Special Issues in Detection and Treatment of Childhood Disorders

Children and Adolescents

Several of the Obsessive Compulsive Related disorders are relatively common in childhood. For many adult patients seen in clinic, the onset of original psychopathology was in childhood but the disorder was missed for years by clinicians. Prompt treatment intervention in childhood may well stem the progression and impact of the illness. Most psychiatric research has been conducted in adults; and psychopathology in children can be quite difficult to disentangle.

OCD has a bimodal distribution in terms of age of onset, with one of the peaks being in childhood (12-14 years) and the other in early adulthood (20 years). OCD prevalence in children (1-4%) is similar to that in adults, that is, fairly commonplace.

Hoarding Disorder occurs in 1-2% of children, and rates of co-morbidity in such individuals are not well characterized: some studies even suggest that children with Hoarding Disorder do not show elevated rates of co-morbidity versus unaffected children. In children with OCD or ADHD, hoarding symptoms are common, occurring in up to one-third of patients. In childhood OCD, co-morbid hoarding is associated with worse insight, higher levels of aggression and anxiety/somatic complaints, higher rates of Panic Disorder, more magical thinking obsessions, and more ordering/arranging compulsions. In childhood ADHD, co-morbid hoarding is associated with more severe ADHD symptoms. Children with learning disability show elevated rates of hoarding (16% of cases), and where both diagnoses exist, ADHD (50%) and OCD (30%) are very frequent.

Childhood prevalence of Body Dysmorphic Disorder (BDD) is not known, but may be similar to that found in adults (0.5-1%), with onset typically occurring in the teenage years, not helped by media focus on body image.

Illness Anxiety Disorder (Hypochondriasis) is very rare in children, but medically unexplained physical symptoms are common and can signify other underlying psychiatric illnesses (e.g., anxiety disorders) or family stressors. Where Hypochondriasis is suspected in a child, consider the family dynamics: there may be excess concern from parents contributing to the child’s complaints, or the child may have experienced a close family member developing a serious illness such as cancer.

Trichotillomania, the archetypal grooming disorder, commonly begins in adolescence (peak onset at 12-13 years of age), and 1-3% of adolescents have the disorder. When Trichotillomania occurs in very young children (4 years and below), it can resolve spontaneously with time and pharmacological treatment may not be indicated (though psychotherapy can be considered). The most common co-morbidities in childhood Trichotillomania include: anxiety disorders (30-60%), and ADHD (30%).

The prevalence of Excoriation (Skin Picking) Disorder in children is not known, although 10-40% of children pick their skin to some degree, suggesting that the pathological form is unlikely to be rare. Adults with childhood onset skin picking behaviors show less awareness of symptoms. Little is known of rates of co-morbidities between Excoriation Disorder and other conditions in childhood.

The majority of Tic Disorders begin before adulthood, as recognized by the inclusion of “onset before 18 years” in the diagnostic criteria (for all Tic Disorders except Other Specified Tic Disorder/ Unspecified Tic Disorder in DSM-5). It has been estimated that up to 8% of children have Tic Disorders, with peak onset at 5-7 years of age. Chronic Tic Disorders occur in 0.3-1.3% of youths. Most common co-morbidities include ADHD (40-70%), OCD (40-55%), learning disability (20-30%), and anxiety/mood disorders (18-30%).

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