.
Aggression toward people or animals, such as intimidation, initiation of fights, use of weapons, cruelty to people, cruelty to animals, rape, confrontational theft or mugging
- 2.
Destruction of property, such as arson or vandalism
- 3.
Deceitfulness or theft, such as breaking into houses or cars or stealing items of nontrivial value
- 4.
Serious violation of rules, such as curfew violation, running away, or truancy before the age of 13 years (for running away to qualify as a symptom, it must occur twice, or once if it was lengthy, and must not be an attempt to escape sexual or physical abuse)
Conduct disorder is classified as childhood onset if symptoms occur before 10 years of age and adolescent onset if symptoms occur at or after 10 years of age. It is further subdivided by severity of offense: mild (e.g., truancy), moderate (e.g., vandalism, nonconfrontational theft), and severe (e.g., rape, confrontational theft). The prevalence of conduct disorder is higher in males than in females. Children initially present with lying, initiating fights, and truancy; as they get older, they progress to more violent acts. Boys are more likely to exhibit acts of violence, such as fighting and stealing, than are girls, who are more likely to exhibit truancy, runaway behavior, and high-risk sexual activity. Half of these children may develop antisocial personality disorder , which is a severe conduct disorder of adulthood that is usually associated with criminal activity. The earlier the onset of conduct disorder, the greater the risk of developing antisocial personality disorder as an adult. These children also have a high frequency of depression, suicidal ideation, personality disorders, anxiety disorders, ADHD, and substance abuse.
Although the cause of conduct disorder is unknown, both genetic and psychosocial factors play a role. A history of parental rejection, difficult infant temperament, physical or sexual abuse, early institutional living, and lack of appropriate discipline are associated with the development of conduct disorder. A biochemical or genetic cause for this condition has been postulated due to the high prevalence of this condition in families with psychiatric disorders.
Conditions Characterized by Disruption in Mood
Mood disorders are divided into those characterized by a depressed mood and those characterized by extremes of mood lability. When assessing mood disturbances, it is essential to screen for symptoms suggestive of bipolar illness as these patients have a risk of becoming manic when treated with antidepressants ( Fig. 27.2 ). The evaluation of any patient with a disruption in mood should include an assessment of the risk of suicide.
Conditions Characterized by Depressed Mood
(See Nelson Textbook of Pediatrics, p. 151.)
Depressive disorders that may present in childhood include DMDD, major depressive disorder, premenstrual dysphoric disorder, persistent depressive disorder (i.e., dysthymia), substance/medication-induced depressive disorder, adjustment disorder with depressed mood, and depressive disorder related to another medical condition.
Major depressive disorder.
Major depressive disorder is associated with serious risks of both suicide and significant social and academic impairment (see Table 27.5 ). Presentations may be subtle. Even though a child may be pervasively sad, he or she may also present with behavior problems and irritability. Patients may also present with somatic complaints, psychosis, or both. The psychotic symptoms are typically mood-congruent auditory hallucinations and delusions of guilt, medical illnesses, or deserving punishment. DSM-5 criteria for major depressive disorder consist of at least a 2-week period of a depressed mood—or irritability in some children—or loss of interest in pleasurable activities, resulting in significant impairment. During this period, the patient has to have at least 5 of the following symptoms:
- 1.
Depressed mood or irritability in some children
- 2.
Loss of interest or pleasure
- 3.
Loss of appetite or overeating
- 4.
Insomnia or hypersomnia
- 5.
Fatigue or loss of energy
- 6.
Feelings of worthlessness or guilt
- 7.
Poor concentration or indecisiveness
- 8.
Suicidal ideation or thoughts of death
- 9.
Psychomotor agitation or retardation
These symptoms should not be secondary to bereavement, medical conditions, substance abuse, or bipolar disorders. Emotional reaction to adverse stressors is a normal part of life. The clinician must decide whether the reaction to the stressor is normal, an adjustment disorder, or major depression.
The occurrence of major depressive disorders in adolescence is as high as 5%. There is also a 3-fold increase in major depression in children who have a parent with depression. The differential diagnosis of major depression encompasses various medical disorders, including neurologic disorders, endocrine disorders such as hypothyroidism or hyperparathyroidism, side effects from medications such as H 2 -blockers or isotretinoin, and substance abuse or use (see Table 27.3 ). Numerous psychiatric conditions are comorbid with major depression. Among these are ODD, conduct disorder, ADHD, anxiety disorders, eating disorders, and substance abuse.
Major depressive disorder can manifest at any age; however, most patients present in early adulthood. Children usually present with somatic complaints, social withdrawal, and irritability, whereas adolescents often present with psychomotor retardation, thoughts of guilt and worthlessness, and excessive sleep. Approximately 15% of children with major depression eventually develop bipolar disorders. Fifty percent of children with major depression have multiple episodes, frequently associated with significant stressors. Approximately 25% of patients with certain chronic medical conditions such as cancer or diabetes develop major depressive disorder during the course of the illness. The main difficulty in diagnosing major depression is that the gravity of the depressive mood is often not always apparent to the parent and the clinician. Given that children and adolescents often present with irritability, sullenness, or mean-spiritedness, the parents and/or clinician may attribute this behavior to typical adolescent behavior. These children do not always appear sad and the clinician should have a high index of suspicion of major depression in any child who presents with sullenness and irritability. Guidelines for evaluating such a patient are as follows:
- 1.
Assess suicidal ideation and ensure the patient’s safety.
- 2.
Obtain collateral information from other sources to determine the child’s functioning and symptoms.
- 3.
Obtain a thorough family history for symptoms and formal diagnoses of mood disorders.
- 4.
Rule out bipolar disorders by assessing for symptoms of mania or hypomania.
- 5.
Investigate primary or comorbid conditions, such as substance abuse.
- 6.
Consider the role of life stressors in relationship to the symptoms.
Premenstrual dysphoric disorder.
Both physical and mood symptoms can occur prior to a female’s menstrual cycle. When the symptoms are severe, they may constitute premenstrual dysphoric disorder, the primary features of which are mood lability, irritability, dysphoria, and anxiety that appear recurrently during the premenstrual phase of a female’s cycle and then resolve around the onset of menses. Delusions or hallucinations have been described but are rare. The 12-month prevalence is as high as 6% of menstruating women. Onset can be any time after menarche. Factors such as stress, a history of trauma, and seasonal changes can contribute. The DSM-5 states that the following criteria must be met:
- 1.
In the majority of cycles, at least 4 of the following symptoms: marked affective lability (mood swings, increased sensitivity to rejection), irritability or anger, increased interpersonal conflicts, depressed mood, feelings of hopelessness or self-deprecating thoughts, anxiety, tension
- 2.
At least 1 of the following: decreased interest in activities, difficulty concentrating, lack of energy, change in appetite, change in sleep, sense of being out of control, physical symptoms of breast tenderness, joint pain, bloating, or weight gain
- 3.
Symptoms present during the majority of cycles over the year prior
The severity of symptoms is similar to that in other psychiatric disorders, such as major depression or generalized anxiety disorder, though the duration of symptoms is shorter. Nonetheless, symptoms do need to be severe and cause marked impairment in functioning in order to satisfy diagnostic criteria. To confirm the diagnosis, daily prospective symptom ratings are required for at least 2 cycles.
Substance-induced mood disorders.
Substance-induced disorders are distinct from substance use disorders. Whereas the latter refer to the negative consequences of substance use over time, the substance-induced disorders refer to the immediate effects of substance use— intoxication and withdrawal —and to the substance-induced mental disorders , which include psychotic disorders, anxiety disorders, depressive disorders, bipolar and related disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunction, delirium, and neurocognitive disorders. The hallmark of substance-induced mental disorders is that the symptoms of the disorder are attributable to the ingestion of the substance and were not present prior to ingestion. While symptoms may abate as the pharmacologic activity of the substance abates, repeated use may lead to chronic changes in neurophysiology, and as such, behavioral effects may persist even when the substance is no longer used.
The substances specified in the DSM-5 include alcohol, caffeine, cannabis (also synthetic cannabinoids), hallucinogens (including phencyclidine and others), inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants, tobacco, and “other.” Defining the symptom complex associated with each individual substance is out of the purview of this text; however, the possibility of substance use/abuse as a cause for behavioral and mood disruption is critical for all physicians to recognize. The patient interview should include time to speak with the patient individually, without a parent or other caregiver present, so as to establish rapport, to incorporate the techniques of normalizing and remaining non-judgmental, and to encourage a patient to discuss their substance use.
Adjustment disorder.
Adjustment disorder is an excessive or maladaptive response to a stressor, and diagnosis is contingent upon the recognition of a particular stressor. Typical stressors for children and adolescents include separations, painful injuries, illness, hospitalization or surgery, parental divorce, change of residency, academic failure, and conflict with peers. The DSM-5 criteria for adjustment disorder are as follows:
- 1.
The symptoms develop within 3 months of the stressor.
- 2.
Significant social and/or academic impairment results.
- 3.
The symptoms do not meet criteria for mood or anxiety disorder.
- 4.
The symptoms do not represent bereavement.
- 5.
The symptoms abate 6 months after termination of the stressor.
This disorder is further classified by the patient’s symptoms, such as depressed mood , anxiety , and/or conduct disorder . Affected patients may be at increased risk for suicide, particularly if social and/or academic impairment are severe. If the stressor is an illness or its treatment, the morbidity of the medical condition may increase as a consequence of noncompliance. The differential diagnosis of adjustment disorder is a mood or anxiety disorder, exacerbation of a personality disorder, or post-traumatic stress disorder (PTSD).
Conditions Characterized by Extremes of Mood Lability
(See Nelson Textbook of Pediatrics, p. 157.)
The bipolar disorders include bipolar I disorder, bipolar II disorder, and cyclothymic disorder. All are characterized by the presence of either mania or hypomania. Mania manifests acutely, leads to significant functional impairments, and is characterized by racing thoughts, distractibility, delusions of grandeur, and other disturbances in thinking. Problematic behaviors during a manic episode include recklessness (e.g., excessive participation in social activities, high-risk sexual activity, buying sprees), agitation, decreased sleep, and excessive talkativeness. A manic episode is defined as an abnormally elevated, euphoric, expansive, or irritable mood for at least 1 week unless treated. This mood disturbance is associated with at least 3 of the following symptoms or 4 if the mood is irritable:
- 1.
Grandiosity
- 2.
Decreased need for sleep
- 3.
Talkativeness
- 4.
Racing thoughts
- 5.
Distractibility
- 6.
Excessive goal-directed activity or psychomotor agitation
- 7.
Reckless pursuit of pleasure
The symptoms of a hypomanic episode are the same, though are present for a shorter duration (i.e., 4 days or fewer), are not associated with psychotic symptoms of delusions or hallucination, and are not severe enough to cause major social or academic dysfunction. Up to 10% of patients with hypomania will eventually develop mania.
Bipolar I disorder is characterized by the presence of manic episodes. Patients may also have prior or subsequent episodes of hypomania or major depression, though these are not required. Bipolar II disorder is characterized by the presence of major depression episodes and hypomania. Cyclothymic disorder is a chronic, cyclic illness of hypomania and depressive symptoms without episodes of major depression.
Comorbid psychiatric conditions include eating disorders, ADHD, conduct disorders, panic disorders, social phobias, adjustment disorders, substance use disorders, and substance-induced disorders. The lifetime prevalence of bipolar I disorder is as high as 1.6%, and that of bipolar II disorder is 0.5%. Approximately 15% of adolescents with recurrent major depression eventually develop bipolar illnesses.
The differential diagnosis of the bipolar disorders includes schizophrenia and medical conditions that cause changes in mental status, particularly thyroid disorders, Cushing disease, and multiple sclerosis (see Table 27.3 ). Substance-induced mood disorders must also be considered, particularly those associated with cocaine, tricyclic antidepressants and selective serotonin reuptake inhibitors. The clinician should obtain a detailed family history as bipolar disorder frequently runs in families. Because the condition is often undiagnosed in parents, the questions should be directed toward the presence of the symptoms for bipolar disorders. The following principles should guide the evaluation of patients with symptoms of depression or mania:
- 1.
Recognize the symptoms mania and hypomania.
- 2.
Remember that depressed patients often have bipolar disorders.
- 3.
Obtain a thorough family history to look for symptoms of mood disorders.
- 4.
Consider bipolar illnesses in patients with any disruptive disorder that does not respond to treatment.
- 5.
Assess for drug and/or alcohol use as substances may induce bipolar disorder, and substance use is frequently a comorbid condition.
Borderline personality disorder is a chronic personality disorder characterized by intense mood lability, impulsivity, identity disturbances, and unstable relationships. The diagnosis may be challenging in adolescents whose appropriate psychologic development includes the forging of identity and personality traits; however, since borderline personality disorder is associated with significant morbidity and potential mortality, it should be considered in the differential diagnosis of a patient presenting with significant mood or behavioral issues. Diagnosis requires 5 or more of the following:
- 1.
Significant efforts to avoid real or imagined abandonment
- 2.
Unstable and intense relationships with extremes of idolization and devaluation
- 3.
Marked identity disturbances with unstable sense of self
- 4.
Significant impulsivity in at least 2 areas that are potentially self-damaging: spending, sexual activity, substance abuse, reckless driving, or binge eating
- 5.
Recurrent suicidal or self-mutilating behavior
- 6.
Intense dysphoria, irritability, or anxiety
- 7.
Chronic feelings of emptiness
- 8.
Inappropriate anger
- 9.
Transient, stress-related paranoia or dissociation
Both genetic and psychosocial factors are believed to be causative. Risk factors for borderline personality disorder include a history of abuse, neglect, or early parental loss. The median population prevalence is approximately 6% in primary care settings and is as high as 10% in outpatient mental health clinics. Females are more frequently diagnosed than males, at a ratio of 3 : 1.
Addressing Suicidal Thoughts and Attempts
Suicide is the second leading cause of death in adolescents, and assessing the risk of suicide is a critical component in the evaluation of any child or teen. Although depression is an important risk factor for suicide, only half of adolescents who attempt suicide have clinically diagnosable depression. In those without depression, strong predictors of suicide are impulsivity and low frustration tolerance. The approach to evaluating suicidality is complicated and includes a stepwise process of probing first for latent thoughts of suicidality ( Table 27.6 ), then for active suicidal intent. Key to this process is assessing whether the child is considering acting on thoughts of death or suicide. To assess risk, the interviewer should focus on the risk factors for completed suicide , which include the following:
- 1.
Male sex
- 2.
Adolescence
- 3.
Formation of a conscious plan
- 4.
Presence of available means (e.g., medications, firearms)
- 5.
Depression
- 6.
Hopelessness
- 7.
Impulsivity
- 8.
Low frustration tolerance
- 9.
Use of intoxicants
- 10.
Sexual identity conflicts
- 11.
Recent death of family member or friend
- 12.
Previous suicide attempts
