Posts Tagged ‘
conduct disorder ’
Friday, May 31st, 2013
The big theme this month was DSM-5. It’s here, we’re reacting – and parents will be dealing with the implications of this diagnostic system for quite some time.
So …. here’s a recap of what was covered this month:
General Issues: Changes Made, Controversies Raised, And What To Expect
An Overview For Parents
The “Saving Normal” Debate
Specific Disorders: What You Need To Know
Autism Spectrum Disorder
Disruptive Mood Dysregulation Disorder
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Wednesday, May 29th, 2013
DSM-5 has raised lots of controversies by making changes to the way some psychiatric disorders are defined. But less controversial is flagging the importance of callous-unemotional traits in childhood as part of the diagnostic approach to Conduct Disorder.
Conduct Disorder refers to a pattern of behavior that consistently violates the rights of others. As kids reach later childhood and their early teens, the types of behaviors include what we would think about as things that would get kids in trouble: destroying property, breaking and entering, fighting, lying, stealing. While some kids may do some of these things now and then, what’s important clinically is when a lot of these behaviors cluster together and occur with some frequency.
There can be many reasons why kids behave this way. It’s clear that kids exhibiting signs of Conduct Disorder require some type of intervention. It’s a pattern of behavior which can be associated with a lot of bad outcomes – dropping out of school, eventual substance abuse, and even jail.
So why are callous-emotional traits relevant, and flagged in DSM-5? The risk for these outcomes may be especially high if a child is showing callous-unemotional traits – such as a lack of empathy, a lack of remorse, and shallow emotions. When tracked over time, youth with these traits are especially likely to show a stable pattern of antisocial behavior over time – from childhood through adulthood. Their actions may be (or become) especially aggressive and violent.
Treating kids with callous-unemotional traits is complicated. A number of behavioral strategies may be considered, as well as some forms of drug treatment (especially if they have symptoms of other disorders, such as ADHD or depression).
DSM-5 has certainly be criticized. There are many hot-button topics raised in the revision. But the inclusion of callous-unemotional traits is an example of how research findings can lead to diagnostic changes that are simply there to signal which kids may be at especially high risk for a number of bad long-term outcomes and hence require some immediate form of intervention. That’s solid information for a clinician to weigh during the evaluation process.
Doctor with checklist via Shutterstock.com
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Tuesday, May 21st, 2013
As a parent, you may be wondering why such a fuss is being made about the release of the DSM-5 (the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association). Here is a brief overview of why it may be (0r become) relevant to you – and why it’s important to learn about the issues that are being debated.
Many Kids Will Experience A Mental Disorder
The primary reason parents need to know about DSM-5 is that many psychiatric disorders that originate in childhood are not uncommon. Consider some rough numbers:
- Around 1 in 50 kids are being diagnosed with Autism Spectrum Disorder
- Around 1 in 10 kids are being diagnosed with Attention Deficit Hyperactivity Disorder
- Around 1 in 10 kids are being diagnosed with Conduct Disorder
- Around 1 in 10 kids are being diagnosed with an Anxiety Disorder
- Around 1 in 10 kids are being diagnosed with a Mood Disorder
- Around 1 in 2 teens have reported meeting diagnostic criteria for at least 1 disorder in their lifetime
Having a good look at these numbers means that lots of parents will be faced at some point in time with the possibility of having their child evaluated for a disorder – and will need to consider treatment options. That’s where the DSM-5 comes in.
DSM-5 Is The Primary Guide For Clinical Diagnosis
The DSM-5 is the handbook used by a broad range of health care professionals who evaluate individuals (youth and adults) for potential psychiatric disorders. It’s an authoritative guide that reflects a consensus statement on the best way to categorize disorders along with the specific symptoms and rules to be used to make a diagnosis. The intention is to make it reflect current clinical thinking that is supported by research. It is not perfect, it reflects a particular point of view by those charged with generating the guidelines, and there is much debate (and criticism) of the diagnostic approach taken by the DSM-5.
All that said, the fact remains that the DSM-5 will be used if you bring your child to a health care professional for evaluation. The clinician will consider lots of information during this process – the DSM-5 does not dictate what information they use and how they get it. It’s intended to serve as a guide to the endpoint of making (or not making) a diagnosis. And it serves as the template for a health care provider to request reimbursement from insurance companies to support treatment.
Why All The Controversy Now?
The DSM-5 is a revision of the prior version which was released in 2000. As such, it includes a number of changes – some of which are minor, some of which are major. Beyond the more general discussions about what’s “normal” and what isn’t, the key things that parents need to know are the practical implications of the changes. As a parent, you should be aware of the changes to disorders that are especially relevant for youth. Here’s a brief overview:
Autism Spectrum Disorder: Major changes have occurred. In the prior version, a spectrum of disorders were available to clinicians, reflecting important variations in symptom profile. Four disorders were listed: Autistic Disorder, Asperger’s Disorder, Childhood Disintegration Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. The key change is that there is now just one diagnosis made of Autism Spectrum Disorder (ASD) – and the other diagnostic categories will no longer be used. Proponents of this change suggest that it is more accurate by defining the core features of ASD that were common to all of the disorders in the spectrum and allowing for differences in severity level under one diagnostic umbrella. Critics suggest that a number of youth who require diagnosis and treatment will not be diagnosed – and that the reliance on severity levels may make it harder for kids with more mild symptoms to receive treatments they need. There’s no answer to these issues yet – they will unfold over time as data are collected. But if your child is evaluated for ASD, it’s in your best interests to be up on the debates and have informed discussions with your clinician in order to make sure you are advocating for the best care for your child.
Attention Deficit Hyperactivity Disorder (ADHD): Minor changes have occurred. In the past, there had to be evidence that a child showed symptoms of ADHD before age 7. That has been extended to age 12 in the DSM-5. There is also more attention to making diagnoses in adults more manageable. All of these changes mean that if you have an older child who has never been diagnosed with ADHD, they might now be evaluated differently. It’s also important to know what isn’t in the DSM-5 – a lower limit on age. That is, there are no guidelines in terms of how young a child may be when making a diagnosis. This is relevant as there have been (controversial) suggestions that kids as young as 4 years of age could be diagnosed (and many in fact have). Know that DSM-5 does not offer guidance here and you will need to make up your own mind if this makes sense for your child – hopefully with the appropriate guidance of a well-trained clinician. Overall, the worry here is that kids of all ages may be overdiagnosed.
Conduct Disorder (CD): Minor changes have occurred. Conduct disorder represents a persistent pattern of rule breaking behavior and behavior that violates the rights of others. It can be diagnosed in young children as well as teens. The primary change has been to incorporate symptoms indicating a callous and unemotional interpersonal style. The thinking here is kids with this profile may be especially prone to experience problems in the future – and require more intensive management and treatment. Be aware that these symptoms will receive more attention now in the diagnostic process.
Disruptive Mood Dysregulation Disorder (DMDD): This diagnosis reflects a major change – it is a new diagnostic category. The idea was to provide a diagnostic option for kids who show persistent irritability and extreme emotional and behavioral outbursts. The rationale for developing the DMDD criteria was to make sure kids who show these symptoms do not get mislabeled as having pediatric bipolar disorder – but still may qualify for treatment. The controversy is that many feel that there is not sufficient evidence to support this new diagnosis – and in the worst case scenario kids who do not have psychiatric problems will be diagnosed with a disorder and get treatment that they don’t need.
Over the next few days, I will publish blog posts that consider each of these four disorders in greater detail, and provide some guidance for parents to help sort through these complex issues. There are no straightforward answers to be found – rather parents need to know about DSM-5 so they can be prepared to navigate the best decisions for their child.
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Wednesday, February 27th, 2013
Following a stimulating Intelligence Squared debate, we’ve been discussing genetic engineering (think of it as directly changing DNA) here at Parents.com – both in terms of using it to create a “Super Baby” and to prevent disease. As a follow-up, let’s consider the likelihood of genetic engineering being a factor in the future for a number of childhood psychiatric disorders – or more to the point, the challenges that lay ahead.
Autism Spectrum Disorder (ASD)
There would be hope that genetic engineering would be feasible in the future, as ASD is believed to be highly genetic in origin. However, the genetic basis for ASD is not clear. In fact, there may be a range of genetic etiologies. For example, some cases may be due to a rare genetic mutation – but there could be a number of mutations that can lead to ASD (not just one identified disease gene) making the idea of genetic engineering more challenging. The majority of ASD cases may reflect a complex mix of genetic and environmental influences – and the latest statistical modeling suggests that the genetic contribution to ASD may not be as strong as previously thought (and that the role of the environment may be more pronounced). For those situations, the idea of using genetic engineering is even more murky, because there may be many genes involved and they probably interact with a variety of environmental factors. All of this is not to say that genetics won’t lead to possible biological therapeutics – rather it’s to point out that the lure of genetic engineering as a solution may not be the avenue that will be pursued.
The best evidence to date suggests that ADHD is due to a mix of genetic factors along with the influence of a number of environmental factors. As discussed above, this makes the pure application of genetic engineering difficult to imagine. There may a large number of genes involved, each of which may only have a small effect on the likelihood of developing ADHD – which, simply put, would make it very difficult to know what genes to target. Again, it’s tough to predict where genetic research will go, but while it may certainly lead to improved treatments over time for ADHD, it’s tough to see the role of genetic engineering.
You’re starting to see a pattern here. Like ADHD, depression is also thought to be influenced by many genes as well as the environment. As discussed above, this constellation of risk factors does not suggest that genetic engineering will be a factor any time soon.
Conduct Disorder (CD)
This is the same deal as the case for ADHD and depression – and it may be that the environment plays an even stronger role in the etiology of CD.
The idea of genetic engineering is provocative. But the reality may be far in the future for most childhood psychiatric disorders – and in many cases it may not be the way in which genetic research gets translated into prevention and intervention.
Molecular Biology Test via Shutterstock.com
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