1 / 40

Classification & Epidemiology in Child Psychiatry

Classification & Epidemiology in Child Psychiatry. John McLennan University of Calgary Jan 17, 2013. Outline. Why classify mental phenomena? A little history of DSM Categories and/or dimensions Quebec epidemiology study Great Smoky Mountain Study. Why classify mental phenomena?.

Download Presentation

Classification & Epidemiology in Child Psychiatry

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Classification & Epidemiology in Child Psychiatry John McLennan University of Calgary Jan 17, 2013

  2. Outline • Why classify mental phenomena? • A little history of DSM • Categories and/or dimensions • Quebec epidemiology study • Great Smoky Mountain Study

  3. Why classify mental phenomena? • May aid communication • May reduce/summarize complex problems • May inform triage and treatment decisions • May advance science • Reliability • Validity • Comparability • Precision

  4. Any concerns about classifying? • Labelling….stigma • Foster/encourage excessive belief/confidence in (i.e., going beyond the science)… • The precision • Explanatory power • Independent existence (vs. social construction, societal bounded notions) • In existence of discrete entities • Mask substantial heterogeneity • E.g., in ADHD, autism

  5. History of categorizing in the USA – pre-DSM • 1840 census: • 1 category: “idiocy/insanity” • Statistical purposes • 1880 census: • 7 categories: mania, melancholia, monomania (e.g., kleptomania), paresis, dementia, dipsomania (e.g., alcoholism), epilepsy • 1917 Statistical Manual for the use of Institutions for the Insane: • 22 categories

  6. Diagnostic & Statistical Manual of Mental Disorders (DSM) • DSM-I (1952) • Glossary of descriptions of diagnostic categories • 106 categories • Included the notion of “reaction” (Adolf Meyer), i.e., reacting to biopsychosocial factors DSM: History of the Manual (APA ,2012)

  7. Diagnostic & Statistical Manual of Mental Disorders (DSM) • DSM-II (1968) • Move away from reaction • Psychodynamic influence • 182 categories

  8. DSM-II • Runaway reaction of childhood • “Individuals with this disorder characteristically escape from threatening situations by running away from home for a day or more without permission. Typically they are immature and timid, and feel rejected at home, inadequate, and friendless. They often steal furtively”. APA - DSM-II (1968) p.50

  9. DSM-III • DSM-III – 1980 • 265 diagnoses • Explicit diagnostic criteria • Influenced by Research Diagnostic Criteria • Multi-axial system • Emphasis on description (vs. theory of etiology) • DSM-III R (Revised) – 1987 • 292 categories • To address inconsistency and lack of clarity

  10. DSM-IV • Task Force • Systematic literature reviews • Reanalysis of data sets • Focused field trials • 16 major diagnostic classes • 297 categories • 1st section: “Disorders usually first diagnosed in infancy, childhood or adolescence” • DSM-IV (TR) - 2000

  11. Disorders usually first diagnosed in infancy, childhood or adolescence • Mental Retardation (Axis II) [“Intellectual Disability”] • Learning Disorders • Motor Skills Disorders • Communication Disorders • Pervasive Developmental Disorders • Attention-deficit and disruptive behavior disorder • Feeding and eating disorders of infancy and childhood • Tic Disorders • Elimination Disorders • Other Disorders of Infancy, Childhood or Adolescence • In addition to application of most of the other DSM-IV diagnoses to children and adolescent e.g., mood and anxiety disorders

  12. DSM-5 • Release expected May 2013 • www.dsm5.org • Section of proposed organizational structure • Neurodevelopmental Disorders • Intellectual Developmental Disorders • Communication Disorders • Autism Spectrum Disorder • Attention Deficit/Hyperactivity Disorder • Specific Learning Disorder • Motor Disorders • [Others….depression, anxiety housed in those categories]

  13. DSM-5 – Child section proposed changes • Various content changes • E.g., in ADHD • Modifications • E.g., Pervasive Development Disorders • Drop Rett’s Disorder • Subsume Asperger’s Disorder into an Autistic Spectrum Disorder • Collapse social and communication impairments into a combined criterion • Create a “sub-syndromal “ disorder “Social Communication Disorder” to be housed under the Communication Disorder group • New Disorders • E.g., Temper Dysregulation Disorder with Dysphoria

  14. DSM-5 – Child section proposed changes • Temper Dysregulation Disorder with Dysphoria • Temper outbursts (severe, frequent) • Negative mood between outbursts • At least 6 years of age • Not meeting mania criteria

  15. Other classification systems • International Classification of Disease (ICD) • 10th edition (1992)….[11th edition partial available, “official?” release in 2015) • Coordinated efforts with DSM system • Chapter 5: Mental and behavioural disorders • Disorders of psychological development • Behavioural & emotional disorders with onset usually occurring in childhood & adolescence • Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (0-3 years) • Axis I: Primary diagnosis • Axis II: Relationship Disorders (e.g., angry/hostile) • Axis V: Functional Emotional Developmental Level • DSM-PC (Primary Care) • Primary care physicians – clinical practice • Child & Adolescent Version • American Academy of Pediatrics

  16. Categorical vs. dimensional • What are the issues?

  17. Categories vs. Dimensions Coghill and Sonuga-Barke, 2012, p.469

  18. Dimensional vs. Categorical • Dimensional –degrees • May be more reflective of underlying distribution • Provides index of severity • Categorical – yes/no; present/absent • May align with service and treatment decision making • Consistent with “preference” of human cognitive processes (clinician, patient, caregiver)….we are “natural categorizers” (Coghill & Sonuga-Barke, 2012) • Usefulness may depends on the situation • Not unique to (child) psychiatry • E.g., hypertension

  19. IQ distribution and Mental Retardation Jensen 1969

  20. Statistical approaches • Newer statistical model (coherent cut kinetics - Meehl) aimed to identify patterns of discontinuity in underlying structure of observed data (and hence can test between categorical and dimensional models) • Try to determine whether a particular disorder represents a discreet causal entity (a real category) or one end of a continuum (part of a dimension) Coghill and Sonuga-Barke, 2012

  21. Evidence for taxons (Coghill & Sonuga-Barke, 2012) • Taxon • A discrete entity that is qualitative different from normal range • Insecure attachment classification • Continuous model a better fit • Anxiety sensitivity • Evidence for a taxon • Depression • Continuous model a better fit for adolescent depression (except maybe melancholy) • Evidence of taxon for child depression • PTSD/reaction • Dimensional model a better fit • ADHD • No evidence for a taxon

  22. Combined use • Categorical diagnosis + quantitative measure of severity, for example • Diagnosis of depression + CDI score • Diagnosis of ADHD + MTA-SNAP-IV score • Other areas of medicine • COPD + measures of lung function

  23. Classification issues • Future-?: • Course • Cause • Response to treatment • Genetic underpinning • Underlying “pathophysiology”

  24. Epidemiology • Definition: • Study of the distribution, determinants and causes of disease in human populations

  25. Key epidemiology questions • How many people (proportion of people) have a particular disease at any one time? • Prevalence: point, period of time, lifetime • How many new cases of this disease will occur during a defined period? • Incidence • Which group in the population is at highest risk for specific diseases? • Are there characteristics of certain environments that increase the risk of particular diseases? • What are the most effective methods of preventing or controlling the spread of specific diseases? Costello et al., 2004

  26. A Key Measurement Issues: Different informants • Type: parents, child, teacher, others (e.g., clinician) • Agreement • Achenbach et al., 1987- correlations • 0.60 for similar informants • 0.28 different types of informants • 0.22 with child report • Reporting on different contexts: home, school, community • How to manage information from multiple informants? • Combine data (e.g., “and” vs. “or”)

  27. Epidemiological study examples • Quebec Study • Great Smoky Mountain Study

  28. Quebec Child Mental Health Survey • 1992 • Cross-sectional • Prevalence of DSM-III-R disorders • 6 months prevalence • N=2400 (representative); 6-14 years of age • Response rate: 83.5% • Informants: parent & child & teacher (6-11y olds) • Diagnostic Interview Schedule for Children (DISC) • Dominic Questionnaire (6-11 y olds)

  29. Quebec Child Mental Health Survey • ADHD: 1.8-9.8% • Teacher>parents>children • Younger>older • Boys>girls

  30. Quebec Child Mental Health Survey • Oppositional Defiant Disorder 0.7-5.8% • Child>parent>teacher (younger) • Parent>child (older) • Conduct Disorder 0.2-2.3% • Child>teacher>parent • Boys>girls • Younger>Older

  31. Quebec Child Mental Health Survey • Separation Anxiety Disorder 0.7-4.9% • Child>parent (younger) • Simple phobia 1.3-14.6% • parent>child • Most common • Substantial drop with impairment criteria • Overanxious/GAD 1.7-5.5% • Child>parent (younger) • Parent>child (older)

  32. Quebec Child Mental Health Survey • Depressive Disorder 1.0-3.5% • Child>parent • Girls>boys (older) • Older girls>younger girls • Younger boys>older boys • One or more disorders 9.6-32.4% • Child and/or parent (32.4%) • Parent + impairment: (9.6%)

  33. Longitudinal studies • Rare in child psychiatry • Essential for prospectively determining incidence and duration patterns

  34. Great Smoky Mountains Study • Cross-sectional & longitudinal • Prevalence of DSM-III-R/IV disorders (3 month prevalence) • 9, 11, 13 years of age + 3 years so up to 16 years of age {“accelerated design”/control for cohort effect} • Stage 1: Randomly selected sample for screening using externalizing items from the Child Behavioural Checklist + expanded questions on substance abuse using parent as informant • Stage 2: top 25% on screening + 1 in 10 of the rest invited to participate in structured interview using the Child and Adolescent Psychiatric Assessment (CAPA) using parent and child as informants • Response rate: • 96% of eligibles agreed to screening (n=3896) • 80% of eligibles agreed to interview (n=2086)

  35. Great Smoky Mountains Study • Parent and/or child report (diagnosis, not impairment) • 20.3% any disorder • 11.9% any emotional or behavioural disorder • 6.8% any emotional disorder • 6.6% any behavioural disorder • 5.7% any anxiety disorder • 5.1% enuresis • 4.2% any tic disorders

  36. Great Smoky Mountains Study • Approximately 1/3rd of children had more than 1 disorder (i.e., comorbidity) • Boys>girls for any psychiatric disorder primarily due to higher rates of behavioural disorders and enuresis (also higher co-morbidity of emotional and behavioural disorders in boys) • Children of the poorest families had higher rates of any disorders and every type except tic disorders, especially behavioural disorders (also co-morbidity) • Urban not higher than rural after controlling for income

  37. Great Smoky Mountains Study • Decreasing with age: • ADHD, SAD, enuresis, encopresis, tics • Increasing with age: • Substance Use Disorders, panic, GAD • Girls only: Depression & social phobia

  38. Impaired but undiagnosed • Angold et al., 1999 • Smoky Mountain data • 7.4% diagnosis + impairment • 11.5% diagnosis, not impaired • 14.2% impaired, no diagnosis • 3.6% parent-child relational problem • 1.4% siblings relational problems • 52% of specialty mental health service users did not meet diagnostic criteria for 29 DSM-III diagnoses

  39. References • American Psychiatric Association (2012) DSM: History of the Manual. http://www.psychiatry.org/practice/dsm/dsm-history-of-the-manual • Angold A, Costello EJ (2009) Nosology and measurement in child and adolescent psychiatry. Journal of Child Psychology & Psychiatry 50(1-2): 9-15. • Aarons G et al (2001) Prevalence of adolescent substance use disorders across five sectors of care. J Am Acad Child Adolesc Psychiatry 40(4): 419-426. • Breton JJ B et al (1999) Quebec Child Mental Health Survey: Prevalence of DSM-III-R mental health disorders. J Child Psychol Psychiat 40(3): 375-384. • Coghill D, Sonuga-Barke E (2012) Annual research review: Categories versus dimensions in the classification and conceptualisations of child and adolescent mental disorders – implications of recent empirical study. Journal of Child Psychology & Psychiatry 53(5): 469-489. • Copeland W, Shanahan L, Costello EJ, Angold A (2011) Cumulative prevalence of psychiatric disorders by young adulthood: A prospective cohort analysis from the Great Smoky Mountains Study. JAACAP 50(3): 252-261. • Costello et al (2005) 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I. Methods and Public Health Burden. Journal of the American Academy of Child and Adolescent Psychiatry 44(10): 972-986. •  Costello et al (2006) 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: II. Developmental Epidemiology Journal of the American Academy of Child and Adolescent Psychiatry 45(1): 8-25

  40. References -2 • First M (2010) Paradigm shifts and the development of the diagnostic and statistical manual of mental disorders: Past experiences and future aspirations. Can Journal of Psychiatry 55(11): 692-700. • Garland A et al (2001) Prevalence of psychiatric disorders in youths across five sectors of care. J Am Acad Child Adolesc Psychiatry 40(4): 409-418. • Jensen A (1969) How much can we boost IQ and scholastic achievement. Harvard Educational Review 39(1) • Kessler R et al (2012) Severity of 12-month DSM-IV disorders in the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry 69(4): 381-389. • Kessler R et al (2012) Prevalence, persistence and sociodemographic correlates of DSM-IV disorders in the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry 69(4): 372-380. • WidigerT, Samuel D (2005) Diagnostic categories or dimensions? A question for the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition. Journal of Abnormal Psychology 114(4): 494-504.

More Related