Child and Adolescent Mental-Health Disorders
- Susan FrauenholtzSusan FrauenholtzSchool of Social Welfare, The University of Kansas. Her primary research and teaching interests include children’s mental health and workplace-related issues. She earned her MSW at the George Warren Brown School of Social Work and is a licensed independent social worker (LISW).
- and Amy MendenhallAmy MendenhallAmy Mendenhall is an Assistant Professor at the University of Kansas School of Social Welfare, and the Director of the School’s Office of Child Welfare and Children’s Mental Health. She received her MSW and PhD from The Ohio State University. Her research focuses on children’s mental health.
Mental-health disorders are widely prevalent in children and adolescents, and social workers are the primary service providers for children and families experiencing these disorders. This entry provides an overview of some of the most commonly seen disorders in children and adolescents: attention deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, separation anxiety disorder, and specific learning disorders. The prevalence, course, diagnostic criteria, assessment guidelines, and treatment interventions are reviewed for each disorder. In addition, the key role of social workers in the identification and intervention of these disorders, as well as ways social workers can support the children and families experiencing these disorders, is discussed.
Mental-health disorders are widely prevalent in children and adolescents, with estimates indicating that as many as 2.7 million children in the United States have a mental-health disorder (Federal Interagency Forum on Child and Family Statistics, 2007), and approximately 13% (13.1%) of all children will experience a diagnosable mental-health disorder in a given year (Merikangas et al., 2010). There is not a clear distinction between childhood and adult disorders because disorders commonly diagnosed in childhood often continue into adulthood, and adult disorders are typically rooted in early childhood conditions and experiences. For convenience, the Diagnostic and Statistical Manual of Mental Disorders–IV (DSM-IV; American Psychiatric Association [APA], 2000) included a separate diagnostic category for disorders that were usually first diagnosed in infancy, childhood, or adolescence. However, DSM-5 (APA, 2013) no longer includes this category, and so disorders formerly included in the category have been moved to categories more reflective of related symptomology, presentation, and etiology. These new categories include neurodevelopmental disorders and disruptive, impulse control, and conduct disorders.
This entry focuses on some of the most commonly diagnosed and recognized mental-health disorders in children and adolescents, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), separation anxiety disorder (SAD), and specific learning disorders. This entry provides a broad overview of these diagnoses and is not meant to be used for diagnostic purposes. When making a diagnosis, the DSM-5 (APA, 2013) should be consulted for a listing of full diagnostic criteria related to each disorder. This encyclopedia also contains other entries that deal with mental-health issues in children and adolescents, including autism spectrum disorder; youth suicide; intellectual disabilities; mental health, adolescents; and mental illness, children.
Attention Deficit Hyperactivity Disorder
Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by behaviors relating to hyperactivity, impulsivity, and inattention that interfere with a child’s ability to function in daily life (APA, 2013). The behaviors are severe enough to cause problems at home, in school, and with peers. In the past, ADHD was referred to as attention deficit disorder (ADD) with or without hyperactivity. However, in the DSM-IV, the name of the disorder was changed to ADHD, which was used even if there is no hyperactivity, and that name remains.
Prevalence estimates of ADHD range from approximately 5% to 8% of children and adolescents, making it the most common neurobehavioral disorder in children (American Academy of Child and Adolescent Psychiatry [AACAP], 2011; APA, 2013). Attention deficit hyperactivity disorder is observed more predominately in males, with approximately 3% of males receiving an ADHD diagnosis for every female in the general population (Hinshaw & Blachman, 2005). One major limitation is that few studies of high quality have been conducted to explore the prevalence of ADHD across racial and ethnic groups.
In the DSM-5 (APA, 2013), ADHD is included in the new diagnostic category called neurodevelopmental disorders. In the prior edition, ADHD was included in the diagnostic category disorders usually first diagnosed in infancy, childhood, or adolescence, which has been removed as a category. The DSM-5 (APA, 2013) diagnostic criteria for ADHD specify that there must be six or more symptoms of inattention or hyperactivity and impulsivity that interfere with functioning and are inconsistent with developmental level for at least six months. Common symptoms of inattentiveness include difficulty sustaining attention in tasks or play activities, difficulty following instructions and failing to finish schoolwork, and difficulty organizing tasks and activities. Symptoms of hyperactivity and impulsivity include frequent fidgeting or squirming in seat, excessive talking and interrupting others to blurt out an answer, and appearing “driven by a motor.”
The DSM-5 (APA, 2013) also specifies that symptoms must be present prior to age 12 and must occur in two or more settings (home, school, work) with evidence of clinically significant impairment in social, academic, or occupational functioning. Additionally, symptoms should not be better accounted for by another mental disorder and should not occur exclusively within the course of pervasive developmental disorder, schizophrenia, or another psychotic disorder.
Based on the varying combinations of presenting symptoms, there are three types of ADHD specified in the DSM-5 (APA, 2013). Attention deficit hyperactivity disorder, combined type, is diagnosed if there are six or more inattentive symptoms and six or more hyperactive or impulsive symptoms. Attention deficit hyperactivity disorder, predominantly inattentive type, is diagnosed if there are six or more inattentive symptoms but hyperactive–impulsive symptom requirements are not met. Attention deficit hyperactivity disorder, predominantly hyperactive–impulsive type, is diagnosed if there are six or more hyperactive and impulsive symptoms but inattentive symptom requirements are not met. Clinicians should also specify that ADHD is “in partial remission” when complete criteria were previously met but have not been met for the past six months, but the symptoms still impair academic or occupational functioning. Specification is also required to describe symptoms as mild, moderate, or severe.
Attention deficit hyperactivity disorder is comorbid with a number of other internalizing and disruptive behavior disorders in numbers that are above chance (Angold, Costello, & Erkanli, 1999). In particular, ODD and CD co-occur with one quarter to one half of children who have the combined presentation of ADHD (APA, 2013).
There does appear to be a genetic component to ADHD because the biological relatives of individuals with ADHD are substantially more likely to develop ADHD themselves. However, although ADHD does appear to be correlated with specific genes, those genes alone are not enough to cause ADHD (APA, 2013). A variety of environmental factors may increase the chances of a child developing ADHD (Rowland, Lesesne, & Abramowitz, 2002), including very low birth weight, smoking during pregnancy, a history of child abuse or neglect, drug and alcohol exposure in utero, and exposure to lead.
Although symptoms of ADHD, such as excessive physical activity, are often reported by parents in children as young as toddlers, ADHD is typically not diagnosed until children begin elementary school. At that point, a child’s inattention becomes more apparent and likely to interfere with achievement and functioning (APA, 2013). The symptoms of ADHD tend to be consistent through early adolescence. For many children with ADHD, the motor hyperactivity subsides somewhat during adolescence but impulsivity, inattention, restlessness, and difficulty planning remain persistent (APA, 2013). As teenagers, a limited number of children will no longer meet diagnostic criteria, but somewhere between 43% and 80% will continue to have ADHD (Mannuzza, Klein, Bonagura, Malloy, Giampino, & Addalli, 1991). With treatment, symptoms of ADHD can be managed successfully, but the disorder often persists into adulthood.
Evaluation for ADHD should include information from multiple sources across settings including parents, schools, and the child, if possible. Several commonly used behavior rating scales are used in the assessment of ADHD. Parent rating scales include Conners Parent Rating Scale–Revised (Conners, 1997), Eyberg Child Behavior Inventory (Eyberg, 1999), and the Home Situations Questionnaire–Revised (Barkley, 1990). Rating scales for the school setting include the Academic Performance Rating Scale (Barkley, 1990), Conners Teacher Rating Scale–Revised (Conners), School Situations Questionnaire–Revised (Barkley, 1990), and Vanderbilt ADHD Diagnostic Parent and Teacher Scales (Wolraich et al., 2003).
In addition, clinicians should consider cultural factors when conducting an assessment because various cultural groups have differing norms regarding child behavior (APA, 2013). Concern has also been raised that even when displaying similar symptoms, African American children are more likely to enter the juvenile justice system instead of receiving mental-health services (Mattox & Harder, 2007).
Pharmacological treatment has demonstrated effectiveness in treating ADHD. The AACAP’s (American Academy of Pediatrics, 2007) Practice Parameters for ADHD recommend that initial psychopharmacological treatment of ADHD should be a trial of one of the medications approved by the Food and Drug Administration for ADHD treatment. These include Adderall, Ritalin, Concerta, and Strattera. If none of the approved medications results in satisfactory improvement, the Practice Parameters recommend a review of the diagnosis and then consideration of behavior therapy or use of medications not approved by the Food and Drug Administration for ADHD treatment. These may include antidepressants such as bupropion, imipramine, nortriptyline, or 2-adrenergic agonists such as clonidine or guanfacine. Dosages should be adjusted to ensure the child is obtaining the greatest benefit from the medication with minimal adverse side effects (American Academy of Pediatrics, 2007).
For many children, pharmacological treatment combined with behavioral therapy is more effective than either one alone (Power et al., 2012). Behavioral interventions typically include components such as token economies, time-outs, and other incentives and interventions to which the child is individually responsive. Classroom behavioral interventions are also often required to assist children with ADHD in managing their behaviors at school and improving academic performance. Barkley (2005) has observed that ADHD treatment tends to be most helpful when it is directed at behaviors at the point of performance in the natural environment.
Although behavioral therapies have garnered support and are most commonly used to treat ADHD, parent training is often recommended (Mattox & Harder, 2007). Parent training is a form of therapy that not only works with the parent to manage a child’s behavior, but also provides an educational component, includes the child, and assists in the reduction of parent–child conflict and family relationship building. Parent training is most likely to be helpful when combined with psychopharmacological and behavioral therapies in a holistic fashion.
Oppositional Defiant Disorder
Children with ODD typically display an irritable or angry mood, are frequently defiant or argumentative, and are vindictive toward others (APA, 2013). The symptoms of ODD can occur in one or more settings, typically including the home and school, and interfere with a child’s ability to develop positive social relationships. The behavioral manifestation of ODD often makes it difficult for a child to perform at his or her full potential.
Community prevalence of ODD has been reported between 1% and 16% depending on criteria used and methods of assessment (Loeber, Burke, Lahey, Winters, & Zera, 2000). The average prevalence rate appears to be approximately 3.3% (APA, 2013). Oppositional defiant disorder seems to be more common in males than in females during early childhood, but in adolescence it appears equally prevalent in males and females (APA, 2013).
In the DSM-5 (APA, 2013), ODD is included in the new diagnostic category of disruptive, impulse control, and conduct disorders. In the prior edition, ODD was included in the diagnostic category of disorders usually first diagnosed in infancy, childhood, or adolescence, which has been removed as a category. The DSM-5 (APA, 2013) criteria for ODD specify that there must be a pattern of negativistic, hostile, and defiant behavior operationalized by the presence of four or more symptoms that occur for at least six months. These symptoms include often losing temper, frequently defying or refusing to comply with adult requests, and deliberately annoying others. For children under the age of five, the behaviors should occur on most days, and for individuals older than five, the behaviors should occur at least once per week. These behaviors should occur more frequently than is typical for the age and developmental level of the individual. The DSM-5 (APA, 2013) also specifies that these behaviors must be causing clinically significant impairment in social, academic, or occupational functioning and must not occur exclusively during a psychotic or mood disorder. If criteria for both ODD and CD are met, then only a diagnosis of CD should be given. Oppositional defiant disorder is often comorbid with ADHD, but can be distinguished by a child’s display of anger or oppositional behavior in situations not solely requiring sustained attention or effort.
Oppositional defiant disorder is believed to stem from a mix of biological, psychological, and social factors. Understanding of the protective and risk factors for ODD relies heavily on the research on CD, and there is little separate research focusing specifically on ODD (American Academy of Pediatrics, 2007). It does appear that various temperamental factors, such as limited frustration tolerance and emotional reactivity, are related to ODD. In addition, inconsistent or harsh child-rearing practices may contribute to the development of ODD. Certain neurobiological markers have been associated with ODD as well, but again, those markers have not been distinguished from those of CD (APA, 2013).
Oppositional defiant disorder is usually manifest by age eight (Connor, 2002) and is relatively stable over time. However, most children no longer meet criteria of the diagnosis after a three-year follow up (Connor; Hinshaw & Anderson, 1996; Loeber et al., 2000). Oppositional defiant disorder is often a developmental antecedent of CD but many children with ODD do not ever develop CD (APA, 2000). It seems that earlier age of onset of ODD symptoms leads to a poorer prognosis with progression into CD (Connor; Loeber et al.). With increasing age, comorbidities with diagnoses such as ADHD, learning disorders, communication disorders, anxiety disorders, and mood disorders begin to appear (APA, 2013; Lavigne et al., 2001). Children with ODD often experience challenges academically and have difficulty forming social relationships with peers (Frankel & Feinberg, 2002).
A wide range of interviews and instruments are available for assessing oppositional behavior and aggression in children and adolescents in different settings. A number of assessment batteries have also been developed to aid in assessment. Parent or teacher report measures include the Conners Rating Scale (parent and teacher versions) (Conners, Sitatenios, Parker, & Epstein, 1998), Children’s Aggression Scale (Halperin, McKay, & Newcorn, 2002), Parent Daily Report (Kazdin & Esveldt-Dawson, 1986), and Interview for Antisocial Behavior (Chamberlain & Reid, 1987). Youth self-report measures include Youth Self-Report (Achenbach, 1991), Buss–Durkee Hostility Inventory (Buss & Durkee, 1957), Buss–Perry Aggression Questionnaire (Buss & Perry, 1992), and Conners/Wells Adolescent Self-Report of Symptoms (Conners et al., 1997). One of the challenges of assessment is that children often do not display the same behaviors during a clinical interview as they do in their natural environments. Therefore, the reports of parents, teachers, and other appropriate observers are particularly critical to obtaining a complete clinical picture (APA, 2013).
Interventions can be delivered in schools, clinics, and other community locations with differing approaches depending on the child’s age. In preschool children, programs such as Head Start (Connor, 2002) and home visitation to high-risk families have produced positive outcomes (Eckenrode et al., 2000). In school-age children, parent management strategies have strong empirical support for disruptive behavior. In general, these approaches focus on the following four principles: (a) reduce positive reinforcement of disruptive behavior; (b) increase reinforcement of prosocial and compliant behavior; (c) apply consequences or punishment for disruptive behavior; and (d) make parental response predictable, contingent, and immediate (American Academy of Pediatrics, 2007). These approaches have been found to be effective in community and clinical samples, and examples of parent management training packages include Incredible Years (Webster-Stratton, Reid, & Hammond, 2004), Triple P-Positive Parenting Program (Sanders, Markie-Dadds, Tully, & Bor, 2000), and Parent–Child Interactional therapy (Brinkmeyer & Eyberg, 2003).
Conduct disorder is characterized by a persistent pattern of behavior that violates age-appropriate social norms and interferes with the basic rights of others. Behaviors typically observed in CD include aggression and violence to others, property damage, deceitfulness, and serious rule violations (APA, 2013). These behaviors exceed what is developmentally appropriate and interfere with social, school, and occupational functioning.
Estimates of the prevalence of CD range from 2% to 10% (APA, 2013), with an average of 6% (AACAP, 2004). Conduct disorder is typically seen more frequently as children enter adolescence and boys have higher prevalence rates of CD than girls. Rates of CD appear relatively stable across countries that differ with respect to race and ethnicity (APA, 2013).
In the DSM-5 (APA, 2013), CD is included in the new diagnostic category of disruptive, impulse control, and conduct disorders. In the prior edition, CD was included in the diagnostic category of disorders usually first diagnosed in infancy, childhood, or adolescence, which has been removed as a category. The DSM-5 (APA, 2013) criteria for CD specify that there must be a repetitive pattern of behavior that violates the basic rights of others or major age-appropriate societal norms as evidenced by the presence of three or more of the identified symptoms in a period of 12 months, with at least one of the criterion present in the past 6 months. Those symptoms include aggression to people or animals, destruction of property, and serious rule violations such as running away repeatedly and school truancy. The behavior must be causing clinically significant impairment in social, academic, or occupational functioning. If criteria for both ODD and CD are met, then only a diagnosis of CD should be given. The disorder is considered to have childhood onset if behavior occurred prior to age 10 and adolescent onset if behavior did not occur until after age 10. There is a diagnostic specifier included in the DSM-5 (APA, 2013) for callous–unemotional presentation, which is given if the person displays at least two of the following traits in the past 12 months: lack of remorse or guilt, callous–lack of empathy, unconcerned about performance, or shallow or deficient affect. Severity is specified as mild, moderate, or severe. Conduct disorder shares similar symptoms with ODD, but can be distinguished by the severity of the symptoms presented in CD.
A variety of factors have been associated with an increased risk of developing CD. There does appear to be a genetic component to CD. Children with a parent or sibling previously diagnosed with CD are more likely to develop it themselves (APA, 2013). Difficulties with impulse control, such as that seen in children with the hyperactive type of ADHD, can contribute to antisocial behaviors (Holmes, Slaughter, & Kashani, 2001). Child temperament also appears to play a role in the formation of CD, with children who display aggression at very young ages being more likely to manifest CD in adolescence (Mandel, 1997). Research has also demonstrated that a number of factors in a child’s familial environment can contribute to later development of CD. These factors include inconsistent supervision, family alcoholism, parental conflict and violence, socioeconomic status, and physical or sexual abuse (APA, 2013; Campbell, 1990; Williams, Anderson, McGee, & Silva, 1990). Difficulties forming friendships and peer rejection have also been linked to CD (Holmes et al.). At the community level, high rates of violence are a risk factor as well (APA, 2013).
Conduct disorder can develop as early as the preschool years, but symptoms most typically begin to present during the middle childhood years through adolescence (APA, 2013). The course of CD varies significantly. It is common for many individuals diagnosed with CD, particularly those with an adolescent onset and mild symptoms, to become adjusted adults with stable social and occupational functioning. However, individuals with an early onset and more severe behaviors have a worse prognosis and are at risk of criminal behavior, substance-related disorders, and a variety of additional psychiatric disorders as adults (APA, 2013). For those individuals whose CD extends into adulthood and involves continued aggression, violence, deceitfulness, and rule violation at home and work, a diagnosis of antisocial personality disorder may be appropriate (APA, 2013).
The assessment of CD requires a comprehensive evaluation. Interviews with parents, teachers, and other sources familiar with a child’s behavior across settings are useful in obtaining a full picture of a child’s behaviors. In addition, various assessment scales, such as the Conners Rating Scale (parent and teacher versions) (Conners et al., 1998), Children’s Aggression Scale (Halperin et al., 2002), Parent Daily Report (Kazdin & Esveldt-Dawson, 1986), and Interview for Antisocial Behavior (Chamberlain & Reid, 1987), can be helpful. Children can complete self-report assessments including the Youth Self-Report (Achenbach, 1991), Buss–Durkee Hostility Inventory (Buss & Durkee, 1957), Buss–Perry Aggression Questionnaire (Buss & Perry, 1992), and Conners/Wells Adolescent Self-Report of Symptoms (Conners et al., 1997). All sources of information should be considered when completing the assessment.
Intervention with children and adolescents diagnosed with CD is generally most effective when it takes a biopsychosocial approach, is multimodal, and is multisystemic (Gerten, 2000). Primary components of treatment for CD include the development of prosocial skills and prosocial peer relationships. A combination of behavioral therapy and psychotherapy is often needed to assist children and adolescents with CD in learning to express emotions and manage their behaviors. Social skills training can also be used to develop problem-solving abilities and form supportive relationships (AACAP, 2004). In addition, family therapy, parent training, and support are needed to implement behavioral interventions, build positive relationships, and cope with the child’s challenging behaviors. Treatment interventions demonstrating effectiveness include Multisystemic Therapy, the Oregon Model Parent Management Training, and Functional Family Therapy (California Evidence-Based Clearinghouse for Child Welfare, 2013). For some children, medication may also be used to address impulse-control problems and stabilize aggressive outbursts (AACAP, 2004).
Separation Anxiety Disorder
Separation anxiety disorder is one of the earliest and most common mental-health disorders of childhood (Kessler et al., 2005). Separation anxiety disorder is typically seen more frequently in early childhood and prevalence rates tend to decline as children move into adolescence (Eisen & Schaefer, 2005). The overall prevalence rate of SAD is estimated to be approximately 4% of children and 1.6% of adolescents in the United States (APA, 2013). Research regarding the prevalence of SAD among girls and boys has yielded mixed results. Generally, SAD appears to be equally common among girls and boys in clinical samples, whereas it is more frequently seen in females in community samples (APA, 2013). However, some studies have indicated a greater prevalence of SAD among girls in both community and clinical samples (Hale, Raaijmakers, Muris, & Meeus, 2005; Last, Hersen, Kazdin, Finkelstein, & Strauss, 1987; Ogliari et al., 2006), whereas other studies have discovered equal gender prevalence of SAD in clinical (Last, Perrin, Hersen, & Kazdin, 1992) and community samples (Cohen et al., 1993). Explanations for the varying prevalence rates of SAD among girls and boys include differences according to whether the parent or child is acting as the primary informant and greater social acceptance of anxiety disorders in females (Compton, Nelson, & March, 2000; Foley et al., 2004).
The DSM-5 (APA, 2013) diagnostic criterion for SAD requires the existence of developmentally inappropriate and excessive anxiety concerning separation from those to whom the individual is attached. This anxiety is evidenced by at least three symptoms such as the following: recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures; persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disaster, or death; persistent and excessive worry about experiencing an untoward event that causes separation from a major attachment figure; and persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. In addition, the fear, anxiety, or avoidance must be persistent for at least four weeks in children and adolescents. The anxiety must also cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. Finally, the anxiety and distress must not be better explained by another mental-health disorder (APA, 2013).
One of the particular difficulties in accurately diagnosing SAD is the challenge of distinguishing it from other mental-health disorders, particularly generalized anxiety disorder (GAD). One key to making the distinction between SAD and GAD is that in SAD the source of distress will be focused predominantly on situations where the child specifically fears separation from the caregiver, whereas in GAD the child’s worries and fears are spread across a variety of situations and are more focused on harm that the child may experience, rather than being away from the caregiver or child’s home (APA, 2013; Eisen & Schaefer, 2005). Separation anxiety disorder is also commonly seen with specific phobia (APA, 2013).
Separation anxiety disorder seems to have a heritable component, with a heritability rate of 73% in a community sample of six-year-old twins (APA, 2013). Compared with the general population, SAD is more common among first-degree relatives, and children whose mothers have anxiety disorders are more frequently diagnosed with SAD (Cooper, Fearn, Willetts, Seabrook, & Parkinson, 2006). Children who have experienced some form of early separation trauma, such as the death or military deployment of a caregiver, or have not developed a secure attachment to their caregiver may be at increased risk of developing SAD. In addition, parenting styles that reward and reinforce excessive attachment rather than child independence might also act as contributing factors in the development of SAD (Eisen & Schaefer, 2005). Children of lower socioeconomic status appear to be at increased risk of developing SAD, with 50% to 75% of children diagnosed with SAD coming from lower-income homes (Last et al., 1992).
Although research indicates that some children with SAD may be at increased risk of developing another anxiety disorder as adults, the majority of children who experience SAD do not have a diagnosable anxiety disorder after extensive follow-up (APA, 2013). Separation anxiety disorder may develop in children as young as preschool age and onset can occur anytime during childhood and adolescence before the age of 18. However, the first occurrence of SAD during adolescence is relatively uncommon. Separation anxiety disorder is often first recognized when a child exhibits school refusal, and studies suggest that even when school refusal symptoms subside, additional social and affective SAD symptoms can remain (Masi, Mucci, & Millepiedi, 2001). Separation anxiety disorder may also develop after a significant life stressor (for example, parental divorce, death of a pet, change of schools). The typical course of SAD involves fluctuating periods of remission and exacerbation (APA, 2013).
The assessment of SAD can be complicated and is best accomplished using a multimethod approach and a variety of informants. Particular challenges in assessment include distinguishing SAD from the typical anxiety sometimes experienced by children and youth as part of the developmental process. Recent research indicates that parents may be most able to determine a child’s level of impairment and make behavioral observations, whereas children are best at reporting internal distress (Allen, Lavallee, Herren, Ruhe, & Schneider, 2010). Semistructured interviews prepared for clinical work with children can be useful in making an accurate diagnosis and include the Diagnostic Interview for Children and Adolescents–Revised (Reich, 1997) and the Anxiety Disorders Interview Schedule for Children (Silverman & Nelles, 1988), which is designed specifically for the diagnosis of anxiety disorders and can assist clinicians in distinguishing SAD from other potential anxiety disorders the child may be experiencing. Questionnaires such as the Multidimensional Anxiety Scale for Children (March, Parker, Sullivan, Stallings, & Conners, 1997) are also helpful in gathering information about the child’s emotions and behaviors across settings. Finally, behavioral observations from a variety of informants, including parents, school staff, child-care providers, and others as appropriate, are extremely valuable in getting a full picture of the child’s manifestation, pattern, and level of anxiety. Such information can also prove useful in developing an initial, child-focused treatment plan. In addition, a consideration of cultural factors is critical in conducting an accurate assessment because there is substantial variation across countries and cultural groups regarding the degree of interdependence among family members that is considered culturally acceptable (APA, 2013).
A variety of therapeutic interventions have demonstrated effectiveness in treating SAD. Psychoeducation for the whole family can be a useful first step to increase child and caregiver understanding of SAD and related treatments. Targeted parent training on the management of SAD and related behaviors appears to reduce parental stress and enhance parents’ sense of self-efficacy (Eisen, Raleigh, & Neuhoff, 2008). Cognitive–behavioral interventions have shown promise by improving children’s coping skills, challenging thought distortions, and alleviating the symptoms of SAD (Schneider et al., 2011). In particular, the Coping Cat Program is an evidence-based treatment for anxiety in children that has demonstrated significant success. Research also suggests that Parent–Child Interaction Therapy may be efficacious, especially for treating young children with SAD (Choate, Pincus, Eyberg, & Barlow, 2005; Pincus, Santucci, Ehrenreich, & Eyberg, 2008). Pharmacological treatment, although not recommended as the first choice in treating SAD, has demonstrated usefulness as an adjunctive treatment, particularly in children who have not responded well to other interventions or who demonstrate severe distress (Masi et al., 2001). Fluoxetine, fluvoxamine, and sertraline have all demonstrated clinical effectiveness (Birmaher, Axelson, & Monk, 2003; RUPP Anxiety Study Group, 2001; Walkup et al., 2008). Consultation with and the inclusion of school staff in treatment planning is also essential if school avoidance is a part of a child’s clinical presentation of SAD (Eisen & Schaefer, 2005).
Specific Learning Disorders
Specific learning disorders are neurodevelopmental disorders that impact the brain’s ability to attend to and process verbal or nonverbal information with accuracy and efficiency (APA, 2013). Children with learning disorders typically experience difficulties with learning and achievement in academic settings and often try very hard to concentrate and succeed in school, yet still struggle to master and maintain academic performance and fall behind grade-level expectations (AACAP, 2011). Specific learning disorders can appear in the areas of reading, written expression, mathematics, or some combination thereof (APA, 2013).
Current estimates regarding the prevalence of learning disorders vary from 5% to 15% among school-age children, depending upon the specific population and how a learning disorder is defined in the epidemiological study (APA, 2013). The AACAP estimates learning disabilities affect approximately 10% of all children (AACAP, 2011). No significant differences in prevalence of learning disorders have been identified between boys and girls. However, there are more than two times as many boys in special education programs than girls because boys are more likely to be evaluated, identified, and placed in special education (AACAP, 2011).
To be diagnosed with a specific learning disorder according to DSM-5 criteria (APA, 2013), a child must demonstrate difficulty learning and applying academic skills for at least six months, despite attempts to target those difficulties. At least one of the following symptoms must be present: inaccurate or slow and effortful word reading; difficulty understanding the meaning of what is read; difficulties with spelling; difficulties with written expression; difficulties mastering number sense, number facts, or calculation; or difficulties with mathematical reasoning. The academic skills impacted must be substantially and quantifiably below those expected for the child’s chronological age and significantly interfere with academic or occupational performance or activities of daily living. Underperformance in the specific learning area must be documented through standardized achievement measures and a thorough clinical assessment. The learning challenges must begin during a child’s school-age years but may not become apparent until academic demands exceed the child’s individual capacities (APA, 2013). The diagnosis of a specific learning disorder should also include specification of the academic domain(s) and subskills that are impacted. A full diagnosis will also include specification of the current severity of the specific learning disorder as mild, moderate, or severe (APA, 2013).
Because academic skills exist along a continuum and can vary significantly, psychometric evaluation is required to confirm a learning disorder diagnosis. Although score cutoffs will vary based on the standardized test used and additional information regarding the child’s learning skills and performance, a score at least 1.5 standard deviations from the mean (or roughly the 7th percentile) is recommended by the APA (2013). Learning disorders often co-occur or may be preceded by developmental delays in language, attention, or motor skills, but the relationship between these delays and learning disorders is not clear (APA, 2013).
Professionals disagree about how to consistently and accurately assess learning disorders in children (Fletcher, Francis, Morris, & Lyon, 2005). To make the most accurate diagnosis possible, an assessment should include a comprehensive evaluation incorporating multiple informants who can gauge the full spectrum of issues that may be impacting a child’s learning and academic performance (AACAP, 2011). A child psychiatrist or school psychologist can conduct the intellectual and education testing required to determine whether a learning disorder is present (AACAP, 2011). In addition, family members, teachers, and other school staff, such as speech and language pathologists or audiologists, should also be included to develop a full understanding of the child’s environment and other potential contributing factors to a child’s learning difficulties. In addition, when conducting assessment of learning disorders, it is extremely important to consider how ethnic and racial background and other cultural factors may impact results and seek to avoid bias (APA, 2013).
Genetic disposition and general medical conditions, such as perinatal injury, can be associated with the development of learning disorders, but many individuals with those conditions do not develop learning disorders and, conversely, individuals with learning disorders often have no such risk factors in their history. A history of lead poisoning, fetal alcohol syndrome, and fragile X syndrome do appear to substantially increase the chances of developing a learning disorder (APA, 2013). Litt, Taylor, Klein, and Hack (2005) discovered an increased risk of developing learning disorders among children with a very low birth weight. Although males are sometimes diagnosed with learning disorders more frequently in school settings, stringent criteria have found no sex-related differences (APA, 2013).
Specific learning disorder symptoms can occur as early as preschool or kindergarten, but learning disorders are not often diagnosed before the first grade or later because formal reading, writing, or mathematical instruction does not occur until that point in many educational settings. Early identification and intervention are crucial in achieving optimal outcomes and many children with learning disabilities, with proper assistance, are able to perform at grade level. However, children with learning disabilities are at an increased risk of not completing high school (APA, 2013). In addition, without intervention, children with learning disorders are also at increased risk of conduct and behavioral problems and the development of other mental-health disorders throughout the life course (Bennett, Brown, Boyle, Racine, & Offord, 2003).
Although social workers are not qualified to conduct the psychometric testing required to formally diagnose learning disorders, they play an active role in providing support and intervention services for children with learning disabilities and their families. A few of the tasks social workers frequently perform include providing needed information to families; McGill, Tennyson, and Cooper (2006) have noted that many families of children with learning disabilities experience frustration and a lack of adequate education regarding their child’s educational needs and related options. Coordinated identification and planning of services, child and family advocacy, social and emotional support, and longer range educational planning are also key intervention components (Rosenkoetter, Hains, & Dogaru, 2007). Sometimes individual, family, or group psychotherapy is recommended to assist a child and his or her family in coping with a learning disorder and assuring a child’s sense of self-esteem, self-efficacy, and social supports are not adversely impacted (AACAP, 2011). Group interventions have also shown promise in increasing students’ knowledge of their disability, fostering self-advocacy skills, and increasing self-esteem and self-confidence (Mishna, Muskat, & Wiener, 2010). Although relatively rare and not consistent with current efforts to keep children in their families and local communities, some children, particularly those with more severe learning disabilities or additional behavioral needs, attend residential schools (McGill et al., 2006).
Social-Work Role in Child and Adolescent Mental-Health Disorders
Social workers who work with children and families in clinical and educational settings will likely encounter children with the various mental-health disorders discussed in this entry on a regular basis. Social workers in those areas of practice should be prepared to recognize the emotional, social, and behavioral symptoms of ADHD, ODD, SAD, and CD, as well as the cognitive and academic symptoms associated with the specific learning disorders. Social workers can play a key role in assessment using a biopsychosocial perspective and, using a family-centered approach, can act collaboratively with children, parents, teachers, and others to identify all factors impacting a child’s behavior (Markward & Bride, 2001). In addition, social workers with proper training, experience, and credentials are qualified to diagnose all of the children’s mental-health disorders discussed in this entry except specific learning disorders. The particular functions served by a social worker will depend on the work setting and the position of the social worker within that setting. Social workers with advanced clinical training can provide specialized individual and family therapy to address the child’s diagnosis and its impact on the family. Social workers who provide case management play a vital role in service coordination, resource and referral, support, and advocacy. Social workers in school, hospital, and other interdisciplinary settings can also act as consultants to colleagues from other professions and assist them in understanding and properly managing the child’s diagnosis and related social and emotional behaviors. Social workers should also be knowledgeable regarding the laws and policies impacting mental-health care in their treatment setting. In particular, social workers in school settings should be aware of the Individuals with Disabilities Education Improvement Act (P.L. 108–446; 2004). All child and family social workers will benefit from continuing education regarding the presentation, diagnosis, and treatment of these common childhood mental-health disorders.
This entry reviewed several childhood disorders that child and family social workers will encounter in their practice, including ADHD, ODD, SAD, and specific learning disorders. Although these disorders appear with varying frequency among children, social workers who work with children and families should be familiar with the general presentation of these disorders and prepared to identify, intervene, and provide appropriate referrals and support to children and families experiencing these disorders as needed. Ongoing research continues to inform our knowledge regarding how these disorders develop, present, and are effectively treated. Social workers will benefit from continued education to support their work with children and families impacted by these disorders, particularly those disorders most commonly seen in the social worker’s particular practice setting.
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