Infant, Child, and Adolescent Disorders
I. Principles of Child and Adolescent Diagnostic Assessment
A comprehensive evaluation of a child includes interviews with the parents, the child, and the family; gathering of information regarding the child’s current school functioning; and often, a standardized assessment of the child’s intellectual level and academic achievement. In some cases, standardized measures of developmental level and neuropsychological assessments are useful. Psychiatric evaluations of children are rarely initiated by the child, so clinicians must obtain information from the family and the school to understand the reasons for the evaluation. In some cases, the court or a child protective service agency may initiate a psychiatric evaluation. Children often have difficulty with the chronology of symptoms and are sometimes reticent to report behaviors that got them into trouble. Very young children often cannot articulate their experiences verbally and are better at showing their feelings and preoccupations in a play situation.
The examiner should make sure that the following areas are covered:
A.
Supplement data from patient interviews with information from family members, guardians, teachers, and outside agencies.
B.
Understand normal development so as to understand fully what constitutes abnormality at a given age. Table 26-1 presents developmental milestones.
C.
Be familiar with the current diagnostic criteria of disorders so as to guide anamnesis on the mental status examination.
D.
Understand the family psychiatric history, which is necessary given the genetic predispositions and environmental influences associated with many disorders.
II. Child Development
Development results from the interplay of maturation of the central nervous system (CNS), neuromuscular apparatus, and endocrine system and various environmental influences (e.g., parents and teachers, who can either facilitate or thwart a child’s attainment of his or her developmental potential). This potential is specific to each person’s given genetic predisposition to (1) intellectual level and (2) mental disorders, temperament, and probably certain personality traits.
Development is continuous and lifelong but is most rapid in early life. The neonatal brain weighs 350 g, almost triples in weight by 18 months, and at 7 years is very close to the adult weight of 1,350 g. Whereas neurogenesis is virtually complete at birth, the arborization of axons and dendrites continues for many years. This and synaptogenesis appear to be influenced by the environment. Because of brain plasticity, some connections are strengthened
and others are developed in response to environmental input. Myelinization continues for decades.
and others are developed in response to environmental input. Myelinization continues for decades.
Table 26-1 Landmarks of Normal Behavioral Development | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The most cited theorists in child development have been Sigmund Freud, Margaret Mahler, Erik Erikson, and Jean Piaget; their work is outlined in Table 26-2.
III. Learning Disorders
Learning disorder is diagnosed when reading, writing, and mathematical skills are significantly lower than expected. The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) includes four diagnostic categories on learning disorders: reading disorder, mathematic disorder, disorder of written expression, and learning disorder not otherwise specified.
A. Reading disorder.
Formally known as dyslexia, reading disorder is characterized by an impaired ability to recognize words, poor comprehension, and slow and inaccurate reading.
Diagnosis. Reading ability is significantly below that expected of a child of the same age, education, and measured intelligence. It is usually identified by the age of 7 years (second grade); however, in some cases, particularly when the disorder is associated with high intelligence, it may not be apparent until the age of 9 years (fourth grade). Associated problems include language difficulties and difficulties in properly sequencing words. Younger children tend to feel shame and humiliation while older children tend to be angry and depressed and exhibit low self-esteem (Table 26-3).
Epidemiology
Occurs in 4% of school-aged children.
Prevalence ranges from 2% to 8%.
Equal rates among females and males.
Etiology
Possible link to chromosome 6 and chromosome 15.
Occipital lobe lesions and hemispheric abnormality have been linked.
Occurs in 35% to 40% of first-degree relatives.
Differential diagnosis
Mental retardation. Reading, along with other skills, is below the achievement expected for a child’s chronologic age.
Attention-deficit/hyperactivity disorder (ADHD). Difficulties with linguistic abilities are not consistent. Reading improves with medication.
Hearing and visual impairments. Should be ruled out with screening tests.
Course and prognosis. Most school-aged children do not need remediation past grade school, with only severe disorders requiring help into middle and high school level.
Table 26-2 A Synthesis of Developmental Theorists
Age (years)
Margaret Mahler
Sigmund Freud
Erik Erikson
Jean Piaget
Comments
0–1
Normal autistic phase (birth to 4 weeks)
- State of half-sleep, half-wake
- Major task of phase is to achieve homeostatic equilibrium with the environment
- Dim awareness of caretaker, but infant still functions as if he or she and caretaker are in state of undifferentiation or fusion
- Social smile characteristic (2–4 months)
First subphase: differentiation (5–10 months)
- Process of hatching from autistic shell (i.e., developing more alert sensorium that reflects cognitive and neurologic maturation)
- Beginning of comparative scanning (i.e., comparing what is and what is not mother)
- Characteristic anxiety: stronger anxiety, which involves curiosity and fear (most prevalent around 8 months)
Oral phase (birth to 1 year)
- Major site of tension and gratification is the mouth, lips, tongue—includes biting and sucking activities
Basic trust vs. basic mistrust (oral sensory) (birth to 1 year)
- Social mistrust demostrated via ease of feeding, depth of sleep, bowel relaxation
- Depends on consistency and sameness of experience provided by caretaker
- Second 6 months teething and biting move infant “from getting to taking”
- Weaning leads to “nostalgia for lost paradise”
- If basic trust is strong, child maintains hopeful attitude
Sensorimotor phase (birth to 2 years)
- Intelligence rests mainly on actions and movements coordinated under schemata: (Schemata is a pattern of behavior in response to a particular environmental stimulus.)
- Environment is mastered through assimilation and accommodation (Assimilation is the incorporation of new environmental stimuli; accommodation is the modification of behavior to adapt to new stimuli.)
- Object permanence is achieved by age 2 years. Object still exists in mind if disappears from view: search for hidden object
- Reversibility in action begins
In contrast to Mahler, other observers of mother–infant pairs are impressed with a mutuality and complementarity (not autism or fusion), which provides a groundwork for relatedness and language development, as if there were a prewiring for these abilities. Piaget and others emphasize the infant’s active striving to manipulate the inanimate environment. This supplements Freud’s work because the infant and young child’s motivation for behavior is not simply to relieve drive tension and attain oral, anal, and phalic gratification.
1–2
Second subphase: practicing (10–16 months)
- Beginning of this phase marked by upright locomotion—child has new perspective and also mood of elation
- Mother used as home base
- Characteristic anxiety: separation anxiety
- Infant now a toddler—more aware of physical separateness, which dampens mood of elation
- Child tries to bridge gap between self and mother—concretely seen as bringing objects to mother
- Mother’s efforts to help toddler often not perceived as helpful, temper tantrums typical
- Characteristic event: rapprochement crisis, wanting to be soothed by mother and yet not able to accept her help
- Symbol of rapprochement: child standing on threshold of door not knowing which way to turn, helpless frustration
- Resolution of crisis occurs as child’s skills improve and child able to get gratification from doing things on own
Anal phase (1–3 years)
- Anus and surrounding area major source of interest
- Acquisition of voluntary sphincter control (toilet training)
Autonomy vs. shame and doubt (muscular–anal) (1–3 years)
- Biologically includes learning to walk, feed self, talk
- Muscular maturation sets stage for “holding on and letting go”
- Need for outer control, firmness of caretaker before development of autonomy
- Shame occurs when child is overtly self-conscious via negative exposure
- Self-doubt can evolve if parents overly shame child (e.g., about elimination)
Preoperational phase (2–7 years)
- Appearance of symbolic functions, associated with language acquisition
- Egocentrism: child understands everything exclusively from own perspective
- Thinking is illogical and magical
- Nonreversible thinking with absence of conversation
- —Animism: belief that inanimate objects are alive (i.e., have feelings and intentions)
- —“Imminent justice,” belief that punishment for bad deeds is inevitable
- —Animism: belief that inanimate objects are alive (i.e., have feelings and intentions)
Supplementing the work of Freud and Mahler, theorists have postulated that severe problems in mother–infant/toddler interactions contribute to the formation of pathological character traits, gender identity disorder, or personality disorders. Angry, frustrating, narcissistic caretakers often produce angry, needy children and adults who cannot tolerate the normal frustrations and disappointments in relationships and whose character formation is grossly distorted.
2–3
Fourth subphase: consolidation and object constancy (24–36 months)
- Child better able to cope with mother’s absence and engage substitutes
- Child can begin to feel comfort-able with mother’s absences by knowing she will return
- Gradual internalization of image of mother as reliable and stable
- Through increasing verbal skills and better sense of time, child can tolerate delay and endure separations
3–4
4–5
Phallic-oedipal phase (3–5 years)
- Genital focus of interest, stimulation, and excitement
- Penis is organ of interest for both sexes
- Genital masturbation common
- Intense preoccupation with castration anxiety (fear of genital loss or injury)
- Penis envy (discontent with one’s own genitals and wish to possess genitals of male) seen in girls in this phase
- Oedipus complex universal: child wishes to have sex with and marry parent of opposite sex and simultaneously be rid of parent of same sex
Initiative vs. guilt (locomo- tor genital) (3–5 years)
- Initiative arises in relation to tasks for the sake of activity, both motor and intellectual
- Guilt may arise over goals contemplated (especially aggressive)
- Desire to mimic adult world; involvement in oedipal struggle leads to resolution via social role identification
- Sibling rivalry frequent
Researchers have amended Freud’s work. Children of both sexes explore and are aware of their own genitals during the second year of life and, with proper parental reinforcement, begin to correctly identify themselves as girls or boys. Penis envy is neither universal nor normative.
Freud emphasized problems with oedipal resolution in psychopathogenesis. His theory accounts for only a part of psychopathology.
5–6
Latency phase (from 5–6 years to 11–12 years)
- State of relative quiescence of sexual drive with resolution of oedipal complex
- Sexual drives channeled into more socially appropriate aims (i.e., schoolwork and sports)
Contrary to Freud, the onset of latency (school age or middle childhood) is now considered primarily a consequence of changes in the CNS and less dependent on the nondemonstrable quiescence and sublimation of sexual drive. During the years 6–8, changes in the CNS are reflected in
6–11
- Formation for superego, one of three psychic structures in mind responsible for moral and ethical development, including conscience
- Other two psychic structures are ego, a group of functions mediating between drives and the external environment, and id, repository of sexual and aggressive drives
- The id is present at birth, and the ego develops gradually from rudimentary structure present at birth
- Industry vs. inferiority (latency) (6–11 years)
- Child is busy building, creating, and accomplishing
- Receives systematic instruction as well as fundamentals of technology
- Danger of sense of inadequacy and inferiority if child despairs of his or her tools/skills and status among peers
- Socially decisive age
- Concrete (operational) phase (7–11 years)
- Emergence of logical (cause–effect) thinking, including reversibility and ability to sequence and serialize
- Understanding of part–whole relationships and classifications
- Child able to take others’ point of view
- Conservation of number, length, weight, and volume
developmental progress of perceptual–sensory–motor functioning and thought processes. In Piaget’s framework, it is the transition from the preoperational to the concrete (operational) phase. Compared with preschoolers, latency children are capable of greater learning, independent functioning, and socialization. Friendships develop with less dependence on parents (and less preoccupation with intrafamilial oedipal rivalries). Today, superego development is considered more prolonged gradual and less related to oedipal resolution.
11+
Genital phase (from 11–12 years and beyond)
- Final stage of psychosexual development—begins with puberty and the biologic capacity for orgasm but involves the capacity for true intimacy
Identity vs. role diffusion (11 years through end of adolescence)
- Struggle to develop ego identity (sense of inner sameness and continuity)
- Preoccupation with appearance, hero worship, ideology
- Group identity (peers) develops
- Danger of role confusion, doubts about sexual and vocational identity
- Psychosocial moratorium, stage between morality learned by the child and the ethics to be developed by the adult
Formal (abstract) phase (11 years through end of adolescence)
- Hypothetical–deductive reasoning, not only on basis of objects but also on basis of hypotheses or propositions
- Capable of thinking about one’s thoughts
- Combinative structures emerge, permitting flexible grouping of elements in a system
- Ability to use two systems of reference simultaneously
- Ability to grasp concept of probabilities
The interplay of child and caretaker is emphasized in the attachment theory of John Bowlby. Mary Ainsworth developed the “strange situation” protocol for examining infant–caretaker separations. “Goodness of fit” between child and caretaker is also stressed in the work on temperament by Chess and Thomas. Infants have inborn differences in certain behavioral dimensions, such as activity level, approach, or withdrawal, intensity of reaction. How parents respond to these behaviors influences development. Lawrence Kohlberg, who was influenced by Piaget, described three levels of moral development: preconventional, in which moral decisions are made to avoid punishment; conventional role conformity, with decisions made to maintain friendships; and in adolescence self-accepted moral principles, (i.e., voluntary compliance with ethical principles).
Adapted from Sylvia Karasu, M.D., and Richard Oberfield, M.D.
Table 26-3 DSM-IV-TR Diagnostic Criteria for Reading Disorder
- Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person’s chronologic age, measured intelligence, and age-appropriate education.
- The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require reading skills.
- If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it.
Coding note: If a general medical (e.g., neurologic) condition or sensory deficit is present, code the breakcondition on Axis III.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association, 2000, with permission.
- State of half-sleep, half-wake
Treatment
Remediation. Effective remediation programs begin with teaching the child to make accurate associations between letters and sounds. Once these skills have been mastered, remediation can target larger components of reading, such as syllables and words. Positive coping strategies include small, structured reading groups that offer individual attention.
Psychotherapy. Coexisting emotional and behavioral problems are treated by appropriate psychotherapeutic means. Parental counseling may be helpful. Social skills improvement is an important component of psychotherapy.
Pharmacotherapy. Used only for an associated psychiatric disorder, such as ADHD.
B. Mathematics disorder.
Child has difficulty with learning and remembering numerals, remembering and applying basic facts about numbers, and is slow and inaccurate in computation.
Diagnosis. Mathematical ability is significantly below what is expected when considering the child’s age, education, and measured intelligence. Children have difficulty learning the names for numbers and signs for addition and subtraction, memorizing multiplication tables, applying computations to word problems, and doing calculations at a reasonable pace (Table 26-4).
Table 26-4 DSM-IV-TR Diagnostic Criteria for Mathematics Disorder
- Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person’s chronologic age, measured intelligence, and age-appropriate education.
- The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability.
- If a sensory deficit is present, the difficulties in mathematical ability are in excess of those usually associated with it.
Coding note: If a general medical (e.g., neurologic) condition or sensory deficit is present, code the breakcondition on Axis III.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association, 2000, with permission.
- Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person’s chronologic age, measured intelligence, and age-appropriate education.
Epidemiology
Occurs in approximately 1% of school-aged children.
May occur more often in females.
Etiology
In part to genetic factors.
Possible right hemisphere deficit, principally in occipital lobe areas.
Differential diagnosis
Mental retardation. Arithmetic difficulties are accompanied by a generalized impairment in overall intellectual functioning.
ADHD or conduct disorder. Should not be overlooked during diagnosis.
Course and prognosis. This disorder is usually identified by the age of 8 years (third grade); however, it can be seen as early as 6 years (first grade) or as late as 10 years (fifth grade). Children with moderate mathematics disorder who do not receive intervention may have complications such as continuing academic difficulties, shame, poor self-concept, frustration, and depression. Such complications can lead to reluctance to attend school, truancy, and hopelessness about academic success.
Treatment
Remediation. Combines effective teaching of mathematical concepts along with continuous practice.
Psychoeducation. Provides positive feedback for good performance in social areas.
C. Disorders of written expression.
Characterized by frequent grammatical and punctuation errors and poor spelling and handwriting skills.
Diagnosis. Child underperforms in composing written text when compared to similar-aged children and intellectual ability. The child has poor spelling, poor punctuation, poor handwriting, and poor organization of written stories. Features manifest in grade school. The child often becomes angry and frustrated because of feelings of inadequacy and failure in academic performance. In severe cases, depressive disorders may be present (Table 26-5).
Table 26-5 DSM-IV-TR Diagnostic Criteria for Disorder of Written Expression
- Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person’s chronologic age, measured intelligence, and age-appropriate education.
- The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).
- If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.
Coding note: If a general medical (e.g., neurologic) condition or sensory deficit is present, code the breakcondition on Axis III.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association, 2000, with permission.
- Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person’s chronologic age, measured intelligence, and age-appropriate education.
Epidemiology
Occurs in approximately 4% of school-aged children.
Three times more likely in males.
Etiology
Causes believed to be similar to those of reading disorder.
Strong concordance between children and first-degree relatives with disorder of written expression.
Differential diagnosis. The confounding effects of ADHD and depressive disorder may interfere with the ability to concentrate. Therefore, treatment of the above disorders may improve the child’s writing performance. Disorder of written expression may occur with other language and learning disorders such as reading disorder, mixed receptive–expressive language disorder, expressive language disorder, mathematics disorder, developmental coordination disorder, and disruptive behavior and attention-deficit disorders (ADDs).
Course and prognosis. In severe cases, symptoms appear by age 7 (second grade); in less severe cases, the disorder may appear by age 10 (fifth grade) or later. Patients with mild to moderate cases usually do well if they receive remedial education early in grade school. Severe cases require continual, extensive remedial treatment through high school and college. Prognosis relies on the severity of the disorder, the age or grade in which intervention is received, the length and continuity of treatment, and the presence or absence of associated or secondary emotional or behavioral problems.
Treatment
Remediation. Treatment includes continuous practice of spelling and sentence writing and review of grammar. Intensive and individually tailored creative writing therapy may provide additional benefit.
Psychotherapy. Psychological therapy including individual, group, or family therapy may be useful in cases of secondary behavioral and emotional problems.
D. Learning disorder not otherwise specified.
A category in DSM-IV-TR for disorders that do not meet the criteria for any specific learning disorder, but cause impairment and reflects learning abilities below those expected for a child’s intelligence, education, and age (Table 26-6). An example is a spelling skills deficit.
IV. Motor Skills Disorder: Developmental Coordination Disorder
Characterized by poor performance in daily activities requiring coordination. This may present with delays in achieving such motor milestones as sitting, crawling, and walking. The disorder may also manifest by clumsy gross and fine motor skills, resulting in poor athletic performance and poor handwriting.
A. Diagnosis.
Disorder may manifest as early as infancy. Diagnosis is based on a history of delay in achieving early motor milestones. The diagnosis may be associated with below-normal scores on performance subtests of
standardized intelligence tests and by normal or above-normal scores on verbal subtests (Table 26-7).
standardized intelligence tests and by normal or above-normal scores on verbal subtests (Table 26-7).
Table 26-6 DSM-IV-TR Diagnostic Criteria for Learning Disorder Not Otherwise Specified | ||
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B. Epidemiology
Prevalence is approximately 5% of school-aged children.
Male-to-female ratio may range from 2:1 to 4:1; however, bias may exist.
C. Etiology
Unknown but probably multifactorial.
Risk factors may include prematurity, hypoxia, perinatal malnutrition, and low birth weight.
Frequently found in children with hyperactivity and learning disorders.
D. Differential diagnosis
Neuromuscular disorders. Patients exhibit more global muscle and neurologic impairment.
Attention-deficit/hyperactivity disorder. Rule out physical carelessness seen in individuals with ADHD.
Mental retardation. Coordination usually does not stand out as a significant deficit compared with other skills.
E. Course and prognosis.
Few data available on outcome. Although clumsiness may continue, some children are able to compensate by developing interest in other skills. Clumsiness generally persists into adolescence and adult life.
Table 26-7 DSM-IV-TR Diagnostic Criteria for Developmental Coordination Disorder | |||
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F. Treatment.
Usually includes versions of sensory integration programs and modified forms of physical education. Sensory integration programs consist of physical activities that increase awareness of motor and sensory function. Adaptive physical education programs incorporate certain sports actions, such as kicking or throwing a ball. Patients may benefit from social skills groups and other prosocial interventions. Secondary academic and emotional problems and coexisting communication disorders should be considered for individual treatments. Parental counseling may be beneficial in reducing parents’ anxiety and guilt, increasing their awareness, and facilitating their confidence.
V. Communication Disorders
Communication disorders are characterized by impairment in understanding and expressing language and the production of speech. There are four major communication disorders: two language disorders (expressive and mixed receptive–expressive communication disorder) and two speech disorders (phonologic disorder and stuttering).
A. Expressive language disorder.
Characterized by deficits in vocabulary, tenses, production of complex sentences, and recall of words.
Diagnosis. Patient presents selective deficits in language skills accompanied by normal function in nonverbal areas and receptive skills. Diagnosis should be confirmed by standardized tests of expressive language and nonverbal intelligence. Severity of the disorder can be determined by the child’s verbal and sign language in various places (i.e., the schoolyard, classroom, home, and playroom) and interaction with other children. In severe cases, the disorder presents by approximately 18 months (Table 26-8).
Epidemiology
Occurs in 3% to 5% of school-aged children.
Two to three times more common in males.
History of relatives with other communication disorders.
Table 26-8 DSM-IV-TR Diagnostic Criteria for Expressive Language Disorder
- The scores obtained from standardized individually administered measures of expressive language development are substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity.
- The difficulties with expressive language interfere with academic or occupational achievement or with social communication.
- Criteria are not met for mixed receptive–expressive language disorder or a pervasive developmental disorder.
- If mental retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association, 2000, with permission.
Etiology
Subtle cerebral damage and maturational lags in cerebral development may be a cause.
Associated with left-handedness and ambilaterality.
Concordance for monozygotic twins.
Genetic, environmental, and educational factors appear to play a role.
Differential diagnosis
Mental retardation. Child has an overall impairment in intellectual functioning, and nonverbal intellectual capacity is not within normal limits.
Mixed receptive–expressive language disorder. Comprehension of language (decoding) is below the expected age-appropriate level.
Pervasive developmental disorder. Child has no inner language or appropriate use of gestures and shows little or no frustration with the inability to communicate verbally.
Aphasia or dysphasia. Child has a history of early normal language development; onset of the disordered language is after a head trauma or other neurologic disorder (i.e., seizure disorder).
Selective mutism. Child has a history of normal language development.
Course and prognosis. The rapidity and degree of recovery depends on the severity of the disorder, the child’s motivation to participate in therapies, and the timely institution of speech and other therapeutic interventions. As many as 50% of children with mild cases recover spontaneously, while severe cases continue to display some features of language impairment.
Treatment
Remedial. Language therapy is aimed at using words to improve communication strategies and social interactions.
Psychotherapy. Can be used as a positive model for more effective communication and broadening social skills in patients where language impairment has affected self-esteem. Supportive parental counseling may be useful in some cases.
B. Mixed receptive–expressive language disorder.
Children are impaired in both understanding and expressing language. Scores on standardized tests in both receptive (comprehension) and expressive language fall substantially below those obtained from standardized measurements of nonverbal intellectual capacity. According to DSM-IV-TR, it is not advised to diagnose receptive language disorder in the absence of expressive language disorder.
Diagnosis. Measurements in both receptive and expressive language development are below measures of nonverbal intellectual capacity. On average, patients show symptoms before the age of 4 years, with severe cases apparent by the age of 2 years and mild cases by age 7 years (second grade) or older (Table 26-9).
Table 26-9 DSM-IV-TR Diagnostic Criteria for Mixed Receptive–Expressive Language Disorder
- The scores obtained from a battery of standardized individually administered measures of both receptive and expressive language development are substantially below those obtained from standardized measures of nonverbal intellectual capacity. Symptoms include those for expressive language disorder as well as difficulty understanding words, sentences, or specific types of words, such as spatial terms.
- The difficulties with receptive and expressive language significantly interfere with academic or occupational achievement or with social communication.
- Criteria are not met for a pervasive developmental disorder.
- If mental retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association, 2000, with permission.
- The scores obtained from a battery of standardized individually administered measures of both receptive and expressive language development are substantially below those obtained from standardized measures of nonverbal intellectual capacity. Symptoms include those for expressive language disorder as well as difficulty understanding words, sentences, or specific types of words, such as spatial terms.
Epidemiology
Prevalence is 3% of school-aged children.
Twice more common in males.
Etiology
Evidence of familial aggregation of mixed receptive–expressive language disorder.
Twin studies implicate a genetic contribution, but no mode of genetic transmission has been proven.
Differential diagnosis
Expressive language disorder. Decoding remains within normal limits.
Phonological disorder or stuttering. Have normal expressive and receptive language competence, despite speech impairments.
Course and prognosis. The prognosis is variable and depends on the nature and severity of the damage. Prognosis is less favorable than those with expressive language disorder alone. Some children achieve close-to-normal language functions. In young children, the disorder is usually severe, the short-term prognosis is poor, and it is likely that they may develop a learning disorder in the future.
Treatment
Remedial. Most patients benefit from a small, special educational setting that allows more individualized learning.
Psychotherapy. Beneficial in patients with associated emotional and behavioral problems. Family counseling in which parents and children can develop more effective, less frustrating means of communicating is beneficial.
C. Phonologic disorder.
The child presents impairment in sound production by substituting one sound for another or omitting sounds that are part of words.
Diagnosis. Delay or failure to produce developmentally expected speech sounds accompanied by normal language development. The child is unable to articulate certain phonemes correctly and may omit,
substitute, or distort the affected phonemes. Most children usually outgrow the disorder by third grade; however, spontaneous recovery is unlikely after fourth grade (Table 26-10).
Table 26-10 DSM-IV-TR Diagnostic Criteria for Phonologic Disorder
- Failure to use developmentally expected speech sounds that are appropriate for age and dialect (e.g., errors in sound production, use, representation, or organization such as, but not limited to, substitutions of one sound for another use of /t/ for target /k/ sound for omissions of sounds such as final consonants).
- The difficulties in speech sound production interfere with academic or occupational achievement or with social communication.
- If mental retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the speech difficulties are in excess of those usually associated with these problems.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association, 2000, with permission.
- Failure to use developmentally expected speech sounds that are appropriate for age and dialect (e.g., errors in sound production, use, representation, or organization such as, but not limited to, substitutions of one sound for another use of /t/ for target /k/ sound for omissions of sounds such as final consonants).
Epidemiology
Variable prevalence of 0.5% by mid- to late adolescence.
Two to three times more common in males.
Common among first-degree relatives.
Etiology
Likely to include perinatal problems, genetics, auditory processing problems, hearing impairment, and structural abnormalities related to speech.
Genetic studies indicate a high concordance among monozygotic twins.
Differential diagnosis
Physical abnormalities causing articulation errors must be ruled out.
Dysarthria is less likely to spontaneously remit.
Hearing impairment, mental retardation, and pervasive developmental disorders should be ruled out.
Course and prognosis. Spontaneous remission of symptoms is common in children whose misarticulations involve only a few phonemes. Articulation problems that persist after the age of 5 years may be comorbid with other speech and language impairments. Auditory perceptual problems are more likely in children with articulation problems after the age of 5 years. Spontaneous remission is rare after the age of 8 years (fourth grade).
Treatment. Speech therapy is the most successful form of treatment. It is indicated when the child’s intelligibility is poor; the child is over the age of 8 years; the speech problem interferes with peer relations, learning, and self-image; the disorder is so severe that many consonants are misarticulated; and errors involve omissions and substitution of phonemes rather than distortions. Parental counseling and monitoring of child–peer relations and school behavior may be beneficial.
Table 26-11 DSM-IV-TR Diagnostic Criteria for Stutteing | ||
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D. Stuttering.
A condition characterized by involuntary disruptions in the flow of speech.
Diagnosis. Disturbance in normal fluency and time patterning of speech. Stuttering appears between the ages of 18 months and 9 years, with peaks at 2 to 3.5 years and 5 to 7 years. Symptoms gradually develop over weeks or months with a repetition of initial consonants (Table 26-11).
Epidemiology
Prevalence is 3% to 4%.
Affects three to four times more males.
Typical onset is 2 to 7 years of age with a peak at 5 years of age.
Spontaneous remission in about 80% of young children.
Etiology. Unknown; organic and learning models have been proposed.
Differential diagnosis
Normal speech dysfluency. Patients are nonfluent with their speech but seem to be at ease.
Spastic dysphonia. Patients have an abnormal breathing pattern.
Cluttering. Patients are unaware of the disturbance in speech.
Course and prognosis. Course is usually long term with periods of remissions and exacerbations. Fifty percent to 80% of patients recover spontaneously, mostly with mild cases.
Treatment
Remediation. Speech therapy, relaxation techniques, and breathing exercises have been employed. Other approaches using distraction include teaching the patient to talk in time to rhythmic movements of the arm, hand, or finger, but this only removes stuttering temporarily. Relaxation techniques are based on the premise that the relaxed state and stuttering are incompatible.
Table 26-12 DSM-IV-TR Diagnostic Criteria for Communication Disorder Not Otherwise Specified
This category is for disorders in communication that do not meet criteria for any specific communication disorder, for example, a voice disorder (i.e., an abnormality of vocal pitch, loudness, quality, tone, or resonance).
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association, 2000, with permission.
Psychotherapy. Classic psychoanalysis, insight-oriented psycho- therapy, group therapy, and other psychotherapeutic techniques have not been successful in treating stuttering, but individual psychotherapy can be helpful in cases that include associated poor self-image, anxiety, or depression. Family therapy should be considered if there is evidence of family dysfunction, a family contribution to symptoms, or family stress caused by trying to cope with, or help, the stutter.
Pharmacotherapy. Treatments such as haloperidol (Haldol) have been used in an attempt to increase relaxation; however, there are no data to assess its efficacy. Recent studies have suggested the use of serotonin–dopamine antagonists including olanzapine (Zyprexa) and risperidone (Risperdal) but data is inconclusive.
E. Communication disorder not otherwise specified.
Disorders that do not meet the diagnostic criteria for any specific communication disorder. Examples include voice disorder, in which the patient has an abnormality in pitch, loudness, quality, tone, or resonance; or cluttering disorder, in which the disturbed rate and rhythm of speech impair intelligibility (Table 26-12).
VI. Pervasive Developmental Disorders
A group of disorders characterized by defects in understanding and expressing language and the production of speech. These disorders affect multiple areas of development (e.g., social skills, contact with reality), are manifested early in life, and cause persistent dysfunction. DSM-IV-TR includes five pervasive developmental disorders: autistic disorder, Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified.
A. Autistic disorder.
Autistic disorder is characterized by qualitative deficits in reciprocal social interaction and communication skills and restricted patterns of behavior.
Diagnosis. Among the principle criteria for diagnosing autism are deficits in language development and difficulty using language to communicate. At first glance, patients do not show physical signs of the disorder; however, they do have minor physical abnormalities such as ear malformations. Autistic children do not demonstrate special attention to important people in their lives and have impaired eye contact and attachment behavior to family members and notable deficits in
interacting with peers. One description of the cognitive style of children with autism is that they are unable to make attributions about the motivation or intentions of others; therefore, they cannot develop empathy. Activities and play are often rigid, repetitive, and monotonous. Common behavior problems include hyperkinesis, hypokinesis, aggression, head banging, biting, scratching, hair pulling, and resistance to change in routine. Prodigious cognitive or visuomotor capabilities may occur in a small subgroup (idiot or autistic savants). See Table 26-13.
Table 26-13 DSM-IV-TR Diagnostic Criteria for Autistic Disorder
- A total of six (or more) items from (1), (2), and (3), with at least two from (1) and one each from (2) and (3).
- Qualitative impairment in social interaction, as manifested by at least two of the following:
- marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
- failure to develop peer relationships appropriate to developmental level
- a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by showing, bringing, or pointing out objects of interest)
- lack of social or emotional reciprocity
- marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
- Qualitative impairments in communication as manifested by at least one of the following:
- delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
- in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
- stereotyped and repetitive use of language or idiosyncratic language
- lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
- delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
- Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
- encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
- apparently inflexible adherence to specific, nonfunctional routines or rituals
- stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
- persistent preoccupation with parts of objects
- encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
- Qualitative impairment in social interaction, as manifested by at least two of the following:
- Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic at imaginative play.
- The disturbance is not better accounted for by Rett’s disorder or childhood disintegrative disorder.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association, 2000, with permission.
- A total of six (or more) items from (1), (2), and (3), with at least two from (1) and one each from (2) and (3).
Epidemiology
Occurs in 0.05% of children.Related posts:
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