Young Families INSIGHTS
May 2004
Linda Swann, NAMI NC Young Families Program Coordinator, Editor
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 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)
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.
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:
- Tell me what happened.
- Tell me what you think your mistake was.
- Review the scenario or moral of what happened.
- 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, and
www.fape.org.
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