Chapter 14 53
Child and Adolescent
Pediatric mental health treatment:
Rewards and Challenges – 1
Evaluation Principles -2
Identify the “team” in the child’s life. 3
Components of the Evaluation 4
Formulating the case and plan 5
Evaluation in Practice 6
Formulating a Differential Diagnosis 7
Attention deficit hyperactivity disorder (ADHD) 9
- Etiology 10
- Assessment 11-12
- Treatment Principles 13-14
Oppositional Defiant Disorder (ODD) 15
- Features and Treatment 17-18
Pervasive Developmental disorders
-Intro and assessment 19-20
-Other Developmental disorders 23-24
-Treatment of PDD 25-26
Language and learning disorders 27-28
- Enuresis 29
- Encopresis 30
Disorders of Eating, Sleeping, and
Attachement Disorders 33-34
-general overview 35-36
-Specific Diagnoses 37-40
Obsessive–Compulsive Disorder (OCD) 41-42
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with
Streptococcal infection) 43-44
Tic Disorders 45-46 (ONE BLANK)
Post-traumatic stress disorder 49-50
Depression in children and adolescents 51-52
Management of depression in youth 53-54
Suicide and suicidal risk in young people 55-56
Bipolar disorder in children and adolescents 57-58
Schizophrenia in children and adolescents 59-60
Schizophrenia in children and adolescents 61-62
Substance abuse in children and adolescents1 63-64
Bukstein OG, Bernet W, Arnold V,
Beitchman J, Shaw J, Benson RS,
Child abuse-issues and management 65-66
Child abuse-alerting signs 67-68
Munchausen Syndrome by Proxy 69-70
Prescribing in Children and Adolescents
- Stimulants 71 to end
- Non-stimulant Medications for ADHD
- Atypical Antipsychotics
Kinlan J, McClellan J, Stock S,
Ptakowski KK; Work Group on
Quality Issues. (2005), Practice
parameters for the assessment
and treatment of children and
adolescents with substance use
disorders. J Am Acad Child
Adolesc Psychiatry 44(6): 609-621.
CHAPTER 14 Child and adolescent 55
Pediatric mental health treatment:
Rewards and Challenges
Treatment of pediatric patients has the potential for large impact. Children and
adolescents are constantly learning from the environment, integrating what
they see and experience in the context of rapid cognitive, social, emotional,
and neurobiological development
Mental health problems can limit the inherent potential in this process.
Clinicians who assess and treat pediatric mental health concerns can help
influence the developmental trajectory of pediatric patients and their families in
order to maximize social, emotional, academic, and vocational development.
The potential impact can be rewarding, but there are important challenges
posed by working with rapidly developing children and their families.
Children and Adolescents are dependent on their caretakers. Mental health is
clearly influenced by environment. This is quite clear when working with
children, adolescents and their families. Pediatric patients are dependent on
their care providers for food, clothing, and developmental support. Each child
brings his or her personal temperament to this environment and the
development of the child is dependent on the match of temperament, as well
as how caregivers and children navigate any mismatch.
Level of development impacts behavior. Behaviors that are considered
normative in one developmental stage may be a source of concern in another.
For example, stranger anxiety is expected to occur at around nine months, but
if a nine year old had significant stranger anxiety it would significantly impair
the ability to engage with their environment at home and school.
Special considerations are needed for building treatment alliance. A strong
treatment alliance with both the young patient and their family is essential for
the provision of effective mental health care. Since pediatric patients are most
often brought into treatment by their adult caregivers, development of this an
alliance with the identified patient can be complex. Cognitive development
also impacts ability to engage in treatment. Traditionally, professionals who
work with pediatric patients have utilized play and/or informal methods in order
to engage children and adolescents as a participant in treatment.
Widespread use of evidence-based treatments is not the norm. The
widespread use of evidence-based treatments requires well-defined
phenomenology and a solid evidence-base for treatments that work in
controlled conditions and the community. Very few conditions in child and
adolescent psychiatry have an evidence base that fulfill all of these conditions.
While there are a number of therapeutic interventions that have proven quite
useful in very controlled environments, few have failed to reach the general
population of care providers and patients in a consistent, effective manner. In
addition, pharmacologic treatments tend to be used in a manner that outpaces
the evidence-base. Ultimately the choice of treatment should be a
combination of evidence-based recommendations, and the specific needs of
the pediatric patient and family.
The Goals of Evaluation
Identify precipitants of referral. Attempt to discern both the chief complaint
and the reason why it rose to the level of referral at this time.
Identify the goals of the child and family.
Obtain an accurate picture of the nature and extent of the child’s behavioral
difficulties, functional impairment and/or subjective distress.
Understand the child’s developmental strengths and limitations in all
domains—cognitive, language, motor, behavioral, ability to form relationship,
Identify the potential individual, family, or environmental factors that may
account for, influence, or ameliorate these difficulties.
Acquire the information necessary to create a responsive biopsychosocial
treatment plan that is patient-centered, family-focused, family driven, and
Clarify the role of the treaters.
Before beginning any evaluation it is important to clarify the nature of the
treatment relationship. This includes the relationship with the family and
patient as well as any referring provider. Whatever the formal relationship
(consultant or collaborator) it is important to clarify the treatment relationship.
Some specific issues include: 1. Who will make recommendations? 2. Who
will implement recommendations? and 3. how will the family will return for
follow-up if problems ensue? There are also specific rules of confidentiality
that must be considered and made clear to patients and their families for
forensic evaluations, custody evaluation and school referrals, just to name a
Confidentiality and Release of Information.
Confidentiality has always been of utmost concern in the mental health field,
but it has come under close scrutiny recently in the United States as new laws
to protect privacy have been established. It is important be obtain releases to
speak to all members of the treatment team. Many mental health institutions
require formal written releases. Specific considerations must be taken for
children and adolescents in the care of someone other than their adoptive or
biological parents. Laws also vary from state-to-state regarding the treatment
of minors without parental consent and commitment to psychiatric hospital. In
all settings, it is important to inform your patient that confidentiality will be
superseded in the face of danger of harm to self or others.
CHAPTER 14 Child and adolescent 57
Identify the “team” in the child’s life.
A care provider who attempts to understand all members of a patient’s team
will be best prepared to clarify treatment goals and respond when goals are
not being met.
Each member of the team brings their own strengths and limitations, as well
as viewpoints. Each member has the potential to take on different roles.
Pediatric patients exist in a biological, genetic, and psychosocial context.
Striving to include all members of the child’s care team will improve the ability
to understand that context and be more responsive. Possible members of the
treatment team can include: parents, grandparents, coaches, clergy, teachers,
school administrators, kin, and other social supports. This list is not merely
limited to traditional medical providers! Identifying all potential members of a
child’s natural treatment team will help expand the treatment options, and
identify the key participants in the formal treatment planning process. The
formation of a formal child and family team is often not mandated until a family
system has reached a breaking point. Thus, encouraging the family to be
inclusive and seek social support, as well as to be a source of information to
clinicians, can be very helpful throughout the treatment process.
Utilize the Entire Treatment Team
As an evaluation occurs, and treatment planning begins it is important to keep
in mind that there are many ways that members of the formal treatment team,
as well as the “informal team” can be utilized. It can often be helpful to try to
identify who is and who isn’t worried about the child and why. Each member of
a child (and the family’s) life will bring their own viewpoints, strengths and
limitations. Some states mandate formal “child and family teams” when
treatment goals have consistently not been met and the child’s situation is
threatening their placement in the community. At this point goals can often
seem reactive and the number of formal health care professionals involved
can sky rocket. These situations can often be avoided with successful use of
a natural “team” early in the evaluation and treatment planning process. When
first evaluating psychosocial and mental health complaints it can be much
easier to focus on strengths of the child and their family system. Also, getting
information from members of the system when they are not in crisis usually
provides a better understanding of the perceived strengths in the child, which
can be utilized to the advantage of the child later. Finally, the identifying
members of the “natural team” and developing a healthy support system that
capitalizes on their strengths can help the child and family meet their initial
goals and move towards recovery.
Components of the Evaluation
Evaluation includes assessment and treatment planning for a child and family.
It can be complex and requires multiple components that a traditional adult
process does not include. In some venues components of this process may be
performed and/or augmented by different members of the treatment team.
This section will include brief information on the key components of
assessment and treatment that are provided by a mental health provider.
Inclusion of each parent or guardian in the process of assessment and
treatment planning is ideal for several reasons. 1. Each guardian may have
different viewpoints, which will help to create a thorough assessment. 2. The
presence of entire family unit present together at least once will help evaluate
the dynamics of the family system. 3. Family history can usually be more
accurately obtained by interviewing each parent, since not everyone shares
their entire personal and/or family mental health history with their partner.
Parents are often the only source of accurate information about history of
pregnancy, developmental history, temperament, and shifts in behavior.
Parents can also give excellent information about overt behaviors such as
hyperactivity and oppositionality.
The child and adolescent interview is an essential part of the evaluation.
Pediatric patients are often the best source of information about internal mood
states- i.e. feeling down or worried. Traditionally ‘play’ has been used as a
way to access the internal mood states of pediatric patients who have difficulty
verbalizing their internal mood states because of their developmental stage or
resistance. Children and adolescents will frequently either understate or inflate
their oppositional and/or behavioral problems. The child and adolescent
interview is also a way to assess the ability of a pediatric patient to talk to a
stranger, and separate from their parents.
Other sources of information
As mentioned in the previous section, information can be gleaned from many
members of the child and adolescent’s life. Checklists and formal instruments
can be used for the pediatric patient, parents, teachers and guardians.
Informal discussions with other members of the treatment team can be very
helpful. Teachers are often an invaluable source of information about a child’s
behavior in both a structured and unstructured environments, and often can
serve as a gauge to help compare the child’s behavior to other classmates his
or her age.
CHAPTER 14 Child and adolescent 59
Formulating the case and plan
Case Formulation - Formulation of the case (bio-psycho-social assessment
and plan, see page ???) should be an ongoing component of the treatment
planning process. The clinician should share the formulation with the family
and consider how the formulation affects the family-centered treatment goals.
Diagnostic considerations – Since mental illness in pediatric patients is
often in a state of evolution, it is important to help the family understand what
mental health conditions are being considered. Families may choose to begin
educating themselves about all of the possibilities at this point, or may simply
want information about “what to look for.” Work with the families individual
needs and requests, and be certain to address comprehensive risks, benefits,
and alternatives of all treatment options.
Prioritizing - Comorbidity is the rule in child and adolescent psychiatry. In
addition children and their families often have multiple needs when they come
for evaluation. One method of formulating a hierarchy is to consider issues
that threaten the safety of the child or others first, then those that threaten
the continuity of the therapy and treatment. Then focus therapeutics on
interventions that will be most likely to improve functionally outcome and
return the child to a normal developmental trajectory. It is important to
recognize these needs, and make recommendations that address the long-
term and short-term priorities of the child and family. It may also be important
to understand the needs of the community in these decisions. For example, if
a young child with bipolar disorder and violent behavior at school seems to be
having increased difficulties because of family discord, it is not appropriate to
simply refer the family for family counseling without addressing the immediate
safety of the child and community, as well as the possibility that a manic
episode may have been triggered.
Evaluation in Practice
It is essential to establish rapport with child and family members.
Define needs of child and family.
Obtain family psychiatric, medical, and social history. A genogram can be
helpful (see chapter 2 page ???)
Inquire about sexual behavior/ HIV risk/ pregnancy, development, sibling
relationships, friendships, temperament, shifts in behavior...
Observe family functioning and interactions. Note patterns of
communication, degree of warmth, power dynamics, alliances…
First establish rapport and gain child’s confidence. Play can be helpful.
Begin with subjects well away from the presenting problem/s (e.g.
interests and hobbies, friends and siblings, school, holidays).
Progress to enquiring about child’s view of the problem, worries, fears,
sleep and appetite, mood, self-image, peer and family relationships,
experiences of bullying or teasing, abuse, persistent thoughts, fantasy life,
abnormal experiences, suicidality, etc. (It may take several interviews to
obtain a full picture.)
Observe: levels of activity and attention; physical and mental level of
development; mood and emotional state; quality of social interaction.
Other sources of information
Obtain consent to contact school for meeting or report from teachers,
school psychologists, etc. Consider asking teacher to complete a behavior
rating scale (e.g. Child Behavior Checklist; Connors’ Teacher Rating Scale).
Obtain consent and consult other caregivers, medical professionals who
have treated the child, and social agencies that have been involved with the
child and/or family.
Psychological tests: may include IQ, personality and developmental
Investigations: hematology; chromosome studies; EEG; CT; etc.
Identify the problem behavior/s—obtain a full description (from parents,
child, teachers, etc.) of the problem behavior/s. This should include the
evolution of the behavior, a chronology of the child’s typical daily activities,
the setting in which the problem behavior occurs, the effects of it on family,
school, relationships, etc, and attitudes of others to the behavior/s. It is
always appropriate to speak to the child alone (if possible) to establish
his/her views, desires, and mental state.
Determine the parental strategy—it is important to find out how the
parents deal with the behavior/s. This includes information about their
expectations, philosophy of parenting, interpretation of the behavior/s,
moral, religious, and cultural views on parenting, etc. Also, how do the
parents react or respond to the behavior/s? How do they discipline or
punish? What do they tolerate? Are they permissive or restrictive? Are they
overprotective or uninvolved? Do they feel empowered or impotent,
CHAPTER 14 Child and adolescent 61
helpless, and incompetent as parents? How do they manage their
frustrations, anger, etc? What coping mechanisms do they have?
Family history and dynamics—as well as gathering a full family history
of health, psychiatric problems, social and cultural circumstances, and
support structures, it is also important to assess parental and sibling
relationships, the presence of any significant stressors or losses, and how
the problem behavior interacts with family dynamics.
Social behavior—the evolution of the child’s social behavior, including
social developmental, attachment behavior, imaginary play, reading of
social cues, relationships, and language use.
School behavior—attendance, changes in school, separation issues,
socialization, performance, peer and teacher interactions and responses,
friendships, bullying, etc.
Child’s health and development—pregnancy, birth, and developmental
milestones. Was the child planned, wanted? How did siblings react? How
did parents and siblings cope? Any post-partum problems? Were there
supports? Also, child’s temperament, illnesses, treatment, etc.
Direct observation of parent-child interaction—during the interview/s it is
important to note how the child behaves and how parents respond and
interact with the child. If siblings can be present their behavior and
interactions can also be evaluated. A home and/or school visit may add
additional information about the behavior in these settings.
Collateral information—teachers, extended family, and social services
may be able to provide important input and permission should be sought to
contact and involve them where appropriate.
Formulation of the case (Bio-psycho-social)
Consider predisposing, precipitating, perpetuating, and protective factors.
Formulate a multaxial diagnosis. See chapter 2 for details.
Create a feasible plan
Determine goals for child and family. Goals should be specific and target
specific behaviors, performance, and domains. For example: “Johnny
should do better with his homework” may translate into “Johnny will turn in
completed homework 90% of the time. “
Determine the methods to meet the goals. Medication can be one method,
although often inadequate alone. Behavioral modification, school intervention,
family therapy, individual therapy can be other essential methods.
Determine who will be responsible for helping the child and/or adolescent
meet each of their goals. Health care providers prescribe medication or
perform therapy. It is important that family members are prepared and able to
take on roles in the implementation of treatment plan
Formulating a Differential Diagnosis
• The interpretation of behavior is contextually, culturally, and
developmentally dependent. Almost all behaviors listed below have the
potential to be considered normal in the correct context.
• Multiple determinants of behavior is the rule.
• Comorbidity is common.
• Genetic predisposition confers potential for many behaviors and
psychiatric diagnosis, but environment always has the potential to
• Parents often bring their children concerned about one specific behavior
or cluster of behaviors, but the key to diagnostic formulation is
maintaining a wide differential diagnosis while assessing resilience and
risk factors within the context of the pediatric patient’s specific context.
The following list contains some examples of diagnostic considerations when
evaluating chief complaints in the field of pediatric mental health.
Hyperactivity—ADHD, oppositional and conduct disorders, anxiety
disorders, depression, mania, autism-spectrum disorders, substance abuse,
sexual abuse, posttraumatic stress disorder.
Inattention—ADHD, oppositional and conduct disorders, Learning
disorders, autism-spectrum disorders mood disorders, anxiety disorders,
substance abuse, sexual abuse, language processing disorders, hearing
Separation problems—attachment disorders, anxiety, depression,
developmental delay, sexual abuse, posttraumatic stress disorder.
Social problems, avoidance—depression, anxiety, social phobia, autism-
spectrum disorders, sexual abuse, posttraumatic stress disorder.
Aggression, hostility—oppositional and conduct disorders, ADHD, mania,
psychosis, depression, anxiety, developmental disorders, Learning
disorders, autism-spectrum disorders, substance abuse, sexual abuse,
posttraumatic stress disorder.
Regression—depression, anxiety, developmental problems, learning
disorders, autism-spectrum disorders, substance abuse, sexual abuse.
Sexually inappropriate behaviors—sexual abuse, learning disorders,
autism-spectrum disorders, conduct disorders, substance abuse, mania,
psychosis, learning disorders, autism-spectrum disorders
Somatic symptoms—anxiety, depression, LD/PDDs, psychosis, sexual
Tantrums—oppositional and conduct disorders, ADHD, depression,
anxiety, learning disorders, autism-spectrum disorders, sexual abuse,
physical problems, mania, psychosis.
Attention deficit hyperactivity disorder (ADHD)
ADHD among the most commonly diagnosed and treated pediatric mental
health problems, and is increasingly being diagnosed in adults as well. The
hallmark symptoms of ADHD are a persistent pattern of inattention and/or
hyperactive/impulsive behaviors that are developmentally inappropriate,
chronic, and interfere with function. DSM-IV-TR specifies that some
symptoms must have been present before 7 years of age, although some
studies have suggested that a large number with the ‘inattentive’ subtype may
have a later onset1. To fulfill diagnostic criteria the ADHD behaviors should
also adversely affect at least 2 functional domains (e.g. academic, familial,
social, occupational) and have persisted for at least 6 months.
Clinical features of ADHD
Inattention symptoms may include: poor attention to details or tendency to
make careless mistakes; easy distractibility; difficulty sustaining attention;
poor listening; poor task completion; disorganization; avoidance of tasks
requiring sustained attention; tendency to lose things necessary for tasks;
Hyperactivity/impulsive symptoms may include: fidgetiness; inability to stay
seated; running or climbing inappropriately; noisiness in play; seeming “on the
go” or “driven like a motor”; excessive talkativeness; prematurely blurting out
answers; inability to take turns; and interrupting others.
Three different subtypes are described: a predominantly inattentive subtype
with at least six inattentive symptoms, a predominantly hyperactive/impulsive
subtype with at least six hyperactive/impulsive symptoms, and a combined
subtype with at least six symptoms from both inattentive and
Epidemiology. The prevalence of ADHD is reported in community studies of
children and adolescents in the USA to be 3–5%, while in the UK a lower rate
of 1% is reported. Such differences are thought to be due to differences in
ascertainment, and have not persisted in studies where similar diagnostic
methods with the same structured interviews were used2.
There is a male predominance of 3:1 in youths. The inattentive subtype is the
most common in community settings, while in psychiatric clinical settings the
combined subtype is the most common. A similar rate of ADHD has been
. Applegate B, et al: Validity of the age-of-onset cri-terion for ADHD: a report from the
DSM-IV field tri-als.[see comment]. Journal Amer Acad of Child & Adolescent Psychiatry
2. Anderson JC: Is childhood hyperactivity the product of western culture?[see comment].
Lancet 1996; 348(9020):73-4
3. Wolraich ML, et al.: Comparison of diagnostic criteria for at-tention-deficit hyperactivity
disorder in a county-wide sample. Journal of the American Academy of Child &
Adolescent Psychiatry 1996; 35(3):319-24
4. Kessler RC, et al.: The prevalence and correlates of adult ADHD in the United States:
results from the National Comorbidity Survey Replication. American Journal of Psychiatry
CHAPTER 14 Child and adolescent 65
reported in a large community sample of adults, though the disorder is
generally thought to be under-diagnosed in that age range.
1. Applegate B, et al.: Validity of the age-of-onset cri-terion for ADHD: a report from the DSM-IV field tri-
als.[see comment]. Journal of the American Academy of Child & Adolescent Psychiatry 1997;
2. Anderson JC: Is childhood hyperactivity the product of western culture? Lancet 1996; 348(9020):73-4
3. Kessler RC, et al.: The prevalence and correlates of adult ADHD in the United States: results from the
National Comorbidity Survey Replication. American Journal of Psychiatry 2006; 163(4):716-23
Etiology of ADHD1
Genetics: Heritability in ADHD is among the highest of psychiatric disorders.
50% rate of concordance in MZ twins; there appears to be separate heritability
for different components of ADHD; 2x increased risk in other siblings;
increased rates of conduct disorders, depression, and substance abuse in
Neurological functional imaging suggests abnormalities in the prefrontal
cortex regardless of stimulant use2.
Cathecolamine Hypothesis: attributes ADHD to dysregulations of dopamine or
norepinephrine activity in the central or peripheral nervous system.
Comorbidity Approximately 50–80% of youths with ADHD have comorbid
disorder, including specific learning disorders (60%); CD and ODD (40%);
depression (15-32%); anxiety disorder (25%); and bipolar disorder (5-10%)3.
In adults, high rates of comorbidity are also noted, including mood and anxiety
disorders, antisocial personality disorders, and substance abuse. Substance
abuse is higher in older adolescents and adults with ADHD, though this
comorbidity is due to the high co-occurrence with conduct disorders and
antisocial personality disorders rather than because of ADHD itself or its
Outcome Impulsive and hyperactive symptoms may remit with maturity, while
inattentive symptoms often persist. Increasing evidence suggests that youths
with ADHD continue to have symptoms of the disorder into adulthood and
these are associated with substantial impairment in multiple domains. Adult
patients with ADHD overall have higher arrest rates, and greater risks of fatal
car accidents, marital problems, and occupational or academic
underachievement. Approximately 30% of youths with ADHD as adults have a
particular problematic course, with academic and occupational
underachievement; progression from ADHD to substance abuse is most
common when there is comorbid conduct disorder.5
1. Spencer TJ, Biederman J, Wilens TE, Faraone SV: Overview and neurobiology of
attention-deficit/hyperactivity disorder. Journal of Clinical Psy-chiatry 2002; 63 Suppl
2. Casey, B., Durston, S. Am J Psychiatry 163:6, June 2006
3. Pliszka SR: Comorbidity of attention-deficit/hyperactivity disorder with psychiatric
disorder: an overview. Journal of Clinical Psychiatry 1998; 59 Suppl 7:50-8
4. Wilens TE: Attention-deficit/hyperactivity disorder and the substance use disorders: the
nature of the rela-tionship, subtypes at risk, and treatment issues. Psy-chiatric Clinics of
North America 2004; 27(2):283-301
5. Cantwell DP: Attention deficit disorder: a review of the past 10 years.[see comment].
Journal of the American Academy of Child & Adolescent Psychiatry 1996; 35(8):978-87
CHAPTER 14 Child and adolescent 67
Assessment of ADHD1
ADHD is a clinical diagnosis with no specific biological or cognitive tests
validated. Evaluation should ideally include:
- Interview with parents to evaluate developmental, medical, and family
history and assess family functioning.
- Interview with child to evaluate for physical disorder, comorbid mood
disorder, anxiety disorder, externalizing disorder, tic disorder, substance
use disorder, developmental disorder, or speech and language problems.
- Patients with ADHD, either youths or adults, tend to under-report their
ADHD symptoms so collaborative history helpful.
- Refer to pediatrician for physical examination to rule out medical problems
(e.g. endocrinopathy, environmental exposure, or neurological disorder,
such as petit mal epilepsy or complex partial seizures).
- Encourage school to conduct educational testing to rule out a comorbid
learning or language disorder.
- Collateral information from school including teachers’ rating scales for
- Specific rating scales for parents and teachers (SNAP-IV-R, Vanderbilt,
ADHD Rating Scale, Conner’s- see next page).
- General behavioral rating scales to screen for ADHD symptoms and other
psychopathology (e.g. Child Behavior Checklist, Teacher’s Report Form).
ADHD Treatment Overview – see end of chapter for details
The Multimodal Treatment Study for ADHD (MTA) suggested that stimulant
medication is a reasonable first-line treatment for most children with ADHD 2
(see ADHD treatment section for details). However, concomitant psychosocial
interventions are also useful, especially in patients with comorbid externalizing
or internalizing disorders. In general, ADHD interventions include the
- Parent management training (see Psychotherapy Chapter)
- Educational/remedial interventions including evaluation for possible
accommodations in the school setting such as preferential seating, un-timed
testing in a separate environment with fewer distractions, use of assignment
books checked by parents, and an organizational advisor.
- Stimulants: generally the first-line treatment with a 70% response rate,
even with most comorbid disorders. Stimulants include methylphenidate
and amphetamine derivatives.
- Non-stimulants: include atomoxetine (Strattera), bupropion (Wellbutrin),
tricyclic antidepressants (desipramine, imipramine, and nortriptyline); and
alpha-2 adrenergic receptor agonists (clonidine and guanfacine). All have
lower response rates than the stimulants. Often more effective for
hyperactive and impulsive symptoms than inattentive symptoms.
- Pharmacological or psychotherapy treatment of comorbid psychiatric
disorders like mood, anxiety or tic disorders sometimes required, and may
need to be initiated first, if they are more functionally impairing.
1.Dulcan M: Practice parameters for the assessment and
treatment of children, adolescents, and adults with attention-
deficit/hyperactivity disorder. American Academy of Child and
Adolescent Psychiatry. Journal of the American Academy of Child
& Adolescent Psy-chiatry 1997; 36(10 Suppl):85S-121S
2. A 14-month randomized clinical trial of treatment strategies for
attention-deficit/hyperactivity disorder. The MTA Cooperative
Group. Multimodal Treatment Study of Children with ADHD.
Archives of General Psychiatry 1999; 56(12):1073-86
CHAPTER 14 Child and adolescent 69
Assessment Scales for ADHD
As with many childhood psychiatric illnesses, ADHD is a diagnosis that occurs
in many environments. As such, a combination of the clinical examination and
often extensive collaboration is needed to provide the information necessary
to obtain a diagnosis. Multiple scales have been developed to aid practitioners
in diagnosis, and some are designed to monitor clinical progress. Several
scales also assist in screening for potential cormorbid psychiatric disorders.
Examples of a few ADHD scales are provided below.
Scale Name Ratings for Completed by Information
SNAP-IV-R A composite of Teachers and Free online
ADHD, ODD, and parents/
Vanderbilt ADHD, with Teachers and Free online
ADHD Parent screens for ODD, parents/
Diagnostic CD, Anxiety, and caregivers
Rating Scale Depression
ADHD Rating ADHD severity and Teachers and Free Online
Scale improvement with parents/
Conner’s ADHD, some ODD/ Teachers and Copyright only.
Rating Scale Anxiety; index for parents/ Self reports for
Revised monitoring caregivers. teens and adults
(CRS-R) treatment available.
Treatment Principles of
Stimulant Pharmacotherapy for ADHD – General Principles
The most effective treatment for ADHD continues to be stimulant
medications such as methylphenidate and
amphetamine/dextroamphetamine, ideally combined with behavioral
treatments. These medications are described in detail at the end of this
chapter. Stimulants are not without controversy, however, and practitioners
must carefully inform families of the risks, benefits, and alternative
Important Warnings About ADHD Stimulants1
“An FDA review of reports of serious cardiovascular adverse events in
patients taking usual doses of ADHD products revealed reports of sudden
death in patients with underlying serious heart problems or defects, and
reports of stroke and heart attack in adults with certain risk factors.”
Another FDA review of ADHD medicines revealed a slight increased risk
(about 1 per 1,000) for drug-related psychiatric adverse events, such as
hearing voices, becoming suspicious for no reason, or becoming manic,
even in patients who did not have previous psychiatric problems.
FDA recommends that children, adolescents, or adults who are being
considered for treatment with ADHD drug products work with their physician
or other health care professional to develop a treatment plan that includes a
careful health history and evaluation of current status, particularly for
cardiovascular and psychiatric problems (including assessment for a
family history of such problems).” This warning included all ADHD
stimulants, as well as atomoxetine (Strattera), a non-stimulant ADHD
medication. There are also serious concerns about abuse of stimulants,
especially in individual with a previous abuse history. Please refer to the
FDA website for the latest updates.
The Multimodal Treatment Study of Children
with Attention Deficit Hyperactivity Disorder2
(MTA) The MTA was an intensive NIMH funded study included 579
elementary school boys and girls with ADHD. Basically, the subjects were
randomly assigned to one of four treatment programs: (1) medication
management alone; (2) behavioral treatment alone; (3) a combination of both;
or (4) routine community care. The results of the study indicated that long-term
combination treatments and the medication-management alone were superior
to intensive behavioral treatment and routine community treatment. And in
some areas—anxiety, academic performance, oppositionality, parent-child
relations, and social skills—the combined treatment was usually superior.
Another advantage of combined treatment was that children could be
successfully treated with lower doses of medicine, compared with the
Follow-up at 24 months: Effects above were fairly consistent even after 24
months. About 70% of the subjects were still taking medication, and 38% of
the behavioral subjects began taking medication.
CHAPTER 14 Child and adolescent 71
Non-stimulant Treatment for ADHD – General Principles
Stimulants are the most effective treatment for ADHD. However, non-
stimulants may be appropriate when patients have failed or not tolerated
stimulants, or have certain comorbid disorders such as tics, depression,
anxiety, or substance abuse (given non-stimulants lack of abuse potential).
Non-stimulant ADHD treatment examples include atomoxetine, bupropion,
tricyclic antidepressants (including imipramine, desipramine, and nortriptyline),
alpha-2 adrenergic receptor agonists (including clonidine and guanfacine).
Refer to the end of this chapter for more details on prescribing in the pediatric
It may be helpful to use agents such as clonidine or guanfacine when children
have difficulty sleeping as one of the side effects of stimulants. These
medications may possibly help with other symptoms of ADHD, though this is
controversial. *However, combining stimulants with alpha-2 adrenergic
receptor agonists such as clonidine or guanfacine have been associated with
rare reports of sudden cardiac death, and the risks and benefits should be
carefully weighed before prescribing such a combination.
1 .Dulcan M: Practice parameters for the assessment and
treatment of children, adolescents, and adults with attention-
deficit/hyperactivity disorder. American Academy of Child and
Adolescent Psychiatry. Journal of the American Academy of Child
& Adolescent Psy-chiatry 1997; 36(10 Suppl):85S-121S
2. Pliszka SR,et al.: The Texas Children's Medication Algorithm
Project: Report of the Texas Consensus Conference Panel on
Medication Treatment of Childhood Attention-Deficit/Hyperactivity
Disorder. Part I. Attention-Deficit/Hyperactivity Disorder. Journal of
the American Academy of Child & Adolescent Psy-chiatry 2000;
Oppositional defiant disorder (ODD)
Key Features An enduring pattern of negative, hostile, and defiant behavior,
without serious violations of societal norms or the rights of others. Behavior
may occur in one situation only (e.g. home) and may lead to social isolation,
depression, or substance abuse.
Epidemiology Onset is between 3 and 8 years old. More common in boys
during childhood but equal rates in adolescence. A common condition
affecting 15–20 % of C & As.
Etiology Temperamental factors; sick or traumatized child; power struggle
between parents and child (NB differentiate from normal autonomous
‘struggle’ of the young child and adolescent).
Outcome One-fourth show no symptoms later in life but many progress to
Conduct Disorder (CD) and/or substance abuse.
Management Same management principles as for CD (see next).
DSM-IV & DSM-IV-TR:
Oppositional Defiant Disorder 313.81
A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6
months, during which four (or more) of the following are present:
(1) often loses temper
(2) often argues with adults
(3) often actively defies or refuses to comply with adults' requests or rules
(4) often deliberately annoys people
(5) often blames others for his or her mistakes or misbehavior
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently
than is typically observed in individuals of comparable age and
B. The disturbance in behavior causes clinically significant impairment in
social, academic, or occupational functioning.
C. The behaviors do not occur exclusively during the course of a Psychotic
or Mood Disorder.
D. Criteria are not met for Conduct Disorder, and, if the individual is age 18
years or older, criteria are not met for Antisocial Personality Disorder.
CHAPTER 14 Child and adolescent 73
Conduct disorder (CD)
DSM-IV-TR Diagnostic criteria for Conduct Disorder
A. A repetitive and persistent pattern of behavior in which the basic rights of
others or major age-appropriate societal norms or rules are violated, as
manifested by the presence of three (or more) of the following criteria in the
past 12 months, with at least one criterion present in the past 6 months:
Aggression to people and animals
(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm to others (e.g., a
bat, brick, broken bottle, knife, gun)
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery)
(7) has forced someone into sexual activity
Destruction of property
(8) has deliberately engaged in fire setting with the intention of causing serious
(9) has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft
(10) has broken into someone else's house, building, or car
(11) often lies to obtain goods or favors or to avoid obligations (i.e., "cons"
(12) has stolen items of nontrivial value without confronting a victim (e.g.,
shoplifting, but without breaking and entering; forgery)
Serious violations of rules
(13) often stays out at night despite parental prohibitions, beginning before
age 13 years
(14) has run away from home overnight at least twice while living in parental or
parental surrogate home (or once without returning for a lengthy period)
(15) is often truant from school, beginning before age 13 years
B. The disturbance in behavior causes clinically significant impairment in
social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for Antisocial
Specify type based on age at onset:
Childhood-Onset (before 10), Adolescent-Onset Type (after 10)
Specify severity: mild, moderate, severe
Conduct disorder in Detail1,2
Key Clinical Features Conduct disorder has been popularized in the literature
as ‘sociopathy.’ By definition, CD is a repetitive and persistent pattern of
behavior in which the basic rights of others or major age-appropriate societal
norms or rules are violated. These violations include aggression or cruelty to
people and animals, destruction of property, deceitfulness or theft and serious
violation of rules (e.g. truanting or running away). Early sexual behavior, gang
involvement, low self-esteem, lack of empathy are also seen. The term
‘delinquent’ is unfashionable and refers to the individual whose behavior leads
them into the criminal justice system—‘young offender’ is the modern term.
CD is important because it is common: it is the cause of great suffering in both
the individual and in society; it is a risk factor for adult antisocial behavior; and
it is a major burden on public resources. In many countries it constitutes one
of the major public mental health problems, making prevention strategies
important (see next).
Epidemiology In North America CD is a common reason for psychiatric
evaluation in children and adolescents. It has an earlier onset and is more
common in boys than in girls.
Etiology A family history of antisocial behavior or substance abuse, possible
low CSF serotonin, impaired executive function, high sensation seeking, and
diminished conditioning to punishment, low IQ, and brain injury are biological
factors associated with risk for CD. Psychosocial risk factors include: parental
criminality and substance abuse; harsh and inconsistent parenting; domestic
chaos and violence; large family size; low socio-economic status and poverty;
early loss and deprivation; lack of a warm parental relationship; school failure;
social isolation; and exposure to abuse and societal violence.
Comorbidity ADHD; substance abuse; suicidality.
Course and outcome CD is often chronic and challenging to treat. Adult
outcomes include: antisocial personality disorder; criminal activity; substance
abuse; and mental disorders. However, less than 50% of CD cases have
severe and persistent antisocial problems as adults.
Predictors of poor outcome: early onset (before 10 yrs); low IQ; poor school
achievement; attentional problems and hyperactivity; family criminal history;
low socio-economic status; other siblings with conduct disorder, and poor
Protective factors are: female gender; high intelligence; resilient temperament;
competence at a skill; warm relationship with a key adult; commitment to
social values; strong and stable community institutions; increased economic
1 Bassarath L (2001) Conduct disorder: a biopsychosocial review. Can J Psychiatry 46, 609–16
2 Waddell C, Lipman E, Offord D (1999) Conduct disorder: practice parameters for assessment,
treatment, and prevention. Can J Psychiatry 44 (supp 2), 35s–39s.
CHAPTER 14 Child and adolescent 75
Assessment of CD
Clarify the purpose of the assessment (clinical, community, forensic).
Obtain a full history with collateral from school, community, legal system.
Identify causal risk and protective factors.
Assess for comorbidity and make a diagnosis (psychometric testing).
Formulate the problem and establish management plan (see opposite.)
Management of CD1
Multiple strategies are indicated:
Ensure the safety of the child
CBT problem-solving skills-in individual/group setting
Parent management training-to improve social exchanges/stability
Functional family therapy-combined CBT/systems approach
Multi-systemic therapy-family-based, including school and community
Medication-only for comorbid disorders (e.g. ADHD—see previous)
Academic and social support-referral to relevant agencies/groups
Some use neuroleptics or lithium to manage extreme aggression
Prevention strategies and policy implications
Preschool child development programs —identifying parents and families
at risk and instituting home visits and support
School programs —identify children at risk and institute classroom
enrichment, home visits, and parent and teacher training
Community programs —identify children and adolescents through their
involvement with social agencies and institute interventions such as
enhanced recreation programs, parent training and adult mentoring of youth
Social and economic restructuring to reduce poverty and to improve family
and community stability.
1. Kazdin AE (2000) Treatments for aggressive
and antisocial children. Child Adolesc Psych Clinics N
America 9, 841–58.
-Pervasive Developmental disorders -
Pervasive developmental disorders (PDDs) are defined as spectrum of behav-
ioral problems commonly associated with autism. In fact, “Autism Spectrum
Disorders” (ASD) is often used interchangeably with PDD. PDD frequently in-
volve a triad of deficits in social skills, communication/ language and behavior.
The feature all have in common is difficulty with social behavior. DSV-IV cate-
gorized PDDs as follows:
Childhood disintegrative disorder
PDDs are characterized by either lack of normal development of skills or loss
of already acquired skills. There is a gender bias with male > female predomi-
nance in all syndromes except Rett’s syndrome (female predominance).
Prevalence of PDDs ranges from 40-60 cases / 10,000.
Assessment of Pervasive Developmental Disorders
The American Academy of Child and Adolescent Psychiatry recommends a
multidisciplinary approach involving psychiatrists, psychologists, pediatricians,
neurologists, speech therapists, OT and primary care teams. The efforts of
various specialists and consultants should be coordinated and one care
provider assume an overall role as coordinator and liaison with schools and
other providers of interventions.
The assessment should include:
1) Complete psychiatric assessment that will vary depending on the child’s
age, history, and previous evaluations. Assessment should include:
a) Pregnancy, Neonatal, and Developmental History
b) Medical history
c) Family and psychosocial factors
d) Intervention history
e) Psychiatric examination of the child in observational settings to
evaluate overall developmental level and specific problem behav-
2) Medical Examination
3) Neurologic examination including complete audiological and visual exami-
nations and taking a seizure history.
4) Diagnostic and Laboratory Studies There is no specific laboratory test for
autism, but specific studies to search for associated conditions are indicated
based on history and clinical presentation. EEG and perhaps MRI, Southern
blot testing for Fragile X genetic and Wood’s lamp examination for tuberous
sclerosis are indicated. The presence of dysmorphic features or other specific
findings may suggest obtaining genetic screening for inherited metabolic disor-
ders, specific genetic syndromes, or chromosome analysis.
CHAPTER 14 Child and adolescent 77
5) Psychological Assessment
Developmental/Intelligence Testing separate es-
timates of verbal and nonverbal (performance) IQ
should be obtained.
Adaptive Skills Assessment of adaptive skills to
document the presence of any associated mental re-
tardation to establish priorities for treatment.
Other assessments PDD-specific neuropsycholog-
ical screening and/or achievement testing may be
Autism Diagnostic Interview-Revised (ADI-R)
Autism Diagnostic Observation Schedule (ADOS)
Autism Behavior Checklists (ABC)
Childhood Autism Rating Scales (CARS)
Checklist for Autism in Toddlers (CHAT)
Occupational and Physical Therapy Assessments
6) Psychoeducation and family and parental support
To the extent possible involve parents and other family members in the pro-
cess of assessment. Various parent and family support groups are available
and can provide important sources of information and support to parents.
National Alliance for Autism Research http://www.naar.org/
International Rett Syndrome Association http://www.rettsyndrome.org/
Childhood Disintegrative Disorder Network http://www.rarediseases.org/
Autism Society of America http://www.autism-society.org/
Aspen of America, Inc. (Asperger’s Syndrome) http://www.maapservices.org/
Cure Autism Now http://www.cureautismnow.org/
7) Differential Diagnosis
Other PDDs; childhood schizophrenia; MR; language disorders; neurological
disorders (Landau-Klefner syndrome); sensory impairment (deafness or blind-
ness); OCD; psychosocial deprivation.
PDD Assessment Summary
Differential diagnosis: childhood schizophrenia; mental retardation;
language disorders; neurological disorders; sensory impairment (deafness
or blindness); OCD; psychosocial deprivation; reactive attachment
A multidisciplinary approach is required, potentially involving a
psychiatrist, psychologist, pediatrician, neurologist, speech therapist,
occupational therapist, and school team.
Full clinical evaluation: including physical and mental state as well as
specific developmental, psychometric, and educational assessments.
Possible genetics consultation for fragile X, Rett’s (in females), or other
Simple rating scales: Autism Behavior Checklist (ABC); Childhood Autism
CHAPTER 14 Child and adolescent 79
History /Definition/ Clinical Features John Haslam in 1809 and Henry
Maudsley in 1867 were the first physicians to provide descriptions of children
with the clinical features of autism. Leo Kanner named the disorder infantile
autism in 1943. Autistic disorder is the prototype of the PDDs defined by quali-
tative impairments in social interaction, communication and restricted and
stereotyped patterns of behavior, interests and activities. Onset of the disorder
may be evident by 18 months and to meet the diagnosis must occur before 3
years of age. 30% of autistic children score in the normal intelligence range
(High-functioning autism, HFA). About 30% have mild to moderate mental re-
tardation and about 40% have serious to profound mental retardation.
DSM-IV-TR Autism Criteria
According to DSM-IV-TR criteria, children with autism have to have a total of
at least six of the following symptoms before age 3, with specific numbers from
each the three broad categories:
At least two symptoms of abnormal social relatedness:
Impaired non-verbal interactive behaviors (e.g. poor eye contact,
inappropriate facial expressions and gestures)
Failure to develop peer relationships
Reduced interest in shared enjoyment
Lack of social or emotional reciprocity
At least one symptom of abnormal communication or play:
Delayed or lack of spoken language
Difficulty initiating or sustaining conversations
Stereotypic, repetitive, or idiosyncratic language
Lack of imaginative or imitative play
At least one symptom of abnormal behaviors:
Stereotyped/restricted, obsessive interests
Rigid adherence to non-functional routines or rituals
Stereotypic/repetitive motor mannerisms (e.g. toe-walking, hand
flapping, body rocking)
Preoccupation with parts of objects
Abnormal symbolic or social play or restricted interests or activities en-
compassing unusual preoccupations and interests; lack of developmentally
appropriate fantasy; adherence to non-functional routines or rituals; resistance
to change; stereotypies and motor mannerisms (e.g., hand or finger-flapping
or body-rocking); and preoccupation with parts of objects.
There are some non-specific neurological and physiological features that
are common to autism, but are not essential or specific features of the disor-
der, such as seizure disorder, motor tics, large head circumference, abnormal
gaze monitoring, increased ambidexterity, hyper- and hypo-sensitivity to sen-
sory stimuli (loud or high pitched sounds, specific textures, bright lights), ab-
normal pain and temperature sensation, and altered immune function.
Autistic children also often demonstrate associated, but non-specific behav-
ioral problems such as poor attention and concentration (60%), hyperactivity
(40%), morbid or unusual preoccupations (43-88%), obsessive phenomena
(7%), compulsive rituals, anxiety and fear (17-74%), mood lability, irritability,
agitation, inappropriate affect (9-44%), sleep problems (11%) or self-injurious
‘Savants’: persons with obvious mental retardation who exhibit unusually high
skill in sharply circumscribed areas, such as visual arts, musical performance,
arithmetic skills (calendar calculating, prime numbers). Studies by Hill and
Rimland suggest that 0.6 % of institutionalized individuals with MR and 9.8%
of mentally retarded autistic individuals demonstrate savant skills.
Epidemiology of PDD/ASD/Autism: In 2007 a CDC surveillance network
found that an average of 6.7 per 1000 eight-year-olds in 2002 had autism
spectrum disorders (ASDs), including pervasive developmental disorder and
Asperger syndrome. The ratio of males to females with ASDs ranged from
roughly 3:1 to roughly 7:1. Autism occurs equally across various races and
socioeconomic statuses. At one time, it was more widely diagnosed in higher
socioeconomic groups, probably due to referral biases1.
The cause of autism is unknown but it is thought to be a disorder of genetic
origins, with a heritability of about 90% with as few as 2 and as many as 15+
genes involved. Neurocognitive studies suggest lack of connectivity may ex-
plain many of the cognitive and emotional deficits. Syndromic autism is seen
at high rates in various genetic disorders (Tuberous sclerosis, Fragile X,
15q11- q13 duplications, Down’s syndrome and single gene disorders of
metabolism such as adenylate lyase deficiency). However, environmental in-
fluences are also important, as concordance in monozygotic twins is less than
100% (36–91% monozygotic twins concordance vs. 10% dizygotic twins con-
cordance) and the phenotypic expression of the disorder varies widely. Envi-
ronmental factors include pre/post-natal infections agents (congenital rubella,
CMV), chemical toxins (thimerasol), autoimmune disorders (MMR- anecdotal,
not proven), obstetric complications.
Neuropathology studies show increased cell packing in the limbic system, re-
duced numbers of Purkinje cells in the cerebellum, age-related changes
in the cerebellar nuclei and inferior olives, cortical dysgenesis, and
increased brain size, especially in the young autistic child (as
measured by head circumference), magnetic resonance image
(MRI) brain volume, and postmortem brain weight. Seizures are common.
1/3 of autistic subjects have elevated whole blood 5-HT. Other neurotransmit-
ters (dopamine DA, norepinephrine, NE, glutamate, gamma-aminobutyric acid,
GABA) and neuropeptides (oxytocin, secretin, beta-endorphins) have been im-
plicated, but the evidence is not as reproducible.
CHAPTER 14 Child and adolescent 81
History/ Definition/ Clinical Features Asperger’s disorder is a neurodevelop-
mental disorder on the autism spectrum, which involves impairments in recip-
rocal social interactions and restricted repetitive and stereotyped patterns of
behavior in the absence of intellectual dysfunction or clinically significant gen-
eral delay in language. The incidence of Asperger’s disorder is conservatively
estimated at 2.6/ 10, 0000, though this figure varies by source.
High-functioning autism and Asperger's Disorder are autism spectrum disor-
ders characterized by cognitive impairments affecting social relatedness and
communication, restricted interests/repetitive behaviors, and average or better
intelligence. According to the American Psychiatric Association, Asperger's
Disorder is differentiated from High-functioning autism by the presence of in-
tact basic language and imaginative play abilities.
Rett’s disorder was first reported on by the Viennese pediatrician Andreas
Rett in 1966. A genetic X-linked disorder largely affecting females (7 cases
are known to exist in males) with an estimated incidence of 3.8/10,000 based
on British Isles survey. There is a period of normal development for the first
5-6 months of life. Head circumference at birth is normal with subsequent de-
celeration of head growth leading to post-natal microcephaly followed by
loss of acquired skills such as purposeful hand function, vocalization, and
communication skills, loss of social engagement early in the course, (although
often social interaction develops later) and appearance of truncal and gait
ataxia. Mutations in the MECP2 gene (methyl CpG binding protein 2 gene, Xq
28) account for 80% of patients with classic Rett’s Disorder. Supportive diag-
nostic criteria include breathing dysfunction, EEG abnormalities (up to 80% of
patients experience epileptic episodes), spasticity, peripheral vasomotor dis-
turbance, scoliosis, and growth retardation. In addition to classic Rett’s Disor-
der, some variants have been described presenting some features of the clas-
sic form, but displaying differences. Mutations in the X-linked CDKL5 gene
(cyclin-dependent kinase-like 5, Xq22) were found in some patients with Rett’s
Childhood disintegrative disorder (CDD) was first described as dementia
infantilis by Theodor Heller a Viennese remedial educator in 1908. CDD is de-
fined in DSM-IV as apparent normal development at least until age 2 fol-
lowed by clinically significant loss of previously acquired skills (before age
10) in at least 2 areas: language (expressive or receptive), social skills or
adaptive behavior, bowel or bladder control, play and motor skills. In addition
patients have abnormalities of functioning in at least 2 of the following ar-
eas: qualitative impairment in social interaction by marked regression resulting
in an autistic, qualitative impairment in communication or repetitive, restricted
and stereotyped behaviors and mentally retarded state (severe to profound
MR >60% with IQ<40). Association of seizures or EEG abnormalities have
been documented in about half the cases of CDD (seizures most commonly
develop after the onset of CDD). Associated behavioral symptomalogy in-
cludes overactivity, affective symptoms/anxiety, deterioration of self-help skills,
aggression, agitation, self-injurious behavior, fecal smearing with compulsive
behavior. Deterioration in social and self-help skills is more marked than motor
skills. The cause is unknown and prognosis poor. Incidence is estimated at
0.2/ 10,000. Males outnumber females by 4:1. Mean age of onset of 3.36
years. Two types of onset have been seen. More commonly onset is insidious
developing over weeks to months and less common over days to weeks.
Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS)
Also known as “Atypical autism” this category is used when there is a severe
and pervasive impairment in the development of reciprocal social interaction
associated with impairment in either verbal or nonverbal communication skills
or with the presence of stereotyped behavior, interests and activities, but does
not meet criteria for other PDDs, schizophrenia, schizotypal personality disor-
der, or avoidant personality disorder. Incidence is estimated at PDD-NOS
20.8/ 10, 0000 with a male predominance.
CHAPTER 14 Child and adolescent 83
Pervasive Developmental Disorders
Treatment strategies for PDDs: Summary
Educational and vocational interventions: most will be eligible for
individualized educational plan with accommodations and services to
address their special needs.
Behavioral interventions: include behavior modification, social skills
training, and CBT methods
Family interventions: educational; support; advocacy
Speech and language therapy; occupational therapy.
Pharmacotherapy: symptom management (e.g. atypical antipsychotics for
stereotypies and aggressive agitation); SSRIs or clomipramine for
compulsive and self-harming behaviors, depression/anxiety; stimulants for
Treat medical conditions (e.g. epilepsy)
Behavioral/psychoeducational interventions have been used to treat the core
symptom features of autism in the realms of communication and social inter-
action. Applied Behavioral Analysis (ABA). A strategy for developing social
skills based on idea that rewarded behaviors will be repeated.
Treatment & Education of Autistic & Related Communication of Handi-
capped Children (TEACCH). Structured teaching approach that uses the
child’s visual and rote memory strengths to improve communication, social
and coping skills
Picture Exchange Communication System (PECS). Helps non-verbal chil-
dren express themselves, reduces maladaptive behaviors.
Play Therapy- counseling to help children express themselves through toys.
Social Stories an intervention to address behavior difficulties
Sensory Integration provides controlled sensory input with the goal being in-
creased adaptive behaviors/responses and less agitation.
Speech Therapy- teaches how to communicate more effectively - how to
hold a conversation, thinking about what the other person in a conversation
understands and believes, and tuning in to the meta-linguistic signals of the
Specific forms of medication treatment have been shown to produce signifi-
cant improvements in problem behaviors associated with autism in double
blind placebo-controlled trials in autistic patients.
Anxiety symptoms, repetitive behaviors as seen in patients who have obses-
sions or compulsions, self-injurious behaviors, and perhaps social avoidance/
withdrawal have been significantly reduced with the use of SSRIs (fluoxetine,
sertraline, clomipramine, fluvoxamine) and atypical antidepressants (mirtazap-
ine and venlafaxine).
Neuroleptics have been shown to reduce irritability, hyperactivity, (risperi-
done), aggression (haloperidol low doses and risperidone)..
Stimulants, NMDA antagonists, and alpha-2 noradrenergic receptor ago-
nists, have been shown to decrease hyperactivity and inattention
(methylphenidate, amantadine, clonidine)
The sometimes exquisite sensitivity of patients who have autism requires
careful initiation, titration, and monitoring of any psychopharmacologic/
pharmacologic treatments. Treatment of associated disorders such as epilep-
sy and GI problems should also be carefully monitored.
In 2006, the U.S. Food and Drug Administration (FDA) approved risperidone
for the treatment of irritability associated with autistic disorder, including symp-
toms of aggression towards others, deliberate self-injuriousness, temper
tantrums, and quickly changing moods, in children and adolescents ages 5 to
16 years. This is the first time the FDA has approved any medication for use in
children and adolescents with autism.
CHAPTER 14 Child and adolescent 85
Language and learning disorders (LLDs)1
LLDs comprise a very common set of problems, with estimates that as many
as 10% to 20% of children and adolescents have a language and/or learning
disorder. The diagnoses of mental retardation, motor skills disorder, ADHD,
mood disorder, anxiety disorder and medical/neurological primary diagnosis
(e.g., fetal alcohol syndrome, prenatal substance abuse, fragile X syndrome)
should be considered since they may be concurrent with or mistaken for
speech, language, or learning disorders.
DSM-IV groups together a number of LLDs that share the following criteria:
- Performance is significantly below that expected for IQ or age
- A discrete developmental disability in the absence of MR
- Commonly presents as school refusal, emotional or behavioral
- 50% have co-morbid psychiatric disorder and/or other LLDs
- Most show strong evidence of heritability
Reading disorder (dyslexia)
Difficulty with reading, in most cases involving a deficit in phonological-pro-
cessing skills. 4% of school-age children (range 2-10%). Male predominance.
There is often a family history of dyslexia. Familial risk to first degree rela-
tives has been found to be between 35% and 45%, compared with the popula-
tion risk of 3% to 10%. Mapped to genes and specific neurobiological profile,
with associated interventions proposed by Shaywitz2.
20% have comorbid ADHD or Conduct Disorder. Management includes 1:1 re-
medial teaching and parent involvement improves long-term outcome.
Disorder of written expression
Often coexists with dyslexia and manifests as difficulties with spelling, syntax,
grammar, and composition. Occurs in 2–8% of school-age children with a 3:1
male predominance. Difficulties may first emerge with the shift from narrative
to expository writing assignments.
Female predominance and occurs in 1–6% of school-age children. Often as-
sociated with visuo-spatial deficits and attributed to right parietal dysfunction.
Family members (e.g., parents and siblings) of children with mathematics dis-
order are 10 times more likely to be diagnosed with mathematics disorder than
are members of the general population.
AACAP (1998) Practice parameters for the assessment and
treatment of children and adolescents with language and learning
disorders. J Am Acad Child Adolesc Psychiatry 37 (10 supp),
2. Shaywitz, SM (2005) Overcoming Dyslexia: A New and
Complete Science-Based Program for Reading Problems at Any
Level. Vintage Press. http://www.childrenofthecode.org/
Includes expressive and receptive language disorders, phonological disorder
Expressive language disorder is diagnosed when scores from standardized
tests measure delays in expressive language, not due to sensory or motor
deficit or environmental deprivation and in excess of delays expected based
on scores of nonverbal intelligence and receptive language abilities. The diffi-
culties with expressive language interfere with academic or occupational
achievement. 3% to 5% of children have a developmental expressive lan-
Mixed Receptive-Expressive Language Disorder is diagnosed when scores
from standardized tests measure delays in both receptive and expressive lan-
guage, not due to sensory or motor deficit or environmental deprivation and in
excess of delays expected based on scores of nonverbal intelligence abilities.
The difficulties with receptive and expressive language interfere with academic
or occupational achievement. Prevalence of either a developmental expres-
sive or receptive language disorder ranges from 1% to 13% of the population.
Phonological Disorder is defined as a failure to develop expected speech
sounds appropriate for age and dialect that compromises academic/occupa-
tional achievement or social communication. The deficit is out of proportion to
MR, sensory deficits or environmental deprivation, if present. Prevalence of
phonological disorder ranges from 1% to more than 20%.
Stuttering is defined as a disturbance in the normal fluency or time pattern of
speech. Persons who stutter usually struggle with the initial syllables of multi-
syllabic words. Onset is usually between the age of 3 and 6 years of age with
a male predominance of 3:1. Rates of natural, unassisted recovery is about
75%. Majority of cases are developmental, but may be acquired (e.g. head
injury). Etiology is thought to be genetic, due to incomplete cerebral domi-
nance and/or hyperdopaminergic state. Management utilizes speech therapy,
and sometimes medication, such as antipsychotics (e.g. risperidone) or SS-
CHAPTER 14 Child and adolescent 87
Elimination Disorders: Enuresis
DSM-IV-TR Diagnostic criteria for Enuresis
A. Repeated voiding of urine into bed or clothes (whether involuntary or
B. The behavior is clinically significant as manifested by either a frequency of
twice a week for at least 3 consecutive months or the presence of clinically
significant distress or impairment in social, academic (occupational), or other
important areas of functioning.
C. Chronological age is at least 5 years (or equivalent developmental level).
D. The behavior is not due exclusively to the direct physiological effect of a
substance (e.g., a diuretic) or a general medical condition (e.g., diabetes,
spina bifida, a seizure disorder).
Specify type: Nocturnal Only, Diurnal Only, Nocturnal and Diurnal
Prevalence reported to be 5-15% of 5 year olds, with 15% remission rate/year
every year after, and 1-2% by teen/adult years. Episodes are usually
involuntary, occur at night, and are more common in males than females.
Enuresis can result in low self-esteem and often becomes a focus for family
Subtypes – nocturnal only (most common), diurnal only, nocturnal and diurnal
Etiology Genetic—75% have a family history of enuresis; Other - generalized
developmental delay; incomplete potty training; psychosocial stressors (e.g.
birth of a sibling, hospitalization, starting school, domestic conflict); comorbid
psychopathology (e.g. depression); organic causes.
Work-up For Nocturnal enuresis: use general medical evaluation (including
personal and family history, physical, height/weight chart, urinalysis and
abdominal exam) to rule out UTI, neurological problems, diabetes mellitus,
seizure, and drug side effects. Consider abdominal x-ray to rule out
constipation. After 8 years old, and with any diurnal component, strongly
consider urological referral.
Management Behavioral modification is the first-line treatment and includes
restricting fluids at night, scheduling toileting times prior to bed, behavioral
management (star charts without or without other rewards), night-lifting,
bell and pad technique, bladder training
Often helpful to implement bowel regimen (see encopresis section)
Pharmacological intervention: use only if behavioral treatment fails
- DDAVP (desmopressin), which is less anticholinergic than imipramine
and does not exacerbate constipation.
- Imipramine: A tricyclic antidepressant. Works due to anticholinergic
effect by increasing sphincter tone. 80% have some improvements but
tolerance may develop after 6 weeks.
Clinical Pearls: Remember to get an EKG because of potential cardiac
implications of tricyclic antidepressants; also weigh benefits and risks
because of risk of death with overdose and/or cardiac side effects.
Other pharmacologic intervention available, but mostly utilized by
DSM-IV-TR Diagnostic criteria for Encopresis
A. Repeated passage of feces into inappropriate places (e.g., clothing or floor)
whether involuntary or intentional.
B. At least one such event a month for at least 3 months.
C. Chronological age is at least 4 years (or equivalent developmental level).
D. The behavior is not due exclusively to the direct physiological effects of a
substance (e.g., laxatives) or a general medical condition except through a
mechanism involving constipation.
Code with or without Constipation and Overflow Incontinence
The DSM criteria are probably physiologically irrelevant. Episodes are almost
Prevalence 1-3% of children 5 year old and older. Most Encopresis has
resolved by adolescence. More common in males than females.
Subtypes With or without constipation and overflow incontinence
Etiology May be caused or related to fecal withholding due to pain, power
struggle, inattention to bowel needs, oppositionality, or physiological problem.
Up to 95% involves some form of fecal constipation. Hirshprung’s disease
rarely cause of encopresis. Often secondary to ADHD.
Work-up: Medical history to rule out neurologic problems, drug side effects,
nutritional problems, and hirschsprung’s disease. History of frequency and
form of stools is essential. Physical exam with complete abdominal exam,
rectal exam, and abdominal x-ray usually sufficient.
Management: Utilize Fiber, water, and laxative to promote consistent soft
stools. Can become increasingly aggressive with laxative use in order to
promote complete bowel clean-out if initial conservative efforts are not
effective. Educate parents and child in order to minimize embarrassment and
family conflict. Consistent behavioral approach to toileting and soiling can be
helpful, no matter what the cause. Parent should reward stool in the toilet, as
opposed to clean underwear.
CHAPTER 14 Child and adolescent 89
Disorders of Eating, Sleeping, and
Sleep problems Complaints about difficulty initiating or maintaining sleep are
common. Although organic pathology can be the cause of sleep problems at
any age, frequent problems prior to age three are most likely due to immaturity
and/or environment and can be corrected by working with parents on
consistent interactional patterns around bedtime. After age 3, psychiatric
pathology can be considered, although environment is the most likely
cause, with physiologic problems in a far 2nd place. The clinician should have
a low threshold for considering oppositionality or “bedtime resistance” for
complaints between age 3-5. After 5 years of age the clinician should consider
all of the above, but with increasing consideration of mental health concerns if
the sleep problem is impairing and associated with other peer, school, or
family difficulties. It is also important to consider formal sleep problems, such
as sleep apnea, sleep walking, sleep terrors, nightmare disorder, and
narcolepsy. Adolescents have an increased difficulty falling asleep due to a
shift in their circadian rhythm, although they may present to the clinician with a
parental complaint of oversleeping, since their overall need for sleep does not
Clinical pearl: Behavioral interventions around bedtime and sleep hygiene
cure most sleep problems.
Clinical pearl: Make questions about sleep part of your routine exam. Be
certain to include questions about napping, especially in adolescent patients
(see sleep chapter for details, p. ?388–425)
Classified as for adult sleep disorders (see pp. ?388–425). The main
syndromes that manifest in children and adolescents are: nightmare disorder
(p. ?418); sleep terror disorder (p. ?415); and sleepwalking disorder (pp.
414?–15). Management is the same as for adults.
Motor skills disorder/ Developmental Coordination Disorder
There are a number of conditions affecting children where the primary problem
involves an impairment of motor function. This may manifest as a delay in
developmental milestones and includes impairments of coordination, fine
motor skills, and gross movement. Gross motor impairments suggest genetic
etiology while fine motor impairments suggest environmental causation.
Treatment involves physiotherapy, OT, and educational assistance.
Failure to Thrive Evaluation for physiological or developmental problems is
imperative. It is important to correct any nutritional deficiency as soon as
possible in order to prevent negative impact on development.
Clinical pearl: refeeding alone is not adequate, since failure to thrive is often
related to either a primary or secondary failure of the feeding process.
Obesity Severe overeating is a behavioral phenotype associated with some
genetic and behavioral conditions. In addition, medications such as mood
stabilizers and antipsychotics are associated with dyslipidemia and obesity. As
such, weight parameters should be monitored in all children.
Feeding and eating disorders of infancy and early
Pica This is a common condition where there is persistent (>1month) eating of
non-nutritive substances at a developmentally inappropriate age (>1 ½ yrs).
Common substances are: dirt, clay, stones, hair, feces, plastic, paper,
wood, string, etc. It is particularly common in individuals with developmental
disabilities and may be dangerous or life-threatening depending on the
substance ingested. Consequences may include toxicity, infection, or GI
ulceration/obstruction. Typically occurs during 2nd and 3rd yrs of life, although
young pregnant women may exhibit pica during pregnancy. Hypothesized
causes include: nutritional deficiencies; cultural factors (e.g. clay);
psychosocial stress; malnutrition and hunger; brain disorders (e.g.
Rumination This is the voluntary or involuntary regurgitation and re-
chewing of partially digested food. Occurs within a few minutes post-prandial
and may last 1–2 hrs. Regurgitation appears effortless and is preceded by
belching. Typical onset 3–6 months of age, may persist for several months
and then spontaneously remit. Also occurs in older individuals with MR. May
result in weight loss, halitosis, dental decay, aspiration, recurrent RTI, and
sometimes asphyxiation and death (5–10% of cases). Causes include: MR; GI
pathology; psychiatric disorders; psychosocial stress. Treatment includes
physical examination and investigations; behavioral methods; nutritional
Eating Disorders: Anorexia Nervosa and Bulimia Nervosa occur mostly in
females, with a typical onset around age 15-19 (although onset is by no
means is limited to this age range). Treatment is challenging, and with very
high relapse rates. Assessment, Diagnosis, and treatment is similar in
adolescents and adults. (see page 375?? for details)
Ellis CR and Schnoes CJ (2002) www.emedicine.com
CHAPTER 14 Child and adolescent 91
Attachment May be defined as the organization of behaviors in the young
child that are designed to achieve physical proximity to a preferred caregiver
at times when the child seeks comfort, support, nurturance, or protection.
According to AACAP Practice Parameters, preferred attachment appears in
the latter part of the first year of life as evidenced by the appearance of
separation protest and stranger warinessJohn Bowlby described the
formation of healthy secure attachment from early infancy, as well as a normal
pattern of separation anxiety commencing between 6 and 9 months, peaking
between 12 and 18 months and decreasing during the 3rd year. Its
developmental course appears to be the same across cultures and is the
same for infants who are in day care, raised in nuclear families, or reared in
larger social groups1. Infants become attached to caregivers with whom they
have had significant amounts of interaction and lack of attachment to a
specific attachment figure is exceedingly rare in reasonably responsive
caregiving environments; signs of reactive attachement disorder (RAD) are not
typically reported in the absence of serious neglect.
Ethology and attachment
The history of attachment theory is closely allied to the development of
ethology, the study of animal behavior in its natural environment. Konrad
Lorenz (an Austrian doctor) and Nico Tinbergen (a Dutch biol- ogist) are
recognized as the fathers of ethology, and shared the Nobel Prize in 1973 for
their contributions to the field. Some of their most important discoveries were
the identification of imprinting, fixed action patterns (FAPs), and innate
releasing mechanisms (IRMs)—all of which have informed the understanding
of infant attachment behavior. Lorenz classically described imprinting in
ducklings and Greylag goslings, the phenomenon where young animals form
an immediate and irreversible social bond with the first moving object they
encounter. The phenomena of FAPs and IRMs were first observed in the
herring gull and the stickleback, and formed a basis for understanding the
complex innate mechanisms that facilitate mother-infant bonding during the
During the 1950s and 1960s, John Bowlby and Margaret Ainsworth used
ethological principles to study the formation of healthy and abnormal
attachment in children. Ainsworth developed the Strange Situation Procedure,
an experiment that she used in several cultural settings to establish universal
patterns of attachment. Healthy attachment was classically described as
‘secure’, while ‘insecure’ attachment encompassed ‘anxious’, ‘resistant’, and
‘avoidant’ types. These latter concepts are recognized in contemporary
nomenclature under the diagnoses ‘separation anxiety disorder’ and ‘reactive
attachment disorder’. Bowlby also coined the term ‘critical period ’to describe
the stage during which the infant is most responsive to developing secure
1. Haugaard&Hazan 2004, Child maltreatment
Reactive Attachment Disorder of Infancy and Early Childhood (RAD)
Prolonged hospitalizations of the child, extreme poverty, or parental
inexperience may predispose to the development of pathologic care, but
grossly pathological care does not always result in the development of RAD.
Persistence of RAD is exceedingly rare in children adopted out of institutions
into more normative care environments and there are no data compatible with
the idea that there is a critical period for attachment formation.
Key Features Early onset of markedly disturbed and developmentally
inappropriate social relatedness across contexts that begins before age 5
RAD is the result of ‘‘pathogenic care’’, and is distinguishable from PDD
(RAD is not diagnosed when PDD is present), and may manifest as either
inhibited or disinhibited subtypes. Pathogenic care is evidenced by either
persistent disregard of child’s basic emotional needs or phsycial needs, or
repeated changes of primary caregiver that prevent formation of stable
Epidemiology Estimated prevalence is less than 1%. The prevalence is
suggested to be from 30% to 40% in foster care.
Symptoms Excessively inhibited, hypervigilant, or highly ambivalent and
contradictory responses such as avoidance or resistance to comforting or
frozen watchfulness in inhibited type. Excessive familiarity with relative
strangers or lack of selectivity in choice of attachment figures in disinhibited
type. Older children may present with peer problems or superficial connection
Differential MR; PDD; ADHD, CD, ODD; LD; social phobia; PTSD.
Assessment Detailed history and direct observation of the child in the context
of his/her relationships with primary caregivers.
Management Therapy that focuses on establishing an attachment relationship
with the child and ameliorating disturbed attachment relationships with
caregivers. Coercive treatments (e.g. holding therapy, rebirthing) are
potentially dangerous and not recommended.
CHAPTER 14 Child and adolescent 93
Anxiety and fear are an inherent part of the human condition and in times of
danger are often adaptive. As a result of changing developmental and
cognitive abilities during childhood, the content of normal fears and anxieties
shifts from concerns about concrete external things to abstract internalized
anxieties. Anxiety disorders are characterized by excessive anxiety or worry
causing significant distress and/or impairment in functioning and their relative
prevalence reflects this shift in content. Thus specific disorders appear more
common during specific stages of development. Children may not be able to
recognize that the fear is excessive or unreasonable.
Epidemiology Anxiety disorders are among the most common psychiatric
disorders in youth. Prevalence rates range from 5–15% with 8% requiring
clinical treatment. Age of onset varies for each disorder but range from early
childhood to 12 yrs. Separation anxiety disorder and specific phobia usually
have onset in early childhood, Generalized Anxiety Disorder (GAD) occurs
across all age groups, while obsessive-compulsive disorder, social phobia,
and panic disorder tend to occur in later childhood and adolescence.
Comorbidity is common and 60-70% have 2 anxiety disorders and 25-30%
has 3 anxiety disorders. Anxiety disorders are very common with depressive
and bipolar disorders, ADHD, CD, and substance abuse.
Etiological factors Genetic vulnerability; temperament that exhibits ‘behavioral
inhibition’ (timidity, shyness, and emotional restraint with unfamiliar people or
situations); anxious attachment; negative life events; dysregulation of 5HT and
NA systems; S allele in 5HTTLRP promoter gene; hypertrophy and
hyperresponsiveness of the amygdale to emotional stimuli.
Organic causes of anxiety Medical conditions such as hyperthyroidism;
cardiac problems such as arrhythmias; respiratory and neurological diseases.
Substances such as alcohol; caffeine; cocaine; amphetamines; cannabis;;
LSD; ecstasy; etc.
Physical examination and interview with child
Interview with parents including developmental and family history and
collateral information from teachers if release of information can be
Instruments: K-SADS; DISC; CBCL; The Screen for Child Anxiety Related
Emotional Disorders (SCARED); The Revised Children’s Manifest Anxiety
Scale (RCMAS); The Multidimensional Anxiety Scale for Children (MASC);
The Pediatric Anxiety Rating Scale (PARS); The State-Trait Anxiety
Inventory for Children (STAI-C); The Social Phobia and Anxiety Inventory
for Children (SPAI-C); The Social Anxiety Scale for Children-Revised
Labellarte MJ, Ginsburg GS, Walkup JT, Riddle MA (1999) The
treatment of anxiety disorders in children and adolescents. Biological
Psychiatry 46, 1567–78.
2 Dadds MR and Barrett PM (2001) Practitioner review:
psychological management of anxiety disorders in childhood. J Child
Psychol Psychiat 42, 999-1011.
(SASC-R); The Fear Survey Schedule for Children-Revised (FSSC-R); The
Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS).
Anxiety Disorder Treatment principles
Cognitive Behavioral Therapy (CBT) is supported by a number of
controlled studies as the psychological treatment of choice for pediatric
anxiety disorders. Focuses on relaxation training, exposure and response
prevention, and cognitive restructuring.
Psycho-education and parent training is very important, particularly for
Psychodynamic therapies include group, family, and individual/play
Pharmacological: SSRIs are first-line agents if CBT is not available or
ineffective. There is no evidence to select a specific SSRI for a particular
anxiety disorder, but available studies demonstrated efficacy of fluvoxamine
in GAD, and Social Phobia (SP), sertraline for GAD, ad Fluoxetine for GAD
and SP. There are positive studies with fluoxetine, sertraline, fluvoxamine,
citalopram, and paroxetine in childhood OCD. The effect size SSRIs in
childhood axiety disorders is bigger than in depressive disorders. Available
data suggest that suicidal activation (see end of chapter page ???for FDA
warning) still needs to be considered in childhood anxiety disorders
regardless of mood symptoms and the significance and safety/follow-up
plan should be discussed with patients and families. Severity of anxiety
symptoms and family history predicts less favorable outcome and one year
of maintenance of the medication after stabilization is suggested.
Combined CBT ad pharmacotherapy is supported by some studies but can
be reserved for slow or poor responders. There are some data supporting
use of buspirone and benzodiazepines (alprazolam and clonazepam) in
older children and adolescents with resistant symptoms. Benzodiazepines
can be helpful with acute or short term management in some cases or in
some children who are very sensitive to side effects of SSRIs (weigh benefit
of benzodiazepines with risk of abuse and possible paradoxical activating
1. Myers K. Winters NC. Ten-year review of rating scales. II: Scales for internalizing disorders.
[Journal Article. Review] Journal of the American Academy of Child & Adolescent Psychiatry.
41(6):634-59, 2002 Jun.,
2. Morrıs TL, March JS. Anxiety Disorders in Children an Adolescents, second edition. The Gulford
Press, New York, NY, 2004.