15 disorders of childhood and adolescence (neurodevelopmental disorders) learning objectives 15 ·  15.1 How does maladaptive behavior appear in different life periods? ·  15.2 What are the common disorders of childhood? ·  15.3 Do anxiety and depression appear in children and adolescents? ·  15.4 What are some specific disorders that occur in childhood? ·  15.5 What are intellectual disabilities? ·  15.6 How can we plan better programs to help children and adolescents? A Case of Adolescent Depression and Attempted Suicide Emily is 15-year-old girl from a middle-class Caucasian background who had a history of depression during her childhood. She had periods of low mood, poor self-esteem, and social withdrawal. She also had symptoms of anxiety and was very reluctant to leave her home. During her year in the seventh grade, she became so fearful of going to school that she missed so many days she had to repeat the grade. She currently is in the eighth grade and has, to this point, missed a great deal of school. Her family became very concerned over Emily’s low mood and isolation, so they enrolled her in an out-patient treatment program for depression, anxiety episodes, and eating disorders. Her depression continued, and she became more isolated, lonely, and depressed and would not leave her room even for meals. One day her grandmother found her in their car in the garage with the engine running in an effort to end her life. Emily was admitted into an inpatient treatment program following her serious suicide attempt. There is a history of psychiatric problems, particularly mood disorders, in her family. Her mother has been hospitalized on three occasions for depression. Her maternal grandfather, now deceased, was hospitalized at one time following a manic depressive episode. In the early phases of her hospitalization, Emily underwent an extensive psychological and psychiatric evaluation. She was administered a battery of tests, including the Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A). She was cooperative with the evaluation and provided the assessment staff with sufficient information regarding her mood and attitudes to assist in developing a treatment program. Emily showed many symptoms of a mood disorder in which both depression and anxiety were prominent features. The psychological evaluation indicated that she was depressed, anxious, and felt unable to deal with the school stress that her condition prompted. Moreover, her physical appearance and eating behavior suggested the strong likelihood of anorexia nervosa. Emily showed an extreme degree of social introversion on several measures and acknowledged her reticence at engaging in social interactions. The assessment psychologist concluded that her personality characteristics of social withdrawal, isolation, and difficult interpersonal relationships would likely result in her having problems in establishing a therapeutic relationship. Her treatment program involv.

1. 15 disorders of childhood and adolescence (neurodevelopmental
disorders)
learning objectives 15
· 15.1 How does maladaptive behavior appear in different life
periods?
· 15.2 What are the common disorders of childhood?
· 15.3 Do anxiety and depression appear in children and
adolescents?
· 15.4 What are some specific disorders that occur in
childhood?
· 15.5 What are intellectual disabilities?
· 15.6 How can we plan better programs to help children and
adolescents?
A Case of Adolescent Depression and Attempted Suicide Emily
is 15-year-old girl from a middle-class Caucasian background
who had a history of depression during her childhood. She had
periods of low mood, poor self-esteem, and social withdrawal.
She also had symptoms of anxiety and was very reluctant to
leave her home. During her year in the seventh grade, she
became so fearful of going to school that she missed so many
days she had to repeat the grade. She currently is in the eighth
grade and has, to this point, missed a great deal of school. Her
family became very concerned over Emily’s low mood and
isolation, so they enrolled her in an out-patient treatment
program for depression, anxiety episodes, and eating disorders.
Her depression continued, and she became more isolated,
lonely, and depressed and would not leave her room even for
meals. One day her grandmother found her in their car in the
garage with the engine running in an effort to end her life.
Emily was admitted into an inpatient treatment program
following her serious suicide attempt.

2. There is a history of psychiatric problems, particularly mood
disorders, in her family. Her mother has been hospitalized on
three occasions for depression. Her maternal grandfather, now
deceased, was hospitalized at one time following a manic
depressive episode.
In the early phases of her hospitalization, Emily underwent an
extensive psychological and psychiatric evaluation. She was
administered a battery of tests, including the Minnesota
Multiphasic Personality Inventory for Adolescents (MMPI-A).
She was cooperative with the evaluation and provided the
assessment staff with sufficient information regarding her mood
and attitudes to assist in developing a treatment program.
Emily showed many symptoms of a mood disorder in which
both depression and anxiety were prominent features. The
psychological evaluation indicated that she was depressed,
anxious, and felt unable to deal with the school stress that her
condition prompted. Moreover, her physical appearance and
eating behavior suggested the strong likelihood of anorexia
nervosa. Emily showed an extreme degree of social introversion
on several measures and acknowledged her reticence at
engaging in social interactions. The assessment psychologist
concluded that her personality characteristics of social
withdrawal, isolation, and difficult interpersonal relationships
would likely result in her having problems in establishing a
therapeutic relationship. Her treatment program involved
supportive cognitive therapy along with antidepressant
medication.
Although she endorsed a broad range of anxiety symptoms, in
her testing and in the intake interview she endorsed few items
regarding suicidal ideation. This was not sufficient evidence to
support a conclusion that she was at less risk for suicide;
however, it could simply reflect her unwillingness to openly

3. discuss her recent attempt. Her past behavior and low mood
indicated a need to consider the possibility of further suicide
attempts.
She remained in inpatient treatment for 3 weeks and was
discharged with the summary that she had shown substantial
improvement. She was, however, referred for further
psychological treatment on an outpatient basis.
Source: Adapted from Williams & Butcher, 2011, pp. 151–63.
Until the twentieth century, little account was taken of the
special characteristics of psychopathology in children;
maladaptive patterns considered relatively specific to
childhood, such as autism, received virtually no attention at all.
Only since the advent of the mental health movement and the
availability of child guidance facilities at the beginning of the
twentieth century have marked strides been made in assessing,
treating, and understanding the maladaptive behavior patterns of
children and adolescents.
The problems of childhood were initially seen simply as
downward extensions of adult-oriented diagnoses. The
prevailing view was one of children as “miniature adults.” But
this view failed to recognize special problems, such as those
associated with the developmental changes that normally take
place in childhood or adolescence. Only relatively recently have
clinicians come to realize that they cannot fully understand
childhood disorders without taking these developmental
processes into account. Today, even though great progress has
been made in providing treatment for disturbed children,
facilities are still inadequate to the task, and most children with
mental health problems do not receive psychological attention.
The number of children affected by psychological problems is
considerable. Research studies in several countries have

4. provided estimates of childhood disorders. Roberts, Roberts, et
al. (2007) found that 17.1 percent of adolescents in large
metropolitan areas of the United States meet the criteria for one
or more DSM diagnoses. Verhulst (1995) conducted an
evaluation of the overall prevalence of childhood disorder based
on 49 studies involving over 240,000 children across many
countries and found the average rate to be 12.3 percent. In most
studies, maladjustment is found more commonly among boys
than among girls; however, for some diagnostic problems, such
as eating disorders (see Chapter 8), rates are higher for girls
than for boys. The most prevalent disorders are attention-
deficit/hyperactivity disorder (ADHD) (Ryan-Krause et
al., 2010) and separation anxiety disorders (Cartwright-Hatton
et al., 2006). Some subgroups of the population—for example,
Native Americans—tend to have higher rates of mental
disorders. One study reported that 23 percent of the Native
American children rated in the sample met criteria for 1 of the
11 mental disorders in the survey and 9 percent met criteria for
2 or more of the disorders (Whitbeck et al., 2006).
Maladaptive Behavior in Different Life Periods
Several behaviors that characterize maladjustment or emotional
disturbance are relatively common in childhood. Because of the
manner in which personality develops, the various steps in
growth and development, and the differing stressors people face
in childhood, adolescence, and adulthood, we would expect to
find some differences in maladaptive behavior in these periods.
The fields of developmental science (Hetherington, 1998) and,
more specifically, developmental psychopathology (Kim-
Cohen, 2007) are devoted to studying the origins and course of
individual maladaptation in the context of normal growth
processes.
It is important to view a child’s behavior in the context of
normal childhood development (Silk et al., 2000). We cannot

5. consider a child’s behavior abnormal without determining
whether the behavior in question is appropriate for the child’s
age. For example, temper tantrums and eating inedible objects
might be viewed as abnormal behavior at age 10 but not at age
2. Despite the somewhat distinctive characteristics of childhood
disturbances at different ages, there is no sharp line of
demarcation between the maladaptive behavior patterns of
childhood and those of adolescence, or between those of
adolescence and those of adulthood. Thus, although our focus in
this chapter will be on the behavior disorders of children and
adolescents, we will find some inevitable carryover into later
life periods.
Varying Clinical Pictures
The clinical picture of childhood disorders tends to be distinct
from the clinical picture of disorders in other life periods. Some
of the emotional disturbances of childhood may be relatively
short lived and less specific than those occurring in adulthood.
However, some childhood disorders severely affect future
development. One study found that individuals who had been
hospitalized as child psychiatric patients (between the ages of 5
and 17) died early in life due to unnatural causes (about twice
the rate of the general population) when followed up from 4 to
15 years later (Kuperman et al., 1988). The suicide risk among
some disturbed adolescents is long-lasting and requires careful
follow-up and attention (Fortune et al., 2007). Suicidal thoughts
are not uncommon in children. Riesch and colleagues (2008)
report that 18 percent of sixth graders have thoughts of killing
themselves. Two other recent studies have reported rates for
children under age 15. Dervic, Brent, and Oquendo (2008)
report that international suicide rates are 3.1 per million.
Hawton and Harriss (2008) report that the long-term risk of
suicide is 1.1 percent, with girls more likely than boys to
commit suicide. Both studies report that difficult family
relationships are the leading cause of suicidal behavior. Being

6. bullied by another child is another factor that has been found to
be associated with risk of suicide (Rivers & Noret, 2010).
Special Psychological Vulnerabilities of Young Children
Young children are especially vulnerable to psychological
problems (Ingram & Price, 2001). In evaluating the presence or
extent of mental health problems in children and adolescents,
one needs to consider the following:
· • They do not have as complex and realistic a view of
themselves and their world as they will have later; they have
less self- understanding; and they have not yet developed a
stable sense of identity or a clear understanding of what is
expected of them and what resources they might have to deal
with problems.
· • Immediately perceived threats are tempered less by
considerations of the past or future and thus tend to be seen as
disproportionately important. As a result, children often have
more difficulty than adults in coping with stressful events
(Mash & Barkley, 2006). For example, children are at risk for
posttraumatic stress disorder after a disaster, especially if the
family atmosphere is troubled—a circumstance that adds
additional stress to the problems resulting from the natural
disaster (Menaghan, 2010).
· • Children’s limited perspectives, as might be expected, lead
them to use unrealistic concepts to explain events. For young
children, suicide or violence against another person may be
undertaken without any real understanding of the finality of
death.
· • Children also are more dependent on other people than are
adults. Although in some ways this dependency serves as a
buffer against other dangers because the adults around him or

7. her might “protect” a child against stressors in the environment,
it also makes the child highly vulnerable to experiences of
rejection, disappointment, and failure if these adults, because of
their own problems, ignore the child (Lengua, 2006).
· • Children’s lack of experience in dealing with adversity can
make manageable problems seem insurmountable (Scott et
al., 2010). On the other hand, although their inexperience and
lack of self-sufficiency make them easily upset by problems that
seem minor to the average adult, children typically recover
more rapidly from their hurts.
The Classification of Childhood and Adolescent Disorders
Until the 1950s no formal, specific system was available for
classifying the emotional or behavioral problems of children
and adolescents. Kraepelin’s (1883) classic textbook on the
classification of mental disorders did not include childhood
disorders. In 1952, the first formal psychiatric nomenclature
(DSM-I) was published, and childhood disorders were included.
This system was quite limited and included only two childhood
emotional disorders: childhood schizophrenia and adjustment
reaction of childhood. In 1966, the Group for the Advancement
of Psychiatry provided a classification system for children that
was detailed and comprehensive. Thus, in the 1968 revision of
the DSM (DSM-II), several additional categories were added.
However, growing concern remained—both among clinicians
attempting to diagnose and treat childhood problems and among
researchers attempting to broaden our understanding of
childhood psycho-pathology—that the then-current ways of
viewing psychological disorders in children and adolescents
were inappropriate and inaccurate for several reasons. The
greatest problem was that the same classification system that
had been developed for adults was used for childhood problems
even though many childhood disorders, such as autism, learning
disabilities, and school phobias, have no counterpart in adult

8. psychopathology. The early systems also ignored the fact that in
childhood disorders, environmental factors play an important
part in the expression of symptoms—that is, symptoms are
highly influenced by a family’s acceptance or rejection of the
behavior. In addition, symptoms were not considered with
respect to a child’s developmental level. Some of the problem
behaviors might be considered age appropriate, and troubling
behaviors might simply be behaviors that the child will
eventually outgrow. In the most recent revision of the
diagnostic and statistical manual (DSM-5), efforts were made to
provide diagnostic classification that is consistent with current
research and contemporary clinical practice.
in review
· • Define developmental psychopathology.
· • Discuss the special psychological vulnerabilities of
children.
Common Disorders of Childhood
At present the DSM-5 provides diagnoses for a large number of
childhood and adolescent disorders or Neurodevelopmental
Disorders. In addition, several disorders, involving intellectual
disability (formerly referred to as mental retardation) are
included. Space limitations do not allow us to explore fully the
mental disorders of childhood and adolescence included in
the DSM system, so we have selected several disorders to
illustrate the broad range of problems that can occur in
childhood and adolescence. Some of these disorders are more
transient than many of the abnormal behavior patterns of
adulthood discussed in earlier chapters—and also perhaps more
amenable to treatment while others have a likelihood of
persistence.

9. Attention-Deficit/Hyperactivity Disorder
Attention-deficit/hyperactivity disorder (ADHD), often referred
to as hyperactivity, is characterized by difficulties that interfere
with effective task-oriented behavior in children—particularly
impulsivity, excessive or exaggerated motor activity, such as
aimless or haphazard running or fidgeting, and difficulties in
sustaining attention (Nigg et al., 2005; see DSM-5 Criteria for
Attention-Deficit/Hyperactivity Disorder). The diagnostic
criteria for ADHD remained relatively unchanged for children
and adolescents in DSM-5.
Children with ADHD are highly distractible and often fail to
follow instructions or respond to demands placed on them
(Wender, 2000). Perhaps as a result of their behavioral
problems, children with ADHD are often lower in intelligence,
usually about 7 to 15 IQ points below average (Barkley, 1997).
Children with ADHD also tend to talk incessantly and to be
socially intrusive and immature. Recent research has shown that
many children with ADHD show deficits on neuropsychological
testing that are related to poor academic functioning
(Biederman et al., 2004)
Watch the VideoJimmy: Attention-Deficit/Hyperactivity
Disorder on MyPsychLab.
Children with ADHD generally have many social problems
because of their impulsivity and overactivity. Hyperactive
children usually have great difficulty in getting along with their
parents because they do not obey rules. Their behavior problems
also result in their being viewed negatively by their peers (Hoza
et al., 2005). In general, however, hyperactive children are not
anxious, even though their overactivity, restlessness, and
distractibility are frequently interpreted as indications of
anxiety. They usually do poorly in school and often show
specific learning disabilities such as difficulties in reading or in
learning other basic school subjects. Hyperactive children also

10. pose behavior problems in the elementary grades. The case
study on page 513 reveals a typical clinical picture.
The symptoms of ADHD are relatively common among children
seen at mental health facilities in the United States, with from 3
to 7 percent reported in the DSM and 8 percent reported in a
recent study in the United Kingdom (Alloway et al., 2010). In
fact, hyperactivity is the most frequently diagnosed mental
health condition in children in the United States (Ryan-Krause
et al., 2010). The disorder occurs most frequently among
preadolescent boys—it is six to nine times more
prevalent among boys than among girls. ADHD occurs with the
greatest frequency before age 8 and tends to become less
frequent and to involve briefer episodes thereafter. ADHD has
also been found to be comorbid with other disorders such as
oppositional defiant disorder (ODD) (Staller, 2006), which we
discuss later. Some residual effects, such as attention
difficulties, may persist into adolescence or adulthood (Odell et
al., 1997). ADHD is found in other cultures (Bauermeister et
al., 2010)—for example, one study of 1,573 children from 10
European countries reported that ADHD symptoms are similarly
recognized across all countries studied and that the children are
significantly impaired across a wide range of domains.
DSM-5 criteria for: Attention-Deficit/Hyperactivity Disorder
· A. A persistent pattern of inattention and/or
hyperactivityimpulsivity that interferes with functioning or
development, as characterized by (1) and/or (2):
· 1. Inattention: Six (or more) of the following symptoms have
persisted for at least 6 months to a degree that is inconsistent
with developmental level and that negatively impacts directly
on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of

11. oppositional behavior, defiance, hostility, or failure to
understand tasks or instructions. For older adolescents and
adults (age 17 and older), at least five symptoms are required.
· a. Often fails to give close attention to details or makes
careless mistakes in schoolwork, at work, or during other
activities (e.g., overlooks or misses details, work is inaccurate).
· b. Often has difficulty sustaining attention in tasks or play
activities (e.g., has difficulty remaining focused during lectures,
conversations, or lengthy reading).
· c. Often does not seem to listen when spoken to directly (e.g.,
mind seems elsewhere, even in the absence of any obvious
distraction).
· d. Often does not follow through on instructions and fails to
finish schoolwork, chores, or duties in the workplace (e.g.,
starts tasks but quickly loses focus and is easily sidetracked).
· e. Often has difficulty organizing tasks and activities (e.g.,
difficulty managing sequential tasks; difficulty keeping
materials and belongings in order; messy, disorganized work;
has poor time management; fails to meet deadlines).
· f. Often avoids, dislikes, or is reluctant to engage in tasks
that require sustained mental effort (e.g., schoolwork or
homework; for older adolescents and adults, preparing reports,
completing forms, reviewing lengthy papers).
· g. Often loses things necessary for tasks or activities (e.g.,
school materials, pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile telephones).
· h. Is often easily distracted by extraneous stimuli (for older
adolescents and adults, may include unrelated thoughts).

12. · i. Is often forgetful in daily activities (e.g., doing chores,
running errands; for older adolescents and adults, returning
calls, paying bills, keeping appointments).
· 2 Hyperactivity and impulsivity: Six (or more) of the
following symptoms have persisted for at least 6 months to a
degree that is inconsistent with developmental level and that
negatively impacts directly on social and academic/occupational
activities:
Note: The symptoms are not solely a manifestation of
oppositional behavior, defiance, hostility, or a failure to
understand tasks or instructions. For older adolescents and
adults (age 17 and older), at least five symptoms are required.
· a. Often fidgets with or taps hands or feet or squirms in seat.
· b. Often leaves seat in situations when remaining seated is
expected (e.g., leaves his or her place in the classroom, in the
office or other workplace, or in other situations that require
remaining in place).
· c. Often runs about or climbs in situations where it is
inappropriate. (Note: In adolescents or adults, may be limited to
feeling restless.)
· d. Often unable to play or engage in leisure activities quietly.
· e. Is often “on the go,” acting as if “driven by a motor” (e.g.,
is unable to be or uncomfortable being still for extended time,
as in restaurants, meetings; may be experienced by others as
being restless or difficult to keep up with).
· f. Often talks excessively.

13. · g. Often blurts out an answer before a question has been
completed (e.g., completes people’s sentences; cannot wait for
turn in conversation).
· h. Often has difficulty waiting his or her turn (e.g., while
waiting in line).
· i. Often interrupts or intrudes on others (e.g., butts into
conversations, games, or activities; may start using other
people’s things without asking or receiving permission; for
adolescents and adults, may intrude into or take over what
others are doing).
· B. Several inattentive or hyperactive-impulsive symptoms
were present prior to age 12 years.
· C. Several inattentive or hyperactive-impulsive symptoms are
present in two or more settings (e.g., at home, school, or work;
with friends or relatives; in other activities).
· D. There is clear evidence that the symptoms interfere with,
or reduce the quality of, social, academic, or occupational
functioning.
· E. The symptoms do not occur exclusively during the course
of schizophrenia or another psychotic disorder and are not
better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality
disorder, substance intoxication or withdrawal).
Source: Reprinted with permission from the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition,
(Copyright 2013). American Psychiatric Association.
CAUSAL FACTORS IN ATTENTION-
DEFICIT/HYPERACTIVITY DISORDER

14. The cause or causes of ADHD in children have been much
debated. It still remains unclear to what extent the disorder
results from environmental or biological factors (Carr et
al., 2006; Hinshaw et al., 2007), and recent research points to
both genetic (Sharp et al., 2009; Ilott et al., 2010) and social
environmental precursors (Hechtman, 1996). Many researchers
believe that biological factors such as genetic inheritance will
turn out to be important precursors to the development of
ADHD (Durston, 2003). But firm conclusions about any
biological basis for ADHD must await further research.
Gina, a Student with Hyperactivity Gina was referred to a
community clinic because of overactive, inattentive, and
disruptive behavior. Her hyperactivity and uninhibited behavior
caused problems for her teacher and for other students. She
would impulsively hit other children, knock things off their
desks, erase material on the blackboard, and damage books and
other school property. She seemed to be in perpetual motion,
talking, moving about, and darting from one area of the
classroom to another. She demanded an inordinate amount of
attention from her parents and her teacher, and she was
intensely jealous of other children, including her own brother
and sister. Despite her hyper-active behavior, inferior school
performance, and other problems, she was considerably above
average in intelligence. Nevertheless, she felt stupid and had a
seriously devaluated self-image. Neurological tests revealed no
significant organic brain disorder.
The search for psychological causes of ADHD has yielded
similarly inconclusive results, although temperament and
learning appear likely to be factors. One study suggested that
family pathology, particularly parental personality, can be
transmitted to children (Goos et al., 2007), and another recent
study found that prenatal alcohol exposure can increase the
severity of problems in children with ADHD (Ware et

15. al., 2012). Currently, ADHD is considered to have multiple
causes and effects (Hinshaw et al., 1997). Whatever cause or
causes are ultimately determined to be influential in ADHD, the
mechanisms underlying the disorder need to be more clearly
understood and explored. There is general agreement that
processes operating in the brain are disinhibiting the child’s
behavior (Nigg, 2001), and some research has found different
EEG patterns occurring in children with ADHD than in children
without ADHD (Barry et al., 2003). At this time, however,
theorists do not agree what those central nervous system
processes are.
TREATMENTS AND OUTCOMES
Although the hyperactive syndrome was first described more
than 100 years ago, disagreement over the most effective
methods of treatment continues, especially regarding the use of
drugs to calm a child with ADHD. Yet this approach to treating
children with ADHD has great appeal in the medical
community; one survey (Runnheim et al., 1996) found that 40
percent of junior high school children and 15 percent of high
school children with emotional and behavioral problems and
ADHD are prescribed medication,
mostly Ritalin (methylphenidate), an amphetamine. In fact,
school nurses administer more daily medication for ADHD than
for any other chronic health problem.
Interestingly, research has shown that amphetamines have a
quieting effect on children—just the opposite of what we would
expect from their effects on adults. For children with ADHD,
such stimulant medication decreases overactivity and
distractibility and, at the same time, increases their alertness
(Konrad et al., 2004). As a result, they are often able to
function much better at school (Hazell, 2007; Pelham et
al., 2002).

16. Fava (1997) concludes that Ritalin can often lower the amount
of aggressiveness in children with ADHD. In fact, many
children whose behavior has not been acceptable in regular
classes can function and progress in a relatively normal manner
when they use such a drug. In a 5-year follow-up study,
Charach, Ickowicz, and Schachar (2004) reported that children
with ADHD on medication showed greater improvement in
teacher-reported symptoms than nontreated children. The
possible side effects of Ritalin, however, are numerous:
decreased blood flow to the brain, which can result in impaired
thinking ability and memory loss; disruption of growth
hormone, leading to suppression of growth in the body and
brain of the child; insomnia; psychotic symptoms; and others.
Although amphetamines do not cure ADHD, they have reduced
the behavioral symptoms in about one-half to two-thirds of the
cases in which medication appears warranted.
Ritalin has been shown to be effective in the short-term
treatment of ADHD (Goldstein, 2009; Spencer, 2004a). There
are newer variants of the drug, referred to as extended-release
methylphenidate (Concerta), that have similar benefits but with
available doses that may better suit an adolescent’s lifestyle
(Mott & Leach, 2004; Spencer, 2004b).
Three other medications for treating ADHD have received
attention in recent years. Pemoline is chemically very different
from Ritalin (Faigel & Heiligenstein, 1996); it exerts beneficial
effects on classroom behavior by enhancing cognitive
processing but has less adverse side effects (Bostic et al., 2000;
Pelham et al., 2005). Strattera (atomoxetine), a noncontrolled
treatment option that can be obtained readily, is an FDA-
approved non-stimulant medication (FDA, 2002). This
medication reduces the symptoms of ADHD (Friemoth, 2005),
but its mode of operation is not well understood. The side
effects for the drug are decreased appetite, nausea, vomiting,
and fatigue. The development of jaundice has been reported,

17. and the FDA (2004) has warned of the possibility of liver
damage from using Strattera. Although Strattera has been shown
to reduce some symptoms of ADHD, further research is needed
to evaluate its effectiveness and potential side effects (Barton et
al., 2005). Another drug that reduces symptoms of impulsivity
and hyperactivity in children with attention deficit/hyperactivity
disorder is Adderall. This medication is a combination of
amphetamine and dextro-amphetamine; however, research has
suggested that Adderall has no advantage or improvement in
results over Ritalin or Strattera (Miller-Horn et al., 2008).
Although the short-term pharmacological effect of stimulants on
the symptoms of hyperactive children is well established, their
long-term effects are not well known (Safer, 1997a). Carlson
and Bunner (1993) reported that studies of achievement over
long periods of time failed to show that the medication has
beneficial effects. The pharmacological similarity of Ritalin and
cocaine, for example, has caused some investigators to be
concerned about its use in the treatment of ADHD (Volkow et
al., 1995). There have also been some reported recreational uses
of Ritalin, particularly among college students. Kapner (2003)
described several surveys in which Ritalin was reportedly
abused on college campuses. In one survey, 16 percent of
students at one university reported using Ritalin, and in another
study 1.5 percent of the population surveyed reported using
Ritalin for recreational purposes within the past 30 days. Some
college students share the prescription medications of friends as
a means of obtaining a “high” (Chutko et al., 2010).
Some authorities prefer using psychological interventions in
conjunction with medications (Mariani & Levin, 2007). The
behavioral intervention techniques that have been developed for
ADHD include selective reinforcement in the classroom
(DuPaul et al., 1998) and family therapy (Everett &
Everett, 2001). Another effective approach to treating children
with ADHD involves the use of behavior therapy techniques

18. featuring positive reinforcement and the structuring of learning
materials and tasks in a way that minimizes error and maximizes
immediate feedback and success (Frazier & Merrill, 1998). An
example is providing a boy with ADHD immediate praise for
stopping to think through a task he has been assigned before he
starts to do it. The use of behavioral treatment methods for
ADHD has reportedly been quite successful, at least for short-
term gains.
The use of psychosocial treatment of ADHD has also shown
positive results (Pelham & Fabiano, 2008; Corcoran, 2011). Van
Lier and colleagues (2004) conducted a school-based behavioral
intervention program using positive reinforcement aimed at
preventing disruptive behavior in elementary school children.
They found this program to be effective with children with
ADHD with different levels of disorder but most effective with
children at lower or intermediate levels.
It is important to recognize that gender differences, as noted
above, are found in ADHD, with the disorder being more
prominent among boys than girls and the symptoms appraised
differently. Recent concerns have been expressed over the
possibility that treatment of females with symptoms of ADHD
might not be provided because they are more often diagnosed as
“predominantly inattentive” than boys. Rucklidge (2010) points
out that females are less likely to be referred to treatment than
males with ADHD although treatments appear to be equally
effective for both genders. She points out that future research
should be attentive to gender differences in the disorder and
further examine potential differences that might occur in
treatment and outcomes.
ADHD BEYOND ADOLESCENCE
A number of changes were made to the diagnostic criteria of
ADHD in the development of DSM-5 in order to expand the

19. diagnoses “across the life span.” Although the diagnostic
criteria were not substantially changed for ADHD in DSM-5,
some adjustments as to age level of the appearance of symptoms
were modified to allow the diagnosis in adult years.
Some researchers have reported that many children with ADHD
retain symptoms and behavior into early adulthood. Kessler,
Adler, and colleagues (2006) reported a prevalence rate of 4.4
percent in adult patients. Many children with ADHD go on to
have other psychological problems such as overly aggressive
behavior or substance abuse in their late teens and early
adulthood (Barkley et al., 2004). For example, Carroll and
Rounsaville (1993) found that 34.6 percent of treatment-seeking
cocaine abusers in their study had met the criteria for ADHD
when they were children. In a 30-year follow-up study of
hyperactive boys with conduct problems, Satterfield and
colleagues (2007) reported that such boys are at substantial
increased risk for adult criminality. Biederman and colleagues
(2010) conducted an 11-year follow-up study of girls with
ADHD and found that girls with ADHD were at high risk for
antisocial, addictive, mood, anxiety, and eating disorders. In
another recent study, college students with ADHD have been
shown to exhibit more on-the-job difficulties than peers without
ADHD (Shifrin et al., 2010). In a recent follow-up study of
children with ADHD, Klein and colleagues (2012) reported that
compared with peers without ADHD, those with ADHD
displayed dysfunction in multiple domains as adults.
Educational and occupational attainment was significantly
compromised, leading to a relative economic disadvantage.
More longitudinal research is clearly needed before we can
conclude that children with ADHD go on to develop similar or
other problems in adulthood. Mannuzza, Klein, and Moulton
(2003) reported that estimates of the numbers of children with
ADHD who will experience symptoms of ADHD in adulthood
are likely to vary considerably. However, some of the research

20. cited suggests that a significant percentage of adolescents
continue to have problems in later life, and many continue to
obtain treatment for ADHD (Doyle, 2006) or for other disorders
such as major depression or bipolar disorder in their adult years
(Klassen et al., 2010).
research CLOSE-UP: Longitudinal Research
Longitudinal research involves studying and collecting baseline
information on a specific group of interest (patients with a
given disorder, high-risk children, etc.) and then following up
with them at a future date (e.g., 1, 5, or even 20 years later) to
determine the changes that have occurred over the intervening
period.
Disruptive, Impulse-Control, and Conduct Disorder
The next group of disorders involves a child’s or an
adolescent’s relationship to social norms and rules of conduct.
In both oppositional defiant disorder and conduct disorder,
aggressive or antisocial behavior is the focus. As we will see,
oppositional defiant disorder is usually apparent by about age 8,
and conduct disorder tends to be seen by age 9. These disorders
are closely linked (Thomas, 2010). However, it is important to
distinguish between persistent antisocial acts—such as setting
fires, where the rights of others are violated—and the less
serious pranks often carried out by normal children and
adolescents. Also, oppositional defiant disorder and conduct
disorder involve misdeeds that may or may not be against the
law; juvenile delinquency is the legal term used to refer to
violations of the law committed by minors. (See the Unresolved
Issues section at the end of this chapter.)
THE CLINICAL PICTURE IN OPPOSITIONAL DEFIANT
DISORDER

21. An important precursor of the antisocial behavior seen in
children who develop conduct disorder is often what is now
called oppositional defiant disorder (ODD) and categorized
under Disruptive, Impulse-Control, and Conduct Disorders
in DSM-5. The criteria for ODD were changed in DSM-5
somewhat from the DSM-IV disorder. The ODD disorder is now
grouped into three subtypes: angry/irritable mood,
argumentative/defiant behavior and vindictiveness. Moreover, a
severity rating has been included as an indicator of severity.
The essential feature is a recurrent pattern of negativistic,
defiant, disobedient, and hostile behavior toward authority
figures that persists for at least 6 months. This disorder usually
begins by the age of 8, whereas full-blown conduct disorders
typically begin from middle childhood through adolescence. The
lifetime prevalence of ODD as reported in a national sample of
adult respondents was relatively high: 11.2 percent for boys and
9.2 percent for girls (Nock et al., 2007). Prospective studies
have found a developmental sequence from oppositional defiant
disorder to conduct disorder, with common risk factors for both
conditions (Hinshaw, 1994). That is, virtually all cases of
conduct disorder are preceded developmentally by oppositional
defiant disorder, but not all children with oppositional defiant
disorder go on to develop conduct disorder within a 3-year
period (Lahey et al., 2000). The risk factors for both include
family discord, socioeconomic disadvantage, and antisocial
behavior in the parents.
DSM-5 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 at least
three of the following 15 criteria in the past 12 months from any
of the categories below, with at least one criterion present in the
past 6 months:

22. 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 damage.
· 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” others).
· 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,

23. beginning before age 13 years.
· 14. Has run away from home overnight at least twice while
living in the 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 personality disorder.
Source: Reprinted with permission from the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition,
(Copyright 2013). American Psychiatric Association.
THE CLINICAL PICTURE IN CONDUCT DISORDER
The essential symptomatic behavior in conduct disorder and
ODD involves a persistent, repetitive violation of rules and a
disregard for the rights of others and is essentially the same as
in DSM-IV. Children with conduct disorder show a deficit in
social behavior (Happe & Frith, 1996; see DSM Criteria for
Conduct Disorder). In general, they manifest such
characteristics as overt or covert hostility, disobedience,
physical and verbal aggressiveness, quarrelsomeness,
vengefulness, and destructiveness. Lying, solitary stealing, and
temper tantrums are common. Such children tend to be sexually
uninhibited and inclined toward sexual aggressiveness. Some
may engage in cruelty to animals (Becker et al., 2004), bullying
(Coolidge et al., 2004), firesetting (Becker et al., 2004; Slavkin
& Fineman, 2000; Stickle & Blechman, 2002), vandalism,
robbery, and even ho-micidal acts. Children and adolescents

24. with conduct disorder are also frequently comorbid for other
disorders such as substance-abuse disorder (Goldstein et
al., 2006) or depressive symptoms (O’Connor et al., 1998).
Zoccolillo, Meyers, and Assiter (1997) found that conduct
disorder is a risk factor for unwed pregnancy and substance
abuse in teenage girls. Goldstein and colleagues (2006) report
that early-onset conduct disorder is highly associated with later
development of antisocial personality disorder (see Chapter 8);
Fergusson, Hor-wood, and Ridder (2007) and Yang and
colleagues (2007) found that conduct disorder in childhood and
adolescence is generally related to later substance use, abuse,
and dependence.
CAUSAL FACTORS IN OPPOSITIONAL DISORDER AND
CONDUCT DISORDER
Understanding of the factors associated with the development of
conduct problems in childhood has increased tremendously in
the past 20 years. Several factors will be covered in the sections
that follow.
A Self-Perpetuating Cycle Evidence has accumulated that a
genetic predisposition (Simonoff, 2001) leading to low verbal
intelligence, mild neuropsychological problems, and difficult
temperament can set the stage for early-onset conduct disorder.
Baker and colleagues (2007) reported strong heritable effects of
conduct problems and antisocal behavior across ethnically and
economically diverse samples. The child’s difficult
temperament may lead to an insecure attachment because
parents find it hard to engage in the good parenting that would
promote a secure attachment. In addition, the low verbal
intelligence and mild neuropsychological deficits that have been
documented in many of these children—some of which may
involve deficiencies in self-control functions such as sustaining
attention, planning, self-monitoring, and inhibiting unsuccessful
or impulsive behaviors—may help set the stage for a lifelong

25. course of difficulties. In attempting to explain why the
relatively mild neuropsychological deficits typically seen can
have such pervasive effects, Moffitt and Lynam (1994) provided
the following scenario: A preschooler has problems
understanding language and tends to resist his mother’s efforts
to read to him. This deficit then delays the child’s readiness for
school. When he does enter school, the typically busy
curriculum does not allow teachers to focus their attention on
students at his low readiness level. Over time, and after a few
years of school failure, the child will be chronologically older
than his classmates, setting the stage for social rejection. At
some point, the child might be placed into remedial programs
that contain other pupils who have similar behavioral disorders
as well as learning disabilities. This involvement with conduct-
disordered peers exposes him to delinquent behaviors that he
adopts in order to gain acceptance.
Hostility and aggressive behavior have been found to play a role
in the development of conduct disorder. Children who develop
this disorder early in childhood are at special risk for problems
later in life.
Age of Onset and Links to Antisocial Personality
Disorder Children who develop conduct disorder at an earlier
age are much more likely to develop psychopathy or antisocial
personality disorder as adults than are adolescents who develop
conduct disorder suddenly in adolescence (Copeland et
al., 2007). The link between conduct disorder and antisocial
personality is stronger among lower-socioeconomic-class
children (Lahey et al., 2005). It is the pervasiveness of the
problems first associated with oppositional defiant disorder and
then with conduct disorder that forms the pattern associated
with an adult diagnosis of psychopathy or antisocial personality.
Although only about 25 to 40 percent of cases of early-onset
conduct disorder go on to develop adult antisocial personality

26. disorder, over 80 percent of boys with early-onset conduct
disorder do continue to have multiple problems of social
dysfunction (in friendships, intimate relationships, and
vocational activities) even if they do not meet all the criteria for
antisocial personality disorder. By contrast, most individuals
who develop conduct disorder in adolescence do not go on to
become adult psychopaths or antisocial personalities but instead
have problems limited to the adolescent years. These
adolescent-onset cases also do not share the same set of risk
factors that the child-onset cases have, including low verbal
intelligence, neuropsychological deficits, and impulsivity and
attentional problems.
Psychosocial Factors In addition to the genetic or constitutional
liabilities that may predispose a person to develop conduct
disorder and adult psychopathy and antisocial personality,
Kazdin (1995) underscored the importance of family and social
context factors as causal variables. Children who are aggressive
and socially unskilled are often rejected by their peers, and such
rejection can lead to a spiraling sequence of social interactions
with peers that exacerbates the tendency toward antisocial
behavior (Freidenfelt & Klinteberg, 2007). Severe conduct
problems can lead to other mental health problems as well.
Mason and colleagues (2004) found that children who report
higher levels of conduct problems are nearly four times more
likely to experience a depressive episode in early adulthood.
This socially rejected subgroup of aggressive children is also at
the highest risk for adolescent delinquency and probably for
adult antisocial personality. In addition, parents and teachers
may react to aggressive children with strong negative affect
such as anger (Capaldi & Patterson, 1994), and they may in turn
reject these aggressive children. The combination of rejection
by parents, peers, and teachers leads these children to become
isolated and alienated. Not surprisingly, they often turn to
deviant peer groups for companionship, at which point a good

27. deal of imitation of the antisocial behavior of their deviant peer
models may occur.
Investigators generally seem to agree that the family setting of a
child with conduct disorder is typically characterized by
ineffective parenting, rejection, harsh and inconsistent
discipline, and parental neglect (Frick, 1998). Frequently, the
parents have an unstable marital relationship, are emotionally
disturbed or sociopathic, and do not provide the child with
consistent guidance, acceptance, or affection. Even if the family
is intact, a child in a conflict-charged home feels overtly
rejected. For example, Rutter and Quinton (1984) concluded
that family discord and hostility are the primary factors
defining the relationship between disturbed parents and
disturbed children; this is particularly true with respect to the
development of conduct disorders in children and adolescents.
Such discord and hostility contribute to poor and ineffective
parenting skills, especially ineffective discipline and
supervision. These children are “trained” in antisocial behavior
by the family—directly via coercive interchanges and indirectly
via lack of monitoring and consistent discipline (Capaldi &
Patterson, 1994). This all too often leads to association with
deviant peers and the opportunity for further learning of
antisocial behavior.
Ineffective parenting, harsh and inconsistent discipline, parental
neglect, and marital discord can all contribute to oppositional
defiant disorder (ODD) and conduct disorders. So can poverty
and parental stress and depression.
In addition to these familial factors, a number of broader
psychosocial and sociocultural variables increase the
probability that a child will develop conduct disorder and, later,
adult psychopathy or antisocial personality disorder (Granic &
Patterson, 2006) or depressive disorder (Boylan et al., 2010).

28. Low socioeconomic status, poor neighborhoods, parental stress,
and depression all appear to increase the likelihood that a child
will become enmeshed in this cycle (Schonberg & Shaw, 2007).
TREATMENTS AND OUTCOMES
By and large, our society tends to take a punitive, rather than a
rehabilitative, attitude toward an antisocial, aggressive youth.
Thus the emphasis is on punishment and on “teaching the child
a lesson.” Such treatment, however, seems to intensify rather
than correct the behavior. Treatment for oppositional defiant
disorder and conduct disorder tends to focus on the
dysfunctional family patterns described above and on finding
ways to alter the child’s aggressive or otherwise maladaptive
behaviors (Behan & Carr, 2000; Milne et al., 2001).
The Cohesive Family Model Therapy for a child with conduct
disorder is likely to be ineffective unless some way can be
found to modify the child’s environment. One interesting and
often effective treatment strategy with conduct disorder is the
cohesive family model (Granic & Patterson, 2006; Patterson et
al., 1998). In this family-group-oriented approach, parents of
children with conduct disorder are viewed as lacking in
parenting skills and as behaving in inconsistent ways, thereby
reinforcing inappropriate behavior and failing to socialize their
children. Children learn to escape or avoid parental criticism by
escalating their negative behavior. This tactic, in turn, increases
their parents’ aversive interactions and criticism. The
child observes the increased anger in his or her parents and
models this aggressive pattern. The parental attention to the
child’s negative, aggressive behavior actually serves to
reinforce that behavior instead of suppressing it. Viewing
conduct problems as emerging from such interactions places the
treatment focus squarely on the interaction between the child
and the parents (Patterson et al., 1991).

29. Obtaining treatment cooperation from parents who are
themselves in conflict with each other is difficult. Often, an
over-burdened parent who is separated or divorced and working
simply does not have the resources, the time, or the inclination
to learn and practice a more adequate parental role (Clarke-
Stewart et al., 2000). In more extreme cases, the circumstances
may call for a child to be removed from the home and placed in
a foster home or institution, with the expectation of a later
return to the home if intervening therapy with the parent or
parents appears to justify it (Hahn et al., 2005).
Unfortunately, children who are removed to new environments
often interpret this removal as further rejection not only by their
parents but by society as well. Unless the changed environment
offers a warm, kindly, and accepting yet consistent and firm
setting, such children are likely to make little progress (see
Pumariega, 2007).
Behavioral and Biologically Based Treatments The
effectiveness of behavior therapy techniques and biologically
based treatments has made the outlook brighter for children
with conduct disorder (Kazdin & Weisz, 2003). A recent study
of treating depression and oppositional defiant behavior with
the antidepressant medication, fluoxetine (Prozac), and
cognitive behavior therapy found a reduction in oppositionality
over those not receiving the medication (Jacobs et al., 2010).
Teaching control techniques to the parents of such children is
particularly important so that they can function as therapists in
reinforcing desirable behavior and modifying the environmental
conditions that have been reinforcing maladaptive behavior in
their children. The changes brought about when parents
consistently accept and reward their child’s positive behavior
and stop focusing on the negative behavior may finally change
their perception of and feelings toward the child, leading to the
basic acceptance that the child has so badly needed.

30. Although effective tactics for behavioral management can be
taught to parents, they often have difficulty carrying out
treatment plans. If this is the case, other techniques, such as
family therapy or parental counseling, are used to ensure that
the parent or person responsible for the child’s discipline is
sufficiently assertive to follow through on the program.
in review
· • Describe two common anxiety disorders found in children
and adolescents.
· • Distinguish among conduct disorder, oppositional defiant
disorder, and juvenile delinquency.
Anxiety and Depression in Children and Adolescents
Anxiety Disorders of Childhood and Adolescence
In modern society, no one is totally insulated from anxiety-
producing events or situations, and the experience of traumatic
events can predispose children to develop anxiety disorders
(Shevlin et al., 2007). Most children are vulnerable to fears and
uncertainties as a normal part of growing up, and children can
get generalized panic disorder just as adults do. Children with
anxiety disorders, however, are more extreme in their behavior
than those experiencing “normal” anxiety. These children
appear to share many of the following characteristics:
oversensitivity, unrealistic fears, shyness and timidity,
pervasive feelings of inadequacy, sleep disturbances, and fear
of school (Goodyer, 2000). Children diagnosed as suffering
from an anxiety disorder typically attempt to cope with their
fears by becoming overly dependent on others for support and
help. In the DSM-5, anxiety disorders of childhood and
adolescence are classified similarly to anxiety disorders in

31. adults (Albano et al., 1996). Research has shown that anxiety
disorders are often comorbid with depressive disorders (Kendall
et al., 2010; O’Neil et al., 2010) or may be influential in later
depression (Silberg et al., 2001); children who have these
comorbid conditions often have significantly more symptoms
than children who have anxiety disorders without depression
(Masi et al., 2000).
Anxiety disorders are common among children. In a recent
review of the epidemiological studies of anxiety in children,
Pine and Klein (2010) conclude that the prevalence for any
anxiety disorder accompanied by impairment appears to be
about 5 to 10 percent. For example, 9.7 percent of children in
one community-based school sample clearly met diagnostic
criteria for an anxiety-based disorder (Dadds et al., 1997).
There is a greater preponderance of anxiety-based disorder in
girls than in boys (Lewinsohn et al., 1998). And, among
adolescents, Goodwin and Gotlib (2004b) reported that panic
attacks occurred in 3.3 percent of a large community-based
epidemiological study.
SEPARATION ANXIETY DISORDER
Separation anxiety disorder, classified under Anxiety Disorders
in DSM-5, is the most common of the childhood anxiety
disorders, reportedly occurring in 2 to 41 percent of children in
past population health studies (Cartwright-Hatton et al., 2006).
Children with separation anxiety disorder exhibit unrealistic
fears, oversensitivity, self-consciousness, nightmares, and
chronic anxiety. They lack self-confidence, are apprehensive in
new situations, and tend to be immature for their age. Such
children are described by their parents as shy, sensitive,
nervous, submissive, easily discouraged, worried, and
frequently moved to tears. Typically, they are overly dependent,
particularly on their parents. The essential feature in the clinical
picture of this disorder is excessive anxiety about separation

32. from major attachment figures, such as their mother, and from
familiar home surroundings (Bernstein & Layne, 2006). In many
cases, a clear psychosocial stressor can be identified, such as
the death of a relative or a pet. The case study below illustrates
the clinical picture in this disorder.
DSM-5 criteria for: Separation Anxiety Disorder
· A. Developmentally inappropriate and excessive fear or
anxiety concerning separation from those to whom the
individual is attached, as evidenced by at least three of the
following:
· 1. Recurrent excessive distress when anticipating or
experiencing separation from home or from major attachment
figures.
· 2. Persistent and excessive worry about losing major
attachment figures or about possible harm to them, such as
illness, injury, disasters, or death.
· 3. Persistent and excessive worry about experiencing an
untoward event (e.g., getting lost, being kidnapped, having an
accident, becoming ill) that causes separation from a major
attachment figure.
· 4. Persistent reluctance or refusal to go out, away from home,
to school, to work, or elsewhere because of fear of separation.
· 5. Persistent and excessive fear of or reluctance about being
alone or without major attachment figures at home or in other
settings.
· 6. Persistent reluctance or refusal to sleep away from home or
to go to sleep without being near a major attachment figure.

33. · 7. Repeated nightmares involving the theme of separation.
· 8. Repeated complaints of physical symptoms (e.g.,
headaches, stomachaches, nausea, vomiting) when separation
from major attachment figures occurs or is anticipated.
· B. The fear, anxiety, or avoidance is persistent, lasting at
least 4 weeks in children and adolescents and typically 6
months or more in adults.
· C. The disturbance causes clinically significant distress or
impairment in social, academic, occupational, or other
important areas of functioning.
· D. The disturbance is not better explained by another mental
disorder, such as refusing to leave home because of excessive
resistance to change in autism spectrum disorder; delusions or
hallucinations concerning separation in psychotic disorders;
refusal to go outside without a trusted companion in
agoraphobia; worries about ill health or other harm befalling
significant others in generalized anxiety disorder; or concerns
about having an illness in illness anxiety disorder.
Source: Reprinted with permission from the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition,
(Copyright 2013). American Psychiatric Association.
Johnny’s Severe Separation Anxiety Johnny was a highly
sensitive 6-year-old who suffered from numerous fears,
nightmares, and chronic anxiety. He was terrified of being
separated from his mother, even for a brief period. When his
mother tried to enroll him in kindergarten, he became so upset
when she left the room that the principal arranged for her to
remain in the classroom. After 2 weeks, however, this
arrangement had to be discontinued, and Johnny had to be
withdrawn from kindergarten because his mother could not

34. leave him even for a few minutes. Later, when his mother
attempted to enroll him in the first grade, Johnny manifested the
same intense anxiety and unwillingness to be separated from
her. At the suggestion of the school counselor, Johnny’s mother
brought him to a community clinic for assistance with the
problem. The therapist who initially saw Johnny and his mother
was wearing a white clinic jacket, which led to a severe panic
reaction on Johnny’s part. His mother had to hold him to keep
him from running away, and he did not settle down until the
therapist removed his jacket. Johnny’s mother explained that he
was terrified of doctors and that it was almost impossible to get
him to a physician even when he was sick.
When children with separation anxiety disorder are actually
separated from their attachment figures, they typically become
preoccupied with morbid fears, such as the worry that their
parents are going to become ill or die.
When children with separation anxiety disorder are actually
separated from their attachment figures, they typically become
preoccupied with morbid fears, such as the worry that their
parents are going to become ill or die. They cling helplessly to
adults, have difficulty sleeping, and become intensely
demanding. Separation anxiety is more common in girls
(Bernstein & Layne, 2006), and the disorder is not very stable
over time (Poulton et al., 2001). One study, for example,
reported that 44 percent of youngsters showed recovery at a 4-
year follow-up (Cantwell & Baker, 1989). However, some
children go on to exhibit school refusal problems (a fear of
leaving home and parents to attend school) and continue to have
subsequent adjustment difficulties. A disproportionate number
of children with separation anxiety disorder also experience a
high number of other anxiety-based disorders such as phobia
and obsessive-compulsive disorder (Egger et al., 2003; Kearney
et al., 2003).

35. CAUSAL FACTORS IN ANXIETY DISORDERS
A number of causal factors have been emphasized in
explanations of the childhood anxiety disorders. Although
genetic factors have been thought to contribute to the
development of anxiety disorders, particularly obsessive-
compulsive disorder, in children (Nestadt et al., 2010), social
and cultural factors are likely to be influential in resulting in
anxiety disorders in children. For example, Potochnick and
Perreira (2010) found an increased risk of anxiety and
depression among immigrant Latino youth. Parental behavior
and family stress in minority families have been particularly
noted as potential influential factors in the origin of anxiety
disorders in children; however, broader cultural factors are also
important considerations.
Anxious children often manifest an unusual constitutional
sensitivity that makes them easily conditionable by aversive
stimuli. For example, they may be readily upset by even small
disappointments—a lost toy or an encounter with an overeager
dog. They then have a harder time calming down, a fact that can
result in a build-up and generalization of surplus fear reactions.
The child can become anxious because of early illnesses,
accidents, or losses that involved pain and discomfort. The
traumatic effect of experiences such as hospitalizations makes
such children feel insecure and inadequate. The traumatic nature
of certain life changes such as moving away from friends and
into a new situation can also have an intensely negative effect
on a child’s adjustment.
Overanxious children often have the modeling effect of an
overanxious and protective parent who sensitizes a child to the
dangers and threats of the outside world. Often, the parent’s
overprotectiveness communicates a lack of confidence in the

36. child’s ability to cope, thus reinforcing the child’s feelings of
inadequacy (Woodruff-Borden et al., 2002).
Indifferent or detached parents (Chartier et al., 2001) or
rejecting parents (Hudson & Rapee, 2001) also foster anxiety in
their children. The child may not feel adequately supported in
mastering essential competencies and in gaining a positive self-
concept. Repeated experiences of failure stemming from poor
learning skills may lead to subsequent patterns of anxiety or
withdrawal in the face of “threatening” situations. Other
children may perform adequately but may be overcritical of
themselves and feel intensely anxious and devalued when they
perceive themselves as failing to do well enough to earn their
parents’ love and respect.
The role that social-environmental factors might play in the
development of anxiety-based disorders, though important, is
not clearly understood. A cross-cultural study of fears
(Ollendick et al., 1996) found significant differences among
American, Australian, Nigerian, and Chinese children and
adolescents. These authors suggest that cultures that favor
inhibition, compliance, and obedience appear to increase the
levels of fear reported. In another study in the United States,
Last and Perrin (1993) reported that there are some differences
between African American and white children with respect to
types of anxiety disorders. White children are more likely to
present with school refusal than are African American children,
who show more PTSD symptoms. This difference might result
from differing patterns of referral for African American and
white families, or it might reflect differing environmental
stressors placed on the children. Several studies have also
reported a strong association between exposure to violence and
a reduced sense of security and psychological well-being
(Cooley-Quille et al., 2001). Children who experience a sense
of diminished control over negative environmental factors may
become more vulnerable to the development of anxiety than

37. those children who achieve a sense of efficacy in managing
stressful circumstances.
TREATMENTS AND OUTCOMES
The anxiety disorders of childhood occasionally continue into
adolescence and young adulthood, leading first to maladaptive
avoidance behavior and later to increasingly idiosyncratic
thinking and behavior or an inability to “fit in” with a peer
group. Typically, however, this is not the case. As affected
children grow and have wider interactions in school and in
activities with peers, they often benefit from experiences such
as making friends and succeeding at given tasks. Teachers who
are aware of the needs of both overanxious and shy, withdrawn
children are often able to ensure that they will have successful
experiences that help alleviate their anxiety.
Biologically Based Treatments Psychopharmacological
treatment of anxiety disorders in children and adolescents is
becoming more common today (Vitiello & Waslick, 2010).
Birmaher and colleagues (2003) evaluated the efficacy of using
fluoxetine in the treatment of a variety of anxiety-based
disorders and found the medication useful. However, the
cautious use of medications with anxiety-based disorders
involves obtaining diagnostic clarity since these conditions
often coexist with other disorders.
Psychological Treatment Behavior therapy procedures,
sometimes used in school settings, often help anxious children
(Mash & Barkley, 2006). Such procedures include assertiveness
training to provide help with mastering essential competencies
and desensitization to reduce anxious behavior. Kendall and
colleagues have reported the successful use of manual-based
cognitive-behavioral treatment (well-defined procedures using
positive reinforcement to enhance coping strategies to deal with
fears) for children with anxiety disorders (Chu &

38. Kendall, 2004). Behavioral treatment approaches such as
desensitization must be explicitly tailored to a child’s particular
problem, and in vivo methods (using real-life situations graded
in terms of the anxiety they arouse) tend to be more effective
than having the child “imagine” situations. Svensson, Larsson,
and Oest (2002) reported successful treatment of phobic
children using brief exposure.
Cognitive behavioral therapy has been shown to be highly
effective at reducing anxiety symptoms in young children
(Legerstee et al., 2010; Hirshfeld-Becker et al., 2010). An
interesting and effective cognitive-behavioral anxiety
prevention and treatment study was implemented in Australia.
In an effort to identify and reduce anxiousness in young
adolescents, Dadds and colleagues (1997) identified 314
children who met the criteria for an anxiety disorder out of a
sample of 1,786 children 7 to 14 years old in a school system in
Brisbane, Australia. They contacted the parents of these anxious
children to engage them in the treatment intervention, and the
parents of 128 of the children agreed to participate. The
treatment intervention involved holding group sessions with the
children in which they were taught to recognize their anxious
feelings and deal with them more effectively than they
otherwise would have. In addition, the parents were taught
behavioral management procedures to deal more effectively
with their child’s behavior. Six months after therapy was
completed, significant anxiety reduction was shown for the
treatment group compared with an untreated control sample.
Childhood Depression and Bipolar Disorder
Childhood depression includes behaviors such as withdrawal,
crying, avoidance of eye contact, physical complaints, poor
appetite, and even aggressive behavior and in some cases
suicide (Pfeffer, 1996a, 1996b). One epidemiological study
(Cohen et al., 1998) reported an association between somatic

39. illness and childhood depressive illness, suggesting that there
may be some common etiologic factors.
In the past, childhood depression has been classified according
to essentially the same DSM diagnostic criteria used for adults.
However, research on the neurobiological correlates and
treatment responses of children, adolescents, and adults has
shown clear differences in hormonal levels and in the response
to treatment (Kaufman et al., 2001). Gaffrey and colleagues
(2011) recently reported an fMRI study indicating that
depressed preschoolers exhibit a significant positive
relationship between depression severity and right amygdala
activity when viewing facial expressions of negative affect.
Childhood depression includes behaviors such as withdrawal,
crying, avoiding eye contact, physical complaints, poor
appetite, and in some extreme cases, aggressive behavior and
suicide.
Future neuroimaging studies are needed to explore these
differences further. One modification used for diagnosing
depression in children is that irritability is often found as a
major symptom and can be substituted for depressed mood, as
seen in the following case.
The Unhappy Child Joey is a 10-year-old boy whose mother and
teacher have shared their concerns about his irritability and
temper tantrums displayed both at home and at school. With
little provocation, he bursts into tears and yells and throws
objects. In class he seems to have difficulty concentrating and
seems easily distracted. Increasingly shunned by his peers, he
plays by himself at recess, and at home he spends most of his
time in his room watching TV. His mother notes that he has
been sleeping poorly and has gained 10 pounds over the past
couple of months from constant snacking. A consultation with

40. the school psychologist has ruled out learning disabilities and
attention-deficit disorder; instead, she says, he is a deeply
unhappy child who expresses feelings of worthlessness and
hopelessness—and even a wish that he would die. These
experiences probably began about 6 months ago when his father,
divorced from Joey’s mother for several years, remarried and
moved to another town, with the result that he spends far less
time with Joey.
Source: Adapted from Hammen & Rudolph, 1996, pp. 153–54.
Depression in children and adolescents occurs with high
frequency. The overall prevalence rates are as follows: under
age 13, 2.8 percent; ages 13 to 18, 5.6 percent (girls, 5.9
percent; boys, 4.6 percent). These rates have been generally
consistent over the past 30 years (Costello et al., 2006).
Lewinsohn and colleagues (1993) report that 7.1 percent of the
adolescents surveyed reported having attempted suicide in the
past; in another epidemiological study, Lewinsohn, Rohde, and
Seeley (1994) point out that 1.7 percent of adolescents between
14 and 18 had made a suicide attempt.
There is an increased use of bipolar diagnosis among children
and adolescents in the United States (see Developments in
Research, p. 523). Moreno and colleagues (2007) reported that
the estimated annual number of youth office-based visits with a
diagnosis of bipolar disorder increased from 25 (1994–1995) to
1,003 (2002–2003) visits per 100,000 population, as did adult
visits, with the majority of visits by males (66.5). A high
percentage of these adolescents received a comorbid diagnosis,
frequently ADHD.
CAUSAL FACTORS IN CHILDHOOD DEPRESSION
The causal factors implicated in the childhood anxiety disorders
are pertinent to the depressive disorders as well.

41. Biological Factors There appears to be an association between
parental depression and behavioral and mood problems in
children (Halligan et al., 2007; Hammen et al., 2004). Children
of parents with major depression are more impaired, receive
more psychological treatment, and have more psychological
diagnoses than children of parents with no psychological
disorders (Kramer et al., 1998). This is particularly the case
when the parent’s depression affects the child through less-
than-optimal interactions (Carter et al., 2001). A controlled
study of family history and onset of depression found that
children from mood-disordered families had significantly higher
rates of depression than those from nondisordered families
(Kovacs et al., 1997). The suicide attempt rate has also been
shown to be higher for children of depressed parents (7.8
percent) than for the offspring of control parents (Weissman et
al., 1992).
Other biological factors might also make children vulnerable to
psychological problems like depression. These factors include
biological changes in the neonate as a result of alcohol intake
by the mother during pregnancy, as prenatal exposure to alcohol
is related to depression in children. M. J. O’Connor’s (2001)
study of children exposed to alcohol in utero reveals a
continuity between alcohol use by the mother and infant
negative affect and early childhood depression symptoms. (See
Developments in Research, p. 373 for a discussion of fetal
alcohol syndrome.)
Learning Factors Learning maladaptive behaviors appears to be
important in childhood depressive disorders, and there are likely
to be learning or cultural factors in the expression of
depression. Stewart, Kennard and colleagues (2004) reported
that depression symptoms and hopelessness are higher in Hong
Kong than in the United States. In addition, a number of studies
have indicated that children’s exposure to early traumatic

42. events can increase their risk for the development of depression.
Children who have experienced past stressful events are
susceptible to states of depression that make them vulnerable to
suicidal thinking under stress (Silberg et al., 1999). Intense or
persistent sensitization of the central nervous system in
response to severe stress might induce hyperreactivity and
alteration of the neurotransmitter system, leaving these children
vulnerable to later depression (Heim & Nemeroff, 2001). A
recent study by Olino and colleagues (2010) found that
temperamental emotionality was associated with having a
depressed parent. Children who are exposed to negative parental
behavior or negative emotional states may develop depressed
affect themselves (Herman-Stahl & Peterson, 1999). For
example, childhood depression has been found to be more
common in divorced families (Palosaari & Laippala, 1996).
Mothers who are depressed may transmit their depression to
their children by their lack of responsiveness to the children as
a result of their own depression (Bagner et al., 2010).
Unfortunately, depression among mothers is all too common.
Exhaustion, marital distress as a result of the arrival of children
in a couple’s lives, delivery complications, and the difficulties
of particular babies may all play a part.
One important area of research is focusing on the role of the
mother–child interaction in the transmission of depressed affect.
Specifically, investigators have been evaluating the possibility
that mothers who are depressed transfer their low mood to their
infants through their interactions with them (Jackson &
Huang, 2000). Depression among mothers is not uncommon and
can result from several sources, such as financial or marital
problems. One study found that parenting problems and
depressed mood in mothers are associated with depression in
children (Oldehinkel et al., 2007).

43. Depressed mothers do not respond effectively to their children
(Goldsmith & Rogoff, 1997), and they tend to be less
sensitively attuned to, and more negative toward, their infants
than nondepressed mothers. Other research has shown that
negative (depressed) affect and constricted mood on the part of
a mother, which shows up as unresponsive facial expressions
and irritable behavior, can produce similar responses in her
infant (Tronick & Cohn, 1989). Interestingly, the negative
impact of depressed mothers’ interaction style has also been
studied at the physiological level. Infants have been reported to
exhibit greater frontal brain electrical activity during the
expression of negative emotionality by their mothers (Dawson
et al., 1997). Although many of these studies have implicated
the mother–child relationship in development of the disorder,
depression in fathers has also been related to depression in
children (Jacob & Johnson, 2001).
developments in RESEARCH: Bipolar Disorder in Children and
Adolescents: Is There an Epidemic?
Bipolar disorder is often characterized by extreme mood swings
and aggressive, irritable behavior (Braaten, 2011). Until recent
years it was thought to largely be a disorder occurring in
adulthood. But in the late 1990s, many psychiatrists began
applying the diagnosis to children and adolescents and
prescribing bipolar medication for their treatment (see Geller &
DelBello, 2008). In DSM-5, the diagnosis of childhood
depression has been modified as a means of preventing the over-
diagnosis of bipolar disorder in children. A new diagnosis,
disruptive mood regulation disorder, has been included for
children at or under age 18 who exhibit persistent irritability
and frequent of lack behavioral control. Bipolar disorder is
often comorbid with other disorders such as ADHD (Klassen et
al., 2010). Is there an epidemic of depression and bipolar
disorder among children and adolescents?

44. As described in Chapter 7, bipolar disorders differ from uni-
polar mood disorders by the presence of manic or hypomanic
symptoms. A person who experiences a manic episode has a
markedly elevated, euphoric, and expansive mood that is often
interrupted by occasional outbursts of intense irritability or
even violence. In order to meet DSM-5 diagnostic criteria, these
extreme moods must persist for at least a week. In addition,
three or more additional symptoms must occur in the same time
period. There must also be significant impairment of life or
social functioning. Hospitalization is often necessary during
manic episodes. In about two-thirds of cases, the manic
episodes either immediately precede or immediately follow a
depressive episode; in other cases, the manic and depressive
episodes are separated by intervals of relatively normal
functioning. Bipolar disorder occurs equally in males and
females and usually starts in adolescence and young adulthood.
The likelihood of a full recovery from bipolar disorder is low
even with the use of mood-stabilizing medications such as
lithium because bipolar disorder is typically a recurrent
condition that continues into adulthood.
The DSM-5 provides criteria to define bipolar disorder in
children that are based on how the disorder typically appears in
adults; however, there is not a specific childhood or adolescent
bipolar condition in the present DSM manual. The diagnostic
criteria for bipolar disorder have not changed over the past
decade (McClellan et al., 2007), even though there is an
increased use of the diagnosis among children and adolescents
in the United States, as noted by recent news media reports
(Carey, 2007) as well as recent research surveys.
The question of overdiagnosis of bipolar disorder in children
has emerged, in part, because of the increased use of
antidepressant prescriptions for children and adolescents. For
example, Harris (2005) points out that during a recent 3-month
period in the child assessment unit at Cambridge Hospital in

45. Massachusetts, a quarter of the children ages 3 to 13 years who
were in her care had been given a diagnosis of bipolar disorder
by their outpatient clinicians and were receiving mood
stabilizers or antipsychotics. Another quarter were believed to
have bipolar disorder by their parents, who requested that
appropriate medications be started. A number of authorities,
however, have questioned the extreme increase in the use of
bipolar diagnoses for children and adolescents and the more
extensive use of medications for treating bipolar disorder
among young people.
Does the increased rate of bipolar diagnosis for young people
result from changes in practice in which clinicians are using the
diagnosis more? Or, are younger people acquiring the disorder
more commonly? Or, are practitioners now recognizing more
patients with the disorder that they had “missed” in the past?
Many experts theorize that the increase reflects the fact that
doctors are more aggressively applying the diagnosis to
children, not an indication that the incidence of the disorder has
increased. Blader and Carlson (2007) point out that the growth
in the rate of bipolar disorder–diagnosed discharges might
reflect a “progressive rebranding” of the same clinical
phenomena for which hospitalized children previously received
different diagnoses such as ADHD. Basing their conclusions on
data from the National Hospital Discharge Survey, Blader and
Carlson reported that the rate of bipolar diagnoses jumped from
10.0 percent to 34.1 percent for all pediatric psychiatric
discharges during the study period, and it rose from 10.2
percent to 25.9 percent in adolescents. They concluded that the
rate for discharge diagnosis of bipolar disorder in children has
increased by 25 percent annually.
The reported increase in depression and bipolar disorder among
children and adolescents has, however, been questioned by some
studies. For example, using published rates of admission in
epidemiological research in the United Kingdom, Costello,

46. Erkanli, and Angold (2006) report different results. They
conducted a meta-analysis of 26 epidemiological studies on
children born between 1965 and 1996 that included nearly
60,000 interviews that allowed for a diagnosis of depression and
concluded that there is not an increased prevalence of
adolescent depression over the past 30 years.
Several authorities have advised caution in the use of bipolar
diagnoses in children and adolescents. Harris (2005) points out
that child and adolescent psychiatrists must demand tighter
criteria and higher quality of evidence in regard to juvenile
bipolar disorder in order to ensure diagnostic accuracy and also
integrate these criteria into case formulations that lead to an
effective treatment plan. One concern resulting from possible
inaccurate diagnoses of bipolar disorder is that psychiatrists
might overprescribe medications used in the treatment of
bipolar disorder (NIMH, 2007).
Considerable evidence has accumulated that depressive
symptoms are positively correlated with the tendency to
attribute positive events to external, specific, and unstable
causes and negative events to internal, global, and stable causes
(Klein et al., 2008); with fatalistic thinking (Roberts et
al., 2000); and with feelings of helplessness (Kistner et
al., 2001). For example, the child may respond to peer rejection
or teasing by concluding that he or she has some internal flaw.
TREATMENTS AND OUTCOMES
The view that childhood and adolescent depression is like adult
depression has prompted researchers to treat children displaying
mood disorders—particularly adolescents who are viewed as
suicidal (Greenhill & Waslick, 1997)—with medications that
have worked with adults. Research on the effectiveness of
antidepressant medications with children is both limited (Emslie
& Mayes, 2001) and contradictory at best, and some studies

47. have found antidepressants to be only moderately helpful
(Wagner & Ambrosini, 2001). Some studies using fluoxetine
(Prozac) with depressed adolescents have shown the drug to be
more effective than a placebo (DeVane & Sallee, 1996; Emslie
et al., 1997), and other research has shown fluoxetine to be
effective in the treatment of depression when administered as
part of cognitive-behavioral therapy (Treatment for Adolescents
with Depression Study [TADS] Team, U.S., 2004), although
complete remission of symptoms was seldom obtained. Anti-
depressant medications may also have some undesirable side
effects (nausea, headaches, nervousness, insomnia, and even
seizures) in children and adolescents. Four accidental deaths
from a drug called desipramine have been reported (Campbell &
Cueva, 1995).
Emslie, Croarkin, and Mayes (2010) recently pointed out that
antidepressants are among the most widely used drugs in
treating children and adolescents for a variety of disorders, with
significant increases over the past 20 years. Primarily,
antidepressants are used for the same disorders as in adults (i.e.,
depression, anxiety).
Depressed mood has come to be viewed as an important risk
factor in suicide among children and adolescents. About 7 to 10
percent of adolescents report having made at least one suicide
attempt (Safer, 1997b). Children who attempt suicide are at
greater risk for subsequent suicidal episodes than are non-
attempters, particularly within the first 2 years after their initial
attempt (Pfeffer et al., 1994), and some research has suggested
that antidepressant medication treatment in children and
adolescents is associated with an increased risk of suicide
(Olfson et al., 2006). Among the childhood disorders,
depression especially merits aggressive treatment. Recent
attention is being paid to the increased potential of suicidal
ideation and behavior in children and adolescents who are
taking SSRIs for their depression (Whittington et al., 2004), and

48. some risk of suicide for those taking the medication has been
noted (Couzin, 2004). The extent to which these medications
represent an additional threat of suicide is being investigated.
An important facet of psychological therapy with children,
whether for depression or anxiety or other disorders, is
providing a supportive emotional environment in which they can
learn more adaptive coping strategies and more effective
emotional expression (see Gillham et al., 2006). Older children
and adolescents often benefit from a positive therapeutic
relationship in which they can discuss their feelings openly
(Harvey & Taylor, 2010). Younger children and those with less
developed verbal skills may benefit from play therapy. Play
therapy has been found to be an effective psychological
treatment with children (Schaefer, 2010; Steele et al., 2007),
particularly using a developmentally appropriate and skill-based
approach (Reddy & Atamanoff, 2006). As a treatment technique,
play therapy emerged out of efforts to apply psychodynamic
therapy to children. Through their play, children often express
their feelings, fears, and emotions in a direct and uncensored
fashion, providing a clinician with a clearer picture of problems
and feelings (Perry & Landreth, 2001). Research has shown that
play therapy is as effective as other types of treatment such as
behavior therapy at engaging children in expressing problems.
In one study, in which play therapy was integrated into an 8-
week intervention program to treat children with conduct
disorder, the subjects showed significant gains at a 2-year
follow-up (McDonald et al., 1997).
The predominant approach for treating depression in children
and adolescents over the past few years has been the combined
use of medication and psychotherapy (Skaer et al., 2000).
Controlled studies of psychological treatment with depressed
adolescents have shown significantly reduced symptoms with
cognitive-behavioral therapy (Horowitz et al., 2007; Mash &
Barkley, 2006). Short-term residential treatment can also be

49. effective with depressed children (Leichtman, 2006). A recent
longitudinal follow-up study of adolescents who had been
treated for depression showed that effective treatment can
reduce the recurrence of depression (Beevers et al., 2007).
in review
· • How do the symptoms of childhood depression compare to
those seen in adult depression?
· • Describe the symptoms of ADHD.
· • Identify four common symptom disorders that can arise in
childhood.
Elimination Disorders (Enuresis, Encopresis), Sleepwalking,
and Tics
The childhood disorders we will deal with in this section—
“elimination disorders” (enuresis and encopresis), sleepwalking,
and tics—typically involve a single outstanding symptom
rather than a pervasive maladaptive pattern. These disorders are
essentially the same in DSM-5 as in DM-IV-TR.
Enuresis
The term enuresis refers to the habitual involuntary discharge of
urine, usually at night, after the age of expected continence (age
5). In DSM-5, functional enuresis is described as bed-wetting
that is not organically caused and classified under elimination
disorders. Children who have primary functional enuresis have
never been continent; children who have secondary functional
enuresis have been continent for at least a year but have
regressed.
Enuresis may vary in frequency, from nightly occurrence to

50. occasional instances when a child is under considerable stress
or is unduly tired. It has been estimated that some 4 to 5 million
children and adolescents in the United States suffer from the
inconvenience and embarrassment of this disorder. Estimates of
the prevalence of enuresis reported in DSM IV are 5 to 10
percent among 5-year-olds, 3 to 5 percent among 10-year-olds,
and 1.1 percent among children age 15 or older. An
epidemiological study in China reported a 4.3 percent
prevalence, with a significantly higher percentage of boys than
girls (Liu et al., 2000).
Enuresis may result from a variety of organic conditions, such
as disturbed cerebral control of the bladder (Goin, 1998),
neurological dysfunction, other medical factors such as
medication side effects (Took & Buck, 1996), or having a small
functional bladder capacity and a weak urethral sphincter
(Dahl, 1992). One group of researchers reported that 11 percent
of their enuretic patients had disorders of the urinary tract
(Watanabe et al., 1994). However, most investigators have
pointed to a number of other possible causal factors: (1) faulty
learning, resulting in the failure to acquire inhibition of
reflexive bladder emptying; (2) personal immaturity, associated
with or stemming from emotional problems; (3) disturbed
family interactions, particularly those that lead to sustained
anxiety, hostility, or both; and (4) stressful events (Haug
Schnabel, 1992). For example, a child may regress to bed-
wetting when a new baby enters the family and becomes the
center of attention.
Medical treatment of enuresis typically centers on using
medications such as the antidepressant drug imipramine. The
mechanism underlying the action of the drug is unclear, but it
may simply lessen the deepest stages of sleep to light sleep,
enabling the child to recognize bodily needs more effectively
(Dahl, 1992). An intranasal desmopressin (DDAVP) has also
been used to help children manage urine more effectively

51. (Rahm et al., 2010). This medication, a hormone replacement,
apparently increases urine concentration, decreases urine
volume, and therefore reduces the need to urinate. The use of
this medication to treat enuretic children is no panacea,
however. Disadvantages of its use include its high cost and the
fact that it is effective only with a small subset of enuretic
children, and then only temporarily. Bath and colleagues (1996)
reported that treatment with desmopressin was disappointing but
conclude that this treatment has some utility as a way to enable
children to stay dry for brief periods of time—for example, at a
camp or on a holiday. Moffatt (1997) suggested that DDAVP
has an important place in treating nocturnal enuresis in
youngsters who have not responded well to behavioral treatment
methods. It is good to remember that medications by themselves
do not cure enuresis and that there is frequent relapse when the
drug is discontinued or the child habituates to the medication
(Dahl, 1992).
When combined with medication such as desmopressin, a urine
alarm (shown here) can be very effective in treating enuresis.
The child sleeps with a wetness detector, which is wired to a
battery-operated alarm in his or her undergarment. Through
conditioning, the child comes to associate bladder tension with
awakening.
Conditioning procedures have proved to be highly effective
treatment for enuresis (Friman et al., 2008). Mowrer and
Mowrer (1938), in their classic research that is still relevant
today, introduced a procedure in which a child sleeps on a pad
that is wired to a battery-operated bell. At the first few drops of
urine, the bell is set off, thus awakening the child. Through
conditioning, the child comes to associate bladder tension with
awakening. Some evidence suggests that a biobehavioral
approach—that is, using the urine alarm along with
desmopressin—is most effective (Mellon & McGrath, 2000).

52. With or without treatment, the incidence of enuresis tends to
decrease significantly with age, but many experts still believe
that enuresis should be treated in childhood because there is
presently no way to identify which children will remain enuretic
into adulthood (Goin, 1998). In an evaluation of research on the
treatment of bed-wetting, Houts, Berman, and Abramson (1994)
concluded that treated children are more improved at follow-up
than nontreated children. They also found that learning-based
procedures are more effective than medications.
Encopresis
The term encopresis describes a symptom disorder of children
who have not learned appropriate toileting for bowel movements
after age 4. This condition, classified under elimination
disorders, in DSM-5, is less common than enuresis;
however, DSM-based estimates are that about 1 percent of 5-
year-olds have encopresis. A study of 102 cases of encopretic
children yielded the following list of characteristics: The
average age of children with encopresis was 7, with a range of
ages 4 to 13. About one-third of encopretic children were also
enuretic, and a large sex difference was found, with about six
times more boys than girls in the sample. Many of the children
soiled their clothing when they were under stress. A common
time was in the late afternoon after school; few children
actually had this problem at school. Most of the children
reported that they did not know when they needed to have a
bowel movement or were too shy to use the bathrooms at
school.
Many encopretic children suffer from constipation, so an
important element in the diagnosis is a physical examination to
determine whether physiological factors are contributing to the
disorder. The treatment of encopresis usually involves both
medical and psychological aspects. Several studies of the use of

53. conditioning procedures with encopretic children have reported
moderate treatment success; that is, no additional incidents
occurred within 6 months following treatment (Friman et
al., 2008). However, research has shown that a minority of
children (11 to 20 percent) do not respond to learning-based
treatment approaches (Keeley et al., 2009).
Sleepwalking
The onset of sleepwalking disorder is usually between the ages
of 6 and 12. The disorder is classified in parasomnias in DSM-
5. The symptoms of sleepwalking disorder involve repeated
episodes in which a person leaves his or her bed and walks
around without being conscious of the experience or
remembering it later.
The incidence of sleepwalking reported for children in
the DSM is high for one episode—between 10 and 30 percent is
relatively common—and girls are more likely to experience
sleepwalking than boys (Mahendran et al., 2006). The incidence
for repeated episodes is usually low—from 1 to 5 percent.
Children subject to this problem usually go to sleep in a normal
manner but arise during the second or third hour of sleep. They
may walk to another room of the house or even outside, and
they may engage in complex activities. Finally, they return to
bed and in the morning remember nothing that had taken place.
While moving about, sleepwalkers’ eyes are partially or fully
open; they avoid obstacles, listen when spoken to, and
ordinarily respond to commands, such as to return to bed.
Shaking them will usually awaken sleepwalkers, and they will
be surprised and perplexed at finding themselves in an
unexpected place. Sleepwalking takes place during NREM
(non–rapid eye movement) sleep, and sleepwalking episodes
usually last only a few minutes (Plazzi et al., 2005). The causes
of sleepwalking—a condition of arousal in which the subject
arises from deep sleep, even displaying long, complex behavior

54. including leaving the bed and walking, with memory
impairment of the event—are not fully understood.
Little attention has been devoted to the treatment of
sleepwalking. Clement (1970), however, reported on the
treatment of a 7-year-old boy through behavior therapy. During
treatment, the therapist learned that just before each
sleepwalking episode, the boy had a nightmare about being
chased by “a big black bug.” After his nightmare began, he
perspired freely, moaned and talked in his sleep, tossed and
turned, and finally got up and walked through the house. He did
not remember the sleepwalking episode when he awoke the next
morning. Assessment data revealed no neurological or other
medical problems and indicated that he was of normal
intelligence. He was, however, found to be a very anxious,
guilt-ridden little boy who avoided performing assertive and
aggressive behaviors appropriate to his age and sex (p. 23). The
therapist focused treatment on having the boy’s mother awaken
him each time he showed signs of an impending episode. After
washing his face with cold water and making sure he was fully
awake, the mother would return him to bed, where he was to hit
and tear up a picture of the big black bug. (At the start of the
treatment program, he had made several of these drawings.)
Eventually, the nightmare was associated with awakening, and
he learned to wake up on most occasions when he was having a
bad dream. Thus the basic behavior therapy followed in this
case was the same as that used in the conditioning treatment for
enuresis, where a waking response is elicited by an intense
stimulus just as urination is beginning and becomes associated
with, and eventually prevents, nocturnal bed-wetting.
Tic Disorders
A tic is a persistent, intermittent muscle twitch or spasm,
usually limited to a localized muscle group. The term is used