Emotional and Behavioral Symptoms

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. Safety should always be assessed and should include risk of suicide, homicide, and abuse (physical, sexual, emotional, and neglect). The history should then focus on delineating the specific behaviors of concern, on identifying any stressors that may be precipitating the behavior ( Table 31.1 ), and on recognizing any associated symptoms that may differentiate which disorder or disorders are causing the behavior ( Table 31.2 ). In addition to primary psychiatric diagnoses, the clinician should focus on possible medical causes of the behaviors in question, including medication side effects, substance misuse, and medical illnesses ( Tables 31.3 and 31.4 ). 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.

TABLE 31.1

Common Precipitants of Psychiatric Symptoms

Substance misuse
Stress
Death or illness of family or friend
Interpersonal conflict, including bullying
Rejection or abandonment
Significant change in routine
Homelessness

TABLE 31.2

Disruptive Behavior Disorders

A “+” indicates symptoms are seen in the disorder. A “-” indicates symptoms are not seen in the disorder.

Symptom	Intermittent Explosive Disorder	Disruptive Mood Dysregulation Disorder	Oppositional Defiant Disorder	Conduct Disorder
Aggressive outbursts	+	+	+	+
Property destruction or physically assaultive	+	+	+	+
Persistently irritable	−	+	+/−	−
Purposefully defiant	−	−	+	+
Vindictive	−	−	+	+
Argues with authority	−	−	+	+
Stealing	−	−	−	+
Use of a weapon or fire setting	−	−	−	+
Run away from home/truancy	−	−	−	+

TABLE 31.3

The MIDAS Mnemonic for Screening for Medical Illness

From Carlat DJ. The Psychiatric Interview . 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2011.

M: Do you take any M edications?
I: Do you have any medical I llnesses?
D: Do you have a primary care D octor?
A: Have you ever had any A llergies, reactions, or side effects?
S: Have you ever had any S urgery?

TABLE 31.4

Medical (Secondary) and Psychiatric (Primary) Causes of Psychosis and/or Depression

Category	Disorders
Psychiatric	Schizophrenia Schizoaffective Schizophreniform Brief psychotic Major depression Bipolar Postpartum
Head trauma	Traumatic brain injury Subdural hematoma
Infectious	Viral infections/encephalitides (HIV infection/encephalopathy, herpes encephalitis, cytomegalovirus. Epstein-Barr virus, COVID-19) Lyme disease Cerebral malaria Endocarditis Neurosyphilis Whipple disease
Inflammatory	Autoimmune encephalitis: NMDAR, limbic, others Systemic lupus erythematosus Sjögren syndrome Hashimoto encephalopathy (steroid-responsive encephalopathy associated with autoimmune thyroiditis [SREAT]) Sydenham chorea Sarcoidosis Celiac disease
Neoplastic	Primary or secondary cerebral neoplasm Paraneoplastic encephalitis: ovarian teratoma-associated autoimmune encephalitis Systemic neoplasm Pheochromocytoma
Endocrine or acquired metabolic	Hepatic encephalopathy Uremic encephalopathy Hypo/hyperparathyroidism Hypo/hyperthyroidism Addison disease Cushing disease Vitamin deficiency: vitamin B ₁₂ , folate, niacin, vitamin C, thiamine Gastric bypass–associated nutritional deficiencies Hypoglycemia Hyponatremia
Vascular	Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) Other vasculitis syndromes Stroke
Degenerative	Idiopathic basal ganglia calcifications, Fahr disease Neuroacanthocytosis Neurodegeneration with brain iron accumulation (NBIA) Tuberous sclerosis Huntington disease Corticobasal ganglionic degeneration Multisystem atrophy, striatonigral degeneration, olivopontocerebellar atrophy
Demyelinating, dysmyelinating	Multiple sclerosis Acute disseminated encephalomyelitis Adrenoleukodystrophy Metachromatic leukodystrophy
Inherited metabolic	Wilson disease Posterior horn syndrome Tay-Sachs disease (adult onset) Neuronal ceroid lipofuscinosis Niemann-Pick disease type C Acute intermittent porphyria Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) Mitochondrial neurogastrointestinal encephalopathy (MNGIE) Cerebrotendinous xanthomatosis Homocystinuria Ornithine transcarbamylase deficiency Phenylketonuria
Syndromes	Williams Prader-Willi Marfan Fragile X Deletion 22q11.2 Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, autonomic dysregulation (ROHHAD) Klinefelter
Epilepsy	Ictal Interictal Postictal Postepilepsy surgery Lafora progressive myoclonic epilepsy Complex partial (temporal lobe)
Substance induced (medications)	Analgesics Acyclovir Androgens (anabolic steroids) Antiarrhythmics Anticonvulsants Anticholinergics Antihypertensives Antineoplastic agents β-Blocking agents Cefepime Clarithromycin Cyclosporine Dextromethorphan Dopamine agonists Ketamine Fluoroquinolones Metronidazole Sulfamethoxazole-trimethoprim Oral contraceptives Sedatives/hypnotics Selective serotonin reuptake inhibitors (SSRIs) (serotonin syndrome) Steroids
Substance induced	Alcohol Amphetamines Cocaine LSD Marijuana and synthetic cannabinoids Methylenedioxymethamphetamine (MDMA, Ecstasy) Phencyclidine Mescaline Psilocybins (mushrooms)
Drug withdrawal syndromes	Alcohol Barbiturates Benzodiazepines Amphetamines SSRIs
Toxins	Heavy metals: lead, mercury, arsenic Carbon monoxide Inhalants Organophosphates St. John’s Wort
Other	Normal-pressure hydrocephalus Ionizing radiation Decompression sickness Narcolepsy

Information should be obtained from multiple sources whenever possible. This can include any adults who have spent significant time with the child, such as parents, other family members, guardians, and teachers. The child should be interviewed separately so as to provide a better chance of obtaining their perspective of the presenting symptoms. The patient may also be more comfortable disclosing a history of abuse or destructive behaviors, such as substance misuse, self-harm, or high-risk sexual activity, during an individual interview. Because some psychiatric disorders demonstrate a strong genetic predisposition, a detailed psychiatric family history should be obtained. Psychiatric illness in family members may be undiagnosed; 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 analysis : 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 (e.g., “How often do you have suicidal thoughts?”).
4.
Symptom amplification : 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. 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 their 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 31.5 . The persistence, frequency, and severity of behaviors should be used to distinguish a behavior that is symptomatic from a behavior that is within normal limits. When a behavior does not meet a clinical threshold, it can be just as important for the provider to reassure a family and provide support during a difficult time of normal development. A classic example would be a 2 year old expressing their autonomy or a teenager struggling to establish their individual identity.

TABLE 31.5

Psychiatric Terms

From Perez DL, Murray ED, Price BH. Depression and psychosis in neurological practice. In: Daroff RB, Jankovic J, Mazziotta JC, Pomeroy SL, eds. Bradley’s Neurology in Clinical Practice . 7th ed. Philadelphia: Elsevier; 2015.

Abulia is the state of reduced impulse to act and think associated with indifference about consequences of action.
Affect is the examiner’s observation of the patient’s emotional state. Frequently used descriptive terms include the following:
- Constricted affect is reduced range and intensity of expression.
- Blunted affect is further reduced. Usually, there is little facial expression and a voice that is monotone and lacking normal prosody.
- Flat describes severely blunted affect in which there is no affective expression.
- Inappropriate affect is an incongruous expression of emotion or behavior relative to the content of a conversation or social norms.
- Labile affect exhibits abrupt and sudden changes in both type and intensity of emotion.
Anxiety is the feeling of apprehension caused by anticipation of danger that may be internal or external.
Apathy is dulled emotional tone associated with detachment or indifference.
Comportment refers to self-regulation of behavior through complex mental processes that include insight, judgment, self-awareness, empathy, and social adaptation.
Compulsion is the uncontrollable impulse to perform an act repetitively.
Confusion is the inability to maintain a coherent stream of thought owing to impaired attention and vigilance. Secondary deficits in language, memory, and visual spatial skills are common.
Delusion is a false, unshakable conviction or judgment that is out of keeping with reality and with socially shared beliefs of the individual’s background and culture. It cannot be corrected with reasoning.
Depression is a sustained psychopathologic feeling of sadness often accompanied by a variety of associated symptoms, particularly anxiety, agitation, feelings of worthlessness, suicidal ideation, abulia, psychomotor retardation, and various somatic symptoms and physiologic dysfunctions and complaints that cause significant distress and impairment in social functioning.
Hallucination is a false sensory perception not associated with real external stimuli.
Mood is the emotional state experienced and described by the patient and observed by others.
Obsession is the pathologic persistence of an irresistible thought or feeling that cannot be eliminated from consciousness by logical effort. It is associated with anxiety and rumination.
Paranoia is a descriptive term designating either morbid-dominant ideas or delusions of self-reference concerning one or more of several themes, most commonly persecution, love, hate, envy, jealousy, honor, litigation, grandeur, and the supernatural.
Prosody is the melodic patterns of intonation in language that convey shades of meaning.
Psychosis is the inability or impaired ability to distinguish reality from hallucinations and/or delusions.
Russell sign is calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time.
Thought process and content. Common descriptive terms include the following:
- Circumstantial thought follows a circuitous route to the answer. There may be many superfluous details, but the patient eventually reaches the answer.
- Linear thought demonstrates goal-directed associations and is easy to follow.
- Loose associations are thoughts that have no logical or meaningful connection with ensuing thoughts.
- Tangential thoughts are initially clearly linked to a current thought but fail to maintain goal-directed associations; the patient never arrives at the desired point or goal.
- Clang associations describe speech in which the sounds of words are similar but not the meanings. The words have no logical connection to each other.
- Flight of ideas describes a rapid stream of thoughts that tend to be related to each other.
- Magical thinking describes the belief that thoughts, words, or actions have power to influence events in ways other than through reality-based mechanisms.
- Thought blocking is characterized by abrupt interruptions in speech during conversation before an idea or thought is finished. After a pause, the individual indicates no recall of what was being said or what was going to be said.

Conditions Characterized by Abnormal Behaviors

Disruptive behaviors are broadly categorized by whether they affect the patient or others, then further classified by whether there is associated difficulty in regulating emotions or behaviors (see Table 31.2 ).

Behaviors That Primarily Affect the Patient

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 one setting (school and home) and must interfere with functioning or development. Prevalence increases with the child’s age and is approximately 9–15% in school-aged children. ADHD is more frequent in males than in females with a ratio of about 2:1 for the predominantly inattentive type and 4:1 for the predominantly hyperactive type. Females may be underdiagnosed as they are more likely to present with the inattention symptoms as compared to the hyperactivity symptoms that tend to be more disruptive and more likely to reach the threshold for seeking care. The DSM-5 specifies that there must be a persistent pattern of inattention and/or hyperactivity–impulsivity with six or more symptoms in either category lasting at least 6 months. Adolescents 17 years of age or older require only five 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

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. When these children become older, they often become less overtly hyperactive. 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 (high-risk sexual activity or substance misuse).

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 one 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. They 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. Being in the clinic can be overstimulating or anxiety provoking for the child. 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 (such as the Vanderbilt Rating Scale) 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, the 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 misuse. Screening for symptoms of sleep disturbances or sleep apnea 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 ( Chapter 40 ). These other movements may be associated with an underlying neurologic condition or may be medication induced. Tics are common with 5–24% of school-aged children having a history of tics. Most do not require treatment and do not progress to a more serious tic disorder. 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 rarely 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 multiple motor and one or more vocal tics lasting longer than a year

The incidence of Tourette disorder is 4–5/10,000. 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 one or more vocal tics must be present, although not necessarily concurrently, 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.

Behaviors That Affect Others

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 two 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, mood disorders, or anxiety disorders. The diagnosis of DMDD should be distinguished from bipolar disorder, which must have distinct episodes of mania or hypomania ( Table 31.6 ). The age of the patient can also help differentiate DMDD and bipolar disorders because bipolar disorders rarely present prior to adolescence. Individuals who meet criteria for DMDD and oppositional defiant disorder (ODD) should only be given the diagnosis of DMDD.

TABLE 31.6

Diagnostic Features of Primary Psychiatric Disorders

The following conditions require clinically significant distress or impairment in social or occupational functioning:
Schizophrenia is a disorder that lasts for at least 6 mo and includes at least 1 mo of active symptoms (two or more of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms).
Schizoaffective disorder is a disorder in which a mood episode and the active symptoms of schizophrenia occur together and were preceded or are followed by at least 2 wk of delusions or hallucinations without prominent mood symptoms.
Major depressive disorder is characterized by one or more major depressive episodes (at least 2 wk of depressed mood or loss of interest accompanied by at least four additional symptoms of depression). Additional symptoms of depression may include significant weight changes, sleep dysfunction, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, diminished concentration, and suicidal ideation or thoughts of death.
A manic episode is defined by an abnormally and persistently elevated, expansive, or irritable mood persisting for at least 1 wk (or less if hospitalization is required). At least three of the following symptoms must be present if the mood is elevated or expansive (four symptoms are required if the mood is irritable): inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences. Psychotic features may be present.
Bipolar I disorder is characterized by the presence of both manic and major depressive episodes or manic episodes alone.
Bipolar II disorder is characterized by the presence of major depressive episodes alternating with episodes of hypomania.
Hypomania is characterized by an abnormally and persistently elevated, expansive, or irritable mood persisting for at least 4 days. Other criteria required for diagnosis are identical to that of a manic episode except that the symptoms are not so severe as to cause marked impairment in social or occupational functioning, hospitalization is not required, and no psychotic symptoms are present.

Intermittent Explosive Disorder

Intermittent explosive disorder (IED) is an impulse control disorder where the child will have significant recurrent behavioral outbursts that are seen as out of proportion to the situation. The outbursts can be violent but are not premeditated. The outbursts can cause significant distress to both the patient and family. IED does not have the persistently angry or irritable mood in between outbursts that is present in DMDD. The DSM-5 requires the following for diagnosis:

1.
Recurrent behavioral outbursts representing failure to control aggressive impulses
2.
Verbal or physical aggression toward property, animals, or other individuals occurring on average twice weekly for 3 months or three behavioral outbursts involving destruction of property and/or physical assault within a 12-month period
3.
Aggression grossly out of proportion to trigger
4.
Outbursts are not premeditated
5.
Chronological age is at least 6 years (or equivalent development level)
6.
The outbursts cause marked distress in the individual or impairment in interpersonal functioning

The diagnosis of IED can be made in addition to ADHD, conduct disorder, oppositional defiant disorder, or autism spectrum disorder. It cannot be made with a diagnosis of DMDD. It is important to rule out other potential causes for the outbursts including bipolar disorder, substance use disorders, and traumatic brain injury.

Substance Use Disorder

Substance use can lead to a wide range of disturbances in mood and behavior. The disturbance can occur during both the period of intoxication and the period of withdrawal. 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 the rights of family and friends.

Oppositional Defiant Disorder

The characteristic feature of ODD is a persistent pattern of both defiant behavior and an angry/irritable mood, argumentative/defiant behavior, or vindictiveness. Affected individuals exhibit at least four 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 their 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, an anxiety, or a psychotic disorder, in which children exhibit oppositional behavior as a reaction to their illness.

Prevalence ranges from 1% to 11%, depending on the population. In prepubertal children, it occurs more frequently in males; 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 psychiatric 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 they have repetitively violated the rights of others and of society. Children with this diagnosis have performed three or more of the following behaviors within the past year and with at least one 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 may have the qualifier of “limited prosocial emotions” such as lack of remorse or guilt, callous lack of empathy, unconcerned about performance, and shallow affect. 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. Males are more likely to exhibit acts of violence, such as fighting and stealing, than are females, 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.

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. 31.1 ). The evaluation of any patient with a disruption in mood should include an assessment of the risk of suicide.

Fig. 31.1, Evaluation of mood disorders.

Conditions Characterized by Depressed Mood

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 suicide, significant social isolation, and academic impairment (see Table 31.6 ). Presentations may be subtle. While children and adolescents can present with classic sad or depressed mood, they may also present with 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 five 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%, with a cumulative prevalence in adolescence of 12% in females and 7% in males. There is also a threefold 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 31.4 ). 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; 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 a major depressive episode 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. Children and adolescents suffering from depression often have a broader range of affect compared with adults, who often appear more sullen. Given that children and adolescents often present with irritability 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 four 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, or tension
2.
At least one 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 to satisfy diagnostic criteria. To confirm the diagnosis, daily prospective symptom ratings are required for at least two 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 or chronic use of the substance and were not present prior to substance use. 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 nonjudgmental, 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, a disruptive behavior disorder, or post-traumatic stress disorder (PTSD).

Conditions Characterized by Extremes of Mood Lability

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, spending sprees, extreme gambling), 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 three of the following symptoms or four 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 hallucinations, 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 at least one major depressive episode 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 31.4 ). 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 of 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 five 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 two 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 31.7 ), 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 gender
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, or significant breakup
12.
Previous suicide attempts

TABLE 31.7

Columbia Suicide Severity Rating Scale–Screener

From Posner K. Columbia - Suicide Severity Rating Scale: Screener/Recent–Self-Report . http://www.cssrs.columbia.edu/scales_practice_cssrs.html .

1.
Have you wished you were dead or wished you could go to sleep and not wake up?
2.
Have you actually had any thoughts about killing yourself?
- If Yes to 2, answer questions 3, 4, 5, and 6. If No to 2, go directly to question 6.
3.
Have you thought about how you might do this?
4.
Have you had any intention of acting on these thoughts of killing yourself, as opposed to you having the thoughts but you definitely would not act on them?
5.
Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
6.
Have you done anything, started to do anything, or prepared to do anything to end your life?

- Response Protocol to Screening, based on last item answered YES.
- Item 1 – Mental Health Referral at discharge
- Item 2 – Mental Health Referral at discharge
- Item 3 – Care Team Consultation (Psychiatric Nurse) and Patient Safety Monitor/Procedures
- Item 4 – Psychiatric Consultation and Patient Safety Monitor/Procedures
- Item 5 – Psychiatric Consultation and Patient Safety Monitor/Procedures
- Item 6 – If over a year ago, Mental Health Referral at discharge
- If between 1 wk and 1 yr ago, Care Team Consultation (Psychiatric Nurse) and Patient Safety Monitor
- If 1 wk ago or less, Psychiatric Consultation and Patient Safety Monitor

Once a patient’s thoughts of suicide have escalated to suicide threats, plans, or attempts, this constitutes a medical emergency and the patient should be immediately referred to an experienced mental health professional or emergency department, and psychiatric hospitalization should strongly be considered.

Conditions Characterized by Worry, Fear, and Panic

These conditions include diagnoses in the broad categories of anxiety disorders, trauma- and stressor-related disorders, and obsessive-compulsive disorder. In childhood, these diagnoses are often comorbid and may include portions of other related disorders. A child with PTSD may experience panic attacks or a child with social anxiety may also have some generalized worries.

Conditions Characterized by Worry

Worries are primarily internal ruminations about the potential to experience negative outcomes from typically benign, everyday events. While often accompanied by somatic symptoms, such as stomach upset and headache, the hallmark of these disorders is the persistence of worry across one or more areas of a child’s life. Conditions characterized by worry are categorized by whether they are associated with unusual behaviors ( Fig. 31.2 ).

Fig. 31.2, Evaluation of worry, fear, and panic. PANS, pediatric acute onset neuropsychiatric disorder.

Worry Without Unusual Behaviors

Generalized anxiety disorder is characterized by excessive worry and concern over many issues. Chronic generalized anxiety may lead to symptoms of depression or somatic complaints, including abdominal pain, nausea, appetite loss, and headaches. DSM-5 criteria are as follows:

1.
Excessive anxiety and worry about various issues for more than 6 months
2.
Difficulty controlling the worry
3.
Anxiety and worry are associated with three of the following:
- a.
  Restlessness
- b.
  Being easily fatigued
- c.
  Difficulty concentrating
- d.
  Irritability
- e.
  Muscle tension
- f.
  Sleep disturbance
4.
Anxiety, worry, or physical symptoms cause significant distress or impairment

The lifetime prevalence of generalized anxiety disorder is approximately 5%, with most cases initially presenting during childhood or adolescence. The disorder is chronic and worsens during periods of stress. Comorbid diagnoses include mood disorders, other anxiety disorders, and substance use disorders.

Adjustment disorder with anxiety

The hallmark of adjustment disorders is an excessive or maladaptive response to a stressor that is out of proportion to that stressor. In adjustment disorder with anxiety , the maladaptive response manifests as excessive worry. It can occur in both children and adolescents. Stressors that children and adolescents may encounter include social separations, parental divorce, illness, injury, moving, academic failure, and peer conflict. The stressor should not represent a perceived threat to the life of oneself or a loved one, which would suggest PTSD. DSM-5 diagnostic criteria are as follows:

1.
Symptoms develop within 3 months of the stressor
2.
Significant impairment results
3.
The symptoms do not meet criteria for an alternative anxiety disorder
4.
The symptoms do not represent bereavement
5.
The symptoms abate 6 months after termination of the stress

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