Ingersoll, R. E., & Previts,
S. B. (in press). The prevalence children’s mental disorders. In E. Welfel
& R. E. Ingersoll The Mental Health Desk Reference: A Source Book for
Counselors. New York: Wiley.
The notion of prevalence is common in medical and psychological research although the methods used to estimate prevalence are less commonly explored in the professional literature. Prevalence is determined through statistical probability and, as the mathematician Morris Kline (1972) noted, statistics are first and foremost a confession of ignorance. The statistics with which mental health professionals estimate the prevalence of mental/emotional disorders are drawn from epidemiological research. Epidemiological research is the study of the incidence, distribution, and consequences of particular problems in one or more specified populations as well as factors that affect distribution of the problems in question (Barlow & Durand, 1999; U. S. Department of Health, Education, and Welfare, 1978).
The effort to gather accurate statistics was initiated by the Association of Medical Superintendents of American Institutions for the Insane (later renamed the American Psychiatric Association - APA). The responsibility for gathering statistics was shifted to the Biometrics branch of the National Institute of Mental Health (NIMH) in 1949 (American Psychiatric Association, 2000a). The APA relies heavily on the epidemiological research of others for the prevalence estimates found in the various Diagnostic and Statistical Manuals (DSM) (personal communication, L. McQueen, Sept 26th, 2000). Epidemiologic research may be carried out by one or two persons or in massive projects like the NIMH Epidemiologic Catchment Area Program (Eaton & Kessler, 1985).
Since statistics are first and foremost a confession of ignorance, prevalence data based upon statistics are always a work in progress to be understood as “best guesses” given available methodologies. Several problems challenge researchers to make accurate estimates regarding the prevalence of a particular disorder. First, there is a significant time lag between the refinement of an edition of the DSM, and the gathering and analysis of data. For example, studies are still being published estimating prevalence based on DSM-III-R criteria (Kessler, et. al., 1997) that was replaced in 1994 by DSM-IV (which was replaced in 2000 by DSM-IV-TR). When the DSM is updated, criteria or descriptors associated with a disorder may change. For example the DSM-IV added symptoms to the symptom list in DSM-III-R for Conduct Disorder (CD)(APA, 1994). The description of Conduct Disorder was again expanded in DSM-IV-TR to include more risk factors and to discuss the relationship between CD and Oppositional Defiant Disorder (ODD) (APA, 2000b).
A second problem associated with estimating prevalence has to do with the methods used. As any researcher knows, some research methods are better than others. There is a paucity of research comparing various methods or data gathering instruments (Boyle, et. al., 1997; Regier, 2000) and reported prevalence rates may vary study by study (Regier, et. al., 1998). Methods of epidemiological research on mental disorders have varied over time. There have been three generations of large-scale epidemiological research using two strategies. Each generation has used different psychiatric nosologies and data collection tools (Kohn, Dohrenwend, & Mirotznik, 1998). The first generation relied primarily on institutional records and key informants but no real standardized procedures for data collection. The second generation utilized structured interviews in the community by non-clinical interviewers that were subsequently rated by a psychiatrist. The third generation (starting around 1980) used clinician and trained non-clinician interviewers in the community to obtain information necessary to determine the presence of mental disorders as categorized in the DSM. This present generation utilizes explicit diagnostic criteria as well as structured clinical interview schedules (Dohrenwend, 1998; Eaton & Kessler, 1985; Kohn, Dohrenwend, & Mirotznik, 1998). Currently, all epidemiologic approaches are based on personal interviews and there is still controversy over the accuracy of the interview method particularly over whether it is appropriate to use lay-interviewers (Dohrenwend, 1998). Dohenwend (1998) noted “…classification systems in psychiatry have been and will continue to be tentative as long as disorders are grouped on the basis of signs and symptoms elicited in interviews” (pp.146-147).
Perhaps the largest problem with epidemiological data is summarized by Blazer and Kaplar (2000) who stated that a central conflict is whether or not symptoms reported by community residents in structured interviews are clinically significant or not. On one side of the debate Regier (2000) noted that the conflict could be resolved with better research methods that would allow a diagnosis to be made from the results of a structured clinical interview. On the other side, Spitzer (1998) and Frances (1998) have asserted that data from epidemiological studies cannot replace clinical judgment. Blazer and Kaplar contended that the conflict could not be resolved because the methodologies of both sides are plagued with measurement error.
Estimating prevalence in children and adolescents is a relatively new undertaking. Prevalence estimates for mental disorders in children are further complicated by the fact that many disorders thought to apply primarily or exclusively to adults (like Bipolar I Disorder) are now being applied to children (McClellan & Werry, 1997). In addition, developmental considerations and comorbidity make diagnosis of children and adolescents much more difficult (House, 1999; US Dept of H & HS, 1999) also see House and Swales this volume). The problems of shifting criteria and refinement of data gathering instruments exist to a greater degree when attempting to estimate the prevalence of mental/emotional disorders in children (Shaffer, et. al., 1996). To add to the variables making prevalence estimates difficult to attain, the self-reports of children younger than 8 or 9 years of age tend to be less reliable than older children or adults and often require corroboration from adults in the children’s lives. In addition, children are more influenced by factors in their immediate environment including parent pathology, abuse, neglect, and family discord (Kazdin, 2000).
Given these caveats, this chapter lists a
brief summary of some of the more common disorders seen in children and
adolescents, and the prevalence rates from the DSM and occasionally other
sources. The aim was to organize the disorders from most prevalent to least
prevalent although this too is merely an estimation given the caveats already
discussed regarding prevalence rates in general. In many cases we have not
found prevalence rates specific to children and adolescents and reproduced the
estimated lifetime prevalence rates.
Some disorders are discussed
in terms of point prevalence, some in terms of lifetime prevalence, and some in
terms of both. Point prevalence refers to the estimated proportion of people in
the population thought to suffer from the disorder at any given point in time.
Lifetime prevalence is an estimate at a given point in time of all individuals
who have ever suffered from the disorder. Incidence refers to the rate of new
cases in a specified period of time (usually annually) (LaBruzza, 1997).
Which of these types
of prevalence or incidence data are sited depends upon the availability of
data. Diagnoses
considered to be rare or with little or no epidemiological data (e. g.
Asperger’s syndrome) were omitted from this chapter. Unless otherwise noted,
the prevalence rates cited are paraphrased from the DSM-IV-TR (APA, 2000b).
Dysthymic
Disorder (DD):
In children, DD seems to occur equally in both sexes and often results in
impaired school performance and social interaction. Children and adolescents with DD are usually irritable and cranky
as well as depressed. They have low
self-esteem and poor skills and are pessimistic. The lifetime prevalence of DD (with or without superimposed Major
Depressive Disorder) is approximately 6%.
The point prevalence of DD is approximately 3%. Rapoport and Ismond
(1996) have noted that the diagnosis is probably underutilized with children.
Keller and Russell (1996) stated that there have been no Epidemiologic studies
of DD in children or adolescents.
Conduct
Disorder (CD):
prevalence (or at least the diagnosis) of CD seems to have increased in the
past ten years and may be higher in urban than in rural settings. Rates vary
widely from 6%-10% for males and 2% to 9% for females. CD is one of the most
frequently diagnosed conditions in all mental health facilities for children.
Adjustment Disorder
(AD): AD
may occur in any age group with males and females being equally affected.
Prevalence rates in samples of children and adolescents range from 2% to 8%.
Learning
Disorders
(LD): Estimates of the prevalence of LD range from 2% to 10%. It is thought
that around 5% of students in public schools in the US are identified as having
a LD.
Reading
Disorder (RD):
“The prevalence of RD is difficult to establish because many studies focus on
the prevalence of LD without careful separation into specific disorders of
Reading, Mathematics or Written Expression” (APA, 2000, p. 52). RD, by itself or combined with Mathematics
Disorder or Disorder of the Written Expression, accounts for approximately four
of every five cases of LD. The
prevalence of RD in the US is estimated to be 4% of school children.
Expressive
Language Disorder: Estimates suggest that the developmental type of Expressive Disorder
may affect 3%-5% of school-aged children.
There are two subtypes (acquired and developmental) and the acquired
type is less common.
Mixed
Receptive-Expressive Language Disorder (MRELD):
It is estimated that the developmental type of MRELD may occur in up to 3% of
school-age children but is probably less common than ELD.
Oppositional
Defiant Disorder (ODD): Rates of ODD range from 2% to 16% but vary depending on the nature of
the population sample and methodology. The fact that many of the symptoms may
be normal developmental behaviors makes diagnosis and prevalence estimates of
this disorder difficult (Rapoport & Ismond, 1996).
Developmental
Coordination Disorder (DCD): prevalence of DCD has been thought to be as high as
6% for children in the age range of 5-11 years.
Phonological
Disorder (PD):
For children 6 and 7 years old prevalence for moderate to severe PD is
estimated at approximately 2%-3% although the prevalence of milder forms of the
disorder is higher. By age 17, the
prevalence falls to 0.5%.
Mathematical
Disorder-
The prevalence of MD is harder to establish than many other disorders because
many studies focus on the prevalence of LD without separation into the specific
disorders of Reading, Mathematics or Written Expression. The prevalence of MD (i.e. when not found in
association with other LD) is estimated at approximately one in every five
cases of LD. It is thought that 1% of
school-age children have MD.
Sleep Terror
Disorder: The
prevalence of sleep terror episodes (as opposed to Sleep Terror Disorder in
which there is recurrence and distress or impairment) is estimated at 1%-6%
among children. There are limited data on the prevalence of the disorder in the
general population.
Sleepwalking
Disorder (SD):
It is estimated that between 10% to 30% of children have had at least one
sleepwalking episode, but the prevalence of SD (marked by repeated episodes and
impairment or distress) is far lower, in the range of 1%-5%.
Bipolar I
Disorder: It
should be noted there is still much controversy over the prevalence of Bipolar I
Disorder among children and adolescents. The DSM-IV-TR estimates that around
10%-15% of adolescents with recurrent Major Depressive Episodes will develop
Bipolar I Disorder. House (1999) noted
that manic episodes (required for the diagnosis of Bipolar I) are rare in
children. McClellan and Werry (1997) noted that “Historically considered rare,
childhood-onset bipolar disorder is now being reported more often, although its
frequency remains an area of some controversy” (p. 157). They add that
currently 20% of adult patients with Bipolar I disorder had their first manic
episode in adolescence. These authors note that currently there is still a
great deal of speculation regarding the actual prevalence of Bipolar I in
children and adolescents.
Generalized
Anxiety Disorder (GAD): In community samples, the 1-year prevalence rate for GAD was
approximately 3% and the lifetime prevalence rate was 5%. In anxiety disorder clinics, it is estimated
that approximately 12% of the individuals present with GAD. There is limited
data on GAD in children because the DSM-IV version of the disorder subsumed the
DSM-III-R disorder Overanxious Disorder of Childhood (ODC) (Bernstein &
Shaw, 1997). The prevalence of ODC has been estimated from 2.9% (Anderson, et.
al. 1987) to 4.6% (Costello, 1989). In a national comorbidity survey, Wittchen,
Zhao, Kessler, & Eaton (1994) estimated a prevalence of 1.3% for males and
1.5% for females in a 15-24 year old age group.
Social Phobia
(SP):
Epidemiological research has reported a lifetime prevalence of SP ranging from
3% to 13%. In children, the diagnosis
should not be made prior to 2.5 years as it would be impossible to
differentiate the symptoms from developmentally normal stranger anxiety. Anderson and colleagues (1987) estimated the
prevalence of SP in New Zealand children to be .9% while Kashani and Orvaschel
(1990) estimated a prevalence of 1% in United States cohort aged 8, 12, and 17.
The median age of onset has been estimated at 12-years of age (Bourdon et. al.,
1988).
Posttraumatic
Stress Disorder (PTSD): The lifetime prevalence for PTSD ranges from 1% to 14% and the
variability is related to the methodology used and the population sampled. Studies of at-risk individuals (e.g. combat
veterans, victims, of volcanic eruption or criminal violence) yield even
broader prevalence rates ranging from 3% to 58%. It should be noted that PTSD
is often related to child abuse which is thought to be under-reported due to
issues of guilt and shame (Bremner, 1999). Bremner (1999) notes that 16% of all
women are estimated to suffer from some form of attempted or completed sexual
abuse prior to their 18th birthday and that a considerable
proportion of them will develop PTSD prior to adulthood.
Obsessive-Compulsive
Disorder (OCD) OCD was previously thought to be rare in the general population but
studies have estimated a lifetime prevalence of 2.5% and 10year prevalence of
1.5%-2.1%. One prevalence study done with adolescents estimated 1% prevalence
among adolescents (Flament, et. al., 1988). General estimates of lifetime
prevalence in community studies of children and adolescents estimate lifetime
prevalence between 1% and 2.3%. The same studies estimate a 1-year prevalence
of .7% for teens and children. The average age of onset ranges from early adolescence
to the mid-twenties.
Cyclothymic
Disorder: The reported a lifetime prevalence of
Cyclothymic Disorder is from 0.4% to 1%.
Prevalence among clinical populations may range from 3% to 5%.
Schizophrenia: Although Schizophrenia occurs in children it is
relatively rare but its occurrence increases in adolescents. Often prodromal
signs are noted in retrospect. Because the disorder tends to be chronic,
incidence rates are much lower than prevalence rates and are estimated to be
approximately 1 per 10,000 per year.
Gender
Identity Disorder (GID): There are no recent
epidemiological studies to provide data on prevalence of this disorder. European data with access to total
population statistics and referrals suggest that roughly 1 per 30,000 adult
males and 1 per 100,000 adult females seek sex-reassignment surgery giving some
vague notion of prevalence estimates.
Feeding
Disorder of Infancy or Early Childhood- Of all pediatric hospital admission, 1%-5% are for
failure to thrive, and as many as half of these may reflect feeding
disturbances without an apparent predisposing general medical condition.
Nightmare
Disorder (ND): It is estimated that between 10% and 15% of children ages 3-5 have
nightmares of sufficient intensity to disturb their parents but the prevalence
of ND is not known (Rapoport & Ismond, 1996).
Enuresis: The prevalence of Enuresis
decreases as children age. At age 5 years the prevalence is 7% for males and 3%
for females; at 10 years the prevalence is 3% for males and 2% for
females. At 18 years, the prevalence is
1% for males and less among females.
Encopresis: Approximately 1% of 5 year olds have Encorpresis, and the disorder
is apparently more common in males than in females.
Anorexia
Nervosa (AN): Epidemiological studies among females in late
adolescence and early adulthood have found rates of 0.5%-1.0% that meet full
criteria for AN. Individuals whose
symptoms fall below the threshold for the disorder (e.g. with Eating Disorder
NOS) are commonly encountered. There are limited data concerning the prevalence
of this disorder in males. The overall
incidence of AN appears to have increased in recent decades.
Bulimia
Nervosa (BN):
Among adolescent and young adult females, the prevalence of BN is approximately
1%-3%. It is estimated that the rate of occurrence of this disorder in males is
approximately 1/10 of that in females.
Panic Disorder
(PD):
Numerous cross-cultural epidemiological studies indicate the lifetime
prevalence of PD to be between 1% and 2%.
One-year prevalence rates are between .5% and 1.5%.
Selective
Mutism (SM): SM is thought to be rare and seen in
fewer than 1% of individuals assessed in the mental health settings.
Stereotypic
Movement Disorder (SMD): The information on SMD is limited. The disorder may result in self-injurious
behaviors. Estimates of prevalence of such behaviors in individuals with Mental
Retardation vary from 2% and 3% in children and adolescents living in the
community.
Major
Depressive Disorder (MDD): Adolescent and adult females are twice as likely to suffer from MDD
(single or recurrent) than adolescent and adult males. In prepubertal children,
boys are more likely than girls to be affected (Cyranowski, Frank, Young, &
Shear, 2000). Studies of MDD report a
wide range of values for the prevalence in adult populations.
Specific
Phobia (SP): It
is difficult to estimate the prevalence of SP in adults and children because,
although relatively common, they must cause marked distress or impairment to
warrant the diagnosis. Lifetime prevalence rates range between 7.2% to 11.3%.
There are no prevalence rates specific to children and adolescents.
Autistic Disorder: In epidemiological studies
of Autistic Disorder, it is estimated that between 2 to 20 of every 10,000
children will be afflicted. The median is 5 children per 10,000.
Substance Use
Disorders (SUDs): The use of psychoactive substances is common among adolescents with 90%
reporting having used alcohol and over 40% reporting having used an illicit
substance (Newcomb & Bentler, 1988). A University of Michigan survey (1995)
indicated that substance use has increased substantially since 1991. There are
no large-scale epidemiological surveys to indicate the level of SUDs in
adolescents but in community surveys, the lifetime prevalence of alcohol abuse or
dependence has ranged from 5.3% in 15-year-olds to 32.4% in 17 to 19-year-olds
(Bukstein, 1997). The current emotional climate around substance abuse and the
legal complications may make it difficult to obtain accurate estimates of
prevalence. Where there are estimates for specific substance use in children or
adolescents in the DSM-IV-TR, those are summarized below. It should be noted
that although each sub-category below bears the generic label for disorders
related to a substance, for most sub-categories, all we have are estimates of
use which give us no clue as to how many users would meet the criteria for
abuse or dependence. For further caveats to the prevalence of substance use and
dependence in general, see Ingersoll and Burns (this volume).
Alcohol-Related Disorders: The first episode of alcohol
intoxication is likely to occur in adolescence.
Amphetamine-Related Disorders: A 1997 survey of high school
seniors estimated that 16% had ever used amphetamines with 10% having used in
the prior year. It is assumed that the purpose of the use in these instances
was to get “high” as opposed to a prescribed use like that for Attention
Deficit Hyperactivity Disorder (ADHD). It should be noted that while a
diagnosis of ADHD increases the risk of substance abuse, treatment with
stimulant medication is in no way correlated with higher risk for stimulant
abuse (Greenhill, 1998).
Cannabis-Related Disorders: A 1995 survey estimated that
42% of high school seniors had ever used a cannabinoid with 35% using in the prior
year.
Cocaine-Related Disorders: The 18-25 year old age
group has the highest estimate use in the past year (5% for cocaine and 1% for
“crack”).
Hallucinogen-Related Disorders: The group with the highest
estimate of having ever used one of these drugs (in 1996) was the 18-25 year
old group. In this group, 16% reported having ever used a hallucinogen with 7%
reporting having used in the past year.
Inhalent-Related Disorders: The use of inhalants is
difficult to estimate but data from 1996 estimate that the highest use was in
the 18-25 year old cohort (11%0 with 12-17 year olds reporting the most use in
the past year (4%).
Nicotine-Related Disorders: Nicotine intake is thought
to typically begin in early adolescence with 95% of those who continue to smoke
at age 20 becoming regular smokers. In 1996, use in the past year was highest
in the 18-25 year old cohort (45%).
Opioid-Related Disorders: A 1997 survey of use among
high school students estimated that about 2% of high school seniors had ever
taken heroin and 10% reported inappropriate use of other analgesics.
Phencyclidine-Related Disorders: According to 1996 data, 3%
of Americans 12 years old and older
report ever using phencyclidine. The highest proportion using phencyclidine in
the past year was 12-17 year olds (.7%).
Sedative, Hypnotic, or Anxiolytic-Related Disorders:
More than
15% of Americans use these medications in any given year. Most take as directed
without any misuse. 1996 data estimate that 6% of Americans have ever taken
these drugs illicitly. The age group with the highest estimated illicit use was
26-34 year olds (3% using “sedatives” and 6% using “tranquilizers”). Those ages
18-25 were most likely to have used illicitly in the past year.
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