Chapter 14                                   53


Child and Adolescent

Psychiatry

Pediatric mental health treatment
Eval...
54

            Bipolar disorder in children and adolescents
            Schizophrenia in children and adolescents
       ...
CHAPTER 14   Child and adolescent 55
                                   psychiatry

Pediatric mental health
treatment
Trea...
56

     also impacts ability to engage in treatment.
     Traditionally, professionals    who   work   with
     pediatri...
CHAPTER 14   Child and adolescent 57
                                    psychiatry
This includes the relationship with th...
58

     different roles.     Pediatric patients exist in a
     biological, genetic, and psychosocial context.
     Striv...
CHAPTER 14   Child and adolescent 59
                                   psychiatry
strengths can help the child and family...
60

     family member (e.g., Grandmothers, Aunts) or
     child care provider (e.g., nanny).
     Child/Adolescent Interv...
CHAPTER 14   Child and adolescent 61
                                    psychiatry
formulation affects the family-centere...
62




     Evaluation in practice
     Parent/Guardian Interview
     -It is essential to establish rapport with child an...
CHAPTER 14   Child and adolescent 63
                                   psychiatry
-Obtain consent and consult other careg...
64

      peer and teacher interactions and responses,
      friendships, bullying, fears about school, etc.
     -Child’s...
CHAPTER 14   Child and adolescent 65
                                    psychiatry



Formulating a differential
diagnosi...
66

      disorders, autism-spectrum disorders,
      substance abuse, sexual abuse, posttraumatic
      stress disorder.
...
CHAPTER 14   Child and adolescent 67
                                    psychiatry
breaking point. Thus, encouraging the ...
68

     The hallmark symptoms of ADHD are a persistent
     pattern of inattention and/or hyperactive/impulsive behaviors...
CHAPTER 14   Child and adolescent 69
                                     psychiatry
categories.




Epidemiology The prev...
70

     anxiety disorders, antisocial personality disorders,
     and substance abuse. Substance abuse is higher
     in ...
CHAPTER 14    Child and adolescent 71
                                     psychiatry
-Interview with parents to evaluate
...
72

                    ODD, and        parents/
                    aggression      caregivers
     Vanderbilt     ADHD, ...
CHAPTER 14   Child and adolescent 73
                                    psychiatry
 disorders sometimes required, and may...
74

      The Multimodal Treatment Study of Childrenwith
          Attention Deficit Hyperactivity Disorder2
     (MTA) Th...
CHAPTER 14     Child and adolescent 75
                                          psychiatry
symptoms of ADHD, though this ...
76




     Oppositional defiant disorder
     (ODD)1
     Key Features An enduring pattern of negative,
     hostile, and...
CHAPTER 14   Child and adolescent 77
                                    psychiatry
    - Obtain key information from chil...
78

     -Medication Choice:
     -Medications should be adjunctive to
      psychotherapeutic treatment. Treatment of
   ...
CHAPTER 14           Child and adolescent 79
                                                     psychiatry
        typic...
80



         Conduct disorder (CD)1,2
     Key    Features Conduct disorder has been
     popularized in the literature ...
CHAPTER 14     Child and adolescent 81
                                        psychiatry
and deprivation; lack of a warm ...
82


     Assessment
         - Clarify the purpose of the assessment
         (clinical, community, forensic).
     Obtai...
CHAPTER 14    Child and adolescent 83
                                       psychiatry
disorder, poor parenting.         ...
84

            has used a weapon that can cause serious
            physical harm to others (e.g., a bat, brick,
        ...
CHAPTER 14   Child and adolescent 85
                                    psychiatry


Pervasive developmental
disorders --...
86

       - Intervention history
       - Psychiatric examination of the child in
         observational settings to eval...
CHAPTER 14   Child and adolescent 87
                                   psychiatry
        support groups are available an...
88

     Autism
     History /Definition/ Clinical Features John Haslam
     in 1809 and Henry Maudsley in 1867 were the f...
CHAPTER 14   Child and adolescent 89
                                    psychiatry
and interests; lack of developmentally...
90

     many of the cognitive and emotional deficits.
     Syndromic autism is seen at high rates in various
     genetic...
CHAPTER 14   Child and adolescent 91
                                    psychiatry

Other developmental disorders
Asperge...
92

     described presenting some features of the classic
     form, but displaying differences. Mutations in the
     X-...
CHAPTER 14   Child and adolescent 93
                                  psychiatry
personality disorder, or avoidant person...
94

             occupational therapy.
         25. Pharmacotherapy: symptom management
             (e.g. atypical antips...
CHAPTER 14   Child and adolescent 95
                                    psychiatry
    33. Anxiety symptoms, repetitive b...
96




     Language and learning
     disorders (LLDs)1
     LLDs comprise a very common set of problems,
     with estim...
CHAPTER 14   Child and adolescent 97
                                    psychiatry
been found to be between 35% and 45%,
...
98

     language disorder ranges from 1% to 13% of the
     population.
     Phonological Disorder is defined as a failur...
CHAPTER 14    Child and adolescent 99
                                       psychiatry
Elimination Disorders: Enuresis
DS...
100

      Management Behavioral modification is the first-line
      treatment and includes restricting fluids at night,
...
CHAPTER 14   Child and adolescent 101
                                   psychiatry




Encopresis
DSM-IV-TR Diagnostic cr...
102

      Etiology May be caused or related to fecal
      withholding due to pain, power struggle,
      inattention to ...
CHAPTER 14   Child and adolescent 103
                                     psychiatry
considered, although environment is ...
104

      soon as possible in order to prevent negative
      impact on development.
      Clinical pearl efeeding alone ...
CHAPTER 14   Child and adolescent 105
                                   psychiatry
investigations;   behavioral   methods...
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
Chapter14, (now Chapter 16) Child and Adolescent Psychiatry
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Chapter14, (now Chapter 16) Child and Adolescent Psychiatry

  1. 1. Chapter 14 53 Child and Adolescent Psychiatry Pediatric mental health treatment Evaluation and FormulationPrinciples Identify the “team” in the child’s life Components of the Evaluation Formulating the case and plan Evaluation in Practice Formulating a Differential Diagnosis Attention deficit hyperactivity disorder (ADHD) Etiology Assessment Treatment Principles Oppositional Defiant Disorder (ODD) Conduct Disorder Criteria Features and Treatment Pervasive Developmental disorders Intro and assessment Autism Other Developmental disorders Treatment of PDD Language and learning disorders Elimination Disorders: Enuresis Encopresis Disorders of Eating, Sleeping, and Thriving Attachement Disorders Anxiety Disorders General overview Specific Diagnoses Obsessive–Compulsive Disorder (OCD) PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection) Tic Disorders Post-traumatic stress disorder Depression in children and adolescents Management of depression in youth Suicide and suicidal risk in young people
  2. 2. 54 Bipolar disorder in children and adolescents Schizophrenia in children and adolescents Schizophrenia in children and adolescents Substance abuse in children and adolescents1 Child abuse-issues and management Child abuse-alerting signs Munchausen Syndrome by Proxy Prescribing in Children and Adolescents Stimulants Non-stimulant Medications for ADHD Lithium Anticonvulsants Atypical Antipsychotics Antidepressants 1 Bukstein OG, Bernet W, Arnold V, Beitchman J, Shaw J, Benson RS, Kinlan J, McClellan J, Stock S, Ptakowski KK; Work Group on Quality Issues. (2005), Practice parameters for the assessment and treatment of children and adolescents with substance use disorders. J Am Acad Child Adolesc Psychiatry 44(6): 609-621.
  3. 3. CHAPTER 14 Child and adolescent 55 psychiatry Pediatric mental health treatment Treatment of pediatric patients has the potential for large impact Children and adolescents are constantly learning from the environment, integrating what they see and experience in the context of rapid cognitive, social, emotional, and neurobiological development. Mental health problems can limit the inherent potential in this process. Clinicians who assess and treat pediatric mental health concerns can help influence the developmental trajectory of pediatric patients and their families in order to maximize social, emotional, academic, and vocational development. The potential impact can be rewarding, but there are important challenges posed by working with rapidly developing children and their families. Children and Adolescents are dependent on their caretakers Mental health is clearly influenced by environment. This is quite clear when working with children, adolescents and their families. Pediatric patients are dependent on their care providers for food, clothing, and developmental support. Each child brings his or her personal temperament to this environment and the development of the child is dependent on the match of temperament, as well as how caregivers and children navigate any mismatch. Level of development impacts behavior Behaviors that are considered normative in one developmental stage may be a source of concern in another. For example, stranger anxiety is expected to occur at around nine months, but if a nine year old had significant stranger anxiety it would significantly impair the ability to engage with their environment at home and school. Special considerations are needed for building treatment alliance A strong treatment alliance with both the young patient and their family is essential for the provision of effective mental health care. Since pediatric patients are most often brought into treatment by their adult caregivers, development of this an alliance with the identified patient can be complex. Cognitive development
  4. 4. 56 also impacts ability to engage in treatment. Traditionally, professionals who work with pediatric patients have utilized play and/or informal methods in order to engage children and adolescents as a participant in treatment. Widespread use of evidence-based treatments is not the norm The widespread use of evidence-based treatments requires well-defined phenomenology and a solid evidence-base for treatments that work in controlled conditions and the community. Very few conditions in child and adolescent psychiatry have an evidence base that fulfills all of these conditions. While there are a number of therapeutic interventions that have proven quite useful in very controlled environments, few some have failed to reach the general population of care providers and patients in a consistent, effective manner. In addition, pharmacologic treatments tend to be used in a manner that outpaces the evidence-base. Ultimately the choice of treatment should be a combination of evidence-based recommendations, and the specific needs of the pediatric patient and family. Evaluation principles The goals of evaluatonevaluation -Identify precipitants of referral. Attempt to discern both the chief complaint and the reason why it rose to the level of referral at this time. -Identify the goals of the child and family. -Obtain an accurate picture of the nature and extent of the child’s behavioral difficulties, functional impairment and/or subjective distress. -Understand the child’s developmental strengths and limitations in all domains— cognitive, language, motor, behavioral, ability to form relationship, etc. -Identify the potential individual, family, or environmental factors that may account for, influence, or ameliorate these difficulties. -Acquire the information necessary to create a responsive biopsychosocial treatment plan that is patient-centered, family-focused, family driven, and culturally competent. Clarify the role of the treatment teamers Before beginning any evaluation it is important to clarify the nature of the treatment relationship.
  5. 5. CHAPTER 14 Child and adolescent 57 psychiatry This includes the relationship with the family and patient as well as any referring provider. Whatever the formal relationship (consultant or collaborator) it is important to clarify the treatment relationship. Some specific issues include: 1. Who will make recommendations? 2. Who will implement recommendations? and 3. Hhow will the family will return for follow-up if problems ensue? There are also specific rules of confidentiality that must be considered and made clear to patients and their families for forensic evaluations, custody evaluation and school referrals, just to name a few examples. Confidentiality and Release of Information Confidentiality has always been of utmost concern in the mental health field, but it has come under close scrutiny recently in the United States as new laws to protect privacy have been established. It is important tobe obtain releases to speak to all members of the treatment team. Many mental health institutions require formal written releases. Specific considerations must be taken for children and adolescents in the care of someone other than their adoptive or biological parents. Laws also vary from state-to-state regarding the treatment of minors without parental consent and commitment to psychiatric hospital. In all settings, it is important to inform your patient that confidentiality will be superseded in the face of danger of harm to self or others. Team approach Identify the “team” in the child’s life A care provider who attempts to understand all members of a patient’s team will be best prepared to clarify treatment goals and respond when goals are not being met. Each member of the team brings their own strengths and limitations, as well as viewpoints. Each member has the potential to take on
  6. 6. 58 different roles. Pediatric patients exist in a biological, genetic, and psychosocial context. Striving to include all members of the child’s care team will improve the ability to understand that context and be more responsive. Possible members of the treatment team can include: parents, grandparents, coaches, clergy, teachers, school administrators, kin, and other social supports. This list is not merely limited to traditional medical providers! Identifying all potential members of a child’s natural treatment team will help expand the treatment options, and identify the key participants in the formal treatment planning process. The formation of a formal child and family team is often not mandated until a family system has reached a breaking point. Thus, encouraging the family to be inclusive and seek social support, as well as to be a source of information to clinicians, can be very helpful throughout the treatment process. Utilize the Entire Treatment Team As an evaluation occurs, and treatment planning begins it is important to keep in mind that there are many ways that members of the formal treatment team, as well as the “informal team” can be utilized. It can often be helpful to try to identify who is and who isn’t worried about the child and why. Each member of a child (and the family’s) life will bring their own viewpoints, strengths and limitations. Some states mandate formal “child and family teams” when treatment goals have consistently not been met and the child’s situation is threatening their placement in the community. At this point goals can often seem reactive and the number of formal health care professionals involved can sky rocket. These situations can often be avoided with successful use of a natural “team” early in the evaluation and treatment planning process. When first evaluating psychosocial and mental health complaints it can be much easier to focus on strengths of the child and their family system. Also, getting information from members of the system when they are not in crisis usually provides a better understanding of the perceived strengths in the child, which can be utilized to the advantage of the child later. Finally, the identifying members of the “natural team” and developing a healthy support system that capitalizes on their
  7. 7. CHAPTER 14 Child and adolescent 59 psychiatry strengths can help the child and family meet their initial goals and move towards recovery. Components of the evaluation Evaluation includes assessment and treatment planning for a child and family. It can be complex and requires multiple components that a traditional adult process evaluation does not include. In some venues, components of this process may be performed and/or augmented by different members of the treatment team. This section will include brief information on the key components of assessment and treatment that are provided by a mental health provider. Parent/Guardian interview Inclusion of each parent or legal guardian in the process of assessment and treatment planning is ideal necessary for several reasons. 1. Each guardian may have different viewpoints, which will help to create a thorough assessment. 2. The presence of entire family unit present together at least once will help evaluate the dynamics of the family system. 3. Family history can usually be more accurately obtained by interviewing each parent, since not everyone shares their entire personal and/or family mental health history with their partner. 4. Consent is needed from all legal guardians before routine treatment initiation (e.g., both parents may have the right consent prior to initiating a treatment, even if one parent says they have full custody. Ask to see the associated legal paperwork and read it carefully). Parents are often the only source of accurate information about history of pregnancy, developmental history, temperament, and shifts in behavior. Parents can also give excellent information about overt behaviors such as hyperactivity and oppositionality. Keep in mind that for some children, the person with most knowledge about the child may be an extended
  8. 8. 60 family member (e.g., Grandmothers, Aunts) or child care provider (e.g., nanny). Child/Adolescent Interview The child and adolescent interview is an essential part of the evaluation. Pediatric patients are often the best source of information about internal mood states- e.gi.e., feeling down or worried. Traditionally ‘play’ has been used as a way to access the internal mood states of pediatric patients who have difficulty verbalizing their internal mood states because of their developmental stage or resistance. Children and adolescents will frequently either understate or inflate their oppositional and/or behavioral problems. The child and adolescent interview is also a way to assess the ability of a pediatric patient to talk to a stranger, and separate from their parents. Other sources of information As mentioned in the previous section, information can be gleaned from many members of the child and adolescent’s life. Checklists and formal instruments can be used for the pediatric patient, parents, teachers and guardians (for examples, see page ### chapter 2). Informal and formal discussions with other members of the treatment team can be very helpful. Teachers are often an invaluable source of information about a child’s behavior in both a structured and unstructured environments, and often can serve as a gauge to help compare the child’s behavior to other classmates his or her age. Formulating the case and plan Case Formulation Formulation of the case (bio- psycho-social assessment and plan, see page ??? –note: in chapter 2) should be an ongoing component of the treatment planning process. The clinician should share the formulation with the family and consider how the
  9. 9. CHAPTER 14 Child and adolescent 61 psychiatry formulation affects the family-centered treatment goals. Diagnostic considerations Since mental illness in pediatric patients is often in a state of evolution, it is important to help the family understand what mental health conditions are being considered. Families may choose to begin educating themselves about all of the possibilities at this point, or may simply want information about “what to look for.” Work with the families and individuals needs and requests, and be certain to address comprehensive risks, benefits, and alternatives of all treatment options. Prioritizing Comorbidity is the rule in child and adolescent psychiatry. In addition cChildren and their families often have multiple needs when they come for evaluation. One method of formulating a hierarchy is to consider issues that threaten the safety of the child or others first, then those that threaten the continuity of the therapy and treatment. Then focus therapeutics on interventions that will be most likely to improve functionally outcome and return the child to a normal developmental trajectory. It is important to recognize these needs, and make recommendations that address the long-term and short-term priorities of the child and family. It may also be important to understand the needs of the community in these decisions. For example, if a young child with bipolar disorder and violent behavior at school seems to be having increased difficulties because of family discord, it is not appropriate to simply refer the family for family counseling without addressing the immediate safety of the child and community, as well as the possibility that a manic episode may have been triggered.
  10. 10. 62 Evaluation in practice Parent/Guardian Interview -It is essential to establish rapport with child and family members. -Define needs and expectations of the child and family. -Obtain family psychiatric, medical, and social history. A genogram can be helpful (see chapter 2 page ???) -Inquire about sexual behavior/ HIV risk/ pregnancy, development, sibling relationships, friendships, temperament, shifts in behavior, suspected substance use, etc. -Observe family functioning and interactions. Note patterns of communication, degree of warmth, power dynamics, alliance. Child/Adolescent Interview -First establish rapport and gain child’s confidence. Play can be helpful. -Begin with subjects well away from the presenting problem/s (e.g., interests and hobbies, friends and siblings, school, holidays). -Progress to enquiring about child’s view of the problem, worries, fears, sleep and appetite, mood, self-image, peer and family relationships, experiences of bullying or teasing, abuse, persistent thoughts, fantasy life, abnormal experiences, suicidality, etc. (It may take several interviews to obtain a full picture.) -Observe: levels of activity and attention; physical and mental level of development; mood and emotional state; quality of social interaction. Other sources of information -Obtain consent to contact school for meeting or report from teachers, school psychologists, etc. Consider asking teacher to complete a behavior rating scale (e.g., Child Behavior Checklist; Connors’ Teacher Rating Scale).
  11. 11. CHAPTER 14 Child and adolescent 63 psychiatry -Obtain consent and consult other caregivers, and medical professionals who have treated the child, and social agencies that have been involved with the child and/or family. -Psychological tests: may include IQ, personality and developmental assessments. -Investigations: hematology; chromosome studies; EEG; CT; etc. Assessment principles -Identify the problem behavior/s—obtain a full description (from parents, child, teachers, providers etc.) of the problem behavior/s. This should include the evolution of the behavior, a chronology of the child’s typical daily activities, the setting in which the problem behavior occurs, the effects of it on family, school, relationships, etc, and attitudes of others to the behavior/s. It is always appropriate to speak to the child alone (if possible) to establish his/her views, desires, and mental state. -Determine the parental strategy—it is important to find out how the parents deal with the behavior/ s. This includes information about their expectations, philosophy of parenting, interpretation of the behavior/s, moral, religious, and cultural views on parenting, etc. Also, how do the parents react or respond to the behavior/ s? How do they discipline or punish? What do they tolerate? Are they permissive or restrictive? Are they overprotective or uninvolved? Do they feel empowered or impotent, helpless, and incompetent as parents? How do they manage their frustrations, anger, etc? What coping mechanisms do they have? -Family history and dynamics—as well as gathering a full family history of health, psychiatric problems, social and cultural circumstances, and support structures, it is also important to assess parental and sibling relationships, the presence of any significant stressors or losses, and how the problem behavior interacts with family dynamics. -Social behavior—the evolution of the child’s social behavior, including social developmental, attachment behavior, imaginary play, reading of social cues, relationships, and language use. -School behavior—attendance, changes in school, separation issues, socialization, performance,
  12. 12. 64 peer and teacher interactions and responses, friendships, bullying, fears about school, etc. -Child’s health and development—pregnancy, birth, and developmental milestones. Was the child planned, wanted? How did siblings react? How did parents and siblings cope? Any peri- or post-partum problems? Were there supports? Also, child’s temperament, illnesses (including head trauma, seizures), treatment (duration, doses, effectiveness), etc. -Direct observation of parent-child interaction—during the interview./s i It is important to note how the child behaves and how parents respond and interact with the child. If siblings can be present, their behavior and interactions with the child can also be evaluated. A home and/or school visit may add additional information about the behavior in these settings. -Collateral information—teachers, extended family, and social services, and other providers may be able to provide important input and permission should be sought to contact and involve them where appropriate. Formulation of the case (Bio-psycho-social) -Consider predisposing, precipitating, perpetuating, and protective factors. -Formulate a multaxial diagnosis. See chapter 2, page ### for details. Create a feasible plan -Determine goals for child and family. Goals should be specific and target specific behaviors, performance, and domains. For example: “Johnny should do better with his homework” may translate into “Johnny will turn in completed homework 90% of the time. “ -Determine the methods to meet the goals. Medication can be one method, although often inadequate alone. Behavioral modification, school intervention, family therapy, individual therapy can be other essential methods. -Determine who will be responsible for helping the child and/or adolescent meet each of their goals. Health care providers prescribe medication or perform therapy. It is important that family members are prepared and able to take on roles in the implementation of treatment plan
  13. 13. CHAPTER 14 Child and adolescent 65 psychiatry Formulating a differential diagnosis Clinical Pearls -The interpretation of behavior is contextually, culturally, and developmentally dependent. Almost all behaviors listed below have the potential to be considered normal in the correct context. -Multiple determinants of behavior is the rule. -Comorbidity is common. -Genetic predisposition confers potential for many behaviors and psychiatric diagnosis, but environment always has the potential to modulate behavior. -Parents often bring their children concerned about one specific behavior or cluster of behaviors, but the key to diagnostic formulation is maintaining a wide differential diagnosis while assessing resilience and risk factors within the context of the pediatric patient’s specific context. Diagnostic considerations The following list contains some examples of diagnostic considerations when evaluating chief complaints in the field of pediatric mental health. -Hyperactivity—ADHD, oppositional and conduct disorders, anxiety disorders, depression, mania, autism-spectrum disorders, substance abuse, sexual abuse, posttraumatic stress disorder. -Inattention—ADHD, oppositional and conduct disorders, Learning disorders, autism-spectrum disorders mood disorders, anxiety disorders, substance abuse, sexual abuse, language processing disorders, hearing deficit. -Separation problems—attachment disorders, anxiety, depression, developmental delay, sexual abuse, posttraumatic stress disorder. -Social problems, avoidance—depression, anxiety, social phobia, autism-spectrum disorders, sexual abuse, posttraumatic stress disorder. -Aggression, hostility—oppositional and conduct disorders, ADHD, mania, psychosis, depression, anxiety, developmental disorders, Learning
  14. 14. 66 disorders, autism-spectrum disorders, substance abuse, sexual abuse, posttraumatic stress disorder. -Regression—depression, anxiety, developmental problems, learning disorders, autism-spectrum disorders, substance abuse, sexual abuse. -Sexually inappropriate behaviors—sexual abuse, learning disorders, autism-spectrum disorders, conduct disorders, substance abuse, mania, psychosis, learning disorders, autism-spectrum disorders -Somatic symptoms—anxiety, depression, LD/PDDs, psychosis, sexual abuse. -Tantrums—oppositional and conduct disorders, ADHD, depression, anxiety, learning disorders, autism-spectrum disorders, sexual abuse, physical problems, mania, psychosis. -Ritualistic behaviors— anxiety, obsessive compulsive disorder, learning disorders, autism-spectrum disorders, psychosis. Team approach Identify the “team” in the child’s life A care provider who attempts to understand all members of a patient’s team will be best prepared to clarify treatment goals and respond when goals are not being met. Each member of the team brings their own strengths and limitations, as well as viewpoints. Each member has the potential to take on different roles. Pediatric patients exist in a biological, genetic, and psychosocial context. Striving to include all members of the child’s care team will improve the ability to understand that context and be more responsive. Possible members of the treatment team can include: parents, grandparents, coaches, clergy, teachers, school administrators, kin, and other social supports. This list is not merely limited to traditional medical providers! Identifying all potential members of a child’s natural treatment team will help expand the treatment options, and identify the key participants in the formal treatment planning process. The formation of a formal child and family team is often not mandated until a family system has reached a
  15. 15. CHAPTER 14 Child and adolescent 67 psychiatry breaking point. Thus, encouraging the family to be inclusive and seek social support, as well as to be a source of information to clinicians, can be very helpful throughout the treatment process. Utilize the Entire Treatment Team As an evaluation occurs, and treatment planning begins it is important to keep in mind that there are many ways that members of the formal treatment team, as well as the “informal team” can be utilized. It can often be helpful to try to identify who is and who isn’t worried about the child and why. Each member of a child (and the family’s) life will bring their own viewpoints, strengths and limitations. Some states mandate formal “child and family teams” when treatment goals have consistently not been met and the child’s situation is threatening their placement in the community. At this point goals can often seem reactive and the number of formal health care professionals involved can sky rocket. These situations can often be avoided with successful use of a natural “team” early in the evaluation and treatment planning process. When first evaluating psychosocial and mental health complaints it can be much easier to focus on strengths of the child and their family system. Also, getting information from members of the system when they are not in crisis usually provides a better understanding of the perceived strengths in the child, which can be utilized to the advantage of the child later. Finally, the identifying members of the “natural team” and developing a healthy support system that capitalizes on their strengths can help the child and family meet their initial goals and move towards recovery. Attention deficit hyperactivity disorder (ADHD) ADHD among the most commonly diagnosed and treated pediatric mental health problems, and is increasingly being diagnosed in adults as well.
  16. 16. 68 The hallmark symptoms of ADHD are a persistent pattern of inattention and/or hyperactive/impulsive behaviors that are developmentally inappropriate, chronic, and interfere with function. DSM-IV-TR specifies that some symptoms must have been present before 7 years of age, although some studies have suggested that a large number with the ‘inattentive’ subtype may have a later onset1. To fulfill diagnostic criteria the ADHD behaviors should also adversely affect at least 2 functional domains (e.g. academic, familial, social, occupational) and have persisted for at least 6 months. Clinical features of ADHD Inattention symptoms may include: poor attention to details or tendency to make careless mistakes; easy distractibility; difficulty sustaining attention; poor listening; poor task completion; disorganization; avoidance of tasks requiring sustained attention; tendency to lose things necessary for tasks; and forgetfulness. Hyperactivity/impulsive symptoms may include: fidgetiness; inability to stay seated; running or climbing inappropriately; noisiness in play; seeming “on the go” or “driven like a motor”; excessive talkativeness; prematurely blurting out answers; inability to take turns; and interrupting others. Three different subtypes are described: a predominantly inattentive subtype with at least six inattentive symptoms, a predominantly hyperactive/impulsive subtype with at least six hyperactive/impulsive symptoms, and a combined subtype with at least six symptoms from both inattentive and hyperactive/impulsive 1 . Applegate B, et al: Validity of the age-of-onset cri-terion for ADHD: a report from the DSM-IV field tri-als.[see comment]. Journal Amer Acad of Child & Adolescent Psychiatry 1997; 36(9):1211-21 2. Anderson JC: Is childhood hyperactivity the product of western culture?[see comment]. Lancet 1996; 348(9020):73-4 3. Wolraich ML, et al.: Comparison of diagnostic criteria for at- tention-deficit hyperactivity disorder in a county-wide sample. Journal of the American Academy of Child & Adolescent Psychiatry 1996; 35(3):319-24 4. Kessler RC, et al.: The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. American Journal of Psychiatry 2006; 163(4):716-23
  17. 17. CHAPTER 14 Child and adolescent 69 psychiatry categories. Epidemiology The prevalence of ADHD is reported in community studies of children and adolescents in the USA to be 3–5%, while in the UK a lower rate of 1% is reported. Such differences are thought to be due to differences in the ascertainment of symptoms, and have not persisted in studies where similar diagnostic methods with the same structured interviews were used2. There is a male predominance of 3:1 in youths. The inattentive subtype is the most common in community settings, while in psychiatric clinical settings the combined subtype is the most common. A similar rate of ADHD has been reported in a large community sample of adults, though the disorder is generally thought to be under-diagnosed in that age range. Etiology Genetics Heritability in ADHD is among the highest of psychiatric disorders. 50% rate of concordance in MZ twins; there appears to be separate heritability for different components of ADHD; 2x increased risk in other siblings; increased rates of conduct disorders, depression, and substance abuse in parents. Neurological Functional imaging suggests abnormalities in the prefrontal cortex regardless of stimulant use .2 Cathecolamine Hypothesis Attributes ADHD to dysregulations of dopamine or norepinephrine activity in the central or peripheral nervous system. Comorbidity Approximately 50–80% of youths with ADHD have comorbid disorder, including specific learning disorders (60%); CD and ODD (40%); depression (15-32%); anxiety disorder (25%); and bipolar disorder (5-10%)3. In adults, high rates of comorbidity are also noted, including mood and
  18. 18. 70 anxiety disorders, antisocial personality disorders, and substance abuse. Substance abuse is higher in older adolescents and adults with ADHD, though this comorbidity is due to the high co- occurrence with conduct disorders and antisocial personality disorders rather than because of ADHD itself or its pharmacological treatment4. 1. Spencer TJ, Biederman J, Wilens TE, Faraone SV: Overview and neurobiology of attention-deficit/hyperactivity disorder. Journal of Clinical Psy-chiatry 2002; 63 Suppl 12:3- 2. Casey, B., Durston, S. Am J Psychiatry 163:6, June 2006 3. Pliszka SR: Comorbidity of attention-deficit/hyperactivity disorder with psychiatric disorder: an overview. Journal of Clinical Psychiatry 1998; 59 Suppl 7:50-8 4. Wilens TE: Attention-deficit/hyperactivity disorder and the substance use disorders: the nature of the rela-tionship, subtypes at risk, and treatment issues. Psy-chiatric Clinics of North America 2004; 27(2):283-301 5. Cantwell DP: Attention deficit disorder: a review of the past 10 years.[see comment]. Journal of the American Academy of Child & Adolescent Psychiatry 1996; 35(8):978-87 Outcome Impulsive and hyperactive symptoms may remit with maturity, while inattentive symptoms often persist. Increasing evidence suggests that youths with ADHD continue to have symptoms of the disorder into adulthood and these are associated with substantial impairment in multiple domains. Adult patients with ADHD overall have higher arrest rates, and greater risks of fatal car accidents, marital problems, and occupational or academic underachievement. Approximately 30% of youths with ADHD as adults have a particular problematic course, with academic and occupational underachievement; progression from ADHD to substance abuse is most common when there is comorbid conduct disorder.5 Assessment1 -ADHD is a clinical diagnosis with no specific biological or cognitive tests validated. Evaluation should ideally include:
  19. 19. CHAPTER 14 Child and adolescent 71 psychiatry -Interview with parents to evaluate developmental, medical, and family history and assess family functioning. -Interview with child to evaluate for physical disorder, comorbid mood disorder, anxiety disorder, externalizing disorder, tic disorder, substance use disorder, developmental disorder, or speech and language problems. -Patients with ADHD, either youths or adults, tend to under-report their ADHD symptoms so collaborative history helpful. -Refer to pediatrician for physical examination to rule out medical problems (e.g. endocrinopathy, environmental exposure, or neurological disorder, such as petit mal epilepsy or complex partial seizures). -Encourage school to conduct educational testing to rule out a comorbid learning or language disorder. -Collateral information from school including teachers’ rating scales for ADHD symptoms. -Specific rating scales for parents and teachers (SNAP-IV-R, Vanderbilt, ADHD Rating Scale, Conner’s- see next page). -General behavioral rating scales to screen for ADHD symptoms and other psychopathology (e.g. Child Behavior Checklist, Teacher’s Report Form). Assessment Scales for ADHD As with many childhood psychiatric illnesses, ADHD is a diagnosis that occurs in many environments. As such, a combination of the clinical examination and often extensive collaboration is needed to provide the information necessary to obtain a diagnosis. Multiple scales have been developed to aid practitioners in diagnosis, and some are designed to monitor clinical progress. Several scales also assist in screening for potential cormorbid psychiatric disorders. Examples of a few ADHD scales are provided below. Scale Name Ratings for Completed by Information SNAP-IV-R A composite Teachers Free online of ADHD, and
  20. 20. 72 ODD, and parents/ aggression caregivers Vanderbilt ADHD, with Teachers Free online ADHD Parent screens for and Diagnostic ODD, CD, parents/ Rating Scale Anxiety, and caregivers Depression ADHD Rating ADHD Teachers Free Online Scale severity and and improvement parents/ with caregivers treatment . Conner’s ADHD, some Teachers Copyright Rating Scale ODD/Anxiety; and only. Self Revised index for parents/ reports for (CRS-R) monitoring caregivers teens and treatment . adults available. Treatment The Multimodal Treatment Study for ADHD (MTA) suggested that stimulant medication is a reasonable first-line treatment for most children with ADHD2 (see ADHD treatment section for details). However, concomitant psychosocial interventions are also useful, especially in patients with comorbid externalizing or internalizing disorders. In general, ADHD interventions include the following: -Parent management training (see Psychotherapy Chapter) -Educational/remedial interventions including evaluation for possible accommodations in the school setting such as preferential seating, un-timed testing in a separate environment with fewer distractions, use of assignment books checked by parents, and an organizational advisor. -Stimulants: generally the first-line treatment with a 70% response rate, even with most comorbid disorders. Stimulants include methylphenidate and amphetamine derivatives. -Non-stimulants: include atomoxetine (Strattera), bupropion (Wellbutrin), tricyclic antidepressants (desipramine, imipramine, and nortriptyline); and alpha-2 adrenergic receptor agonists (clonidine and guanfacine). All have lower response rates than the stimulants. Often more effective for hyperactive and impulsive symptoms than inattentive symptoms. -Pharmacological or psychotherapy treatment of comorbid psychiatric disorders like mood, anxiety or tic
  21. 21. CHAPTER 14 Child and adolescent 73 psychiatry disorders sometimes required, and may need to be initiated first, if they are more functionally impairing. Treatment Principles of ADHD Stimulant Pharmacotherapy for ADHD – General Principles The most effective treatment for ADHD continues to be stimulant medications such as methylphenidate and amphetamine/dextroamphetamine, ideally combined with behavioral treatments. These medications are described in detail at the end of this chapter. Stimulants are not without controversy, however, and practitioners must carefully inform families of the risks, benefits, and alternative treatments. Important Warnings About ADHD Stimulants1 “An FDA review of reports of serious cardiovascular adverse events in patients taking usual doses of ADHD products revealed reports of sudden death in patients with underlying serious heart problems or defects, and reports of stroke and heart attack in adults with certain risk factors.” Another FDA review of ADHD medicines revealed a slight increased risk (about 1 per 1,000) for drug-related psychiatric adverse events, such as hearing voices, becoming suspicious for no reason, or becoming manic, even in patients who did not have previous psychiatric problems. FDA recommends that children, adolescents, or adults who are being considered for treatment with ADHD drug products work with their physician or other health care professional to develop a treatment plan that includes a careful health history and evaluation of current status, particularly for cardiovascular and psychiatric problems (including assessment for a family history of such problems).” This warning included all ADHD stimulants, as well as atomoxetine (Strattera), a non-stimulant ADHD medication. There are also serious concerns about abuse of stimulants, especially in individual with a previous abuse history. Please refer to the FDA website for the latest updates.
  22. 22. 74 The Multimodal Treatment Study of Childrenwith Attention Deficit Hyperactivity Disorder2 (MTA) The MTA was an intensive NIMH funded study included 579 elementary school boys and girls with ADHD. Basically, the subjects were randomly assigned to one of four treatment programs: (1) medication management alone; (2) behavioral treatment alone; (3) a combination of both; or (4) routine community care. The results of the study indicated that long-term combination treatments and the medication-management alone were superior to intensive behavioral treatment and routine community treatment. And in some areas—anxiety, academic performance, oppositionality, parent-child relations, and social skills—the combined treatment was usually superior. Another advantage of combined treatment was that children could be successfully treated with lower doses of medicine, compared with the medication-only group. Follow-up at 24 months: Effects above were fairly consistent even after 24 months. About 70% of the subjects were still taking medication, and 38% of the behavioral subjects began taking medication. 1.http://www.fda.gov/bbs/topics/NEWS/2007/NEW01568.html 2.http://www.nimh.nih.gov/publicat/adhd.cfm Non-stimulant Treatment for ADHD – General Principles Stimulants are the most effective treatment for ADHD. However, non-stimulants may be appropriate when patients have failed or not tolerated stimulants, or have certain comorbid disorders such as tics, depression, anxiety, or substance abuse (given non-stimulants lack of abuse potential). Non-stimulant ADHD treatment examples include atomoxetine, bupropion, tricyclic antidepressants (including imipramine, desipramine, and nortriptyline), alpha-2 adrenergic receptor agonists (including clonidine and guanfacine). Refer to the end of this chapter for more details on prescribing in the pediatric ADHD population. It may be helpful to use agents such as clonidine or guanfacine when children have difficulty sleeping as one of the side effects of stimulants. These medications may possibly help with other
  23. 23. CHAPTER 14 Child and adolescent 75 psychiatry symptoms of ADHD, though this is controversial. *However, combining stimulants with alpha-2 adrenergic receptor agonists such as clonidine or guanfacine have been associated with rare reports of sudden cardiac death, and the risks and benefits should be carefully weighed before prescribing such a combination. 1 .Dulcan M: Practice parameters for the assessment and treatment of children, adolescents, and adults with attention- deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child & Adolescent Psy-chiatry 1997; 36(10 Suppl):85S-121S 2. Pliszka SR,et al.: The Texas Children's Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part I. Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child & Adolescent Psy-chiatry 2000; 39(7):908-19 1.Dulcan M: Practice parameters for the assessment and treatment of children, adolescents, and adults with attention- deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child & Adolescent Psy-chiatry 1997; 36(10 Suppl):85S-121S 2. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Archives of General Psychiatry 1999; 56(12):1073-86
  24. 24. 76 Oppositional defiant disorder (ODD)1 Key Features An enduring pattern of negative, hostile, and defiant behavior, without serious violations of societal norms or the rights of others. Behavior may occur in one situation only (e.g., home) and may lead to social isolation, depression, or substance abuse. Epidemiology Onset is between ~3 and 8 years old. More common in boys during childhood but equal rates in adolescence. A common condition affecting 15–20 % of C & As. Girls may express their ODD in covert ways not classically defined (e.g., verbally, through relationships, and passive gestures). Etiology A stacking of risk factors: biological (genetics, temperament, baseline underarousal, toxin exposure), psychological (attachment and/or aggression issues), and social (poverty, poor structure, violence). Management - Parent Management Training (PMT) targeting social skills, conflict resolution, and anger management can be highly effective as an intervention (see psychotherapy chapter page &&&). Some children may benefit from home visits or head start programs. Some schools offer prevention programs using these strategies. - At each step, focus on therapeutic alliance with family and child, cultural sensitivity and consideration of family-specific needs.
  25. 25. CHAPTER 14 Child and adolescent 77 psychiatry - Obtain key information from child and parents/ guardians: Core Symptoms of ODD, Age at Onset, Duration of Symptoms, and Degree of Functional Impairment. Consider additional information from outside sources as needed and permitted by the child and parents. - Utilize rating scales to aid in diagnosis and tracking of ODD symptoms (e.g., Connors Rating Scale (CTRS), Child Behavior Checklist (CBCL)). - Assess for all possible comorbid psychiatric conditions, and treat per clinical judgment. - Develop a team-approach treatment plan using problem solving skills for the child, and family/ parent intervention strategies, such as: - Reducing positive reinforcement of disruptive behavior. - Increasing reinforcement of prosocial and compliant behavior, using positive reinforcement (e.g., parental attention), and fair and specific punishment (e.ge.g., time out, loss of tokens, and/or loss of privileges). - Apply consequences and/or punishment for disruptive behavior. - Parental responses are predictable, contingent, and immediate. - Medication Usage -General Guidelines: MedicationS should only be used in combination with psychotherapeutic interventions (use alone is typically not effective). Therapeutic alliance with close monitoring is essential. Avoid pPolypharmacy. If one choice is ineffective, switch classes before adding more medication.
  26. 26. 78 -Medication Choice: -Medications should be adjunctive to psychotherapeutic treatment. Treatment of comorbid ADHD symptoms may help with ODD symptoms (see ADHD treatment pages &&& and end of chapter). -If ODD symptoms are more similar to CD (e.g., highly aggressive), may consider treatment strategies used in CD (see next, page &&&) - Use least restrictive setting and monitor closely for safety to self and others. Occasionally, more intensive treatment (e.g., day programs, hospitalization, out-of- home placement) may be required. Programs such as boot camps or incarceration are felt to only worsen behaviors, and generally are not recommended. Outcome In general 67% do not meet criteria after 3 years; About 30% continue on to Conduct Disorder (CD), and 10% continue from there to Antisocoial personality disorder (ASPD). Earlier onset ODD has a worse prognosis. Cormorbidities seen more as age increases, and include ADHD (most common), anxiety, and mood disorders. ADHD plus ODD results in worse outcomes, and may facilitate the transition to CD. DSM-IV & DSM-IV-TR: Oppositional Defiant Disorder -A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present: - often loses temper - often argues with adults - often actively defies or refuses to comply with adults' requests or rules - often deliberately annoys people - often blames others for his or her mistakes or misbehavior - is often touchy or easily annoyed by others - is often angry and resentful - is often spiteful or vindictive Note: Consider a criterion met only if the behavior occurs more frequently than is
  27. 27. CHAPTER 14 Child and adolescent 79 psychiatry typically observed in individuals of comparable age and developmental level. - The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. - The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder. - Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder. 1. Steiner, H; Remsing, L. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Oppositional Defiant Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 2007. 46(1): 126-141.
  28. 28. 80 Conduct disorder (CD)1,2 Key Features Conduct disorder has been popularized in the literature as ‘sociopathy.’ By definition, CD is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. These violations include aggression or cruelty to people and animals, destruction of property, deceitfulness or theft and serious violation of rules (e.g., truancyting or running away). Early sexual behavior, gang involvement, low self-esteem, lack of empathy are also seen. The term ‘delinquent’ is unfashionable and refers to the individual whose behavior leads them into the criminal justice system—‘young offender’ is the modern term. CD is important because it is common: it is the causes of great suffering in both the individual and in society. ; iIt is a risk factor for adult antisocial behavior;, and it is a major burden on public resources. In many countries it constitutes one of the major public mental health problems, making prevention strategies important (see next). Epidemiology In North America CD is a common reason for psychiatric evaluation in children and adolescents, and is. It has an earlier onset and is more common in males. in boys than in girls. Etiology A family history of antisocial behavior or substance abuse, possible low CSF serotonin, impaired executive function, high sensation seeking, and diminished conditioning to punishment, low IQ, and brain injury are biological factors associated with risk for CD. Psychosocial risk factors include: parental criminality and substance abuse; harsh and inconsistent parenting; domestic chaos and violence; large family size; low socio-economic status and poverty; early loss 1 Bassarath L (2001) Conduct disorder: a biopsychosocial review. Can J Psychiatry 46, 609–16 2 Waddell C, Lipman E, Offord D (1999) Conduct disorder: practice parameters for assessment, treatment, and prevention. Can J Psychiatry 44 (supp 2), 35s–39s. 3. Kazdin AE (2000) Treatments for aggressive and antisocial children. Child Adolesc Psych Clinics N America 9, 841–58.
  29. 29. CHAPTER 14 Child and adolescent 81 psychiatry and deprivation; lack of a warm parental relationship; school failure; social isolation; and exposure to abuse and societal violence. Comorbidity ADHD;, substance abuse;, s suicidal ideation, for example.ity. 1 Bassarath L (2001) Conduct disorder: a biopsychosocial review. Can J Psychiatry 46, 609–16 2 Waddell C, Lipman E, Offord D (1999) Conduct disorder: practice parameters for assessment, treatment, and prevention. Can J Psychiatry 44 (supp 2), 35s–39s.
  30. 30. 82 Assessment - Clarify the purpose of the assessment (clinical, community, forensic). Obtain a full history with collateral from school, community, legal system. - Identify causal risk and protective factors. - Assess for comorbidity and make a diagnosis. (psychometric testing). - Formulate the problem and establish management plan. See forensic chapters for more details. Management13 Multiple strategies are indicated: - Ensure the safety of the child - CBT problem-solving skills-in individual/group setting/ family therapy - Parent management training-to improve social exchanges/stability - Multi-systemic therapy-family-based, including school and community - Medication-only for comorbid disorders (e.g. ADHD—see previous) - Academic and social support-referral to relevant agencies/groups Medication Usage-Typically only for comorbid disorders (e.g., ADHD, see page &&&). If used for CD, the purpose is typically to management of extreme aggression. In such cases, stabilization of the environment should occur first, to avoid confusion as to the cause of improvement. Atypical antipsychotics appear to be the most common treatment choice, though some promise of improvement has been shown with mood stabilizers (lithium, divalproex), antipsychotics, and stimulants. Course and outcome Adult outcomes include: antisocial personality disorder; criminal activity; substance abuse; and other mental disorders. However, less than 50% of CD cases have severe/persistent antisocial problems. Predictors of poor outcome EPredictors of Poor outcome: Early onset (<10 yrs old); low IQ; poor school achievement; attentional problems/ hyperactivity ADHD; family criminal history; low socio-economic statusSES; siblings with conduct
  31. 31. CHAPTER 14 Child and adolescent 83 psychiatry disorder, poor parenting. P rotective factors FProtective Factors: Female gender; high intelligence; resilient temperament; competence at a skilled; warm relationship with a key adult; commitment to social values; strong and/ stable community institutions; increased economic status. Prevention strategies and policy implications: - First identify parents and families at risk. Then work with: - Preschool child development programs/ School programs Institute classroom enrichment, home visits/ support, parent and teacher training. - Community programs Involvement with social agencies; institute interventions (recreation programs, parent training and mentoring programs). - Social and economic restructuring to reduce poverty and to improve family and community stability. 1. Kazdin AE (2000) Treatments for aggressive and antisocial children. Child Adolesc Psych Clinics N America 9, 841–58. DSM-IV-TR Diagnostic criteria for Conduct Disorder A repetitive, and persistent pattern of behavior in which the basic rights of others or major age- appropriate societal norms or rules are violated, as manifested by the presence 3+ criteria in the past 12 months, with 1+ criterion present in the past 6 months: Aggression to people and animals often bullies, threatens, or intimidates others; often initiates physical fights;
  32. 32. 84 has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun); has been physically cruel to people; has been physically cruel to animals; has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery); has forced someone into sexual activity Destruction of property has deliberately engaged in fire setting with the intention of causing serious damage; has deliberately destroyed others' propertyy (other than by fire setting) Deceitfulness or theft has broken into someone else's house, building, or car; often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others); has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) Serious violations of rules often stays out at night despite parental prohibitions, beginning before age 13 years; has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period); is often truant from school, beginning before age 13 years; The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. - If the individual is age 18+ years years or older old, criteria are not met for Antisocial Personality Disorder;. - Specify Onset: Specify type based on age at onset: Childhood-Onset (before < 10), Adolescent-Onset Type (after >10); Specify. Specify severity: mild, moderate, severe 3
  33. 33. CHAPTER 14 Child and adolescent 85 psychiatry Pervasive developmental disorders -- introduction Pervasive developmental disorders (PDDs) are defined as spectrum of behavioral problems commonly associated with autism. In fact, “Autism Spectrum Disorders” (ASD) is often used interchangeably with PDD. PDD frequently involves a triad of deficits in social skills, communication/ language and behavior. The feature all have in common is difficulty with social behavior. DSV-IV-TR categorizesd PDDs as follows: 1. Autistic Disorder 2. Asperger’s disorder 3. Rett’s syndrome 4. Childhood disintegrative disorder 5. PDD-NOS PDDs are characterized by either lack of normal development of skills or loss of already acquired skills. There is a gender bias with male > female predominance in all syndromes except Rett’s syndrome (female predominance). Prevalence of PDDs ranges from 40-60 cases / 10,000. Assessment of Pervasive Developmental Disorders The American Academy of Child and Adolescent Psychiatry recommends a multidisciplinary approach involving psychiatrists, psychologists, pediatricians, neurologists, speech therapists, OT and primary care teams. The efforts of various specialists and consultants should be coordinated and one care provider assumes an overall role as coordinator and liaison with schools and other providers of interventions. The assessment should include: 6. Complete psychiatric assessment that will vary depending on the child’s age, history, and previous evaluations. Assessment should include (see page ### beginning of chapter for more details): - Pregnancy, Neonatal, and Developmental History - Medical history - Family and psychosocial factors
  34. 34. 86 - Intervention history - Psychiatric examination of the child in observational settings to evaluate overall developmental level and specific problem behaviors 7. Medical Examination 8. Neurologic examination including complete audiological and visual examinations and taking a seizure history. 9. Diagnostic and Laboratory Studies There is no specific laboratory test for autism, but specific studies to search for associated conditions are indicated based on history and clinical presentation. EEG and perhaps MRI, Southern blot testing for Fragile X genetic and Wood’s lamp examination for tuberous sclerosis are indicated. The presence of dysmorphic features or other specific findings may suggest obtaining genetic screening for inherited metabolic disorders, specific genetic syndromes, or chromosome analysis. 10. Psychological Assessment - Developmental/Intelligence Testing separate estimates of verbal and nonverbal (performance) IQ should be obtained. - Adaptive Skills Assessment of adaptive skills to document the presence of any associated mental retardation to establish priorities for treatment. - Other assessments PDD-specific neuropsychological screening and/or achievement testing may be needed. Examples: Autism Diagnostic Interview-Revised (ADI- R) Autism Diagnostic Observation Schedule (ADOS) Autism Behavior Checklists (ABC) Childhood Autism Rating Scales (CARS) Checklist for Autism in Toddlers (CHAT) Speech-Language-Communication Assessments Occupational and Physical Therapy Assessments 11. Psychoeducation and family and parental support. To the extent possible involve parents and other family members in the process of assessment. Various parent and family
  35. 35. CHAPTER 14 Child and adolescent 87 psychiatry support groups are available and can provide important sources of information and support to parents. - National Alliance for Autism Research: http://www.naar.org/ - International Rett Syndrome Association : http://www.rettsyndrome.org/ - Childhood Disintegrative Disorder Network: http://www.rarediseases.org/ - Autism Society of America: http://www.autism-society.org/ - Aspen of America, Inc. (Asperger’s Syndrome): http://www.maapservices.org/ - Cure Autism Now: http://www.cureautismnow.org/ 12. Differential Diagnosis Other PDDs; childhood schizophrenia; MR; language disorders; neurological disorders (Landau-Klefner syndrome); sensory impairment (deafness or blindness); OCD; psychosocial deprivation. PDD Assessment Summary 13. Differential diagnosis: childhood schizophrenia; mental retardation; language disorders; neurological disorders; sensory impairment (deafness or blindness); OCD; psychosocial deprivation; reactive attachment disorders. 14. A multidisciplinary approach is required, potentially involving a psychiatrist, psychologist, pediatrician, neurologist, speech therapist, occupational therapist, and school team. 15. Full clinical evaluation: including physical and mental state as well as specific developmental, psychometric, and educational assessments. 16. Possible genetics consultation for fFragile X, Rett’s (in females), or other genetic disorders. 17. Simple rating scales: Autism Behavior Checklist (ABC); Childhood Autism Rating Scales (CARS); In-depth studies: Autism Diagnostic Interview-Revised (ADI-R); Autism Diagnostic Observation Schedule (ADOS).
  36. 36. 88 Autism History /Definition/ Clinical Features John Haslam in 1809 and Henry Maudsley in 1867 were the first physicians to provide descriptions of children with the clinical features of autism. Leo Kanner named the disorder infantile autism in 1943. Autistic disorder is the prototype of the PDDs defined by qualitative impairments in social interaction, communication and restricted and stereotyped patterns of behavior, interests and activities. Onset of the disorder may be evident by 18 months and to meet the diagnosis must occur before 3 years of age. 30% of autistic children score in the normal intelligence range (High-functioning autism, HFA). About 30% have mild to moderate mental retardation and about 40% have serious to profound mental retardation. DSM-IV-TR Autism Criteria According to DSM-IV-TR criteria, children with autism have to have a total of at least six of the following symptoms before age 3, with specific numbers from each the three broad categories: 18. At least two symptoms of abnormal social relatedness: - Impaired non-verbal interactive behaviors (e.g. poor eye contact, inappropriate facial expressions and gestures) - Failure to develop peer relationships - Reduced interest in shared enjoyment - Lack of social or emotional reciprocity 19. At least one symptom of abnormal communication or play: - Delayed or lack of spoken language - Difficulty initiating or sustaining conversations - Stereotypic, repetitive, or idiosyncratic language - Lack of imaginative or imitative play 20. At least one symptom of abnormal behaviors: - Stereotyped/restricted, obsessive interests - Rigid adherence to non-functional routines or rituals - Stereotypic/repetitive motor mannerisms (e.g. toe-walking, hand flapping, body rocking) - Preoccupation with parts of objects Abnormal symbolic or social play or restricted interests or activities encompassing unusual preoccupations
  37. 37. CHAPTER 14 Child and adolescent 89 psychiatry and interests; lack of developmentally appropriate fantasy; adherence to non-functional routines or rituals; resistance to change; stereotypies and motor mannerisms (e.g., hand or finger-flapping or body-rocking); and preoccupation with parts of objects. There are some non-specific neurological and physiological features that are common to autism, but are not essential or specific features of the disorder, such as seizure disorder, motor tics, large head circumference, abnormal gaze monitoring, increased ambidexterity, hyper- and hypo-sensitivity to sensory stimuli (loud or high pitched sounds, specific textures, bright lights), abnormal pain and temperature sensation, and altered immune function. Autistic children also often demonstrate associated, but non-specific behavioral problems such as poor attention and concentration (60%), hyperactivity (40%), morbid or unusual preoccupations (43-88%), obsessive phenomena (7%), compulsive rituals, anxiety and fear (17-74%), mood lability, irritability, agitation, inappropriate affect (9-44%), sleep problems (11%) or self-injurious behaviors (24-43%). ‘Savants’: persons with obvious mental retardation who exhibit unusually high skill in sharply circumscribed areas, such as visual arts, musical performance, arithmetic skills (calendar calculating, prime numbers). Studies by Hill and Rimland suggest that 0.6 % of institutionalized individuals with MR and 9.8% of mentally retarded autistic individuals demonstrate savant skills. Epidemiology In 2007 a CDC surveillance network found that an average of 6.7 per 1000 eight-year- olds in 2002 had autism spectrum disorders (ASDs), including pervasive developmental disorder and Asperger syndrome. The ratio of males to females with ASDs ranged from roughly 3:1 to roughly 7:1. Autism occurs equally across various races and socioeconomic statuses. At one time, it was more widely diagnosed in higher socioeconomic groups, probably due to referral biases1. Etiology The cause of autism is unknown but it is thought to be a disorder of genetic origins, with a heritability of about 90% with as few as 2 and as many as 15+ genes involved. Neurocognitive studies suggest lack of connectivity may explain
  38. 38. 90 many of the cognitive and emotional deficits. Syndromic autism is seen at high rates in various genetic disorders (Tuberous sclerosis, Fragile X, 15q11- q13 duplications, Down’s syndrome and single gene disorders of metabolism such as adenylate lyase deficiency). However, environmental influences are also important, as concordance in monozygotic twins is less than 100% (36–91% monozygotic twins concordance vs. 10% dizygotic twins concordance) and the phenotypic expression of the disorder varies widely. Environmental factors include pre/post- natal infections agents (congenital rubella, CMV), chemical toxins (thimerasol), autoimmune disorders (MMR- anecdotal, not proven), obstetric complications. Neuropathology Neuropathology studies show increased cell packing in the limbic system, reduced numbers of Purkinje cells in the cerebellum, age-related changes in the cerebellar nuclei and inferior olives, cortical dysgenesis, and increased brain size, especially in the young autistic child (as measured by head circumference), magnetic resonance image (MRI) brain volume, and postmortem brain weight. Seizures are common. Neurochemistry 1/3 of autistic subjects have elevated whole blood 5-HT. Other neurotransmitters (dopamine DA, norepinephrine, NE, glutamate, gamma-aminobutyric acid, GABA) and neuropeptides (oxytocin, secretin, beta- endorphins) have been implicated, but the evidence is not as reproducible.
  39. 39. CHAPTER 14 Child and adolescent 91 psychiatry Other developmental disorders Asperger’s disorder History/ Definition/ Clinical Features Asperger’s disorder is a neurodevelopmental disorder on the autism spectrum, which involves impairments in reciprocal social interactions and restricted repetitive and stereotyped patterns of behavior in the absence of intellectual dysfunction or clinically significant general delay in language. The incidence of Asperger’s disorder is conservatively estimated at 2.6/ 10, 0000, though this figure varies by source. High-functioning autism and Asperger's Disorder are autism spectrum disorders characterized by cognitive impairments affecting social relatedness and communication, restricted interests/repetitive behaviors, and average or better intelligence. According to the American Psychiatric Association, Asperger's Disorder is differentiated from High-functioning autism by the presence of intact basic language and imaginative play abilities. Rett’s disorder Rettff’s disorder was first reported on by the Viennese pediatrician Andreas Rett in 1966. A genetic X-linked disorder largely affecting females (7 cases are known to exist in males) with an estimated incidence of 3.8/10,000 based on British Isles survey. There is a period of normal development for the first 5-6 months of life. Head circumference at birth is normal with subsequent deceleration of head growth leading to post-natal microcephaly followed by loss of acquired skills such as purposeful hand function, vocalization, and communication skills, loss of social engagement early in the course, (although often social interaction develops later) and appearance of truncal and gait ataxia. Mutations in the MECP2 gene (methyl CpG binding protein 2 gene, Xq 28) account for 80% of patients with classic Rett’s Disorder. Supportive diagnostic criteria include breathing dysfunction, EEG abnormalities (up to 80% of patients experience epileptic episodes), spasticity, peripheral vasomotor disturbance, scoliosis, and growth retardation. In addition to classic Rett’s Disorder, some variants have been
  40. 40. 92 described presenting some features of the classic form, but displaying differences. Mutations in the X-linked CDKL5 gene (cyclin-dependent kinase- like 5, Xq22) were found in some patients with Rett’s Disorder variant. Childhood disintegrative disorder (CDD) CDD was first described as dementia infantilis by Theodor Heller a Viennese remedial educator in 1908. CDD is defined in DSM-IV as apparent normal development at least until age 2 followed by clinically significant loss of previously acquired skills (before age 10) in at least 2 areas: language (expressive or receptive), social skills or adaptive behavior, bowel or bladder control, play and motor skills. In addition patients have abnormalities of functioning in at least 2 of the following areas: qualitative impairment in social interaction by marked regression resulting in an autistic, qualitative impairment in communication or repetitive, restricted and stereotyped behaviors and mentally retarded state (severe to profound MR >60% with IQ<40). Association of seizures or EEG abnormalities have been documented in about half the cases of CDD (seizures most commonly develop after the onset of CDD). Associated behavioral symptomalogy includes overactivity, affective symptoms/anxiety, deterioration of self-help skills, aggression, agitation, self-injurious behavior, fecal smearing with compulsive behavior. Deterioration in social and self-help skills is more marked than motor skills. The cause is unknown and prognosis poor. Incidence is estimated at 0.2/ 10,000. Males outnumber females by 4:1. Mean age of onset of 3.36 years. Two types of onset have been seen. More commonly onset is insidious developing over weeks to months and less common over days to weeks. Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) Also known as “Atypical autism” this category is used when there is a severe and pervasive impairment in the development of reciprocal social interaction associated with impairment in either verbal or nonverbal communication skills or with the presence of stereotyped behavior, interests and activities, but does not meet criteria for other PDDs, schizophrenia, schizotypal
  41. 41. CHAPTER 14 Child and adolescent 93 psychiatry personality disorder, or avoidant personality disorder. Incidence is estimated at PDD-NOS 20.8/ 10, 0000 with a male predominance. Treatment of Pervasive Developmental Disorders Treatment strategies for PDDs: Summary 21. Educational and vocational interventions: most will be eligible for individualized educational plan with accommodations and services to address their special needs. 22. Behavioral interventions: include behavior modification, social skills training, and CBT methods 23. Family interventions: educational; support; advocacy 24. Speech and language therapy;
  42. 42. 94 occupational therapy. 25. Pharmacotherapy: symptom management (e.g. atypical antipsychotics for stereotypies and aggressive agitation); SSRIs or clomipramine for compulsive and self-harming behaviors, depression/anxiety; stimulants for ADHD symptoms. 26. Treat medical conditions (e.g. epilepsy) Behavioral Treatment Behavioral/psychoeducational interventions have been used to treat the core symptom features of autism in the realms of communication and social interaction. Applied Behavioral Analysis (ABA). A strategy for developing social skills based on idea that rewarded behaviors will be repeated. 27. Treatment & Education of Autistic & Related Communication of Handicapped Children (TEACCH). Structured teaching approach that uses the child’s visual and rote memory strengths to improve communication, social and coping skills 28. Picture Exchange Communication System (PECS). Helps non-verbal children express themselves, reduces maladaptive behaviors. 29. Play Therapy- counseling to help children express themselves through toys. 30. Social Stories an intervention to address behavior difficulties 31. Sensory Integration provides controlled sensory input with the goal being increased adaptive behaviors/responses and less agitation. 32. Speech Therapy- teaches how to communicate more effectively - how to hold a conversation, thinking about what the other person in a conversation understands and believes, and tuning in to the meta-linguistic signals of the other person. Pharmacotherapy Specific forms of medication treatment have been shown to produce significant improvements in problem behaviors associated with autism in double blind placebo-controlled trials in autistic patients.
  43. 43. CHAPTER 14 Child and adolescent 95 psychiatry 33. Anxiety symptoms, repetitive behaviors as seen in patients who have obsessions or compulsions, self-injurious behaviors, and perhaps social avoidance/withdrawal have been significantly reduced with the use of SSRIs (fluoxetine, sertraline, clomipramine, fluvoxamine) and atypical antidepressants (e.g., mirtazapine) and SNRIs (e.g., venlafaxine). 34. Neuroleptics have been shown to reduce irritability, hyperactivity, (risperidone), aggression (haloperidol low doses and risperidone).. 35. Stimulants, NMDA antagonists, and alpha-2 noradrenergic receptor agonists, have been shown to decrease hyperactivity and inattention (methylphenidate, amantadine, clonidine) The sometimes exquisite sensitivity of patients who have autism requires careful initiation, titration, and monitoring of any psychopharmacologic/ pharmacologic treatments. Treatment of associated disorders such as epilepsy and GI problems should also be carefully monitored. In 2006, the U.S. Food and Drug Administration (FDA) approved risperidone for the treatment of irritability associated with autistic disorder, including symptoms of aggression towards others, deliberate self-injuriousness, temper tantrums, and quickly changing moods, in children and adolescents ages 5 to 16 years. This is the first time the FDA has approved any medication for use in children and adolescents with autism.
  44. 44. 96 Language and learning disorders (LLDs)1 LLDs comprise a very common set of problems, with estimates that as many as 10% to 20% of children and adolescents have a language and/or learning disorder. The diagnoses of mental retardation, motor skills disorder, ADHD, mood disorder, anxiety disorder and medical/neurological primary diagnosis (e.g., fetal alcohol syndrome, prenatal substance abuse, fragile X syndrome) should be considered since they may be concurrent with or mistaken for speech, language, or learning disorders. DSM-IV groups together a number of LLDs that share the following criteria: 36. Performance is significantly below that expected for IQ or age 37. A discrete developmental disability in the absence of MR 38. Commonly presents as school refusal, emotional or behavioral problems 39. 50% have co-morbid psychiatric disorder and/or other LLDs 40. Most show strong evidence of heritability Reading disorder (dyslexia) Difficulty with reading, in most cases involving a deficit in phonological-processing skills. 4% of school-age children (range 2-10%). Male predominance. There is often a family history of dyslexia. Familial risk to first degree relatives has 1 . AACAP (1998) Practice parameters for the assessment and treatment of children and adolescents with language and learning disorders. J Am Acad Child Adolesc Psychiatry 37 (10 supp), 46s–62s. 2. Shaywitz, SM (2005) Overcoming Dyslexia: A New and Complete Science-Based Program for Reading Problems at Any Level. Vintage Press. http://www.childrenofthecode.org/
  45. 45. CHAPTER 14 Child and adolescent 97 psychiatry been found to be between 35% and 45%, compared with the population risk of 3% to 10%. Mapped to genes and specific neurobiological profile, with associated interventions proposed by Shaywitz2. 20% have comorbid ADHD or Conduct Disorder. Management includes 1:1 remedial teaching and parent involvement improves long-term outcome. Disorder of written expression Often coexists with dyslexia and manifests as difficulties with spelling, syntax, grammar, and composition. Occurs in 2–8% of school-age children with a 3:1 male predominance. Difficulties may first emerge with the shift from narrative to expository writing assignments. Mathematics Disorder Female predominance and occurs in 1–6% of school-age children. Often associated with visuo- spatial deficits and attributed to right parietal dysfunction. Family members (e.g., parents and siblings) of children with mathematics disorder are 10 times more likely to be diagnosed with mathematics disorder than are members of the general population. Communication Disorders Includes expressive and receptive language disorders, phonological disorder and stuttering. Expressive language disorder is diagnosed when scores from standardized tests measure delays in expressive language, not due to sensory or motor deficit or environmental deprivation and in excess of delays expected based on scores of nonverbal intelligence and receptive language abilities. The difficulties with expressive language interfere with academic or occupational achievement. 3% to 5% of children have a developmental expressive language disorder. Mixed Receptive-Expressive Language Disorder is diagnosed when scores from standardized tests measure delays in both receptive and expressive language, not due to sensory or motor deficit or environmental deprivation and in excess of delays expected based on scores of nonverbal intelligence abilities. The difficulties with receptive and expressive language interfere with academic or occupational achievement. Prevalence of either a developmental expressive or receptive
  46. 46. 98 language disorder ranges from 1% to 13% of the population. Phonological Disorder is defined as a failure to develop expected speech sounds appropriate for age and dialect that compromises academic/occupational achievement or social communication. The deficit is out of proportion to MR, sensory deficits or environmental deprivation, if present. Prevalence of phonological disorder ranges from 1% to more than 20%. Stuttering is defined as a disturbance in the normal fluency or time pattern of speech. Persons who stutter usually struggle with the initial syllables of multisyllabic words. Onset is usually between the age of 3 and 6 years of age with a male predominance of 3:1. Rates of natural, unassisted recovery is about 75%. Majority of cases are developmental, but may be acquired (e.g. head injury). Etiology is thought to be genetic, due to incomplete cerebral dominance and/or hyperdopaminergic state. Management utilizes speech therapy, and sometimes medication, such as antipsychotics (e.g. risperidone) or SSRIs.
  47. 47. CHAPTER 14 Child and adolescent 99 psychiatry Elimination Disorders: Enuresis DSM-IV-TR Diagnostic criteria for Enuresis 41. Repeated voiding of urine into bed or clothes (whether involuntary or intentional). 42. The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. 43. Chronological age is at least 5 years (or equivalent developmental level). 44. The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder). Specify type: Nocturnal Only, Diurnal Only, Nocturnal and Diurnal Prevalence reported to be 5-15% of 5 year olds, with 15% remission rate/year every year after, and 1-2% by teen/adult years. Episodes are usually involuntary, occur at night, and are more common in males than females. Enuresis can result in low self-esteem and often becomes a focus for family conflict. Subtypes – nocturnal only (most common), diurnal only, nocturnal and diurnal Etiology Genetic—75% have a family history of enuresis; Other - generalized developmental delay; incomplete potty training; psychosocial stressors (e.g. birth of a sibling, hospitalization, starting school, domestic conflict); comorbid psychopathology (e.g. depression); organic causes. Work-up For Nocturnal enuresis: use general medical evaluation (including personal and family history, physical, height/weight chart, urinalysis and abdominal exam) to rule out UTI, neurological problems, diabetes mellitus, seizure, and drug side effects. Consider abdominal x-ray to rule out constipation. After 8 years old, and with any diurnal component, strongly consider urological referral.
  48. 48. 100 Management Behavioral modification is the first-line treatment and includes restricting fluids at night, scheduling toileting times prior to bed, behavioral management (star charts without or without other rewards), night-lifting, bell and pad technique, bladder training 45. Often helpful to implement bowel regimen (see encopresis section) 46. Pharmacological intervention: use only if behavioral treatment fails - DDAVP (desmopressin), which is less anticholinergic than imipramine and does not exacerbate constipation. - Imipramine: A tricyclic antidepressant. Works due to anticholinergic effect by increasing sphincter tone. 80% have some improvements but tolerance may develop after 6 weeks. - Other pharmacologic intervention available, but mostly utilized by pediatric urologists. Clinical Pearl Remember to get an EKG because of potential cardiac implications of tricyclic antidepressants; also weigh benefits and risks because of risk of death with overdose and/or cardiac side effects. Elimination Disorders:
  49. 49. CHAPTER 14 Child and adolescent 101 psychiatry Encopresis DSM-IV-TR Diagnostic criteria for Encopresis 47. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional. 48. At least one such event a month for at least 3 months. 49. Chronological age is at least 4 years (or equivalent developmental level). 50. The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation. Code with or without Constipation and Overflow Incontinence The DSM criteria are probably physiologically irrelevant. Episodes are almost always involuntary. Prevalence 1-3% of children 5 year old and older. Most Encopresis has resolved by adolescence. More common in males than females. Subtypes With or without constipation and overflow incontinence
  50. 50. 102 Etiology May be caused or related to fecal withholding due to pain, power struggle, inattention to bowel needs, oppositionality, or physiological problem. Up to 95% involves some form of fecal constipation. Hirshprung’s disease rarely cause of encopresis. Often secondary to ADHD. Work-up Medical history to rule out neurologic problems, drug side effects, nutritional problems, and hirschsprung’s disease. History of frequency and form of stools is essential. Physical exam with complete abdominal exam, rectal exam, and abdominal x-ray usually sufficient. Management Utilize Fiber, water, and laxative to promote consistent soft stools. Can become increasingly aggressive with laxative use in order to promote complete bowel clean-out if initial conservative efforts are not effective. Educate parents and child in order to minimize embarrassment and family conflict. Consistent behavioral approach to toileting and soiling can be helpful, no matter what the cause. Parent should reward stool in the toilet, as opposed to clean underwear. Disorders of Eating, Sleeping, and Thriving Sleep problems Complaints about difficulty initiating or maintaining sleep are common. Although organic pathology can be the cause of sleep problems at any age, frequent problems prior to age three are most likely due to immaturity and/or environment and can be corrected by working with parents on consistent interactional patterns around bedtime. After age 3, psychiatric pathology can be
  51. 51. CHAPTER 14 Child and adolescent 103 psychiatry considered, although environment is the most likely cause, with physiologic problems in a far 2nd place. The clinician should have a low threshold for considering oppositionality or “bedtime resistance” for complaints between age 3-5. After 5 years of age the clinician should consider all of the above, but with increasing consideration of mental health concerns if the sleep problem is impairing and associated with other peer, school, or family difficulties. It is also important to consider formal sleep problems, such as sleep apnea, sleep walking, sleep terrors, nightmare disorder, and narcolepsy. Adolescents have an increased difficulty falling asleep due to a shift in their circadian rhythm, although they may present to the clinician with a parental complaint of oversleeping, since their overall need for sleep does not decrease. Clinical pearl Behavioral interventions around bedtime and sleep hygiene cure most sleep problems. Clinical pearl Make questions about sleep part of your routine exam. Be certain to include questions about napping, especially in adolescent patients (see sleep chapter for details, p. ?388– 425) Sleep disorders Classified as for adult sleep disorders (see pp. ?388–425). The main syndromes that manifest in children and adolescents are: nightmare disorder (p. ?418); sleep terror disorder (p. ?415); and sleepwalking disorder (pp. 414?– 15). Management is the same as for adults. Motor skills disorder/ Developmental Coordination Disorder There are a number of conditions affecting children where the primary problem involves an impairment of motor function. This may manifest as a delay in developmental milestones and includes impairments of coordination, fine motor skills, and gross movement. Gross motor impairments suggest genetic etiology while fine motor impairments suggest environmental causation. Treatment involves physiotherapy, OT, and educational assistance. Failure to Thrive Evaluation for physiological or developmental problems is imperative. It is important to correct any nutritional deficiency as
  52. 52. 104 soon as possible in order to prevent negative impact on development. Clinical pearl efeeding alone is not adequate, since failure to thrive is often related to either a primary or secondary failure of the feeding process. Obesity Severe overeating is a behavioral phenotype associated with some genetic and behavioral conditions. In addition, medications such as mood stabilizers and antipsychotics are associated with dyslipidemia and obesity. As such, weight parameters should be monitored in all children. Feeding and eating disorders of infancy and early childhood1 Pica This is a common condition where there is persistent (>1month) eating of non-nutritive substances at a developmentally inappropriate age (>1 ½ yrs). Common substances are: dirt, clay, stones, hair, feces, plastic, paper, wood, string, etc. It is particularly common in individuals with developmental disabilities and may be dangerous or life-threatening depending on the substance ingested. Consequences may include toxicity, infection, or GI ulceration/obstruction. Typically occurs during 2nd and 3rd yrs of life, although young pregnant women may exhibit pica during pregnancy. Hypothesized causes include: nutritional deficiencies; cultural factors (e.g. clay); psychosocial stress; malnutrition and hunger; brain disorders (e.g. hypothalamic problem). Rumination This is the voluntary or involuntary regurgitation and re-chewing of partially digested food. Occurs within a few minutes post-prandial and may last 1–2 hrs. Regurgitation appears effortless and is preceded by belching. Typical onset 3–6 months of age, may persist for several months and then spontaneously remit. Also occurs in older individuals with MR. May result in weight loss, halitosis, dental decay, aspiration, recurrent URI, and sometimes asphyxiation and death (5–10% of cases). Causes include: MR; GI pathology; psychiatric disorders; psychosocial stress. Treatment includes physical examination and 1 Ellis CR and Schnoes CJ (2002) www.emedicine.com
  53. 53. CHAPTER 14 Child and adolescent 105 psychiatry investigations; behavioral methods; nutritional advice. Eating Disorders: Anorexia Nervosa and Bulimia Nervosa occur mostly in females, with a typical onset around age 15-19 (although onset is by no means is limited to this age range). Treatment is challenging, and with very high relapse rates. Assessment, Diagnosis, and treatment is similar in adolescents and adults. (see page 375?? for details)

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