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Diagnosing Disorders Usually First Evident in Childhood

(9-6-06)

The first grouping

The first grouping of diagnoses in DSM-IV-TR is labeled, “Disorders Usually First Evident in Infancy, Childhood, or Adolescence.” It is an unusual grouping because it is not thematically defined, as are most diagnostic groupings in DSM or etiologically defined (such as the OBS, general medical condition, and drug categories). Caution is necessary because:

  • 1) not all children with mental disorders have mental disorders found in this first grouping
  • 2) adults may be diagnosed with the disorders from the first grouping
  • It is therefore useful to train yourself not to speak or thinking of the first grouping as “the child section”, “the child disorders”, etc.
  • Also, there is no clear logical or thematic sequencing of the subsections
  • Finally, recall that Mental Retardation (and Borderline Intellectual Functioning) is diagnosed on Axis II

Most of the subsections in the first grouping of disorders have “The essential feature(s)”

Comorbidities & developmental courses

  • Mental Retardation and everything
  • ADHD (and ODD)
  • LD [primarily verbal/Reading] + [early childhood] language and speech problems
  • behavior problems (CD & ODD) + [adolescence] substance use/abuse/dependence
    • arithmetic problems + NVLD + Dev Coordination Dis + (maybe) Ausperger’s Syndrome
  • ADHD + Tourette’s Syndrome + (sometimes) OCD
  • ODD to (sometimes) CD to (sometimes) Antisocial Personality Disorder
  • childhood problems to (sometimes) schizophrenia (with worse prognosis)
  • childhood onset dysthymia to major depression (adolescent/adult)
  • anxiety problems during childhood to most anxiety disorders in adulthood
  • ADHD (childhood) to ADHD residual (attention problems & impulsivity, hyperactivity becomes less noticeable)
  • disruptive behavior problems (ADHD, CD, {ODD ?}) to mood and anxiety disorders as adult
  • ADHD ? Bipolar Disorder
  • Bipolar Disorder diagnosed in child/adol does not appear to reliably predict Bipolar I Disorder as adult [controversal]

Specific Diagnostic Issues

  • Attention problems
  • Milich, Whidiger & Landau (1987) suggested some behavior were useful for as “inclusionary” or “exclusionary” predictors for DSM-III diagnoses:
    • stealing suggests Conduct Disorder, the absence of stealing suggests Conduct Disorder is not present
    • lying and suspension from school do not differentiate Conduct Disorder and ADHD (both symptoms occur commonly with both disorders)
    • the absence of lying strongly suggests Conduct Disorder is not present
    • the authors suggest that the absence of “doesn’t listen”, “acts without thinking” and “easily distracted” are useful in excluding Conduct Disorder–it is unlikely the child is manifesting a Conduct Disorder if they do not show these symptoms
  • Milich, Balentine, & Lynam (2001) review the literature and conclude that ADHD Combined Type and ADHD Predominantly Inattentive Type are distinct and unrelated disorders.
  • I have found that asking if a child can sit through a family meal (if the family typically eats together at a table) is a useful probe in evaluating potential ADHD.
  • PDD

Attention deficits as nonspecific symptoms

(9-6-06)

Attention problems are explicitly noted as primary or associated symptoms in a number of DSM-IV-TR episodes and disorders:

  • low intelligence p. 91
  • Autistic Disorder p. 72
  • Asperger’s Disorder p. 81
  • ADHD p. 85
  • Delirium p. 136
  • Alcohol Intoxication p. 214
  • Schizophrenia p. 305
  • Major Depression p. 350
  • Mania p. 358
  • Hypomania p. 365
  • Dysthymia p. 377

In addition, attention problems can be noted clinically in an even wider array of emotional and behavioral syndromes:

  • Conduct Disorder
  • Oppositional Defiant Disorder
  • Learning Disorders
  • Tourette’s Disorder
  • Reactive Attachment Disorder
  • traumatic brain injury
  • seizure disorders
  • Anxiety Disorders
    • Generalized Anxiety Disorder
    • Panic Disorder
    • Phobia
    • Obsessive Compulsive Disorder
    • Posttraumatic Stress Disorder
  • Sleep Disorders — Primary Insomnia
  • pain syndromes
  • dissociative syndromes
  • some Personality Disorders
    • Schizotypal
    • Borderline
    • Histrionic

Pervasive Developmental Disorders

(10-5-04)

  • Autism
  • Asperger’s syndrome
    • GILLBERG’S CRITERIA FOR ASPERGER’S DISORDER:
      • 1.Severe impairment in reciprocal social interaction
        • (at least two of the following)
        • (a) inability to interact with peers
        • (b) lack of desire to interact with peers
        • (c) lack of appreciation of social cues
        • (d) socially and emotionally inappropriate behavior
      • 2.All-absorbing narrow interest
        • (at least one of the following)
        • (a) exclusion of other activities
        • (b) repetitive adherence
        • (c) more rote than meaning
      • 3.Imposition of routines and interests
        • (at least one of the following)
        • (a) on self, in aspects of life
        • (b) on others
      • 4.Speech and language problems
        • (at least three of the following)
        • (a) delayed development
        • (b) superficially perfect expressive language
        • (c) formal, pedantic language
        • (d) odd prosody, peculiar voice characteristics
        • (e) impairment of comprehension including misinterpretations of literal/implied meanings
      • 5.Non-verbal communication problems
        • (at least one of the following)
        • (a) limited use of gestures
        • (b) clumsy/gauche body language
        • (c) limited facial expression
        • (d) inappropriate expression
        • (e) peculiar, stiff gaze
      • 6.Motor clumsiness: poor performance on neurodevelopmental examination
    • (All six criteria must be met for confirmation of diagnosis.)
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