Children and Adolescents with Social and Emotional

PartOneTheCurrentStateofPracticewithChildrenandAdolescents1TheCurrentStateofAssessment,Diagnosis,andTreatmentofChildrenandAdolescentswithSocialandEmotionalProblemsAtatimewhenincreasingnumbersofchildrenarebeingdiagnosedandtreatedforemotionalproblems,theunsettlingthoughtofmisdiagnosingchildrenwhoneedhelpbutarenotbeingservedbecauseofracialandgenderissues,andtreatmentoflargenumbersofchildrenwhoare,inreality,respondinginnormalwaystomaturationalandsocialchangeshasbeguntocaptureagreatdealofattentioninthepopularandprofessionalliterature.Unlikemostadults,youngchildrenareoftenunableorunwillingtotalkabouttheirsymptoms,leavingmentalhealthprofessionalstorelyonobservationandinformationfromparentsandteachers,whichmaybeincorrectorbiased.Becausechildrendevelopsoquickly,whatmaylooklikeattentiondeficitdis-orderinJanuarymayseemlikesomethingelseorperhapsnothingatallinthesummer.Sosubjectiveistheprocessofevaluatingtheproblemsencounteredbychildrenthatthetrialanderrorsearchforadiagnosisandtreatmentoftenendswithseriouserrors.Also,adultdiagnosesareoftenusedinlieuofdiagnosticcategoriesforchildren(USDepartmentofHealthandHumanServices,2000).TheSurgeonGeneral’sReport(USDepartmentofHealthandHumanSer-vices,2000)suggeststhatmanyhumanserviceprofessionalsprefernottouseadiagnosiswithchildrenbecause“[m]anyofthesymptoms,suchasoutburstsofaggression,difficultyinpayingattention,fearfulnessorshyness,difficultiesinunderstandinglanguage,foodfads,ordistressofachildwhenhabitualbehaviorsareinterferedwith,arenormalinyoungchildrenandmayoccursporadicallythroughoutchildhood”(Chapter3).Contrarytothecurrentpracticeofassigningadiagnosisindicatingseriousemotionalproblemsusingadultdiagnosticcategories,theSurgeonGeneral’sReport(USDepartmentofHealthandHumanServices,2000)wiselycautionscliniciansabouttheuseofadultdiagnosticcategoriesbynotingthat:Well-trainedcliniciansovercomethisproblembydeterminingwhetheragivensymptomisoccurringwithanunexpectedfrequency,lastingforanunexpectedlengthoftime,orisoccurringatanunexpectedpointindevelopment.Clinicianswithlessexperiencemayeitherover-diagnosenormalbehaviorasadisorderormissadiagnosisbyfailingtorecognizeabnormalbehavior.Inaccuratediagnosesaremorelikelyinchildrenwithmildformsofadisorder(Chapter3).Copyright©2009ElsevierInc.Allrightsreserved.4TheCurrentStateofPracticewithChildrenandAdolescentsYettheproblemofmisdiagnosingchildrenseemsmoreseriousthanever,withnewandincreasinglyarcanediagnosticcategoriesdevelopingthatsuggesttheexistenceofverylargenumbersofAmericanchildrenwithemotionalproblems.Somecommonlydiagnosedmentaldisordersinyoungerchildrenincludeatten-tiondeficithyperactivitydisorder(ADHD),depression,anxiety,andopposi-tionaldefiantdisorder(ODD).TheDSM-IV(AmericanPsychiatricAssociation,1994)saysthatODDexistsifachilddemonstratesfourofeightofthefollowingbehaviorpatterns:“(a)oftenlosestemper;(b)oftenargueswithadults;(c)isoftentouchyoreasilyannoyedbyothers;(d)andisoftenspitefulorvindictive.”(p.93).Thesebehaviorsarecharacteristicofmanychildrenandadolescentsandwouldnot,inandofthemselves,givemostchildrenanaccuratediagnosisofoppositionaldefiantdisorder.Attentiondeficitdisorderisperhapsthemostcommondiagnosisusedwithchildren.QuestionsusedtodetermineADHD,suchas“Doesthechildhavedif-ficultyinsustainingattention,followinginstructions,listening,organizingtasks?Doesheorshefidget,squirm,impulsivelyinterrupt,leavetheclassroom?”aresuchcommonbehaviors,particularlyinboys,thatonemightaskwhyattentiondisorderisadiagnosisgiventoboysataratetwicethatofgirlswhentherates,medicallyspeaking,arethesame.Moretroublingisthefindingregardingseriousmentaldisorders.Carey(2007)reportsthatthenumberofAmericanchildrenandadolescentstreatedforbi-polardisorderincreased40-foldfrom1994to2003,andhascertainlyrisenfurthersince2003.AccordingtoCarey,instudiesofdoctorsinprivateorgrouppracticeinNewYork,MarylandandMadrid,thenumbersofvisitsinwhichdoctorsrecordeddiagnosesofbi-polardisorderincreasedfrom20000in1994to800000in2003,aboutonepercentofthepopulationunderage20.Carey(2007,p.1)alsonotesthat:AccordingtogovernmentsurveysatleastsixmillionAmericanchildrenhavedifficultiesthatarediagnosedasseriousmentaldisorders,anumberthathastripledsincetheearly1990seventhoughoneofthelargestcontinuingsurveysofmentalillnessinchildren,tracking4500childrenages9to13,foundnocasesoffull-blownbi-polardisorderandonlyafewchildrenwiththemildflightsofexcessiveenergythatcouldbeconsiderednascentbi-polardisorder.Moreover,thesymptomsdiagnosedasseriousemotionalproblemsinchildrenoftenbarelittleresemblancetothoseinadults.Instead,children’smoodsoftenfliponandoffthroughouttheday,andtheirupswingsoftenlookmorelikeextremeagitationthanbi-polardisorder.InaninterviewwithJudithRapoport,chiefofchildpsychiatryattheNationalInstituteofMentalHealth,Dess(2000)askedifchildhoodonsetschizophreniaisontheincrease.Rapoportrespondedthatin8years,NIMHhadidentifiedonly55casesofearlychildhoodschizophreniaandnotesthattheyarelookinghardtofindothercasestoprovideadditionalinformationontheearlyphysicalTheCurrentStateofAssessment,Diagnosis,andTreatmentofChildren5ande