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The Texas Model for Comprehensive School Counseling Programs

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Child Mind Institute | Transforming Children’s Lives.

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The Child Mind Institute is an independent nonprofit dedicated to transforming the lives of children struggling with mental health and learning disorders.

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Children’s Mental Health Disorder Fact Sheet for the Classroom

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Addressing Anxiety in School Settings Information for Counselors

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Inside Higher Ed | Higher Education News, Events and Jobs

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More than half of the college students who visited their campus counseling centers during the 2015-16 academic year reported symptoms of anxiety, according to a survey by the Association for University and College Counseling Center Directors.

This marks the seventh year in a row that anxiety has been the top complaint among students seeking mental health services. This year, 51 percent of students who visited a counseling center reported having anxiety, followed by depression (41 percent), relationship concerns (34 percent) and suicidal ideation (20.5 percent). Many students reported experiencing multiple conditions at once.

Since 2009, when anxiety overtook depression as the No. 1 concern among college students, the number of students experiencing anxiety has steadily increased.

This survey was conducted between September 2015 and August 2016. In total, 529 counseling center directors representing that many institutions responded to the survey, with an even split between public and private institutions. The majority of respondents came from four-year colleges, but community colleges, professional schools and art schools were also included.

In an effort to reflect the makeup of their student bodies, counseling centers have diversified their clinical staff members. Of new hires, 62.2 percent are white, 15.3 percent black, 7.5 percent Latino and 10 percent Asian. This compares to current clinical staff, who are 70.9 percent white, 10.1 percent black, 7.3 percent Latino and 7.9 percent Asian.

"Student populations have become more diverse," said Micky Sharma, president of the AUCCCD and director of counseling and consultation services at Ohio State University. "Counseling services work to create a staff that represents their student bodies."

At Ohio State, for example, the counseling center now offers clinical services in nine different languages to meet the needs of their international students, who make up about 12 percent of the student body, Sharma said.

Regardless of race, ethnicity, gender or sexual orientation, "anyone could show up with anxiety or depression or a relationship issue," Sharma said. "A university counseling center is charged with providing help for everybody."

Another key finding in the survey is that 41.6 percent of counseling centers hired additional staff members in the last academic year, compared to about 26 percent in 2011 and 36 percent in 2016.

College counseling centers continue to grow to match the demands of their students, according to David Reetz, the lead researcher and coordinator for the 2016 survey and director of counseling and psychological services at the Rochester Institute of Technology.

"More students are seeking services because we continue to be more and more aware that a student's health and well-being have a lot to do with their success in their academic programs and the quality of their student life experience," Reetz said.

In fact, of the students surveyed, about 72 percent who used counseling services said it helped their academic performance in some way.

As more students continue to seek out mental health services and campus counseling centers try to keep up with new hires, the question of student wait times becomes key.

For the first time, this year's survey asked counseling center directors about average wait times for students based on the number of business days between when the appointment was scheduled and when it occurred.

The survey team found that, on average, students waited between six and eight business days for counseling services. However, as might be expected, institutions with a lower ratio of professional staff to students saw shorter wait times.

Reetz noted that the wait-time average is a "tricky number," given that some students opt to schedule their first appointment farther out to accommodate their own schedules.

"Students don't necessarily want to be seen right away," Reetz said, adding that, generally, "the more staff a center has, the shorter that wait time is between initial contact and first appointment."

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Anxiety and depression are the primary concerns for students seeking counseling services

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Survey of campus counseling centers finds increased demand for services, as well as additional positions and more diversity in hiring.

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Dr. Kathleen Ries Merikangas, Ph.D, Ms. Jian-ping He, M.Sc., Dr. Marcy Burstein, Ph.D., Ms. Sonja A. Swanson, Sc.M., Dr. Shelli Avenevoli, Ph.D., Ms. Lihong Cui, M.Sc., Dr. Corina Benjet, Ph.D., Dr. Katholiki Georgiades, Ph.D., and Dr. Joel Swendsen, Ph.D.

Abstract

Objective

To present estimates of the lifetime prevalence of DSM-IV mental disorders with and without severe impairment, their comorbidity across broad classes of disorder, and their sociodemographic correlates.

Method

The National Comorbidity Survey-Adolescent Supplement NCS-A is a nationally representative face-to-face survey of 10,123 adolescents aged 13-18 years in the continental U.S. DSM-IV mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview.

Results

Anxiety disorders were the most common condition (31.9%), followed by behavior disorders (19.1%), mood disorders (14.3%), and substance use disorders (11.4%), with approximately 40% of those with one class of disorder also meeting criteria for another class of lifetime disorder. The overall prevalence of disorders with severe impairment and/or distress was 22.2%; (11.2% with mood disorders; 8.3% with anxiety disorders; 9.6% behavior disorders). The median age of onset for disorder classes was earliest for anxiety (6 years), followed by 11 years for behavior, 13 years for mood, and 15 years for substance use disorders.

Conclusions

These findings provide the first prevalence data on a broad range of mental disorders in a nationally representative sample of U.S. adolescents. Approximately one in every 4-5 youth in the U.S. meets criteria for a mental disorder with severe impairment across their lifetime. The likelihood that common mental disorders in adults first emerge in childhood and adolescence highlights the need for a transition from the common focus on treatment of U.S. youth to that of prevention and early intervention.

Keywords: Epidemiology, adolescents, mental disorders, National Comorbidity Survey, correlates

INTRODUCTION

There has been tremendous growth in the field of child psychiatric epidemiology over the past two decades. The results of numerous community surveys in specific regions of the U.S. ⁻ have shown that about one in every three to four children suffers from a mental disorder and that about one in ten has a Serious Emotional Disturbance, ⁻ with few affected youth receiving adequate mental health care. However, there has been a lack of empirical data on the prevalence and distribution of a wide range of DSM-IV mental disorders from a nationally representative sample of children or adolescents. Such information is necessary to establish resource allocation priorities for prevention, treatment, and research.

Based on the recommendations of the landmark Surgeon General's Report on Mental Health and the recommendations of a subgroup of the National Institute of Mental Health (NIMH) National Advisory Mental Health Council, the NIMH established several research initiatives to address the lack of national statistics on mental health in children. Instruments for assessing mental health were added to two large national surveys including the Strengths and Difficulties Questionnaire (SDQ) to the National Health Interview Survey, and selected modules from the National Institute of Mental Health Diagnostic Interview Schedule for Children (DISC) Version 4 to the National Health and Nutrition Examination Survey. In addition to these measures, the National Comorbidity Survey Replication (NCS-R) was extended to assess a broad range of DSM-IV disorders in a nationally representative sample of youth aged 13-18 years, referred to as the National Comorbidity Survey Adolescent Supplement (NCS-A). ⁻

The goals of the present report are: (1) to present the lifetime prevalence estimates of mental disorders and the proportion of disorders that are associated with severe impairment in a nationally representative sample of U.S. adolescents; (2) to examine the magnitude of overlap in the major classes of mental disorders; and (3) to describe the individual and familial sociodemographic correlates of these disorders.

Method

Sample and Procedure

The NCS-A is a nationally representative, face-to-face survey of 10,123 adolescents aged 13-18 years in the continental US. The survey was administered by the professional interview staff of the Institute for Social Research at the University of Michigan. The NCS-A was carried out in a dual-frame sample that included a household sub-sample and a school sub-sample., , The overall NCS-A adolescent response rate combining the two sub-samples was 82.9%. Comparisons of sample and population distributions on census sociodemographic variables and the school sample on school characteristics revealed only minor differences that were corrected with post-stratification weighting.

One parent or parent surrogate of each participating adolescent was asked to complete a self-administered questionnaire (SAQ) that contained informant questions about the adolescent's mental health. The full SAQ was completed by 6,491 parents. These recruitment and consent procedures were approved by the Human Subjects Committees of both Harvard Medical School and the University of Michigan. Once the survey was completed, cases were weighted for variation in within-household probability of selection (in the household sub-sample) and for residual discrepancies between the sample and the US population on the basis of socio-demographic and geographic variables. These weighting procedures are discussed in more detail elsewhere., Socio-demographic variables assessed in the NCS-A include age (in years), sex, race/ethnicity, parent education, urbanicity, and marital status of parents. A poverty index ratio, based on family size and the ratio of family income to the family's poverty threshold level, (≤1.5 poor, ≤3, ≤6, and > 6) was also included.

presents the weighted socio-demographic characteristics of the study sample. About half of the sample was male (51.3%) and the mean age was 15.2 years, with a larger proportion of youth aged 13-14 years (36.2%), and approximately equal distributions of youth aged 15 (20.5%), 16 (21.0%), and 17-18 (22.3%) years. The sample was comprised of 65.6% non-Hispanic Whites, 15.1% non-Hispanic Blacks, and 14.4% Hispanics. In terms of family characteristics, 84.5% of the sample had parents who had completed at least high school, 14.7% had a poverty index ratio at 1.5 or lower, nearly half of the sample resided in a metropolitan area, and 78.6% had parents who were married or cohabiting.

Table 1

Measures

Diagnostic assessment

Details of the diagnostic and risk factor measures are described by Merikangas et al. Briefly, a modified version of the World Health Organization (WHO) Composite International Diagnostic Interview Version 3.0 (CIDI), a fully structured interview administered by trained lay interviewers to generate DSM-IV diagnoses was administered to adolescents. Modifications to the CIDI involved enhancing the wording and appropriateness of the instrument for assessment of adolescents. Lifetime disorders assessed in the CIDI included mood disorders and episodes (major depressive disorder [MDD] or dysthymic disorder, bipolar I or II [BPD]), anxiety disorders (panic disorder, agoraphobia, social phobia, specific phobia, generalized anxiety disorder [GAD], posttraumatic stress disorder [PTSD], separation anxiety disorder [SAD]), behavior disorders (attention deficit/hyperactivity disorder [ADHD], oppositional defiant disorder [ODD], and conduct disorder [CD]), substance use disorders (alcohol abuse/dependence, drug abuse/dependence), and eating disorders (anorexia nervosa, bulimia nervosa, and binge eating disorder). Parents (or parent surrogates) were mailed a self-administered questionnaire (SAQ) in order to collect additional information on adolescent sociodemographic characteristics, developmental background, mental and physical health, and other family- and community-level factors. Parents who completed the SAQ provided full DSM-IV diagnostic information about MDD and dysthymic disorder, SAD, ADHD, ODD, and CD, whereas those completing the abbreviated SAQ only reported on ADHD. Based on prior research that has documented the value of supplemental parent reports, , information from both the parent and adolescent were combined for major depression and behavior problems and classified as positive if either informant endorsed the diagnostic criteria. Definitions of all psychiatric disorders adhered to DSM-IV criteria and diagnostic hierarchy rules were applied for every disorder, with the exception of oppositional defiant disorder and substance use disorders. Psychiatric disorders derived from the modified CIDI showed good concordance with a clinical reappraisal sub-sample.

Impairment criteria embedded in DSM-IV required endorsement of some/a lot/extreme level of impairment or moderate/severe/very severe level of symptom severity. In order to more clearly identify disorders that were clinically significant, our definition of severe lifetime disorders used higher thresholds of impairment that required endorsement of "a lot" or "extreme" impairment in daily activities, or "severe or very severe" distress. Severe emotional disorders required both distress and impairment to be present, and severe behavior disorders (ADHD, ODD, and CD) required endorsement of symptom criteria by both the parent and the adolescent.

Statistical Analysis

All statistical analyses were completed with the SUDAAN software package and utilize the Taylor series linearization method to take into account the complex survey design. Cross-tabulations were used to calculate prevalence and comorbidity. Logistic regression analysis was used to examine demographic correlates of prevalence; regression models included all sociodemographic variables simultaneously, and adjusted odds ratios are presented. Age-of-onset curves were generated using the Kaplan-Meier survival analysis method. Multivariate significance tests were calculated using Wald Chi-Square tests based on coefficient variance-covariance matrices that were adjusted for design effects using the Taylor series method. Statistical significance was based on two-sided design-based tests evaluated at a level of significance of 0.05.

Results

Lifetime Prevalence

presents the lifetime prevalence rates of DSM-IV mental disorders by sex, age group, total DSM-IV disorders and disorders with severe impairment. Mood disorders affected 14.3% of the total sample, corresponding to 11.7% who met criteria for MDD or dysthymia and 2.9% for BPD. Females were twice as likely to experience unipolar mood disorders as compared to males, and somewhat more likely to experience BPD. The prevalence of all mood disorders increased uniformly with age, with a nearly two-fold increase from the 13-14 year age group to the 17-18 year age group. Severe cases of mood disorder (11.2% of the total sample) represented 74.4% of all MDD or dysthymic disorders, and 89.7% of all cases of BPD. The sex-specific rates for severe disorders (not presented in the table) maintained the same general patterns as were observed for the overall prevalence rates.

Table 2

Nearly one in three adolescents (31.9%) met criteria for an anxiety disorder, with rates for individual disorders ranging from 2.2% for GAD to 19.3% for specific phobia. All anxiety disorder subtypes were more frequent in females (the greatest sex difference being observed for PTSD). The aggregate category of any anxiety disorder was stable across age groups, but considerable variance was observed by disorder subtype. In particular, the prevalence of PTSD, panic disorder, social phobia and GAD showed modest but consistent increases with age. Severe anxiety disorders were present in 8.3% of the total sample, representing all individuals with panic disorder or agoraphobia, a moderate proportion of individuals with GAD (54.5%) or PTSD (30%), and only a small proportion of individuals with social phobia (14.3%), SAD (7.9%) and specific phobia (3.1%); yielding prevalence rates of 1.3% for social phobia, and 0.6% for SAD and specific phobia, respectively.

The prevalence of ADHD was 8.7%, with three times as many males being affected by this condition as females. The prevalence of severe ADHD was 4.2%, or approximately half of all cases in the sample. ODD was present in 12.6% of the sample (6.5% for severe cases) and 6.8% met criteria for CD (2.2% for severe cases). Although the rates of ADHD and ODD remained relatively stable by age group, rates of CD increased to a peak of 9.6% among the oldest adolescents.

Substance use disorders were present in 11.4% of the sample, corresponding to 8.9% of adolescents with drug abuse/dependence and 6.4% with alcohol abuse/dependence. These disorders were somewhat more frequent in males, and a five to eleven-fold increase in prevalence was observed across increasing age groups. The rates for severe substance use disorders were identical to those of the DSM-IV disorders because impairment criteria were embedded in the diagnostic definitions for these disorders. Concerning other conditions, 2.7% of adolescents had manifested eating disorders at some point in their lifetime. These disorders were more than twice as prevalent among females and demonstrated modest increases with age.

Finally, 49.5% of the total sample was affected by at least one class of disorder, but less than half had disorders with severe impairment (27.6%), and only 22.2% exclusive of substance use disorders. Approximately 20% of the sample (40% of all affected individuals) also met criteria for a disorder from at least one additional class. These comorbidity rates were similar for males and females. No age differences were observed for adolescents affected by one class of disorder, but comorbidity with additional classes strongly increased with age.

presents the age-specific incidence curves for each of the broad classes of lifetime mental disorder. Anxiety disorders occurred earliest with a steep slope beginning in early childhood, and leveling off after age 12. Risk was fairly low for mood and behavior disorders until early adolescence when it began to rise steadily. Substance use disorders appeared to have the latest age of onset with a steep increase in incidence after age 15. The estimated risk at age 18 was 17.6% for behavior disorders, 18.2% for mood disorders, 23.8% for substance use disorders, and 26.2% for anxiety disorders. The median age of disorder onset was 6 for anxiety disorders, 11 for behavior disorders, 13 for mood disorders, and 15 for substance use disorders (data not shown).

displays the proportion of adolescents affected by one or more broad classes of disorder among those with at least one DSM-IV disorder. A small majority of affected adolescents (61%) met criteria for disorders from one class only, with anxiety disorders being the most frequent condition to occur alone (35%) and smaller proportions having only behavior (14%), mood disorders (6%), or substance use disorders (6%). About one-quarter (25%) of adolescents affected by at least one class of disorder also met criteria for a disorder from one additional class, 11.0% were affected by three classes of disorders and 3% were affected by four classes of disorder.

Socio-demographic Correlates

presents the results of multivariate analyses of the association between individual and familial sociodemographic characteristics on classes of lifetime mental disorders in the adolescents. Mood and anxiety disorders were more prevalent among females in these multivariate analyses, whereas males had higher rates of behavior and substance use disorders. Rates of mood and substance use disorders were higher among older adolescents. There were few racial/ethnic differences in the major classes of mental disorders, with the exception of increased rates of anxiety disorders and lower rates of substance use disorder among non-Hispanic Black adolescents compared to non-Hispanic White adolescents, and higher rates of mood disorders among Hispanic adolescents compared to non-Hispanic Whites.

Table 3

With respect to parental characteristics, the prevalence rates of anxiety disorders, substance use disorders and behavior disorders were higher for respondents whose parents were divorced or separated relative to respondents of currently married or cohabitating parents. Rates of mood disorders were lower among children of parents who were never married compared to currently married or cohabitating parents. Parental poverty level and urbanicity were not associated with any of the classes of mental disorder. However, the most consistent association between parental characteristics and mental disorders in children emerged for parental education. Adolescents whose parents were not college graduates were at increased risk for all disorder classes.

The findings from multivariate analyses for these sociodemographic characteristics and classes of severe mental disorders (results not shown, but available upon request) were highly similar to those of all mental disorders, with limited exceptions. In particular, anxiety disorders were more prevalent in older adolescents, among 'other' ethnic minorities, among adolescents whose parents were not college graduates, and among adolescents whose parents were divorced or separated.

Two-way interactions for any significant main effects were tested for each class of disorder. After adjusting for family-wise experimental errors with a Bonferroni correction, no interactions were observed between individual and parental demographic correlates and anxiety or behavior disorders. There were four significant interactions for other disorders: (1) the prevalence of mood disorders was higher in White adolescents in homes with higher levels of parental education than that in Blacks and Hispanics; (2) rates of substance use disorders increased more dramatically with age for males than females; (3) sex differences in substance use disorders were largest for Blacks compared to other ethnic groups; and (4) increased rates of substance use disorders were observed among Hispanic adolescents whose parents were divorced, however, rates were decreased among Blacks whose parents were never married or divorced.

Discussion

These findings provide the first lifetime prevalence data on a broad range of mental disorders in a nationally representative sample of U.S. adolescents. The prevalence rates reported here closely approximate those of our nationally representative sample of adults using nearly identical methods, suggesting that the majority of mental disorders in adults emerge prior to adulthood. These rates are somewhat higher than those of prior studies, but within the ranges of estimates summarized in a meta-analysis of international community surveys of mental disorders in youth. In addition, the NCS-A provides a more comprehensive assessment of a wide range of DSM-IV disorders and subtypes than most previous studies. Despite the high prevalence rates, however, only about one in every four-to-five youths meet criteria for a lifetime mental disorder that is associated with severe role impairment and/or distress. The prevalence of severe emotional and behavior disorders is even higher than the most frequent major physical conditions in adolescence, including asthma or diabetes which have received widespread public health attention.

The finding that only about half of youth with a lifetime DSM-IV disorder report severe impairment confirms previous research demonstrating that a smaller proportion of youth with mental disorders actually have sufficiently severe distress or impairment to warrant immediate intervention. According to prior research, about one out of every ten youths with a current mental disorder fulfill criteria for Serious Emotional Disorder (SED) based on the Substance Abuse and Mental Health Services Administration (SAMSHA) definition (e.g., a mental health problem that has a drastic impact on a child's ability to function socially, academically, and emotionally). , While our study did not strictly assess all of the criteria for SED, our estimates of severe disorders were based on the full diagnostic criteria for DSM-IV disorders accompanied by severe impairment in major life roles.

Our data document the early onset of major classes of mental disorders. Among affected adolescents, 50% of disorders had their onset by age 6 for anxiety disorders, by age 11 for behavior disorders, by age 13 for mood disorders and by age 15 for substance use disorders. These findings closely approximate those of prospective studies of child and adolescent samples that have documented the incidence and progression of childhood mental disorders., ⁻ The early age of onset of anxiety has been well-established and our findings on specific subtypes of anxiety closely track those of prospective community-based research that reveal differential peak periods of onset of specific subtypes of anxiety. ⁻ Prospective studies have also shown that the average age of onset of major depression and dysthymia is between 11 and 14 years, with a steady increase in incidence across adolescence that continues through early adulthood. Our cross-sectional data reflect this increase with a near doubling of rates from 13-14 years (8.4%) to 17-18 years (15.4%). Also consistent with prior cross-sectional and prospective research, the median onset of behavior disorders is slightly earlier than that of mood disorders, with a later peak for conduct disorder than for oppositional defiant disorder. Finally, the later onset and steeper increase in rates of substance use disorders across adolescence has been repeatedly demonstrated, despite different prevalence periods and assessment methods.

About 40% of affected youth in the NCS-A reported more than one class of lifetime disorder, with mood disorders being the most likely to co-occur with other classes. Non-random patterns of comorbidity between discrete classes of mental disorders have been documented extensively in prior community samples of youth. ⁻ Future analyses of these data will investigate specific concurrent and prospective comorbidity patterns as well as their sociodemographic and clinical correlates.

In addition to providing prevalence estimates, the findings also confirm observations from previous U.S. and international investigations of adolescents concerning the association of sociodemographic characteristics and mental disorders. In particular, female adolescents were more likely than males to have mood and anxiety disorders, but less likely to have behavioral and substance use disorders. Non-Hispanic Blacks were less likely to have substance use disorders compared to Whites, a finding that is similar to prior community studies of adolescents and adults. The increased prevalence of mood and substance use disorders in older adolescents has also been observed in previous investigations, thus indicating the importance of prevention strategies for early and mid-adolescence. By contrast, the stability of certain anxiety and behavioral disorders across this same developmental period suggests that earlier interventions before puberty may be appropriate for many of these conditions.

The strong links between adolescent mental disorders and parental characteristics indicate the importance of the family context in the development of mental disorders. Our finding of a prominent effect of parental education on mental disorders has been well-documented for both child physical and mental health outcomes., Divorce was often associated with mental disorders in youth, particularly anxiety, behavior and substance use disorders. The mechanisms underlying the impact of non-intact homes on mental disorders in youth, including both biologic or genetic vulnerability, and indirect influences on disruptions in the home environment, warrant further study., , However, the significant interactions observed among several sociodemographic characteristics attest to the complexity of these associations. For example, increased rates of substance use disorders among Hispanic adolescents whose parents were divorced may reflect interactions of individual, familial and broader environmental influences that should be considered simultaneously in modeling the nature of risk and resilience in adolescent mental disorders., The lack of strong effects for some sociodemographic characteristics, such as poverty, may also be attributable to the multivariate statistical approach that adjusted for confounded variables.

The present findings should be interpreted in the context of several study-specific limitations. First, the cross-sectional nature of the survey limits our ability to document temporal ordering of mental disorders and putative risk and protective factors. Second, assessment of lifetime disorders is based on retrospective recall that is subject to numerous types of bias. Although we employed a number of methods to increase the validity of retrospective reports of age of onset, it is unlikely that we were able to completely correct for recall biases. A third limitation is that surrogate information was obtained only from one parent using a self-administered questionnaire rather than a direct interview, and only for a limited number of disorders assessed in the survey. The lack of prior evidence for integrating parent and child reports based on different modes of administration led us to apply an empirical approach based on previous research on cross-informant diagnostic estimates. In addition to study-specific limitations, a critical view is warranted concerning current diagnostic nomenclature more generally. Adolescence is a period of change and maturation in which emotional and behavioral difficulties may be common, and it is difficult to establish universally acceptable definitions of disorder or severity thresholds. The high comorbidity across classes of disorders also raises questions regarding the permeability of diagnostic categories and the plasticity of adolescent development. The pertinence of current and alternative developmentally-appropriate diagnostic criteria for adolescent mental disorders deserves careful attention and would benefit from continued debate.

Despite these limitations, our findings document the high prevalence of mental disorders in youth, and specify that just over one in four-to-five adolescents in the general population suffers from disorders that result in severe impairment. Considered with recent estimates indicating that the annual economic burden of mental disorders on the well-being of American youth and their families approaches a quarter of one trillion dollars, these findings underscore the key public health importance of mental health in American youth. The present data can inform and guide the development of priorities for future research and health policy by providing previously lacking prevalence estimates in a nationally representative sample of U.S. adolescents, as well as the individual, familial and environmental correlates of mental disorders. Prospective research is now needed to understand the risk factors for mental disorder onset in adolescence, as well as the predictors of the continuity of these disorders into adulthood.

Acknowledgments

The National Comorbidity Survey Adolescent Supplement (NCS-A) and the larger program of related NCS surveys are supported by the National Institute of Mental Health (U01-MH60220) and the National Institute of Drug Abuse (R01 DA016558) with supplemental support from Substance Abuse and Mental Health Services Administration (SAMHSA), the Robert Wood Johnson Foundation (RWJF; Grant 044708), and the John W. Alden Trust. The NCS-A was carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative.

This work was supported by the Intramural Research Program of the National Institute of Mental Health. The views and opinions expressed in this article are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or U.S. Government.

Footnotes

Disclosure: Drs. Merikangas, Burstein, Avenevoli, Benjet, Georgiades, and Swendsen, and Ms. He, Ms. Swanson, and Ms. Cui report no biomedical financial interests or potential conflicts of interest.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Contributor Information

Dr. Kathleen Ries Merikangas, Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health.

Ms. Jian-ping He, Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health.

Dr. Marcy Burstein, Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health.

Ms. Sonja A. Swanson, Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health.

Dr. Shelli Avenevoli, Division of Developmental Translational Research, National Institute of Mental Health.

Ms. Lihong Cui, Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health.

Dr. Corina Benjet, National Institute of Psychiatry Ramón de la Fuente, Mexico.

Dr. Katholiki Georgiades, McMaster University.

Dr. Joel Swendsen, National Scientific Research Center (CNRS), Bordeaux, France.

References

1. Costello E, Mustillo S, Keeler G, Angold A. Prevalence of psychiatric disorders in childhood and adolescence. In: Levin B, Petrila J, hennessy K, editors. Mental Health Services: A Public Health Perspective. Oxford: 2004. pp. 111-128. [ Google Scholar]

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Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A)

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Dr. Kathleen Ries Merikangas, Ph.D, Ms. Jian-ping He, M.Sc., Dr. Marcy Burstein, Ph.D., Ms. Sonja A. Swanson, Sc.M., Dr. Shelli Avenevoli, Ph.D., Ms. Lihong Cui, M.Sc., Dr. Corina Benjet, Ph.D., Dr. Katholiki Georgiades, Ph.D., and Dr. Joel Swendsen, Ph.D.

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National Eating Disorders Association - Educator Toolkit

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Teaching Students with Emotional Disturbances- 8 Tips for Teachers

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The School Counselor’s Role in Addressing Eating Disorder Sympt

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Eating Issues and Body Image in Elementary School

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Eating Issues in Schools- Detection, Management, and Consultation with Allied Professionals

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Bipolar Disorder, Depression &  Schizophrenia

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Bipolar Disorder, Depression &  Schizophrenia

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Module 3- Professional Presentation- Educating Others on Eating Disorders

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A Closer Examination of Bipolar Disorder in School-Age Children

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Historical Underpinnings of Bipolar Disorder Diagnostic Criteria

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Individuals with Disabilities Education Act

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Individuals with Disabilities Education Act (IDEA)

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The U.S. Department of Education’s Individuals with Disabilities Education Act website brings together department and grantee IDEA information and resources. The IDEA makes available a free appropriate public education to and ensures special education and related services to eligible children with disabilities.

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Basic Description

A blueprint or plan for a child's special education experience at school.

A blueprint or plan for how the school will provide support and remove barriers for a student with a disability.

What It Does

Provides individualized special education and related services to meet a child's unique needs.

Provides services and changes to the learning environment to enable students to learn alongside their peers.

As with an IEP, a 504 plan is provided at no cost to families.

These services are provided at no cost to families.

What Law Applies

The Individuals with Disabilities Education Act (IDEA)

Section 504 of the Rehabilitation Act of 1973

This is a federal civil rights law to stop discrimination against people with disabilities.

This is a federal special education law for children with disabilities.

Who's Eligible

To get an IEP, there are two requirements:

To get a 504 plan, there are two requirements:

1. A child has any disability. Section 504 covers a wide range of different struggles in school.

2. The disability must interfere with the child's ability to learn in a general education classroom.

Section 504 has a broader definition of a disability than IDEA. (It says a disability must substantially limit one or more basic life activities. This can include learning, reading, communicating, and thinking.) That's why a child who doesn't qualify for an IEP might still be able to get a 504 plan.

1. A child has one or more of the 13 disabilities listed in IDEA. The law lists specific challenges, like learning disabilities, ADHD, autism, and others.

2. The disability must affect the child's educational performance and/or ability to learn and benefit from the general education curriculum. The child must need specialized instruction to make progress in school.

Independent Educational Evaluation

Families can ask the school district to pay for an independent educational evaluation (IEE) by an outside expert. The district doesn't have to agree.

Doesn't allow families to ask for an IEE. As with an IEP evaluation, families can always pay for an outside evaluation themselves.

Families can always pay for an outside evaluation themselves, but the district may not give it much weight.

Who Creates It

There are strict legal requirements about who participates. An IEP is created by an IEP team that must include:

The rules about who's on the 504 team are less specific than they are for an IEP.

A 504 plan is created by a team of people who are familiar with the child and who understand the evaluation data and special services options. This might include:

The child's parent or caregiver

General and special education teachers

The school principal

The child's parent or caregiver

At least one of the child's general education teachers

At least one special education teacher

School psychologist or other specialist who can interpret evaluation results

A district representative with authority over special education services

With a few exceptions, the entire team must be present for IEP meetings.

What's in It

The IEP sets learning goals and describes the services the school will provide. It's a written document.

There is no standard 504 plan. Unlike an IEP, a 504 plan doesn't have to be a written document.

A 504 plan generally includes the following:

Specific accommodations, supports, or services for the child

Names of who will provide each service

Name of the person responsible for ensuring the plan is implemented

Here are some of the most important things the IEP must include:

The child's present levels of academic and functional performance-how the child is currently doing in school

Annual education goals for the child and how the school will track progress

The services the child will get-this may include special education, related, supplementary, and extended school year services

The timing of services-when they start, how often they occur, and how long they last

Any accommodations-changes to the child's learning environment

Any modifications-changes to what the child is expected to learn or know

How the child will participate in standardized tests

How the child will be included in general education classes and school activities

Notice

When the school wants to change a child's services or placement, it has to tell families in writing before the change. This is called prior written notice. Notice is also required for any IEP meetings and evaluations.

The school must notify families about an evaluation or a "significant change" in placement. Notice doesn't have to be in writing, but most schools do so anyway.

Families also have "stay put" rights to keep services in place while there's a disagreement about the IEP.

Consent

A parent or caregiver must consent in writing for the school to evaluate a child. They must also consent in writing before the school can provide the services in an IEP.

A parent or caregiver's consent is required for the school district to evaluate a child.

How Often It's Reviewed and Revised

The IEP team must review the IEP at least once a year.

The rules vary by state. Generally, a 504 plan is reviewed each year and a reevaluation is done every three years or when needed.

The child must be reevaluated every three years to determine whether services are still needed.

How to Resolve Disputes

IDEA gives families several ways to resolve disputes (usually in this order):

Section 504 gives families several options for resolving disagreements with the school:

Mediation

Alternative dispute resolution

Impartial hearing

Complaint to the Office for Civil Rights (OCR)

Lawsuit

Funding/Costs

Students receive these services at no charge.

Students receive these services at no charge.

States do not receive extra funding for students with 504 plans. But the federal government can take funding away from programs (including schools) that don't meet their legal duty to serve kids with disabilities.

IDEA funds can't be used to serve students with 504 plans.

States receive additional funding for students with IEPs.

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IEP vs. 504 Plan: What's the Difference?

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Basic Description A blueprint or plan for a child's special education experience at school. A blueprint or plan for how the school will provide support and remove barriers for a student with a disability. What It Does Provides individualized special education and related services to meet a child's unique needs.

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Gender Differences in Depression in Representative National Samples Meta-Analyses of Diagnoses and Symptoms

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Diagnosing Psychotic Disorders - Mood and Psychosis

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School Mental Health Referral Pathways Toolkit

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Finding the motivation to make positive lifestyle changes can be hard for anyone. For teenagers, it can be especially difficult when parents are the ones telling them to do it. But if they've fallen into unhealthy habits like vaping or alcohol abuse, change can be beneficial. Motivational interviewing is a form of therapy that creates a safe, non-judgmental environment for teens to establish their own goals and values and see how changing unhealthy behaviors can benefit them in the long run.

This series of articles comes from the Child Mind Institute, with most available in English and Spanish. Why might teens be resistant to therapy and how can parents and others to help them get the treatment they need? The articles explain how motivational interviewing can help teens gain the self-confidence to make important behavioral changes. To read more about motivational interviewing, and to connect with the articles in both English and Spanish, please visit CPIR's abstract.

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Center for Parent Information and Resources | Your Central Hub for Parent Centers Serving Families of Children With Disabilities

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Finding the motivation to make positive lifestyle changes can be hard for anyone. For teenagers, it can be especially difficult when parents are the ones telling them to do it. But if they've fallen into unhealthy habits like vaping or alcohol abuse, change can be beneficial.

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ASCA Ethical Standards for School Counselors

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Childhood Schizophrenia: What Are the First Signs? | Child Mind Institute

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Oppositional Defiant Disorder- A Guide for Parents

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Early Development of Comorbidity Between Symptoms of Attention-Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD)

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Children’s Mental Health Fact Sheet for the Classroom - Conduct Disorder

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Mental Health Disorders of Childhood and Adolescence - Conduct Disorder

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Home - ADDA - Attention Deficit Disorder Association

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Empowering adults with adhd to live their best lives A Different Brain Requires a Different Approach Whether you're newly diagnosed, wondering if you have ADHD, or simply ready to take charge of your life - we're here to help. Have ...

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Attention Deficit Hyperactivity  Disorder - Fact Sheet

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Counseling Youth With  Attention-Deficit Hyperactivity Disorder (ADHD)

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Addressing Conduct Disorder in Elementary School Children- An Application of the ASCA National Model

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Out of Sight, Out of Mind- A Case Study of an Alternative School for Students with Emotional Disturbance (ED)

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Mindfulness for Students Classified with Emotional Behavioral Disorder

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Characteristics of Students with Emotional Disturbance Manifesting Internalizing Behaviors- A Latent Class  Analysis

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ASSESSMENT OF  THE RISK  FACTORS INVOLVED IN THE ONSET OF ANXIETY  DISORDERS IN CHILDREN AND ADOLESCENTS

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Students with Anxiety- The Role of the Professional School Counselor

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Behavioral disorders also known as conduct disorders are one of the most common forms of disability among children and young adults and is the most frequently cited reason for referral to mental health services. The appearance of behavioral disorders is increasing dramatically in our K-12 classrooms. As a result, their presence severely constrains the ability of the school systems to educate students effectively. The prevalence of behavioral problems among children and young adults is substantial. Many surveys indicate that behavioral disorders vary among young adults, ranging from 2 and 6 percent among K-12 students. This percentage translates into 1.3 to 3.8 million cases of behavioral disorders among the school and pre-college population.

Behavior disorders have also been referred to in a variety of different terminologies, including but not limited to:

1. Emotional and Behavior Disorders (EBD)

2. Emotional Conflict (EC)

3. Serious Emotional Disturbance (SED)

Behavioral disorders become apparent when the student displays a repetitive and impact persistent pattern of behavior that results in the significant disruption of other students. Such disturbances may cause significant impairments in academic, social, and or occupational functioning. Among the characteristics of a behavioral disorder among children and adolescents are:

General Strategies

Multidisciplinary educational teams, including parents, must design programs to meet the individual behavioral and academic needs of identified SED students. Most students can benefit from supportive treatments provided in general education programs. For others, at least temporary placements in special education classrooms, schools, or institutional programs may be appropriate.

Special education programs usually attempt to provide a structured environment where students experience a high degree of success; rules and routines are predictable; and students are consistently rewarded for appropriate behavior. Behavior management techniques, such as positive reinforcement, token economies, contracting, and time-out, which rely on direct measurement and monitoring of behavioral change, are commonly used in SED programs. The assessment and systematic teaching of social skills through modeling, discussion, and rehearsal are frequently used to help students increase control over their behavior and improve their relations with others. In addition, supportive therapies involving music, art, exercise, and relaxation techniques, as well as affective education, individual, and group counseling are sometimes employed to improve self-understanding, self-esteem, and self-control. The following are strategies that may be effective with students with EBD:

Teacher Presentation

Laboratory

Group Interaction and Discussion

1. Acknowledge the contributions of the student with an emotional disorder.

2. Call for responses and participation commensurate with the student's socialization skills.

3. As the student's comfort level rises and when a safe topic is available, encourage the student to be a group spokesperson.

4. Along with the student, devise a contingency plan in which inappropriate forms of response are replaced by appropriate ones.

5. Gradually increase the challenges in the student's participation in group exercises while providing increased positive reinforcement.

6. Help the student to feel as though he or she has something worthwhile to contribute to the discussion.

7. Some students may experience considerable strain in social adjustment in a group context. It may be necessary to work gradually toward group activities. One can devise a strategy of progressing from spectatorship to one-to-one instruction and eventually to small group discussion.

8. Should monitor carefully to ensure that the nondisabled students do not dominate the discussion or detract in any way from the successful performance of the student with the behavioral disorder.

Reading

1. It is necessary to target specific pro-social behaviors for appropriate instruction and assessment to occur such as:

1. Taking turns, working with partner, following directions.

2. Reading in group or with others.

3. Increasing positive relationships by means of awards when they read appropriately.

4. Demonstrating appropriate reading

2. Instructional strategies involving self-control, self-reinforcement, self-monitoring, self-management, problem solving, cognitive behavior modification, and metacognitive skills should be focused on teaching students reading skills

Research

1. Review and discuss with the student the steps involved in a research activity. Think about which step(s) may be difficult for the specific functional limitations of the student and jointly devise accommodations for that student.

2. Use appropriate laboratory and field strategies.

3. Depending on the site of the research check the previous two sections.

4. Show clear examples of what the students should expect as an outcome of their research.

Field Experiences

1. Use appropriate general strategies.

2. Consider alternate activities/exercises that can be utilized with less difficulty for the student, but has the same or similar learning objectives.

3. In field activities acknowledge the contributions and assistance of the student with an emotional disorder.

4. Help the student to feel as though he or she has something worthwhile to contribute to the field trip.

5. Use a buddy system.

6. Gradually increase the challenges in the student's participation in field exercises while providing increased positive reinforcement.

7. Group participation in field activities is highly desirable because it enhances social contacts.

8. Make the student with the behavioral disorder become one of the field trip leader of an activity which can often reduce their disorder.

9. Special efforts should be made to get students with behavioral disorders to interact with other students.

10. You should encourage students to practice field skills during their free hours.

11. Every effort should be made to arouse the interest of such students in activities, so they will learn to perform the activities with success and pleasure with appropriate behaviors.

Testing

1. Be sensitive to the student's reactions to the various aspects of assessment.

2. For each student, accumulate in his or her portfolio several examples of work (quizzes, assignments, projects) that demonstrate knowledge of the subject matter or the unit of study.

3. Make special arrangements for the student with an emotional disorder according to what their special needs are and that they do not compromise the integrity of the testing situation.

4. Stay on top of student progress through informal assessment, don't wait until it's too late to discover that there is a problem.

5. Provide private room/smaller group setting/alternative test site (with proctor present); alternatively screens to block out distractions.

Organizations

Council for Exceptional Children-Council for Children with Behavior Disorders (CCBD)
The Council for Children with Behavioral Disorders (CCBD) is dedicated to supporting the professional development and enhancing the expertise of those who work on behalf of children with challenging behavior and their families. It is a division of the Council for Exceptional Children (CEC).

CCBD Foundation
The CCBD Foundation was founded in 1997 by the Council for Children with Behavioral Disorders (CCBD), to support its mission of improving the education of children and youth with emotional or behavioral disorders (EBD).

Resources

Council for Exceptional Children (Behavior Disorders/Emotional Disturbance)
The Council for Exceptional Children (CEC) page on EBD. The Council for Exceptional Children (CEC) is the largest international professional organization dedicated to improving the educational success of individuals with disabilities and/or gifts and talents.

BehaviorDisorder.org
The site offers information on behavior disorders, conduct disorders, and other behavior problems.

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Behavioral disorders also known as conduct disorders are one of the most common forms of disability among children and young adults and is the most frequently cited reason for referral to mental health services. The appearance of behavioral disorders is increasing dramatically in our K-12 classrooms. As a result, their presence severely constrains the ability of the school systems to educate students effectively.

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Obsessive Compulsive Disorder and the School Counselor

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"We initially chose IRIS because of the past experiences and their credible research-based, high-quality modules that align with specific areas of growth and need to support a state-directed corrective action plan in our region."

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"We initially chose IRIS because of the past experiences and their credible research-based, high-quality modules that align with specific areas of growth and need to support a state-directed corrective action plan in our region."

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Credit: Julius-Maximilians-Universität Würzburg, JMU

An overactive molecular signal pathway in the brain region of the amygdala can lead to obsessive-compulsive disorder (OCD). A research team from Würzburg has established this connection.

Some people have an extreme fear of dirt or bacteria. As a result, they may develop a habit of compulsive washing and repeatedly cleaning their hands or body. They are trapped in a vicious circle, as the fear of new contamination returns quickly after washing. Sufferers see no way out. They are even incapable of changing their behaviour when the excessive washing has led to skin irritation or damage.

Around two percent of the general population suffer from some kind of obsessive-compulsive disorder (OCD) at least once in their life. The disorder is characterised by persistent intrusive thoughts which the sufferers try to compensate for by repetitive ritualized behaviour.

Like depression, eating disorders and other mental diseases, OCD is treated with antidepressants. However, the drugs are non-specific, that is they are not tailored to the respective disease. Therefore, scientists have been looking for new and better targeted therapies that have fewer side effects.
Missing protein triggers urge to wash
Professor Kai Schuh from the Institute of Physiology at the Julius-Maximilians-Universität (JMU) Würzburg (Germany) and his team explore the underlying causes of obsessive-compulsive disorder in collaboration with the JMU's Departments of Psychiatry and Neurology.

"We were able to show in mouse models that the absence of the protein SPRED2 alone can trigger an excessive grooming behaviour," Schuh says. He believes that this finding is crucial as no clear trigger for this type of disorder has been identified until now. Previous research pointed to multiple factors being responsible for developing OCD.

Occurring in all cells of the body, the protein SPRED2 is found in particularly high concentrations in regions of the brain, namely in the basal ganglia and the amygdala. Normally, the protein inhibits an important signal pathway of the cell, the so-called Ras/ERK-MAP kinase cascade. When it is missing, this signal pathway is more active than usual.
Hyperactive signal cascade in the brain
"It is primarily the brain-specific initiator of the signal pathway, the receptor tyrosine kinase TrkB, that is excessively active and causes the overshooting reaction of the downstream components", biologist Dr. Melanie Ullrich explains.

Administering an inhibitor to attenuate the overactive signal cascade in the animal model improves the obsessive-compulsive symptoms. Moreover, the JMU research team was able to treat the OCD with an antidepressant, similarly to standard therapy in humans. Their detailed results have been published in the journal Molecular Psychiatry.
New targets for therapies pinpointed
"Our study delivers a valuable new model that allows the disease mechanisms to be investigated and new therapy options for obsessive-compulsive disorders to be tested," Professor Schuh says.

The recently discovered link between OCDs and the Ras/ERK-MAP kinase cascade also opens up new targets for therapy. Drugs that inhibit this cascade are already available and some of them are approved for human treatment.

According to Melanie Ullrich, these are cancer drugs, as overactivation of the Ras/ERK-MAP kinase cascade is also a frequent trigger of cancer: "So we are wondering whether such drugs could also be effective in the treatment of obsessive-compulsive disorders and whether they are beneficial in terms of side effects."

More information: M Ullrich et al. OCD-like behavior is caused by dysfunction of thalamo-amygdala circuits and upregulated TrkB/ERK-MAPK signaling as a result of SPRED2 deficiency, Molecular Psychiatry (2017). DOI: 10.1038/mp.2016.232

Provided by Julius-Maximilians-Universität Würzburg

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An overactive molecular signal pathway in the brain region of the amygdala can lead to obsessive-compulsive disorder (OCD). A research team from Würzburg has established this connection. Some people have an extreme fear of dirt or bacteria. As a result, they may develop a habit of compulsive washing and repeatedly cleaning their hands or body.

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Suffering in Silence- Examining Obsessive Compulsive Behaviors in the School Setting

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Italian Journal of Pediatrics 43, Article number: 84 (2017) Cite this article

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Abstract

Conduct Disorder (CD) is a psychiatric diagnosis characterized by a repetitive and persistent pattern of behaviour in which the basic rights of others and major age-appropriate social norms or rules are violated. Callous Unemotional (CU) traits are a meaningful specifier in subtyping CD for more severe antisocial and aggressive behaviours in adult psychopathology; they represent the affective dimension of adult psychopathy, but they can be also detected in childhood and adolescence. The CU traits include lack of empathy, sense of guilt and shallow emotion, and their characterization in youth can improve our diagnostic, prognostic and therapeutic abilities. A strong genetic liability, in interaction with parenting and relevant environmental factors, can lead to elevated levels of CU traits in children. We pointed out that CU traits can be detected in early childhood, may remain stable along the adolescence, but a decrease following intensive and specialized treatment is possible. We here provide a narrative review of the available evidences on CU traits in three main domains: aetiology (encompassing genetic liability and environmental risk factors), presentation (early signs and longitudinal trajectories) and treatments.

Background

Psychopathic traits, previously considered as a meaningful (negative) specifier for severe antisocial and aggressive behaviours in adult psychopathology, have been re-discovered as a relevant factor in subtyping CD in youth [ 6]. The current concept of psychopathy comes from Hervey Cleckley's seminal paper, describing a pattern of personality characterized by low levels of empathy and sense of guilt, arrogance, superficial charm, irresponsible and resulting antisocial behaviours [ 7]. Subsequent research, based on latent class analysis, better disentangled this issue in three conceptually separated, but inter-correlated domains: an interpersonal domain, consisting of grandiose-manipulative traits; an affective domain, consisting of callous unemotional (CU) traits; and a behavioural domain, consisting of daring-impulsive traits [ 8]. The grandiose-manipulative domain (also named narcissism) is characterized by verbal and manipulative abilities, superficial charm, egocentricity and glibness. The callous unemotional traits consist of lack of empathy and remorse, with short-lived emotions. The daring-impulsive domain (also named impulsivity or psychopathy-related impulsivity) traits include irresponsibility, proneness to boredom, novelty seeking and antisocial behaviour. Previous research pointed out that these domains are not exclusive of adult psychopathology, but they can also be found in children and adolescents [ 9], leading to the concept of childhood psychopathy, firstly conceptualized by Forth and colleagues [ 10], and further supported by Frick [ 11] and Lynam [ 12]. Subsequent studies [ 6, 13] confirmed that the multidimensional structure of adult psychopathy is detectable also in the adolescent populations. Furthermore, these studies on children/adolescents strongly suggested the association between psychopathic personality traits and conduct problems (CP), namely aggression and law violation [ 14, 15, 16]. As said before, the, DSM-5 [ 2] has consolidated this connection, considering the callous unemotional (CU) traits as the LPE specifier for the CD. This specifier, defining a specific subtype of patients with CD, includes symptoms such as lack of remorse or guilt, callous lack of empathy, lack of concern about performance, and shallow or deficient affect. About 12 to 46% of youth with CD show significant CU traits [ 17, 18, 19, 20]. The presence of CU traits in children and adolescents with CD defines a subclass of children characterized by a poorer adolescence outcome both in clinical and control samples [ 21], with increased risk for developing psychopathy in adulthood, with severe and persistent antisocial behaviour [ 3].

However, these studies raise the issue of translating the measures of CU traits into DSM-5 criteria of CD with LPE. According to DSM-5, CU traits should be present "persistently over at least 12 months and in more than one relationship or setting" [ 2]. Therefore, it is important to verify whether these features reflect the child's typical pattern of interpersonal and emotional functioning, and not sporadic occurrences in specific situations.

Disentangling CD patients through an evaluation of the presence of CU traits is a crucial component of the assessment. However, clinical assessment of CU traits may present specific caveats. Firstly, the stability of CU traits is not well established, as not all the children presenting these characteristics at the first evaluation will continue to show them across childhood, and until early adolescence [ 22, 23, 24]. Many factors may be implicated in the development and maintenance of the CU traits, although it is hard to separately test the specific contribution of each element, i.e., genetic vs. environmental, to the onset and progression of these traits. Children grow up with their biological parents, thus they receive the genetic heritage, but at the same time, they are exposed to parents' personality traits as well as to parenting strategies.

Graphical representation of the concept of developmental psychopathy, from a personality-based psychopathology (upper side) as well as a DSM-5 oriented (lower side) perspectives. GM: grandiose-manipulative, DI: daring-impulsive, CU: callous-unemotional

Neurocognitive issues

Previous studies showed that altered neuro-cognitive functions (e.g. intelligence, attentional network, processing of external stimuli) may underlie dysfunctional personality disorder features [ 27]. Similarly, many studies have documented neuro-cognitive correlates of psychopathy in children and adolescent.

In regard to intelligence, it is generally accepted that grandiose manipulative (narcissism) domain is linked to better performances in several cognitive areas, whereas CU traits were negatively associated with verbal intelligence, creativity, practicality and analytic thinking; finally, the daring-impulsive dimension was positively associated with measures of creativity, practicality, and analytic thinking, but not with verbal abilities [ 28, 29].

Factors contributing to the onset and development of CU traits

In 2014 Frick et al. [ 34], reviewed nine publications about the heritability of CU traits and found that genetically accounted variations of CU traits ranged from 42% to 68% [ 35, 36, 37, 38, 39], and that a great part of the stability in CU traits during development is genetically driven [ 36, 40, 41]. These studies also indicate that, in front of a large shared genetic effect between the CD and the CU traits, the coexistence of specific genetic influences for both the constructs suggests the existence of a partially specific genetic aetiology [ 35, 37, 38, 42, 43].

Other factors that may contribute to the onset and the development of CU traits are represented by parents' temperament and personality traits and by the parent-child interaction.

Two recent studies involving 561 adopted children and their biological mothers and adoptive families explored the first critical issue [ 44, 45]. In the first study [ 44], temperament (fearlessness) of the biological mother predicted CU behaviour of the adopted child at 27 months, via earlier fearlessness measured at 18 months; similarly, low affiliative behaviour of biologic mothers directly predicted child CU behaviours, although without any correlation with child affiliative behaviours tested at 18 months. Furthermore, adoptive mothers with highly positive parenting buffered the risk for developing CU traits via fearlessness. In the second study [ 45], a specific heritable pathway to CU behaviour was suggested: antisocial behaviour of the biological mother predicted CU behaviours of the child in late toddler period. Furthermore, more positively reinforcing mothers buffered inherited risk for early CU behaviours. These relevant studies strongly suggest that positive parenting has an effect on buffering genetic predisposition to develop CU traits.

The relation between parenting and CU traits development is bidirectional [ 46]. If the association between some features of dysfunctional parenting and the presence of CU traits in offspring has been supported by previous research, on the other hand children showing high CU traits can induce negative modifications in parenting behaviour. Although few studies specifically explored these mutual influences, preliminary evidences suggest that CU traits may be more predictive of changes in parenting over time than parenting on changes in CU traits [ 47, 48]. Some studies indicated that the presence of CU traits in children with CD is associated with low warmth in parenting [ 49, 50], others found harsh, inconsistent, and coercive discipline to be highly associated with CP in youth with normative levels of CU traits [ 50, 51, 52, 53, 54, 55]. Viding, Fontaine, Oliver, & Plomin [ 56], in their study on monozygotic twins, found that negative parental discipline operates as a non-shared environmental risk factor for developing CP during the transition to early adolescence, but not for the development of CU traits.

However, studies investigating the association between quality of parenting and prospective change in CU traits in preschool samples have found that multiple domains of parenting (positive parenting, parental involvement, and poor monitoring/supervision) uniquely predicted changes in CU traits [ 47], and that high CU traits at ages 3-4 were predicted by parent harshness [ 57]. Other studies have investigated the direct prediction of CU traits by parenting in middle and late childhood. Loney, Huntenburg, Counts-Allan, and Schmeelk [ 58] assessed the intergenerational continuity of psychopathic traits, and found that the association was mediated by parenting. Parental-reported corporal punishment and child-reported parental warmth/involvement predicted CU traits, as children with low levels of anxiety who reported low parental warmth showed increased CU features 1 year later [ 59]. Other studies have related an increase in psychopathic characteristics to parental psychological aggression and inconsistency [ 60], or to poor supervision, physical punishment, and poor parent-child communication [ 61], or to maternal reports of harsh parenting at age 4 [ 62]. On the contrary, Vitacco, Neumann, Ramos, and Roberts [ 63] found that poor parental monitoring and inconsistent discipline were both related to impulsivity and narcissism, but not to CU traits.

In a recent publication exploring developmental trajectories of CU traits, youth with persisting high CU traits had experienced more maternal harshness, low parental knowledge, and monitoring compared to the moderate or low CU youth groups [ 64]. More specifically, harshness increased significantly across groups from low to high CU traits, and youth with low CU traits reported higher parental warmth, but there were no differences between the warmth reported by high compared to moderated groups.

In a study about effects of positive and negative parenting practices on the levels of child CU in 126 Italian children treated by a multi-modal approach including parent-training, Muratori et al. [ 65] found that increased levels of positive parenting predicted a decrease in the levels of CU traits in children. In addition, low levels of CU traits at the intermediate evaluation promoted an increase of positive parenting 1 year later. In contrast to previous studies [ 56], they found that negative parenting practices are unrelated to the level of CU traits when positive parenting is taken into account. Finally, Waller, Shaw and Hyde [ 66] observed that the presence of fearlessness at 24 months predicted CU behaviours at 42 months, but only when parents exhibited low levels of positive parenting. Furthermore, they showed that this association had a lasting effect on the presence of CU behaviour at 11-12 years. In summary, all these data suggest that the trajectory of children at high risk for CU behaviours could be modified by high levels of positive parenting [ 67].

Tuvblad and colleagues' study [ 70] on genetic and environmental determinants of the psychopathic personality in a community sample of 5-year-old twins indicated that both genetic and shared environmental influences are of importance for psychopathy personality traits in childhood. Regarding the CU dimension, they found a moderate (25%) genetic influence and a higher (48%) shared environmental influence. Shared environmental risk factors include family related factors (e.g., neglect, parental stressors) and contextual factors in the surrounding community.

A recent study from Kahn, Deatre-Deckard, King-Casas and Kim-Spoon [ 71] has investigated the influences of both parenting and household environment on the intergenerational similarity in CU traits. They found a mediating role of hostile parenting in the association between parent and adolescent CU traits, especially in the context of high household chaos. They concluded that there is a heightened vulnerability to intergenerational transmission of these traits in a contest of household chaos that may exacerbate the effects of hostile parenting on CU traits during adolescence.

Early signs and developmental trajectories

Although most of the studies about CU traits associated to CD are focused on children and adolescents, more recently the interest has been expanded to early childhood and toddler age, in order to detect early sings of CU behaviours. The possibility of detecting the origins of CU traits early in childhood is given by the emerging knowledge about individual differences in empathy and conscience as early as at the age of 2 or 3 years [ 79]. Consequently, several measures were developed or adapted to specifically assess possible precursors of CU traits (for a review see [ 80]). Aim of these studies is a timely identification of children at high risk of developing CD or antisocial behaviours, in a developmental phase with more malleable behaviour, when early interventions can be more effective [ 81]. In this earlier age, "CU behaviours" is a more adequate definition rather than "CU traits", given the lesser evidences about their stability over time [ 67].

Higher CU behaviours in children as early as 3 year-old are related to lower guilt and empathy, more proactive aggression [ 67], and, perspectively, to CU traits in late childhood [ 67, 82, 83].

In his seminal work about the neurobiological basis of psychopathy, Blair [ 84] proposed that CU traits and behaviours emerge from a fearless temperament expressed through low arousal to others' distress and punishment, leading to reduced learning about the consequences of harmful behaviours, and increasing the risk of CU behaviours. The measure of CU behaviours in children focuses on the presence of lack of empathy and guilt, in addition to a reduced emotional responsivity to others' feelings or cues [ 21]. As a possible early indicator of CU behaviours in the adoption study mentioned above, Waller et al. [ 44] showed that the experimental observation of higher fearlessness and low affiliative behaviours at 18 months were related to higher CU behaviours referred by adoptive mothers at 27 months.

Recently, Goffin et al. [ 85] published the results of a long-term longitudinal study exploring early antecedents of CU traits and their evolution in typically developing children from toddler age to 12. They use observational measures to score guilt (in breaking a valued object situation), empathy (hurting the parent during play) and fearlessness in toddlers and preschoolers, and related these findings tolater parent-rated measures of CU traits and externalizing behaviours during scholar and pre-adolescent age. They found that children who were unconcerned to transgression (either breaking objects or hurting others) early in development exhibited higher CU traits in middle childhood. However, those links were moderated by child's early temperament, being significant only in children high on fearlessness and not in fearful ones.

The developmental stability of CU traits has been investigated in several studies. In their review, Frick et al. [ 34] report a relative stability of CU traits from the age of 3-4 years-old according to parent rating. Although the CU trait levels tend to decreases across childhood and adolescence in a large number of children, those showing an elevated level of CU traits are at higher risk for keeping them in older ages. Other longitudinal studies have suggested that CU traits are relatively stable across childhood, and from childhood to adolescence. Dadds and colleagues [ 22] found moderate 1-year stability estimates for features of callousness ( r = .55) in a community sample of young Australian children. Frick and colleagues [ 86] reported high 4-year stability estimates for parent ratings of callousness (interclass correlation = .71) from late childhood to middle adolescence. A more recent study of longitudinal invariance found that the rank-order stability of CU was moderate ( r = .50, p < .001) during an 8-year period from childhood into adolescence among boys [ 87]. Fontaine, McCrory, Boivin, Moffitt, and Viding [ 73], using a person-centered approach (growth mixture modeling), showed that in children substantial decreases in CU traits across development were more common than substantial increases (see also Frick et al., [ 86]).

Also, Klingzell et al. [ 88] investigated joint trajectories of CU traits and conduct problems during early childhood in a community sample and found a close relationship between them (e.g. CU and conduct problems tend to decrease together or remain stable together) and with fearlessness and psychopathic traits. Despite the differences in stability across studies, these estimates of stability are comparable to those reported for others psychopathological constructs [ 89].

Treatment

Conduct problems are usually highly impairing social, familial, and school functioning, and a management of this impairment is needed. Some specifiers, such as CU traits (or LPE DSM-5 specifier), as well as early age of onset of symptoms and comorbidities, should promote more timely referrals, assessments, and possibly an intensive treatment, and follow-ups.

The treatment of CP among children and adolescents with CU traits has been explored in depth, but so far, neither a proven psychological nor a definitive psychopharmacological treatment is available [ 90]. A recent systematic review by Hawes, Price, and Dadds [ 91] showed that CU traits were associated with increased risk for poor post-treatment outcomes. However, recent research has also suggested that children and adolescents with elevated CU traits are not "untreatable" and that they can improve with intensive treatments, tailored to the unique emotional, cognitive, and motivational styles [ 92].

Some recent and promising treatments specifically focused in ameliorating CU traits in the context of behavioural problems will be presented below and summarized in Table 1.

Table 1 Currently available psychotherapeutic treatments for children with conduct disorder and high CU traits

Coaching and Rewarding Emotional Skills (CARES) Module is a brief emotional training program for assisting empathy and emotional development in young children with CP and CU traits. The CARES module was designed to be delivered to children between the ages of 3.5 and 8 years with non-normative levels of CU traits immediately after completion of parent management training, and when CP have been reduced to below clinical significance. CARES is the first targeted treatment designed for young children to ameliorate empathy-related deficits in processing negative emotions central to CU traits. The key treatment objectives of CARES are: (a) to enhance attention to critical facial cues signalling distress in child, parents and others, to improve emotion recognition and labelling; (b) improve emotional understanding by linking emotion to context, and by identifying contexts and situations that elicit child anger and frustration; (c) teach prosocial and empathic behaviour through social stories, parent modelling, and role play; (d) increase emotional labelling and prosocial behaviour through positive reinforcement; (e) and increase child's frustration tolerance through modelling, role-playing, and reinforcing child's use of learned cognitive-behavioural strategies to decrease the incidence of aggressive behaviours. Datyner et al. [ 93], in a case study, provided initial support for the short-term effectiveness of a brief adjunctive module to a PT intervention, to address empathy and emotions recognition deficits, and CU traits in children with CP + CU.

Salekin et al. [ 96] tested a positive psychological intervention, named Mental Models, to reduce the behaviour problems in youth with higher CU traits. Using a combination of motivational techniques, cognitive behaviour training, and instruction on positive emotion, youth received 12 didactic sessions. The intervention was group-focused and included group sizes of four to 24 (mode = 6). The first group included all youth ( n = 24), and the group size was then reduced to six individuals per group. The intervention involved a motivational component, whereby youth were motivated to participate in treatment. This component included some discussions on brain development and the new neural connections that can result through the process of active learning. Each week, many of the exercises were geared toward increasing positive emotions and positive ways of interacting with other individuals. Some exercises included writing assignments, entailing youth communicating their thoughts on strengths, ways to problem-solve, identification of emotions, and so forth. Youth were provided ways of thinking about these goals (models) and were also asked to generate their own ideas for setting goals and making plans for the future, to verbalize goals internally, and to mentally visualize the steps to accomplish a given goal, or to a better decision-making (including improving their choices, behaviour and citizenship within the institution). According to Salekin et al. [ 96], the intervention was effective at reducing interpersonal CU traits in youth, as well as improving their amenability to treatment.

Although these new interventions specifically developed for children with CD and elevated CU traits are promising, other more traditional treatments addressed for behavioural problems are available [ 25]. The Coping Power Program is a multi-component treatment program, delivered in a group setting, and has been developed using a contextual social-cognitive model as a conceptual framework for identifying intervention objectives [ 97]. The contextual social-cognitive model focuses on the contextual parenting processes, and on children's sequential cognitive processing in the development and escalation of children's behavioural problems. The CopingPower-child component includes 36 group sessions delivered over 12 months. In addition, 16 parent sessions are delivered over the same period. Parents also participate in small group sessions of five families; usually one parent per family attends the sessions. The child and his/her parent receive the treatment on the same day.

A recent study [ 98] found that the Coping Power program can lead to a significant decrease in CU traits, and this reduction was maintained at the 1-year follow-up evaluation. Authors hypothesized that the specific intervention on parenting practices promoted the decrease in CU traits in children; and that Coping Power group therapy can improve emotion sharing with peers, children's understanding of other people's emotions, and consequently has a beneficial influence on their empathy as well [ 99].

Discussion

The aim of this paper was to provide a brief review of the main features of childhood psychopathy, and specifically on the CU traits, which represent its affective dimension (e.g. which encompasses multiple deficits in emotional processing). Paediatricians manage the health of children and adolescents since their birth, including behaviour and mental health issues, and, usually, they are the primary care specialists who provide the first contact for children and their families. Therefore, they could represent the first step in identifying the presence of CU traits, and the possible developmental pathways to antisocial behaviours, and in promoting early interventions. Additionally, considering the caveats in clinical assessment, paediatricians may help to identify the "persistently over at least 12 months and in more than one relationship or setting" DMS-5 criterion.

Implications are straightforward. A thorough knowledge of family interactions, easily available for paediatricians, is crucial for early identification as well for a therapeutic alliance with parents and children. Some of the existing instruments can be possibly implemented in paediatric settings [ 26], even if an easier and quicker questionnaire, more suitable for a population based screen, is still lacking. Further researches should fill this gap.

The identification of behavioural problems and CU traits during childhood may be helpful to promote early interventions. As pointed out in the paper, there are currently available some promising treatment programs, specifically addressed for children and adolescents with CD and high level of CU traits (e.g., Coping Power Program, CARES, ERT, Mental Models), whose main targets are the improvement of emotion recognition, the enhancement of prosocial and empathic behaviour, and the improvement of parenting skills. Well designed, randomized trials should be the next step for evidence based treatments directly targeting CU traits.

Conclusion

As a summary, we conclude that a strong genetic liability, in interaction with parenting and relevant environmental factors, can lead to elevated levels of CU traits; they can be detected in early childhood, may remain stable along the adolescence, but a possible decrease following intensive and specialized treatment is possible. We maintain that a strict collaboration among paediatricians, child psychiatrists, clinical psychologists and all other professionals devoted to child mental and physical health is needed to early detection and management of these severely impaired patients.

Abbreviations

APSD:

Antisocial process screening device

CARES:

Coaching and rewarding emotional skills

CD:

Conduct disorder

CP:

Conduct problems

CPTI:

Child problematic traits inventory

CU:

Callous unemotional

DSM-5:

Diagnostic and statistical manual of mental disorder- 5 edition

ERT:

Emotion recognition training

ICU:

Inventory of callous unemotional traits

LPE:

Limited pro-social emotion

PCS:

Childhood Psychopathy Scale

PT:

Parent training

UNSW system:

University of New South Wales system

YPI:

Youth psychopathic traits inventory

References

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Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

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Affiliations

1. Department of Medicine and Surgery, Clinic of Child and Adolescent Neuropsychiatry, University of Salerno, Baronissi, SA, Italy

Simone Pisano & Giangennaro Coppola

2. IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy

Pietro Muratori, Valentina Levantini, Annarita Milone & Gabriele Masi

3. Department of Mental and Physical Health and Preventive Medicine, Child and Adolescent Psychiatry Division, University of Studies of Campania "Luigi Vanvitelli", Naples, Italy

Chiara Gorga & Gennaro Catone

4. Department of Pediatrics, Hospital "F. Veneziale", Isernia, Italy

Raffaella Iuliano

Contributions

SP, PM, AM and GM conceived the manuscript, wrote the draft of the manuscript and critically reviewed it. CG, RI, GC, GC, and VL wrote parts of the manuscript, designed figures and tables, provided comments on the manuscript for important intellectual content, critically reviewed it. All authors read and approved the final manuscript.

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Correspondence to Raffaella Iuliano.

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Competing interests

GM was in the advisory boards for Eli Lilly, Shire and Angelini, has received research grants from Eli Lilly, Shire, and Lundbeck, and has been speaker for FB, Eli Lilly, Shire, Lundbeck, and Otsuka. All the other authors declare that they have no competing interests.

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Pisano, S., Muratori, P., Gorga, C. et al. Conduct disorders and psychopathy in children and adolescents: aetiology, clinical presentation and treatment strategies of callous-unemotional traits. Ital J Pediatr 43, 84 (2017). https://doi.org/10.1186/s13052-017-0404-6
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Keywords

Conduct disorder

Callous unemotional traits

Psychopathy

Children

Adolescents

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