Quality of life in children with psychiatric disorders: self-, parent, and clinician report

OBJECTIVE: To study the relationship between child psychiatric disorders and quality of life (QoL). METHOD: In a sample of 310 children (ages 6-18 years) referred for psychiatric problems, children, parents, and clinicians reported on psychopathology and subjective and objective QoL indicators. RESULTS: Six diagnostic categories were distinguished: attention-deficit and disruptive behavior disorders, anxiety disorders, pervasive developmental disorders, mood disorders, other disorders, and no diagnosis. In overall QoL, no differences were found between the diagnostic categories, except in clinician's ratings, who rated children with pervasive developmental disorder as having a poorer QoL than children with other diagnoses. In each diagnostic category specific QoL subdomains were affected: for children with attention-deficit and disruptive behavior disorder, school functioning and social functioning; for children with anxiety disorder, emotional functioning; for children with pervasive developmental disorder, social functioning; and for children with mood disorder, emotional functioning. CONCLUSIONS: Across multiple raters, the distinguished child psychiatric disorders had a different impact on QoL. Knowledge about domains of QoL that are affected in specific child psychiatric disorders can help clinicians to focus on particular QoL domains during the diagnostic process and to define adequate treatment goals.     

Convergent and divergent validity of the schedule for affective disorders and schizophrenia for school-age children – present and lifetime version diagnoses in a sample of children and adolescents with obsessive–compulsive disorder

The presence of comorbid conditions associated with paediatric obsessive–compulsive disorder (OCD) is reported to range from 50 to 80% and to have an impact on treatment outcome. Accurate identification of comorbid psychiatric disorders is necessary in order to provide personalised care. Reliable and valid diagnostic interviews are essential in the process of establishing the correct diagnoses. The objective of this study was to evaluate the convergent and divergent validity of four diagnose categories generated by the Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS-PL). The diagnose categories were: anxiety, depression, attention deficit hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD). The K-SADS-PL was applied in a clinical sample of youth aged 7–17 years (N?=?269), who were participants in the Nordic long-term OCD-treatment study (NordLOTS). Youth and parents completed measures to evaluate symptoms of anxiety, depression, ADHD, and ODD. Convergent and divergent validity of K-SADS-PL anxiety diagnosis was supported based on both anxiety self- and parent-reports. Similarly, support was found for convergent and divergent validity of ADHD and ODD diagnoses. For depressive disorder, support for convergent validity was found based on the depression self-report. Support for divergent validity of depression was found based on both the depression self- and parent-reports. Results of the present study suggest that the K-SADS-PL generates valid diagnoses of comorbid anxiety disorders, depression disorders, ODD, and ADHD in children and adolescents with OCD.     

Psychosocial and pharmacological treatment for pediatric anxiety disorders

Anxiety disorders in children and adolescents are highly prevalent and associated with long-term impairment. This article reviews the main diagnostic features of the most common pediatric anxiety disorders, including specific phobia, separation anxiety disorder, generalized anxiety disorder and social anxiety disorder, and highlights the state-of-the-art treatments for these diagnoses. The most recent evidence for empirically supported treatments is described, namely cognitive-behavioral therapy and selective serotonin-reuptake inhibitors. The review concludes by providing practitioners with recommendations for treating pediatric anxiety and highlighting areas for further investigation.     

Asthma severity and psychopathology in a tertiary care department for children and adolescent

 The purpose of this study was to evaluate the relationships between severe asthma, type and incidence of psychiatric problems in a pediatric population. A group of 92 children and adolescents (63 boys and 29 girls) (mean age 11.7) was investigated over one year by a pediatric pneumology/allergy service unit. The psychopathological problems of two groups were compared: “mild” (n=12) and “moderate/severe” (n=80) persistent asthma as defined by the National Heart Lung and Blood Institute (NIH). Various questionnaires were completed by the patients including the CBCL and the CPRS. The patients were examined by an experienced psychologist using the French version of the revised semi-structured diagnostic interview Kiddie-SADS. Twelve cases with intermittent or mild persistent asthma and 80 cases with moderate and severe persistent asthma were found. The child gender ratio and the social class of the parents did not differ significantly across groups. Moderate/severe asthma was more often associated with DSM-IV psychiatric disorders. Similarly, there were more symptoms in the severe group as indicated by several questionnaires. The hyperactivity index (CPRS) was higher for the severely affected group, who also exhibited fewer daytime activities. Social skills, school skills, and self esteem were, overall, on a similar level as those of the mildly affected group. Severe persistent asthma and moderate persistent asthma were not significantly different for the prevalence of psychiatric disorders and symptoms, even if children with severe asthma had a trend toward being diagnosed with more DSM-IV anxiety disorders and higher STAIC scores. Both of them had significantly higher total CBCL scores and CPRS hyperactivity index than intermittent and mild asthma. Moderate and severe persistent asthma appears to be associated with both incidence and particular categories of psychiatric problems, particularly anxiety disorders and anxious/depression symptoms. These observations suggest that it would be valuable to pay more attention to psychopathological problems of children suffering from severe asthma. Received: 24 February 1997 Accepted: 7 December 1997     

Psychiatric Comorbidities among Female Adolescents with Anorexia Nervosa

This study investigated current comorbid Axis I diagnoses associated with Anorexia Nervosa (AN) in adolescents. The sample included 101 female adolescents treated at a psychiatric unit for primary DSM-IV diagnoses of AN. 73.3% of the AN patients were diagnosed as having a current comorbidity of at least one comorbid Axis I diagnosis, with no differences across AN subtypes. Mood disorders (60.4%) were most commonly identified, followed by the category anxiety disorders without obsessive-compulsive disorders (OCD) (25.7%), OCD (16.8%) and substance use disorders (7.9%). Two specific diagnoses differed across the two subtypes of AN. Substance use disorder was 18 times, and the category anxiety disorder without OCD was three times as likely to co-occur with AN binge-eating disorder and purging type than with AN restricting type. Clinicians should be alerted to the particularly high rate of psychiatric comorbidities in adolescents suffering from AN.     

Comorbidity among childhood anxiety disorders

This paper reports on 73 consecutive admissions to an outpatient anxiety disorder clinic for children and adolescents. Patients were evaluated with a structured diagnostic interview for primary and secondary disorders with DSM-III criteria in order to examine patterns of comorbidity. The most common primary diagnoses for the sample included separation anxiety disorder (33%), overanxious disorder (15%), social phobia of school (15%), and major depression (15%). Children with a primary diagnosis of separation anxiety disorders were most likely to receive a concurrent diagnosis of overanxious disorder. Alternatively, children with a primary diagnosis of overanxious disorder were most likely to receive an additional diagnosis indicative of a social anxiety problem, either social phobia or avoidant disorder. Children with a primary major depression most often exhibited social phobia and/or overanxious disorder. No clear-cut pattern of comorbidity emerged for the social phobic (school) group. These findings are discussed in terms of their comparability with results recently obtained from an adult anxiety clinic population.     

Obsessive-compulsive disorder and immunocompetence

OBJECTIVE: A postinfectious, autoimmune response may be associated with the development of pediatric obsessive-compulsive disorder (OCD). According to this model, antistreptococcal antibodies cross-react with basal ganglia neurons following streptococcus infection. This autoimmune reaction disrupts a basal ganglia-thalamocortical circuit and generates obsessive-compulsive symptoms. One implication of this model is that prolonged immunologic stress may be a risk factor for OCD. That is, immunologic stress may compromise the blood-brain barrier and permit the influx of antistriatal antibodies into the central nervous system. This article explores one part of this putative relationship by investigating whether adult OCD patients, compared to members of other psychiatric groups, demonstrate a higher incidence of recurrent infections and other conditions suggestive of compromised immune function. METHOD: To test this hypothesis, we conducted a medical records review of 100 consecutive patients evaluated at a private psychiatric clinic specializing in the treatment of anxiety disorders. Sixty-five patients met diagnostic criteria for an Axis-I syndrome. Primary diagnoses included OCD, posttraumatic stress disorder, social anxiety disorder, generalized anxiety disorder, panic disorder with agoraphobia, and dysthymic disorder. Each medical record was reviewed for the presence of target syndromes or presenting symptoms suggestive of compromised immune function. RESULTS: Chart review revealed an increased rate of immune-related symptoms and syndromes among OCD patients in comparison to other anxiety and mood disorder groups. Groups did not differ significantly in the incidence of non-immune symptoms and syndromes. CONCLUSION: Adult OCD patients appear to have an increased rate of immune-related diseases above and beyond that seen in other psychiatric disorders.     

Categorical and dimensional aspects of co-morbidity in obsessive-compulsive disorder (OCD)

Objective Obsessive-compulsive disorder (OCD) defined at the diagnostic level encompasses divergent symptoms and is often associated with other psychiatric problems. The present study examines OCD versus co-morbid symptom patterns in OCD in children and adolescents in order to investigate the presence of diagnostic heterogeneity. Subjects and methods A total of 113 outpatients with primary OCD participated. The patients’ and primary caretakers’ responses on semi-structured interviews (child version of Schedule for Affective Disorders and Schizophrenia and the Children’s Yale-Brown Obsessive Compulsive Scale) and parents’ responses on the Child Behaviour Checklist were used in the study. Psychiatric diagnoses were related to CBCL syndrome scores and CBCL scores were compared with the Swedish normative data. Results Co-morbid diagnoses were very common and only one out of five patients had only OCD. The most common group was the neuropsychiatric disorders (47%) where tic disorders were most common (27%), especially among boys (40.8%; P = .006, Fisher’s exact test). Also anxiety disorders were common (39.8%) as were affective disorders (24.8%) neither with any gender differences. Diagnoses of disruptive disorders were less common (8.8%), almost exclusively of the oppositional kind (ODD) (8.8%). From the dimensional point of view using the CBCL, patients with OCD scored higher than Swedish youngster generally do, and some gender differences were seen in that girls scored higher on anxiety and depression while both girls and boys had high scores on thought problems, attention problems and especially aggressive behaviour. Comorbidities explained from 25 to 50% scores of the CBCL sub-syndrome scales, often with both main effects and through complex patterns of interaction with gender, OCD-severity and other co-morbid problems. Conclusions While co-morbid problems is an important facet of OCD, sub-syndromal levels of symptoms that can be assessed using a dimensional approach, is a large part of the total symptom burden in these youngsters. Our data indicate contributions of different pathways for girls and for boys for several comorbid problems together with OCD-severity.     

Stability and natural history of DSM-III childhood diagnoses

Follow-up or natural history outcome data for various DSM-III child and adolescent psychiatric diagnoses are presented. The data are relevant not only to our understanding of the specific disorders but also to the validity of the DSM-III diagnostic categories. "Semi-blind" psychiatric evaluations of 151 children were made as they presented to a community speech/language clinic and again approximately 4 years later. The follow-up data revealed high stability for only three diagnoses: infantile autism, attention deficit disorder with hyperactivity, and oppositional disorder. The data revealed that several of the DSM-III subcategories lacked predictive validity. This was true for the distinctions between attention deficit disorder with versus without hyperactivity; and between avoidant, separation anxiety, and overanxious disorders. Surprisingly low stability was found for conduct disorder diagnoses as were surprisingly poor prognoses for parent-child problems and adjustment disorders.     

The treatment of anxiety disorders in children and adolescents.

Anxiety disorders are the most common psychiatric conditions in the pediatric population, with prevalence estimates ranging from 5-18%. Children and adolescents with excessive anxiety often meet diagnostic criteria for a number of disorders within the DSM-IV. Unfortunately, the current diagnostic system is controversial because of high rates of symptom overlap, comorbidity with other psychiatric disorders, and lack of biological markers that would support a more empirical anxiety nosology. Treatment strategies for pediatric anxiety disorders have important historical roots. Several controlled studies of cognitive-behavioral therapy (CBT) demonstrate efficacy for pediatric anxiety disorders. In contrast, no controlled psychopharmacology studies have demonstrated efficacy in children and adolescents with anxiety disorders, except obsessive-compulsive disorder; however, several large, methodologically sound psychopharmacotherapy trials are underway for pediatric anxiety disorders. This update will review the current status of psychosocial and psychopharmacologic treatment of pediatric anxiety disorders. In addition, a brief discussion of nosology, epidemiology, and developmental course of anxiety is included. Preliminary psychopharmacology treatment and CBT treatment algorithms are presented for pediatric anxiety disorders, based on the best available data. Recommendations for future research directions are also discussed.     

Anxiety and depressive disorders in fathers and mothers of anxious school-refusing children.

OBJECTIVE: To examine anxiety and depressive disorders in the mothers and fathers of children with anxious school refusal and to test for the existence of differences in familial aggregation between children suffering from school refusal related to separation anxiety disorder and those suffering from phobic disorder-based school refusal. METHOD: Using a blind standardized diagnostic evaluation (Schedule for Affective Disorders and Schizophrenia-Lifetime version, modified for the study of anxiety disorders; Diagnostic Interview for Genetic Studies; and Schedule for Affective Disorders and Schizophrenia for School-Age Children), the authors compared parental lifetime psychiatric illness for the 2 groups of anxious school refusers. RESULTS: Relationships between specific anxiety disorders in children and their parents revealed increased prevalence of simple phobia and simple and/or social phobia among the fathers and mothers of phobic school refusers, and increased prevalence of panic disorder and panic disorder and/or agoraphobia among the fathers and mothers of school refusers with separation anxiety disorder. Simple and/or social phobia in the father, simple phobia in the mother, and age of the father were associated with the group of phobic school refusers. CONCLUSIONS: The data show the high prevalence of both anxiety and depressive disorders in fathers and mothers of anxious school refusers. Significant differences were observed in familial aggregation considering the subgroups of anxious school-refusing children.     

Parental psychopathology in child and adolescent obsessive-compulsive disorder

Purpose To identify the lifetime prevalence of obsessive-compulsive disorder (OCD) and other psychiatric diagnoses in parents of OCD pediatric patients as well as the frequency of onset of psychiatric disorders in the 6 months prior to evaluation. Methods Parents (n = 63) of 32 children and adolescents (20 males and 12 females; mean age of 13.3 ± 2.4) with OCD and parents of (n = 63) 32 age and sex-matched controls with no psychiatric diagnosis were examined. The semi-structured SCID-I was used to identify axis I psychiatric disorders and SCID-II to evaluate personality disorders. Results Mothers of patients had significantly more psychiatric diagnoses than control mothers (P = 0.001). Only parents of patients had diagnosis of OCD (P = 0.01) and psychiatric diagnosis (Adjustment Disorders, Major Depression, Anxiety Disorders) with onset during the 6 months prior to evaluation (P = 0.001). The duration of disease in children appeared to be related to development of morbidity in parents (P = 0.04). Parents of patients also showed a higher incidence of personality disorders (P = 0.01), in particular avoidant (6 versus 1 parents, P < 0.055) and obsessive-compulsive (9 versus 2 parents, P = 0.016) personality disorders. Conclusions The findings suggest that there may be an excess of psychopathology in parents of children with OCD as compared to parents of pediatric and non-psychiatric patients. Adjustment disorders with depressive and anxious symptoms are significantly more frequent in mothers of OCD children after the onset of the disease.     

CBCL-pediatric bipolar disorder phenotype: severe ADHD or bipolar disorder?

Summary Background. In children with pediatric bipolar disorder (PBD), a consistent pattern of elevations in hyperactivity, depression/anxiety, and aggression has been identified on the child behavior checklist (CBCL-PBD profile). The aim of the present study was to estimate the prevalence of the CBCL-PBD profile in a child psychiatric sample, and to determine ICD-10 diagnoses in CBCL-PBD patients. Methods. We studied a sample of 939 consecutively referred children and adolescents, aged 4–18 years. ICD-10 discharge diagnoses were established in consensus conferences. The CBCL 4–18 was completed by parents as part of the diagnostic routine. Results. A total of 62 subjects (6.6%; 95% CI=5.2–8.4) met criteria for the CBCL-PBD phenotype. More than 75% of CBCL-PBD subjects were clinically diagnosed with disruptive behavior disorders (ADHD, ODD, and CD). Two patients (0.2% of the total sample) received a formal diagnosis of bipolar disorder, but did not show the CBCL-PBD phenotype. Conclusions. A considerable number of children in Germany are referred to psychiatric care with a mixed phenotype of aggression, anxiety, depression and attention problems. Our study demonstrated a comparable prevalence and similar clinical characteristics as reported from other countries using different diagnostic approaches. However, the CBCL-PBD phenotype does not correspond with clinical consensus diagnoses of bipolar disorder, but with severe disruptive behavior disorders. Correspondence: Martin Holtmann, Department of Child and Adolescent Psychiatry and Psychotherapy, J.W. Goethe-University, Deutschordenstrasse 50, 60528 Frankfurt/Main, Germany     

Obsessive—compulsive disorder in childhood

Twenty children who met DSM-III-R criteria for obsessive-compulsive disorder (OCD) were identified among 190 consecutive referrals to an anxiety clinic for children and adolescents. Children and their families were assessed directly for lifetime psychopathology with structured diagnostic interviews, at which time sociodemographic data also were collected. Results indicated that clinically referred childhood OCD is more common among boys, and that boys have an earlier age-at-onset than their female counterparts. As true for adult patients with the disorder, obsessions without compulsions were relatively rare, multiple rituals were common, and the most common compulsive ritual was washing. Comorbid anxiety disorders were common among the children, but depressive disorders were rare. Examination of the psychiatric histories of the first- degree relatives (mothers, fathers, siblings) yielded a prevalence rate of 7.7% for OCD; thus, we did not obtain strong support for the notion that the disorder aggregates within families. Findings from this study provide independent confirmation of results previously obtained from the NIMH cohort of OCD children.     

Pharmacotherapy of childhood anxiety disorders

Anxiety disorders are among the most common psychiatric disorders of childhood, yet limited data is available regarding the use of psychotropic medications for these conditions. Until recently, much of the data on the pharmacologic treatment of pediatric anxiety disorders has consisted of case reports and small open-label studies, with the exception of pediatric obsessive-compulsive disorder (OCD), which has had a comparatively rich literature consisting of several double blind trials. This void has been lessening, however, with four double blind, placebo-controlled studies published in the past year alone. Although the majority of pharmacologic studies of pediatric anxiety continue to focus on the treatment of OCD, additional reports on treatment of generalized anxiety disorder, panic disorder, social anxiety disorder, and separation anxiety disorder have recently been published. This article will review significant pharmacologic studies published in the prior year, and the role of pharmacotherapy in the treatment of pediatric anxiety disorders.     

Clinical Correlates of Comorbid Obsessive–Compulsive Disorder and Depression in Youth

A burgeoning body of literature addresses the comorbidity of depression and OCD in adults. The purpose of this study was to extend this area of research to children and adolescents by examining the clinical correlates associated with co-occurring depressive disorders in a clinical sample of youth with OCD. Participants included children and adolescents seeking treatment at a university-based research clinic. One group was comprised of 28 children (ages 10–17 years) who met diagnostic criteria for OCD but had no comorbid depressive disorders, whereas the second group consisted of 28 children matched for age and gender who met diagnostic criteria for OCD and co-occurring depressive disorder. The two groups were compared on measures of broad-band psychopathology, internalizing problems, social difficulties, and family characteristics. As anticipated, findings revealed comorbid depression and OCD was associated with more severe internalizing problems, more extensive obsessive–compulsive symptomatology, and more social problems. Youth with comorbid depression and OCD also had higher family conflict and lower family organization compared to those with OCD and no depression. These results may have implications for the treatment of youth with comorbid OCD and depression.     

Japanese midwives as psychiatric diagnosticians: application of criteria of DSM-IV mood and anxiety disorders to case vignettes

It is believed in Japan that only psychiatrists are capable of providing reliable psychiatric diagnosis. However, more awareness of mental health issues related to perinatal care means that midwives are now required to have psychiatric diagnostic skills. The purpose of the present paper was to examine how well Japanese midwives agreed with a psychiatrist on diagnoses of different psychiatric disorders. Vignettes of 29 cases including DSM-IV mood disorders (major depressive disorder and bipolar disorder) and anxiety disorders (generalized anxiety disorder, panic disorder, phobic disorders, and obsessive-compulsive disorder) were distributed to 12 Japanese midwives. They decided the DSM-IV diagnoses independently and compared them with those made by an expert. The kappa coefficients of the diagnoses with a base rate of 0.1 or more were moderate to almost perfect (0.64-0.83). The accuracy of symptom assessment was also satisfactory. Appropriately trained Japanese midwives can use the diagnostic criteria for psychiatric disorders reliably. It is therefore feasible to dispatch midwives who are trained in psychiatric diagnosis to antenatal clinics.     

The Ability of the Symptom Checklist SCL-90 to Differentiate Various Anxiety and Depressive Disorders

We studied the use of the Symptom Checklist-90 (SCL-90) to differentiate between specific anxiety and depressive disorders and/or their symptoms in 280 patients with 6 DSM-III-R diagnoses: major depression (MD), panic disorder (PD), generalized anxiety disorder (GAD), social phobia (SP), obsessive-compulsive disorder (OCD), and mixed anxiety and depression (MAD). Using a comparison group, we found specific patterns for some of the diagnostic categories. Both the MD and MAD subjects had significantly high paranoid ideation, interpersonal sensitivity, hostility, and psychoticism, as well as high depression subscale scores; those with PD and GAD has the highest anxiety and somatization scores; and those with SP or OCD had a mixed pattern. When ranking the severity of psychopathology, the disorders ordered from most to least were MAD, MD, PD, GAD, SP, and OCD. Subsyndromal levels of symptoms frequently were associated with the various conditions. Use of the SCL-90 subscale helps to enlarge our understanding of the various anxiety and depressive disorders.     

Temperament and character among Korean children and adolescents with anxiety disorders

The purpose of this study was to evaluate the temperament and character of children and adolescents with anxiety disorders in samples from Korean community. The study subjects were children and adolescents diagnosed with social phobia (n = 66), separation anxiety disorder (n = 47), specific phobia (n = 415), and obsessive–compulsive disorder (n = 42) with the diagnostic interview schedule for children, version IV (DISC-IV) in representative community samples. Among these, we excluded other psychiatric disorder comorbid samples, with the exception of externalizing disorders. We assessed the subjects of each anxiety group using the junior temperament and character inventory (JTCI). Social phobias were significantly associated with high harm avoidance and low self-directedness on the JTCI. The association of specific phobias with high harm avoidance, and obsessive–compulsive disorder with low self-directedness was also significant. Separation anxiety disorder was not associated with any temperament and character on the JTCI. Children and adolescents with anxiety disorders have different temperaments and character profiles in accordance with diagnostic groups, which implies the specific pathophysiological mechanism of each anxiety disorder.