Past Issues
Psychiatrists Need to Know More about Childhood-onset Mental
Disorders
Childhood-onset mental disorders have not
been paid enough attention in our society, i.e., by
the Taiwanese Society of Psychiatry, for a variety
of reasons. The increased need of clinical services
and research on child and adolescent mental disorders
has emerged as an issue during the past decade
in Western countries, as well as in Taiwan. I
would like to take two common childhood-onset
mental disorders, Attention-Deficit/Hyperactivity
Disorder (ADHD) and Autism Spectrum Disorders
(ASD) as examples to address why psychiatrists
need to know more about childhood-onset
mental disorders.
ADHD, characterized by inattention, hyperactivity, and impulsivity, affects 7.5% of the school-age children in Taiwan [1] and 3~10% of children and adolescents in Western countries [2], with a worldwide-pooled prevalence estimated at 5.29% [3]. Around 60% of children with ADHD continue to have clinically significant symptoms of ADHD when they grow up as adults [4]. ADHD is now recognized as a commonly occurring and impairing disorder not only among children and adolescents, but also adults. Numerous studies, including those in Taiwan, have strongly suggested that pharmacotherapy (methylphenidate [5] and atomoxetine [6]) are effective treatment strategies for ADHD.
Based on the number of symptoms and the functional impairment, autistic disorder, Asperger disorder, and atypical autism are all categorized as ASD. ASD is a pervasive, highly heritable, clinically heterogeneous neuro-developmental disorder with prominent impairments in social reciprocity and language/communication, and restricted repetitive behaviors or interests [7]. ASD is a common (1%), long-term catastrophic disease with tremendous impact on individuals, families, and society [8]. Although the overall adult outcome for autism remains poor [9], the introduction of early intervention, with particular attention to the treatment of language impairment, has improved the outcome.
Estimates are that there are more than 200,000 children with ADHD and 40,000 with ASD in Taiwan. However, there are only 134 boardcertified child psychiatrists, and less than 20 of them work with child psychiatric patients full time, causing a huge gap between child psychiatrists and the need for care. Moreover, as few as 10% of children with ADHD seek psychiatric treatment; the majority of them are not identified and a substantial proportion of them are treated by alternative methods. Although early intervention for ASD should be carried out by child psychiatrists, pediatric neurologists, rehabilitation physicians, or other disciplines and paramedical therapists, the majority of children with ASD receive early intervention by rehabilitation physicians (mentioned above as one that should carry this out), who may not provide the appropriate intervention strategies for these children. Accordingly, there is a critical need of child psychiatrists to provide excellent clinical service to child psychiatric patients, given that several disciplines, including pediatricians, rehabilitation doctors, and family doctors, have redirected their clinical interest to ADHD and ASD, despite the psychiatric approach being the most suitable one for treating these patients. I have faith that our training in psychiatry can provide a more optimal treatment for these patients than other disciplines.
Why do psychiatrists need to know more about childhood mental disorders, particularly ADHD and ASD? These children will grow up with enduring impairments in several social domains and they are more likely to develop other mental disorders, which, along with their persistent core symptoms of ADHD or ASD, may require further psychiatric care. Therefore, psychiatrists may see adult patients with ADHD or ASD, who may or may not have had childhood diagnoses of these two disorders. I strongly suggest that it is our responsibility to treat individuals with childhood-onset mental disorders from childhood to adulthood, because none of the doctors in other disciplines can do a better job than we can. In order to meet this commitment, psychiatrists need to know more about ADHD and ASD, and the rationales are described below:
First, the diagnosis of ADHD or ASD requires a childhood diagnosis of these two disorders, or information about the persistent core symptoms of these two disorders in childhood. Familiarity with the core symptoms of these two disorders and knowledge about their expression, assessment, and treatment modalities in childhood will greatly improve the accurate diagnoses of ADHD and ASD in adulthood, though the clinical manifestation may vary over time.
Second, treatment strategies for adults with ADHD and adults with ASD may differ from those for patients with psychosis or neurosis. For example, methylphenidate or atomoxetine should be prescribed for adults with ADHD, even though there is comorbidity with depression or other psychiatric conditions, because the psychiatric comorbidity may be secondary to the core symptoms of ADHD. In addition, cognitive behavioral therapy is effective in helping adults with ADHD to organize their schedules and carry out their responsibilities. With regard to treatment for ASD, no medication has been reported to be effective in treating the core symptoms of ASD, but some medication can be used to treat associated symptoms like hyperactivity, tics, compulsive behaviors, or aggression, yet with limited effect. However, behavioral therapy is the most effective treatment approach for managing the behavioral problems of individuals with ADHD.
Third, a proportion of grown-ups with ASD may need inpatient care at some point in life. Without knowing the behavioral characteristics of these patients, psychiatrists may feel frustrated with ineffective pharmacotherapy, which should be integrated with behavioral modification. Grownups with severe impairments may be institutionalized in a home for the disabled; however, individuals with ASD are clinically and functionally different from individuals with mental retardation, and homes for the disabled are usually not designed for individuals with ASD. Although a small proportion of adults with ASD may be hospitalized at mental hospitals, they may be treated in the same way as patients with schizophrenia, although they are different from patients with schizophrenia and their treatment strategies should be different.
The literature has clearly documented that childhood and adolescent psychopathology predicts adult psychopathology and functional impairment [1]. Assessment and treatment of mental disorders in childhood (ADHD and ASD are two examples thereof) can offset the adverse outcome in adulthood. More child psychiatrists are needed for the primary, secondary, and tertiary prevention of mental problems in Taiwanese children and adolescents, and to participate in child psychiatry research. I would like to encourage young psychiatrists or residents to receive fellow training in child psychiatry to fill in the major gap in clinical and research needs in child psychiatry. I would also like to draw attention to adult psychiatrists and to the need to support your colleagues, who work mainly with child and adolescent psychiatric patients, to continue the hard but meaningful work for our young generation's mental health; and to know about childhood mental disorders such as ADHD and ASD in order to make accurate diagnoses and provide optimal treatments for grownups with ADHD or ASD. I firmly believe that lifetime care of individuals with childhood-onset mental disorders is the responsibility of psychiatrists, and that we can do a much better job than doctors in other disciplines.
References
Susan Shur-Fen Gau, M.D., Ph.D.
Department of Psychiatry,
National Taiwan University Hospital & College of Medicine,
National Taiwan University
ADHD, characterized by inattention, hyperactivity, and impulsivity, affects 7.5% of the school-age children in Taiwan [1] and 3~10% of children and adolescents in Western countries [2], with a worldwide-pooled prevalence estimated at 5.29% [3]. Around 60% of children with ADHD continue to have clinically significant symptoms of ADHD when they grow up as adults [4]. ADHD is now recognized as a commonly occurring and impairing disorder not only among children and adolescents, but also adults. Numerous studies, including those in Taiwan, have strongly suggested that pharmacotherapy (methylphenidate [5] and atomoxetine [6]) are effective treatment strategies for ADHD.
Based on the number of symptoms and the functional impairment, autistic disorder, Asperger disorder, and atypical autism are all categorized as ASD. ASD is a pervasive, highly heritable, clinically heterogeneous neuro-developmental disorder with prominent impairments in social reciprocity and language/communication, and restricted repetitive behaviors or interests [7]. ASD is a common (1%), long-term catastrophic disease with tremendous impact on individuals, families, and society [8]. Although the overall adult outcome for autism remains poor [9], the introduction of early intervention, with particular attention to the treatment of language impairment, has improved the outcome.
Estimates are that there are more than 200,000 children with ADHD and 40,000 with ASD in Taiwan. However, there are only 134 boardcertified child psychiatrists, and less than 20 of them work with child psychiatric patients full time, causing a huge gap between child psychiatrists and the need for care. Moreover, as few as 10% of children with ADHD seek psychiatric treatment; the majority of them are not identified and a substantial proportion of them are treated by alternative methods. Although early intervention for ASD should be carried out by child psychiatrists, pediatric neurologists, rehabilitation physicians, or other disciplines and paramedical therapists, the majority of children with ASD receive early intervention by rehabilitation physicians (mentioned above as one that should carry this out), who may not provide the appropriate intervention strategies for these children. Accordingly, there is a critical need of child psychiatrists to provide excellent clinical service to child psychiatric patients, given that several disciplines, including pediatricians, rehabilitation doctors, and family doctors, have redirected their clinical interest to ADHD and ASD, despite the psychiatric approach being the most suitable one for treating these patients. I have faith that our training in psychiatry can provide a more optimal treatment for these patients than other disciplines.
Why do psychiatrists need to know more about childhood mental disorders, particularly ADHD and ASD? These children will grow up with enduring impairments in several social domains and they are more likely to develop other mental disorders, which, along with their persistent core symptoms of ADHD or ASD, may require further psychiatric care. Therefore, psychiatrists may see adult patients with ADHD or ASD, who may or may not have had childhood diagnoses of these two disorders. I strongly suggest that it is our responsibility to treat individuals with childhood-onset mental disorders from childhood to adulthood, because none of the doctors in other disciplines can do a better job than we can. In order to meet this commitment, psychiatrists need to know more about ADHD and ASD, and the rationales are described below:
First, the diagnosis of ADHD or ASD requires a childhood diagnosis of these two disorders, or information about the persistent core symptoms of these two disorders in childhood. Familiarity with the core symptoms of these two disorders and knowledge about their expression, assessment, and treatment modalities in childhood will greatly improve the accurate diagnoses of ADHD and ASD in adulthood, though the clinical manifestation may vary over time.
Second, treatment strategies for adults with ADHD and adults with ASD may differ from those for patients with psychosis or neurosis. For example, methylphenidate or atomoxetine should be prescribed for adults with ADHD, even though there is comorbidity with depression or other psychiatric conditions, because the psychiatric comorbidity may be secondary to the core symptoms of ADHD. In addition, cognitive behavioral therapy is effective in helping adults with ADHD to organize their schedules and carry out their responsibilities. With regard to treatment for ASD, no medication has been reported to be effective in treating the core symptoms of ASD, but some medication can be used to treat associated symptoms like hyperactivity, tics, compulsive behaviors, or aggression, yet with limited effect. However, behavioral therapy is the most effective treatment approach for managing the behavioral problems of individuals with ADHD.
Third, a proportion of grown-ups with ASD may need inpatient care at some point in life. Without knowing the behavioral characteristics of these patients, psychiatrists may feel frustrated with ineffective pharmacotherapy, which should be integrated with behavioral modification. Grownups with severe impairments may be institutionalized in a home for the disabled; however, individuals with ASD are clinically and functionally different from individuals with mental retardation, and homes for the disabled are usually not designed for individuals with ASD. Although a small proportion of adults with ASD may be hospitalized at mental hospitals, they may be treated in the same way as patients with schizophrenia, although they are different from patients with schizophrenia and their treatment strategies should be different.
The literature has clearly documented that childhood and adolescent psychopathology predicts adult psychopathology and functional impairment [1]. Assessment and treatment of mental disorders in childhood (ADHD and ASD are two examples thereof) can offset the adverse outcome in adulthood. More child psychiatrists are needed for the primary, secondary, and tertiary prevention of mental problems in Taiwanese children and adolescents, and to participate in child psychiatry research. I would like to encourage young psychiatrists or residents to receive fellow training in child psychiatry to fill in the major gap in clinical and research needs in child psychiatry. I would also like to draw attention to adult psychiatrists and to the need to support your colleagues, who work mainly with child and adolescent psychiatric patients, to continue the hard but meaningful work for our young generation's mental health; and to know about childhood mental disorders such as ADHD and ASD in order to make accurate diagnoses and provide optimal treatments for grownups with ADHD or ASD. I firmly believe that lifetime care of individuals with childhood-onset mental disorders is the responsibility of psychiatrists, and that we can do a much better job than doctors in other disciplines.
References
| 1. | Gau SS, Chong MY, Chen TH, Cheng AT: A 3-year panel study of mental disorders among adolescents in Taiwan. Am J Psychiatry 2005;162:1344-50. |
| 2. | Faraone SV, Sergeant J, Gillberg C, Biederman J: The worldwide prevalence of ADHD: Is it an American condition? World Psychiatry. 2003;2: 104-13. |
| 3. | Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA: The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 2007;164:942-8. |
| 4. | Biederman J,Mick E, Faraone SV: Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry 2000;157:816-8 |
| 5. | Gau SS, Shen HY, Soong WT, Gau CS: An openlabel, randomized, active-controlled equivalent trial of osmotic release oral system methylphenidate in children with attention-deficit/hyperactivity disorder in Taiwan. J Child Adolesc Psychopharmacol 2006;16:441-55. |
| 6. | Gau SS, Huang YS, Soong WT, et al.: A randomized, double-blind, placebo-controlled clinical trial on once-daily atomoxetine in Taiwanese children and adolescents with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol 2007;17:447-60 |
| 7. | Newschaffer CJ, Fallin D, Lee NL: Heritable and nonheritable risk factors for autism spectrum disorders. Epidemiol Reviews 2002;24:137-53. |
| 8. | Baird G, Simonoff E, Pickles A, et al.: Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet 2006; 368:210-5. |
| 9. | Howlin P, Goode S, Hutton J, RutterM: Adult outcome for children with autism. J Child Psychol Psychiatry 2004;45:212-29. |
Susan Shur-Fen Gau, M.D., Ph.D.
Department of Psychiatry,
National Taiwan University Hospital & College of Medicine,
National Taiwan University
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