Explore an overview of behavioral disorders in childhood and adolescents

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Explore an overview of behavioral disorders in childhood and adolescents. If you were a parent without any understanding of behavioral disorders or how to help your child, you can see how overwhelming it can be when a child is diagnosed. Explore online websites that are educational in nature with the content geared toward reaching parents. Provide an assessment on how helpful and effective these websites are.

Be sure to review five websites, and then prepare an assessment of these sites by answering the following questions for your assignment. Your response to each question should include at least four sentences:

• Who is the intended audience of the website?
• Does the person(s) producing the content have credibility to do so? Is the person qualified to write this content?
• Is the information provided supported by research?
• Was the information easy to understand with the wording and language used?
• Were concrete suggestions provided to parents that conveyed support?
• What specific behavioral disorders were addressed on these sites?
• If you were a parent with a child or adolescent behavioral disorder, would this site be helpful?
• Did you find these sites credible?
• Determine which level of progression does the content being evaluated falls under (such as first episode of problem behavior, chronic or recurrent problem behavior).

You are not expected to know if the information is reliable and accurate because this is an exercise where you are being asked to view these websites from a parent’s perspective.

Introduction John W. Barnhill, M.D. The DSM-5 chapter on anxiety disorders brings together a cluster of presentations in which anxiety, fear, and avoidance are prominent. Among the most prevalent psychiatric diagnoses, anxiety disorders can also be among the most difficult to definitively diagnose. One complicating factor is that anxiety, fear, and avoidance are normal and adaptive responses, leading to some inevitable ambiguity in evaluations of people with mild symptoms. Another factor is that anxiety-related emotions can be most prominently experienced as somatic symptoms. Fear—a normal response to a real or perceived imminent threat—is almost always associated with autonomic hyperarousal; such hyperarousal can be difficult for patients to identify or describe, especially if it is chronic. Similarly, anxiety—the emotional experience of fear unaccompanied by a clear threat—may be experienced as muscle tension and vigilance, which can blend imperceptibly into background noise for someone with chronically elevated anxiety levels. A third complication is that anxiety disorders are often comorbid with one another and with mood and personality disorders, which can make it difficult to adequately attend to the manifestations of each diagnosis. Finally, definitions of anxiety disorders are descriptive of phenomena with unknown pathophysiologies, and despite many advances, the field of psychiatry is not yet close to definitively identifying nosological categories based on underlying etiology. One important diagnostic shift involves panic, which is described in two different ways in DSM-5. Panic attacks are now understood to occur as part of a broad spectrum of psychiatric diagnoses and to have significance in regard to severity, course, and morbidity, and they can now be identified as a specifier for all DSM-5 anxiety disorders, as well as for some other DSM-5 disorders. Panic attacks can be subtyped simply as expected or unexpected. When persistent panic attacks induce an ongoing, significant fear of further panic attacks, panic disorder is the likely diagnosis. Historically linked to panic disorder, agoraphobia is identified in DSM-5 as a distinct diagnosis that can develop in the context of a variety of stressors and psychiatric syndromes. As with specific phobia and social anxiety disorder, agoraphobia no longer requires that individuals over age 18 perceive the anxiety as unreasonable. Instead, the clinician can make a judgment as to whether the anxiety is out of proportion to the actual danger or threat. To reduce the likelihood of overdiagnosing transient fears, these disorders must persist for at least 6 months for all individuals rather than just for those under age 18. A significant structural shift within DSM-5 is the movement of separation anxiety disorder into the chapter on anxiety disorders. Separation anxiety disorder still requires an onset before age 18, but the hope is that with a general adult population prevalence of over 6%, it will be more commonly addressed in adults than it has been in the past, when the disorder was listed among disorders of children and adolescents. Another significant structural change among the DSM-5 anxiety-related disorders is the shift of obsessive-compulsive disorder and posttraumatic stress disorder into their own chapters. These new chapters include clusters of disorders in which anxiety plays a prominent role but which also have other features (e.g., obsessions/compulsions or a significant trauma history). The various anxiety-related disorders can often be clearly differentiated, but they can also be difficult to distinguish and can often be comorbid with each other and with most other psychiatric diagnoses. A chief complaint of “anxiety” does not make the diagnosis but is instead the beginning of a clinical thought process that can range throughout DSM-5. Case 5.1 Fears and Worries Loes Jongerden, M.A.Susan Bögels, Ph.D. Logan was a 12-year-old boy who was referred to mental health care for longstanding anxiety about losing his parents and relatively recent fears about getting a severe disease. Although his parents described a long history of anxiety, Logan’s acute problem began 5 weeks prior to the consultation, when he watched a television show about rare and fatal diseases. Afterward, he became scared that he might have a hidden disease. His parents reported three “panic attacks” in the prior month, marked by anxiety, dizziness, sweats, and shortness of breath. About that same time, Logan began to complain of frequent headaches and stomachaches. Logan’s own theory was that his bodily aches were caused by his fears about being ill and about his parents going away, but the pain was still uncomfortable. He insisted he was not scared about having more panic attacks but was petrified about being left sick and alone. These illness fears developed several times a week, usually when Logan was in bed, when he “felt something” in his body, or when he heard about diseases. Logan had begun to suffer from anxieties as a young child. Kindergarten was notable for intense separation difficulties. He was briefly bullied in third grade, which led to his first panic attacks and worsening anxiety. According to his parents, “there always seemed to be a new anxiety.” These included fear of the toilet, the dark, sleeping alone, being alone, and being pestered. Logan’s most persistent fear revolved around his parents’ safety. He was generally fine when both were at work or at home, but when they were in transit, or anywhere else, he was generally afraid that they would die in an accident. When the parents were late from work or when they tried to go out together or on an errand without him, Logan became frantic, calling and texting incessantly. Logan was predominantly concerned about his mother’s safety, and she had gradually reduced her solo activities to a minimum. As she said, it felt like “he would like to follow me into the toilet.” Logan was less demanding toward his father, who said, “When we comfort him all the time or stay at home, he’ll never become independent.” He indicated that he believed his wife had been too soft and overprotective. Logan and his family underwent several months of psychotherapy when Logan was age 10. The father said therapy helped his wife become less overprotective, and Logan’s anxiety seemed to improve. She agreed with this assessment, although she said she was not sure what she was supposed to do when her son was panicking whenever she tried to leave the house or whenever he worried about getting a disease. Logan’s developmental history was otherwise unremarkable. His grades were generally good. His teachers agreed that he was quiet but had several friends and collaborated well with other children. He was quick, however, to negatively interpret the intentions of other children. For example, he tended to be very sensitive to any indication that he was being picked on. Logan’s family history was pertinent for panic disorder, agoraphobia, and social anxiety disorder (social phobia) in the mother. The maternal grandmother was described as “at least as” anxious as Logan’s mother. The father denied psychiatric illness in his family. On examination, Logan was a friendly, articulate boy who was cooperative and goal directed. He was generally in a “good mood” but cried when talking about his fears of dying and getting sick. He denied suicidality and hopelessness but indicated he was desperate to get over his problems before starting high school. His cognition was good. His insight and judgment appeared intact except as related to his anxiety issues. Diagnosis • Separation anxiety disorder with panic attacks Discussion Logan has had separation fears since he was a young child. To qualify for separation anxiety disorder, DSM-5 requires three of eight symptoms. Logan has at least five, including longstanding, excessive, and disturbing fears of anticipated separations; of harm to his parents; of events that could lead to separations; and of being left alone. He also had physical complaints that could be traced to fears of dying and separation. Logan also has panic attacks. He does not meet criteria for a panic disorder, however, because he is not afraid of having an attack. Instead, his panic seems related to fears of separation or getting a disease. Panic attacks would, therefore, be listed as a specifier of separation anxiety disorder. Although Logan is anxious about having an illness, his symptoms do not appear to meet criteria for illness anxiety disorder: the duration of his fear of diseases is not 6 months, he does not visit doctors, and he seeks reassurance not about his health but about being left alone by his attachment figures. His symptoms do not meet criteria for generalized anxiety disorder because his predominant concern is specifically about separation from his parents. He may have met criteria for social anxiety disorder (social phobia) in the past (fear of being pestered), but social fears do not appear to dominate the clinical picture at this point in time. Anxiety disorders have been present in the mother and grandmother, which may indicate a genetic predisposition. Multigenerational anxiety may also be transmitted via learning, modeling, and overprotective parenting. In Logan’s case, the mother is noted to have panic disorder, agoraphobia, and social anxiety disorder, and both parents agree that her own anxieties have influenced her parenting style. In particular, Logan’s fears appear to be rewarded: the parents stay home, rarely leave Logan alone, and respond quickly to all his calls and text messages. They appear to have frequent conversations about his fears but may not spend enough time discussing compensatory strategies. The father does seem to try to encourage Logan’s autonomy, but the parents appear to not agree on the correct overall strategy. Unsupportive coparenting may have contributed to the maintenance of Logan’s problems. One potentially important change in DSM-5 has been the relocation of separation anxiety disorder into the anxiety disorder chapter. In DSM-III and DSM-IV, it was located in the chapter aimed at disorders that begin in infancy, childhood, and adolescence. Separation anxiety disorder can extend into adulthood, however, and Logan’s mother may herself have suffered from adult separation anxiety disorder (as well as from her other anxiety disorders). Her own fears of separation may well be affecting how she is raising her son and be contributing to his ongoing anxiety. Case 5.2 Panic Carlo Faravelli, M.D. Maria Greco was a 23-year-old single woman who was referred for psychiatric evaluation by her cardiologist. In the prior 2 months, she had presented to the emergency room four times for acute complaints of palpitations, shortness of breath, sweats, trembling, and the fear that she was about to die. Each of these events had a rapid onset. The symptoms peaked within minutes, leaving her scared, exhausted, and fully convinced that she had just experienced a heart attack. Medical evaluations done right after these episodes yielded normal physical exam findings, vital signs, lab results, toxicology screens, and electrocardiograms. The patient reported a total of five such attacks in the prior 3 months, with the panic occurring at work, at home, and while driving a car. She had developed a persistent fear of having other attacks, which led her to take many days off work and to avoid exercise, driving, and coffee. Her sleep quality declined, as did her mood. She avoided social relationships. She did not accept the reassurance offered to her by friends and physicians, believing that the medical workups were negative because they were performed after the resolution of the symptoms. She continued to suspect that something was wrong with her heart and that without an accurate diagnosis, she was going to die. When she had a panic attack while asleep in the middle of the night, she finally agreed to see a psychiatrist. Ms. Greco denied a history of previous psychiatric disorders except for a history of anxiety during childhood that had been diagnosed as a “school phobia.” The patient’s mother had committed suicide by overdose 4 years earlier in the context of a recurrent major depression. At the time of the evaluation, the patient was living with her father and two younger siblings. The patient had graduated from high school, was working as a telephone operator, and was not dating anyone. Her family and social histories were otherwise noncontributory. On examination, the patient was an anxious-appearing, cooperative, coherent young woman. She denied depression but did appear worried and was preoccupied with ideas of having heart disease. She denied psychotic symptoms, confusion, and all suicidality. Her cognition was intact, insight was limited, and judgment was fair. Diagnosis • Panic disorder Discussion Ms. Greco has panic attacks, which are abrupt surges of fear and/or discomfort that peak within minutes and are accompanied by physical and/or cognitive symptoms. In DSM-5, panic attacks are seen as a particular kind of fear response and are not found only in anxiety disorders. As such, panic is conceptualized in two ways within DSM-5. The first is as a “panic attack” specifier that can accompany any DSM-5 diagnosis. The second is as a panic disorder when the individual meets the more restrictive criteria for the disorder. Ms. Greco appears to satisfy the multiple criteria required for panic disorder. First, her panic attacks are recurrent, and she more than meets the requirement for four of 13 panic symptoms: palpitations, sweating, trembling, smothering, chest pain, and a persistent fear of dying. The diagnosis also requires that the panic attacks affect the person between episodes. Not only does Ms. Greco constantly worry about having a heart attack (despite medical workups and frequent reassurance), she avoids situations and activities that might trigger another panic attack. These symptoms also have to last at least 1 month (Ms. Greco has been symptomatic for 2 months). The diagnosis of panic disorder also requires an evaluation for the many other causes of panic. These include medications, medical illness, substances of abuse, and other mental disorders. According to the history, this 23-year-old woman takes no medications, has no medical illness, and denies use of substances of abuse. Her physical examinations, electrocardiograms, routine lab results, and toxicology screens are either normal or negative. It might be useful to ask Ms. Greco specifically about herbal and complementary medications, but it appears that her symptoms are psychiatric in origin. Many psychiatric disorders are associated with panic, and Ms. Greco may have been primed for panic attacks by another condition. She reports a childhood history of anxiety and “social phobia,” although those symptoms appear to have remitted. Her mother killed herself 4 years earlier in the context of a recurrent major depression. Details are unknown. Such a traumatic event would undoubtedly have some sort of effect on Ms. Greco. In fact, there would likely be two different traumas: the abrupt effects of the suicide and the more long-standing effects of having a chronically or recurrently depressed mother. Further exploration might focus on the psychosocial events leading up to these panic attacks. For example, Ms. Greco’s “school phobia” may have been a manifestation of undiagnosed separation anxiety disorder, and her recent panic may have developed in the setting of dating, sexual exploration, and/or a move away from her father and younger siblings. She does not present a pattern of panic in response to social anxiety or a specific phobia, but she also denies that her symptoms are psychiatric, and so may not recognize the link between her panic symptoms and another set of symptoms. It might be useful to assess Ms. Greco for anxiety sensitivity, which is the tendency to view anxiety as harmful, and for “negative affectivity,” which is the proneness to experience negative emotions. Both of these personality traits may be associated with the development of panic. Because certain symptom clusters are often not recognized spontaneously by patients as either symptoms or clusters of symptoms, it would be useful to look more specifically for such disorders as posttraumatic stress disorder and obsessive-compulsive disorder. In addition, it might be helpful to explore the sequence of symptoms. For example, the patient’s panic seems to have led to her worries about heart disease. If the illness worries preceded the panic, she might also have an illness anxiety disorder or somatic symptom disorder. Frequently comorbid with panic are depressive and bipolar disorders. Ms. Greco does have depressive symptoms, including insomnia and a preoccupation with death, but otherwise her symptoms do not appear to meet criteria for a depression diagnosis. Her symptoms would, however, need to be observed longitudinally. Not only does her mother’s history of depression increase her risk for depression, but she may not be especially insightful into her own emotional states. It would also be useful to specifically look for symptoms of bipolar disorder. Mania and hypomania are often forgotten by patients or are not perceived as problematic, and a missed diagnosis could lead to inappropriate treatment and an exacerbation of bipolar symptoms. Furthermore, the development of panic appears to increase the risk of suicide. Although more should be explored, Ms. Greco does appear to have a panic disorder. DSM-5 suggests the assessment of whether the panic is expected or unexpected. It appears that Ms. Greco’s initial panic attacks occurred in situations that might have been seen as stressful, such as while driving and at work, and so may or may not have been expected. Her last episode happened while she was asleep, however, so her panic attacks would be classified as unexpected. DSM-5 has delinked agoraphobia from panic disorder. They can be comorbid, but agoraphobia is now recognized as developing in a variety of situations. In Ms. Greco’s case, her active avoidance of driving, exercise, and caffeine is better conceptualized as a behavioral complication of panic disorder rather than a symptom of agoraphobia. Accurate diagnosis and treatment are important to prevent her symptoms from becoming more severe and chronic. Case 5.3 Adolescent Shyness Barbara L. Milrod, M.D. Nadine was a 15-year-old girl whose mother brought her for a psychiatric evaluation to help with her long-standing shyness. Although Nadine was initially reluctant to say much about herself, she said she felt constantly tense. She added that the anxiety had been “really bad” for several years and was often accompanied by episodes of dizziness and crying. She was generally unable to speak in any situation outside of her home or school classes. She refused to leave her house alone for fear of being forced to interact with someone. She was especially anxious around other teenagers, but she had also become “too nervous” to speak to adult neighbors she had known for years. She said it felt impossible to walk into a restaurant and order from “a stranger at the counter” for fear of being humiliated. She also felt constantly on her guard, needing to avoid the possibility of getting attacked, a strategy that really only worked when she was alone in her home. Nadine tried to conceal her crippling anxiety from her parents, typically telling them that she “just didn’t feel like” going out. Feeling trapped and incompetent, Nadine said she contemplated suicide “all the time.” Nadine had always been “shy” and had been teased at recess since she started kindergarten.