Textbook of Child, Adolescent, and Youth Mental Disorders PDF

Edited by Judit Balázs Mónika Miklósi TEXTBOOK OF CHILD, ADOLESCENT AND YOUTH MENTAL DISORDERS...

Edited by Judit Balázs Mónika Miklósi TEXTBOOK OF CHILD, ADOLESCENT AND YOUTH MENTAL DISORDERS Semmelweis Publishers Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Judit Balázs MD, PhD, Child, Adolescent and Adult Psychiatrist Judit Balazs is professor and chair of the Department of Developmental and Clinical Child Psychology at the Institute Psychology Eotvos Lorand University, Budapest, Hungary and professor at the Bjorknes University College, Oslo, Norway. She is director of education and research at the Vadaskert Child and Adolescent Psychiatric Hospital and Outpatient Clinic, Budapest, Hungary, where she is also practicing. She is currently the president of the Child and Adolescent Psychiatry Section of the European Psychiatric Association and the president elect of the Hun- garian Psychiatric Association. Her main interests are attention-deficit/hyperactivity disorder, youth suicide prevention and subthreshold mental disorders. Mónika Miklósi PhD, senior lecturer, clinical psychologist Mónika Miklósi is a faculty member at the Eötvös Loránd University, Psychological Institute, Department of Developmental and Clinical Child Psychology. She is a licensed clinical psychologist at the Heim Pál National Institute of Pediatrics, Centre of Mental Health. Her main research interests are the influence of parenting on child and adolescent psychopathology and the application of third generation cognitive-behavioral approaches to parenting. We do not think that we need to convince anybody who is interested in this textbook, no matter if it is a student, professional or interested non-professional, that a psychiatric disorder is a great burden for any adolescent or adult patient. Often it is however not only a burden for the patient, but it will also greatly affect their environment and thus most of society. Given that many psychiatric diseases are already present in childhood or adolescence, it is important that we improve our screening methods for these age-groups. We believe that children and adolescents who suffer from a psychiatric disease should all have access to adequate, up-to-date and evidence-based treatment possibilities to reduce their suffering and improve their functioning and quality of life. This will also reduce the burden that a psychiatric disease can put on all that are directly or indirectly involved, and thus ultimately on most of society. The most important aim of this textbook was therefor to provide up-to-date, evidence-based as well as responsible information regarding psychiatric diseases to help achieve this goal. Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  TEXTBOOK OF CHILD, ADOLESCENT AND YOUTH MENTAL DISORDERS Edited by Judit Balázs, Mónika Miklósi Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  TEXTBOOK OF CHILD, ADOLESCENT AND YOUTH MENTAL DISORDERS Edited by Judit Balázs, Mónika Miklósi Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 ) The original Hungarian edition [Balázs Judit, Miklósi Mónika (szerk.): A gyermek- és ifjúkor pszichés zavarainak tankönyve] was published by Semmelweis Publishing House, Budapest, 2015 The editors give thanks to József Kurgyis for taking very good care of the administrative tasks related to the textbook, Lajos Simon MD for his help with the chapter titled “Gender Dysphoria” and Raechel Drew for professional proof-reading of the text-book. Professional readers: Júlia Gádoros, Zsolt Demetrovics Translation: Gabriella Felhõsi, clinical psychologist Ó Semmelweis Publisher, 2018 Ó Judit Balázs MD, Mónika Miklósi, 2018 e-ISBN 978-963-331-497-5 The book and media (whether e-book, CD, or other digital issue) are under copyright protection, exclusive publishing rights are reserved. Reproduction of any part or all of it is lawful only with the prior written permission of the authors, the reader of the Hungarian edition, and the publisher. Chief publisher: László Táncos Chief editor: Judit Vincze Ó Cover: László Táncos SKD: 605 Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 ) Authors: Ildikó Baji MD PhD, college associate professor, child and adolescent psychiatrist Semmelweis University Faculty of Health Sciences, Department of Family Care Methodology, Budapest Title of chapter: 2.1. Psychopathology and Mental Status Judit Balázs MD PhD, professor, child and adolescent psychiatrist Department of Developmental and Clinical Child Psychology, Institute of Psychology, Faculty of Education and Psychology, ELTE Eötvös Loránd University, Budapest; Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest Title of chapters: 1.1. The Significance of Childhood, Adolescent, and Adult Psychiatric Disorders, the Burden of Disease; 2.2. Classification Systems; 2.3. Clinical Assessment: The Diagnostic Process. Methods of Assessment; 3.1.5. Attention Deficit/Hyperactivity Disorder / Hyperkinetic Disorder; 3.2.14. Suicidal Behavior and Non-Suicidal Self-Injury Csilla Barna clinical psychologist Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest Title of chapter: 3.2.8. Elimination Disorders Emese Bognár clinical psychologist Vadaskert Child and Adolescent Psychiatry, Budapest Title of chapter: 3.1.6. Tic Disorders Zsolt Demetrovics PhD, DSc, professor, clinical psychologist Department of Clinical Psychology and Addiction, Institute of Psychology, Faculty of Education and Psychology, ELTE Eötvös Loránd University, Budapest Title of chapter: 3.2.13. Psychoactive Substance-Related and Addictive Disorders Luca Farkas clinical psychologist Hertfordshire Partnership, NHS Trust, United Kingdom Title of chapters: 3.2.10. Sexual Dysfunctions; 3.2.11. Gender Dysphoria István Fedor MD MA child and adolescent psychiatrist, psychologist Heim Pál Children’s Hospital, Budapest Title of chapter: 3.2.5. Trauma and Stressor Related Disorders Gyöngyvér Ferenczi-Dallos MD PhD child and adolescent psychiatrist Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest Title of chapters: 3.2.1. Schizophrenia Spectrum and Other Psychotic Disorders; 5.1. Child Abuse and Forensic Child Psychiatry Mária Gallai MD, child and adolescent psychiatrist Heim Pál Children’s Hospital Mentalhygiene Center, Budapest Title of chapter: 3.2.6. Somatic Symptom and Related Disorders Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 ) Julianna Gádoros MD PhD, child and adolescent psychiatrist Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest Title of chapter: 5.3. The Mental Health Care System for Children and Adolescents with Psychiatric Disorders József Halász MD PhD, associate professor, child and adolescent psychiatrist Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest Fejér County Specialized Pedagogical Service; Óbuda University, Alba Regia Technical Faculty Title of chapter: 3.2.12. Disruptive, Impulse-Control, and Conduct Disorders Klára Horváth MD, PhD student Department of Experimental Psychology, University of Oxford, Oxford Title of chapter: 3.2.9. Sleep-Wake Disorders Krisztina Kapornai MD PhD, associate professor, child and adolescent psychiatrist University of Szeged, Pediatric Clinic, Department of Child and Adolescent Psychiatry, Szeged Title of chapter: 3.2.2. Mood Disorders Ágnes Keresztény PhD, assistant lecturer Department of Developmental and Clinical Child Psychology, Institute of Psychology, Faculty of Education and Psychology, ELTE Eötvös Loránd University, Budapest Title of chapter: 2.2. Classification Systems Enikõ Kiss MD PhD, senior lecturer, child and adolescent psychiatrist University of Szeged, Faculty of Medicine Pediatric Clinic, Department of Child and Adolescent Psychiatry, Szeged Title of chapter: 2.1. Psychopathology and Mental Status Beatrix Koronczai PhD, clinical psychologist, senior lecturer Department of Developmental and Clinical Child Psychology, Institute of Psychology, Faculty of Education and Psychology, ELTE Eötvös Loránd University, Budapest Title of chapter: 3.2.13. Psychoactive Substance-Related and Addictive Disorders Alpár S Lázár PhD, Lecturer Faculty of Health and Medical Sciences, University of East Anglia, United Kingdom Title of chapter: 3.2.9. Sleep-Wake Disorders Nóra M. Ribiczey PhD, senior lecturer Department of Developmental and Clinical Child Psychology, Institute of Psychology, Faculty of Education and Psychology, ELTE Eötvös Loránd University, Budapest Title of chapter: 5.2. The Child Protection System Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 ) Andrea Mészáros college senior lecturer Institute for the Psychology of Special Needs, Bárczi Gusztáv Faculty of Special Education, ELTE Eötvös Loránd University, Budapest; National Training Specialized Pedagogical Service, ELTE Eötvös Loránd University, Budapest Title of chapters: 3.1.1. Intellectual Disability; 3.1.2. Communication Disorders and Specific Learning Disorders; 3.1.3. Motor Disorders Gergely Mészáros MD child and adolescent psychiatrist, PhD student Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest; Semmelweis University, School of Ph.D. Studies, Budapest Title of chapter: 3.2.1. Schizophrenia Spectrum and Other Psychotic Disorders Mónika Miklósi PhD clinical psychologist, senior lecturer Department of Developmental and Clinical Child Psychology, Institute of Psychology, Faculty of Education and Psychology, ELTE Eötvös Loránd University, Budapest; Heim Pál Children’s Hospital, Mental Hygiene Center Title of chapters: 1.2. Developmental Psychopathology; 2.3. Clinical Assessment: The Diagnostic Process. Methods of Assessment; 4.1. Psychotherapy in Children and Adolescents Péter Nagy MD child and adolescent psychiatrist Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest Title of chapter: 3.2.3. Anxiety Disorders Laura Németh clinical psychologist Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest Title of chapter: 3.2.4. Obsessive-Compulsive and Related Disorders Bea Pászthy MD PhD, associate professor, child and adolescent psychiatrist, paediatrician, psychotherapist, clinical pharmacologist Semmelweis University, Faculty of Medicine, 1st Department of Paediatrics, Department of Child and Adolescent Psychiatry, Budapest Title of chapter: 3.2.7. Eating Disorders Csilla Prekop special education pedagogue Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest Title of chapter: 3.1.4. Autism Spectrum Disorder Krisztina Stefanik PhD, associate professor Institute for the Psychology of Special Needs, Bárczi Gusztáv Faculty of Special Education, ELTE Eötvös Loránd University, Budapest Title of chapter: 3.1.4. Autism Spectrum Disorder Zsanett Tárnok PhD, clinical psychologist, neuropsychologist Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest Title of chapter: 3.1.6. Tic Disorders Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 ) Ágnes Vetró MD PhD, associate professor University of Szeged, Faculty of Medicine Pediatric Clinic, Department of Child and Adolescent Psychiatry, Szeged Title of chapter: 3.2.2. Mood Disorders János Vizi MD LLD Nyírõ Gyula Hospital – National Institute of Psychiatry and Addictology, Budapest Title of chapter: 5.1. Child Abuse and Forensic Child Psychiatry János Zámbori MD honorary associate professor Institute of Psychology, Faculty of Education and Psychology, ELTE Eötvös Loránd University, Budapest Title of chapter: 4.2. Psychopharmacology Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  IX CONTENTS ABBREVIATIONS.......................................... XI 1. INTRODUCTION........................................... 1 1.1. The significance of childhood, adolescent and adult psychiatric disorders, the burden of disease (Judit Balázs)................................. 2 1.2. Developmental Psychopathology (Mónika Miklósi)................... 5 2. THE DIAGNOSIS OF CHILD, ADOLESCENT, AND ADULT PSYCHIATRIC DISORDERS. 11 2.1. Psychopathology and Mental Status (Ildikó Baji, Enikõ Kiss)............. 12 2.2. Classification Systems (Judit Balázs, Ágnes Keresztény)............... 21 2.3. Clinical Assessment: The Diagnostic Process. Methods of Assessment (Mónika Miklósi, Judit Balázs)............................. 25 3. PSYCHIATRIC DISORDERS.................................... 33 3.1. Psychiatric Disorders with Onset Typically Occurring in Childhood and Adolescence. Neurodevelopmental Disorders..................... 34 3.1.1. Intellectual disability (intellectual developmental disorder).......... 34 (Andrea Mészáros) 3.1.2. Communication disorders and specific learning disorder (Andrea Mészáros)............................... 39 3.1.3. Motor disorders (Andrea Mészáros)....................... 51 3.1.4. Autism spectrum disorders (Stefanik Krisztina, Prekop Csilla)......... 59 3.1.5. Attention deficit/hyperactiviy disorder / hyperkinetic disorder (Judit Balázs).................................. 66 3.1.6. Tic disorders (Zsanett Tárnok, Emese Bognár)................. 73 3.2. Psychiatric disorders with onset at any age....................... 79 3.2.1. Schizophrenia Spectrum and Other Psychotic Disorders (Gergely Mészáros, Gyöngyvér Ferenczi-Dallos)................ 79 3.2.2. Mood disorders (Krisztina Kapornai, Ágnes Vetró)............... 88 3.2.3. Anxiety disorders (Péter Nagy)........................ 98 3.2.4. Obsessive-compulsive and related disorders (Laura Németh)......... 106 3.2.5. Trauma- and stressor-related disorders (István Fedor)............ 111 3.2.6. Somatic symptom and related disorders (Mária Gallai)............ 121 3.2.7. Eating disorders (Bea Pászthy)........................ 128 3.2.8. Elimination disorders (Csilla Barna)..................... 138 3.2.9. Sleep-wake disorders (Alpár Sándor Lázár, Klára Horváth)......... 144 3.2.10. Sexual dysfunctions (Luca Farkas)...................... 155 3.2.11. Gender dysphoria (Luca Farkas)....................... 161 3.2.12. Disruptive, impulse-control, and conduct disorders (József Halász)...... 165 Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  X CONTENTS 3.2.13. Substance-related and addictive disorders (Zsolt Demetrovics, Beatrix Koronczai.................... 177 3.2.14. Suicidal behavior and non-suicidal self-injury (Judit Balázs)......... 185 4. THERAPY........................................... 191 4.1. Psychotherapy in Children and Adolescents (Mónika Miklósi)............ 192 4.2. Pharmacological basis of drug treatment (János Zámbori).............. 197 5. LEGAL AND FORENSIC ISSUES. THE MENTAL HEALTH CARE SYSTEM FOR CHILDREN AND ADOLESCENTS WITH PSYCHIATRIC DISORDERS......... 207 5.1. Child abuse and forensic child psychiatry (János Vizi, Gyöngyvér Ferenczi-Dallos). 208 5.2. The child protection system (Nóra M. Ribiczey).................... 217 5.3. The mental health care system for children and adolescents with psychiatric disorders (Júlia Gádoros)......................... 220 Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  XI ABBREVIATIONS ADHD Attention-Deficit/Hyperactivity GXE Gene–Environment Interaction Disorder HRT Habit Reversal Training ADOS Autism Diagnostic Observation IFP International Classification of Diseases Schedule Individual Family Psychoeducation AN Anorexia Nervosa MAOA Monoamine Oxidase A APA American Psychiatric Association MAOI Monoamine Oxidase Inhibitor ASD Autismus Spectrum Disorder MDD Major Depressive Disorder BDZ Benzodiazepin MFPG Multi-Family Psychoeducation Groups BN Bulimia Nervosa NICE National Institute for Health and Care BP I; BP II Bipolar I. Disorder; Bipolar II. Disorder Excellence BP Bipolar NMS Neuroleptic Malignant Syndrome CAPS-CA Scale for Children and Adolescents NSSI Non-Suicidal Self Injury CBT Cognitive Behavioral Therapy OCD Obsessive-compulsive Disorder CPAP Continuous Positive Airway Pressure ODD Oppositional Defiant Disorder DALY Disability-Adjusted Life Year OSAS Obstructive Sleep Apnoe Syndrome DBS Deep Brain Stimulation PANAS Positive and Negative Affect Schedule DBT Dialectical Behavior Therapy PANDAS Pediatric Autoimmune Neuropsychiatric DMDD Disruptive Mood Dysregulation Disorders Associated with Streptococcal Disorder Infections DSM Diagnostic and Statistical Manual PAS Parent Alienation Syndroma of Mental Disorders PLMD Periodic Lim Movement Disorder DSM-5 Diagnostic and Statistical Manual PTSD Posttraumatic Stress Disorder of Mental Disorders, Fifth Edition RLS Restless Leg Sydrome ECT Electroconvulsive Therapy SDQ Strengths and Difficulties Questionnaire EMDR Eye Movement Desensitisation and SSRI Selective Serotonin Reuptake Inhibitors Reprocessing TEGYESZ Regional Child Protection Service in ERP Exposure and Response Prevention Hungary GABA Gamma-Aminobutyric Acid UEMS European Union of Medical Specialists GABAA Gamma-Aminobutyric Acid-Antagonist WHO World Health Organization GOS Great Ormond Street Criteria YGTSS Yale-Global Tic Severity Scale Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 ) Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 ) 1. 1.1. The Significance of Childhood, INTRODUCTION Adolescent and Adult Psychiatric Disorders, the Burden of Disease (Judit Balázs) 1.2. Developmental Psychopathology (Mónika Miklósi) Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  2 1.1. THE SIGNIFICANCE OF CHILDHOOD, ADOLESCENT AND ADULT PSYCHIATRIC DISORDERS, THE BURDEN OF DISEASE Judit Balázs I do not think that students, colleagues, lated for the total population and also ac- and other non-professionals who hold this cording to different criteria, such as age, book in their hand need to be “persuaded” gender, and geographic region. In Europe, about psychiatric disorders being a great three of the top ten disorders on the Burden burden on those, either children or adults, of Disease list are psychiatric disorders, who have to live with such problems. Often when measured across the lifespan for it is not only a burden on the person living males and females combined. In third place with a mental disorder, but also on their en- we find unipolar depression, while in vironment, and thus, on the whole society. fourth place alcohol abuse follows ischemic In the introductory chapter of our textbook, heart disease and cardio-vascular diseases. we try to present, from various aspects, why Self-harm is in tenth place. It is estimated this is so. that by 2030, major depressive episode will Harvard University and the World Bank become the number one disease with the created the concept of “Burden of Disease” greatest Burden of Disease in Europe (in the in 1990, adopted by the World Health USA it is already) (WHO, 2013). It is a re- Organisation (2018) in 1996 (Murray and markable fact that 50% of all DALYs are Lopez, 1996; World Bank, 1993). Previ- psychiatric disorders; thus, the burden of ously, the harmfulness of a disease was these diseases on society is very high. measured by the extent to which it contrib- There are several reasons why psychiat- uted to early mortality. One of the fre- ric disorders rank so high on the Burden of quently used measures of the concept “Bur- Disease list. Very often these disorders oc- den of Disease”, besides early mortality, cur at a young age, often with a chronic or takes into account the number of years that recurrent course. We also know that the ear- the individual has to live with disease. lier the onset of a psychiatric disorder, the It is measured by the number of life worse the prognosis (Balázs et al., 2006). years spent with a disability (disability-ad- According to epidemiological studies, one justed life year: DALY). DALY is calcu- Wei Yue Hung in four children struggles with a psycholog- 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  1.1. 3 The significance of childhood, adolescent and adult psychiatric disorders, the burden of disease (Judit Balázs) ical problem during some phase of growing diseases such as diabetes, cardiac diseases, up (Costello et al., 2005). Psychiatric disor- or epilepsy that the analysis and improve- ders in childhood may also affect the devel- ment of quality of life was emphasized opment of the child. Depending on the na- among professionals. In recent years, ex- ture of the problem, they can have adverse perts have focused on quality of life issues effects on academic achievement. This can during clinical work and research in cases be the case, for example, in attention-defi- of psychiatric disorders as well. Quality of cit/hyperactivity disorder or even in anxiety life is a multidimensional concept that in- disorders or mood disorders, when a child corporates somatic, social, and cannot concentrate on school tasks and psychological domains (Danckaerts et al., therefore cannot progress according to their 2010). abilities. Psychiatric disorders can also In assessing quality of life, the subjec- have adverse effects on social relationships. tive self-evaluation of the general health Parent-child or teacher-student relation- condition, impairments, and everyday func- ships can suffer (e.g., in oppositional defi- tioning of the individual is important ant disorder, conduct disorder), and peer re- (Argwal et al., 2012). In the case of chil- lationships can be affected (e.g., in the case dren, the role of the so-called proxy evalua- of anxiety disorder or mood disorders). tors, primarily the parents, is also impor- Conversely, as described above, func- tant. However, parents are not completely tional impairment is defined as a criterion “outsiders” or objective observers, since for a psychiatric disorder by classification they have a special, close relationship with systems – the Diagnostic and Statistical their child and take active part in their ev- Manual of Mental Disorders (DSM) issued eryday life. Concerning psychiatric disor- by the American Psychiatric Association ders, both parents and children reported (American Psychiatric Association, 2013) lower quality of life than their healthy peers or the International Classification of Dis- (Kiss et al., 2009; Velõ et al., 2014). It is in- eases (ICD) issued by the World Health Or- teresting to note that a child’s self-assess- ganisation (WHO), which define when a di- ment and a parent’s assessment of the child agnosis of a psychiatric disorder can be es- often differ (Dallos et al., 2017; Kiss et al., tablished. A psychiatric disorder is diag- 2009). nosed only when its symptoms or their con- Because of all these issues, prevention, sequences cause functional impairment; early diagnosis, and treatment of thus, by definition, these disorders are psychological disorders is of utmost damaging to everyday life. importance. Since a significant proportion The concept of quality of life – which is of psychiatric problems occur at an early broader than the above-described impair- age, this age group also needs closer ment of functioning – has been at the fore- attention in terms of prevention. front of sociology and economics, and more Furthermore, it is important that children recently, psychology and medicine. First, it and adults with psychiatric problems get to Wei Yue Hung was 1083in cases of Budapest, children Prater living Utca 73, 4/402 with somatic a specialist, / [email protected] / are diagnosed in good time, Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Chapter 1 4 INTRODUCTION and receive appropriate, up-to-date, Comorbid Psychiatric Conditions According to Both a Categorical and a Dimensional Approach. evidence-based treatment, so that their Journal of Attention Disorders. J Atten Disord, quality of life and functionality can 21:(9) 721-730. improve, and the burden of disease on them Danckaerts, M., Sonuga-Barke, E. J., Banaschewski, T., Buitelaar, J., Döpfner, M., Hollis, C., Santosh, and on society can be reduced. This P., Rothengerger, A., Sergeant, J., Streinhausen, textbook tries to be of assistance in this H. C., Taylor, E., Zuddas, A., Coghill, D. (2010). The quality of life of children with attention defi- process. cit/hyperactivity disorder: a systematic review. Eur Child Adolesc Psychiatry, 19, 83–105. Kiss, E., Kapornai, K., Baji, I., Mayer, L., Vetró, A. (2009). Assessing quality of life: mother-child References agreement in depressed and non-depressed Hun- garian. Eur Child Adolesc Psychiatry, 18, 265-273. American Psychiatric Association (2013). Diagnostic Murray, C. J. L., Lopez, A. D. (1996). The global bur- and statistical manual of mental disorders, 5th den of disease: a comprehensive assessment of edn. (DSM-5). Washington, DC: American Psy- mortality and disability from diseases, injuries chiatric Association and risk factors in 1990 and projected to 2020. Agarwal, R., Goldenberg, M., Perry, R., & IsHak, W. Cambridge: Harvard University Press W. (2012). The quality of life of adults with atten- Velõ, Sz., Keresztény, Á., Miklósi, M., Dallos, Gy., tion deficit hyperactivity disorder: a systematic Szentiványi, D., Gádoros, J., Balázs, J. (2014). review. Innovations in clinical neuroscience, 9, „Frissen” diagnosztizált, kezelést még nem kapó 10–21. figyelemhiányos-hiperaktivitás zavarú gyerme- Balázs, J., Dallos, Gy., Németh, L., Bíró, A., Prekop, kek és serdülõk életminõsége. [Quality of life of Cs., Gádoros, J. (2006). Gyermekpszichiátriai newly diagnosed, treatment naive children and epidemiológia. [Epidemiology in Child psychia- adolescents with attention-deficit hyperactivity try] Orvostovábbképzõ Szemle, Sept, 3-15. disorder]. Psychiatr Hung, 29, 410-417. Costello, E. A., Egger, H., Angold, A. (2005). 10-year World Bank (1993). World Development Report Research Update review: The epidemiology of 1993. Washington: World Bank Child and Adolescent Psychiatric Disorders: I. World Health Organization (2018). International Methods and Public Health Burden. J Am Acad Child Statistical Classification of Diseases 11th Revi- Adolesc Psych, 44, 972-986. sion. World Health Organization, Geneva Dallos, Gy., Miklósi, M., Keresztény, Á., Velõ, Sz., World Health Organization (2013). Global health es- Szentiványi, D., Gádoros, J., Balázs, J. (2017). timates for deaths by cause, age, and sex for years Self- and Parent-Rated Quality of Life of a Treat- 2000-2011. Geneva: World Health Organization. ment Naïve Sample of Children With ADHD: Available at http://www.who.int/healthinfo/ The Impact of Age, Gender, Type of ADHD, and global_health_estimates/en/ Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  5 1.2. DEVELOPMENTAL PSYCHOPATHOLOGY Mónika Miklósi THE DISCIPLINE OF DEVELOPMENTAL depends on early developmental PSYCHOPATHOLOGY experiences, current conditions, and the time spent on a given developmental path. Definition of developmental This approach defines psychopathology as psychopathology a consistent divergence from functional developmental pathways (Sroufe, 2013). Developmental psychopathology is a macro-paradigm synthesizing the results of Traditional models of developmental disciplines targeting development and psychopathology psychopathology (e.g., developmental psy- chology, psychopathology, neuroscience, Models of developmental psycho- genetics, personality psychology, and evo- pathology intend to explain the role of envi- lutionary psychopathology) in order to ex- ronmental factors and a child’s characteris- plain normal and abnormal development. tic traits in the development of psycho- Its goal is to explore normative develop- pathology. Models can be grouped accord- mental pathways and the divergence from ing to whether the environment and/or the these pathways, as well as the associations child are attributed a passive or active role between psychopathology and develop- in development (state/trait and environmen- mental changes throughout the lifespan tal models). Different factors can have inde- (Lewis, 2014). pendent effects, additive effects (additive Development is considered cumulative models), or multiple factors can interact (earlier developmental stages impact actual with each other (transformational models) developmental level), and factors in- (Lewis, 2014). fluencing development act in a probabilistic manner. Similar initial conditions may have The role of gene-environment interplay in several different outcomes (multifinality), psychopathology and different developmental pathways may lead to the same developmental outcome Modern genetic research has largely (equifinality). A switch between different contributed to the study of the validity of Wei Yue Hung developmental paths is possible, but this traditional models of developmental 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Chapter 1 6 INTRODUCTION psychopathology. Genetic studies failed to COMT gene variant (Caspi et al., 2005). identify unique genetic markers for specific These genetic characteristics are called en- mental disorders but uncovered a number of vironmentally mediated genetic factors mechanisms through which the interplay of (Rutter, Moffitt and Caspi, 2006). genetic and environmental factors influ- Epigenetics deals with the “biological ences the development and course of mental imprint” of environmental impacts. disorders. Environmental factors can influence the According to our knowledge, genetic effects of genes by altering gene expression factors act in a probabilistic way and work (Meaney and Ferguson-Smith, 2010). For together with environmental factors example, animal studies suggest that early (Rutter, Moffitt and Caspi, 2006). adverse environment (e.g., perinatal stress, Heritability is not a fixed entity, it is a func- malnutrition, early separation from the tion of environmental characteristics. Envi- caregiver) affects the functioning of the ronment may trigger, compensate, en- HPA-axis through altered genetic hance, or reduce hereditary effects. A sig- expression. This change is persistent, and it nificant environmental risk factor (e.g. pre- can also be transmitted to the next mature birth or divorce) may reduce their generation under certain conditions role (Robbers et al., 2012) while a favour- (Meaney and Szyf, 2005). able environment may increase their role in The third type of interplay between producing a given behaviour. For example, genetic and environmental factors includes the heritability of antisocial behaviour was causal mechanisms which indicate genetic found to be 0% in the most dysfunctional control over environmental exposure families, while it was 80% in less dysfunc- (gene-environment correlations). A passive tional families (Button et al., 2005). gene-environment correlation refers to the The first category of interplay between mechanism through which parents create a genetic and environmental factors is called special child-rearing environment as a gene-environment interaction, in which result of their own heritable characteristics case the interaction of a specific environ- (e.g., quality of parental care), which in turn mental factor and a specific genetic factor may increase or decrease the risk for influences the development of psycho- psychopathology in the child. Second, the pathology. This means that the combined child’s heritable behaviour evokes an effect of genetic and environmental factors environmental response which may then differs from their additive effect: they can influence the child’s mental health strengthen, weaken, or alter the effect of (evocative gene-environment correlation). each other, or the genetic factor may change An anxious child, for example, is more the sensitivity of an individual to a particu- likely to elicit over-protective caregiver lar environmental factor. For example, in responses, while an impulsive child often the Dunedin longitudinal study, the rela- evokes rejection from a caregiver. In tionship between adolescent marijuana use addition, based on inherited characteristics, Wei Yue Hung and schizophrenia 1083 Budapest, was Prater Utca influenced 73, 4/402 by a a child / [email protected] / selects and shapes his or her own Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  1.2. 7 Developmental Psychopathology (Mónika Miklósi) environment. For example, a child decides AGE-RELATED CHARACTERISTICS AND where and how to spend free time (active PSYCHOPATHOLOGY gene-environment correlation). Children with ADHD, for example, are more likely to Age-related norms join a deviant peer group, which then increases the likelihood of substance abuse In order to differentiate between normal or comorbid conduct problems (Thapar et and abnormal behaviour, we need informa- al., 2006). The environmental factors listed tion about the normative developmental here (all environmental factors involved in pathways, possible normal variants and gene-environment correlation) are age-related norms. There are some symp- therefore called genetically mediated toms that may be considered part of norma- environmental factors (Rutter, 2013). tive development at certain ages (e.g., sepa- ration anxiety); however, they are consid- MENTAL DISORDERS IN THE LIGHT OF ered pathological if they are too strong or DEVELOPMENTAL PSYCHOPATHOLOGY too stable in relation to the child’s age. Other symptoms (e.g., agoraphobia) are Lifespan development considered pathological at any age (DSM-5, APA, 2013). Knowledge about Lifespan development theory is a very the sensitive periods of development for recent approach in research and practice certain functions is also essential as the ef- (Pine et al., 2010). During preparation of fects of specific environmental risk factors the DSM-5 (APA, 2013) two workgroups may increase during these periods (Pine et reviewed the classifications in light of de- al., 2010). velopmental perspectives. A significant proportion of mental disorders (according Child, adolescent and adult forms of to some studies nearly three quarters; see psychopathology Kim-Cohen et al., 2003) onset prior to the age of 18, and childhood mental disorders The appearance of symptoms of mental (even at subclinical levels) constitute risk disorders may vary in children, adolescents, factors for adjustment in adulthood and adults. Core symptoms and main diag- (Hofstra et al., 2001). Therefore, coopera- nostic criteria are the same across tion between professionals working with age-groups, but age-related or developmen- different age groups is necessary. tal characteristics alter the symptomatic picture. This age-related variability can be observed in most mental disorders (Pine et al., 2010). Concerning ADHD, hyperactiv- ity symptoms generally decrease, while at- tention deficit symptoms remain stable, or Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Chapter 1 8 INTRODUCTION even increase, with age (Döpfner et al., lar disease. For example, a risk factor in 2014). early childhood for anxiety disorders is be- Age-related variability of symptoms havioural inhibition (Pine et al., 2010). must be distinguished from age-related subtypes, which are basically different dis- Age-related functional impairments ease categories in specific age groups (Pine et al., 2010). For example, when comparing Determining the level of functional im- the manifestation of obsessive-compulsive pairment is a key criterion in the classifica- disorder in children to adolescents or adults, tion of mental disorders (APA, 2013). Be- it differs not only in the appearance of cause of typical discrepancies between re- symptoms but also in the sex ratio and typi- ports gathered from different sources of in- cal comorbidities. Age at onset is a term formation, it is important to take into con- closely related to the concept of age-spe- sideration both the child and caregiver re- cific subtypes. Some mental disorders can ports (Dallos et al., 2014). The dependence appear at all ages (e.g., post-traumatic stress of a child on his or her environment also af- disorder), while others demonstrate a typi- fects the perception of the level of impair- cal age of onset with one or two age-related ment (e.g., some parents allow the object of peaks. For some disorders (e.g., ADHD, tic phobia to be avoided, while others encom- disorders), classification systems also re- pass the child in problem situations) (Pine quire early emergence of symptoms et al., 2010). It is also important to consider (DSM-5, APA, 2013). In many cases of dis- not only the actual level of functionality, ease (e.g., conduct disorder, obses- but also to examine the extent to which the sive-compulsive disorder), age at onset re- symptoms affect a child’s ability to over- fers to an age-specific subtype, which is in- come the developmental challenges of formative regarding the appearance of his/her age and to reach the next level of de- symptoms, comorbid states, choice of ther- velopment. apy, and prognosis. The time of onset and the time at which a Continuity and discontinuity of mental diagnosis can be applied do not necessarily disorders coincide. For example, a pervasive devel- opmental disorder is apparently present Childhood and adolescent mental disor- from birth (or even earlier); however, under ders may disappear (discontinuity) or con- two years of age the functions most affected tinue in adulthood (continuity). In some by the disorder are still underdeveloped, cases (e.g., specific phobia), mental disor- thus the symptoms are less specific and ders appear in the same form in all age have a small predictive value. In some groups (homotypic continuity). In other cases, mental disorders are preceded by cases, however, although there is an inter- conditions that do not fulfil the criteria for a pretable continuity in the course of the dis- psychiatric diagnosis but can be considered ease, its manifestation varies with age Wei Yue Hung as a precursor 1083 or risk Budapest, Prater Utcafactor for/ [email protected] 73, 4/402 the particu- (heterotypic / continuity). The onset of de- Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  1.2. 9 Developmental Psychopathology (Mónika Miklósi) pression, for example, is often preceded by dinal evidence of a gene X environment interac- tion. Biological Psychiatry, 57, 1117-1127. the onset of an anxiety disorder, but the op- Dallos, Gy., Miklósi, M., Keresztény, Á., Velõ, Sz., posite may also occur: depression is fol- Szentiványi, D., Gádoros, J., Balázs, J. (2014). lowed by an anxiety disorder. Continuity in Self- and Parent-Rated Quality of Life of a Treat- ment Naïve Sample of Children With ADHD: this case is therefore bidirectional. There The Impact of Age, Gender, Type of ADHD, and are also unidirectional forms of heterotypic Comorbid Psychiatric Conditions According to Both a Categorical and a Dimensional Approach. continuity, for instance, under unfavourable Journal of Attention Disorders, [Epub ahead of conditions, ADHD may continue in an anti- print] DOI: 10.1177/1087054714542003. social personality disorder, while the onset Döpfner, M., Hautmann, C., Görtz-Dorten, A., Klasen, F., Ravens-Sieberer, U., The BELLA of ADHD is never preceded by the develop- study group. (2014). Long-term course of ADHD ment of antisocial personality disorder. symptoms from childhood to early adulthood in a There are several means for heterotypic community sample. European Child and Adoles- cent Psychiatry, Nov 14. [Epub ahead of print]. continuity of mental disorders, for example, Hofstra, M. B., Van Der Ende, J., Verhulst, F. C. common genetic background (e.g., anxiety (2001). Adolescents’ self-reported problems as predictors of psychopathology in adulthood: and depression), individual’s responses to 10-year follow-up study. The British Journal of the mental disorder (e.g., attempts to “treat” Psychiatry, 179, 203-209. depression by substance abuse), also, an Kim-Cohen, J., Caspi, A., Moffitt, T. E., Harrington, H., Milne, B. J., Poulton, R. (2003). Prior Juve- early-onset mental disorder may produce nile Diagnoses in Adults With Mental Disorder. environmental risk factors for later-onset Developmental Follow-Back of a Prospec- tive-Longitudinal Cohort. Arch Gen Psychia- mental disorders (e.g., ADHD and conduct try, 60, 709-717. disorders). Research on the continuity and Lewis, M. (2014): Toward the development of the sci- discontinuity of mental disorders is highly ence of developmental psychopathology. In: Lewis, M., Rudolph, K. D. (Szerk.) (2014). Hand- significant for prevention (Rutter, book of Developmental Psychopathology. 3rd ed. Kim-Cohen and Maughan, 2006). New York, Springer, 3-23. Meaney, M. J., Ferguson-Smith, A. C. (2010). Epigenetic regulation of the neural transcriptome: The meaning of the marks. Nature References Neuroscience, 13, 1313-1318. Meaney, M. J., Szyf, M. (2005). Environmental pro- gramming of stress responses through DNA American Psychiatric Association (2013). Diagnostic methylation: Life at the interface between a dy- and statistical manual of mental disorders, 5th namic environment and a fixed genome. Dia- edn. (DSM-5). Washington, DC: American Psy- logues in Clinical Neuroscience, 7, 103-123. chiatric Association Pine, D. S., Costello, E. J., Dahl, R., James, R., Button, T. M., Scourfield, J., Martin, N., Purcell, S., Leckman, J. F., Leibenluft, E., Zeanah, C. H. McGuffin, P. (2005). Family dysfunction inter- (2011). Increasing the developmental focus in acts with genes in the causation of antisocial DSM-5: Broad issues and specific potential ap- symptoms. Behavior Genetics, 35, 115-120. plications in anxiety. In D. A. Regier, W. E. Nar- Caspi, A., Moffitt, T. E., Cannon, M., McClay, J., row, E. A. Kuhl, & D. J. Kupfer (Eds.), The con- Murray, R., Harrington, H., Taylor, A., ceptual evolution of DSM-5 (pp. 305–321). Arseneault, L., Williams, B., Braithwaite, A., Washington, DC: American Psychiatric Publish- Poulton, R., Craig, I. W. (2005). Moderation of ing. the effect of adolescent-onset cannabis use on Robbers, S., van Oort, F., Huizink, A., Verhulst, F., adult psychosis by a functional polymorphism in van Beijsterveldt, C., Boomsma, D., Bartels, M. the catechol-O-methyltransferase gene: Longitu- (2012). Childhood problem behavior and paren- Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Chapter 1 10 INTRODUCTION tal divorce: Evidence for gene-environment in- Sroufe, L. A. (2013). The promise of developmental teraction. Social Psychiatry and Psychiatric Epi- psychopathology: Past and present. Develop- demiology, 47, 1539-1548. ment and Psychopathology, 25, 1215–1224. Rutter, M., Kim-Cohen, J., Maughan, B. (2006). Con- Taylor, S. (2011). Early versus late onset obses- tinuities and discontinuities in psychopathology sive-compulsive disorder: Evidence for distinct between childhood and adult life. Journal of subtypes. Clinical Psychology Review, 31, Child Psychology and Psychiatry, 47, 276-295. 1083-1100. Rutter, M., Moffitt, T. E., Caspi, A. (2006). Gene-en- Thapar, A., van den Bree, M., Fowler, T., Langley, K., vironment interplay and psychopathology: multi- Whittinger, N. (2006). Predictors of antisocial ple varieties but real effects. Journal of Child behaviour in children with attention deficit hy- Psychology and Psychiatry, 47, 226-261. peractivity disorder. European Child and Adoles- Rutter, M. (2013): Developmental psychopathology: cent Psychiatry, 15, 118-125. A paradigm shift or just a relabeling? Develop- ment and Psychopathology 25, 1201-1213. Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 ) 2. THE DIAGNOSIS 2.1. Psychopathology and Mental Status (Ildikó Baji, Enikõ Kiss) OF CHILD, 2.2. Classification Systems (Judit Balázs, Ágnes Keresztény) A D O L E S C E N T , AN D 2.3. Clinical Assessment: The Diagnostic ADULT P SYCHIATRIC Process. Methods of Assessment (Mónika Miklósi, Judit Balázs) DISORDERS Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 ) 2.1. PSYCHOPATHOLOGY AND MENTAL STATUS Ildikó Baji, Enikõ Kiss Psychopathology describes abnormal outside environment, or continuously mon- psychological functioning. Psychological itors the activity of the adults. Lack of eye abnormality can be characterized as devi- contact can occur in pervasive developmen- ant, dysfunctional, endangering, distress- tal disorder. It is also possible to have eye ing, and causes suffering. contact for a short time but in an inadequate way or not sustaining it for a longer period. APPEARANCE SPEECH The patient’s clothing and the physical impression they make is described. Neglect, Speech is examined while taking the clothing that is inappropriate for the anamnesis. During a mental status examina- weather, dirty face and hands are all impor- tion the psychiatrist asks open ended ques- tant cues in younger children. Flashy tions and evaluates not just the content of clothes, extensive make-up, body jewelry, the answers but the physical characteristics and unusual haircut might be observed in of speech as well. Problems of articulation older children. It is important to take note of (lisping, stuttering, hardly understandable wounds on the skin, e.g., cutting on the in- speech) should be noted, just like very loud ner side of the wrists (non-suicidal self-in- or very quiet talk, or grammatical difficul- jury). ties (e.g., inflection, speaking in 3rd person singular about self). Repeating the end of a question instead of answering it (echolalia), BEHAVIOR or using self-made words should be noted. Dysarthria is the problem of pronunciation. The patient’s attitude towards the exam- It is also possible that the child does not un- iner might be cooperative, hostile, oppos- derstand spoken language. If the child can ing, or indifferent. It should be mentioned not talk, we should look at nonverbal com- in the mental status if the child is not listen- munication. Does the child use his or her ing to her name, does not take notice of the hands to show what he/she wants? Is there Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  2.1. 13 Psychopathology and Mental Status (Ildikó Baji, Enikõ KIss) some kind of compensation for the lack of gether with delusions. The narrowing effect speech? If the child talks only to certain of prejudice can be noticed when a patient people and not to others, it is called mutism. has a strong emotional attachment to some- body that interferes with the realistic evalu- ation of events. Lose consciousness in COGNITION healthy individuals appears in the form of absent-mindedness or lack of concentra- Consciousness tion. Its pathological form is called confu- sion, in which the patient engages in con- Consciousness enables the individual to tact, but is “not present” in the situation as recognize, process, and rate signals from his or her thoughts wander off. When pa- the environment, and to differentiate be- tients are under serious psychological stress tween the self and the outside world. The for a long time that prevents them from normal level of consciousness (vigilance) making a realistic judgement of their situa- enables the reception of external stimuli. In- tion, they might perform an inappropriate tegrity of consciousness refers to the sequence of behaviours that is incongruent integrity of its inner contents. with the self in order to solve the situation. Disorders of vigilance range from full Such a behavioural sequence might be, for consciousness to total lack of awareness example, the murder of the newborn baby (coma). Vigilance can be stable or fluctuat- by an unmarried mother. ing. Changes in the level of consciousness Disorders of integrity and vigilance to- include mild stupor (recognition of external gether are present in tenebrosity (ordered stimuli becomes difficult), somnolence (the type) in which awareness is intact, the indi- patient slumbers when left alone but can be vidual might carry out long series of activi- woken up by stronger stimuli) stupor (reacts ties and behavior seems normal; but, activi- only to stronger stimuli, usually pain) and ties are incongruous with the situation and coma (patient lacks awareness, is not possi- are followed by amnesia. In the disordered ble to wake). These symptoms are signs of type of tenebrosity the relationship between organic brain dysfunction which usually re- the patient and the external world is signifi- sults from neurological problems. cantly decreased, consciousness is nar- Disorders of integrity (with intact vigi- rowed to a specific area of thoughts and lance) range from narrow consciousness feelings, activities do not have any associa- through optimally working consciousness tion with the situation, and emotions are ex- to disintegration and total dissociation. Nar- treme. There might be hallucinations and/or row consciousness limits thinking and con- delusions followed by amnesia. Delirium is sideration, and it lacks personality specific the deepest form of unconsciousness and it recognition. Healthy variants are over- involves disorientation (in time and space), concentration and prejudice, while patho- hallucinations, significant restlessness, and logical forms can occur in depression, to- vegetative symptoms. Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Chapter 2 14 THE DIAGNOSIS OF CHILD, ADOLESCENT, AND ADULT PSYCHIATRIC DISORDERS Orientation Perception The assessment of orientation involves Perception is the recognition of stimuli two parts: orientation in person (auto- by the different organs of the sensory sys- psychic) and orientation in time, place, and tem. Stimuli are processed in the corre- situation (allopsychic). When a person is sponding primary sensory cortex. This is well-oriented in himself and his environ- the process of apperception. Perceptual dis- ment, he knows who is who, and what kind turbances are discussed according to the of relationship exists among the people specific sensory organs. Disturbances can around him. When people are disorientated be quantitative or qualitative. Quantitative in place and time, it is important to examine disturbances include, among others, hyper- the severity: Are they aware that they are in acusis (i.e. the intensification of hearing), or a hospital, which city they are in, and what macropsy/micropsy (i.e. when the patient year, season, month, day, or time of day it sees things bigger or smaller than they exist is. in reality). Often, neurological problems can be found in the background. Attention Qualitative perceptual disturbances in- clude illusions and hallucinations. Illusions Attention is the focusing of senses that are caused by inaccurate recognition or in- enables the individual to concentrate on accurate processing of stimuli. An example stimuli important to them. Problems of at- might be when the patient sees a shadow as tention are a lack of concentration or dis- a frightening figure, hears a sound as a tractibility, when focusing for a longer pe- threatening noise, or even thinks of these riod of time is difficult. The person pays at- stimuli as an attack. Illusions frequently ap- tention to unimportant stimuli and does not pear in exaggerated emotional states. concentrate on important ones. Attention Derealization (the individual feels that the drifts easily, even in the lack of external environment has changed, seems to be un- stimuli. Hypervigil attention is easily real) and depersonalization (the individuals switched; it can be a symptom of mania, or feels as an outside observer of their own schizophrenia. The opposite is hypovigil at- life) are both psychiatric phenomena which tention which is difficult to arouse, tardy, most often occur in the state of severe anxi- and can be a symptom of depression. ety, stress, and depression. Deja vu and Trans-state is present during focused atten- jamais vu are illusions of time. Deja vu is tion and altered mental state; it is most the sensation in which a new situation expe- frequently present during hypnosis or rienced at the moment is thought to have dissociative disorders. been experienced before. The opposite phe- nomenon is jamais vu, when an already ex- perienced event is thought to be completely new and unknown by the patient. Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  2.1. 15 Psychopathology and Mental Status (Ildikó Baji, Enikõ KIss) Hallucinations are deviations in percep- are pseudo-hallucinations experienced as if tion which manifest in the central nervous they were real. Most frequently these system in the absence of external stimuli. involve hearing sounds. A hallucinations exhibits all the characteris- tics of a sensation, and the patient experi- Memory ences it as real. They can involve any sen- sory function: auditory, visual, tactile, ol- Memory functions can be divided into factory, and gustatory. Hallucinations can four areas: immediate memory, short-term be elementary or complex. Auditory and vi- memory, working memory, and long-term sual hallucinations are the most frequent memory. Immediate memory covers a few types. Auditory hallucinations might ap- seconds, it can have an individual time span pear as sounds from outside, but can also be (e.g., remembering a sequence of numbers perceived as inner sounds. It can be a famil- immediately after hearing it). Short-term iar voice or an unfamiliar one, and it can be memory is involved in remembering infor- commenting on the activity of the patient, mation from the last few minutes. The or might be imperative, giving commands working memory is able to carry out to the patient. It can be one voice or several combinative actions which are forgotten voices talking to each other or to the patient. when not in use. Finally, long-term memory Visual hallucinations can be elementary engrains learned information. Since these lights, sparklings, geometric shapes, or functions connect to different regions of the complex visions (when the patient sees brain, they can be damaged independently complete scenes). Tactile or haptic halluci- of each other. nations (formication) are strange feelings, Disorders of memory can be quantitative as if insects, ants, or worms were crawling or qualitative. A quantitative memory prob- on or underneath one’s skin. Olfactory and lem is called amnesia, when recalling mem- gustatory hallucinations most often appear ories becomes partly or fully impossible. together with paranoid delusions when the This most often has an organic background, patient is afraid of other people wanting to such as a traumatic skull injury. Retrograde harm them. Most frequently they smell an amnesia involves the damage of recalling unpleasant odor or taste an unpleasant fla- earlier memories, while congrad amnesia is vor. Patients with coenesthesia report characterized by the loss of the details of an pathological sensory experiences from dif- actual event or the whole event, and ferent organs, in the abdomen or the chest, anterograde amnesia is when newly learned which can be pain or a bizarre inability to information is not remembered. Psycho- function. These can be reasonable human genic amnesias are connected to the actual experiences (e.g., intestines stop working, psychological state of the patient., such as heart stops beating), but can be totally un- the memory deficit which develops as a re- reasonable ones as well (e.g., body is action to traumatic stress. Examples are empty, organs become mellow and flow out dissociative amnesia, which can be a tem- Wei Yue Hung of theBudapest, 1083 body).Prater Furthermore, hallucinations Utca 73, 4/402 porary, / [email protected] / total, or partial inability to recall Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Chapter 2 16 THE DIAGNOSIS OF CHILD, ADOLESCENT, AND ADULT PSYCHIATRIC DISORDERS memories, or dissociative fuga, which de- has been completed, usually in conjunction velops unexpectedly, might last for a few with catatonic symptoms. Tacky thinking is hours or few days, and the patient cannot re- when the patient gets stuck on one subject, member anything during that time. Qualita- and it is hard to avert them from there. It is tive deficits are called paramnesia -when characteristic of epilepsy, depression, and the patient mixes real and unreal memories schizophrenia. Monodeism means thoughts during recall, confabulation - when the pa- going around the same axle, it is a symptom tient remembers events that never hap- of depression. Formal thought disorders are pened, or pseudologia phantastica (patho- thought removal and thought broadcasting, logical lying)- when the patient recalls a both being signs of schizophrenia. The pa- mass of memories that lack reality. The tient thinks that their thoughts are con- latter is frequent in personality disorders. trolled externally by others or hears their own thoughts out loud or broadcasted to the Thought outside world. This is usually strange and disturbing for the patient. Thought is divided according to form Incoherent thinking includes unintelligi- and content. Formal thought disorders in- ble thought series, thoughts following each clude problems with the sequences of other without logical connection. thoughts, linking memories, external and Perseveration means getting stuck with a internal perception of thoughts. Problems thought evoked by a former stimulus. The with the content of thought include faulty patient is unable to change to a new thought thinking processes. when a new stimulus presents itself. All of Formal thought disorders are loose as- these can be examined by talking to the sociations in which the flow of ideas is so patient. fast that the individual is incapable of carry- Disturbances in the content of thought ing out the whole thought series and there- include preoccupation and delusions. Pre- fore it appears fragmented. They include occupation is a false, illogical belief which flight of ideas and thought rushing. Flight is regarded as problematic by the patient but of ideas is a series of thoughts following impossible to get rid of. Delusions are be- each other incoherently. In thought rushing, liefs which are based on faulty interpreta- more than one thought comes into con- tion of external stimuli, yet in which the pa- sciousness at the same time, which disturbs tient unwaveringly believes. There are vari- associations. Neologisms are new words ous forms regardless of the subject. They with meaning only to the patient. All of the can be mood-congruent, corresponding to above can be symptoms of schizophrenia. the actual mood (for example a depressed The opposite of the above phenomenon patient might think that the world will come is slow association and hesitant thinking, to an end because of them), or mood-incon- which might be symptoms of depression or gruent, differing from the actual mood. mental retardation. Thought blocking is the Megalomania is the exaggeration of one’s Wei Yue Hung inner interruption 1083 Budapest, Praterof thinking Utca before 73, 4/402 an idea own / importance, the individual endows / [email protected] Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  2.1. 17 Psychopathology and Mental Status (Ildikó Baji, Enikõ KIss) themselves with unreal characteristics. An extraterrestrial beings having put electrodes example is erotomanic delusion, in which into the patient’s brain. Disturbances in the the incorrect thought consists in a non-exis- content of thought include obsession, which tent love relationship, or religious delu- is the presence of one or more anxiety pro- sions. Micromanic delusions are the oppo- voking thoughts that are experienced as site, decreasing the role of the individual, senseless (the individual knows that the ruining their self-esteem. This type of dis- thought originates from them) and repug- turbance includes guilty, sinful delusions, nant. It evokes significant anxiety and usu- persecutory, zelotypic (jealousy), nihilistic, ally leads to compulsions (for example fear and querulatory (altercation) delusions, as of getting sick or catching an infection well as delusions of poverty. Delusions can might result in frequent hand-washing and be about self-accusation, when the individ- bathing). Hypochondria is the unreasonable ual exaggerates their own errors, blames fear of illnesses which is not based on or- themselves for negative events, feelings of ganic cause but rather on faulty explanation shame are increased. The patient with delu- of certain body signs or feelings. sions of persecution believes that every- Abstract thinking is a repeated mental thing happening around them is aimed at change between certain conceptions and spying on them: people around them are specific examples. The ability of abstract talking about them, they are mentioned neg- thinking is difficult to rate before the age of atively on TV, being controlled from the 12-13. There are individuals who never de- outside by someone, their activities are in- velop this skill. Patients might mention fluenced, and by all this others want to harm jokes, metaphors, aphorisms during the ex- them. Zelotypic delusions or delusions of amination, which carries information about jealousy often ruin the patient’s relation- their abstract thinking. One can assess this ships, might even result in violent acts. ability by asking the patient to explain the A patient with delusion of poverty thinks meaning of proverbs or idioms. An average that all their money will be lost or others person is able to interpret their meaning, will take away their money, therefore they whereas another person lacking this ability continuously collect and hide things. Delu- cannot. sion of nihilism is described when the pa- tient feels as if part of their body perishes, they and/or others stop existing, or the PSYCHOMOTOR ACTIVITY world comes to an end. Delusions of alter- cation incline the patient to get into argu- Psychomotor activity is a manifestation ments, file accusations, initiate court hear- of the personality including personal im- ings against people around them. Delusions pulses, motivation, will, anticipations, and of reference are beliefs about the patient’s wishes. It presents in motor activity and will, thoughts, feelings being controlled behavior. from the outside. Bizarre delusions are Problems include acceleration, which Wei Yue Hung completely impossible, false beliefs such as 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / in psychomotor agitation and hyper- results Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Chapter 2 18 THE DIAGNOSIS OF CHILD, ADOLESCENT, AND ADULT PSYCHIATRIC DISORDERS activity. Psychomotor agitation is the result congruent, they are in equilibrium, when in- of an inner uneasiness causing motor and congruent, then subjective inner feelings do cognitive oversensitivity; hyperactivity is not match the objective appearance of the the increased intent to move. Psychomotor same feelings. It is important to note if retardation or the general slowing down mood or emotion is inappropriate for the might be a symptom of depression. Echo- situation. praxia is the mimicry of another person’s Expression of affect might be within the movement. Catatonia can be a positive or normal range, but it can also be excessive or negative movement problem. The person constricted. Excessive emotional manifes- might take on a strange posture or might be- tations are usually unstable, change quickly come wax-like flexible (waxy flexibility), and suddenly, and develop independently or totally motionless, keeping the posture of external stimuli. Those might be charac- for a long time (crystallization). Catatonic teristic of mania or schizophrenia. Blunted excitement is an agitated purposeless motor affect might appear in the form of apathy activity which is not influenced by outside (nothing matters, total disinterest) or in the factors. Stereotyped movements and man- more severe stupor (flat affect) character- ners are also disorders of motor activity, ized by the total lack of emotions. This can which are strange involuntary repetitive be seen from the facial expression, body movements, e.g., flying, twisting, wringing movements, posture, and the tone of voice of hands, fingers, or complex movements of the patient. Ambivalence is the presence involving the whole body, most frequently of positive and negative emotions regarding observed in autistic children. Tics are invol- the same subject. Regressive reactions carry untary, repeated motor or vocal activities emotional tension and usually involve a ranging from simple movements (blinking) setback to a lower emotional state. or trivial sounds (hawking) to complex and Other emotions include different fears, combined ones. Cross impulse appears sud- which are called phobias. Specific phobia is denly, it has a pathological subject, has the fear of a specific thing, situation, or ani- significant emotional charge, and results in mal. Anxiety can be generalized if different activity without previous consideration. things are feared over the same time period. Agoraphobia is the fear of open spaces, which can accompany panic disorder or can MOOD AND AFFECT occur without it. Separation anxiety is the fear of the separation from a loved one. Per- Mood and affect are characteristics of formance anxiety develops at school recita- the emotional state of the individual. Mood tion or written exam and can cause signifi- is the subjective feeling of emotion, affect is cant decrease in performance. Agitation is the outside appearance of that emotion, its the sign of severe anxiety accompanied by objective reflection that is seen from the motor restlessness. outside. Mood and affect can be congruent Wei Yue Hung or incongruent. 1083 When Budapest, Prater Utca mood and 73, 4/402 affect are / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  2.1. 19 Psychopathology and Mental Status (Ildikó Baji, Enikõ KIss) Mood is characterized by intensity, patient’s behavior and verbal responses can depth, duration, and fluctuation. Normal help with this assessment. mood is euthymic. Dysphoric mood is a lower mood state, depression is even more MENTAL STATUS EXAMINATION negative. Depression might be character- ized by irritability and anhedony (losing Mental status contains the symptoms one’s interest in activities, or it might pres- and information about the patient’s behav- ent as boredom in young people). ior. It is based on the observation of the pa- Alexithymia is the inability to feel emo- tient and uses the collected information tions, the individual is not aware of their about the individual’s thought process, own emotions or cannot describe them. emotions, and behavior during the exami- Positive changes in emotion include eupho- nation. Mental state is usually written after ria (increased mood) and expansive mood, talking to the patient. The clinician starts to which is emotion without limits. It is impor- build rapport, collects information about tant to take note of the presence of the disorder, and maps discrepancies from bereavement. normal functioning in certain areas of psychopathology. Mental status changes from day to day, or even from hour to hour; INSIGHT therefore, the continuous tracking of a pa- tient’s mental status is very important for Insight is the patient’s awareness and the psychiatrist and the health care team. understanding of his/her own symptoms Changes in mental state give information and illness. It is not equivalent to the sever- about the progress of an illness, remission ity of illness. Patients often are not aware of or aggravation of symptoms, and effective- the emotional origin of their symptoms. ness of therapy. Heteroanamnesis (second Sometimes psychotic patients understand opinion from another informant) is of great that hallucinations are a symptom of their importance in the examination of the pa- illness which requires close monitoring. tient. It is possible that a certain symptom is not present at the time of the assessment, but the person giving a second opinion, usu- JUDGEMENT ally the parent, informs about symptoms which were present a few hours, few days Judgement is the patient’s capacity for before. These symptoms should not be in- social norms and appropriate behavior. cluded in the medical history. Mental state Judgement can be assessed based on should contain only discrepancies noticed whether or not patients understand the by the examiner. Most important mental likely outcome of their behavior and behave characteristics should be noted even if they accordingly, and if they are able to cooper- are not pathological. These are the ate during the examination and therapy. The following: Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Chapter 2 20 THE DIAGNOSIS OF CHILD, ADOLESCENT, AND ADULT PSYCHIATRIC DISORDERS p Appearance: clothing, physique p Mood and affect: adequate/inadequate p Behavior: it is important to note cooper- mood, increased or depressed mood, ir- ation and conventionality and also ritability, emotional lability, anger, am- whether the behavior of the child is ap- bivalence present, emotional manifesta- propriate for her age tions p Speech: appropriate for biological age, p Insight speech disorders, speech development, p Judgement speech problems p Cognition: 7 level of consciousness: states of References, suggested readings alertness, auto- and allopsychic, spa- tial, temporal orientation American Psychiatric Assosiation (2013). Diagnostic 7 attention: vigilance, directedness, and Statistical Manual of Mental Disorders – Fifth Edition-DSM-V. Washington DC concentration Williams and Wilkins (1994) Kaplan and Sadock’s 7 perception: perception is appropriate Synopsis of Psychiatry, 7th edition. Williams and Wilkins, Baltimore, pp 276-280. for the sensation, visions, hallucina- Wright, P., Stern, J., Phelan Saunders, M. (2012). tions present Core psychiatry. Elsevier, London,pp 83-93. 7 memory: immediate, short-term, Füredi, J., Németh, A., Tariska P. (2009) Hungarian Handbook of Psychiatry. In Hungarian: A working and long-term memory pszichiátria magyar kézikönyve. Medicina Pub- 7 intelligence: vocabulary appropriate lisher Budapest, pp 134-149. for age, ability to count, read, write, Magyar, I. (1993) Psychiatry, In Hungarian: Psychiátria. Semmelweis Publisher, Budapest. school grade pp 54-55., pp 58-63. 7 thought: form and content Vetró, Á. (2008). Child and Adolescent Psychiatry. In Hungarian: Gyermek-és Ifjúságpszichiátria. p Psychomotor activity: retarded or hyper- Medicina Publisher, Budapest, pp 70-71. active, stereotyped behaviors, tics, mim- ics, pantomimics Wei Yue Hung 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  21 2.2. CLASSIFICATION SYSTEMS Judit Balázs, Ágnes Keresztény THE SIGNIFICANCE OF two systems have developed in parallel. CLASSIFICATION SYSTEMS Updated editions of both classification sys- tems are published periodically, following In child psychiatry, as well as in other ar- up-to-date research findings and clinical ex- eas of medical science, it is very important periences from the field of psychiatry. The that the diagnoses of certain disorders is release of a new edition is preceded by ex- based on objective, clearly defined criteria. tensive preparation, a process involving Classification systems are designed to en- several professionals from different disci- sure a diagnosis based on these criteria and plines. The construction and development are intended to guarantee that patients re- of these classification systems is based on ceive the same diagnosis for the same prob- professional consensus, with an elaborate lem in different parts of the world across review of evidence from the literature, as cultures. Furthermore, a classification sys- well as extensive testing of the validity and tem ensures that professionals use the same reliability of the systems (American Psychi- terminology, and that a given disorder is atric Association, 2013; World Health Or- characterised by the same etiology, ganization, 2018). The DSM was first pub- symptomatology, course, and prognosis. Its lished in 1952, while the current, fifth ver- clinical relevance is that evidence-based sion was published in 2013 (American Psy- treatments are available for certain prob- chiatric Association, 2013). The ICD was lems. Standardized terminology and diag- first published in 1948; 11th edition version nostic criteria also form a basis for research was just published (World Health and education related to psychiatric disor- Organization, 2018). ders. The ICD comprises other areas of medi- Currently two major classification sys- cal science as well beside psychiatric disor- tems are used: the Diagnostic and Statistical ders, while DSM focuses solely on psychi- Manual of Mental Disorders (DSM) pub- atric disorders (American Psychiatric Asso- lished by the American Psychiatric Associ- ciation, 2013; World Health Organization, ation (2013), and the International Classifi- 2018). cation of Diseases (ICD) published by the Classification systems use the phrase Wei Yue Hung ’disorder’ consistently and deliberately. World Health Organization (2018). The 1083 Budapest, Prater Utca 73, 4/402 / [email protected] / Judit Balázs, Mónika Miklósi - Textbook of child, adolescent and youth mental disorders www.semmelweiskiado.hu ( trid:41932 )  Chapter 2 22 THE DIAGNOSIS OF CHILD, ADOLESCENT, AND ADULT PSYCHIATRIC DISORDERS The rationale behind this usage is that the symptoms for a period of time defined by term ’disorder’ expresses the complex role the classification system is not sufficient for of psychological, biological, social and cul- an automatic diagnosis. A diagnosis is only tural factors better than words such as applicable if these symptoms have a nega- ’problem’ or ’illness’. Moreover, profes- tive impact on a patient’s functioning in sionals assume that this phrase imposes less daily life. Furthermore, classification sys- stigmatization. tems require that symptoms cause func- tional impairment in more than one domain, (e.g., at school, at home). In this way, clas- PRINCIPLES OF CLASSIFICATION sification systems try to exclude the possi- bility of establishing a diagnosis as the re- Both classification systems are free from sult of situational effects (American theoretical concepts. The diagnoses of psy- Psychiatric Association, 2013; World chiatric disorders are based on the principle Health Organization, 2018). of syndromatology; thus, a classification A further important criterion used by the system defines the type of symptoms, the classification systems is the differential di- number of symptoms, and how long symp- agnostic viewpoint: the syndrome must not toms must be present in order to establish a be present as a consequence of another dis- diagnosis. Furthermore, classification sys- order (American Psychiatric Association, tems require the onset of symptoms prior to 2013; World Health Organization, 2018). a defined age for certain diagnoses. For ex- The two classification systems differ in ample, symptoms of Autism Spectrum Dis- the way they handle co-occuring disorders. order must present before age 3. Atten- The DSM acknowledges and brings atten- tion-de