1.

Introduction to Psychopathology
Normal development, common problems during the normal development phase, Etiology/Risk factors
of psychopathology
2. Classification of psychiatric disorders
Classification of psychiatric disorders in children and adolescents(ICD-10 & DSM-V), epidemiology,
3. Psychopathology of Childhood Disorders: Clinical Picture, assessment and intervention
Mental Retardation, Specific Learning Disorders (Reading disorder, Spelling Disorder, disorder of
written expression, Arithmetical Disorder), Pervasive Developmental Disorders (Autism, Asperger’s
Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, PDD NOS), Specific Speech &
Language Disorders
4. Externalizing Disorders
Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorders (ODD), Conduct
Disorder (CD), Alcohol and Substance Use Disorders, Juvenile Delinquency
5. Internalizing Disorders
Anxiety Disorder (Separation Anxiety Disorder, Social Phobia, Selective Mutism, Obsessive
Compulsive Disorders) Depressive Disorders, Suicide and Injurious Behavior
6. Other psychological disorders
Bipolar Affective Disorder, Psychotic Disorders, Eating Disorders, Bowel & Bladder Control
Disorders, Sleep and Movement Disorders, Obesity, Selective Mutism, Tourette’s & Tic Disorder,

1. Disorder in Children and Adolescents

https://www.msdmanuals.com/professional/pediatrics/psychiatric-disorders-in-children-and-
adolescents/social-anxiety-disorder-in-children-and-adolescents#Symptoms-and-Signs_v29591766

2. International Statistical Classification of Diseases and Related Health Problems (ICD)

https://www.who.int/standards/classifications/classification-of-diseases
 1. Introduction to Psychopathology
Normal development, common problems during the normal development phase, Etiology/Risk
factors of psychopathology

Three major models used to understand psychopathology are the biological, psychological, and
sociocultural models. Each model offers a different perspective on the causes and treatment of mental
disorders, but a biopsychosocial approach is often considered the most comprehensive.
1. Biological Model: This model emphasizes the role of biological factors, including genetics, brain
chemistry, and the nervous system, in the development of psychopathology. It often suggests that
mental disorders can be treated with medication, electroconvulsive therapy, or other biological
interventions.
2. Psychological Model: This model focuses on psychological factors, such as learning, personality,
stress, and cognition, as contributors to psychopathology. It includes perspectives like
psychodynamic, behavioral, and cognitive-behavioral approaches, which emphasize the importance of
early life experiences, unconscious processes, and maladaptive thoughts and behaviors.
3. Sociocultural Model: This model highlights the influence of social, cultural, and environmental
factors, such as gender, race, ethnicity, and social support, in the development and expression of
psychopathology. It recognizes that individual behaviors and experiences are shaped by the broader
social context in which they occur.

Introduction
The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to
understand a person's medical condition it is not simply the biological factors to consider, but also the
psychological and social factors [1].
  Bio (physiological pathology)
 Psycho (thoughts emotions and behaviours such as psychological distress, fear/avoidance
beliefs, current coping methods and attribution)
 Social (socio-economical, socio-environmental, and cultural factors suchs as work issues,
family circumstances and benefits/economics)
This model is commonly used in chronic pain with the view that the pain is a psychophysiological
behaviour pattern that cannot be categorised into biological, psychological, or social factors alone.
There are suggestions that physiotherapy should integrate psychological treatment to address all
components comprising the experience of chronic pain.

The diagram below shows an example of this model.

Diagram of the Biopsychosocial model.

Physiotherapists must know how biopsychosocial factors interact in patients with chronic pain to
explain the perpetuation of this condition and use it as a basis for planning the intervention program.
The evidence has suggested a clinical biopsychosocial assessment for the physiotherapeutic
management of patients with chronic pain in order to understand and explain the predominant
mechanism of pain and psychosocial factors that may or may not be modified for the patient to
improve their condition.[4]
This clinical evaluation is carried out during the data collection at the patient's entrance. A practical
guide is proposed to take biopsychosocial data using the PSCEBSM (Pain–Somatic and medical
factors–Cognitive factors–Emotional factors–Behavioral factors–Social factors–Motivation) model.
P- Type of pain
Clinical identification and differentiation of the dominant pain mechanism:
 nociceptive pain
 neuropathic pain
 non-neuropathic pain of central sensitization.
Using the following tools:
1. Classification criteria for differentiating predominant pain proposed by Nijs et al.
2. Widespread pain index/Body Diagram : ≥ 7 score suggesting generalized pain, therefore, non-
neuropathic pain of central sensitization
3. Central Sensitization Inventory (CSI) : 40 score suggesting non-neuropathic pain of central
sensitization
S- Somatic and medical factors
For physical therapist the physical examination is a very important part of his intervention - essential
to:
 Be aware that some findings of clinical examinations such as
mobility, strength, neurodynamics, coordination, etc. could be altered because there is greater
sensitivity to mechanical stimulation and modified movement patterns in patients with non-
neuropathic pain of central sensitization.
 Main goal in this stage is to evaluate the quality of movement, if the pattern of movement
causes the pain to persist and if there is kinesiofobia
 Ask about current or previous health conditions, the disuse of body parts, changes in
movement patterns, exercise capacity, strength and muscle tone during movement, the action
of the drug in the CNS It is useful for data collection
C- Cognition / Perceptions
Both influence biologically on hypersensitivity in the brain by activating neuromatrix pain and also
influence the emotional and behavioral factors. :
1. Ask about perceptions: expectations of the intervention, expectations of the prognosis of their
pain, understanding of their situation and the strategies they have available to face their
situation, what the pain represents emotionally
2. Brief Illness Perception Questionnaire (Brief IPQ)
3. Pain Catastrophizing Scale (PCS)
E- Emotional factors
Ask if there is fear of specific movements, avoidance behaviors, psychological traumatic appearance
of pain, psychological problems at work, family, finances, society, etc. It is also suggested to use the
following scales:
1. State-Trait Anxiety Inventory (STAI)
2. Tampa-Scale of Kinesiophobia (TSK) and Fear Avoidence Belief Questionare
3. Injustice Experience Questionnaire (IEQ)
 4. Patient Health Questionnaire-2 (PHQ-2), or Patient Health Questionnaire-9 (PHQ-9), or
Center of Epidemiologic Studies Depression Scale (CES-D)
B- Behavioral factors
Can lead to avoid activity or movement due to fear, which in turn is presented as physical inactivity or
disuse and, finally, disability. Therefore it is important to evaluate the behavior and adaptations that
the patient has made due to the pain.
S- Social factors
It refers to the social and environmental factors in which the patient develops, which could be useful
and supportive or harmful and stressful for the improvement of the patient's health condition. The data
collection can be divided as follows:
1. Housing or living situation
2. Social environment
3. Work
4. Relationship with the partner
5. Previous interventions
M- Motivation
Evaluating the motivation in the patient and his willingness to change is useful to modify his thoughts
regarding the relationship pain-kinesiophobia, pain-disability, and acceptance-catastrophism. For this
purpose, the following scale can be used:
1. Psychology Inflexibility in Pain Scale (PIPS)
o PIPS "evaluates components of psychological inflexibility (avoidance and fusion)" [5]

Clinical Contribution
 The use of the biopsychosocial model as a clinical practice guide in physiotherapy allows the
physiotherapist to be aware of all the factors that influence the patient's state of health. In
addition, it allows laying the foundations of pain neuroscience education
 The psychosocial factors the patient deals with can mean the intervention of other health
professionals besides the physiotherapist ie important to take into account the professional
limits, as well as the ethical principles that ensure the comprehensive management of the
patient.
The following videos emphasise the importance of using the biopsychosocial model to improve
patient functionality and the problem that currently exists for physiotherapists in the use of this
approach

Criticisms of the model

 There is still minimal use of the biopsychosocial model in education, clinical care, and
research. The biopsychosocial model cannot be consistently defined for an individual (data is
not obtained systematically, making it untestable and non-scientific).
  Patient centered interview methods have been suggested to be used in practice, such that
clinicians can identify a scientific BPS model specific to each patient with an agreed-upon,
evidence-based patient-centered interviewing method can be more useful as these are
reproducible and can elicit relevant patient information

Biopsychosocial model vs. Biomedical model

Refer the link below for more detail
https://www.acsu.buffalo.edu/~dgthomas/Abpsy/lecture16.html

The biopsychosocial and biomedical models offer distinct perspectives on understanding and
addressing health and illness.

Biomedical model
The biomedical model, which was historically prevalent, takes a reductionist approach by
focusing on biological factors and treating diseases through medical interventions. It sees
diseases as isolated physical abnormalities.

While this approach was once deemed sufficient, research within psychology and the social
sciences cast doubt on its effectiveness.

Biopsychosocial model
The biopsychosocial model adopts a holistic viewpoint, acknowledging the complex interplay
of biological, psychological, and social factors in shaping health and illness. It sees diseases
as outcomes of dynamic interactions among various dimensions. The model emphasizes the
interconnectedness of these dimensions, recognizing their mutual influence on an individual's
health.

The BPSM has been extended to consider additional holistic elements influencing the
perceived necessity for healthcare and the focus on health-related matters: Information,
Beliefs, and Conduct. Based on the model's dependence on perception, it has been considered
imperative to actively engage the individuals or communities whose requirements are being
addressed, regardless of whether the focus is on their health, education, employment,
housing, or any other needs. A key term in the biopsychosocial model is "syndemic" which
refers to a set of health problem factors that interact synergistically with each other ranging
from socioeconomic status to genetics.

Etiology / AND RISK FACTORS OF PSYCHOPATHOLOGY

Rothman, an American epidemiologist (1976, p. 588) defined a cause as “an event, condition or
characteristic without which the disease would not have occurred”. A risk factor can also be a cause
but all risk factors are not causes. A risk factor is the one that increases the chance of having a
particular condition. Let’s understand this with an example. Ishaan’s dietary habits are not good as it
includes sugary, fried and fatty foods; for the sake of simplicity, we will call it unhealthy diet and he is
also overweight. Arjun has the same diet (unhealthy diet) but he is not overweight as he compensates
for his calorie intake with his active lifestyle. Kabir has a healthy diet. His calorie intake is typical for
someone of his age group but he is also overweight. Kabir suffers from hypothyroidism which results
in slower metabolism that burns fewer calories. Here, we can clearly see that unhealthy diet is not
necessarily a reason behind being overweight. According to Rothman’s definition of a cause (as
mentioned above), we have to be sure that the condition wouldn’t have happened without this specific
factor. So, in Ishaan’s case we can say that his unhealthy diet led to him being overweight. However,
if we talk about the general condition, it might not be so clear. Unhealthy diet definitely increases the
chance of being overweight but if we look at it carefully we can see that what’s causing weight gain is
the difference between calories intake and calories burned. Since an unhealthy diet may increase the
calorie intake, it eventually may increase the chance of gaining too much weight. Thus, the term that
should be used here is “risk factor”.

Various terms can be used to specify the role a particular factor may play as an etiological or causal
factor in abnormal behaviour displayed by an individual. Some of these are described here.
 Necessary cause can be understood as a condition that must exist for a disorder to occur. For
instance, general paresis (a degenerative brain disorder) cannot develop unless a person has
contracted syphilis previously. Many mental disorders do not appear to have a necessary
cause.
 Sufficient cause is a condition that guarantees the occurrence of a disorder. For example,
hopelessness is understood to be a sufficient cause of depression or the fact that if
hopelessness occurs then depression will also occur. However, it is important to note here that
a sufficient cause may not be a necessary cause. So, we can say that hopelessness is not a
necessary cause of depression; there are other causes or causal factors as well that lead to
depression.
 Contributory causes are the ones that increase the probability of the occurrence of a disorder
but they are neither necessary nor sufficient for the disorder to occur. For example, parental
rejection may increase the probability of a child having difficulty in dealing with close
intimate relationships later in life. Here, parental rejection is a contributory cause for
difficulties that the individual may develop later in life, but it is neither necessary nor
sufficient.
Another important consideration while understanding the causes is the time frame in which they
operate.
 There are distal causal factors which occur relatively early in life but manifest their effects
after many years. For instance, if we take the above given example only, parental rejection or
loss of a parent early in life may become a distal contributory cause predisposing an
individual to depression later in life.
 There are proximal causal factors which operate shortly before the occurrence of symptoms
of a particular disorder. For example, an event or a condition may prove too much for
someone, triggering the onset of a disorder; divorce could lead to depression.
 A reinforcing contributory cause is the one that maintains the already occurring
maladaptive behaviour. For instance, some secondary gain like sympathy, relief from
unwanted responsibility due to illness could be some of the examples. Another interesting
example here could be that when a person has depression, their behaviour alienates them from
friends and family, which further enhances their sense of rejection reinforcing the existing
depression (Joiner & Timmons, 2009).
For most forms of psychopathology, we do not have an answer as to what is a necessary or a sufficient
cause behind them, but we do have a sound understanding of various contributory causes. We have a
fair understanding of proximal, distal and reinforcing causal factors as well but the picture is further
complicated by the fact that what is a proximal cause at one stage may also serve as a distal
contributory cause, predisposing the individual to a disorder in later life. For example, loss of a parent
can be a proximal cause for grief reaction of a child but may also serve as a distal contributory cause
for later if the child develops depression as an adult.
Another useful categorization is grouping them into predisposing, precipitating, and perpetuating
factors.
 Predisposing factors are those that determine the vulnerability to other causes that are
present at the time of illness; something that puts the individual at risk of developing an
illness or a problem, for instance, genetic endowment, some birth trauma, psychological
factors during infancy or childhood.
 Precipitating factors are the ones that occur shortly before the onset of a disorder, so they
trigger the onset of a problem. These can be physical (brain injury caused by accident) or
psychological (loss of a loved one) in nature, or even a combination of the two.
 Perpetuating factors are the ones that maintain a disorder once it occurs. Understanding of
perpetuating factors plays an important role while deciding a line of treatment for the
individual.
 Unit 2
Classification of psychiatric disorders
Classification of psychiatric disorders in children and adolescents(ICD-10 & DSM-V),
epidemiology

Classification of psychiatric disorders in

children and adolescents(ICD-10 & DSM-V)
Epidemiology
Epidemiology
Epidemiology is the study of the distribution and determinants of health-related states or
events in specified populations, and the application of this study to the control of health
problems
Epidemiology is the branch of medical science that investigates all the factors that determine
the presence or absence of diseases and disorders. Epidemiological research helps us to
understand how many people have a disease or disorder, if those numbers are changing, and
how the disorder affects our society and our economy. Epidemiology is often described as the
basic science of public health.

Psychiatric epidemiology is a field which studies the causes (etiology) of mental disorders
in society, as well as conceptualization and prevalence of mental illness. It is a subfield of the
more general epidemiology. It has roots in sociological studies of the early 20th century
In the context of the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition, Text Revision), epidemiology refers to the study of the distribution and determinants of
mental disorders in populations. It focuses on understanding the prevalence, incidence, risk factors,
and causes of mental disorders in specific groups of people. Essentially, it's about understanding how
and why mental disorders occur, who is affected, and how common they are.
Key Aspects of Epidemiology in DSM-5-TR:
 Prevalence:
The proportion of a population that has a specific mental disorder at a given time.
 Incidence:
The rate at which new cases of a mental disorder occur in a population over a specific period.
 Risk Factors:
Sociodemographic, psychological, and biological factors that increase the likelihood of developing a
mental disorder.
 Causes:
Understanding the underlying causes, including genetic, environmental, and behavioral factors, that
contribute to the development and maintenance of mental disorders.
 Comorbidity:
The occurrence of multiple mental disorders in the same individual.
 Treatment and Prevention:
Using epidemiological findings to inform the development and implementation of effective
prevention programs and treatments for mental disorders.
In epidemiology, incidence refers to the rate of new cases of a disease or condition occurring in a
population over a specific time period, while prevalence refers to the proportion of individuals in a
population who have a particular disease or condition at a specific point in time or over a specific
period.
Incidence:
 Measures the risk of developing a new case of a disease.
 Calculated by dividing the number of new cases by the total population at risk over a specific
time period.
 Helps assess the rate at which new cases are appearing in a population.
Prevalence:
 Reflects the total number of existing cases of a disease, both new and old, in a population at a
specific point in time.
 Can be expressed as a percentage or as the number of cases per a certain population size (e.g.,
per 1,000 people).
 Helps assess the burden of disease within a population.
Relationship between incidence and prevalence:
 Prevalence is influenced by both incidence and the duration of the disease.
 A higher incidence (more new cases) will tend to increase prevalence, as more people are
diagnosed with the condition.
 A longer duration of the disease (people live longer with the condition) will also tend to
increase prevalence.
 Conversely, a lower incidence or shorter disease duration will tend to decrease prevalence.

Prevalence
Prevalence looks at existing cases, while incidence looks at new cases.
In a population of 10,000 people, 500 persons are reported to be affected by a certain disease. So what
is the prevalence of this disease in this population?
The mathematical way to calculate this would be:

This formula will provide us with the information as a percentage. By dividing 500 by 10,000 and
multiplying the result by 100 (to make it a percentage), we find out that 5% of the population is
affected. So the prevalence of the disease in our population is 5%.
Rather than expressing prevalence as a percentage, we can also describe it as the number of people
affected in a standard sized population, for example 1,000 people. So instead we would calculate:

This means that for every 1,000 patients, 50 of them have the disease.
Prevalence is like describing a group photo:
 How many people can you see there? That number is your population.
 How many people share a certain feature (e.g. same hair colour)? This number is used to
calculate prevalence.
In epidemiology, we actually have three different ways to calculate the prevalence:
 Point prevalence: The number of cases of a health event at a certain time. For example, in a
survey you would be asked if you are currently smoking.
 Period prevalence: The number of cases of a health event in reference to a time period, often
12 months. For example, in a survey you would be asked if you have smoked during the past
12 months.
 Lifetime prevalence: The number of cases of the health event in reference to the total
lifetime. For example, in a survey, you would be asked if you have ever smoked.
Incidence
HIV is nowadays a treatable infection with a normal life expectancy. This means that with stable
numbers of new cases, prevalence numbers will increase. Looking at the new cases (incidence)
provides a deeper understanding of what is going on.

In a population of 1,000 non-diseased persons, 28 were infected with HIV over two years of
observation. The incidence proportion is 28 cases per 1,000 persons, i.e. 2.8% over a two year period
or 14 cases per 1,000 person-years (incidence rate), because the incidence proportion (28 per 1,000) is
divided by the number of years
Unit 3
Psychopathology of Childhood Disorders: Clinical
Picture, assessment and intervention
Mental Retardation
Introduction
Intellectual disability is a condition that limits intelligence and disrupts abilities necessary for living
independently. Signs of this lifelong condition appear during childhood. Most people with this will
need some degree of assistance throughout their lives.
Support programs and educational offerings can help with managing symptoms and effects.
What is intellectual disability?
An intellectual disability is when limitations in your mental abilities affect intelligence, learning, and
everyday life skills. The effects of this can vary widely. Some people may experience minor effects
but still live independent lives. Others may have severe effects and need lifelong assistance and
support.
A common misconception is that intellectual disability is just a limitation on intelligence as assessed
by a simple IQ test. An IQ test is only one piece of information. Some people have an average or
above-average IQ but have trouble with other abilities necessary for everyday life.
Other people have lower-than-average IQs but also have skills and abilities that are strong enough that
they don’t meet the criteria for intellectual disability, or they meet criteria for a milder form of
intellectual disability than an IQ test indicates.
In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders,
fifth edition text revision (DSM-5-TR), the formal name for this condition is “intellectual
developmental disorder.” Although for many individuals, the exact cause of their intellectual disability
is unknown, many cases of intellectual disability happen because of differences in brain development.
Less commonly, they can develop because of brain damage from an illness, injury or other events
when a person is younger than 18 years old.
How common is intellectual disability?
Intellectual disability is uncommon but widespread. Worldwide, it affects 1% to 3% of children. It’s
slightly more common in men than in women.

DSM V TR

Diagnostic Criteria
Intellectual developmental disorder (intellectual disability) is a disorder with onset during the
developmental period that includes both intellectual and adaptive functioning deficits in conceptual,
social, and practical domains. The following three criteria must be met:
A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking,
judgment, academic learning, and learning from experience, confirmed by both clinical assessment
and individualized, standardized intelligence testing.
B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural
standards for personal independence and social responsibility. Without ongoing support, the adaptive
deficits limit functioning in one or more activities of daily life, such as communication, social
participation, and independent living, across multiple environments, such as home, school, work, and
community.
C. Onset of intellectual and adaptive deficits during the developmental period.
Note: The term intellectual developmental disorder is used to clarify its relationship with the WHO
ICD-11 classification system, which uses the term Disorders of Intellectual Development. The
equivalent term intellectual disability is placed in parentheses for continued use. The medical and
research literature use both terms, while intellectual disability is the term in common use by
educational and other professions, advocacy groups, and the lay public. In the United States, Public
Law 111-256 (Rosa’s Law) changed all references to “mental retardation” in federal laws to
“intellectual disability.”
Specify current severity (see Table 1):
F70 Mild
F71 Moderate
F72 Severe
F73 Profound
The diagnosis of intellectual developmental disorder is based on both clinical assessment and
standardized testing of intellectual functions, standardized neuropsychological tests, and
standardized tests of adaptive functioning.
Global Developmental Delay
F88
This diagnosis is reserved for individuals under the age of 5 years when the clinical severity level
cannot be reliably assessed during early childhood. This category is diagnosed when an individual
fails to meet expected developmental milestones in several areas of intellectual functioning and
applies to individuals who are unable to undergo systematic assessments of intellectual functioning,
including children who are too young to participate in standardized testing. This category requires
reassessment after a period of time.
ICD 10 criteria
What are the symptoms of intellectual disability?
The symptoms of intellectual disability revolve around difficulties in different skill sets, including
academic skills, social skills and domestic skills.
Intellectual disability affects:
Intelligence-related symptoms
“Intelligence” is the umbrella term for your ability to understand and interact with the world around
you. It goes beyond the traditional language and math skills an IQ test measures. Intelligence-related
symptoms of intellectual disability can mean you have any of the following:
 Delayed or slowed learning of any kind (such as in school or from real-life experiences).
 Slowed reading speed.
 Difficulties with reasoning and logic.
 Problems with judgment and critical thinking.
 Trouble using problem-solving and planning abilities.
 Distractibility and difficulty focusing.
Adaptive behaviours
Adaptive behaviours revolve around abilities and learned skills you need to live and support yourself
independently. Symptoms of adaptive behaviour-related limitations can mean you have any of the
following:
 Slower learning of toilet training and self-care activities (bathing, dressing, etc.).
 Slower social development.
 Little or no fear or apprehension of new people (lack of “stranger danger” behaviours).
 Needing help from parental figures or other caregivers with basic daily activities (bathing,
using the bathroom, etc.) past the expected age.
 Difficulty learning how to do chores or other common tasks.
 Trouble understanding concepts like time management or money.
 Needing help managing healthcare appointments or medications.
 Trouble understanding social boundaries.
 Difficulty with or limited understanding of social interactions, including friendships and
romantic relationships.
What causes intellectual disability?
Intellectual disabilities can happen for many reasons. Experts also suspect that in many cases, there
are multiple causes and contributing factors. Causes and contributing factors can influence the
development of intellectual disability before or during birth or during the earliest years of childhood.
Prebirth causes or contributing factors include, but aren’t limited to, the following:
 Genetics and inheritance. Many conditions that cause intellectual disability happen because
of genetic mutations. Some of these mutations can be passed from generation to generation.
Examples include Down syndrome, Fragile X syndrome or Prader-Willi syndrome.
 Infections. Some infections — like toxoplasmosis and rubella — can disrupt fetal
development, resulting in conditions that can cause intellectual disability, such as cerebral
palsy.
 Teratogens. These are substances that can disrupt fetal development. Examples include
alcohol, tobacco, certain medications, radiation exposure and more.
 Medical conditions. Having certain medical conditions while pregnant can cause
developmental differences in a fetus. Those can later result in intellectual disability. Examples
include hormonal conditions like hypothyroidism.
Causes that can happen during birth include:
 Lack of oxygen (hypoxia).
 Premature birth.
 Other types of brain injury during birth.
Causes that can happen during early childhood include:
 Injuries or accidents. These can cause intellectual disability if they result in brain damage.
 Toxic exposures. Heavy metals like lead and mercury can damage your brain and cause
intellectual disability.
 Infections. Common infections that spread to your nervous system, such
as measles or meningitis, can cause intellectual disability.
 Tumors or growths in the brain. This includes cancers and benign (noncancerous) growths.
 Medical conditions. Seizures and various types of epilepsy, such as Lennox-Gastaut
syndrome, can cause brain damage. That can cause intellectual disability.

What conditions can cause or happen along with intellectual disability?

Many of the differences in the brain that cause or contribute to intellectual disability can also cause or
contribute to other conditions or mental health issues. Some of the medical and mental health
conditions that can occur alongside intellectual disability (but can also occur in an individual without
an intellectual disability) include:
 Attention-deficit/hyperactivity disorder (ADHD).
 Autism spectrum disorder.
  Impulse control disorders.
 Mood disorders, especially anxiety disorders and depression.
 Movement disorders.
People with intellectual disability due to a specific genetic disorder may also have a higher chance of
developing certain health problems related to the underlying condition. Your healthcare provider can
tell you more about what conditions your child might have a greater risk of and what you can do to
help your child avoid more severe issues.

Diagnosis and Tests

How is it diagnosed?
Diagnosing intellectual disability is usually a process that takes multiple steps. That’s because
diagnosing it requires assessing your intelligence and adaptive behavior capabilities. A key part of the
diagnosis is understanding strengths, not just challenges. Knowing someone’s strengths can help tailor
treatments and interventions to bolster their strengths and help them cope with challenges.
There are different tests and methods that can help with these assessments, depending on your age.
Some forms of testing can identify intellectual disability in very young children. But these tests
generally can’t identify how severe it is until they’re old enough for IQ testing and a full assessment
of adaptive functioning.
When possible, experts classify intellectual disability severity into four categories:
 Mild. People with this severity level have an average mental age of between 9 and 12. Their
disability may interfere with learning or complex tasks. However, they can often work around
these issues, especially with specialized interventions and assistance earlier in life. They also
often work and live independently. About 85% of people with intellectual disability have this
level of severity.
 Moderate. People with moderate intellectual disability have an average mental age of 6 to 9
years. They can communicate using simple language. They achieve an education of about an
elementary school level. Many can learn to live independently to some degree but will need
varying levels of help along the way, such as the kind of support found in a group home.
 Severe. People with severe intellectual disability have an average mental age of between 3
and 6 years. They use single words, phrases and/or gestures to communicate. They benefit
from daily care and support with activities and daily life.
 Profound. People with this level of intellectual disability have an average mental age of 3
years and below. They usually communicate nonverbally, understanding some gestures and
emotional cues. They benefit from 24/7 medical care and support for all activities and aspects
of life.
What tests will be done to diagnose this condition?
In addition to the tests and assessments for intelligence and adaptive behaviors, many lab, diagnostic
and imaging tests can help with diagnosis. The possible tests depend on your symptoms. Testing can
help your provider identify the underlying cause, which can help guide treatment.
Possible tests include:
 Laboratory testing of blood, urine and more. These can identify underlying causes of
intellectual disability or related conditions.
 Genetic counseling. Identifying genetic conditions that are causing or contributing to
intellectual disabilities can help prevent or limit complications related to these underlying
conditions.
Imaging tests. These are especially helpful with identifying conditions that involve differences in
brain structure, such as cephalic disorders.
https://my.clevelandclinic.org/health/diseases/5998-cephalic-disorders
Other tests may be possible, depending on the condition you have or that a healthcare provider
suspects. Your provider can tell you more about the possible tests and which ones they recommend.

Management and Treatment

How is intellectual disability treated?
There’s no way to cure or treat intellectual disability directly. With good treatment, individuals with
intellectual disability can have a good quality of life. The treatments focus on helping with adaptive
behaviors and life skills.
Treatment types include:
 Education support and interventions. These can help with changes to educational programs
and structure. An example of educational support is an Individualized Education Plan (IEP),
which creates a custom educational plan and expectations.
 Behavioural support and interventions. These kinds of interventions can help with learning
adaptive behaviours and related skills.
 Vocational training. This can help people with intellectual disabilities learn work-related
skills.
 Family education. This can help family and loved ones of those with intellectual disability
learn more about intellectual disability and how to support a loved one who has it.
 Various medications can help with conditions that are related to or happen alongside
intellectual disability. While these don’t treat intellectual disability itself, they can help with
some of the symptoms that may contribute.
 Community support. A person and/or their family can contact local government agencies or
support organizations. Doing so can help them get access to the services they benefit from,
including supports in home or work environments and options for daytime activities.
Outlook / Prognosis
What can I expect if my child has intellectual disability?
People who have milder forms of intellectual disability or conditions that cause it may be able to
recognize some of the differences between themselves and others. However, a key part of intellectual
disability is that it disrupts your ability to fully process and understand what’s happening to you or
around you.
Because of that, many individuals with intellectual disability can’t fully understand how this condition
affects them. Instead, parental figures or other caregivers are more likely to notice the signs and
symptoms of intellectual disability in their child or a child of a close loved one.
Remember that your child will still have goals, desires, and strengths. It’s important that you help
your child identify these so they can live their best life with the proper support.
People with intellectual disability may also be unable to recognize when others are trying to take
advantage of them. Support programs can help teach people with intellectual disability to protect
themselves, but caregiver support and oversight are vital to their well-being.
What’s the outlook for intellectual disability?
The outlook for intellectual disability depends on many factors, especially how severe it is, the
underlying cause and any other conditions that happen along with it. Your child’s healthcare provider
is the best source of information on your child’s outlook and what you can do to help manage their
condition.
Most people with intellectual disability will need some form of support throughout their lives.
However, there are programs and organizations that can help along the way. Many people with
intellectual disabilities can go on to live independently to varying degrees. Depending on their needs,
preferences and desires, many have jobs, families and other components that make up everyday life.
Overall, with the correct support, individuals with an intellectual disability can have a good quality of
life.
Specific Learning Disorders (Reading disorder, Spelling Disorder, disorder
of written expression, Arithmetical Disorder)

Introduction
Learning disabilities (disorders) affect how your child’s brain takes in and uses
information. There are multiple types, like dyslexia and nonverbal learning disorders.
Learning disabilities are manageable with interventions that can help your child learn
in a different way.
What is a learning disability?
Learning disabilities (LDs) affect how your brain processes information. This could include
how you:
 Acquire (take in) information.
 Organize information.
 Retain information.
 Understand information.
 Use information.
LDs can involve verbal (words or speech) and/or nonverbal information. They typically affect
how you read, write and/or do math. They can range from mild to severe.
Learning disabilities don’t affect intelligence and are different from intellectual disabilities.
People with LDs have specific issues with learning. But they have an average or above-
average IQ (intelligence quotient).
Most people with an LD find out about it early in school. But some people don’t get a
diagnosis until adolescence or adulthood.
What’s the difference between a learning disability and a learning disorder?
Many people use “learning disability” and “learning disorder” interchangeably. But there are
technical differences:
 Learning disorder: This is a diagnostic term. A licensed professional (like
a psychologist) diagnoses someone with a learning disorder based on certain criteria.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) defines
“learning disorder” and its criteria.
  Learning disability: This is a legal term. A public school identifies a student with a
learning disability based on a variety of assessments and documentation. This may
result in legal rights, like the right to an individualized education plan (IEP). In the
U.S., the Individuals with Disabilities Education Act (IDEA) defines what a learning
disability is.

What are specific learning disorders?

“Specific learning disorder” is the term the Diagnostic and Statistical Manual of Mental
Disorders uses to describe neurodevelopmental disorders that involve consistent difficulty in
at least one of three major areas:
 Reading.
 Writing.
 Math.
Specific learning disorders include:
 Dyslexia (reading disability): This LD makes reading and language-related tasks
harder. Dyslexia happens because of disruptions in how your brain processes written
words so you can understand them. This may look like issues with spelling simple
words, learning the names of letters, rhyming, sounding out new words and more.
 Dysgraphia: This LD affects your ability to turn your thoughts into written language
despite exposure to adequate instruction and education. This may look like issues with
handwriting legibility, spelling, holding a pencil correctly, the rate or speed of writing,
grammar, and more.
 Dyscalculia: This LD affects your ability to understand number-based information and
math. This may look like issues with counting upwards, doing simple calculations
from memory, memorizing multiplication tables, organizing math problems and more.
Nonverbal learning disorder
Nonverbal learning disorders affect activities that don’t involve words or speech, like:
 Problem-solving.
 Visual-spatial tasks
 Recognizing social cues.
The DSM-5-TR doesn’t currently recognize nonverbal LDs as a type of specific learning
disorder. But research shows that about 5% of people with LDs have cognitive and academic
difficulties associated with nonverbal LDs.
Nonverbal learning disorders can affect:
 Social abilities, like using social language (slang or informal language) or
understanding facial expressions or body language.
  Executive functioning, like planning, organizing and emotional regulation.
 Visual-spatial awareness, which can cause issues with coordination.
 Math skills, particularly comprehension of more advanced math topics.

How common are learning disabilities?

Learning disabilities are relatively common. Researchers estimate that 10% of people in the
U.S. receive an LD diagnosis at some point in their lives. About 5% of school-aged children
globally have LDs.
Dyslexia is the most common. It accounts for at least 80% of LDs.

What causes learning disabilities?

Researchers still have a lot to learn about learning disabilities and their causes. Currently,
they think LDs result from a combination of genetic and environmental factors. It’s important
to note that learning disabilities don’t result from physical sensory issues, like low
vision or hearing loss.
Studies show that risk factors for LDs include:
 Biological family history of LDs.
 Premature birth.
 Fetal exposure to alcohol or other substances.
 A history of a speech and language developmental delay.
 Malnutrition.
 Exposure to environmental toxins, like lead.
 Adverse childhood experiences (ACEs).
 Traumatic brain injury (TBI).
LDs often exist alongside other disorders, including:
 Attention-deficit/hyperactivity disorder (ADHD).
 Anxiety.
 Bipolar disorder.
 Depression.
 Obsessive-compulsive disorder (OCD).
 Oppositional defiant disorder (ODD).
Some studies show that LDs affect 20% to 70% of children with psychiatric conditions.
If you think your child has a learning disorder, you should formally request testing through
their school system. Schools are required to evaluate a child (age 3 to 21) if they’re suspected
of having a disability that affects their learning or educational performance.

Management and Treatment

How are learning disabilities managed?
People with learning disabilities need different or additional help learning. This help — or
management — varies based on the type of learning disability and its severity. You and your
child may work with several professionals to find the best learning plan for them. This team
may include:
 Educators.
 Educational remediation specialists.
 Psychologists.
 Special education services.
 Healthcare providers, like occupational and physical therapists.
In general, educational interventions fall into the following levels:
 Accommodation: Your child has access to the mainstream education curriculum with
supportive or assistive resources without changing the educational content.
 Modification: Your child’s school adapts your child’s goals and objectives as well as
provides services to reduce the effect of the learning disability. For example, your
child may be able to orally give test answers instead of writing them.
 Remediation: Your child’s school provides specific interventions to decrease the
severity of the learning disability.

If your child qualifies for special education services, they’ll receive an Individualized
Education Program (IEP). This personalized education plan:
 Lists academic goals for your child.
 Specifies the services your child will receive.
 Lists the specialists who’ll work with your child.
Some children require specialized learning in only one area while they continue to attend
regular classes. Other children may need separate, more intensive educational programs. As
required by U.S. law, children with LDs should participate as much as possible in classes
with their peers who don’t have LDs.
It may take time to find the best strategy for your child. Know that your diligence in helping
your child is worth it.
Outlook / Prognosis
What can I expect if my child has a learning disability?
Even though children don’t outgrow learning disabilities, they can learn to adapt and improve
their skills. Children who receive early diagnoses and interventions are more likely to
overcome challenges while maintaining a positive self-image.
They may also build on personal strengths that tend to come with learning disorders. For
example, people with dyslexia are often especially creative. Children with learning
disabilities can grow to become very productive and successful adults.
What are the complications of learning disabilities?
If your child has an LD, they may experience self-esteem issues or believe they aren’t
intelligent. They also have a higher risk of developing mental health conditions like anxiety
or depression.
Positive support from caregivers, teachers and friends can help your child overcome these
obstacles. But don’t hesitate to reach out to a mental health professional, as well.

In 2013, the DSM-5* changed the diagnostic criteria for Specific Learning Disorder (SLD) to
combine all three learning disorders (reading, mathematics, and written expression) into one
overarching diagnosis. Specific learning disorders (often referred to as a learning disorder or
learning disability, see note on terminology) are neurodevelopmental disorders that are
typically diagnosed in early school-aged children, although may not be recognized until
adulthood. They are characterized by a persistent impairment in at least one of three major
areas: reading, written expression, and/or math.

An estimated 5 to 15% of school-age children struggle with a learning disability. 1 An

estimated 80% of those with learning disorders have an impairment in reading in particular
(commonly referred to as dyslexia). Dyslexia is common, affecting 20% of the
population.2 Dyslexia affects males and females equally. Specific learning disorder often
occurs along with other neurodevelopmental disorders (such as ADHD) and with anxiety.
Types of Specific Learning Disorders: Dyslexia, Dysgraphia, and Dyscalculia
The merging of three separate learning disorders into one diagnostic category under Specific
Learning Disorder (SLD) in the DSM-5 required three different specifiers to identify the
area(s) of academic weakness:
1. With impairment in reading (dyslexia)
 2. With impairment in written expression (dysgraphia)
3. With impairment in mathematics (dyscalculia)
Dyslexia
The specifier “with impairment in reading” is added to the SLD diagnosis when a person
demonstrates significant impairment in one or more of the reading subskills including word
reading accuracy, reading rate or fluency, and/or reading comprehension. Dyslexia may be
used as an alternative term that refers to problems with word reading fluency or word reading
accuracy, decoding, and spelling.
Problems in reading may begin even before learning to read. For example, children with
dyslexia may have trouble with breaking down spoken words into syllables andor recognizing
words that rhyme. People with dyslexia often have difficulty connecting letters they see on a
page with the sounds they make. As a result, reading becomes slow and effortful and is not a
fluent process for them. People with dyslexia may also have difficulty with writing accuracy
and spelling.
Adolescents and adults with dyslexia often try to avoid activities that involve reading when
they can (reading for pleasure, reading instructions). They often gravitate to other media such
as pictures, video, or audio.
Dysgraphia
An impairment in writing skills is assigned to the specifier “with impairment in written
expression” and refers to those children with impaired spelling and problems with writing
that can include difficulties with accuracy, grammar, and punctuation accuracy, and/or clarity
or organization of written expression. Problems in reading begin even before learning to read.
For example, children may have trouble breaking down spoken words into syllables and
recognizing words that rhyme. Dysgraphia is the term used to describe difficulties with
putting one’s thoughts on to paper. Kindergarten-age children with impairment in written
expression may not be able to recognize and write letters as well as their peers.
Dyscalculia
The third SLD specifier “with impairment in mathematics” is for individuals who
demonstrate significantly below average skills in number sense, memorization of arithmetic
facts, accurate or fluent calculation, and/or accurate math reasoning. The term
“dyscalculia” is used to describe difficulties with learning number number-related concepts,
with processing numerical information, with learning arithmetic facts or with using the
symbols and functions to perform accurate or fluent math calculations.
Severity Levels
In addition to specifying the domain of learning disorder, the degree of severity should also
be indicated in the SLD diagnosis. There are three levels of SLD severity.
 Mild: Some difficulties with learning in one or two academic areas, but may be able
to compensate with appropriate accommodations or support services.
  Moderate: Significant difficulties with learning, requiring some specialized teaching
and some accommodations or supportive services may be needed in school, in the
workplace, or at home for activities to be completed accurately and efficiently.
 Severe: Severe difficulties with learning, affecting several academic areas and
requiring ongoing intensive specialized teaching for most of the school years. Even
with accommodations, an individual with a severe SLD may not be able to perform
academic tasks with efficiency.

DSM V TR Criteria
Specific Learning Disorder
Diagnostic Criteria
A. Difficulties learning and using academic skills, as indicated by the presence of at least one
of the following symptoms that have persisted for at least 6 months, despite the provision of
interventions that target those difficulties:
1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or
slowly and hesitantly, frequently guesses words, has difficulty sounding out words).
2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but not
understand the sequence, relationships, inferences, or deeper meanings of what is read).
3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation
errors within sentences; employs poor paragraph organization; written expression of ideas
lacks clarity).
5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor
understanding of numbers, their magnitude, and relationships; counts on fingers to add
single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst of
arithmetic computation and may switch procedures).
6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical
concepts, facts, or procedures to solve quantitative problems).
B. The affected academic skills are substantially and quantifiably below those expected for
the individual’s chronological age, and cause significant interference with academic or
occupational performance, or with activities of daily living, as confirmed by individually
administered standardized achievement measures and comprehensive clinical assessment. For
individuals age 17 years and older, a documented history of impairing learning difficulties
may be substituted for the standardized assessment.
C. The learning difficulties begin during school-age years but may not become fully manifest
until the demands for those affected academic skills exceed the individual’s limited capacities
(e.g., as in timed tests, reading or writing lengthy, complex reports for a tight deadline,
excessively heavy academic loads).
D. The learning difficulties are not better accounted for by intellectual disabilities,
uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial
adversity, lack of proficiency in the language of academic instruction, or inadequate
educational instruction.
Note: The four diagnostic criteria are to be met based on a clinical synthesis of the
individual’s history (developmental, medical, family, educational), school reports, and
psychoeducational assessment.
Coding note: Specify all academic domains and subskills that are impaired. When more than
one domain is impaired, each one should be coded individually according to the following
specifiers.
Specify if:
F81.0 With impairment in reading:
Word reading accuracy
Reading rate or fluency
Reading comprehension
Note: Dyslexia is an alternative term used to refer to a pattern of learning difficulties
characterized by problems with accurate or fluent word recognition, poor decoding, and poor
spelling abilities. If dyslexia is used to specify this particular pattern of difficulties, it is
important also to specify any additional difficulties that are present, such as difficulties with
reading comprehension or math reasoning.
F81.81 With impairment in written expression:
Spelling accuracy
Grammar and punctuation accuracy
Clarity or organization of written expression
F81.2 With impairment in mathematics:
Number sense
Memorization of arithmetic facts
Accurate or fluent calculation
Accurate math reasoning
Note: Dyscalculia is an alternative term used to refer to a pattern of difficulties characterized
by problems processing numerical information, learning arithmetic facts, and performing
accurate or fluent calculations. If dyscalculia is used to specify this particular pattern of
mathematic difficulties, it is important also to specify any additional difficulties that are
present, such as difficulties with math reasoning or word reasoning accuracy.
Specify current severity:
Mild: Some difficulties learning skills in one or two academic domains, but of mild enough
severity that the individual may be able to compensate or function well when provided with
appropriate accommodations or support services, especially during the school years.
Moderate: Marked difficulties learning skills in one or more academic domains, so that the
individual is unlikely to become proficient without some intervals of intensive and
specialized teaching during the school years. Some accommodations or supportive services at
least part of the day at school, in the workplace, or at home may be needed to complete
activities accurately and efficiently.
Severe: Severe difficulties learning skills, affecting several academic domains, so that the
individual is unlikely to learn those skills without ongoing intensive individualized and
specialized teaching for most of the school years. Even with an array of appropriate
accommodations or services at home, at school, or in the workplace, the individual may not
be able to complete all activities efficiently.

ICD 10 Criteria
F81.0 Specific reading disorder
The main feature of this disorder is a specific and significant impairment in the development
of reading skills, which is not solely accounted for by mental age, visual acuity problems, or
inadequate schooling. Reading comprehension skill, reading word recognition, oral reading
skill, and performance of tasks requiring reading may all be affected. Spelling difficulties are
frequently associated with specific reading disorder and often remain into adolescence even
after some progress in reading has been made. Children with specific reading disorder
frequently have a history of specific developmental disorders of speech and language, and
comprehensive assessment of current language functioning often reveals subtle
contemporaneous difficulties. In addition to academic failure, poor school attendance and
problems with social adjustment are frequent complications, particularly in the later
elementary and secondary school years. The condition is found in all known languages, but
there is uncertainty as to whether or not its frequency is affected by the nature of the language
and of the written script.
Diagnostic guidelines
The child's reading performance should be significantly below the level expected on the basis
of age, general intelligence, and school placement. Performance is best assessed by means of
an individually administered, standardized test of reading accuracy and comprehension. The
precise nature of the reading problem depends on the expected level of reading, and on the
language and script. However, in the early stages of learning an alphabetic script, there may
be difficulties in reciting the alphabet, in giving the correct names of letters, in giving simple
rhymes for words, and in analysing or categorizing sounds (in spite of normal auditory
acuity).
Later, there may be errors in oral reading skills such as shown by:
(a)omissions, substitutions, distortions, or additions of words or parts of words;
(b) slow reading rate;
(c)false starts, long hesitations or "loss of place" in text, and inaccurate phrasing; and
(d)reversals of words in sentences or of letters within words.
There may also be deficits in reading comprehension, as shown by, for example:
(e)an inability to recall facts read;
(f)inability to draw conclusions or inferences from material read; and
(g)use of general knowledge as background information rather than of information from a
particular story to answer questions about a story read.
In later childhood and in adult life, it is common for spelling difficulties to be more profound
than the reading deficits. It is characteristic that the spelling difficulties often involve
phonetic errors, and it seems that both the reading and spelling problems may derive in part
from an impairment in phonological analysis. Little is known about the nature or frequency
of spelling errors in children who have to read non-phonetic languages, and little is known
about the types of error in non-alphabetic scripts.
Specific developmental disorders of reading are commonly preceded by a history of disorders
in speech or language development. In other cases, children may pass language milestones at
the normal age but have difficulties in auditory processing as shown by problems in sound
categorization, in rhyming, and possibly by deficits in speech sound discrimination, auditory
sequential memory, and auditory association. In some cases, too, there may be problems in
visual processing (such as in letter discrimination); however, these are common among
children who are just beginning to learn to read and hence are probably not directly causally
related to the poor reading. Difficulties in attention, often associated with overactivity and
impulsivity, are also common. The precise pattern of developmental difficulties in the
preschool period varies considerably from child to child, as does their severity; nevertheless
such difficulties are usually (but not invariably) present.
Associated emotional and/or behavioural disturbances are also common during the school-
age period. Emotional problems are more common during the early school years, but conduct
disorders and hyperactivity syndromes are most likely to be present in later childhood and
adolescence. Low self-esteem is common and problems in school adjustment and in peer
relationships are also frequent.
Includes:
"backward reading"
developmental dyslexia
specific reading retardation
spelling difficulties associated with a reading disorder
Excludes:
acquired alexia and dyslexia (R48.0)
acquired reading difficulties secondary to emotional disturbance
(F93.-)
spelling disorder not associated with reading difficulties story read.

F81.1 Specific spelling disorder

The main feature of this disorder is a specific and significant impairment in the development
of spelling skills in the absence of a history of specific reading disorder, which is not solely
accounted for by low mental age, visual acuity problems, or inadequate schooling. The ability
to spell orally and to write out words correctly are both affected. Children whose problem is
solely one of handwriting should not be included, but in some cases spelling difficulties may
be associated with problems in writing. Unlike the usual pattern of specific reading disorder,
the spelling errors tend to be predominantly phonetically accurate.
Diagnostic guidelines
The child's spelling performance should be significantly below the level expected on the basis
of his or her age, general intelligence, and school placement, and is best assessed by means of
an individually administered, standardized test of spelling. The child's reading skills (with
respect to both accuracy and comprehension) should be within the normal range and there
should be no history of previous significant reading difficulties. The difficulties in spelling
should not be mainly due to grossly inadequate teaching or to the direct effects of deficits of
visual, hearing, or neurological function, and should not have been acquired as a result of any
neurological, psychiatric, or other disorder.
Although it is known that a "pure" spelling disorder differs from reading disorders associated
with spelling difficulties, little is known of the antecedents, course, correlates, or outcome of
specific spelling disorders.

Includes: specific spelling retardation (without reading disorder)

Excludes: acquired spelling disorder (R48.8)

spelling difficulties associated with a reading disorder (F81.0)
spelling difficulties mainly attributable to inadequate teaching
Pervasive Developmental Disorders
(Autism, Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, PDD NOS),

Autism Spectrum Disorder

Introduction
Autism is a difference in how your child’s brain works that causes them to socialize and
behave in unique ways. Early signs of autism include limited eye contact and body language
and repetitive motions or speech. Behavioral therapies and other support can help autistic
kids (and adults) make the most of their strengths and manage any challenges.
What is autism?
Autism is a difference in how your child’s brain works that shapes how they interact with the
world around them. This difference is something they’re born with — it has nothing to do
with your parenting style, foods, vaccines or anything else your child encountered after birth.
We don’t know exactly why some people are autistic and others aren’t, but we do know:
 Autism isn’t a disease. This is important because we try to “cure” diseases. With
autism, the goal isn’t a cure. Instead, we find ways to help your child identify and
make the most of their strengths while managing any challenges they might face.
 Autistic people are neurodivergent. Neurodivergent is a word that describes people
whose brains are different than what’s “typical,” or expected. They may excel more in
certain areas and need more support in other areas compared to
their neurotypical peers.
 Autism is a spectrum. Everyone on this planet is unique — and that fact doesn’t
change when we’re talking about autistic kids (or adults). Autism is a spectrum in the
sense that there’s a very wide range of personality traits, strengths and challenges you
might have when you’re autistic — just as there is for any other person.
 Autism is often misunderstood. For decades, people (including doctors) have said
and done things that we now know are wrong or even harmful to autistic people. For
example, early forms of behavioral therapy used strict methods to try and get kids to
act and talk like their peers. We can’t erase this history, but we’ve learned from it.
Today’s therapies help autistic kids and their families gain skills without forcing kids
to fit into a certain mold. But plenty of autism myths still exist, and it takes time to get
the truth out there.
When discussing autism, it’s important to acknowledge that words aren’t perfect. And
sometimes, “medspeak” that healthcare providers use — like disorder, symptoms or diagnosis
— doesn’t quite match the lived experience of autistic people or their families. Throughout
this article, we’ll use such language as needed to describe how healthcare providers can
support your family — while recognizing that autism is an identity, not just a diagnosis.
What is autism spectrum disorder?
Autism spectrum disorder (ASD) is the full medical name for autism. A book called
the DSM-5-TR defines autism spectrum disorder as a difference in brain functioning that
affects how a person communicates and interacts with others. For example, an autistic person
may not use eye contact or body language in the same ways as someone who’s neurotypical.
This brain difference also affects various aspects of a person’s behavior, interests or activities.
For example, they may repeat the same movements or sounds (a behavior known as
“stimming”) to regulate their emotions. They may also prefer a fixed routine and value
sameness over change.
How common is ASD?
About 1 in every 31 kids in the U.S. are autistic. This is based on data gathered in the U.S. in
2022.
It might seem like autism is becoming more common. But the increasing prevalence is likely
because healthcare providers have better knowledge and resources than in the past. So,
they’re better able to identify and support autistic people, which leads to more office visits
and diagnoses — and a rise in the numbers.

Diagnostic Criteria
A. Persistent deficits in social communication and social interaction across multiple contexts, as
manifested by all of the following, currently or by history (examples are illustrative, not exhaustive;
see text):
1. 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.
2. Deficits in nonverbal communicative behaviours 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.
3. 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.

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):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor
stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. 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 same route or eat same food every day).
3. 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).
4. 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).
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 developmental disorder (intellectual
disability) or global developmental delay. Intellectual developmental disorder and autism spectrum
disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and
intellectual developmental disorder, social communication should be below that expected for 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 current severity based on social communication impairments and restricted, repetitive patterns
of behavior (see Table 2):
Requiring very substantial support
Requiring substantial support
Requiring support
Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Specify if:
Associated with a known genetic or other medical condition or environmental factor (Coding
note: Use additional code to identify the associated genetic or other medical condition.)
Associated with a neurodevelopmental, mental, or behavioral problem
Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental disorder, p. 135, for
definition) (Coding note: Use additional code F06.1 catatonia associated with autism spectrum
disorder to indicate the presence of the comorbid catatonia.)
Criteria for an autism diagnosis
Your child must have difficulties in all three of the following social areas:
 Social-emotional reciprocity. This is the back-and-forth nature of socializing. The most
common example is a conversation. One person says something, and the other person
responds. Autistic kids may engage in such give-and-take socializing less than expected.
 Nonverbal communication. These are things like eye contact and body language —
movements and subtle gestures that add meaning to the words we say. Autistic children may
not use these cues in expected ways, and/or they may not understand what others mean by
them.
 Developing and maintaining relationships. This involves seeking people to spend time with
and sharing interests together. It also involves judging how to approach others and which
behaviors are appropriate in different situations. Autistic kids may not initiate or develop
friendships in ways their neurotypical peers expect.
AND your child must do at least two of the following:
 Engage in repetitive movements, use of objects or speech. This means doing or saying the
same thing over and over, more than you might expect. For example, your child might
repeatedly make the same hand motions, move one part of a toy or say a certain phrase.
 Insist on the same routine or ways of doing things. This means relying heavily on sameness
and resisting change. Your child may want to do tasks a certain way or in a particular order
and get upset by attempts to do things differently.
 Have very intense or unusual interests. This is interest in a certain object or topic that’s
stronger or more consuming than you’d expect. For example, you might not be surprised if
your child loves superhero cartoons, but an intense interest would mean that’s all your child
wants to watch or talk about.
 React more than expected to sights, sounds and textures and/or seek out sensory experiences.
Reacting more than expected (hyper-reactivity) means getting overwhelmed or upset by
sensory input like big crowds, loud noises and certain textures. On the flipside, some kids
seek out sensory experiences because they’re underwhelmed by what’s around them. This
involves sniffing or touching certain objects for longer (or more often) than other kids might.

What causes autism?

Researchers haven’t found a single cause of autism. It’s likely a combination of genetics and certain
things related to pregnancy, labor and delivery (what you might see referred to as “environmental
factors” or “prenatal events”). These factors all interact to lead to the brain differences we see in
autism.
Specific things that may make autism more likely in your child include:
 Becoming pregnant over age 35.
 Becoming pregnant within 12 months of having another baby.
 Having gestational diabetes.
  Having bleeding during pregnancy.
 Using certain medications (like valproate) while pregnant.
 Smaller than expected fetal size (intrauterine growth restriction).
 Reduced oxygen to the fetus during pregnancy or delivery.
 Giving birth early.
These factors may directly change how your baby’s brain develops. Or they may affect how certain
genes work, in turn leading to brain differences.
Is autism genetic?
Yes — but the genetic causes of autism are complicated. There’s not a single, specific gene
variation that’s unique to autism. This makes autism different from some other genetic conditions,
like cystic fibrosis, where providers can pinpoint a specific gene variation and say, “ah!”, there it is.
Instead, many gene variations are linked to autism. This means autistic people might have one or more
gene variations that play a role in their brain differences.
Not all autistic people have a clear genetic cause. For example, genetic testing for your child may
reveal no gene variations associated with autism. This finding doesn’t change their diagnosis. And it
doesn’t rule out a genetic cause. It’s possible that other gene variations contribute to autism, and
researchers simply haven’t identified them yet.
Is autism inherited?
It can be. It’s easy to confuse genetics with inheritance. When we say autism is genetic, we mean
variations in certain genes affect how your baby’s brain works. Those gene variations might pop up
for the first time in your baby — in this case, they’re not inherited. But it’s also possible for biological
parents to pass down gene variations to their children. We think autism can be inherited because we
see patterns among siblings.
With autism, inheritance sometimes happens in the form of genetic syndromes. There’s a higher
prevalence of autism in some genetic syndromes, like fragile X syndrome, Down
syndrome and tuberous sclerosis. With these syndromes, your child is autistic but also has a wide
range of other developmental changes. Each syndrome is passed down through the generations in
specific ways — for example, through one or both biological parents.

What should I know about autism treatment?

Because autism isn’t a disease, providers don’t “treat” it. After all, it isn’t something that “goes away”
or can be “cured.” It’s simply the way your child’s brain works. And it’s a part of their identity that’ll
always remain in some form — even if certain characteristics become more or less noticeable over
time.
But providers do manage the aspects of autism that may pose challenges for your child or keep them
from maximizing their strengths. Management involves a range of therapies that help your child build
skills (like social communication) they’ll need now and in the future. Some therapies teach you and
other family members strategies for supporting your child. The earlier such support begins (ideally
before age 3), the more it can benefit your child in the long run.
Examples of specific therapies include:
 Behavioral therapies, like applied behavior analysis (ABA).
 Family therapy.
 Speech therapy.
 Occupational therapy.
Treatment for co-occurring conditions
Some autistic kids have other conditions that need support or treatment. Conditions that may co-occur
with autism include:
 Attention-deficit/hyperactivity disorder (ADHD).
 Anxiety disorders.
 Avoidant/restrictive food intake disorder (ARFID).
 Conduct disorder or oppositional defiant disorder.
 Bipolar disorders.
 Depressive disorders.
 Digestive issues, like constipation.
 Epilepsy.
 Intellectual disabilities.
 Obsessive-compulsive disorder (OCD).
 Schizophrenia spectrum disorder.
 Sleep disorders.
Providers manage or treat these conditions with things like:
 Cognitive behavioral therapy (CBT).
 Medications.
 Referrals for educational support — for example, to create an Individualized Education Plan
(IEP) to meet your child’s learning needs.

Complications
Because people with autism spectrum disorder often have a hard time interacting socially,
communicating or behaving, this can lead to problems with:
 School and learning.
 Getting a job.
 Not being able to live on their own.
 Being isolated socially.
 Stress within the family.
 Being a victim and being bullied.
What is pervasive developmental disorder (PDD)?
Pervasive developmental disorder was once a term used to describe a group of developmental delays
that affect social and communication skills. But now healthcare providers call it autism spectrum
disorder (ASD). This name change occurred in 2013, when the American Psychiatric Association
reclassified the four following conditions into one umbrella diagnosis in the DSM-5:
 Autistic disorder.
 Asperger’s syndrome.
 Childhood disintegrative disorder.
 Pervasive developmental disorder not otherwise specified (PDD-NOS).
Note: “Autism spectrum disorder” is the correct, updated term for “pervasive developmental
disorder.” But for this article, we’ll use both terms.
People with pervasive developmental disorder may experience a range of challenges, including:
 Delays in language or communication.
 Trouble adjusting to changes in their routines or surroundings.
 Difficulty relating to others.
How common is pervasive developmental disorder?
Pervasive developmental disorder is the most common subtype of autism spectrum disorder, making
up about 47% of all ASD diagnoses.
Symptoms and Causes
What are the symptoms of pervasive developmental disorder?
The most common pervasive developmental disorder symptoms include difficulty with
communication and social interactions. Children with PDD may also:
 Engage in repetitive behaviors like rocking or hand flapping.
 Have difficulty expressing their thoughts through language.
 Have a hard time with routine changes.
 Avoid eye contact.
 Have trouble engaging in conversation.
 Have difficulty controlling their emotions.
 Speak with a flat or high-pitched voice.
No two people with pervasive developmental disorder are the same. Symptoms can range from mild
to severe — and most people fall somewhere between the two ends of the spectrum.
What causes pervasive developmental disorder?
Researchers are still working to find a specific cause for pervasive development disorder. But it’s
likely there’s a combination of genetic and environmental factors rather than a single cause. Possible
factors include:
  Genetics. Plenty of experts believe that genetics plays a major role in PDD. But they’re still
learning exactly how. Many people with pervasive developmental disorder have gene
mutations (changes). In fact, scientists have found more than 100 genes on different
chromosomes that contribute to autism spectrum disorder in some way. But it’s complex. Not
everyone with PDD has the same mutations in every gene. And some of these same mutations
appear in people without PDD. Currently, most researchers agree that specific genetic
mutations likely cause specific symptoms — or control how severe those symptoms become.
At the very least, these genetic mutations can increase your risk for PDD.
 Environment. If you’re more prone to PDD because of a genetic mutation, then certain
situations or environments can further increase your chances of developing it. For instance, if
you have a specific genetic mutation, then getting an infection or coming into contact with a
certain toxin can cause PDD.
 Biology. Researchers continue to examine biological factors that may increase your risk of
PDD. This includes conditions that affect your metabolism, immune system or certain areas
of your brain.
Pervasive developmental disorder risk factors
A risk factor is something that increases your chances of getting a certain condition. Experts have
identified some risk factors for PDD, including:
 Having a sibling with PDD or another type of ASD.
 Some genetic conditions like fragile X syndrome or Down syndrome.
 Having biological parents who were at least 35 when you were born (advanced maternal age).
 Low birth weight.
What are the complications of pervasive developmental disorder?
While every person with PDD has their own challenges, the severity of symptoms can vary widely.
Some children with PDD have typical language skills, while others may not speak at all. Your
healthcare provider can help determine what types of resources your child might need. Early diagnosis
and treatment can often reduce your child’s symptoms.
Diagnosis and Tests
How do healthcare providers diagnose pervasive developmental disorder?
There’s no lab test or medical exam that can diagnose pervasive developmental disorder. Instead,
healthcare providers observe a person’s behavior and look at their developmental history.
The American Academy of Pediatrics recommends that all children have screenings for autism
spectrum disorder when they’re 18 to 24 months of age. Most healthcare providers screen children
during routine developmental and wellness checkups. During these checkups, your provider will talk
and interact with your child. They’ll also ask you questions about how your child moves, behaves and
communicates at home.
While most diagnoses occur in early childhood, providers can also diagnose PDD and other types of
ASD in older children, teens and adults. If you think you or your child could have pervasive
developmental disorder or a related condition, talk to your healthcare provider. They can do an
evaluation or refer you to someone who specializes in ASD.
Management and Treatment
How do healthcare providers treat pervasive developmental disorder?
Healthcare providers use a variety of treatments to manage PDD, including:
 Supportive therapies.
 Medications.
 Complementary medicine.
No two people are the same. What works for one may not work for another because each person has
specific and unique needs. Your healthcare provider will design a personalized approach to give help
and support where it’s needed most.
Supportive therapies
Supportive therapy is the mainstay treatment for pervasive developmental disorder. This can include
things like:
 Speech therapy to help build communication and comprehension skills.
 Occupational therapy to strengthen coordination and help you learn routine tasks like
bathing, getting dressed and brushing your teeth.
 Physical therapy to develop motor skills and learn ways to exercise and increase stamina.
 Applied behavioral analysis (ABA), a type of behavior therapy that aims to increase positive
behaviors and decrease negative ones.
Medications
There are no medications that treat PDD directly. But many people with pervasive developmental
disorder have attention-deficit/hyperactivity disorder (ADHD), anxiety, depression or other similar
conditions. In these cases, medications can help improve your overall quality of life.
Complementary medicine
Complementary medicine involves combining nontraditional approaches with traditional treatments.
This can include a wide range of things like:
 Art therapy.
 Music therapy.
 Massage.
 Acupuncture.
 Yoga.
 Meditation.
Your provider can help you find complementary therapies to enhance your overall health and
wellness.
What is Rett syndrome?
Rett syndrome is a rare genetic and neurological condition that primarily affects girls. A genetic
variant causes it and plays an important role in brain development. The condition leads to symptoms
that affect motor function, communication, and cognitive abilities.
For the first few months of your child’s life, they’ll develop and meet growth milestones as expected.
After 6 months, however, your child will lose the ability to perform previously learned skills . This
includes purposeful hand use and communication. Symptoms typically show up in stages as your
child gets older. Symptoms that affect your child’s development will stop getting worse (progressing)
with time. But they won’t go away. Your child will need care and support throughout their life.
Symptoms and Causes
Rett syndrome is a condition that affects your child’s movement and development.
Rett syndrome symptoms
Your child will develop as expected until about 6 months. The first signs of Rett syndrome
are developmental delays. These start when your child doesn’t reach expected milestones for their
age. Examples could include waving, walking, and speaking their first words.
As your child gets older, symptoms of developmental regression (loss of learned skills) become more
visible.
Symptoms that affect your child’s muscles, movement, and behaviour include:
 Balance and coordination challenges (difficulty walking)
 Difficulty speaking
 Difficulty swallowing or chewing (can lead to trouble maintaining a healthy weight
or malnutrition)
 Muscle weakness or spasticity
 Problems performing familiar movements on command (apraxia)
 Repeated hand movements like wringing, squeezing or clapping
Other symptoms of Rett syndrome include:
 Difficulty sleeping
 Gastrointestinal problems (reflux or constipation)
 Intellectual disability
 Irritability
 Scoliosis
 Slow growth
Life-threatening symptoms may include:
 Breathing issues
  Heartbeat irregularities
 Seizures
Rett syndrome facial features
Children with Rett syndrome may have a small head size compared to the rest of their body
(microcephaly). This can make facial features look more pronounced. But, there aren’t identifiable
facial features for this condition.
Many symptoms of Rett syndrome overlap with another condition called Angelman syndrome. Some
common features include speech and communication impairment, developmental delay, seizures and
sleep disturbances. Facial feature changes are common with Angelman syndrome, like deep-set eyes,
a wide mouth and widely spaced teeth, for example. These features don’t happen with Rett syndrome.
Rett syndrome stages
This condition progresses in stages that happen as your child gets older. They might experience
different symptoms at each stage. Not all children go through every stage. For example, some people
with Rett syndrome are never able to walk.
Rett syndrome stages include:
 Stage I, early onset, starts when your child is between 6 and 18 months. Your child’s
development slows, like delays in crawling or a lack of eye contact. Your child will have low
muscle tone and feeding challenges.
 Stage II, the rapid progressive stage, usually occurs between ages 1 and 4 years. Your child
may lose some language skills and the use of their hands. They may constantly wring their
hands. Some children also experience behaviors that resemble autism spectrum disorder, like
a lack of interest in socializing.
 Stage III, the plateau or pseudo-stationary stage, usually occurs between ages 2 and 10 years.
Your child’s symptoms from stage II may improve, like communication and motor skills.
They may show interest in socializing. Seizures are common.
 Stage IV, or the late motor deterioration stage, may happen at any time after stage III. Your
child may lose walking skills and muscle strength. Your child should keep their
communication and thinking abilities.
Rett syndrome causes
A genetic variant of the MECP2 gene causes most cases of Rett syndrome. This gene provides
instructions to make the MECP2 protein. This protein holds the connection (synapse) between nerve
cells and helps your child’s brain function as expected.
Not all cases of Rett syndrome affect the MECP2 gene. Some gene variants (like deletions) or genetic
variants to other genes, like CDJK5 and FOXG1, can lead to atypical types. Some unidentified genes
can also cause symptoms.
The genetic change occurs spontaneously (randomly). It’s not usually inherited.
Rett syndrome in males
Rett syndrome almost always affects females. This is because the genetic change that causes it
happens on the X chromosome. You have two X chromosomes if you’re female.
Since males have one X chromosome and one Y chromosome, this condition rarely affects them. A
variant on a child’s only X chromosome can lead to miscarriage or death during early infancy due to
severe symptoms.
Healthcare providers identify this gene change in males as MECP2-related severe neonatal
encephalopathy. This condition can cause similar symptoms, like intellectual disability, seizures and
difficulty with movement.

How is Rett syndrome treated?

Treatment varies based on your child’s specific symptoms. For example, medications can treat
seizures and movement challenges. If your child has difficulty with motor skills and language, their
provider may recommend:
 Occupational therapy
 Physical therapy
 Speech therapy
For children 2 years of age and older, a medication called trofinetide showed success during clinical
trials. It’s the first FDA-approved treatment specifically for Rett Syndrome. It’s not a cure but is
considered a disease-modifying treatment. You’ll need to discuss and work closely with your medical
team to explore this option.
In addition, your child may benefit from:
 A brace or surgery for scoliosis
 Frequent monitoring for heart abnormalities
 Nutritional support
 Special education programs in school
There isn’t a cure for Rett syndrome. Your child’s providers can help manage their symptoms
throughout their life.
5. Internalizing Disorders
Anxiety Disorder (Separation Anxiety Disorder, Social Phobia, Selective Mutism, Obsessive
Compulsive Disorders), Depressive Disorders, Suicide, and Injurious Behaviour

Anxiety Disorders
Anxiety disorders are a group of mental disorders characterized by excessive and persistent fear or
anxiety that interferes with daily life. They can include conditions like generalized anxiety disorder
(GAD), panic disorder, social anxiety disorder, specific phobias, and more

Separation Anxiety Disorder

Introduction
Separation anxiety is a typical phase for many infants and toddlers. Young children often have a
period where they get anxious or distressed when they have to separate from their parent or main
caregivers. The fear and anxiety are out of proportion to the situation and not developmentally
appropriate. A child’s attachment figure is usually a parent but can be anyone they’ve bonded with,
including a grandparent or other caregiver. Examples of this can be tears at daycare drop-off or getting
fussy when a new person holds them. This usually starts to improve by about 2 to 3 years of age.
That’s because separation anxiety is a normal developmental stage babies go through as they learn
more about the world around them. They typically grow out of this stage by age 3.
In some children, intense and ongoing separation anxiety is a sign of a more serious condition known
as separation anxiety disorder. Separation anxiety disorder can be identified as early as preschool age.
Your child may have separation anxiety disorder if separation anxiety seems more intense than other
kids of the same age or lasts a longer time, interferes with school or other daily activities, or includes
panic attacks or other problem behaviours. Most often, separation anxiety relates to the child's anxiety
about being away from parents or guardians, but it could relate to another close caregiver.
In adults, the anxiety usually centers on their child or romantic partner. But some older kids
experience separation anxiety beyond the point where it’s developmentally expected. That’s when
healthcare providers consider a diagnosis of separation anxiety disorder. Symptoms can also appear in
adults with or without a history of childhood separation anxiety.
Separation anxiety disorder can get in the way of daily life. Children with this condition may refuse to
go to school. Adults may miss work or have trouble focusing.

Recognizing separation anxiety disorder in children

Separation anxiety disorder symptoms can look a little different depending on your child’s age. For
example, a preschooler might not know how to put their feelings into words. They may simply get
upset. An older child might tell you about their nightmares or describe their fears in detail.
If you force a separation despite your child’s protests, then your child may appear sad or uninterested
in whatever setting they’re in (like school). They may have difficulty concentrating on schoolwork
and not seem to care about engaging with peers. These are behaviors their teacher might observe.
If away from home for several days (for example, at camp), a child with separation anxiety disorder
might get extremely homesick and feel miserable until they’re allowed to leave. It’s also possible for a
child with this disorder to show anger or even aggression toward anyone they perceive as keeping
them from you.
Recognizing separation anxiety disorder in adults
When you love someone, it’s hard not to worry about them. It’s simply a part of life. But the distress
with separation anxiety disorder is out of proportion to the situation. It may also start to interfere with
your work or relationships. For example, you might call off work to stay with your loved one or text
them often to make sure they’re OK (and worry until they reply).
When you’re living with this disorder, you might not always feel your worries are out of proportion to
the situation. Maybe it’s only when your child or partner gets frustrated with your checking on them
that you realize your anxiety is more than typical.
What are the complications of separation anxiety disorder?
Separation anxiety disorder disrupts your life and makes it hard to do necessary and desired things.
Children might:
 Have trouble focusing on schoolwork, causing them to fall behind in classes.
 Have a hard time engaging with peers or joining in social activities.
 Miss opportunities to learn, gain social skills and become more independent.
Adults might:
 Have trouble focusing on work or other responsibilities.
 Encounter conflicts in their relationships, especially with attachment figures.
 Miss opportunities to travel or do other meaningful activities

Diagnostic Criteria
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to
whom the individual is attached, as evidenced by at least three of the following:
1. Recurrent excessive distress when anticipating or experiencing separation from home or from
major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or about possible harm to
them, such as illness, injury, disasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being
kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, o r elsewhere
because of fear of separation.
5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures
at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a
major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomach-aches, nausea, vomiting)
when separation from major attachment figures occurs or is anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and
typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social, academic,
occupational, or other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing to leave home
because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations
concerning separation in psychotic disorders; refusal to go outside without a trusted companion in
agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety
disorder; or concerns about having an illness in illness anxiety disorder.

Associated Features
When separated from major attachment figures, children and adults with separation anxiety disorder
may exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work or play.
Depending on their age, individuals may have fears of animals, monsters, the dark, muggers, burglars,
kidnappers, car accidents, plane travel, and other situations that are perceived as presenting danger to
the family or themselves. Some individuals become homesick and extremely uncomfortable when
away from home. Separation anxiety disorder in children may lead to school refusal, which in turn
may lead to academic difficulties and social isolation. When extremely upset at the prospect of
separation, children may show anger or occasionally aggression toward someone who is forcing
separation. When alone, especially in the evening or the dark, young children may report unusual
perceptual experiences (e.g., seeing people peering into their room, frightening creatures reaching for
them, feeling eyes staring at them). Children with this disorder may be described as demanding,
intrusive, and in need of constant attention, and, as adults, may appear dependent and overprotective
as parents. Adults with the disorder are likely to text or phone their major attachment figures
throughout the day and repeatedly check on their whereabouts. The individual’s excessive demands
often become a source of frustration for family members, leading to resentment and conflict within
the family.
Risk factors
A child may have an increased risk of developing separation anxiety disorder if they:
 Experience the loss of someone close to them.
 Go through a stressful situation like their parents getting divorced.
 Switch schools or move to a new place.
 Have a history of anxiety disorders in their biological family.
 a family history of anxiety or depression
 shy, timid personalities
 low socioeconomic status
 overprotective parents
 a lack of appropriate parental interaction
 problems dealing with kids their own age

Risk factors for developing separation anxiety disorder as an adult include:

 Loss of a loved one.
 Illness in a loved one.
 Big life changes, like a move, entering a romantic relationship and becoming a parent.
 Diagnosis of an anxiety disorder as a child.
  Diagnosis of other anxiety or mental health disorders as an adult.
 moving to a new home
 switching schools
 divorce
 the death of a close family member

Etiology
Genetic Factors
The majority of the patients who are diagnosed with separation anxiety disorder are found to have a
history of other psychiatric conditions themselves, or in their family. Therefore, researchers believe
separation anxiety disorder to be a heritable disorder and of genetic origin.
The first-degree relatives of patients with a history of mental illness are usually at a higher risk of
developing separation anxiety disorder, albeit the precise genetic trigger has not been identified yet.
Genetic and physiological
There is evidence that separation anxiety disorder may be heritable. Heritability was estimated at 73%
in a community sample of 6-year-old twins, with higher rates found in girls. Children with separation
anxiety disorder display particularly enhanced sensitivity to respiratory stimulation using CO2-
enriched air. Separation anxiety disorder also appears to aggregate in families.

Biological Factors
Similar to other psychiatric disorders, separation anxiety disorder also involves imbalances in
neurotransmitter levels. In the patients with separation anxiety disorder, the regulation mechanism that
controls the optimal level of such brain chemicals is impaired. Serotonin and norepinephrine levels
are believed to be majorly affected in such patients.
This results in poor central regulation of emotions, and amplified stress responses to low-level
triggers of danger.
Environmental Factors
While genetic and biological factors are believed to be the causal triggers of separation anxiety
disorder, environmental factors also form a major set of contributors. And unlike the above two,
environmental factors can be pinpointed relatively easily by closely observing the surroundings and
events of the patient’s life.
There exists a panoply of environmental stressors. The most basic one is an abrupt change in the
surroundings of a child who is prone to the disorder, such as, for example, the family moving to a new
city because of the parents’ work commitments. Having to adjust to a new dwelling, school,
neighborhood, and locality altogether can get too much for the child to handle.
Additionally, children may also “learn” anxious behavior from their parents or grandparents who are
over-protective and show excessive concern about their safety. They subconsciously imbibe a habit of
worrying extensively from the mere observation of their surroundings, and eventually fail to see
anything abnormal in that habit.
Stress and trauma are other important triggers of anxiety. Major losses such as the unexpected death
of a family member to whom the patient was closely attached can render the person very lonely and
traumatized. Separation from a caregiver, a close friend, or a pet may all have similar impacts with
varying severities according to the given situation. Partners with an emotionally interdependent
romantic relationship also find it really difficult to cope if faced with separation or divorce. The
extreme unfamiliarity with the new emotional space and unpreparedness to deal with the change can
contribute heavily to separation anxiety disorder.

Environmental
Separation anxiety disorder often develops after life stress, especially a loss (e.g., the death of a
relative or pet; an illness of the individual or a relative; a change of schools; parental divorce; a move
to a new neighborhood; immigration; a disaster that involved periods of separation from attachment
figures). Being bullied during childhood has been shown to be a risk factor for the development of
separation anxiety disorder. In young adults, other examples of life stress include leaving the parental
home, entering into a romantic relationship, and becoming a parent. A history of parental
overprotection and intrusiveness may be associated with separation anxiety disorder in both childhood
and adulthood.
 Life events: If one has lost someone very close to them due to death, divorce, illness, moving,
etc., they may develop a separation anxiety disorder.
 Family history: As genetics play a role in this disorder, having a family member with a
separation anxiety disorder or other anxiety-related condition, makes it more likely for an
individual to develop the same disorder

How is separation anxiety disorder treated?

Therapy and medication are used to treat SAD. Both treatment methods can help a child deal with
anxiety in a positive way.
Therapy
The most effective therapy is cognitive behavioral therapy (CBT). With CBT, children are taught
coping techniques for anxiety. Common techniques are deep breathing and relaxation.
Parent-child interaction therapy is another way to treat SAD. It has three main treatment phases:
 Child-directed interaction (CDI), which focuses on improving the quality of the parent-
child relationship. It involves warmth, attention, and praise. These help strengthen a child’s
feeling of safety.
 Bravery-directed interaction (BDI), which educates parents about why their child feels
anxiety. Your child’s therapist will develop a bravery ladder. The ladder shows situations that
cause anxious feelings. It establishes rewards for positive reactions.
 Parent-directed interaction (PDI), which teaches parents to communicate clearly with their
child. This helps to manage poor behavior.
The school environment is another key to successful treatment. Your child needs a safe place to go
when they feel anxious. There should also be a way for your child to communicate with you if
necessary during schools hours or other times when they’re away from home. Finally, your child’s
teacher should encourage interaction with other classmates. If you have concerns about your child’s
classroom, speak with the teacher, principle, or a guidance counselor.
1. The first-line treatment for separation anxiety disorder is talk therapy (psychotherapy),
especially the form known as cognitive behavioral therapy (CBT). CBT helps a person
understand how their thoughts affect their actions.
2. Other therapy options include:
 Dialectical behavioral therapy (DBT), which helps a person find a balance between
accepting who they are and welcoming change.
 Family therapy, which improves relationships among family members. In this case, it also
educates everyone in your family about separation anxiety disorder.
Medications
If talk therapy doesn’t help enough, you or your child may need medication. Your provider will
explain the exact type of medication that’s best and how long it’ll be needed.
Medications to treat separation anxiety disorder in children
Providers sometimes use selective serotonin reuptake inhibitors (SSRIs) to treat separation anxiety
disorder in children age 6 or older. Specific medications prescribed include:
 Fluoxetine (Prozac®).
 Sertraline (Zoloft®).
 Paroxetine (Paxil®, Pexeva®).
Possible adverse effects include insomnia, vomiting and changes in appetite. A more serious concern
with SSRI use in children is the increased risk for suicidal ideation.
Your child’s provider will keep a close eye on your child to look for signs they might be thinking
about suicide. They’ll want to see your child for regular follow-ups, as often as once a week during
the first month and then every other week during the second month. They’ll also tell you what to look
out for at home
Don’t hesitate to share questions or concerns with your child’s provider at any point in this process,
including before your child starts taking any medication.
Medications to treat separation anxiety disorder in adults
Your provider may prescribe antidepressants like SSRIs or anti-anxiety
medications like benzodiazepines.
Your provider will tell you more about the possible side effects and risks of specific medications
you’re taking. For example, benzodiazepines can be habit-forming. SSRIs may increase your risk for
suicidal thoughts or behavior, especially when you first start taking them.
All medications come with risks and benefits. You and your provider can work together to find the
best treatment option for you.
Social Phobia
What is the difference between social anxiety and social phobia?
There isn’t a significant difference between social anxiety disorder and social phobia. Social
anxiety disorder used to be called social phobia. Prior to 1994, a diagnosis of social phobia
meant you experienced fear and anxiety when performing in front of people. In 1994,
the Diagnostic and Statistical Manual of Mental Disorders (DSM) changed the name to
“social anxiety disorder” and expanded the criteria for diagnosis. It was changed to include
the fear and anxiety of being judged or watched by others in social situations, not just when
performing.

Introduction
Social anxiety disorder (formerly known as social phobia) is a mental health condition where
you experience intense and ongoing fear of being judged negatively and/or watched by
others. Social anxiety disorder (social phobia) is a medical condition that causes fear and
anxiety when you’re around people in social situations. People with social anxiety fear being
judged or watched by others. This disorder is treatable with talk therapy and medications such
as antidepressants.
If you have social anxiety disorder, you have anxiety or fear in specific or all social
situations, including:
 Meeting new people.
 Performing in front of people.
 Taking or making phone calls.
 Using public restrooms.
 Asking for help in a restaurant, store or other public place.
 Dating.
 Answering a question in front of people.
 Eating in front of people.
 Participating in an interview.
A core feature of social anxiety disorder is that you’re afraid of being judged, rejected and/or
humiliated.
Who does social anxiety affect?
Social anxiety disorder is a common mental health condition that can affect anyone. Most
people who have social anxiety disorder experience symptoms before they’re 20 years
old. Females experience higher rates of social anxiety than males.
How common is social anxiety disorder?
Social anxiety disorder isn’t uncommon. Approximately 5% to 10% of people across the
world have social anxiety disorder. It’s the third most common mental health condition
behind substance use disorder and depression.

Diagnostic Criteria
A. Marked fear or anxiety about one or more social situations in which the individual is
exposed to possible scrutiny by others. Examples include social interactions (e.g., having a
conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and
performing in front of others (e.g., giving a speech).
Note: In children, the anxiety must occur in peer settings and not just during interactions with
adults.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be
negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or
offend others).
C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,
clinging, shrinking, or failing to speak in social situations.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation
and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental
disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns
or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Specify if:
Performance only: If the fear is restricted to speaking or performing in public.
ICD 10 criteria

Specifiers
Individuals with the performance only type of social anxiety disorder have performance fears
that are typically most impairing in their professional lives (e.g., musicians, dancers,
performers, athletes) or in roles that require regular public speaking. Performance fears may
also manifest in work, school, or academic settings in which regular public presentations are
required. Individuals with performance only social anxiety disorder do not fear or avoid non-
performance social situations.
Risk and Prognostic Factors
Temperamental- Underlying traits that predispose individuals to social anxiety disorder
include behavioral inhibition and fear of negative evaluation, as well as harm avoidance.
Personality traits consistently associated with social anxiety disorder are high negative
affectivity (neuroticism) and low extraversion.
Environmental- There is evidence that negative social experiences, particularly peer
victimization, are associated with the development of social anxiety disorder, although causal
pathways remain unknown. Childhood maltreatment and adversity are risk factors for social
anxiety disorder. Among African Americans and Caribbean Blacks in the United States,
everyday forms of ethnic discrimination and racism are associated with social anxiety
disorder.
Genetic and physiological - Traits predisposing individuals to social anxiety disorder, such
as behavioral inhibition, are strongly genetically influenced. The genetic influence is subject
to gene-environment interaction; that is, children with high behavioral inhibition are more
susceptible to environmental influences, such as socially anxious modeling by parents. Also,
social anxiety disorder is heritable. First-degree relatives have a two to six times greater
chance of having social anxiety disorder, and liability to the disorder involves the interplay of
disorder specific (e.g., fear of negative evaluation) and nonspecific (e.g., negative affectivity
[neuroticism]) genetic factors. Genetic contribution to social anxiety disorder has been found
to be higher for social anxiety disorder in children than social anxiety disorder in adults and
higher for social anxiety symptoms than a clinical diagnosis of social anxiety disorder.
Causes
Like many other mental health conditions, social anxiety disorder likely arises from a
complex interaction of biological and environmental factors. Possible causes include:
 Inherited traits. Anxiety disorders tend to run in families. However, it isn't entirely
clear how much of this may be due to genetics and how much is due to learned
behavior.
 Brain structure. A structure in the brain called the amygdala (uh-MIG-duh-luh) may
play a role in controlling the fear response. People who have an overactive amygdala
may have a heightened fear response, causing increased anxiety in social situations.
 Environment. Social anxiety disorder may be a learned behaviour — some people
may develop significant anxiety after an unpleasant or embarrassing social situation.
Also, there may be an association between social anxiety disorder and parents who
either model anxious behaviour in social situations or are more controlling or
overprotective of their children.
What causes social anxiety disorder?
The exact cause of social anxiety disorder is unknown, but it may resultTrusted Source from
a combination of factors.
Physical, biological, and genetic factors likely play a role, according to scientists. Problems
with neurotransmitter systems may lead to imbalances in the hormones serotonin, dopamine,
and glutamate. These brain chemicals help regulate mood.
Environmental factors may contribute, but only as part of a complex interaction that also
involves biological and genetic features, some experts say.
Factors that may contribute include a history of:
 emotional, physical, or other kinds of abuse
 negative interactions with peers
 overcontrolling parenting styles
 having an insecure attachment style
Negative experiences may lead to a type of post-traumatic stress disorder (PTSD), where
social anxiety is a symptom.
Anxiety disorders can run in families, but it’s unclear whether this is due to genetic or
environmental factors.

Risk factors
Several factors can increase the risk of developing social anxiety disorder, including:
 Family history. You're more likely to develop social anxiety disorder if your
biological parents or siblings have the condition.
 Negative experiences. Children who experience teasing, bullying, rejection, ridicule
or humiliation may be more prone to social anxiety disorder. In addition, other
negative events in life, such as family conflict, trauma or abuse, may be associated
with this disorder.
 Temperament. Children who are shy, timid, withdrawn or restrained when facing
new situations or people may be at greater risk.
 New social or work demands. Social anxiety disorder symptoms typically start in the
teenage years, but meeting new people, giving a speech in public or making an
important work presentation may trigger symptoms for the first time.
 Having an appearance or condition that draws attention. For example, facial
disfigurement, stuttering or tremors due to Parkinson's disease can increase feelings of
self-consciousness and may trigger social anxiety disorder in some people.
Complications
Left untreated, social anxiety disorder can control your life. Anxieties can interfere with
work, school, relationships or enjoyment of life. This disorder can cause:
 Low self-esteem
 Trouble being assertive
 Negative self-talk
 Hypersensitivity to criticism
  Poor social skills
 Isolation and difficult social relationships
 Low academic and employment achievement
 Substance abuse, such as drinking too much alcohol
 Suicide or suicide attempts
Other anxiety disorders and certain other mental health disorders, particularly major
depressive disorder and substance abuse problems, often occur with social anxiety disorder.
Prevention
There's no way to predict what will cause someone to develop an anxiety disorder, but you
can take steps to reduce the impact of symptoms if you're anxious:
 Get help early. Anxiety, like many other mental health conditions, can be harder to
treat if you wait.
 Keep a journal. Keeping track of your personal life can help you and your mental
health professional identify what's causing you stress and what seems to help you feel
better.
 Set priorities in your life. You can reduce anxiety by carefully managing your time
and energy. Make sure that you spend time doing things you enjoy.
 Avoid unhealthy substance use. Alcohol and drug use and even caffeine or nicotine
use can cause or worsen anxiety. If you're addicted to any of these substances, quitting
can make you anxious. If you can't quit on your own, see your health care provider or
find a treatment program or support group to help you.

 What is the prognosis (outlook) for social anxiety disorder?

 People with social anxiety disorder respond very well to treatment, whether that’s in
the form of cognitive behavioral therapy (CBT), medication or both. Some people
who have social anxiety disorder may have to take medication for the rest of their
lives to manage their social anxiety. Others may only need to take medication or be in
psychological therapy for a certain amount of time.
 If left untreated, social anxiety disorder can be debilitating and can result in poor
education outcomes, declining job performance, lower-quality relationships and an
overall decreased quality of life. A large percentage of people who have social anxiety
disorder and don’t get treatment can develop major depression and/or alcohol use
disorder. Because of this, it’s very important to contact your healthcare provider and
seek treatment if you have symptoms of social anxiety.
Social Anxiety Disorder in Children and Adolescents
Social anxiety disorder is a persistent fear of embarrassment, ridicule, or humiliation in social
settings. Typically, affected children avoid situations that might provoke social scrutiny (eg,
school). Diagnosis is by clinical criteria. Treatment is with behavioural therapy; in severe
cases, selective serotonin reuptake inhibitors (SSRIs) are used.
Symptoms and Signs
The first symptoms of social anxiety disorder in adolescents may be excessive worrying
before attending a social event or excessive preparation for a class presentation. The first
symptoms in children may be tantrums, crying, freezing, clinging, or withdrawing in social
situations. Avoidant behaviours (eg, refusing to go to school, not going to parties, not eating
in front of others) can follow. Complaints often have a somatic focus (eg, “My stomach
hurts,” “I have a headache”). Some children have a history of many medical appointments
and evaluations in response to these somatic complaints.
Affected children are terrified that they will humiliate themselves in front of their peers by
giving the wrong answer, saying something inappropriate, becoming embarrassed, or even
vomiting. In some cases, social anxiety disorder emerges after an unfortunate and
embarrassing incident. In severe cases, children may refuse to talk on the telephone or even
refuse to leave the house.
Treatment
 Behavioural therapy
 Sometimes an anxiolytic
Behavioural therapy is the cornerstone of treatment for social anxiety disorder. Children
should not be allowed to miss school. Absence serves only to make them even more reluctant
to attend school.
If children and adolescents are not sufficiently motivated to participate in behavioral therapy
or do not respond adequately to it, an anxiolytic such as a selective serotonin reuptake
inhibitor (SSRI) may help (see table Medications for Long-Term Treatment of Anxiety and
Related Disorders). Treatment with an SSRI may reduce anxiety enough to facilitate
children’s participation in behavioural therapy.

Cognitive behavioural therapy (CBT): CBT helps you learn new ways to manage anxiety,
for example, how to replace negative thoughts with positive ones.
Acceptance and commitment therapy (ACT): In ACT people learn to use mindfulness,
acceptance, and behavioural strategies to be more present and figure out how to live a value-
based life despite negative feelings.
Group therapy or a support group: This helps you learn social skills and techniques to
interact with people in social settings. Working in a group will help you see that you’re not
alone and enable role play of practical solutions.
Exposure therapy: In this type of therapy, a healthcare professional will help you gradually
face social situations rather than avoiding them
Medication
Medications can help improve your symptoms and help you function in your daily life.
Medications that can treat social anxiety disorder includeTrusted Source:
 selective serotonin reuptake inhibitors (SSRIs) , such as paroxetine (Paxil)
and Sertraline (Zoloft)
 selective norepinephrine reuptake inhibitors (SNRIs), for example, venlafaxine
(Effexor)
 propanol
SSRIs and SNRIs can take several weeksTrusted Source to have an effect, but propanolol is a
short-acting drug that you can use when you need it.
You may start with a low dose and gradually increase your prescription to avoid side effects.
If you’re unhappy with one medication, the doctor may offer an alternative.
What medications are used to treat social anxiety disorder?
Antidepressants are effective for depression and anxiety disorders and are a frontline form of
treatment for social anxiety disorders. Anti-anxiety medications are typically used for shorter
periods of time. Blood pressure medication known as beta-blockers can be used for
symptoms of social anxiety disorder as well. Specific medications that are used to treat social
anxiety disorder include:
 SSRIs (selective serotonin reuptake inhibitors): SSRIs are a type of antidepressant.
Common SSRIs used to treat social anxiety disorder include fluoxetine
(Prozac®), sertraline (Zoloft®), paroxetine, citalopram and escitalopram.
 SNRIs (serotonin-norepinephrine reuptake inhibitors): SNRIs are another type of
antidepressant. Venlafaxine or duloxetine (Cymbalta®) are common SNRIs used to
treat social anxiety disorder.
 Benzodiazepines: These medications are used for short periods of time, either while
the antidepressants start to work or used on-demand in situations that provoke anxiety.
They aren’t intended to be used for long periods. Lorazepam or alprazolam are
examples of benzodiazepines.
 Beta-blockers: Some beta-blockers are used to treat or prevent physical symptoms of
anxiety, such as a fast heart rate. Propranolol or metoprolol are examples of beta-
blockers.
It could take time to figure out the best dosage and type of medication for you. Know that
starting the process of treating your social anxiety disorder brings you one step closer to
feeling better.
Selective Mutism
Introduction
Having selective mutism means some social situations cause so much fear or anxiety that you
find speaking difficult or impossible. This anxiety disorder usually starts in childhood, but the
effects can be lifelong. Identifying and treating this condition quickly improves its overall
outlook, especially during early childhood.
What is selective mutism?
Selective mutism (SM) is a mental health condition where you can’t talk in certain situations
because of fear or anxiety. It usually affects young children, but it can also affect adolescents
and adults.
This condition is more than being shy, bashful or timid. SM is an anxiety disorder. It can
overlap with other anxiety-related conditions and have lingering effects later in life.

Diagnostic Criteria
A. Consistent failure to speak in specific social situations in which there is an expectation for
speaking (e.g., at school) despite speaking in other situations.
B. The disturbance interferes with educational or occupational achievement or with social
communication.
C. The duration of the disturbance is at least 1 month (not limited to the first month of
school).
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the
spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder (e.g., childhood-onset
fluency disorder) and does not occur exclusively during the course of autism spectrum
disorder, schizophrenia, or another psychotic disorder.
Diagnosis in children
A child can successfully overcome selective mutism if it's diagnosed at an early age
and appropriately managed.
It's important for selective mutism to be recognised early by families and schools so they can
work together to reduce a child's anxiety. Staff in early years settings and schools may receive
training so they're able to provide appropriate support.
If you suspect your child has selective mutism and help is not available, or there are
additional concerns – for example, the child struggles to understand instructions or follow
routines – speak to a GP and ask them to refer you to a local specialist service for a formal
diagnosis.
You can also contact a speech and language therapy clinic directly. Do not accept the opinion
that your child will grow out of it or they are "just shy".
Your GP or local integrated care board (ICB) should be able to give you the telephone
number of your nearest NHS speech and language therapy service or another specialist
service that can help in your area.
Your child may also need to see a mental health professional or school educational
psychologist.
The clinician may initially want to talk to you without your child present, so you can speak
freely about any anxieties you have about your child's development or behaviour.
They'll want to find out whether there's a history of anxiety disorders in the family, and
whether anything is causing distress, such as a disrupted routine or difficulty learning a
second language. They'll also look at behavioural characteristics and take a full medical
history.
A person with selective mutism may not be able to speak during their assessment, but the
clinician should be prepared for this and be willing to find another way to communicate.
For example, they may encourage a child with selective mutism to communicate through
their parents, or suggest that older children or adults write down their responses or use a
computer. They may watch the child playing or watch a video of them speaking in a
comfortable environment.
Diagnosis in adults
It's possible for adults to overcome selective mutism, although they may continue to
experience the psychological and practical effects of spending years without social interaction
or not being able to reach their academic or occupational potential.
Adults will ideally be seen by a mental health professional with access to support from a
speech and language therapist or another knowledgeable professional.
Diagnosis guidelines
Selective mutism is diagnosed according to specific guidelines. These include observations
about the person concerned as outlined:
 they do not speak in specific situations, such as during school lessons or when they
can be overheard in public
 they can speak normally in situations where they feel comfortable, such as when
they're alone with parents at home, or in their empty classroom or bedroom
 their inability to speak to certain people has lasted for at least 1 month (2 months in a
new setting)
 their inability to speak interferes with their ability to function in that setting
 their inability to speak is not better explained by another behavioural, mental or
communication disorder
Associated difficulties
A child with selective mutism will often have other fears and social anxieties, and they may
also have additional speech and language difficulties.
They're often wary of doing anything that draws attention to them because they think that by
doing so, people will expect them to talk.
For example, a child may not do their best in class after seeing other children being asked to
read out good work, or they may be afraid to change their routine in case this provokes
comments or questions. Many have a general fear of making mistakes.
Accidents and urinary infections may result from being unable to ask to use the toilet and
holding on for hours at a time. School-aged children may avoid eating and drinking
throughout the day so they do not need to excuse themselves.
Children may have difficulty with homework assignments or certain topics because they're
unable to ask questions in class.
Teenagers may not develop independence because they're afraid to leave the house
unaccompanied. And adults may lack qualifications because they're unable to participate in
college life or subsequent interviews.

Symptoms and Causes

Selective mutism makes you talk less or feel unable to talk in situations where you aren’t
comfortable. Otherwise, you have no difficulty with talking.
What are the symptoms of selective mutism?
The “selective” in this condition’s name means it only happens in certain situations
(remember that it’s not a willful or deliberate choice not to talk). If you have SM, you have
no trouble talking in comfortable situations. However, you consistently find talking difficult
or impossible in uncomfortable situations.
The symptoms can take different forms. Some people are completely unable to talk (or nearly
so). Others may communicate less or in limited ways.
Total or near-total inability to communicate
This is going to great lengths to avoid communicating or avoiding it entirely. It can look like:
 Feeling unable to speak. It can happen because you feel overwhelmed or paralyzed by
fear or anxiety. It can appear that you’re refusing to talk, but is an “autopilot”
response rather than a deliberate choice.
 Tense or stiff posture, freezing or feeling unable to move.
 A “deer in the headlights” or blank expression.
 Avoiding eye contact.
 Avoiding social interactions or not participating in them.
 Not asking for things wanted or needed (such as a child in school not asking a teacher
if they can go to the bathroom, leading to daytime wetting).
 Behaving disruptively (such as throwing temper tantrums) to avoid talking.
Nonverbal communication
  Preferring to use widely understood sounds (such as “uh-uh” for “no” and “uh-huh”
for yes) or other noises instead of words.
 Using nonverbal communication to avoid talking (such as writing responses or
pointing to things in a book).
 Using gestures or other movements (such as facial expressions, pointing, miming, or
nodding or shaking your head) rather than words.
Minimal or reduced communication
 Slowed responses.
 Using single-word responses or very short sentences.
 Mumbling, stuttering or whispering.
 Changing one’s voice (speaking in a robot-like voice or changing one’s natural pitch
and tone).
Other symptoms[
Besides lack of speech, other common behaviors and characteristics displayed by selectively
mute people, according to Elisa Shipon-Blum's findings, include:
 Shyness, social anxiety, fear of social embarrassment or social isolation and
withdrawal
 Difficulty maintaining eye contact
 Blank expression and reluctance to smile or incessant smiling
 Difficulty expressing feelings, even to family members
 Tendency to worry more than most people of the same age
 Sensitivity to noise and crowds
On the flip side, there are some positive traits observed in many cases:
 Above average intelligence, inquisitiveness, or perception
 A strong sense of right and wrong
 Creativity
 Love for the arts
 Empathy
 Sensitivity for other people
What causes selective mutism?
Most children and adults with selective mutism are hypothesized to have an inherited
predisposition to anxiety. They often have inhibited temperaments, which is hypothesized to
be the result of over-excitability of the area of the brain called the amygdala.[16] This area
receives indications of possible threats and sets off the fight-or-flight response. Behavioral
inhibitions, or inhibited temperaments, encompass feelings of emotional distress and social
withdrawals. In a 2016 study,[17] the relationship between behavioral inhibition and selective
mutism was investigated. Children between the ages of three and 19 with lifetime selective
mutism, social phobia, internalizing behavior, and healthy controls were assessed using the
parent-rated Retrospective Infant Behavioral Inhibition (RIBI) questionnaire, consisting of 20
questions that addressed shyness and fear, as well as other subscales. The results indicated
behavioral inhibition does indeed predispose selective mutism. Corresponding with the
researchers’ hypothesis, children diagnosed with long-term selective mutism had a higher
behavioral inhibition score as an infant. This is indicative of the positive correlation between
behavioral inhibition and selective mutism.
Experts can’t fully explain why SM happens. However, they suspect several possible factors
may cause or contribute to it. These include:
Other mental health conditions
SM has strong connections to other mental health conditions. These aren’t necessarily causes.
They’re simply more likely to happen in people with SM. These conditions include:
 Social anxiety disorder. This is extremely common in people who have SM. Experts
estimate that 75% to 100% of people with SM also have this.
 Phobias.
 Other anxiety disorders.
 Autism spectrum disorder.
 Separation anxiety.
  Post-traumatic stress disorder (PTSD).
Family history or genetics
Anxiety disorders can run in families. People with SM are much more likely to have a first-
degree relative (a parent, sibling or child) with SM or another anxiety disorder.
Other communication disorders
Some children develop SM because of anxiety related to how they talk or how well they
understand others (like from auditory processing disorders or learning delays).
Children can also develop SM because of speech disorders (like stuttering or other forms
of fluency disorder). Some children develop SM because they don’t like their voice or feel
anxious about how they sound.
Social circumstances
Children with certain social factors or circumstances are more likely to develop SM. These
include:
 Being bullied.
 Traumatic events or abuse.
 Family problems (such as emotional, verbal or physical violence in the home).
 Immigrating to a place with a different primary language.
What are the complications of selective mutism?
SM can negatively affect your life in many ways. These can include:
 Social difficulties, loneliness or isolation.
 Developing other anxiety-related conditions or symptoms.
 Impacts on academic achievement or work performance.
Diagnosis and Tests
How is selective mutism diagnosed?
A mental health provider, like a psychiatrist or psychologist, will usually diagnose SM. Other
providers, especially speech-language pathologists or speech therapists, may rule out other
conditions to help with the diagnosis.
A provider makes this diagnosis based on symptoms and behaviors. They’ll ask questions
about your (or your child’s) experiences and other factors that could contribute to this
condition.
Your provider will typically use screening questionnaires, checklists or other tools to help
determine if you meet the criteria. The American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders, fifth edition text revision™(often referred to as “the
DSM-5®”) has five criteria that you must meet to receive a diagnosis of SM:
  You consistently don’t talk in social situations where it’s expected, but have no
trouble talking in other situations.
 Not talking affects your social, educational or work life, or any combination of the
three.
 The inability to talk lasts longer than one month.
 Not talking isn’t because you have trouble speaking or understanding the main
language others are using.
 Your difficulty talking isn’t because of another communication disorder
like stuttering, and it isn’t only happening in connection with autism spectrum
disorder, schizophrenia spectrum disorders or other conditions that involve psychosis.
Management and Treatment
How is selective mutism treated, and is there a cure?
With treatment, it’s possible to reduce the severity and frequency of symptoms. With early
diagnosis and treatment, some people may see the symptoms vanish entirely.
The most common treatment approaches are:
Mental health therapy
Mental health therapy (especially cognitive behavioral therapy, or CBT) is generally the first
option. It’s also the most likely to help. Behavioral therapy helps you understand and cope
with anxiety and other distressing feelings that cause SM symptoms. It can also help with
modifying tantrums or other disruptive behaviors that can happen with SM.
For children, these forms of therapy should involve the people raising them, too. Parental
figures (including legal guardians or other loved ones) can contribute to the success of mental
health therapy.
Speech therapy
Speech therapy involves working with a speech therapist or another specialized healthcare
professional. It can be particularly helpful when SM happens with speech disorders.
Medications
Medications can be part of treatment for SM, especially if mental health or speech therapy
aren’t effective on their own.
The most common medications for treating SM are selective-serotonin reuptake inhibitors
(SSRIs). These mainly treat depression but can also treat anxiety-related disorders, including
SM. Other medications may also help. Your healthcare provider (or your child’s provider) can
tell you more about these and help you choose.
Complications/side effects of medications
Your healthcare provider is the best person to tell you about the possible side effects and
complications of the specific medication(s) you’re taking, and what you can do to limit or
avoid those effects.
Outlook / Prognosis
What can I expect if my child or I have SM?
In children, SM can affect how they do in school, socialize and make friends. It can also
cause children to avoid talking even when it’s important.
If you have SM as an adult, it can continue to have negative effects. SM can keep you from
making friends or developing relationships (social, work, romantic, etc.). It can also affect
how you do at school or at work.
How long does selective mutism last?
For many people, the symptoms seem to disappear by adulthood. The symptoms can still be
there, but shift and look more like another anxiety disorder (especially social anxiety
disorder).
What’s the outlook for selective mutism?
The outlook for SM is good overall, especially with early diagnosis and treatment. When
diagnosed and treated in early childhood, most people with SM can overcome or learn to
cope with it, so it doesn’t affect their lives as much (or at all).
When SM goes undetected or untreated, the outlook is less positive. It isn’t dangerous, but
the negative effects can be significant. People with SM often experience anxiety and
depression. Some struggle with social situations and feel lonely or isolated. It can also affect
their education, career and other important parts of their lives.

Treatment
[edit]
Contrary to popular belief, people with selective mutism do not necessarily improve with age.
[22]
Effective treatment is necessary for a child to develop properly. Without treatment,
selective mutism can contribute to chronic depression, further anxiety, and other social and
emotional problems.[23][24][25]
Consequently, treatment at an early age is important. If not addressed, selective mutism tends
to be self-reinforcing. Others may eventually expect an affected child to not speak and
therefore stop attempting to initiate verbal contact. Alternatively, they may pressure the child
to talk, increasing their anxiety levels in situations where speech is expected. Due to these
problems, a change of environment may be a viable consideration. However, changing school
is worth considering only if the alternative environment is highly supportive, otherwise a
whole new environment could also be a social shock for the individual or deprive them of any
friends or support they have currently. Regardless of the cause, increasing awareness and
ensuring an accommodating, supportive environment are the first steps towards effective
treatment. Most often affected children do not have to change schools or classes and have no
difficulty keeping up except on the communication and social front. Treatment in teenage or
adult years can be more difficult because the affected individual has become accustomed to
being mute, and lacks social skills to respond to social cues.[citation needed]
The exact treatment depends on the person's age, any comorbid mental illnesses, and a
number of other factors. For instance, stimulus fading is typically used with younger children
because older children and teenagers recognize the situation as an attempt to make them
speak, and older people with this condition and people with depression are more likely to
need medication.[26]
Like other disabilities, adequate accommodations are needed for those with the condition to
succeed at school, work, and in the home. In the United States, under the Individuals with
Disabilities Education Act (IDEA), a federal law, those with the disorder qualify for services
based upon the fact that they have an impairment that hinders their ability to speak, thus
disrupting their lives. This assistance is typically documented in the form of an Individualized
Education Program (IEP). Post-secondary accommodations are also available for people with
disabilities.[citation needed]
Under another law in the US, Section 504 of the Rehabilitation Act of 1973, public school
districts are required to provide a free, appropriate public education to every "qualified
handicapped person" residing within their jurisdiction. If the child is found to have
impairments that substantially limit a major life activity (in this case, learning), the education
agency has to decide what related aids or services are required to provide equal access to the
learning environment.[27]
Social Communication Anxiety Treatment (S-CAT) is a common treatment approach by
professionals and has proven to be successful. [28] S-CAT integrates components of behavioral-
therapy, cognitive-behavioral therapy (CBT), and an insight-oriented approach to increase
social communication and promote social confidence. Tactics such as systemic
desensitization, modeling, fading, and positive reinforcement enable individuals to develop
social engagement skills and begin to progress communicatively in a step-by-step manner.
There are many treatment plans that exist and it is recommended for families to do thorough
research before deciding on their treatment approach.[citation needed]
Self-modeling
[edit]
An affected child is brought into the classroom or the environment where the child will not
speak and is videotaped. First, the teacher or another adult prompts the child with questions
that likely will not be answered. A parent, or someone the child feels comfortable speaking to,
then replaces the prompter and asks the child the same questions, this time eliciting a verbal
response. The two videos of the conversations are then edited together to show the child
directly answering the questions posed by the teacher or other adult. This video is then shown
to the child over a series of several weeks, and every time the child sees themself verbally
answering the teacher/other adult, the tape is stopped and the child is given positive
reinforcement.[citation needed]
Such videos can also be shown to affected children's classmates to set an expectation in their
peers that they can speak. The classmates thereby learn the sound of the child's voice and,
albeit through editing, have the opportunity to see the child conversing with the teacher. [29][30]
Mystery motivators
[edit]
Mystery motivation is often paired with self-modeling. An envelope is placed in the child's
classroom in a visible place. On the envelope, the child's name is written along with a
question mark. Inside is an item that the child's parent has determined to be desirable to the
child. The child is told that when they ask for the envelope loudly enough for the teacher and
others in the classroom to hear, the child will receive the mystery motivator. The class is also
told of the expectation that the child ask for the envelope loudly enough that the class can
hear.[29][30][31]
Stimulus fading
[edit]
Affected subjects can be brought into a controlled environment with someone with whom
they are at ease and can communicate. Gradually, another person is introduced into the
situation. One example of stimulus fading is the sliding-in technique,[22] where a new person
is slowly brought into the talking group. This can take a long time for the first one or two
faded-in people but may become faster as the patient gets more comfortable with the
technique.
As an example, a child may be playing a board game with a family member in a classroom at
school. Gradually, the teacher is brought in to play as well. When the child adjusts to the
teacher's presence, then a peer is brought in to be a part of the game. Each person is only
brought in if the child continues to engage verbally and positively.[29][30][31]
Desensitization
[edit]
The subject communicates indirectly with a person to whom they are afraid to speak through
such means as email, instant messaging (text, audio or video), online chat, voice or video
recordings, and speaking or whispering to an intermediary in the presence of the target
person. This can make the subject more comfortable with the idea of communicating with this
person.
Shaping
[edit]
The subject is slowly encouraged to speak. The subject is reinforced first for interacting
nonverbally, then for saying certain sounds (such as the sound that each letter of the alphabet
makes) rather than words, then for whispering, and finally saying a word or more.[32]
Spacing
[edit]
Spacing is important to integrate, especially with self-modeling. Repeated and spaced out use
of interventions is shown to be the most helpful long-term for learning. Viewing videotapes
of self-modeling should be shown over a spaced out period of time of approximately 6 weeks.
[29][30][31]

Drug treatments
[edit]
Some practitioners believe there would be evidence indicating anxiolytics to be helpful in
treating children and adults with selective mutism, [33] to decrease anxiety levels and thereby
speed the process of therapy. Use of medication may end after nine to twelve months, once
the person has learned skills to cope with anxiety and has become more comfortable in social
situations.[citation needed] Medication is more often used for older children, teenagers, and adults
whose anxiety has led to depression and other problems.
Medication, when used, should never be considered the entire treatment for a person with
selective mutism. However, the reason why medication needs to be considered as a treatment
at all is because selective mutism is still prevalent, despite psychosocial efforts. But while on
medication, the person should still be in therapy to help them learn how to handle anxiety and
prepare them for life without medication, as medication is typically a short-term solution.
[citation needed]

Since selective mutism is categorized as an anxiety disorder, using similar medication to treat
either makes sense. Antidepressants have been used in addition to self-modeling and mystery
motivation to aid in the learning process. [further explanation needed][29][30] Furthermore, SSRIs in
particular have been used to treat selective mutism. In a systematic review, ten studies were
looked at which involved SSRI medications, and all reported medication was well tolerated.
[34]
In one of them, Black and Uhde (1994) conducted a double-blind, placebo-controlled
study investigating the effects of fluoxetine. By parent report, fluoxetine-treated children
showed significantly greater improvement than placebo-treated children. In another, Dummit
III et al. (1996) administered fluoxetine to 21 children for nine weeks and found that 76% of
the children had reduced or no symptoms by the end of the experiment. [35] This indicates that
fluoxetine is an SSRI that is indeed helpful in treating selective mutism.

Treating selective mutism

With appropriate handling and treatment, most children are able to overcome selective
mutism. But the older they are when the condition is diagnosed, the longer it will take.
The effectiveness of treatment will depend on:
 how long the person has had selective mutism
 whether or not they have additional communication or learning difficulties or
anxieties
  the co-operation of everyone involved with their education and family life
Treatment does not focus on the speaking itself, but reducing the anxiety associated with
speaking.
This starts by removing pressure on the person to speak. They should then gradually progress
from relaxing in their school, nursery or social setting, to saying single words and sentences
to one person, before eventually being able to speak freely to all people in all settings.
The need for individual treatment can be avoided if family and staff in early years settings
work together to reduce the child's anxiety by creating a positive environment for them.
This means:
 not letting the child know you're anxious
 reassuring them that they'll be able to speak when they're ready
 concentrating on having fun
 praising all efforts the child makes to join in and interact with others, such as passing
and taking toys, nodding and pointing
 not showing surprise when the child speaks, but responding warmly as you would to
any other child
As well as these environmental changes, older children may need individual support to
overcome their anxiety.
Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) helps a person focus on how they think about
themselves, the world and other people, and how their perception of these things affects their
thoughts and feelings. CBT also challenges fears and preconceptions through graded
exposure.
Behavioural therapy
Behavioural therapy concentrates on helping combat current difficulties using a gradual step-
by-step approach to help conquer fears.
Techniques
There are several techniques based on CBT and behavioural therapy that are useful in treating
selective mutism. These can be used at the same time by individuals, family members and
school or college staff, possibly under the guidance of a speech and language therapist or
psychologist.
Graded exposure
In graded exposure, situations causing the least anxiety are tackled first. With realistic targets
and repeated exposure, the anxiety associated with these situations decreases to a manageable
level.
Older children and adults are encouraged to work out how much anxiety different situations
cause, such as answering the phone or asking a stranger the time.
Stimulus fading
In stimulus fading, the person with selective mutism communicates at ease with someone,
such as their parent, when nobody else is present.
Another person is gradually introduced into the situation and, once they're included in
talking, the parent withdraws. The new person can introduce more people in the same way.
Shaping
Shaping involves using any technique that enables the person to gradually produce a response
that's closer to the desired behaviour.
For example, starting with non-verbal communication, gradually moving to making eye
contact, saying short words and then longer sentences and, finally, 2-way conversation.
Positive and negative reinforcement
Positive and negative reinforcement involves responding favourably to all forms of
communication and not inadvertently encouraging avoidance and silence.
If the child is under pressure to talk, they'll experience great relief when the moment passes,
which will strengthen their belief that talking is a negative experience.
Desensitisation
Desensitisation is a technique that involves reducing the person's sensitivity to other people
hearing their voice by sharing voice or video recordings.
For example, email or instant messaging could progress to an exchange of voice recordings
or voicemail messages, then more direct communication, such as telephone or Skype
conversations.
You could also record your child at home and encourage them to watch or listen to
themselves speaking.
Medicine
Medicine is only really appropriate for older children, teenagers and adults whose anxiety has
led to depression and other problems.
Medicine should never be prescribed as an alternative to environmental changes and
behavioural approaches. Though some health professionals recommend using a combination
of medicine and behavioural therapies in adults with selective mutism.
However, antidepressants may be used alongside a treatment programme to decrease anxiety
levels, particularly if previous attempts to engage the individual in treatment have failed.
Advice for parents
 Do not pressurise or bribe your child to encourage them to speak.
  Let your child know you understand they're scared to speak and have difficulty
speaking at times. Tell them they can take small steps when they feel ready and
reassure them that talking will get easier.
 Do not praise your child publicly for speaking because this can cause embarrassment.
Wait until you're alone with them and consider a special treat for their achievement.
 Reassure your child that non-verbal communication, such as smiling and waving, is
fine until they feel better about talking.
 Do not avoid parties or family visits, but consider what environmental changes are
necessary to make the situation more comfortable for your child.
 Ask friends and relatives to give your child time to warm up at his or her own pace
and focus on fun activities rather than getting them to talk.
 As well as verbal reassurance, give them love, support and patience.

How is selective mutism treated?

Treatment varies based on the needs of your child, and may include:
 Stimulus fading. Involve the child in a relaxed situation with someone they can talk
to freely. Then very slowly bring someone new into the room.
 Shaping. Using a structured approach to reinforce and encourage all efforts by your
child to communicate, such as with gestures or whispering, until audible speech is
achieved.
 Self-modeling. This is done by having your child watch a video of themself
communicating well at home to raise self-confidence.
 Speech therapy. This can be done for any underlying speech problems, if needed.
 Family and behavioral therapy. These can help with emotional issues. Some
medicines may be used to lower anxiety.
 Speaking with your child’s teachers. Your child’s teachers can help make
communication at school less scary. For example, a teacher may have your child only
speak in small groups at first, instead of to the whole class.
With treatment, a child is likely to stop having selective mutism. With no treatment, the
speaking problems are more likely to continue
Obsessive Compulsive Disorders
Introduction
Obsessive-compulsive disorder (OCD) features a pattern of unwanted thoughts and fears
known as obsessions. These obsessions lead you to do repetitive behaviors, also called
compulsions. These obsessions and compulsions get in the way of daily activities and cause a
lot of distress.
Ultimately, you feel driven to do compulsive acts to ease your stress. Even if you try to
ignore or get rid of bothersome thoughts or urges, they keep coming back. This leads you to
act based on ritual. This is the vicious cycle of OCD.

What is obsessive-compulsive disorder (OCD)?

Obsessive-compulsive disorder (OCD) is a condition in which you have frequent unwanted
thoughts and sensations (obsessions) that cause you to perform repetitive behaviors
(compulsions). The repetitive behaviors can significantly interfere with social interactions
and performing daily tasks.
OCD is usually a life-long (chronic) condition, but symptoms can come and go over time.
Everyone experiences obsessions and compulsions at some point. For example, it’s common
to occasionally double-check the stove or the locks. People also often use the phrases
“obsessing” and “obsessed” very casually in everyday conversations. But OCD is more
extreme. It can take up hours of a person’s day. It gets in the way of normal life and activities.
Obsessions in OCD are unwanted, and people with OCD don’t enjoy performing compulsive
behaviours.
Obsessions in OCD
In OCD, obsessions are unwanted, intrusive thoughts or mental images that cause intense
anxiety. People with OCD can’t control these thoughts. Most people with OCD realize that
these thoughts are illogical or irrational.
Common examples include:
 Fear of coming into contact with perceived contaminated substances, such as germs or
dirt.
 Fear of causing harm to yourself or someone else because you’re not careful enough
or you’re going to act on a violent impulse.
 Unwanted thoughts or mental images related to sex.
 Fear of making a mistake.
 Excessive concern with morality (“right or wrong”).
 Feelings of doubt or disgust.
 Need for order, neatness, symmetry or perfection.
 Need for constant reassurance.
Compulsions in OCD
In OCD, compulsions are repetitive actions that you feel like you have to do to ease or get rid
of the obsessions.
People with OCD don’t want to perform these compulsive behaviors and don’t get pleasure
from them. But they feel like they have to perform them or their anxiety will get worse.
Compulsions only help temporarily, though. The obsessions soon come back, triggering a
return to the compulsions.
Compulsions are time-consuming and get in the way of important activities that you value.
They don’t have to match the content of your obsessions.
Examples include:
 Arranging things in a very specific way, such as items on your dresser.
 Bathing, cleaning or washing your hands over and over.
 Collecting or hoarding items that have no personal or financial value.
 Repeatedly checking things, such as locks, switches and doors.
 Constantly checking that you haven’t caused someone harm.
 Constantly seeking reassurance.
 Rituals related to numbers, such as counting, doing a task a specific amount of times,
or excessively preferring or avoiding certain numbers.
 Saying certain words or prayers while doing unrelated tasks.
Compulsions can also include avoiding situations that trigger obsessions. One example is
refusing to shake hands or touch objects that other people touch a lot, like doorknobs.

Obsessive-Compulsive Disorder
Diagnostic Criteria
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time
during the disturbance, as intrusive and unwanted, and that in most individuals cause marked
anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to
neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g.,
praying, counting, repeating words silently) that the individual feels driven to perform in
response to an obsession or according to rules that must be applied rigidly.
2. The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or
preventing some dreaded event or situation; however, these behaviors or mental acts are not
connected in a realistic way with what they are designed to neutralize or prevent, or are
clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per
day) or cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g.,
excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in
body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding
disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in
excoriation [skinpicking] disorder; stereotypies, as in stereotypic movement disorder;
ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling,
as in substance-related and addictive disorders; preoccupation with having an illness, as in
illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in
disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive
disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and
other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive disorder
beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably
true.
With absent insight/delusional beliefs: The individual is completely convinced that
obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder.
Risk factors
Factors that may raise the risk of causing obsessive-compulsive disorder include:
 Family history. Having parents or other family members with the disorder can raise
your risk of getting OCD.
 Stressful life events. If you've gone through traumatic or stressful events, your risk
may increase. This reaction may cause the intrusive thoughts, rituals and emotional
distress seen in OCD.
 Other mental health disorders. OCD may be related to other mental health disorders,
such as anxiety disorders, depression, substance abuse or tic disorders.
What causes OCD?
Researchers don’t know what exactly causes OCD. But they think several factors contribute
to its development, including:
 Genetics: Studies show that people who have a first-degree relative (biological parent
or sibling) with OCD are at a higher risk for developing the condition. The risk
increases if the relative developed OCD as a child or teen.
 Brain changes: Imaging studies have shown differences in the frontal cortex and
subcortical structures of the brain in people who have OCD. OCD is also associated
with other neurological conditions that affect similar areas of your brain,
including Parkinson’s disease, Tourette’s syndrome and epilepsy.
 PANDAS syndrome: PANDAS is short for “pediatric autoimmune neuropsychiatric
disorders associated with streptococcal infections.” It describes a group of conditions
that can affect children who have had strep infections, such as strep throat or scarlet
fever. OCD is one of these conditions.
 Childhood trauma: Some studies show an association between childhood trauma,
such as abuse or neglect, and the development of OCD.
 Learning. Obsessive fears and compulsive behaviors can be learned from watching
family members or learning them over time.
Complications
Issues due to obsessive-compulsive disorder include:
 Excessive time spent taking part in ritualistic behaviors.
 Health issues, such as contact dermatitis from frequent hand-washing.
 Having a hard time going to work or school or taking part in social activities.
 Troubled relationships.
 Poor quality of life.
 Thoughts about suicide and behavior related to suicide.

Management and Treatment

How is OCD treated?
The most common treatment plan for OCD involves psychotherapy (talk therapy) and
medication.
If this treatment doesn’t help your OCD symptoms and your symptoms are severe, your
provider may recommend transcranial magnetic stimulation (TMS).
Psychotherapy for OCD
Psychotherapy, also called talk therapy, is a term for a variety of treatment techniques that
aim to help you identify and change unhealthy emotions, thoughts and behaviors. You work
with a mental health professional, such as a psychologist.
There are several types of psychotherapy. The most common and effective forms for treating
OCD include:
 Cognitive behavioral therapy (CBT): During CBT, a therapist will help you
examine and understand your thoughts and emotions. Over several sessions, CBT can
help alter harmful thoughts and stop negative habits, perhaps replacing them with
healthier ways to cope.
 Exposure and response prevention (ERP): ERP is a type of CBT. During ERP, a
therapist exposes you to your feared situations or images and has you resist the urge
to perform a compulsion. For example, your therapist may ask you to touch dirty
objects but then stop you from washing your hands. By staying in a feared situation
without anything negative happening, you learn that your anxious thoughts are just
thoughts and not necessarily reality.
 Acceptance and commitment therapy (ACT): ACT helps you learn to accept
obsessive thoughts as just thoughts, taking the power away from them. An ACT
therapist will help you learn to live a meaningful life despite your OCD symptoms.
Mindfulness techniques such as meditation and relaxation can also help with symptoms.
Medication for OCD
Medications called serotonin reuptake inhibitors (SRIs), selective SRIs (SSRIs) and tricyclic
antidepressants may help treat OCD.
Healthcare providers most often recommend SSRIs for OCD and prescribe them at much
higher doses than they do for anxiety or depression. U.S. Food and Drug Administration
(FDA)-approved SSRIs include:
 Fluoxetine.
 Fluvoxamine.
 Paroxetine.
 Sertraline.
It may take up to eight to 12 weeks for these medications to start working.

How do I take care of myself if I have OCD?

Aside from seeking medical treatment for OCD, practicing self-care can help manage your
symptoms. Examples include:
  Getting quality sleep.
 Exercising regularly.
 Eating a healthy diet.
 Spending time with loved ones who support you and understand OCD.
 Practicing relaxation techniques, such as meditation, yoga, massage and visualization.
 Joining an in-person or online support group for people who have OCD.

Outlook / Prognosis
What is the prognosis of OCD?
The prognosis (outlook) of OCD can vary. OCD is often a lifelong condition that can wax
and wane.
People with OCD who receive appropriate treatment often experience increased quality of
life and improved social, school and/or work functioning.
If you don’t receive treatment, the cycle of obsessions and compulsions is more difficult to
break and treat, as structural changes in your brain take place. Because of this, it’s key to seek
medical care as soon as possible if you or your child experience symptoms.
Depressive Disorders
Introduction
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest.
Also called major depressive disorder or clinical depression, it affects how you feel, think and
behave and can lead to a variety of emotional and physical problems. You may have trouble
doing normal day-to-day activities, and sometimes you may feel as if life isn't worth living.
More than just a bout of the blues, depression isn't a weakness and you can't simply "snap
out" of it. Depression may require long-term treatment. But don't get discouraged. Most
people with depression feel better with medication, psychotherapy or both.
Depressive disorders include disruptive mood dysregulation disorder, major depressive
disorder (including major depressive episode), persistent depressive disorder, premenstrual
dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder
due to another medical condition, other specified depressive disorder, and unspecified
depressive disorder. The common feature of all of these disorders is the presence of sad,
empty, or irritable mood, accompanied by related changes that significantly affect the
individual’s capacity to function (e.g., somatic and cognitive changes in major depressive
disorder and persistent depressive disorder). What differs among them are issues of duration,
timing, or presumed etiology.

What are the types of depression?

The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) classifies depressive disorders as the following:
 Clinical depression (major depressive disorder): A diagnosis of major depressive
disorder means you’ve felt sad, low or worthless most days for at least two weeks
while also having other symptoms such as sleep problems, loss of interest in activities
or change in appetite. This is the most severe form of depression and one of the most
common forms.
 Persistent depressive disorder (PDD): Persistent depressive disorder is mild or
moderate depression that lasts for at least two years. The symptoms are less severe
than major depressive disorder. Healthcare providers used to call PDD dysthymia.
 Disruptive mood dysregulation disorder (DMDD): DMDD causes chronic, intense
irritability and frequent anger outbursts in children. Symptoms usually begin by the
age of 10.
 Premenstrual dysphoric disorder (PMDD): With PMDD, you have premenstrual
syndrome (PMS) symptoms along with mood symptoms, such as extreme irritability,
anxiety or depression. These symptoms improve within a few days after
your period starts, but they can be severe enough to interfere with your life.
  Depressive disorder due to another medical condition: Many medical conditions
can create changes in your body that cause depression. Examples
include hypothyroidism, heart disease, Parkinson’s disease and cancer. If you’re able
to treat the underlying condition, the depression usually improves as well.
There are also specific forms of major depressive disorder, including:
 Seasonal affective disorder (seasonal depression): This is a form of major
depressive disorder that typically arises during the fall and winter and goes away
during the spring and summer.
 Prenatal depression and postpartum depression: Prenatal depression is depression
that happens during pregnancy. Postpartum depression is depression that develops
within four weeks of delivering a baby. The DSM refers to these as “major depressive
disorder (MDD) with peripartum onset.”
 Atypical depression: Symptoms of this condition, also known as major depressive
disorder with atypical features, vary slightly from “typical” depression. The main
difference is a temporary mood improvement in response to positive events (mood
reactivity). Other key symptoms include increased appetite and rejection sensitivity.
People with bipolar disorder also experience episodes of depression in addition
to manic or hypomanic episodes.
Causes
It's not known exactly what causes depression. As with many mental disorders, a variety of
factors may be involved, such as:
 Biological differences. People with depression appear to have physical changes in
their brains. The significance of these changes is still uncertain but may eventually
help pinpoint causes.
 Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that
likely play a role in depression. Recent research indicates that changes in the function
and effect of these neurotransmitters and how they interact with neurocircuits
involved in maintaining mood stability may play a significant role in depression and
its treatment.
 Hormones. Changes in the body's balance of hormones may be involved in causing
or triggering depression. Hormone changes can result with pregnancy and during the
weeks or months after delivery (postpartum) and from thyroid problems, menopause
or a number of other conditions.
 Inherited traits. Depression is more common in people whose blood relatives also
have this condition. Researchers are trying to find genes that may be involved in
causing depression.
Risk factors
Depression often begins in the teens, 20s or 30s, but it can happen at any age. More women
than men are diagnosed with depression, but this may be due in part because women are more
likely to seek treatment.
Factors that seem to increase the risk of developing or triggering depression include:
 Certain personality traits, such as low self-esteem and being too dependent, self-
critical or pessimistic
 Traumatic or stressful events, such as physical or sexual abuse, the death or loss of a
loved one, a difficult relationship, or financial problems
 Blood relatives with a history of depression, bipolar disorder, alcoholism or suicide
 Being lesbian, gay, bisexual or transgender, or having variations in the development
of genital organs that aren't clearly male or female (intersex) in an unsupportive
situation
 History of other mental health disorders, such as anxiety disorder, eating disorders or
post-traumatic stress disorder
 Abuse of alcohol or recreational drugs
 Serious or chronic illness, including cancer, stroke, chronic pain or heart disease
 Certain medications, such as some high blood pressure medications or sleeping pills
(talk to your doctor before stopping any medication)
Complications
Depression is a serious disorder that can take a terrible toll on you and your family.
Depression often gets worse if it isn't treated, resulting in emotional, behavioral and health
problems that affect every area of your life.
Examples of complications associated with depression include:
 Excess weight or obesity, which can lead to heart disease and diabetes
 Pain or physical illness
 Alcohol or drug misuse
 Anxiety, panic disorder or social phobia
 Family conflicts, relationship difficulties, and work or school problems
 Social isolation
 Suicidal feelings, suicide attempts or suicide
 Self-mutilation, such as cutting
 Premature death from medical conditions
Prevention
There's no sure way to prevent depression. However, these strategies may help.
  Take steps to control stress, to increase your resilience and boost your self-esteem.
 Reach out to family and friends, especially in times of crisis, to help you weather
rough spells.
 Get treatment at the earliest sign of a problem to help prevent depression from
worsening.
 Consider getting long-term maintenance treatment to help prevent a relapse of
symptoms.

Disruptive Mood Dysregulation Disorder

Introduction
Disruptive mood dysregulation disorder (DMDD) is a childhood condition that causes
chronic, intense irritability and frequent temper outbursts that are out of proportion to the
situation. While it’s normal for children to go through periods of moodiness, DMDD is more
severe and longer-lasting. The temper outbursts are greatly out of proportion in intensity
and/or duration to the situation. The condition disrupts your child’s daily life. Symptoms need
to begin before the age of 10 to meet diagnostic criteria. It’s treatable with psychotherapy
(talk therapy) and/or medication
Development and Course
The onset of disruptive mood dysregulation disorder must be before age 10 years, and the
diagnosis should not be applied to children with a developmental age of younger than 6 years.
It is unknown whether the condition presents only in this age-delimited fashion. Because the
symptoms of disruptive mood dysregulation disorder are likely to change as children mature,
use of the diagnosis should be restricted to age groups similar to those in which validity has
been established (6–18 years).
Approximately half of children with disruptive mood dysregulation disorder living in a
predominantly rural area in a large U.S. study continue to have symptoms that meet criteria
for the condition 1 year later, although those children whose symptoms no longer meet the
threshold for the diagnosis often have persistent, clinically impairing irritability. Rates of
conversion from severe, non-episodic irritability to bipolar disorder are very low. Instead,
children with disruptive mood dysregulation disorder are at increased risk to develop unipolar
depressive and/or anxiety disorders in adulthood.
What is the difference between disruptive mood dysregulation, oppositional defiant
disorder (ODD) and bipolar disorder?
Oppositional defiant disorder (ODD) is a behavioral condition in which your child displays a
continuing pattern of uncooperative, defiant and sometimes hostile behavior toward people in
authority. While some of its symptoms overlap with ODD, DMDD is considered a more
severe condition with a significant mood component.
Children who meet the criteria for both ODD and DMDD are only diagnosed with DMDD.
Bipolar disorder (BD) is a lifelong mood disorder that causes intense shifts in mood, energy
levels, thinking patterns and behavior. These shifts can last for days, weeks or months and
interrupt your ability to carry out day-to-day tasks.
While similar behaviors may overlap between bipolar disorder and DMDD, the symptoms of
BD are contained within episodes. The symptoms of DMDD are ongoing. Additionally,
bipolar is less common in children and adolescents. BD is usually a lifelong condition,
whereas DMDD is more likely to “change” into major depressive disorder or generalized
anxiety disorder later in life.
Before DMDD became an official diagnosis in 2013, most children with DMDD were
misdiagnosed with bipolar disorder.

Diagnostic Criteria
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or
behaviourally (e.g., physical aggression toward people or property) that are grossly out of
proportion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with the developmental level.
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day,
nearly every day, and is observable by others (e.g., parents, teachers, peers).
E. Criteria A–D have been present for 12 or more months. Throughout that time, the
individual has not had a period lasting 3 or more consecutive months without all of the
symptoms in Criteria A–D.
F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with
peers) and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or after age 18
years.
H. By history or observation, the age at onset of Criteria A–E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full
symptom criteria, except duration, for a manic or hypomanic episode have been met.
Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly
positive event or its anticipation, should not be considered as a symptom of mania or
hypomania.
J. The behaviours do not occur exclusively during an episode of major depressive disorder
and are not better explained by another mental disorder (e.g., autism spectrum disorder,
posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder).
Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive
disorder, or bipolar disorder, though it can coexist with others, including major depressive
disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use
disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation
disorder and oppositional defiant disorder should only be given the diagnosis of disruptive
mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic
episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.
K. The symptoms are not attributable to the physiological effects of a substance or another
medical or neurological condition.

What is the treatment for disruptive mood dysregulation disorder?

As DMDD is a newly recognized condition, there haven’t been many research studies on its
treatment. Current treatments are mainly based on research focused on other childhood
conditions associated with irritability, such as anxiety and ADHD. The good news is that
many of these treatments also work for DMDD.
The two main treatment options for DMDD are psychotherapy (talk therapy) and
medications. In many cases, healthcare providers recommend psychotherapy first before
trying medications.
Psychotherapy
Psychotherapy, also called talk therapy, is a term for a variety of treatment techniques that
aim to help a person identify and change unhealthy emotions, thoughts and behaviors.
Psychotherapy takes place with a trained, licensed mental health professional, such as a
psychologist or psychiatrist. It can provide support, education and guidance to your child
and/or your family to help them with DMDD.
Different types of psychotherapy that may help with DMDD include:
 Cognitive behavioral therapy (CBT): CBT is one of the most common forms of
psychotherapy. During CBT for DMDD, a mental health professional helps your child
take a close look at their thoughts and emotions. Your child will come to understand
how their thoughts affect their actions. Through CBT, your child can unlearn negative
thoughts and behaviors and learn to adopt healthier thinking patterns and habits. The
 mental health professional can help your child increase their ability to tolerate
frustration without having an outburst.
 Dialectical behavior therapy (DBT): DBT is based on CBT, but it’s specially adapted
for people who experience emotions very intensely. DBT may help your child learn to
regulate their emotions and avoid extreme or prolonged outbursts.
 Parent training: Your child’s provider may recommend combining therapy for your
child with parent training. This therapy teaches parents or caregivers more effective
ways to respond to irritable behavior, such as anticipating events that might lead their
child to have an outburst and attempting to prevent it. Training also focuses on the
importance of being consistent with your child and using positive reinforcement to
decrease unwanted behaviors and promote healthy behaviors.
Medication
Currently, the U.S. Food and Drug Administration (FDA) hasn’t approved any medications
specifically for treating DMDD. However, healthcare providers may prescribe certain
medications to help manage DMDD symptoms, including:
 Stimulants: Providers traditionally prescribe stimulants for the treatment of ADHD.
Research suggests that stimulant medications may also decrease irritability in children
with DMDD.
 Antidepressants: Providers sometimes prescribe antidepressants to treat irritability and
mood issues that children with DMDD may experience. One study suggests
that citalopram, when combined with methylphenidate (a stimulant), can decrease
irritability in children with DMDD.
 Certain atypical antipsychotic (neuroleptic) medications: Providers sometimes
prescribe these medications to treat children with irritability, severe outbursts or
aggression. Providers typically only prescribe these medications for DMDD if all
other treatment approaches have been unsuccessful.
All medications have side effects. It’s important to monitor your child for any side effects and
talk to their provider if side effects develop.

Outlook / Prognosis
What is the prognosis for disruptive mood dysregulation disorder?
Children with DMDD can experience significant issues in school, at home and in social
relationships.
If left untreated, children with DMDD are at high risk of developing depression and/or
anxiety disorders in adulthood. Because of this, it’s important to seek help for your child as
soon as possible if they’re showing signs of DMDD.
Prevention
Can DMDD be prevented?
Although it might not be possible to prevent DMDD, recognizing and acting on symptoms
when they first appear can minimize distress to your child and family. It can also help prevent
many of the problems associated with the condition.
Living With
How can I help my child with disruptive mood dysregulation disorder?
If your child has disruptive mood dysregulation disorder, aside from getting them
professional care, you can help them and yourself in the following ways:
 Learn as much as you can about DMDD: Talk to your child’s healthcare provider or
mental health professional. Ask questions about treatment options and new research
on DMDD.
 Communicate regularly with your child’s healthcare provider: It’s important to work
closely with your child’s provider to make treatment decisions that are best for them.
 Work with your child’s teacher or school counselor: Together, you can develop
strategies and accommodations that can help your child thrive in school.
 Take a time-out or break when needed: If you’re about to make the conflict with your
child worse instead of better, take a break and step away. This also sets a good
example for your child. Support your child if they decide to take a break to prevent
escalating a negative situation.
 Take care of yourself: Maintain interests and hobbies that you enjoy and manage
stress. Try to work with and gain support from the other adults who are interacting
with your child

Major Depressive Disorder

Introduction
Clinical depression (major depressive disorder) causes a persistently low or depressed mood
and a loss of interest in activities that you used to enjoy. Clinical depression can also affect
how you sleep, your appetite and your ability to think clearly. The symptoms must last for at
least two weeks to receive a diagnosis. Clinical depression is a chronic condition, but it
usually occurs in episodes, which can last several weeks or months. You’ll likely have more
than one episode in your lifetime. This is different from persistent depressive disorder, which
is mild or moderate depression that lasts for at least two years. The condition is treatable,
usually with medication and psychotherapy.

There are several subtypes of major depressive disorder. Some of the most common subtypes
include:
  Seasonal affective disorder (seasonal depression).
 Prenatal depression and postpartum depression.
 Atypical depression.
People with clinical depression often have other mental health conditions, such as:
 Substance use disorder (dual diagnosis).
 Panic disorder.
 Social anxiety disorder.
 Obsessive-compulsive disorder.

Diagnostic Criteria
A. Five (or more) of the following symptoms have been present during the same 2- week
period and represent a change from previous functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
1.Depressed mood most of the day, nearly every day, as indicated by either subjective report
(e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
(Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day.
(Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another
medical condition.
Note: Criteria A–C represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may include the feelings of intense sadness,
rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A,
which may resemble a depressive episode. Although such symptoms may be understandable
or considered appropriate to the loss, the presence of a major depressive episode in addition
to the normal response to a significant loss should also be carefully considered. This decision
inevitably requires the exercise of clinical judgment based on the individual’s history and the
cultural norms for the expression of distress in the context of loss.
D. At least one major depressive episode is not better explained by schizoaffective disorder
and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or
other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are
substance-induced or are attributable to the physiological effects of another medical
condition.

Coding and Recording Procedures

The diagnostic code for major depressive disorder is based on whether this is a single or
recurrent episode, current severity, presence of psychotic features, and remission status.
Current severity and psychotic features are only indicated if full criteria are currently met for
a major depressive episode. Remission specifiers are only indicated if the full criteria are not
currently met for a major depressive episode.
Codes are as follows:
Severity/course specifier Single episode Recurrent episode*
Mild (p. 214) F32.0 F33.0
Moderate (p. 214) F32.1 F33.1
Severe (p. 214) F32.2 F33.2
With psychotic features** F32.3 F33.3
(pp. 212–213)
In partial remission (p. 214) F32.4 F33.41
In full remission (p. 214) F32.5 F33.42
Unspecified F32.9 F33.9
*For an episode to be considered recurrent, there must be an interval of at least 2 consecutive
months between separate episodes in which criteria are not met for a major depressive
episode. The definitions of specifiers are found on the indicated pages.
**If psychotic features are present, code the “with psychotic features” specifier irrespective
of episode severity.
In recording the name of a diagnosis, terms should be listed in the following order: major
depressive disorder, single or recurrent episode, severity/psychotic/remission specifiers,
followed by as many of the following specifiers without codes that apply to the current
episode (or the most recent episode if the major depressive disorder is in partial or full
remission).
Note: The specifier “with seasonal pattern” describes the pattern of recurrent major
depressive episodes.
Specify if:
With anxious distress (pp. 210–211)
With mixed features (p. 211)
With melancholic features (pp. 211–212)
With atypical features (p. 212)
With mood-congruent psychotic features (p. 213)
With mood-incongruent psychotic features (p. 213)
With catatonia (p. 213). Coding note: Use additional code F06.1.
With peripartum onset (p. 213)
With seasonal pattern (applies to pattern of recurrent major depressive episodes) (p. 214)

Types of depression
Symptoms caused by major depression can vary from person to person. To clarify the type of
depression you have, your doctor may add one or more specifiers. A specifier means that
you have depression with specific features, such as:
 Anxious distress — depression with unusual restlessness or worry about possible
events or loss of control
 Mixed features — simultaneous depression and mania, which includes elevated self-
esteem, talking too much and increased energy
 Melancholic features — severe depression with lack of response to something that
used to bring pleasure and associated with early morning awakening, worsened mood
 in the morning, major changes in appetite, and feelings of guilt, agitation or
sluggishness
 Atypical features — depression that includes the ability to temporarily be cheered by
happy events, increased appetite, excessive need for sleep, sensitivity to rejection, and
a heavy feeling in the arms or legs
 Psychotic features — depression accompanied by delusions or hallucinations, which
may involve personal inadequacy or other negative themes
 Catatonia — depression that includes motor activity that involves either
uncontrollable and purposeless movement or fixed and inflexible posture
 Peripartum onset — depression that occurs during pregnancy or in the weeks or
months after delivery (postpartum)
 Seasonal pattern — depression related to changes in seasons and reduced exposure
to sunlight

Who does clinical depression affect?

Clinical depression can affect anyone, including children and adults. Most cases tend to begin
in your 20s, but it can develop at any age.
Clinical depression is more likely to affect women than men. It’s also more common in
people without close interpersonal relationships and people who are divorced, separated or
widowed.
How common is clinical depression?
Clinical depression (major depressive disorder) is common. It’s one of the most common
mental health conditions. It affects 5% to 17% of people at some point in their lives.

What causes clinical depression?

 Brain chemistry: An imbalance of neurotransmitters, including serotonin,
norepinephrine and dopamine, contributes to the development of depression.
Researchers used to think these imbalances were a primary issue. However, recent
theories suggest that disturbances in more complex neural circuits cause secondary
imbalances of neurotransmitters.
 Genetics: If you have a first-degree relative (biological parent or sibling) with clinical
depression, you’re about three times as likely to develop the condition as someone
without a family history of the condition. However, you can have clinical depression
without a family history of it.
 Childhood development: Multiple adverse childhood experiences (ACEs) such
as abuse and trauma are associated with the development of clinical depression later
in life.
  Stressful life events: Difficult experiences, such as the death of a loved one, trauma,
divorce, isolation and lack of support, can trigger clinical depression in people who
are susceptible to it.
Management and Treatment
How is clinical depression treated?
Treatment of clinical depression (major depressive disorder) often involves medications
and/or psychotherapy (talk therapy). Studies show that the combination of these treatments is
more effective than either of them alone.
Psychotherapy involves talking with a mental health professional, such as a psychologist.
Your therapist helps you identify and change unhealthy emotions, thoughts and behaviors.
There are many types of psychotherapy — cognitive behavioral therapy
(CBT) and interpersonal therapy (IPT) are the most common types for treating clinical
depression. You may see your therapist once a week or once every other week.
Prescription depression medications called antidepressants can help change the brain
chemistry that causes depression. There are several different types of antidepressants. It may
take time and trying more than one medication to figure out the one that works best for you.
Antidepressants have side effects, which often improve with time.
For severe clinical depression that hasn’t responded to other treatments, electroconvulsive
therapy (ECT) is very effective. It involves passing a mild electric current through your brain,
causing a short seizure. ECT is safe. It involves general anesthesia and doesn’t hurt.
Other types of stimulation therapy for medication-resistant depression include:
 Transcranial magnetic stimulation (TMS).
 Vagus nerve stimulation (VNS).
 Ketamine and esketamine.

Outlook / Prognosis
What is the prognosis of clinical depression (major depressive disorder)?
The prognosis (outlook) for clinical depression depends on a few factors, including:
 Its severity.
 If it’s treated or untreated.
 If you have other mental health or medical conditions.
The prognosis is better in people who have mild episodes, seek treatment and have strong
support systems. The prognosis is worse in people who have other psychiatric or personality
disorders and who are 60 years or older when they’re diagnosed.
Untreated episodes of clinical depression (major depressive disorder) can last six to 12
months.
About two-thirds of people with clinical depression think about suicide. About 10% to 15%
of people with the condition die by suicide.
The good news is that clinical depression is one of the most treatable mental health
conditions. Approximately 80% to 90% of people with the condition who seek treatment
eventually respond well to treatment.
What are the possible complications of clinical depression?
Clinical depression (major depressive disorder) can greatly interfere with your daily
functioning and quality of life if it’s not treated.
People with clinical depression are at a high risk of developing anxiety disorders and
substance use disorders, which further increase their risk of suicide.
Depression can make underlying medical conditions worse or more difficult to manage, such
as:
 Diabetes.
 Hypertension (high blood pressure).
 Chronic obstructive pulmonary disease (COPD).
 Coronary artery disease.
People with clinical depression are also at high risk of developing self-destructive behavior as
a coping mechanism for their symptoms
Persistent depressive disorder (PDD)
Introduction
Persistent depressive disorder (PDD), formerly known as dysthymia or dysthymic disorder, is
mild or moderate depression that doesn’t go away. If you have persistent depressive disorder,
you may experience low mood, as well as other symptoms, occurring most days without
going away. Persistent depressive disorder (PDD) is a mild to moderate chronic depression. It
involves a sad or dark mood most of the day, on most days, for two years or more. PDD is
common and can happen to anyone at any age. The most effective treatment combines
medication, counseling, and healthy lifestyle choices.
Causes
The exact cause of persistent depressive disorder is not known. As with major depression, it
may involve more than one cause, such as:
 Biological differences. People with persistent depressive disorder may have physical
changes in their brains. It's not clear how these changes affect the disorder, but they
may eventually help determine the causes.
 Brain chemistry. Neurotransmitters are naturally occurring brain chemicals.
Research indicates that changes in neurotransmitters may play a large part in
depression and its treatment.
 Inherited traits. Persistent depressive disorder appears to be more common in people
whose blood relatives also have the condition. Researchers are trying to find genes
that may be involved in causing depression.
 Life events. As with major depression, traumatic events such as the loss of a loved
one, financial problems or a high level of stress can trigger persistent depressive
disorder in some people.
Risk factors
Persistent depressive disorder often begins early — in childhood, the teen years or young
adult life — and continues for a long time. Certain factors appear to increase the risk of
developing persistent depressive disorder, including:
 Having a first-degree blood relative, such as a parent or sibling, with major depressive
disorder or other depressive disorders.
 Traumatic or stressful life events, such as the loss of a loved one or major financial
problems.
 Personality traits that include negativity, such as low self-esteem, being too dependent
or self-critical, or always thinking the worst will happen.
  History of other mental health disorders, such as a personality disorder.

Diagnostic Criteria
This disorder represents a consolidation of DSM-IV-defined chronic major depressive
disorder and dysthymic disorder.
A. Depressed mood for most of the day, for more days than not, as indicated by either
subjective account or observation by others, for at least 2 years.
Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the
individual has never been without the symptoms in Criteria A and B for more than 2 months
at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode.
F. The disturbance is not better explained by a persistent schizoaffective disorder,
schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum
and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication) or another medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Note: If criteria are sufficient for a diagnosis of a major depressive episode at any time during
the 2-year period of depressed mood, then a separate diagnosis of major depression should be
made in addition to the diagnosis of persistent depressive disorder along with the relevant
specifier (e.g., with intermittent major depressive episodes, with current episode).
Specify if:
With anxious distress (pp. 210–211)
With atypical features (p. 212)
Specify if:
In partial remission (p. 214)
In full remission (p. 214)
Specify if:
Early onset: If onset is before age 21 years.
Late onset: If onset is at age 21 years or older.
Specify if (for most recent 2 years of persistent depressive disorder):
With pure dysthymic syndrome: Full criteria for a major depressive episode have not been
met in at least the preceding 2 years.
With persistent major depressive episode: Full criteria for a major depressive episode have
been met throughout the preceding 2-year period
With intermittent major depressive episodes, with current episode: Full criteria for a
major depressive episode are currently met, but there have been periods of at least 8 weeks in
at least the preceding 2 years with symptoms below the threshold for a full major depressive
episode.
With intermittent major depressive episodes, without current episode: Full criteria for a
major depressive episode are not currently met, but there has been one or more major
depressive episodes in at least the preceding 2 years.
Specify current severity:
Mild (p. 214)
Moderate (p. 214)
Severe (p. 214)

Management and Treatment

How is persistent depressive disorder treated?
The most effective persistent depressive disorder treatment combines medications and talk
therapy, or counseling.
Antidepressants are prescription drugs that can relieve depression. There are many different
kinds of medications for the treatment of depression. You may need to take medication for a
month or longer before you feel a difference. Make sure to continue taking the medication
exactly as your healthcare provider prescribes. If you have side effects, let your healthcare
provider know.
Counseling can also help manage persistent depressive disorder. One type of
therapy, cognitive behavioral therapy (CBT), is often helpful for depression. A therapist or
psychologist will help you examine your thoughts and emotions and how they affect your
actions. CBT can help you unlearn negative thoughts and develop more positive thinking.
Outlook / Prognosis
Does persistent depressive disorder ever go away?
With medication, talk therapy and lifestyle changes, you can manage persistent depressive
disorder and feel better.
But if your symptoms come back or don’t improve, talk to your healthcare provider.
Prevention
Can persistent depressive disorder be prevented?
Although you can’t prevent depression, you can take steps to help reduce your risk of
developing it. These things may also help improve your symptoms if you’ve already been
diagnosed:
 Get physical activity several times a week.
 Avoid alcohol and recreational drugs.
 Meditate.
Depressive Disorders in Children and Adolescents
Introduction
Depressive disorders are characterized by sadness or irritability that is severe or persistent
enough to interfere with functioning or cause considerable distress. Diagnosis is by clinical
criteria. Treatment is with antidepressants, supportive and cognitive-behavioral therapy, or a
combination of these modalities.

Depressive disorders in children and adolescents include

 Disruptive mood dysregulation disorder
 Major depressive disorder
 Persistent depressive disorder (dysthymia)
The term depression is often loosely used to describe the low or discouraged mood that
results from disappointment (eg, serious illness) or loss (eg, death of a loved one). However,
such low moods, unlike depression, occur in waves that tend to be tied to thoughts or
reminders of the triggering event, resolve when circumstances or events improve, may be
interspersed with periods of positive emotion and humor, and are not accompanied by
pervasive feelings of worthlessness and self-loathing. The low mood usually lasts days rather
than weeks or months, and suicidal thoughts and prolonged loss of function are much less
likely. Such low moods are more appropriately called demoralization or grief. However,
events and stressors that cause demoralization and grief can also precipitate a major
depressive episode.
The etiology of depression in children and adolescents is unknown but is similar to etiology
in adults; it is believed to result from interactions of genetically determined risk factors and
environmental stress (particularly early life stress such as abuse, injury, natural disaster,
domestic violence, death of family member, and deprivation .
During the COVID-19 pandemic, depression symptoms doubled in youths, especially in older
adolescents and mental health care visits for depression increased by 43% . After controlling
for child gender, age and pre-COVID-19 depressive symptoms, connectedness to caregivers
and child screen time were significant predictors of child COVID-19 depressive symptoms .
Symptoms and Signs
Basic manifestations of depressive disorders in children and adolescents are similar to those
in adults but are related to typical concerns of children, such as schoolwork and play.
Children may be unable to explain inner feelings or moods. Depression should be considered
when previously well-performing children do poorly in school, withdraw from society, or
commit delinquent acts.
In some children with a depressive disorder, the predominant mood is irritability rather than
sadness (an important difference between childhood and adult forms). The irritability
associated with childhood depression may manifest as overactivity and aggressive, antisocial
behavior.
In children with intellectual disability, depressive or other mood disorders may manifest as
somatic symptoms and behavioral disturbances.
Disruptive mood dysregulation disorder
Disruptive mood dysregulation disorder involves persistent irritability and frequent episodes
of behavior that is very out of control, with onset at age 6 to 10 years. Many children also
have other disorders, particularly oppositional defiant disorder, attention-deficit/hyperactivity
disorder (ADHD), or an anxiety disorder. The diagnosis is not made before age 6 years or
after age 18 years. As adults, patients may develop unipolar (rather than bipolar) depression
or an anxiety disorder.
Manifestations include the presence of the following for ≥ 12 months (with no period of ≥ 3
months without all of them):
 Severe recurrent temper outbursts (eg, verbal rage and/or physical aggression toward
people or property) that are grossly out of proportion to the situation and that
occur ≥ 3 times/week on average
 Temper outbursts that are inconsistent with developmental level
 An irritable, angry mood present every day for most of the day and observed by others
(eg, parents, teachers, peers)
The outbursts and angry mood must occur in 2 of 3 settings (at home or school, with peers).
Major depressive disorder
Major depressive disorder is a discrete depressive episode lasting ≥ 2 weeks. It occurs in as
many as 2% of children and 5% of adolescents. Major depressive disorder can first occur at
any age but is more common after puberty. Untreated, major depression may remit in 6 to 12
months. Risk of recurrence is higher in patients who have severe episodes, who are younger,
or who have had multiple episodes. Persistence of even mild depressive symptoms during
remission is a strong predictor of recurrence.
For diagnosis, ≥ 1 of the following must be present for most of the day nearly every day
during the same 2-week period:
 Feeling sad or being observed by others to be sad (eg, tearful) or irritable
 Loss of interest or pleasure in almost all activities (often expressed as profound
boredom)
In addition, ≥ 4 of the following must be present:
  Decrease in weight (in children, failure to make the expected weight gain) or decrease
or increase in appetite
 Insomnia or hypersomnia
 Psychomotor agitation or retardation observed by others (not self-reported)
 Fatigue or loss of energy
 Decreased ability to think, concentrate, and make choices
 Recurrent thoughts of death (not just fear of dying) and/or suicidal ideation or plans
 Feelings of worthlessness (ie, feeling rejected and unloved) or excessive or
inappropriate guilt
Major depression in adolescents is a risk factor for academic failure, substance use,
and suicidal behavior. While depressed, children and adolescents tend to fall far behind
academically and lose important peer relationships. In very severe depression, psychotic
symptoms may emerge.
Persistent depressive disorder (dysthymia)
Dysthymia is a persistent depressed or irritable mood that lasts for most of the day for more
days than not for ≥ 1 year plus ≥ 2 of the following:
 Poor appetite or overeating
 Insomnia or hypersomnia
 Low energy or fatigue
 Low self-esteem
 Poor concentration
 Feelings of hopelessness
Symptoms may be more or less intense than those of a major depressive disorder.
A major depressive episode may occur before the onset or during the first year (ie, before the
duration criterion is met for persistent depressive disorder).
Diagnosis
 Psychiatric assessment
 Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5-TR)
criteria
Diagnosis of depressive disorders is based on symptoms and signs, including the criteria
listed above.
Sources of information include an interview with the child or adolescent and information
from parents and teachers. Several brief questionnaires are available for screening. They help
identify some depressive symptoms but cannot be used alone for diagnosis. Specific close-
ended questions help determine whether patients have the symptoms required for diagnosis of
major depression, based on DSM-5-TR criteria.
History should include causative factors such as domestic violence, sexual abuse and
exploitation, and drug adverse effects. Questions about suicidal behavior (eg, ideation,
gestures, attempts) should be asked.
A careful review of the history and appropriate laboratory tests are needed to exclude other
disorders (eg, infectious mononucleosis, thyroid disorders, substance use disorders) that can
cause similar symptoms.
Other psychiatric disorders that can increase the risk and/or modify the course of depressive
symptoms (eg, anxiety and bipolar disorders) must be considered. Some children who
eventually develop a bipolar disorder or schizophrenia may present initially with major
depression.
After depression is diagnosed, the family and social setting must be evaluated to identify
stresses that may have precipitated depression.
Treatment
 Concurrent measures directed at the family and school
 For adolescents, usually antidepressants plus psychotherapy
 For preadolescents, psychotherapy followed, if needed, by antidepressants
Appropriate measures directed at the family and school must accompany direct treatment of
the child to enhance continued functioning and provide appropriate educational
accommodations. Brief hospitalization may be necessary in acute crises, especially when
suicidal behavior is identified.
For adolescents (as for adults), a combination of psychotherapy and antidepressants usually
greatly outperforms either modality used alone . For preadolescents, the situation is much less
clear. Most clinicians opt for psychotherapy in younger children; however, medications can
be used in younger children (fluoxetine can be used in children ≥ 8 years), especially when
depression is severe or has not previously responded to psychotherapy.
Usually, a selective serotonin reuptake inhibitor (SSRI; see table Medications for Long-Term
Treatment of Depression, Anxiety, and Related Disorders) is the first choice when an
antidepressant is indicated. Children should be closely monitored for the emergence of
behavioral side effects (eg, disinhibition, behavioral activation), which are common but are
usually mild to moderate. Usually, decreasing the medication dose or changing to a different
medication eliminates or reduces these effects. Rarely, such effects are severe (eg,
aggressiveness, increased suicidality). Behavioral adverse effects are idiosyncratic and may
occur with any antidepressant and at any time during treatment. As a result, children and
adolescents taking such drugs must be closely monitored.
Adult-based research has suggested that antidepressants that act on both the serotonergic and
adrenergic/dopaminergic systems may be modestly more effective; however, such
medications (eg, duloxetine, venlafaxine, mirtazapine; certain tricyclics,
particularly clomipramine) also tend to have more adverse effects. Such drugs may be
especially useful in treatment-resistant cases. Nonserotonergic antidepressants such
as bupropion and desipramine may also be used with a selective serotonin reuptake inhibitor
(SSRI) to enhance efficacy. In very severe depression, psychotic and/or manic symptoms may
require treatment with an antipsychotic medication.
Transcranial magnetic stimulation—although not yet approved by the Food and Drug
Administration (FDA) for use in youths—has been used, particularly when patients do not
respond to or tolerate medications. Preliminary studies of transcranial magnetic stimulation in
adolescents show similar clinical effects and tolerability as in adults. Larger ongoing studies
will soon provide more data on noninvasive brain stimulation in adolescent depression.
As in adults, relapse and recurrence are common. Children and adolescents should remain in
treatment for at least 1 year after symptoms have remitted. Most experts recommend that
children who have experienced ≥ 2 episodes of major depression be treated indefinitely.
Suicide risk and antidepressants
Suicide risk and treatment with antidepressants have been topics of debate and research. In
2004, the US FDA did a meta-analysis of 23 previously conducted trials of 9 different
antidepressants . Although no patients completed suicide in these trials, a small but
statistically significant increase in suicidal ideation was noted in children and adolescents
taking an antidepressant (about 4% vs about 2%), leading to a black box warning on all
classes of antidepressants (eg, tricyclic antidepressants, SSRIs, serotonin-
norepinephrine reuptake inhibitors such as venlafaxine, and tetracyclic antidepressants such
as mirtazapine).
In 2006, a meta-analysis (from the United Kingdom) of children and adolescents being
treated for depression found that compared with patients taking a placebo, those taking an
antidepressant had a small increase in self-harm or suicide-related events (4.8% vs 3.0% of
those treated with placebo). However, whether the difference was statistically significant or
not varied depending on the type of analysis (fixed-effects analysis or random-effects
analysis). There was a nonsignificant trend toward an increase in suicidal ideation (1.2% vs
0.8%), self-harm (3.3% vs 2.6%), and suicide attempts (1.9% vs 1.2%). There appear to have
been some differences in risk between different medications; however, no direct head-to-head
studies have been done, and it is difficult to control for severity of depression and other
confounding risk factors.
Observational and epidemiologic studies have found no increase in the rate of suicide
attempts or completed suicide in patients taking antidepressants. Also, despite a decrease in
prescriptions for antidepressants following the black-box warning, the adolescent suicide rate
increased by 14%. Using data from commercial claims and nationwide registers to estimate
risks and benefits of medications in relation to suicidal events, SSRIs were associated with
significantly decreased suicidal events.
In general, although antidepressants have limited efficacy in children and adolescents, the
benefits appear to outweigh risks. The best approach seems to be combining treatment with
medications with psychotherapy and minimizing risk by closely monitoring treatment.
Whether or not medications are used, suicide is always a concern in a child or adolescent
with depression. The following should be done to reduce risk:
  Parents and mental health care practitioners should discuss the issues in depth.
 The child or adolescent should be supervised at an appropriate level.
 Psychotherapy with regularly scheduled appointments should be included in the
treatment plan.

Unit 4
Externalizing Disorders
Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorders (ODD),
Conduct Disorder (CD), Alcohol and Substance Use Disorders, Juvenile Delinquency

Q4- ODD & Conduct differentiation

Q17-How would you modify behaviour at home and school (ADHD) (behaviour
modification can be talked about)
Q- differentiation b/w internalized and externalised disorders)

Attention Deficit Hyperactivity Disorder (ADHD)

Introduction
ADHD stands for attention-deficit/hyperactivity disorder. It’s a neurodevelopmental disorder,
which means it affects how your brain develops. Symptoms begin before age 12 and include
fidgeting, difficulty paying attention and losing things. Despite its name, ADHD doesn’t
mean that you lack attention. It means that it’s harder for you to control your attention or
direct it to certain tasks. ADHD causes symptoms like difficulty focusing, trouble sitting still
and impulsive behaviors. But it also allows you to “get in the zone” and hyperfocus on things
you really enjoy.
ADHD symptoms begin in childhood (commonly between ages 3 and 6) and may continue
into adulthood. But some people don’t get a diagnosis until they’re adults. There’s no cure for
ADHD, but treatments like medications and behavioral therapies can help manage symptoms.

Diagnostic Criteria
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development, as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months
to a degree that is inconsistent with developmental level and that negatively impacts directly
on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance,
hostility, or failure to understand tasks or instructions. For older adolescents and adults (age
17 and older), at least five symptoms are required.
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at
work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty
remaining focused during lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in
the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or
duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential
tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has
poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
(e.g., schoolwork or homework; for older adolescents and adults, preparing reports,
completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books,
tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may
include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older
adolescents and adults, returning calls, paying bills, keeping appointments).
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted
for at least 6 months to a degree that is inconsistent with developmental level and that
negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance,
hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age
17 and older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her
place in the classroom, in the office or other workplace, or in other situations that require
remaining in place).
c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or
adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable
being still for extended time, as in restaurants, meetings; may be experienced by others as
being restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes people’s
sentences; cannot wait for turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities;
may start using other people’s things without asking or receiving permission; for adolescents
and adults, may intrude into or take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings
(e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication
or withdrawal).
Specify whether:
F90.2 Combined presentation: If both Criterion A1 (inattention) and Criterion
A2 (hyperactivity-impulsivity) are met for the past 6 months.
F90.0 Predominantly inattentive presentation: If Criterion A1 (inattention) is met but
Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.
F90.1 Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-
impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.
Specify if:
In partial remission: When full criteria were previously met, fewer than the full criteria have
been met for the past 6 months, and the symptoms still result in impairment in social,
academic, or occupational functioning.
Specify current severity:
Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present,
and symptoms result in no more than minor impairments in social or occupational
functioning.
Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
Severe: Many symptoms in excess of those required to make the diagnosis, or several
symptoms that are particularly severe, are present, or the symptoms result in marked
impairment in social or occupational functioning.

Associated Features
 Delays in language, motor, or social development are not specific to ADHD but often
co-occur.
 Emotional dysregulation or emotional impulsivity commonly occurs in children and
adults with ADHD.
 Individuals with ADHD self-report and are described by others as being quick to
anger, easily frustrated, and overreactive emotionally.
 Even in the absence of a specific learning disorder, academic or work performance is
often impaired.
 Individuals with ADHD may exhibit neurocognitive deficits in a variety of areas,
including working memory, set shifting, reaction time variability, response inhibition,
 vigilance, and planning/organization, although these tests are not sufficiently sensitive
or specific to serve as diagnostic indices.
 Although ADHD is not associated with specific physical features, rates of minor
physical anomalies (e.g., hypertelorism, highly arched palate, low-set ears) may be
elevated. Subtle motor delays and other neurological soft signs may occur. (Note that
marked co-occurring clumsiness and motor delays should be coded separately [e.g.,
developmental coordination disorder].)
 Children with neurodevelopmental disorders with a known cause (e.g., fragile X
syndrome, 22q11 deletion syndrome) may often also have symptoms of inattention
and impulsivity/hyperactivity; they should receive an ADHD diagnosis if their
symptoms meet the full criteria for the disorder.

Prevalence
Population surveys suggest that ADHD occurs worldwide in about 7.2% of children;
however, cross-national prevalence ranges widely, from 0.1% to 10.2% of children
and adolescents. Prevalence is higher in special populations such as foster children or
correctional settings. In a cross-national meta-analysis, ADHD occurred in 2.5% of
adults.
ADHD types
There are four types of ADHD that healthcare providers diagnose in children and adults:
 Inattentive ADHD. This involves difficulty focusing, finishing tasks and staying
organized. With this type, you have few or no hyperactivity symptoms.
 Hyperactive-impulsive ADHD. This involves difficulty sitting still or having “quiet
time.” You have excess energy and are extremely talkative. You may also interrupt
others and act without thinking it through first. You may show less obvious trouble
with paying attention.
 Combined presentation. This is the most common type of ADHD, and it’s what most
people associate with the condition. You have many inattentive
symptoms and hyperactive-impulsive symptoms.
 Unspecified presentation. This is when you have severe symptoms that interfere
with daily life, but your symptoms don’t meet the official criteria for the types listed
above. In this case, providers assign “unspecified ADHD” as the diagnosis.
Providers also use the terms mild, moderate and severe to describe how much symptoms
affect your daily life.
Diagnosis of ADHD
 Clinical criteria based on the DSM -5-TR

Other diagnostic considerations

Differentiating between ADHD and other conditions can be challenging. Overdiagnosis must
be avoided, and other conditions must be accurately identified. Many ADHD signs expressed
during the preschool years could also indicate communication problems that can occur in
other neurodevelopmental disorders (eg, autism spectrum disorder) or in certain learning
disorders, anxiety, depression, or behavioral disorders.
Clinicians should consider whether the child is distracted by external factors (ie,
environmental input) or by internal factors (ie, thoughts, anxieties, worries). However, during
later childhood, ADHD signs become more qualitatively distinct; children with the
hyperactive/impulsive type or combined type often exhibit continuous movement of the
lower extremities, motor impersistence (eg, purposeless movement, fidgeting of hands),
impulsive talking, and a seeming lack of awareness of their environment. Children with the
predominantly inattentive type may have no physical signs.
Medical assessment is focused on identifying potentially treatable conditions that may
contribute to or worsen symptoms and signs. Assessment should include seeking a history of
prenatal exposures (eg, illicit substances, alcohol, tobacco), perinatal complications or
infections, central nervous system infections, traumatic brain injury, cardiac disease, sleep-
disordered breathing, poor appetite and/or picky eating, and a family history of ADHD.
Developmental assessment is focused on determining the onset and course of symptoms and
signs. The assessment includes checking developmental milestones, particularly language
milestones, and the use of ADHD-specific rating scales (eg, the Vanderbilt Assessment Scale,
the Conners Comprehensive Behavior Rating Scale, the ADHD Rating Scale-5). Versions of
these scales are available for both families and school staff, allowing assessment across
different situations as required by DSM-5-TR criteria. Note that scales should not be used
alone to make a diagnosis.
Educational assessment is focused on documenting core symptoms and signs; it may
involve reviewing educational records and using rating scales or checklists. However, rating
scales and checklists alone often cannot distinguish ADHD from other developmental
disorders or from behavioral disorders

ADHD causes
ADHD is genetic. This means your child is born with certain gene changes that cause
differences in their brain development (neurodivergence). Often, the gene changes that cause
ADHD are passed down within biological families. Kids with ADHD commonly have
biological parents or siblings with the condition.
Researchers continue to look into how ADHD affects the brain. Here’s what we know so far.
With ADHD, the frontal lobe of your child’s brain is wired in a way that makes it harder for
them to use directed attention. Directed attention is the ability to focus on something you
don’t find very interesting.
We use directed attention to plan, multitask and solve problems (executive functions). It can
take a lot of energy to use directed attention, especially when there are other, more interesting
things around us.
If your child has ADHD, it takes even more energy than usual to direct their attention to
things they have to do. That means after a long day at school, your child might resist doing a
task that otherwise seems simple — like hanging up their coat or backpack. The attention it
requires to do these “basic” chores is simply not available to them.
On the other hand, your child is better than most neurotypical kids at using automatic
attention. This is the type of attention we use to focus on something we’re interested in. It
allows for something called hyperfocus, or the ability to “get in the zone” and do something
for hours on end. Your child might use hyperfocus to become really good at a hobby or game
or to reach certain goals.
Causes
While the exact cause of ADHD is not clear, research efforts continue. Factors that may be
involved in the development of ADHD include:
 Genetics. ADHD can run in families, and studies indicate that genes may play a role.
 Environment. Certain environmental factors also may increase risk, such as lead
exposure as a child.
 Problems during development. Problems with the central nervous system at key
moments in development may play a role.

Risk factors
Experts believe that some people have genes that predispose them to ADHD. In other words,
the genes make ADHD a possibility for that person. But then, certain environmental
factors tip the scales and cause ADHD to develop.
Environmental risk factors include:
 Exposure to certain toxins during fetal development, including tobacco, alcohol
or lead
 Low birth weight (the lower the weight, the higher the risk)
 Preterm birth
 Environmental - Very low birth weight and degree of prematurity convey a greater
risk for ADHD; the more extreme the low weight, the greater the risk. Prenatal
exposure to smoking is associated with ADHD even after controlling for parental
psychiatric history and socioeconomic status. A minority of cases may be related to
reactions to aspects of diet. Neurotoxin exposure (e.g., lead), infections (e.g.,
encephalitis), and alcohol exposure in utero have been correlated with subsequent
ADHD, but it is not known whether these associations are causal.
 Genetic and physiological- The heritability of ADHD is approximately 74%. Large-
scale genome-wide association studies (GWAS) have identified a number of loci
enriched in evolutionarily constrained genomic regions and loss-of-function genes as
well as around brain-expressed regulatory regions. There is no single gene for ADHD
 Visual and hearing impairments, metabolic abnormalities, and nutritional deficiencies
should be considered as possible influences on ADHD symptoms. ADHD is elevated
in individuals with idiopathic epilepsy

Risk factors
Risk of ADHD may increase if:
 You have blood relatives, such as a parent or sibling, with ADHD or another mental
health disorder
 Your mother smoked, drank alcohol or used drugs during pregnancy
 As a child, you were exposed to environmental toxins — such as lead, found mainly
in paint and pipes in older buildings
 You were born prematurely

Complications of this condition

ADHD can affect how your child feels about themselves and how they engage with the world
around them. Without proper treatment, your child may have:
 Low self-esteem
 Poor grades and an inability to reach their full potential
 Difficulty in social situations, partly due to peers teasing them or not wanting to hang
out with them
  An increased risk of developing substance use disorders when they’re older
 Frequent driving accidents and injuries
 Trouble getting and keeping a job when they’re older
Complications
ADHD can make life difficult for you. ADHD has been linked to:
 Poor school or work performance
 Unemployment
 Financial problems
 Trouble with the law
 Alcohol or other substance misuse
 Frequent car accidents or other accidents
 Unstable relationships
 Poor physical and mental health
 Poor self-image
 Suicide attempts

Management and Treatment

What should I know about ADHD treatment?
ADHD treatments fall into two main groups: behavioral interventions (which teach practical
skills) and medications. The exact treatment plan varies according to a person’s age and
individual needs.
If your child has ADHD, their provider may recommend one or more of the following:
 Parent training. Therapists teach you how to help your child build on their strengths
and improve behaviors that cause them difficulty. For example, you learn how to
establish a routine for your child, encourage positive behaviors and respond to
negative ones.
 Social skills groups. Your child may benefit from social skills training groups. These
groups meet for one or two hours a week, typically over a six-to-12-week period.
Your child learns new skills for interacting with peers in a supervised setting.
 Medications (pharmacotherapy). ADHD medications improve your child’s ability
to use directed attention, in turn improving symptoms and — more importantly —
their quality of life and relationships. Providers monitor your child to see how the
 medicines are working and whether your child has side effects. They adjust
medication types and doses as needed.
The goal of ADHD treatment is to improve symptoms as your child goes about their daily
life. For younger children (ages 4 and 5), providers recommend parent training before trying
medication. Usually, the best treatment for older kids, adolescents and adults is a combination
of behavioral interventions and medication.
There’s currently no evidence that traditional “talk” or “play” therapies help kids with
ADHD. But your child’s provider may recommend such therapies for co-occurring
conditions.

Treatment of ADHD
 Behavioral therapy
 ADHD behavior therapy: Children with ADHD often benefit from behavior therapy,
social skills training, parent skills training and counseling, which may be provided by
a psychiatrist, psychologist, social worker or other mental health professional. Some
children with ADHD may also have other conditions such as an anxiety disorder or
depression. In these cases, counseling may help both ADHD and the coexisting
problem. Examples of therapy include:
- Behavior therapy. Teachers and parents can learn behavior-changing strategies,
such as token reward systems and timeouts, for dealing with difficult situations.
- Social skills training. This can help children learn appropriate social behaviors.
 - Parenting skills training. This can help parents develop ways to understand and
guide their child's behavior.
- Psychotherapy. This allows older children with ADHD to talk about issues that
bother them, explore negative behavior patterns and learn ways to deal with their
symptoms.
- Family therapy. Family therapy can help parents and siblings deal with the stress of
living with someone who has ADHD.
Stimulant medications:
- Currently, stimulant drugs (psychostimulants) are the most commonly prescribed
medications for ADHD. Stimulants appear to boost and balance levels of brain
chemicals called neurotransmitters. These medications help improve the signs and
symptoms of inattention and hyperactivity — sometimes effectively in a short period
of time.
- Examples include:
 Amphetamines. These include dextroamphetamine (Dexedrine),
dextroamphetamine-amphetamine (Adderall XR, Mydayis) and
lisdexamfetamine (Vyvanse).
 Methylphenidates. These include methylphenidate (Concerta, Ritalin, others)
and dexmethylphenidate (Focalin).
- Stimulant drugs are available in short-acting and long-acting forms. A long-acting
patch of methylphenidate (Daytrana) is available that can be worn on the hip.
- The right dose varies from child to child, so it may take some time to find the correct
dose. And the dose may need to be adjusted if significant side effects occur or as your
child matures. Ask your doctor about possible side effects of stimulants.

 Medication therapy, typically with stimulants such

as methylphenidate or dextroamphetamine (in short- and long-acting preparations)

Treatment recommendations for children with ADHD vary by age :

 Preschool-aged children: Initial treatment is with behavioral therapy. Medications
may be considered if the response to behavioral interventions is inadequate or if the
symptoms are moderate-to-severe (eg, impulsive running, aggressive outbursts, other
behavior that put the child or others at risk for injury).
 School-aged children: Initial treatment is behavioral therapy in combination with
medications.
Randomized trials show that in school-aged children, behavioral therapy alone is less
effective than therapy with stimulant medications alone, while the combination is best. There
are also data to support the use of methylphenidate in preschool-aged children who are
unresponsive to behavioral therapy alone, although the overall benefit appears to be smaller
than for school-aged children. Although correction of the underlying neurophysiologic
differences of patients with ADHD does not occur with medication therapy, medications are
effective in alleviating ADHD symptoms and they permit participation in activities
previously inaccessible because of poor attention and impulsivity. Medications often interrupt
the behavioral symptoms, enhancing behavioral and academic interventions, motivation, and
self-esteem.
Treatment of ADHD in adults follows similar principles, but, as in children, medication
selection and dosing need to be individualized, depending on benefits, side effects, and other
medical conditions .
Stimulant medications
Stimulant preparations that include methylphenidate or amphetamine salts are most widely
used. Response varies greatly, and dosage depends on the severity of the behavior and the
child’s ability to tolerate the medication. Dosing is adjusted in frequency and amount until the
optimal balance between response and adverse effects is achieved.
Methylphenidate is usually started at the lowest dose orally once a day (immediate-release
form) for children and increased in frequency weekly, usually to approximately 2 to 3 times
per day or every 4 hours during waking hours; many clinicians try to use morning and
midday dosing. If response is inadequate but the medication is tolerated, dose can be
increased. The goal is to find an optimal balance between benefits and adverse effects for
each individual. Doses that are too low and do not provide adequate benefit may lead families
to abandon treatment early while doses that are too high may cause serious side effects with
or without adequate clinical benefit. The dextro isomer of methylphenidate is the active
moiety and is available for prescription at one half the dose.
Dextroamphetamine (immediate-release form) is typically started (often in combination with
racemic amphetamine) orally once a day, which can then be increased to 2 or 3 times a day or
every 4 hours during waking hours. Dose titration should balance effectiveness against
adverse effects; actual doses vary significantly among individuals, but, in general, higher
doses increase the likelihood of unacceptable adverse effects. In
general, dextroamphetamine doses are approximately two thirds those
of methylphenidate doses.
For methylphenidate or dextroamphetamine, once an optimal dosage is reached, an
equivalent dosage of the same medication in a sustained-release form is often substituted to
avoid the need for medication administration in school. Long-acting preparations include wax
matrix slow-release tablets, biphasic capsules containing the equivalent of 2 doses, and
osmotic release pills and transdermal patches that provide up to 12 hours of coverage. Both
short-acting and long-acting liquid preparations are also available. Pure dextro preparations
(eg, dextromethylphenidate) are often used to minimize adverse effects such as anxiety; doses
are typically half those of mixed preparations. Prodrug preparations are also sometimes used
because of their smoother release, longer duration of action, fewer adverse effects, and lower
abuse potential. Learning is often enhanced by low doses, but improvement in behavioral
symptoms often requires higher doses.
Dosing schedules of stimulants can be adjusted to cover specific days and times (eg, during
school hours, while doing homework). Medication holidays may be tried on weekends, on
holidays, or during longer breaks from school. Placebo periods (for 5 to 10 school days to
smooth out day-to-day variability) are recommended to determine whether the medications
are still needed.
Common adverse effects of stimulant medications include
 Sleep disturbances (eg, insomnia)
  Headache
 Stomachache
 Appetite suppression
 Elevated heart rate and blood pressure
Depression is a less common adverse effect and may often represent an inability to easily
shift focus (overfocusing). This can manifest as a dulled demeanor (sometimes described by
families as being zombie-like) rather than actual clinical childhood depression. In fact,
stimulants are sometimes used as adjunctive treatment for depression. A dulled demeanor can
sometimes be addressed by cutting the stimulant dose or trying a different medication.
Individuals with anxiety disorders can also experience exacerbations of anxiety symptoms.
Studies have shown growth in height slows over 2 years of stimulant medication use, and
adult height potential may be diminished with chronic stimulant use.
Nonstimulant medications
Atomoxetine, a selective norepinephrine reuptake inhibitor, is also used. The medication is
effective, but data are mixed regarding its efficacy compared with stimulants. Some children
have nausea, sedation, irritability, and temper tantrums; rarely, liver toxicity and suicidal
ideation occur. The starting dose is titrated weekly. The long half-life allows once-a-day
dosing but requires continuous use to be effective.
Selective norepinephrine reuptake inhibitor antidepressants such
as bupropion and venlafaxine, alpha-2 agonists such as clonidine and guanfacine, and other
psychoactive medications are sometimes used when stimulants are ineffective or cause
unacceptable adverse effects, but they are less effective and are not recommended as first-line
medications. Sometimes these medications are used in combination with stimulants for
synergistic effects; close monitoring for adverse effects is essential.
Adverse drug interactions are a concern with ADHD treatment. Medications that inhibit the
metabolic enzyme CYP2D6, including certain selective serotonin reuptake inhibitors (SSRIs)
that are sometimes used in patients with ADHD, can increase the effect of stimulants. Review
of potential drug interactions is an important part of pharmacologic management of patients
with ADHD.
Behavioral management
Counseling, including cognitive-behavioral therapy (eg, goal-setting, self-monitoring,
modeling, role-playing), is often effective and helps children understand ADHD and how to
cope with it. Structure and routines are essential.
Classroom behavior is often improved by environmental control of noise and visual
stimulation, appropriate task length, novelty, coaching, and teacher proximity.
When difficulties persist at home, parents should be encouraged to seek additional
professional assistance and training in behavioral management techniques. Adding incentives
and token rewards reinforces behavioral management and is often effective. Children with
ADHD in whom hyperactivity and poor impulse control predominate are often helped at
home when structure, consistent parenting techniques, and well-defined limits are
established.
Elimination diets, megavitamin treatments, use of antioxidants or other compounds, and
nutritional and biochemical interventions have had the least consistent effects. Biofeedback
can be helpful in some cases but is not recommended for routine use because evidence of
sustained benefit is lacking.

Outlook / Prognosis
How long does ADHD last?
ADHD doesn’t go away but doesn’t have to be an impairing condition. You can’t outgrow it,
but treatment can help manage your symptoms. Thanks to effective treatments, some people
don’t show impairment from ADHD symptoms once they’ve reached adulthood. But for
others, symptoms still affect their daily life. Providers tailor care to each individual’s needs.
Prognosis for ADHD
Traditional classrooms and academic activities often exacerbate symptoms and signs in
children with untreated or inadequately treated ADHD. Social and emotional adjustment
problems may be persistent. Poor acceptance by peers and loneliness tend to increase with
age and with the obvious display of symptoms. Substance abuse may result if ADHD is not
identified and adequately treated because many adolescents and adults with ADHD self-
medicate with both legal (eg, caffeine) and illegal (eg, cocaine, amphetamines) substances.
Although hyperactivity symptoms and signs tend to diminish with age, adolescents and adults
may display residual difficulties. Predictors of poor outcomes in adolescence and adulthood
include
 Coexisting low intelligence
 Aggressiveness
 Social and interpersonal problems
 Parental mental or behavioral health disorders
Problems in adolescence and adulthood manifest predominantly as academic failure, low self-
esteem, and difficulty learning appropriate social behavior. Adolescents and adults who have
predominantly impulsive ADHD may have an increased incidence of personality trait
disorders and antisocial behavior; many continue to display impulsivity, restlessness, and
poor social skills. People with ADHD seem to adjust better to work than to academic and
home situations, particularly if they can find jobs that do not require intense attention to
perform.
Oppositional defiant disorder
Introduction
Oppositional defiant disorder (ODD) is a condition in which your child displays a pattern of
uncooperative, defiant and angry behavior toward people in authority. Oppositional defiant
disorder (ODD) is a behavior condition in which your child displays a continuing pattern of
uncooperative, defiant and sometimes hostile behavior toward people in authority. This
behavior often disrupts your child’s normal daily functioning, including relationships and
activities within their family and at school. ODD is treatable with psychotherapy and parent
management training.
It’s common for children — especially those two to three years old and in their early teens —
to be oppositional or defiant of authority once in a while. They might express their defiance
by arguing, disobeying or talking back to adults, including their parents or teachers. When
this behavior lasts longer than six months and goes beyond what’s usual for your child’s age,
it might suggest that they have ODD.
The majority of children and teens who have ODD also have at least one other mental health
condition, including:
 Attention-deficit hyperactivity/disorder (ADHD).
 Anxiety disorders, including obsessive-compulsive disorder (OCD).
 Learning differences.
 Mood disorders, such as depression.
 Impulse control disorders.
About 30% of children with ODD develop a more serious behavior condition called conduct
disorder. ODD behaviors can continue into adulthood if ODD isn’t properly diagnosed and
treated.
What’s the difference between ODD and ADHD?
Approximately 40% of children with attention-deficit/hyperactivity disorder (ADHD) also
have oppositional defiant disorder or a related conduct disorder. While these two conditions
commonly occur together, they’re distinct conditions.
ODD is related to a child’s conduct and how they interact with their parents, siblings,
teachers and friends. ADHD is a neurodevelopmental disorder that causes a person to be
easily distracted, disorganized and excessively restless.
Who does oppositional defiant disorder affect?
ODD most commonly affects children and teenagers, but it can also affect adults. It most
commonly begins by age 8.
Some children outgrow ODD or receive proper treatment for it, while others continue to have
symptoms through adulthood.
Boys are more likely to have ODD in their younger years than girls. But teenagers are
affected equally.
Your child is more likely to develop ODD if they have the following risk factors:
 A history of child abuse or neglect.
 A parent or caregiver who has a mood disorder or who has substance or alcohol use
disorders.
 Exposure to violence.
 Inconsistent discipline and lack of adult supervision.
 Instability in their family, such as divorce, moving to different houses often and
changing schools frequently.
 Financial problems in their family.
 Parents who have or have had ODD, attention-deficit/hyperactivity disorder (ADHD)
or behavioral problems.

How common is oppositional defiant disorder?

Researchers estimate that oppositional defiant disorder affects 2% to 11% of children. This
range is so wide because some children may be misdiagnosed as having conduct disorder,
and teenagers, as a population, are often underdiagnosed.

The prevalence of ODD declines with increasing age.

Diagnostic Criteria
A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness
lasting at least 6 months as evidenced by at least four symptoms from any of the following
categories, and exhibited during interaction with at least one individual who is not a sibling.
Angry/Irritable Mood
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
Argumentative/Defiant Behavior
4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures or with
rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.
Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months.
Note: The persistence and frequency of these behaviors should be used to distinguish a
behavior that is within normal limits from a behavior that is symptomatic. For children
younger than 5 years, the behavior should occur on most days for a period of at least 6
months unless otherwise noted (Criterion A8). For individuals 5 years or older, the behavior
should occur at least once per week for at least 6 months, unless otherwise noted (Criterion
A8). While these frequency criteria provide guidance on a minimal level of frequency to
define symptoms, other factors should also be considered, such as whether the frequency and
intensity of the behaviors are outside a range that is normative for the individual’s
developmental level, gender, and culture.
B. The disturbance in behavior is associated with distress in the individual or others in his or
her immediate social context (e.g., family, peer group, work colleagues), or it impacts
negatively on social, educational, occupational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic, substance use,
depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood
dysregulation disorder.
Specify current severity:
Mild: Symptoms are confined to only one setting (e.g., at home, at school, at
work, with peers).
Moderate: Some symptoms are present in at least two settings.
Severe: Some symptoms are present in three or more settings.

Specifiers
It is not uncommon for individuals with oppositional defiant disorder to show symptoms only
at home and only with family members. However, the pervasiveness of the symptoms is an
indicator of the severity of the disorder.
What causes oppositional defiant disorder (ODD)?
Researchers believe that the cause of oppositional defiant disorder is a complex combination
of biological, genetic and environmental factors:
 Genetic factors: Research suggests that genetics account for about 50% of the
development of ODD. Many children and teens with ODD have close family
members with mental health conditions, including mood disorders, anxiety disorders
and personality disorders. Further, many children and teens with ODD also have other
mental health conditions, such as ADHD, learning differences, or depression and
anxiety disorder, which suggests a genetic link between the conditions.
 Biological factors: Some studies suggest that changes to certain areas of your brain
can lead to behavior disorders. In addition, ODD has been linked to issues with
certain neurotransmitters, which help nerve cells in your brain communicate with each
other. If these chemicals are out of balance or not working properly, messages might
not make it through your brain correctly, leading to symptoms.
 Environmental factors: Having a chaotic family life, childhood maltreatment and
inconsistent parenting can all contribute to the development of ODD. In addition, peer
rejection, deviant peer groups, poverty, neighborhood violence and other unstable
social or economic factors may contribute to the development of ODD.
Risk factors
Oppositional defiant disorder is a complex problem. Possible risk factors for ODD include:
 Temperament — a child who has a temperament that includes difficulty managing
emotions, such as reacting with strong emotions to situations or having trouble
tolerating frustration.
 Parenting issues — a child who experiences abuse or neglect, harsh or inconsistent
discipline, or a lack of proper supervision.
 Other family issues — a child who lives with parent or family relationships that are
unstable or has a parent with a mental health condition or substance use disorder.
 Environment — problem behaviors that are reinforced through attention from peers
and inconsistent discipline from other authority figures, such as teachers.
Complications
Children and teenagers with oppositional defiant disorder may have trouble at home with
parents and siblings, in school with teachers, and at work with supervisors and other authority
figures. Children and teens with ODD may struggle to make and keep friends and
relationships.
ODD also may lead to other problems, such as:
 Poor school and work performance.
 Antisocial behavior.
 Legal problems.
  Impulse control problems.
 Substance use disorder.
 Suicide.
Many children and teens with ODD also have other mental health conditions, such as:
 Attention-deficit/hyperactivity disorder (ADHD).
 Conduct disorder.
 Depression.
 Anxiety disorders.
 Learning and communication disorders.
Treating these other mental health conditions may help reduce ODD symptoms. It may be
difficult to treat ODD if these other conditions are not evaluated and treated appropriately.

Management and Treatment

How is oppositional defiant disorder treated?
Treatment for ODD varies based on many factors, including:
 Your child’s age.
 The severity of their symptoms.
 Your child’s ability to take part in and tolerate specific therapies.
 If your child has other conditions, such as ADHD, learning differences and/or OCD.
Treatment of ODD should involve your child, your family and their school.
Treatment usually consists of a combination of the following:
 Parent management training (PMT).
 Psychotherapy (talk therapy).
 School-based interventions.
Parent management training for ODD
Parent management therapy (PMT) is the main treatment for oppositional behaviors. It
teaches parents ways to change their child’s behavior in the home by using positive
reinforcement to decrease unwanted behaviors and promote healthy behaviors.
There are different types of training programs, which usually involve multiple sessions over
several weeks. During the sessions, parents learn to identify problem behaviors, as well as
positive interactions, and to apply punishment or reinforcement as appropriate.
PMT has been shown to decrease conduct problems in multiple contexts and family
backgrounds significantly.
Psychotherapy for ODD
Psychotherapy (talk therapy) is a term for a variety of treatment techniques that aim to help
you identify and change troubling emotions, thoughts and behaviors. Working with a mental
health professional, such as a psychologist or psychiatrist, can provide support, education and
guidance to your child and your family.
Common types of psychotherapy that help treat ODD include:
 Cognitive behavioral therapy (CBT): This is a structured, goal-oriented individual
type of therapy. A therapist or psychologist helps your child take a close look at their
thoughts and emotions. Your child will come to understand how their thoughts affect
their actions. Through CBT, your child can unlearn negative thoughts and behaviors
and learn to adopt healthier thinking patterns and habits. CBT-based anger
management training is useful in treating anger problems in children with ODD. In
older children, problem-solving skills training and perspective-taking are helpful
therapy strategies.
 Family-focused therapy: This therapy is for children with ODD and their caregivers.
During this treatment, your child and family will join together in therapy sessions of
psychoeducation regarding ODD, communication improvement and problem-solving
skills. It can help identify factors in your home life that may contribute to or worsen
aggressive behaviors.
School-based interventions for ODD
Supportive interventions to improve school performance, peer relationships and problem-
solving skills are very useful in the treatment of ODD.
These interventions may include:
 Education and tools for your child’s teacher(s) to improve classroom behavior.
 Techniques to prevent oppositional behavior or the worsening of such behavior.
 Other methods that help your child follow classroom rules and acceptable social
interactions.
Medications for ODD
Although there isn’t medication formally approved to treat ODD, your child’s healthcare
provider or psychiatrist might prescribe certain medications to treat other conditions they may
have, such as ADHD, OCD or depression. If left untreated, these conditions can make the
symptoms of ODD worse.
Outlook / Prognosis
What is the prognosis (outlook) for oppositional defiant disorder (ODD)?
Children with ODD can experience significant issues in school, at home and in social
relationships.
Mild to moderate forms of ODD often improve with age, but more severe forms can evolve
into conduct disorder.
A lack of treatment and parental support often leads to a poor prognosis for oppositional
defiant disorder, while adequate treatment of coexisting conditions (such as ADHD or OCD),
individual and/or family therapy, and positive parenting are associated with a good prognosis.

What is oppositional defiant disorder (ODD) in children?

Oppositional defiant disorder (ODD) is a type of behavior disorder. It's mostly diagnosed in
childhood. Children with ODD show a pattern of uncooperative, defiant, and hostile behavior
toward peers, parents, teachers, and other authority figures. They are more troubling to others
than they are to themselves.
What causes ODD in a child?
Experts don’t know what causes ODD. But there are 2 main theories for why it occurs:
 Developmental theory. This theory suggests that the problems start when children
are toddlers. Children and teens with ODD may have had trouble learning to become
independent from a parent or other main person to whom they were emotionally
attached. Their behavior may be normal developmental issues that are lasting beyond
the toddler years.
 Learning theory. This theory suggests that the negative symptoms of ODD are
learned attitudes. They mirror the effects of negative reinforcement methods used by
parents and others in power. The use of negative reinforcement increases the child’s
ODD behaviors. That’s because these behaviors allow the child to get what they want:
attention and reaction from parents or others.
Which children are at risk for ODD?
ODD is more common in boys than in girls. Children with these mental health problems are
also more likely to have ODD:
 Mood or anxiety disorders
 Conduct disorder
 Attention-deficit/hyperactivity disorder (ADHD)
What are the symptoms of ODD in a child?
Symptoms and Signs of Oppositional Defiant Disorder
Typically, children with oppositional defiant disorder tend to frequently do the following:
 Lose their temper easily and repeatedly
  Argue with adults
 Defy adults
 Refuse to obey rules
 Deliberately annoy people
 Blame others for their own mistakes or misbehavior
 Be easily annoyed and angered
 Be spiteful or vindictive
Many affected children also lack social skills.

Most symptoms seen in children and teens with ODD also happen at times in other children
without it. This is very true for children around ages 2 or 3, or during the teen years. Many
children tend to disobey, argue with parents, or defy authority. They may often behave this
way when they are tired, hungry, or upset. But in children and teens with ODD, these
symptoms happen more often and are more severe. They also interfere with learning and
school adjustment. And in some cases, they disrupt the child’s relationships with others.
Symptoms of ODD may include:
 Having frequent temper tantrums
 Arguing a lot with adults
 Refusing to do what an adult asks
 Always questioning rules and refusing to follow rules
 Doing things to annoy or upset others, including adults
 Blaming others for the child’s own misbehaviors or mistakes
 Being easily annoyed by others
 Often having an angry attitude
 Speaking harshly or unkindly
 Seeking revenge or being vindictive
ODD can be mild, moderate, or severe:
 Mild ODD. The symptoms occur only in 1 setting (home or school).
 Moderate ODD. The symptoms are seen in at least 2 settings (home and school).
 Severe ODD. The symptoms occur in 3 or more settings (for instance at home or
school, with peers, or in public).
Many of these symptoms can be caused by other mental health problems. Make sure your
child sees a healthcare provider for a diagnosis.
How is ODD diagnosed in a child?
If you see symptoms of ODD in your child or teen, get a diagnosis right away. Early
treatment can often prevent future problems.
Before a mental health referral is made, your child's healthcare provider will want to rule out
any other health problems. Once this is done, a child psychiatrist or qualified mental health
expert can diagnose ODD. They will talk with you and your child's teachers about your
child’s behavior. They may also watch your child. In some cases, your child may need mental
health testing.
For a child to be diagnosed with ODD, symptoms must be present for at least 6 months. A
certain number of symptoms must also be present and observed during interactions with at
least 1 person who is not a sibling. The criteria used for children younger than age 5 is
slightly different. Providers will also figure out if your child's behavior is outside a range of
normal behaviors expected for their developmental level, culture, and gender.
Extreme defiance can also occur because of certain situations. And it can be a sign of an
undiagnosed learning disability. So it's important that all possibilities are looked at closely
before making a diagnosis.
How is ODD treated in a child?
Early treatment can often prevent future problems. Treatment will depend on your child’s
symptoms, age, and health. It will also depend on how bad the ODD is.
Children with ODD may need to try different therapists and types of therapies before they
find what works for them. Coordination between healthcare providers, family, and school is
key to treatment success. Treatment may include:
 Cognitive-behavioral therapy. A child learns to better solve problems and
communicate. They also learn how to control impulses and anger.
 Family therapy. This therapy helps make changes in the family. It improves
communication skills and family interactions. Having a child with ODD can be very
hard for parents. It can also cause problems for siblings. Parents and siblings need
support and understanding.
 Peer group therapy. A child learns better social skills.
 Medicines. These are not often used to treat ODD. But a child may need them for
other symptoms or disorders, such as ADHD or anxiety disorders.
Conduct Disorder (CD)
Introduction
Conduct disorder (CD) is a mental health condition that involves a consistent pattern of
aggressive and disobedient behaviours. It affects children and teens and is treatable with
various forms of psychotherapy (talk therapy).
Conduct disorder (CD) is a mental health condition that affects children and teens that’s
characterized by a consistent pattern of aggressive behaviours and actions that harm the well-
being of others. Children with conduct disorder also often violate rules and societal norms.
Conduct disorder lies on a spectrum of disruptive behavioural disorders, which also
includes oppositional defiant disorder (ODD). In some cases, ODD leads to CD.
Conduct disorder often occurs alongside other psychiatric conditions, including:
 Depression.
 Attention-deficit/hyperactivity disorder (ADHD).
 Learning disorders.
What is the difference between conduct disorder and personality disorders?
A personality disorder is a mental health condition that involves long-lasting, disruptive
patterns of thinking, behavior, mood and relating to others. Most personality disorders begin
in the teen years when personality further develops and matures. As a result, almost all people
diagnosed with personality disorders are above the age of 18.
One exception to this is antisocial personality disorder (ASPD) — approximately 80% of
people with this disorder will have started to show symptoms by the age of 11.
There’s not much difference between conduct disorder (CD) and ASPD, but CD is typically
diagnosed in children. If an adult meets the criteria for both conditions, then a mental health
professional would give them a diagnosis of ASPD instead of CD.
Who does conduct disorder affect?
Conduct disorder affects children and adolescents. It can have early onset before age 10, but
commonly develops in adolescence (between ages 10 years to 19 years).
The condition is more common in male children than female children. The average age of
presentation is 10 years to 12 years in males and 14 years to 16 years in females.
How common is conduct disorder?
Conduct disorder affects anywhere between 2% and 10% of children and adolescents in the
United States.
Types of conduct disorder
There are three types of conduct disorder. They’re categorized according to the age at which
symptoms of the disorder first occur:
  Childhood onset occurs when the signs of conduct disorder appear before age 10.
 Adolescent onset occurs when the signs of conduct disorder appear during the teen
years.
 Unspecified onset means the age at which conduct disorder first occurs is unknown.
Some children will be diagnosed with conduct disorder with limited prosocial emotions.
Children with this specific conduct disorder are often described as callous and unemotional.

Diagnostic Criteria

A. A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate
societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in
the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:

Aggression to People and Animals

1. Often bullies, threatens, or intimidates others.

2. Often initiates physical fights.

3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife,
gun).

4. Has been physically cruel to people.

5. Has been physically cruel to animals.

6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).

7. Has forced someone into sexual activity.

Destruction of Property

8. Has deliberately engaged in fire setting with the intention of causing serious damage.

9. Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or Theft

10. Has broken into someone else’s house, building, or car.

11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).

12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and
entering; forgery).

Serious Violations of Rules

13. Often stays out at night despite parental prohibitions, beginning before age 13 years.

14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or
once without returning for a lengthy period.

15. Is often truant from school, beginning before age 13 years.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational
functioning.

C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Specify whether:

F91.1 Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to
age 10 years.

F91.2 Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10
years.

F91.9 Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough
information available to determine whether the onset of the first symptom was before or after age 10 years.

Specify if:

With limited prosocial emotions: To qualify for this specifier, an individual must have displayed at least two of
the following characteristics persistently over at least 12 months and in multiple relationships and settings.
These characteristics reflect the individual’s typical pattern of interpersonal and emotional functioning over this
period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier,
multiple information sources are necessary. In addition to the individual’s self-report, it is necessary to consider
reports by others who have known the individual for extended periods of time (e.g., parents, teachers, co-
workers, extended family members, peers).

Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong (exclude remorse
when expressed only when caught and/or facing punishment). The individual shows a general lack of concern
about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting
someone or does not care about the consequences of breaking rules.

Callous—lack of empathy: Disregards and is unconcerned about the feelings of others. The individual is
described as cold and uncaring. The individual appears more concerned about the effects of his or her actions on
himself or herself, rather than their effects on others, even when they result in substantial harm to others.

Unconcerned about performance: Does not show concern about poor/problematic performance at school, at
work, or in other important activities. The individual does not put forth the effort necessary to perform well,
even when expectations are clear, and typically blames others for his or her poor performance.

Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem
shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions “on” or “off”
quickly) or when emotional expressions are used for gain (e.g., emotions displayed to manipulate or intimidate
others).

Specify current severity:

Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct
problems cause relatively minor harm to others (e.g., lying, truancy, staying out after dark without permission,
other rule breaking).

Moderate: The number of conduct problems and the effect on others are intermediate between those specified
in “mild” and those in “severe” (e.g., stealing without confronting a victim, vandalism).

Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct
problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while
confronting a victim, breaking and entering).
Subtypes

Three subtypes of conduct disorder are provided based on the age at onset of the disorder. Both childhood-onset
and adolescent-onset subtypes can occur in a mild, moderate, or severe form. An unspecified-onset subtype is
designated when there is insufficient information to determine age at onset.

In childhood-onset conduct disorder, individuals are usually male, have disturbed peer relationships, may have
had oppositional defiant disorder during early childhood, and usually have symptoms that meet full criteria for
conduct disorder prior to puberty. Individuals with the childhood-onset type may be more likely to display
aggression toward others than individuals with the adolescent-onset type. Many children with this subtype also
have concurrent attentiondeficit/ hyperactivity disorder (ADHD) or other neurodevelopmental difficulties.
Individuals with childhood-onset type are more likely to have persistent conduct disorder into adulthood than
are those with adolescent-onset type. Individuals with adolescent-onset conduct disorder tend to have more
normative peer relationships (although they often display conduct problems in the company of others).

Specifiers

A minority of individuals with conduct disorder exhibit characteristics that qualify for the “with limited
prosocial emotions” specifier. The indicators of this specifier are those that have often been labeled as callous
and unemotional traits in research. Other personality features, such as thrill seeking, fearlessness, and
insensitivity to punishment, may also distinguish those with characteristics described in the specifier. Individuals
with characteristics described in this specifier may be more likely than other individuals with conduct disorder
to engage in aggression that is planned for instrumental gain. Individuals with conduct disorder of any subtype
or any level of severity can have characteristics that qualify for the specifier “with limited prosocial emotions,”
although individuals with the specifier are more likely to have childhood-onset type and a severity specifier
rating of severe.

Although the validity of self-report to assess the presence of the specifier has been supported in some research
contexts, individuals with conduct disorder with this specifier may not readily admit to the traits in a clinical
interview. Thus, to assess the criteria for the specifier, multiple information sources are necessary. Also, because
the indicators of the specifier are characteristics that reflect the individual’s typical pattern of interpersonal and
emotional functioning, it is important to consider reports by others who have known the individual for extended
periods of time and across relationships and settings (e.g., parents, teachers, co-workers, extended family
members, peers).

Associated Features

Especially in ambiguous situations, aggressive individuals with conduct disorder frequently misperceive the
intentions of others as more hostile and threatening than is the case and respond with aggression that they then
feel is reasonable and justified. Personality features of trait negative emotionality and poor self-control,
including poor frustration tolerance, irritability, temper outbursts, suspiciousness, insensitivity to punishment,
thrill seeking, and recklessness, frequently co-occur with conduct disorder. Substance misuse is often an
associated feature, particularly in adolescent girls.
What Causes Conduct Disorder in Children?

Many factors seem to contribute to this disorder. Research has found that children and teens with conduct
disorder seem to have an impairment in the frontal lobe of the brain. This interferes with their ability to plan,
avoid harm, and learn from negative experiences.

In addition, these factors seem to put children and teens at a higher risk to develop conduct disorder:

 Having experienced abuse, parental rejection or neglect.

 Being diagnosed with other psychiatric disorders.

 Biological parents diagnosed with ADHD, alcohol use disorder, depression, bipolar disorder, or
schizophrenia.

 Poor nutrition.

 Living in poverty.

 Maternal psychopathology.

 Poor parenting / lack of parental involvement.

 Inconsistent, overly harsh, or otherwise ineffective discipline.

 Exposure to violence.

 Peer delinquency.

 Having been subjected to physical, sexual, and/or emotional abuse.

 Lack of adequate parental or other adult supervision.

What causes conduct disorder?

Researchers aren’t sure what exactly causes conduct disorder (CD), but they think it’s a complex combination of
genetic/biological and environmental factors.

Genetic/biological factors:

 Various studies show that certain characteristics of CD can be inherited, including antisocial behavior,
impulsivity, temperament, aggression and insensitivity to punishment.

 High testosterone levels are associated with aggression.

 Traumatic brain injury, seizures and neurological damage can contribute to aggression.

Parental, familial and environmental factors:

 Parents of adolescents with CD often have engaged in substance use and antisocial behaviors. They’re
also frequently diagnosed with ADHD, mood disorders, schizophrenia or antisocial personality
disorder.

 A home environment that lacks structure and adequate supervision with frequent conflicts between
parents can lead to maladaptive behavior in children, which can lead to CD.

 Children exposed to frequent domestic violence are more likely to develop CD.

 Living in low social and economic environments with overcrowding and unemployment leads to
economic and social stress with a lack of adequate parenting. CD affects more children living in low
economic environments than not.
  Availability of drugs and increased crime in a child’s neighborhood increases their risk of developing
CD.

It’s important to note that conduct disorder can occur in children from high-functioning, healthy families.

What Causes Conduct Disorder?

The exact cause of conduct disorder is not known, but it is believed that a combination of biological, genetic,
environmental, psychological, and social factors play a role.

 Biological: Some studies suggest that defects or injuries to certain areas of the brain can lead to
behavior disorders. Conduct disorder has been linked to particular brain regions involved in regulating
behavior, impulse control, and emotion. Conduct disorder symptoms may occur if nerve cell circuits
along these brain regions do not work properly. Further, many children and teens with conduct disorder
also have other mental illnesses, such as attention-deficit/hyperactivity disorder (ADHD), learning
disorders, depression, substance abuse, or an anxiety disorder, which may contribute to the symptoms
of conduct disorder.

 Genetics: Many children and teens with conduct disorder have close family members with mental
illnesses, including mood disorders, anxiety disorders, substance use disorders, and personality
disorders. This suggests that a vulnerability to conduct disorder may be at least partially inherited.

 Environmental: Factors such as a dysfunctional family life, childhood abuse, traumatic experiences, a
family history of substance abuse, and inconsistent discipline by parents may contribute to the
development of conduct disorder.

 Psychological: Some experts believe that conduct disorders can reflect problems with moral awareness
(notably, lack of guilt and remorse) and deficits in cognitive processing.

 Social: Low socioeconomic status and not being accepted by their peers appear to be risk factors for
the development of conduct disorder.

Impact of Parenting Style on Conduct Disorder?

Parenting styles significantly impact the development of conduct disorder, with harsh, inconsistent, and
neglectful parenting styles being linked to higher levels of conduct problems. Specifically, authoritarian
parenting, characterized by strict rules and limited responsiveness, has been associated with negative behavioral
outcomes like conduct disorders, while authoritative parenting, which combines high expectations with warmth
and support, can help reduce these issues.

Elaboration:

 Negative Parenting Styles:

 Harsh or Punitive Parenting: This involves using overly strict rules, harsh punishments, and
limited responsiveness to the child's needs. This can lead to feelings of resentment, fear, and a
lack of trust, potentially contributing to behavioral problems.

 Inconsistent Parenting: Erratic disciplinary practices, where rules are not consistently
enforced, can confuse children and make them feel unsure of what is expected.

 Neglectful Parenting: This involves a lack of involvement, supervision, and emotional

support, which can leave children feeling unloved and unsupported.

 Positive Parenting Styles:

 Authoritative Parenting: This style balances high expectations with responsiveness, warmth,
and support. It involves clear rules and expectations, but also provides a sense of
understanding and empathy. This can lead to children feeling secure and empowered, which
promotes prosocial behaviors.
  Responsive Parenting: This involves being attentive to a child's needs, providing emotional
support, and fostering positive interactions.

Prognosis for Conduct Disorder

Usually, disruptive behaviors stop during early adulthood, but in about one third of cases, they persist. Many of
these cases meet the criteria for antisocial personality disorder. Early onset is associated with a poorer
prognosis.

Some children and adolescents subsequently develop mood or anxiety disorders, somatic symptom or related
disorders, substance-related disorders, or early adult–onset psychotic disorders. Children and adolescents with
conduct disorder tend to have higher rates of physical and other psychiatric disorders.

What is the prognosis (outlook) for conduct disorder?

The prognosis (outlook) for conduct disorder depends on how early the condition developed and if it was
treated.

Usually, the disruptive behaviors of conduct stop during early adulthood, but in about one-third of cases, they
continue. Many of these cases meet the criteria for antisocial personality disorder.

Early onset of the condition (before 10 years of age) is associated with a poorer prognosis and is strongly
associated with a significant decline in school performance.

Some children and adolescents with conduct disorder develop other mental health conditions, including:

 Mood or anxiety disorders.

 Somatic symptom disorder.

 Alcohol use disorder and/or substance use disorder.

 Early adult-onset psychotic disorders.

Depression and bipolar disorder may also develop in the teen years and early adulthood. Suicidal ideation can be
a complication of these conditions. It’s important to get your child immediate medical care if they’re talking
about or threatening suicide.

Treatment of Conduct Disorder

 Medications to treat comorbid disorders

 Psychotherapy

 Sometimes placement in a residential center

Treating comorbid disorders with medications and psychotherapy may improve self-esteem and self-control and
ultimately improve control of conduct disorder. Medications may include stimulants, mood stabilizers, and
atypical antipsychotics, especially short-term use of risperidone.

Moralization and dire admonitions are ineffective and should be avoided. Individual psychotherapy, including
cognitive therapy and behavior modification, may help. Often, seriously disturbed children and adolescents must
be placed in residential centers where their behavior can be managed appropriately, thus separating them from
the environment that may contribute to their aberrant behavior.

Management and Treatment

How is conduct disorder treated?

The go-to treatment for conduct disorder (CD) is multiple forms of psychotherapy (talk therapy) for your child
and family, as well as community-based treatment.

Therapies include:

 Parent management training: The goal of this therapy is to train the child’s parents to set consistent
discipline with proper rewarding of positive behaviors.

 Psychotherapy: “Psychotherapy” is a term for a variety of treatment techniques that aim to help a
person identify and change troubling emotions, thoughts and behaviors. Working with a mental health
professional can provide support, education and guidance to the person and their family. Psychotherapy
for conduct disorder usually needs to target family life and school with a focus on improving family
dynamics, academic functioning and improving your child’s behavior in the context of various
environments.

 Anger management training: The goal of anger management is to reduce both your child’s emotional
feelings and the physiological arousal that anger causes. You can’t get rid of or totally avoid the things
or people that make them angry, so anger management training teaches your child how to control their
reactions.

 Individual psychotherapy, such as cognitive behavioral therapy: Individual therapy for a child with
conduct disorder focuses on developing problem-solving skills, strengthening relationships by
resolving conflicts and learning skills to decline negative influences in their environment.

 Community-based treatment: This treatment involves therapeutic schools and residential treatment
centers that can provide a structured program to reduce disruptive behaviors.

Healthcare providers typically don’t use medication to directly treat conduct disorder, but as other mental health
conditions often occur alongside conduct disorder, your child may benefit from medication to manage these
conditions.

How is conduct disorder treated in a child?

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the
condition is.

Treatment for conduct disorder may include:

 Cognitive-behavioral therapy. A child learns how to better solve problems, communicate, and handle
stress. He or she also learns how to control impulses and anger.

 Family therapy. This therapy helps make changes in the family. It improves communication skills and
family interactions.

 Peer group therapy. A child develops better social and interpersonal skills.

 Medicines. These are not often used to treat conduct disorder. But a child may need them for other
symptoms or disorders, such as ADHD.

How can I help prevent conduct disorder in my child?

Experts don’t know exactly why some children develop conduct disorder. Things such as a traumatic
experience, social problems, and biological factors may be involved. To reduce the risk for this disorder, parents
can learn positive parenting strategies. This can help to create a closer parent-child relationship. It can also
create a safe and stable home life for the child.

How can I help my child live with conduct disorder?

Early treatment for your child can often prevent future problems. Here are things you can do to help your child:

 Keep all appointments with your child’s healthcare provider.

 Take part in family therapy as needed.

 Talk to your child’s healthcare provider about other providers who will be involved in your child’s care.
Your child may get care from a team that may include counselors, therapists, social workers,
psychologists, and psychiatrists. Your child’s care team will depend on his or her needs and how
serious the disorder is.

 Tell others about your child’s conduct disorder. Work with your healthcare provider and schools to
develop a treatment plan.

 Reach out for support. Being in touch with other parents who have a child with conduct disorder may
be helpful. If you feel overwhelmed or stressed out, talk with your healthcare provider about a support
group for caregivers of children with conduct disorder.
Unit 6
Other psychological disorders

Bipolar Affective Disorder

Bipolar Affective Disorder

Introduction
Bipolar Affective Disorder is a mental health condition among mood disorders in which a
person experiences extreme highs and lows (mania and depression). This disorder can cause
emotional fluctuations and serious changes in energy levels and functioning. People with
bipolar disorder can be overly energetic, cheerful and confident during manic periods, while
during depressive periods they may experience deep sadness, hopelessness and low energy.
This disorder can profoundly affect a person's emotional, physical and social life. However,
with early diagnosis and treatment, individuals with this disorder can greatly improve their
quality of life and manage their symptoms effectively.
What are the Causes of Bipolar Affective Disorder?
Bipolar Affective Disorder is a complex mental disorder caused by a combination of genetic,
biological and environmental factors. Although the exact causes of this disorder are not fully
known, the following factors are thought to play an important role:

1. Genetic Factors:
Family History: Bipolar disorder is more common in people with a genetic predisposition.
People with a family history of bipolar disorder have a higher risk of developing the disorder.
If a parent has bipolar disorder, the child is more likely to develop the disorder.
Genetic Predisposition: Genetic factors can affect chemical imbalances in the brain. Research
shows that people with bipolar disorder may have certain genetic variations.

2. Biochemical Factors:

Brain Chemistry: Bipolar disorder is associated with an imbalance of chemicals in the brain
called neurotransmitters (such as serotonin, dopamine, norepinephrine). These chemicals
regulate mood, energy levels and thought processes. Disturbances in the balance of these
substances can cause extreme mood swings.

Changes in Brain Structure: Some studies show that people with bipolar disorder have
changes in brain structure and function. In particular, structural changes in brain regions such
as the frontal lobe, hippocampus and amygdala can lead to problems in regulating emotional
responses.

3. Environmental Factors:
Stressful Life Events: Although bipolar disorder can occur with a genetic predisposition,
often stressful life events can trigger the disorder. Major life changes, traumatic events,
losses, family problems or financial difficulties can initiate or worsen symptoms of bipolar
disorder.

Traumas: Traumatic events in childhood, such as physical, sexual or emotional abuse, can
increase the risk of bipolar disorder. Post-traumatic stress disorder (PTSD) and other mental
health problems may also play a role in the development of this disorder.

4. Hormonal Changes:
Impact of Hormones: It is thought that hormonal changes can trigger symptoms of bipolar
disorder, especially in women. Hormonal fluctuations such as pregnancy, the postpartum
period and menopause can lead to the onset of this disorder or exacerbate symptoms.

5. Alcohol and Drug Use:

Substance Abuse: Alcohol or drug use can trigger bipolar disorder or worsen existing
symptoms. Alcohol and drugs can increase manic or depressive episodes by affecting brain
chemistry.

6. Lack of Sleep Patterns and Routines:

Sleep Disorders: Disruption of regular sleep habits can trigger symptoms of bipolar disorder.
Lack of sleep is a particularly important factor in the onset of manic episodes. Lack of sleep
can increase mood instability, making the disorder more difficult to control.

7. Medication and Adherence to Treatment:

Misuse of Medication: In some individuals with bipolar disorder, certain medications, such
as antidepressants, can trigger episodes of mania or hypomania. Therefore, medication use in
the treatment of bipolar disorder should be carefully regulated.
Compliance with Treatment: Non-compliance with treatment and irregular use of
medication can also worsen symptoms. Regular use of medication under the supervision of a
doctor plays a critical role in reducing the effects of this disorder.

Bipolar affective disorder is a complex disorder caused by a combination of genetic

predisposition, chemical imbalances in the brain and environmental factors. The combination
of these causes can lead to a person's inability to manage mood swings and the emergence of
this disorder. If left untreated, it can seriously affect a person's daily life and overall health.

Bipolar Disorder
Bipolar disorder (formerly known as manic-depressive illness or manic depression) is a
lifelong mood disorder and mental health condition that causes intense shifts in mood, energy
levels, thinking patterns and behavior. These shifts can last for hours, days, weeks or months
and interrupt your ability to carry out day-to-day tasks.
There are a few types of bipolar disorder, which involve experiencing significant fluctuations
in mood referred to as hypomanic/manic and depressive episodes. However, people with
bipolar disorder aren’t always in a hypomanic/manic or depressive state. They also
experience periods of normal mood, known as euthymia.

What are the types of bipolar disorder?

There are four types of bipolar disorder, including:
 Bipolar I disorder: People with bipolar I disorder have experienced one or more
episodes of mania. Most people with bipolar I will have episodes of both mania and
depression, but an episode of depression isn’t necessary for a diagnosis. The
depressive episodes usually last at least two weeks. To be diagnosed with bipolar I,
your manic episodes must last at least seven days or be so severe that you need
hospitalization. People with bipolar I can also experience mixed states (episodes of
both manic and depressive symptoms).
 Bipolar II disorder: People with bipolar II experience depressive episodes and
hypomanic episodes. But they never experience a full manic episode that’s
characteristic of bipolar I disorder. While hypomania is less impairing than mania,
bipolar II disorder is often more debilitating than bipolar I disorder due to chronic
depression being more common in bipolar II.
 Cyclothymic disorder (cyclothymia): People with cyclothymic disorder have a
chronically unstable mood state. They experience hypomania and mild depression for
at least two years. People with cyclothymia may have brief periods of normal mood
(euthymia), but these periods last fewer than eight weeks.
 Other specified and unspecified bipolar and related disorders: If a person doesn’t
meet the diagnostic criteria for bipolar I, II or cyclothymia but has still experienced
 periods of clinically significant abnormal mood elevation, it’s considered other
specified or unspecified bipolar disorder.

Mania and hypomania

Mania and hypomania are different, but they have the same symptoms. Mania is more severe
than hypomania. It causes more noticeable problems at work, school and social activities, as
well as getting along with others. Mania also may cause a break from reality, known as
psychosis. You many need to stay in a hospital for treatment.
Manic and hypomanic episodes include three or more of these symptoms:
 Being much more active, energetic or agitated than usual.
 Feeling a distorted sense of well-being or too self-confident.
 Needing much less sleep than usual.
 Being unusually talkative and talking fast.
 Having racing thoughts or jumping quickly from one topic to another.
 Being easy to distract.
 Making poor decisions. For example, you may go on buying sprees, take sexual risks
or make foolish investments.
Major depressive episode
A major depressive episode includes symptoms that are severe enough to cause you to have a
hard time doing day-to-day activities. These activities include going to work or school, as
well as taking part in social activities and getting along with others.
An episode includes five or more of these symptoms:
 Having a depressed mood. You may feel sad, empty, hopeless or tearful. Children and
teens who are depressed can seem irritable, angry or hostile.
 Having a marked loss of interest or feeling no pleasure in all or most activities.
 Losing a lot of weight when not dieting or overeating and gaining weight. When
children don't gain weight as expected, this can be a sign of depression.
 Sleeping too little or too much.
 Feeling restless or acting slower than usual.
 Being very tired or losing energy.
 Feeling worthless, feeling too guilty or feeling guilty when it's not necessary.
 Having a hard time thinking or concentrating, or not being able to make decisions.
 Thinking about, planning or attempting suicide.
Other features of bipolar disorder
Symptoms of bipolar disorders, including depressive episodes, may include other features,
such as:
 Anxious distress, when you're feeling symptoms of anxiety and fear that you're losing
control.
 Melancholy, when you feel very sad and have a deep loss of pleasure.
 Psychosis, when your thoughts or emotions disconnect from reality.
The timing of symptoms may be described as:
 Mixed, when you have symptoms of depression and mania or hypomania at the same
time.
 Rapid cycling, when you have four mood episodes in the past year where you switch
between mania and hypomania and major depression.
Also, bipolar symptoms may happen when you're pregnant. Or symptoms can change with
the seasons.
Symptoms in children and teens
Symptoms of bipolar disorder can be hard to identify in children and teens. It's often hard to
tell whether these symptoms are the usual ups and downs or due to stress or trauma, or if
they're signs of a mental health problem other than bipolar disorder.
Children and teens may have distinct major depressive or manic or hypomanic episodes. But
the pattern can vary from adults with bipolar disorder. Moods can shift fast during episodes.
Some children may have periods without mood symptoms between episodes.
The most noticeable signs of bipolar disorder in children and teenagers may be severe mood
swings that aren't like their usual mood swings.

What types of therapy are used to treat bipolar disorder?

Psychotherapy, also called “talk therapy,” can be an effective part of the treatment plan for
people with bipolar disorder.
Psychotherapy is a term for a variety of treatment techniques that aim to help you identify
and change troubling emotions, thoughts and behaviors. Working with a mental health
professional, such as a psychologist or psychiatrist, can provide support, education and
guidance to you and your family.
Different types of therapy for bipolar disorder include:
 Psychoeducation: Psychoeducation is the way mental health professionals teach
people about their mental health conditions. As bipolar disorder is a complex
 condition, learning about the condition and how it can affect your life can help you
and your loved ones manage and cope with it better.
 Interpersonal and social rhythm therapy (IPSRT): This therapy is designed to help
you improve your moods by understanding and working with your biological and
social rhythms. IPSRT is an effective therapy for people with mood disorders,
including bipolar disorder. It emphasizes techniques to improve medication adherence
(taking your medication regularly), manage stressful life events and reduce
disruptions in social rhythms (day-to-day differences in habitual behaviors). IPSRT
teaches you skills that let you protect yourself against the development of future
manic or depressive episodes.
 Family-focused therapy: This therapy is for adults and children with bipolar disorder
and their caregivers. During this treatment, your loved ones will join you in therapy
sessions of psychoeducation regarding bipolar disorder, communication improvement
training and problem-solving skills training.
 Cognitive behavioral therapy (CBT): This is a structured, goal-oriented type of
therapy. Your therapist or psychologist helps you take a close look at your thoughts
and emotions. You’ll come to understand how your thoughts affect your actions.
Through CBT, you can unlearn negative thoughts and behaviors and learn to adopt
healthier thinking patterns and habits.
What medications are used to treat bipolar disorder?
Certain medications can help manage symptoms of bipolar disorder. You may need to try
several different medications, with guidance from your healthcare provider, before finding
what works best.
Medications healthcare providers generally prescribe to treat bipolar disorder include:
 Mood stabilizers.
 Second-generation (“atypical”) neuroleptics (also called antipsychotics).
 Antidepressants.
If you’re taking medication for bipolar disorder, you should:
 Talk with your healthcare provider to understand the risks, side effects and benefits of
the medication.
 Tell your healthcare provider about any prescription drugs, over-the-counter
medications or supplements you’re already taking.
 Tell your healthcare provider right away if you’re experiencing concerning side
effects. They may need to change your dose or try a different medication.
 Remember that medication for bipolar disorder must be taken consistently, as
prescribed.
Mood stabilizers for bipolar disorder
People with bipolar disorder typically need mood-stabilizing medication to manage manic or
hypomanic episodes.
Types of mood stabilizers and their brand names include:
 Lithium (Eskalith®, Lithobid®, Lithonate®).
 Valproic acid (Depakene®).
 Divalproex sodium (Depakote®).
 Carbamazepine (Tegretol®, Equetro®).
 Lamotrigine (Lamictal®).
Lithium is one of the most widely prescribed and studied medications for treating bipolar
disorder. Lithium is a natural salt and will reduce symptoms of mania within two weeks of
starting therapy, but it may take weeks to months before the manic symptoms are fully
managed. Because of this, healthcare providers often prescribe other drugs like antipsychotic
drugs or antidepressant drugs to help manage symptoms.
Thyroid gland and kidney problems can sometimes develop when taking lithium, so your
healthcare provider will monitor the function of your thyroid and kidneys, as well as monitor
the levels of lithium in your blood, as levels can easily become too high.
Anything that lowers the level of sodium in your body, such as switching to a low-sodium
diet, heavy sweating, fever, vomiting or diarrhea may cause a toxic buildup of lithium in your
body. Be aware of these conditions and alert your doctor if you’re on lithium and experience
them.
The following are signs of lithium toxicity (lithium overdose). Call your healthcare provider
immediately or go to the nearest emergency room if you experience:
 Blurred vision or double vision.
 Irregular pulse.
 Extremely fast or slow heartbeat.
 Difficulty breathing.
 Confusion and dizziness.
 Severe trembling or convulsions.
 Passing large amounts of pee.
 Uncontrolled eye movements.
 Unusual bruising or bleeding.
Neuroleptic medications for bipolar disorder
Healthcare providers often prescribe second-generation or atypical neuroleptics
(antipsychotics) in combination with a mood stabilizer for people with bipolar disorder.
These medications help with both manic and depressive episodes.
Only four of these drugs are U.S. Food and Drug Administration (FDA)-approved to help
treat bipolar depression, including:
 Cariprazine (Vraylar®).
 Lurasidone (Latuda®).
 Olanzapine-fluoxetine combination (Symbyax®).
 Quetiapine (Seroquel®).
However, other medications, such as olanzapine (Zyprexa®), risperidone (Risperdal®)
and aripiprazole (Abilify®), are commonly prescribed as well.
Antidepressants for bipolar disorder
Healthcare providers sometimes prescribe antidepressant medication to treat depressive
episodes in bipolar disorder, combining the antidepressant with a mood stabilizer to prevent
triggering a manic episode.
Antidepressants are never used as the only medication to treat bipolar disorder because only
taking an antidepressant drug can trigger a manic episode.

What other medical treatments are used for bipolar disorder?

Other treatment options your healthcare provider may consider for treating bipolar disorder
include:
 Electroconvulsive therapy (ECT): This is a procedure in which a brief application
of an electric current to your brain, through your scalp, induces a seizure. It’s most
often used to treat people with severe depression. ECT is very safe and highly
effective for medication-resistant depression or acute life-threatening mania. It’s the
best treatment for mania if you're pregnant. ECT is uses general anesthesia, so you’ll
be asleep during the procedure and won’t feel any pain.
 Transcranial magnetic stimulation (TMS): This therapy involves a short
electromagnetic coil that passes an electric current into your brain. Healthcare
providers sometimes use it to treat medication-resistant depression. It’s an alternative
to ECT. TMS isn’t painful and doesn’t require general anesthesia.
 Thyroid medications: These medications can sometimes act as mood stabilizers.
Studies have shown positive results in reducing symptoms in females with hard-to-
treat, rapid-cycling bipolar disorder.
 Ketamine treatment: Ketamine, an anesthetic, given at low doses through an IV, has
been proven to provide short-term antidepressant and antisuicidal effects for people
with bipolar disorder.
  Hospitalization: This is considered an emergency option in bipolar disorder care. It
becomes necessary when someone is experiencing a severe depressive or manic
episode and they’re an immediate threat to themselves or others.
What lifestyle changes can help with bipolar disorder?
Your healthcare team will likely recommend making lifestyle changes to stop patterns of
behavior that worsen the symptoms of bipolar disorder. Some of these lifestyle changes
include:
 Quit drinking alcohol and/or using recreational drugs and tobacco: It’s essential
to quit drinking and using drugs, including tobacco, since they can interfere with
medications you may take. They can also worsen bipolar disorder and trigger a mood
episode.
 Keep a daily diary or mood chart: Keeping track of your daily thoughts, feelings
and behaviors can help you be aware of how well your treatment is working and/or
help you identify potential triggers of manic or depressive episodes.
 Maintain a healthy sleep schedule: Bipolar disorder can greatly affect your sleep
patterns, and changes in your frequency of sleep can even trigger an episode.
Prioritize a routine sleeping schedule, including going to sleep and getting up at the
same times every day.
 Exercise: Exercise has been proven to improve mood and mental health in general, so
it may help manage your symptoms related to bipolar disorder. Since weight gain is a
common side effect of bipolar disorder medications, exercise may also help with
weight management.
 Meditation: Meditation has been shown to be effective in improving the depression
that’s part of bipolar disorder.
 Manage stress and maintain healthy relationships: Stress and anxiety can worsen
mood symptoms in many people with bipolar disorder. It’s important to manage your
stress in a healthy way and to try to eliminate stressors when you can. A big part of
this is maintaining healthy relationships with friends and family who support you, and
letting go of toxic relationships with people who add stress to your life.
Outlook / Prognosis
What is the outlook (prognosis) of bipolar disorder?
The prognosis for bipolar disorder is often poor unless it’s properly treated. Many people
with bipolar disorder who receive appropriate treatment can live fulfilling and productive
lives.
Bipolar disorder results in approximately a nine-year reduction in expected life span, and as
many as 1 in 5 people with bipolar disorder commit suicide. An estimated 60% of all people
with bipolar disorder have drug or alcohol dependence.
This is why it’s essential to seek medical care and stay committed to treatment for bipolar
disorder.
Regular and continued use of medication can help reduce episodes of mania and depression.
By knowing how to recognize the symptoms and triggers of these episodes, there’s a better
chance for effective treatment and finding coping methods that may prevent long periods of
illness, extended hospital stays and suicide.

Bipolar I Disorder
For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic
episode. The manic episode may have been preceded by and may be followed by hypomanic
or major depressive episodes.
Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least 1 week and present
most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of
the following symptoms (four if the mood is only irritable) are present to a significant degree
and represent a noticeable change from usual behaviour:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or
occupational functioning or to necessitate hospitalization to prevent harm to self or others, or
there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication, other treatment) or another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological
effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I
diagnosis.
Note: Criteria A–D constitute a manic episode. At least one lifetime manic episode is
required for the diagnosis of bipolar I disorder.
Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least 4 consecutive days
and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more)
of the following symptoms (four if the mood is only irritable) have persisted, represent a
noticeable change from usual behavior, and have been present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational
functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by
definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication, other treatment) or another medical condition.
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the
physiological effect of that treatment is sufficient evidence for a hypomanic episode
diagnosis. However, caution is indicated so that one or two symptoms (particularly increased
irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for
diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.
Note: Criteria A–F constitute a hypomanic episode. Hypomanic episodes are common in
bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2- week
period and represent a change from previous functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report
(e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful).
(Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day. (Note: In
children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another
medical condition.
Note: Criteria A–C constitute a major depressive episode. Major depressive episodes are
common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may include the feelings of intense sadness,
rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A,
which may resemble a depressive episode. Although such symptoms may be understandable
or considered appropriate to the loss, the presence of a major depressive episode in addition
to the normal response to a significant loss should also be carefully considered. This decision
inevitably requires the exercise of clinical judgment based on the individual’s history and the
cultural norms for the expression of distress in the context of loss.1
Bipolar I Disorder
A. Criteria have been met for at least one manic episode (Criteria A–D under “Manic
Episode” above).
B. At least one manic episode is not better explained by schizoaffective disorder and is not
superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other
specified or unspecified schizophrenia spectrum and other psychotic disorder.
Coding and Recording Procedures
The diagnostic code for bipolar I disorder is based on type of current or most recent episode
and its status with respect to current severity, presence of psychotic features, and remission
status. Current severity and psychotic features are only indicated if full criteria are currently
met for a manic or major depressive episode. Remission specifiers are only indicated if the
full criteria are not currently met for a manic, hypomanic, or major depressive episode. Codes
are as follows:
Associated Features
During a manic episode, individuals often do not perceive that they are ill or in need of
treatment and vehemently resist efforts to be treated. Individuals may change their dress,
makeup, or personal appearance to a more sexually suggestive or flamboyant style. Some
perceive a sharper sense of smell, hearing, or vision. Gambling and antisocial behaviours may
accompany the manic episode. Mood may shift very rapidly to anger or depression; some
individuals may become hostile and physically threatening to others and, when delusional,
become physically assaultive or suicidal. Serious consequences of a manic episode (e.g.,
involuntary hospitalization, difficulties with the law, serious financial difficulties) often result
from poor judgment, loss of insight, and hyperactivity. Depressive symptoms occur in some
35% of manic episodes (see “with mixed features” specifier, p. 170), and mixed features are
associated with poorer outcome and increased suicide attempts. Bipolar I disorder is also
associated with significant decrements in quality of life and well-being.
Trait-like features associated with the diagnosis include hyperthymic, depressive,
cyclothymic, anxious, and irritable temperaments, sleep and circadian rhythm disturbances,
reward sensitivity, and creativity. Having a first-degree relative with bipolar disorder
increases the risk of diagnosis approximately 10-fold.
Bipolar II Disorder
Diagnostic Criteria
For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a
current or past hypomanic episode and the following criteria for a current or past major
depressive episode:
Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least 4 consecutive days
and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more)
of the following symptoms have persisted (four if the mood is only irritable), represent a
noticeable change from usual behavior, and have been present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational
functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by
definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication, other treatment) or another medical condition.
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the
physiological effect of that treatment is sufficient evidence for a hypomanic episode
diagnosis. However, caution is indicated so that one or two symptoms (particularly increased
irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for
diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.
Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2- week
period and represent a change from previous functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to a medical condition.
1.Depressed mood most of the day, nearly every day, as indicated by either subjective report
(e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful).
(Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day. (Note: In
children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another
medical condition.
Note: Criteria A–C constitute a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may include the feelings of intense sadness,
rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A,
which may resemble a depressive episode. Although such symptoms may be understandable
or considered appropriate to the loss, the presence of a major depressive episode in addition
to the normal response to a significant loss should be carefully considered. This decision
inevitably requires the exercise of clinical judgment based on the individual’s history and the
cultural norms for the expression of distress in the context of loss.
Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode (Criteria A–F under
“Hypomanic Episode” above) and at least one major depressive episode (Criteria A–C under
“Major Depressive Episode” above).
B. There has never been a manic episode.
C. At least one hypomanic episode and at least one major depressive episode are not better
explained by schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or other specified or unspecified
schizophrenia spectrum and other psychotic disorder.
D. The symptoms of depression or the unpredictability caused by frequent alternation
between periods of depression and hypomania causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
Coding and Recording Procedures
Bipolar II disorder has one diagnostic code: F31.81. Its status with respect to current severity,
presence of psychotic features, course, and other specifiers cannot be coded but should be
indicated in writing (e.g., F31.81 bipolar II disorder, current episode depressed, moderate
severity, with mixed features; F31.81 bipolar II disorder, most recent episode depressed, in
partial remission).
Specify current or most recent episode:
Hypomanic
Depressed
If current episode is hypomanic (or most recent episode if bipolar II disorder is in partial or
full remission):
In recording the diagnosis, terms should be listed in the following order: bipolar II disorder,
current or most recent episode hypomanic, in partial remission/in full remission (p. 175) (if
full criteria for a hypomanic episode are not currently met), plus any of the following
hypomanic episode specifiers that are applicable.
Note: The specifiers “with rapid cycling” and “with seasonal pattern” describe the pattern of
mood episodes.
Specify if:
With anxious distress (p. 169–170)
With mixed features (pp. 170–171)
With rapid cycling (p. 171)
With peripartum onset (pp. 173–174)
With seasonal pattern (pp. 174–175)
If current episode is depressed (or most recent episode if bipolar II disorder is in partial or
full remission):
In recording the diagnosis, terms should be listed in the following order: bipolar II disorder,
current or most recent episode depressed, mild/moderate/severe (if full criteria for a major
depressive episode are currently met), in partial remission/in full remission (if full criteria for
a major depressive episode are not currently met) (p. 175), plus any of the following major
depressive episode specifiers that are applicable.
Note: The specifiers “with rapid cycling” and “with seasonal pattern” describe the pattern of
mood episodes.

Specify if:
With anxious distress (pp. 169–170)
With mixed features (pp. 170–171)
With rapid cycling (p. 171)
With melancholic features (pp. 171–172)
With atypical features (pp. 172–173)
With mood-congruent psychotic features (p. 173)
With mood-incongruent psychotic features (p. 173)
With catatonia (p. 173). Coding note: Use additional code F06.1.
With peripartum onset (pp. 172–174)
With seasonal pattern (pp. 174–175)

Specify course if full criteria for a mood episode are not currently met:
In partial remission (p. 175)
In full remission (p. 175)

Specify severity if full criteria for a major depressive episode are currently met:
Mild (p. 175)
Moderate (p. 175)
Severe (p. 175)
Cyclothymic Disorder
Diagnostic Criteria
A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous
periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and
numerous periods with depressive symptoms that do not meet criteria for a major depressive
episode.
B. During the above 2-year period (1 year in children and adolescents), Criterion A symptoms
have been present for at least half the time and the individual has not been without the
symptoms for more than 2 months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
D. The symptoms in Criterion A are not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic disorder.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
Specify if:
With anxious distress (see pp. 169–170)

Bipolar Disorder in Children and Adolescents

Bipolar disorder typically begins during mid-adolescence through the mid-20s. In many
children, the initial manifestation is one or more episodes of depression. (See also Bipolar
Disorders in adults.)
Bipolar disorder is rare in children. In the past, bipolar disorder was diagnosed in prepubertal
children who were disabled by intense, unstable moods. However, because such children
typically progress to a depressive rather than bipolar disorder, they are now classified as
having disruptive mood dysregulation disorder.
Etiology
Heredity is involved and several genetic variants have been associated with bipolar disorder ,
although there are currently no markers useful for diagnosing bipolar disorder. However,
neuroimaging studies in youths report smaller volumes in the amygdala and prefrontal cortex
as well as lack of the normal increase in volume of the amygdala and anterior white matter
that occurs in normal controls during adolescence.
Certain drugs (eg, cocaine, amphetamines, phencyclidine, certain antidepressants) and
environmental toxins (eg, lead) can exacerbate or mimic the disorder. Certain disorders (eg,
thyroid disorders) can cause similar symptoms. There are also a few case reports of mania
associated with asymptomatic and symptomatic COVID-19 infections in youths.
Symptoms and Signs
Bipolar disorder is characterized by recurrent episodes of elevated mood (mania or
hypomania). Manic episodes alternate with depressive episodes, which can be more frequent.
During a manic episode in adolescents, mood may be very positive or hyperirritable; the 2
moods often alternate depending on social circumstances. Speech is rapid and pressured,
sleep is decreased, and self-esteem is inflated. Mania may reach psychotic proportions (eg, “I
have become one with God”). Judgment may be severely impaired, and adolescents may
engage in risky behaviors (eg, promiscuous sex, reckless driving).
Prepubertal children may experience dramatic moods, but the duration of these moods is
much shorter (often lasting only a few moments) than that in adolescents.
Onset is characteristically insidious, and children typically have a history of always being
very temperamental and difficult to manage.
Diagnosis
 Psychiatric assessment
 Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, (DSM-5-TR)
criteria
 Testing for toxicologic causes
Diagnosis of bipolar disorder is based on identification of symptoms of mania as described
above, plus a history of remission and relapse.
A number of medical disorders (eg, thyroid disorders, brain infections or tumors) and drug
intoxication must be ruled out with appropriate medical assessment, including a toxicology
screen for drugs of abuse and environmental toxins. The interviewer should also search for
precipitating events, such as severe psychologic stress, including sexual abuse or incest.
Treatment
 Mania: 2nd-generation antipsychotics, sometimes mood stabilizers
 Depression: 2nd-generation antipsychotics plus an SSRI, sometimes lithium
For mania, 2nd-generation antipsychotics are the first line of treatment. Agents
include aripiprazole, lurasidone, olanzapine, quetiapine, risperidone, ziprasidone. Lithium or
other mood stabilizers (divalproex, lamotrigine, carbamazepine) may be used for patients
who fail 2 or 3 trials of antipsychotics .
For depression, 2nd-generation antipsychotics combined with a selective serotonin reuptake
inhibitor (SSRI) are the first line of treatment. Lithium is an alternative and may also be
combined with an SSRI. Compared to other mood stabilizers and
antipsychotics, lithium results in decreased suicidality, less depression and better
psychosocial function. These findings mimic those found in adults . Antidepressants should
not be used alone but in combination with the antipsychotics or lithium. Antidepressants do
not increase the risk of treatment-emergent mania (as was thought in the past) but may
destabilize children and adolescents with a bipolar disorder. Psychotherapy is also important.

Psychotic Disorders
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and-adolescents/schizophrenia-in-children-and-adolescents