This is a glimpse of psych disorders that commonly affect pediatric populations. In plain English, it’s usually just bad behavior when parents and families seek help. However, “bad” is subjective and the DSM-5 tries to categorize or objectively defined these behaviors to lessen the confusion in mental health care. Plus it’s not NICE to call someone bad when it may be a real underlined concern. Depression, anxiety, or other mood disorders are generally more manageable than a child fighting and screaming but they all represent something that needs to be addressed.
The issue with mood conditions is how treatment may take longer due to not identifying the symptoms such as the “It’s just their personality” assumptions or just tolerating the behavior or mood while hoping everything gets better. Therefore, the child’s behaviors may become more pathological or dysfunctional, which is why early treatment is so important and shouldn’t be stigmatized. When medications are indicated for a child it’s usually due to the following common diagnosis; ADHD/ADD, ASD, Conduct, DMDD, IED, ODD. Here are the DSM-5 criteria that I try to incorporate in my notes:
The DSM-5 Criteria
Attention Deficit Disorder-Hyperactivity Disorder (ADHD): developmentally inappropriate and persistent difficulty with inattention and/or hyperactivity with symptoms present in multiple settings. People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. It includes the following category of behaviors:
- Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
- Often has trouble holding attention on tasks or play activities.
- Often does not seem to listen when spoken to directly.
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
- Often has trouble organizing tasks and activities.
- Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
- Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted
- Is often forgetful in daily activities.
- Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
- Often fidgets with or taps hands or feet, or squirms in seat.
- Often leaves seat in situations when remaining seated is expected.
- Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
- Often unable to play or take part in leisure activities quietly.
- Is often “on the go” acting as if “driven by a motor”.
- Often talks excessively.
- Often blurts out an answer before a question has been completed.
- Often has trouble waiting their turn.
- Often interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, the following conditions must be met:
- Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
- Several symptoms are present in two or more settings, (such as at home, school or work; with friends or relatives; in other activities).
- There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
- The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
- Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
- Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
- Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well.
Diagnosing ADHD in Adults
ADHD often lasts into adulthood. To diagnose ADHD in adults and adolescents age 17 years or older, only 5 symptoms are needed instead of the 6 needed for younger children. Symptoms might look different at older ages. For example, in adults, hyperactivity may appear as extreme restlessness or wearing others out with their activity.
Autism Spectrum Disorder (ASD): to meet diagnostic criteria for ASD according to DSM-5, a child must have persistent deficits in each of three areas of social communication and interaction (see A.1. through A.3. below) plus at least two of four types of restricted, repetitive behaviors (see B.1. through B.4. below).
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):
- Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
- Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
Specify current severity:
Severity is based on social communication impairments and restricted, repetitive patterns of behavior.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):
- Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
- Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the same food every day).
- Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
- Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
Specify current severity:
Severity is based on social communication impairments and restricted, repetitive patterns of behavior.
C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for the general developmental level.
Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.
Specify if:
- With or without accompanying intellectual impairment. With or without accompanying language impairment
- Associated with a known medical or genetic condition or environmental factor (Coding note: Use additional code to identify the associated medical or genetic condition.)
- Associated with another neurodevelopmental, mental, or behavioral disorder. (Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or behavioral disorder[s].
- With catatonia (refer to the criteria for catatonia associated with another mental disorder). (Coding note: Use additional code 293.89 catatonia associated with an autism spectrum disorder to indicate the presence of the comorbid catatonia.)
What are the DSM-5 levels of severity for the ASD diagnosis?
There are no subtypes of ASD. The distinction is based on the severity of presentation and the degree of support required by each individual with ASD. The severity assessment scale (Levels 1-3) is based on the level of support needed for daily functioning:
- Level 1: Requiring support – Without supports in place, deficits in social communication cause noticeable impairments, and inflexibility of behavior causes significant interference with functioning in one or more contexts.
- Level 2: Requiring substantial support – Marked deficits in verbal and nonverbal social communication skills apparent even with supports in place with limited initiation of social interactions and reduced/abnormal responses to social overtures from others; restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts.
- Level 3: Requiring very substantial support – Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning with very limited initiation of social interactions and minimal response to social overtures from others; restricted/repetitive behaviors markedly interfere with functioning in all spheres.
What Is PDD and Asperger’s Disorder?
PDD and Asperger’s disorder are old terms, belonging to the previous diagnostic (DSM IV) criteria. These terms are no longer in use, as they belong to the previous (DMS IV) criteria, but you may still hear some professionals use these when talking about a child diagnosed with Autistic disorder prior to 2013. There are a total of five different PDDs, explained below:
- Childhood Autism: always presents before 36 months of age, these children may have some speech developmental and social interactive regression, usually around 18 months of age. The diagnosis of childhood autism must meet the specific DMS IV criteria and will therefore present with poor eye contact, pervasive ignoring, language delay, and other features. Per definition, these children will have a severe impairment in speech, communication, or social interaction. Many of them will be completely non-verbal and “in their own world,” with lifelong, severe impairment.
- Asperger’s Syndrome: these are kids with a form of autism that affects language less, yet there are difficulties with appropriate speech and communicative development. Mostly, however, these children have social interaction difficulties and impairments related to a restricted, repetitive, stereotype behavior. These kids may have very high IQ’s, may do very well academically, have a superior memory for “unimportant” details, such as the birth dates of all baseball players, some historical or geographical trivia, yet they lack the skills to care for themselves and live independently. These individuals may talk repetitively about a certain topic without understanding that it may be boring to others. The “amount” of memory of these individuals is incredible and one may expect different degrees of impairments with Asperger’s syndrome. This may involve more or less memory and more or less social communicative impairment with regards to being able to live independently. As long as a child or individual seems “different” or “odd” and has a thought process that doesn’t fit the way everyone else thinks, yet shows some of the required autistic characteristics, Asperger’s syndrome should be considered. Many people with this condition remain undiagnosed because of their ability to compensate with their memory or excellent academic abilities, yet they are considered by others to be “socially inept,” “weird,” “nerds,” “bizarre,” “eccentric,” etc. A typical example of a child with Asperger’s syndrome would be that of a child who has some odd behaviors, poor eye contact, “sluggish” social interaction abilities, and an extreme interest in a central topic such as a washing machine. The child likes to sit and watch the washing machine door rotate, knows everything about it including its operative and professional manual and may spend hours perseverating about it. Such a child when he has a play date, may try to involve his “friend” in his most exciting interest (the washing machine) without realizing how boring it is to others and that will be the end of the play dates forever. This pattern may present itself in different degrees and circumstances, but the principal is the same: the lack of the ability to understand how other people perceive what you do, say, or express with body language and facial expressions.
- Childhood Disintegrative Disorder: these are kids who develop normally for the first 3 years of life. Later they seem to regress and develop some autistic features associated with a severe functional impairment. These children must be thoroughly evaluated for the possibility of the development of seizures, affecting the speech areas of the brain, or Landau Kleffner syndrome (acquired epileptiform aphrasia), where seizure activity “robs” the brain from previously acquired speech.
- Rett’s Disease: this affects only girls. These are girls who develop normally until 6 months of age and regress. Their regression is associated with microcephaly (small head). The head size seems to stop growing from 6 months and on, from the time of the observed regression. Recently a specific chromosomal marker (MEC-P-2) has been associated with this disorder and is now commercially available in some laboratories.
- PDD NOS: will present similarly to the kids who have autism, but will have a lesser degree of a severe impairment. These kids are more likely to be verbal and have some degree of verbal or non-verbal effective communication, yet they must have the autistic features (as per the DSM IV criteria) and a severe impairment in social interaction, communication, or repetitive stereotype behavior. This term is reserved for children with a severe impairment who do not fully qualify for any other autistic diagnosis, due to age of onset or combination of autistic features.
Conduct Disorder “Antisocial Behaviors”: repetitive significant violations of social rules and the rights of others over the course of a year. Conduct disorder can present with limited prosocial emotions, lack of remorse or guilt, lack of empathy, lack of concern for performance, and shallow or deficient affect. Symptoms vary by individual, but the four main groups of symptoms are described below:
Aggression to people and animals
- Often bullies, threatens, or intimidates others
- Often initiates physical fights
- Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
- Has been physically cruel to people
- Has been physically cruel to animals
- Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
- Has forced someone into sexual activity (rape or molestation)
Destruction of property
- Has deliberately engaged in fire setting with the intention of causing serious damage
- Has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft
- Has broken into someone else’s house, building, or car
- Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
- Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Serious violations of rules
- Often stays out at night despite parental prohibitions, beginning before age 13 years
- Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
- Is often truant from school, beginning before age 13 years
Disruptive Mood Dysregulation Disorder (DMDD): is a childhood condition of extreme irritability, anger, and frequent, intense temper outbursts. DMDD symptoms go beyond being a “moody” child—children with DMDD experience severe impairment that requires clinical attention.
DMDD symptoms typically begin before the age of 10, but the diagnosis is not given to children under 6 or adolescents over 18. A child with DMDD experiences:
- Irritable or angry mood most of the day, nearly every day
- Severe temper outbursts (verbal or behavioral) at an average of three or more times per week that are out of keeping with the situation and the child’s developmental level
- Trouble functioning due to irritability in more than one place (e.g., home, school, with peers)
To be diagnosed with DMDD, a child must have these symptoms steadily for 12 or more months.
Intermittent Explosive Disorder include (IED): Recurrent outbursts that demonstrate an inability to control impulses, including either of the following:
- Verbal aggression (tantrums, verbal arguments or fights) or physical aggression that occurs twice in a week-long period for at least three months and does not lead to destruction of property or physical injury (Criterion A1)
- Three outbursts that involve injury or destruction within a year-long period (Criterion A2)
- Aggressive behavior is grossly disproportionate to the magnitude of the psychosocial stressors (Criterion B)
- The outbursts are not premeditated and serve no premeditated purpose (Criterion C)
- The outbursts cause distress or impairment of functioning, or lead to financial or legal consequences (Criterion D)
- The individual must be at least six years old (Criterion E)
- The recurrent outbursts cannot be explained by another mental disorder and are not the result of another medical disorder or substance use (Criterion F)
It is important to note that DSM-5 now includes two separate criteria for types of aggressive outbursts (A1 and A2) which have empirical support:
- Criterion A1: Episodes of verbal and/or non damaging, nondestructive, or non injurious physical assault that occur, on average, twice weekly for three months. These could include temper tantrums, tirades, verbal arguments/fights, or assault without damage. This criterion includes high frequency/low intensity outbursts.
- Criterion A2: More severe destructive/assaultive episodes which are more infrequent and occur, on average, three times within a twelve-month period. These could be destroying an object without regard to value, assaulting an animal or individual. This criterion includes high-intensity/low-frequency outbursts.
Oppositional Defiance Disorder (ODD): Developmentally inappropriate opposition and defiance towards adults, instructions, or rules for more than 6 months. For some children, symptoms may first be seen only at home, but with time, it extends to other settings, such as school and with friends but the location doesn’t matter. DSM-5 criteria include emotional and behavioral symptoms that last at least six months:
Angry and irritable mood:
- Often and easily loses temper
- Is frequently touchy and easily annoyed by others
- Is often angry and resentful
Argumentative and defiant behavior:
- Often argues with adults or people in authority
- Often actively defies or refuses to comply with adults’ requests or rules
- Often deliberately annoys or upsets people
- Often blames others for his or her mistakes or misbehavior
Vindictiveness:
- Is often spiteful or vindictive
- Has shown spiteful or vindictive behavior at least twice in the past six months
ODD can vary in severity:
- Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers.
- Moderate. Some symptoms occur in at least two settings.
- Severe. Some symptoms occur in three or more settings.
DSM-5 Disorders to be Considered at Different Ages
| Preschool (2-5 years) | School Age (6-12) | Adolescence (13-17) |
|---|---|---|
| ADHD (age>3, if severe) | ADHD | ADHD |
| ASD | Adjustment Disorder | Adjustment Disorder |
| Communication Disorders | Conduct Disorder | Anorexia Nervosa, Bulimia |
| Encopresis | Encopresis | Conduct, Bipolar Disorders, GAD, MDD, Dysthymia |
| Intellectual (Developmental) Disability Disorder | ID, Specific Learning Disorder | ID, Specific Learning Disorder |
| ODD | Insomnia, Parasomnias | Insomnia, obstructive sleep apnea |
| Selective Mutism | Tourette's, Trichotillmania | OCD, ODD, Panic, PTSD, Tourettes, Trichotillmania, SAD |
| Separation Anxiety | MDD, OCD, ODD, PTSD, Social Anxiety | Schizophrenia, Specific Phobias, Somatic Symptoms |
| Specific Phobia | Specific Phobia, Somatic Symptom Disorder | Substance Use Disorders |
References
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- Autism: CDC & Child Brain
- Hilt, R. J., & Nussbaum, A. M. (2016). DSM-5 pocket guide for child and adolescent mental health. Arlington, VA: American Psychiatric Association Publishing. (table)
