STUDY OF PSYCHIATRIC DISORDERS IN CHILDREN AND ADOLESCENTS TO INTRODUCE A NEWER CLASSIFICATION SYSTEM

STUDY OF PSYCHIATRIC DISORDERS IN CHILDREN AND ADOLESCENTS TO INTRODUCE A NEWER CLASSIFICATION SYSTEM Shyamanta Das 1, Dipesh Bhagabati 2, Puneet Mathur 3, Angshuman Kalita 4, Nabanita Sengupta 5, Sakhee Bujarbarua 6, Suranjita Mazumdar 7, Bornali Das 8 1Assistant Professor, Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati, Assam. 2Professor, Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati, Assam. 3Post Graduate Trainee, Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati, Assam. 4Post Graduate Trainee, Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati, Assam. 5Post Graduate Trainee, Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati, Assam. 6Statistician, Pune, Maharashtra. 7Post Graduate Trainee, Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati, Assam. 8Lecturer, Psychiatric Social Work, Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati, Assam. ABSTRACT BACKGROUND Onset of most psychiatric disorders is before adulthood. Good empirical data is required for extending adult criteria for application to children and adolescents. Unfortunately, the data are sparse on which to build such estimates. We aimed to study the childhood and adolescent psychiatric disorders in order to arrive at a newer classification system. METHODS Sample consisted of children and adolescents up to 18 years of age. Study period was from September 2014 to August 2015. Diagnoses were made according to the ICD 10 clinical descriptions and diagnostic guidelines (WHO 1992). RESULTS Total sample size was 94. Mean age was 14.67 years. 62 were girls. We found 48 children and adolescents with emotional disorders, 3 with disruptive disorders, and 5 with developmental disorders. Comorbidity was equal in both within each grouping and across groups in our study. CONCLUSIONS Enormous advancements in classification of childhood and adolescent psychiatric conditions in the recent years provide stronger empirical basis on which to support the current schemes. KEYWORDS Diagnosis. Comorbidity. Tertiary Prevention. HOW TO CITE THIS ARTICLE: Das S, Bhagabati D, Mathur P, Kalita A, Sengupta N, Bujarbarua S, Mazumdar S, Das B. Study of psychiatric disorders in children and adolescents to introduce a newer classification system. Journal of Research in Psychiatry and Behavioral Sciences 2015; Vol. 1, Issue 1, July-December 2015; Page: 6-10. INTRODUCTION The majority of mental health problems occurring in childhood and adolescence are in fact an excess of behaviour exhibited by many young people. Seldom are they qualitatively distinct to be of the kind usually observable in adult conditions. Therefore, there is a high probability of psychiatrists in particular being criticised for talking about disorders or diagnoses. This is for medicalising a child s difficulties. On the other hand, other professionals and parents may prefer to call the same conditions emotional and behavioural difficulties. [16] Developmental psychopathology denotes the scientific study of how abnormalities can be understood in terms of processes underpinning human development. [2,15] Financial or Other, Competing Interest: None. Submission 09-12-2015, Peer Review 10-12-2015, Acceptance 14-12-2015, Published 16-12-2015. Corresponding Author: Dr. Shyamanta Das, 10, C. K. Agarwalla Road, Ambari, Uzan Bazar, Guwahati- 781001, Assam, India. E-mail: dr.shyamantadas@gmail.com As a child develops, mental processes and behaviour change. As a result, it is not always clear whether the same diagnoses should be applied across the age range. Moreover, empirical data should be good enough to extent adult criteria for the application into children. [16] It is necessary to pay attention to the early years in an attempt to reduce the burden of psychiatric disorder. Onset of most mental illnesses is before adulthood. These disorders are chronic and relapsing. [4] The National Comorbidity Survey Replication. [10] found that of the 46.4 per cent of all participants reported one or more psychiatric disorders during their lifetime. Half reported onset by age 12, and three-quarters by age 24. [10] Considering the possibility of forgetting early episodes by older participants. [7] the likelihood of onset in childhood is even more common than this. [4] The burden of mental illness is felt in childhood and adolescence itself. Therefore, it is important to know the extent of the problems. This will help to plan for treatment and prevention. But, the data for such estimates are sparse. [4] Journal of Research in Psychiatry and Behavioral Sciences/ Vol. 1/ Issue 1/ July-December, 2015 Page 6

AIMS We aimed to study childhood and adolescent psychiatric disorders in order to arrive at a newer classification system. METHODS AND METHODOLOGY Sample consisted of children and adolescents up to 18 years of age who were admitted in the Department of Psychiatry of Gauhati Medical College Hospital, Guwahati. Study period was for one year from September 2014 to August 2015. Diagnoses were made according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD 10) clinical descriptions and diagnostic guidelines. [17] Being an observational work without intervention and based on chart review, the study was exempt from the institutional ethical clearance. The same was applicable for the informed consent as well. Data were analysed by descriptive statistical methods. RESULTS Total sample size was 94. Mean age was 14.67 years (standard deviation [SD] 1.828, 94% confidence interval [CI] 14.295-15.045, minimum 8, maximum 17). Considering the fact that the minimum age of our sample was 8 years and maximum 17, as well as our earlier similar work where the three age groups were 1-5, 6-10, and 11-15. [5] the present sample was divided into three groups of 8-10, 11-14, and 15-17 years. Three belonged to the age group of 8-10 years (3.19%), 37 in 11-14 (39.36%), and 54 in 15-17 (57.45%). Thirty two were boys (34.04%) and 62 were girls (96.88%). The boy: girl in the age groups of 8-10, 11-14, and 15-17 years 2:1, 12:25, and 18:36, respectively. Fig. 1 shows age and sex distribution of children and adolescents with psychiatric disorders. Fig. 1: Age and sex distribution of children and adolescents with psychiatric disorders We found 48 children and adolescents with emotional disorders (Depression [Six], anxiety [One], obsessivecompulsive disorder [Two], reaction to severe stress [acute stress reaction and post-traumatic stress disorder], and adjustment disorders [Four], dissociative [35]), three with disruptive disorders (Hyperkinetic disorders [One] and conduct disorders [Two]), and five with developmental disorders (mental retardation [Four], specific developmental disorders of scholastic skills [One], and pervasive developmental disorders [One]; the adolescent with pervasive developmental disorder had comorbid mental retardation). Nine adolescents had schizophrenia, 19 children and adolescents had acute and transient psychotic disorders, and an adolescent was diagnosed as unspecified nonorganic psychosis. Manic episode (Two) and bipolar affective disorder (Five) was found in seven adolescents. Tic disorders were found in two children. Two child and adolescent had epilepsy. One adolescent was suffering from organic mood [Affective] disorder, and another adolescent had mental disorder due to brain damage and dysfunction and to physical disease in the form of mild cognitive disorder; a third adolescent received the diagnosis of unspecified organic or symptomatic mental disorder. In the age group of 8-10 years, the number of children and adolescents with emotional, disruptive, and developmental disorders was 1:1:0 (Dissociative; hyperkinetic disorder; and nil; respectively). In the age group of 11-14 years, the number of children and adolescents with emotional, disruptive, and developmental disorders were 19:1:4 (Depression, reaction to severe stress, and adjustment disorders [Three], dissociative (15); conduct disorder; mental retardation [Three] and pervasive developmental disorder, respectively). In the age group of 15-17 years, the number of children and adolescents with emotional, disruptive, and developmental disorders were 28:1:1: (Depression [Five], anxiety, obsessive-compulsive disorder [Two], acute stress reaction, dissociative [19]; conduct disorder; specific Journal of Research in Psychiatry and Behavioral Sciences/ Vol. 1/ Issue 1/ July-December, 2015 Page 7

developmental disorders of scholastic skills; respectively; one adolescent has comorbid depression and conduct disorder and specific developmental disorders of scholastic skills). Fig. 2 shows these childhood and adolescent psychiatric disorders in relation to age. Fig. 2: Childhood and adolescent psychiatric disorders in relation to age Among boys, diagnosis of emotional disorders was made in seven children and adolescents (Depression, adjustment disorder, and dissociative [Five]), disruptive disorders in two (Hyperkinetic disorder and conduct disorder), and developmental disorders in five (Mental retardation [Four], specific developmental disorders of scholastic skills, and pervasive developmental disorder; one adolescent had comorbid mental retardation and pervasive developmental disorder). Among girls, diagnosis of emotional disorders was made in 41 children and adolescents (Depression [Five], anxiety, obsessive-compulsive disorder [Two], reaction to severe stress, including acute stress reaction and posttraumatic stress disorder [Three], dissociative [30]), disruptive disorder in one (Conduct disorder), and developmental disorders in none. Fig. 3 shows these childhood and adolescent psychiatric disorders in relation to sex. Fig. 3: Childhood and adolescent psychiatric disorders in relation to sex Comorbidity in our study was equal in both within each grouping and across groups. Within each grouping, comorbidity was found in one adolescent and another adolescent had across groups comorbidity (Table). Journal of Research in Psychiatry and Behavioral Sciences/ Vol. 1/ Issue 1/ July-December, 2015 Page 8

Within each grouping Developmental disorder (Mental retardation) developmental disorder (Pervasive developmental disorder) Across grouping Emotional disorder (Depression) disruptive disorder (Conduct disorder) developmental disorder (Specific developmental disorders of scholastic skills) Table: Comorbidity within each grouping and across groups The adolescent having comorbidity within each grouping was a boy of 14 years. The adolescent having comorbidity across grouping was a boy of 15 years. Interestingly, comorbidity was also observed between dissociative and epilepsy (An adolescent boy of 15 years), mental retardation and epilepsy (A boy child of 12 years), and hyperkinetic disorder and tic disorder (Combined vocal and multiple motor tic disorder [De la Tourette s syndrome]) in a boy child of eight years DISCUSSION We did a preliminary work on the subject in a different institute. [5] We studied 26 children up to the age of 15 years, 16 of them were boys, attending psychiatry outpatient department of a newly opened academic medical centre in the initial six months from its inception from February to July 2011. We found nine children with emotional disorders, five with disruptive disorders, and ten with developmental disorders; comorbidity in our study was equal in both within each grouping and across groups. In child psychiatry, developmental psychopathology contributed validating criteria including epidemiological data like age of onset and sex ration. Childhood psychosis was a unitary classification initially. Later on with observation of difference in the age of onset, the distinction between autism and schizophrenia was validated. Moreover, disruptive disorders are common in boys and emotional disorders in girls. [16] A well-researched, valid, and simple way lumps child disorders into three groups: [16] emotional disorders, disruptive disorders, and developmental disorders. Emotional disorders include anxiety, depression, phobias, somatisation, and obsessive-compulsive disorder. Disruptive disorders include conduct disorder and hyperactivity. Developmental disorders include intellectual disability, the autistic spectrum, language and reading delays, and enuresis and encopresis. It is said that comorbidity is very common within each grouping and occurs in a minority across groups. [16] The odds ratio for anxiety with either attention-deficit/hyperactivity disorder (ADHD) or conduct disorder is three, for anxiety and depression eight, and ADHD and conduct disorder ten in a meta-analysis of community samples. [1] Rates are even higher in clinical samples. [16] But, in our sample, comorbidity within each grouping and across grouping was equal. In addition, like the boy child of 12 years with the comorbidity of mental retardation and epilepsy in our sample, Nath and Naskar [12] found the prevalence of seizure disorder to be 22% among the 100 intellectually disabled they studied. Apart from shared risk factors and overlap between risk factors, comorbidity may arise through another mechanism of one disorder creating an increased risk for the other. Oppositional defiant disorder and attachment disorder following early deprivation are examples of shared risk factors. Depression in mother not only can give rise to the possibility of depression in son through genetic vulnerability but also has the potential to contribute to conduct disorder through inconsistent discipline. This is an example of overlap between risk factors. Drug dependency resulting from conduct disorder is an example of one disorder creating an increased risk for the other. A fourth possibility is the comorbid pattern that constitutes a meaningful syndrome. This is true for depressive conduct disorder. [14] Current classificatory systems have few emotional disorder categories that are specific to childhood. But, they are mostly subtypes of anxiety. Mood disorders are diagnosed according to adult criteria. And the consequence is that surveys of depression find prevalence rates close to zero under eight years of age. [16] Yet there are miserable children. They cry frequently. They say that they are unhappy. They look sad and are withdrawn. [13] The United Kingdom has carried out a national prevalence study. [6,11] The UK study found that almost one child in ten (9.5 per cent) aged five to 15 had a psychiatric disorder based on the ICD-10 classification system. Prevalence was higher in adolescents (11.2 per cent at 11 to 15) than in children (8.2 per cent at five to ten), and in boys (11.4 per cent than girls 7.6 per cent). Conduct disorders were the most common (5.3 per cent), followed by anxiety disorders (3.8 per cent). Depression was rare in both sexes and all age groups (0.9 per cent overall), as were hyperkinetic disorders (1.4 per cent). Seven per cent of previously unaffected children developed a psychiatric disorder in the three years between the interviews. Four per cent developed a new emotional disorder (Anxiety and/or depression), and five per cent a behavioural and/or hyperkinetic disorder. More girls developed emotional disorders, and more boys developed behavioural disorders. Persistence, measured as the presence of the same diagnosis the years apart, was higher for behavioural disorders (43 per cent) than for emotional disorders (About one in four). A study of youth age seven to 14 in south-eastern Brazil found an overall prevalence of 12.7 per cent. Behavioural disorders were the most common (seven per cent), followed by anxiety disorders (5.2 per cent) and ADHD (1.8 per cent). Depression was rare (1.0 per cent). [4] Other studies from around the world. [3] usually generate prevalence rates of around 20 per cent. A meta-analysis of 26 studies of child and adolescent depression. [9] estimated the prevalence of adolescent depression (5.6 per cent) as twice that of childhood depression (2.9 per cent), and that of adolescent girls (5.9 per cent) as significantly higher than that of adolescent boys (4.6 per cent). Traditional division of prevention in epidemiology is into three categories. This depends on level of risk in concerned population. When a child develops psychiatric disorder that is clinically definable, the focus at present is on clinical treatment. It is rare as far as tertiary prevention is concerned. But, considering the early onset of most psychiatric disorders, this is clearly a vitally important area for future work. [4] Journal of Research in Psychiatry and Behavioral Sciences/ Vol. 1/ Issue 1/ July-December, 2015 Page 9

Fourth Category? Our finding of a total of 38 children and adolescents (40.43% of the sample size) with the diagnoses of schizophrenia, acute and transient psychotic disorders, unspecified nonorganic psychosis, manic episode, bipolar affective disorder, and tic disorders calls for the need of a fourth category, apart from those of emotional disorders, disruptive disorders, and developmental disorders. Or, can we think of accommodating these diagnoses in the proposed three categories? If yes, then in what ways? These are the areas on which further work can be undertaken to more reliably validate this classificatory approach in the field of child and adolescent psychiatry. IMPLICATION There is enough evidence to believe that such a classificatory system could be a valid one. Being a simpler one, it has the potential to bridge the gaps that exit between psychiatry and rest of the branches of the medical science, notable paediatrics in this case. Moreover, the different stakeholders in the care of the child and adolescent, e.g. parents, teachers, family physicians, can also feel at home with such an approach. Thus, the needy in the childhood and adolescence age group with mental health problems can avail appropriate care without discrimination and stigma. LIMITATIONS Sample size was small and recruited only from indoor psychiatry department of a tertiary care teaching hospital. In epidemiology, sampling is of central importance. An important first step is counting cases. However, there exists the possibility of biases in simple counting of cases presented for treatment. [4] This is specially so in child psychiatry. The reason being the presence of gatekeepers in the form of parents, teachers, and paediatricians. [8] Community-based data is an alternative solution. CONCLUSION There have been enormous advancements in classification of child psychiatric conditions and contribution of developmental psychopathology provides support to current schemes. Still, there exist considerable obstacles that need to be overcome for undertaking major steps forward and works like this and similar future approaches have the potential to become the ladders toward the same. REFERENCES 1. Angold A, Costello E, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 1999;40:57-87. 2. Cicchetti D. The emergence of developmental psychopathology. Child Dev. 1984;55:1-7. 3. Costello EJ, Angold A. Developmental epidemiology. In: Cicchetti D, Cohen D, editors. Theory and method. Hoboken: Wiley; 2006:41-75. 4. Costello EJ, Angold A. Epidemiology of psychiatric disorder in childhood and adolescence. In: Gelder MG, Andreasen NC, Lopez-Ibor JJ Jr, Geddes JR, editors. New oxford textbook of psychiatry. 2nd ed. Oxford: Oxford University Press; 2009:1594-9. 5. 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