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Great Smoky Mountain Study Raises Estimates Of Youth with Mental Illness

Several new findings from the seven-year Great Smoky Mountain Study (GSMS) have led some researchers to conclude that a higher number of children reach adolescence with psychiatric disorders than previously thought.

The results, reported in the August 2003 Archives of General Psychiatry, show that by the time children in the study reached age 16, 1 in 3 had or had had at least one psychiatric disorder. As children grew older, psychiatric disorders were more likely to be accompanied by significant functional impairment.

While girls had higher rates of anxiety and depressive disorders, boys had significantly higher rates of behavioral disorders, especially conduct disorder. One in four children diagnosed with a psychiatric disorder during the study had two or more comorbid disorders. Depression was linked with conduct disorder in girls, while depression was linked with substance abuse disorders in boys.

A randomized multistage study of 1,420 children and adolescents residing in western North Carolina was conducted between 1993 and 2000. Three cohorts of children were recruited at ages 9, 11, and 13 and assessed yearly until age 16. Both parents and children were interviewed yearly during the study.

The researchers, who are in the departments of psychiatry and behavioral sciences and biostatistics and bioinformatics at Duke University Medical School, used the Child and Adolescent Psychiatric Assessment (CAPA) developed by psychiatrist and co-investigator Adrian Angold, M.D., and psychologist and principal investigator Jane Costello, Ph.D.

The CAPA measures three-month prevalence rates because the researchers found that memory recall of symptoms decreased after three months. The CAPA is compatible with DSM-IV criteria and is considered by research experts to be a valid, reliable instrument.

Costello and her colleagues predicted in a 1996 article based on the first wave of data from the GSMS study that 1 in 6 children would have at least one psychiatric disorder by age 16. When the second wave of data was available in 2000 and analyzed, the authors revised their original prediction to about 1 in 3 children.

Peter Jensen, M.D., director of the Center for the Advancement of Children's Mental Health in New York City, commented to Psychiatric News that Costello's finding is similar to that of Ronald Kessler, Ph.D., and his colleagues; they conducted the National Comorbidity Survey of 15- to 54-year-olds published by the Archives in 1994. The authors found that up to 30 percent of 15-year-olds had one or more psychiatric disorders.

"Globally, clinicians are reporting higher rates of depression and behavioral disorders in youth than in the past decade. This may reflect better diagnostic tools and the cohorts' age difference," said Jensen.

The researchers found that "[o]nce children, particularly girls, develop a psychiatric disorder, their chances of continuing to have one, or of developing another episode after remission, are much higher than those of their unaffected peers." A pattern of having the same disorder diagnosed at various points in time was significant for all disorders except specific phobias.

Costello told Psychiatric News, "I was surprised by how much continuity there was among diagnosed psychiatric disorders except for specific phobias. This homogeneity was greater in girls than in boys."

David Shaffer, M.D., a psychiatrist and expert on mood disorders in youth, commented, "I found the paper interesting not because the numbers were very different from what others had reported, but because it illustrates the way disorders unfold, taking into account common comorbidities that exist for many important disorders."

He continued, "We know that anxiety and depression often co-occur and one precedes the other, but this study shows the bidirectional movement between the disorders and how they oscillate between one another over time."

Shaffer also commented on the connection between anxiety and substance abuse. "The paper, while not fully exploring this, does cast light on the old idea that depression predisposes someone to substance abuse. Self-medication with substances for anxiety makes a whole lot more sense than self-medication for depression because so many substances do relieve anxiety, while it is unclear that they relieve depression."

The abstract of Costello's study (Prevalence and Development of Psychiatric Disorders in Childhood and Adolescence) is posted on the Web at:

http://archpsyc.ama-assn.org/cgi/content/abstract/60/8/837

Source:

Archives of General Psychiatry, vol. 60 no. 8, August 2003)

 

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BIPOLAR DISORDER IN CHILDREN & ADOLESCENTS:
WHAT'S IN A NAME?
By Diane Weaver

I hear there is controversy about diagnosing bipolar disorder in children. What is this controversy all about?

"Classic" bipolar disorder, as defined in the DSM-IV (Diagnostic & Statistical Manual), consists of cycles of mania lasting at least one week and depression lasting at least two weeks, often with periods of normal mood lasting months or years. Many adults with bipolar disorder, however, can look back over their teen and childhood years and describe a fairly consistent group of symptoms. This suggests child- and adolescent- syndromes that either precede classic bipolar or, in fact, are bipolar disorder.

Children and adolescents exhibit somewhat different patterns of symptoms than adults. For example, children typically cycle between mania and depression more rapidly, usually several times a day. Children also experience "mixed mania," depression and mania simultaneously. Early-onset bipolar often begins with one or more depressive episodes, unlike adult-onset, which more often begins with a manic episode. Barbara Geller, M.D. of Washington University, St. Louis, has found that childhood-onset bipolar tends to be more intense with more severe symptoms than adult-onset bipolar.

To cloud the diagnostic picture further, childhood-onset bipolar is likely to coexist with Attention Deficit Disorder (ADD). When bipolar symptoms begin in the teen years, there is less likelihood of comorbid ADD. Adult-onset bipolar disorder has even less of a relationship to ADD. ADD and bipolar disorder have some overlapping symptoms, making differential diagnosis difficult.

To add to the mixture of symptoms, anxiety disorders are also often associated. For example, adults with bipolar disorder very often have panic disorder as well. The equivalent in childhood is believed by some researchers to be bipolar with separation anxiety disorder. Often children with bipolar disorder follow their mother or primary caregiver from room to room and experience anxiety when at school or otherwise separated from the caregiver.

Other co-occurring ("comorbid") conditions may include obsessive-compulsive disorder, Tourette's Disorder, learning disabilities, oppositional-defiant disorder, conduct disorder, self-mutilation, and eating disorders.

G. Robert DeLong, M.D., Professor of Pediatrics (Neurology) at Duke University, has found than autism-spectrum disorders - especially Asperger's Disorder - occur in families with bipolar disorder at an unusually high rate. There may be an association between these two disorders. Many children have both bipolar and Asperger's..

Additionally, children and adolescents with bipolar disorder tend to have ADD, mood and anxiety disorders, as well as alcoholism in their family history.

Symptoms may change over time. For example, a child may start out with what appears to be obsessive-compulsive disorder and depression, which then morphs into bipolar in the teen years. One-quarter to one-third of teens with depression will eventually develop bipolar disorder.

Symptoms may disappear entirely in the teen years, only to reappear in adult years. Occasionally symptoms weaken over time. There are many patterns. Science has not yet sorted out the underlying relationship between groups of symptoms and brain functioning. The diagnostic names now used may disappear over the next few decades as we learn more about the actual brain malfunctions causing various patterns of symptoms.

Peter Jensen, M.D., of Columbia University's School of Medicine, recommends that parents and clinicians expect symptoms and diagnoses to change as the illness(es) unfold. This is a reflection of the current imperfect state of diagnosis and the unpredictable course of these disorders. We do not really understand their progression over the developmental years, and we do not understand the relationship of the illnesses with one another. The best we can do for now is to keep track of symptoms and treat them. Diagnoses are useful "handles" for describing a particular group of symptoms, but do not necessarily reflect biological reality.

Many psychiatrists now diagnose bipolar disorder in children and adolescents. It is nice to have a name for the disorder. Other psychiatrists are reluctant to use the name "bipolar," and may instead diagnose "Intermittent Explosive Disorder," or "Mood Disorder, not otherwise specified." What matters the most is that the psychiatrist diligently pursue medication trials that include mood stabilizers, working in partnership with parents and child to achieve the best symptom control with the least bothersome side-effects.

One thing is not in doubt. What is increasingly being diagnosed as childhood-onset bipolar is intense, severe and debilitating. No controversy over the naming of the illness should obscure the suffering it causes children and families, nor should it delay aggressive treatment.

 

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Success, the BEST Motivator

How many times do children hear that they would do better in school if they would just "try harder?" According to Rick Lavoie, international expert on learning differences, the statement should actually be, "If children did better, they would try harder." In other words, success is the best motivator of all. This is the philosophy that teachers should use in the classroom and parents, at home.

Rick Lavoie, a former special education teacher, presents workshops for parents of children with disabilities and for professionals. He grew up with ADD - attention deficit disorder - and found himself in trouble a lot. He says that people with ADD need "stimulation like other people need oxygen."

For students to be truly motiviated, Lavoie says three things need to be present:

• The goal must be attractive,
• The effort must be realistic, and
• The likelihood of success must be high.

As a matter of fact, Lavoie says "every human behavior is motivated. Motivation is constant even thought performance, behavior, and productivity might change." He goes on to say that offering gifts and treats does not motivate children, even if it gets them to change their behavior. Research, we learn, has proven that even competition is not motivating, says Lavoie.

He tells the story of a young boy who had convinced everyone, even his parents and teachers, that he was unable to read because of deafness. The eight-year old boy underwent exploratory surgery rather than admit the truth to his parents. He simply did not know how to read. He was so motivated to avoid embarrassment in front of his classmates that he faked deafness.

Lavoie also talks a lot about social skills. He says, "You can't do anything without social skills." Every environment is social. As a matter of fact, he adds that social competence is a measure of adult success - "more than academic skills." Many children with disabilities, we know, lack social skills. Some even totally miss social cues. These children do not know when they are violating the "hidden curriculum" at school. They don't know when someone is mistreating them. They don't understand that the tough kids hang out at a certain entrance to the building and they should avoid using that door.

For that reason, Lavoie recommends that teachers include formal social skills training in their classroom. It should be part of a student's Individualized Education Program (IEP). We should also remember that administering punishment is no way to teach social skills. "No one makes a social error on purpose," says Lavoie. Use social errors to teach, not punish.

Lavoie also promotes a teaching method called "social skills autopsy." It involves examining the cause of the social error, figure out the damage, and work to prevent a recurrence. Steps include:

1. Tell me what happened.
2. Tell me what you think your mistake was.
3. Review the scenario or moral of what happened.
4. Do social skills homework. Use the new skill and report back to the teacher.

Source:

Pacesetter, Summer 2003, Vol. 26, Issue 2)

PACER, a training and information center for families of children with all disabilities, provides a wide variety of resources, including free e-newsletters, to parents and professionals. For more information on making decisions about education and other services for children with disabilities check out their web sites:

www.pacer.org

www.taalliance.org

www.fape.org