Child and Adolescent Psychiatry

Robert Goodman, Stephen Scott

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118340929
• Edition: 3
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Child and Adolescent Psychiatry has been widely acclaimed since the publication of its first edition in 1997(originally titled Child Psychiatry ). Each chapter has been designed to present the key facts, concepts and emerging facets of the area, drawing on clinical experience as well as the latest research findings. These guiding principles are followed in the third edition, which has been updated to reflect the varied advances in research and clinical practice that inform the subject.

Child and Adolescent Psychiatry is structured into four main parts: first, an introductory section on assessment, classification and epidemiology; second, a section covering each of the main specific disorders and presentations; third, a section on the major risk factors predisposing to child psychiatric disorders; and fourth, a section on the main methods of treatment, covering also prevention, service organization and interpersonal and family therapies as well as fostering and adoption.

• Spans child and adolescent psychiatry
• Includes many practical tips on successful assessment and treatment techniques
• Comprehensive coverage of topics, written in an accessible style by international experts in the field
• Up to date information on prevention issues

Written in an accessible style, the book will be of benefit to all those working with children and adolescents with mental health problems: as an invaluable resource for trainee psychiatrists, paediatricians and general practitioners; as a textbook for undergraduate students in medicine, nursing and related fields; and as a refresher for active clinicians.

Supported by a companion website featuring over 200 multiple choice questions and answers to assist those preparing for examinations, including MRCPsych.

PART 1

Assessment, Classification and Epidemiology

CHAPTER 1

Assessment

Performing a thorough psychiatric assessment of a child or adolescent can all too easily become a long and dreary list of topics to be covered and observations to be made – turning the occasion into an aversive experience for all concerned. It is far better to start with a clear idea of the goals and then pursue them flexibly. Ends and means are different: this first part of the chapter deals with ends; the second half of the chapter deals with means, providing some ‘how to’ tips with suggestions about the order in which to ask things.

Five key questions

During an assessment you need to engage the family and lay the foundations for treatment while focusing on five key questions, given in the following list, and remembered by the mnemonic SIRSE. There is a lot to be said for carrying out a comprehensive assessment on the first visit, provided this does not result in such a pressured interview that it puts the family off coming again. As long as you are able to engage the family, it is not a disaster if the assessment is incomplete after the first session provided you recognise the gaps and fill them in during subsequent sessions. Indeed, all assessments should be seen as provisional, generating working hypotheses that have to be updated and corrected over the entire course of your contact with the family. Just as it is a mistake to launch into treatment without an adequate assessment, it is also a mistake to forget that your assessment may need to be revised during the course of treatment. Consider the need for a reassessment if treatment does not work.

Symptoms	What sort of problem is it?
Impact	How much distress or impairment does it cause?
Risks	What factors have initiated and maintained the problem?
Strengths	What assets are there to work with?
Explanatory model	What beliefs and expectations do the family bring with them?

Though child and adolescent psychiatrists and their colleagues may be involved in many types of assessment, these five key questions will be relevant in nearly all cases, albeit with variations in emphasis and approach. Most of the rest of this chapter focuses on an approach that seeks, where possible, to explain the presenting complaint in terms of the child or adolescent having one or more disorders – leading on to a fuller formulation involving aetiology, prognosis and treatment. For some referrals, however, it may be more appropriate to focus on parenting difficulties or problems of the family system as a whole rather than on the problems of the presenting individual.

Symptoms

Most of the psychiatric syndromes that affect children and adolescents involve combinations of symptoms (and signs) from four main areas: emotions, behaviour, development and relationships. As with any rule of thumb, there are exceptions, most notably schizophrenia and anorexia nervosa. The four domains of symptoms are:

1. emotional symptoms

2. behavioural problems

3. developmental delays

4. relationship difficulties.

The emotional symptoms of interest to child and adolescent psychiatrists will be very familiar to most mental health trainees. As with adults, it is appropriate to enquire about anxieties and fears (and also about any resultant avoidance). Ask, too, about misery and, if relevant, about associated depressive features including worthlessness, hopelessness, self-harm, inability to take pleasure in activities that are usually enjoyable (anhedonia), poor appetite, sleep disturbance and lack of energy. Classical symptoms of obsessive-compulsive disorder can be present in young children, even preschoolers. One difference in emphasis from adult psychiatry is the need to enquire rather more carefully about ‘somatic equivalents’ of emotional symptoms, for example, Monday morning tummy aches may be far more evident than the underlying anxiety about school or separation.

Parental reports are the primary source of information on the emotional symptoms of young children, with self-reports becoming increasingly important for older children and adolescents. Somewhat surprisingly, parents and their children often disagree with one another about the presence or absence of emotional symptoms. When faced with discrepant reports, it is sometimes straightforward to decide who to believe. Perhaps the parents have described in convincing detail a string of incidents in which their child's fear of dogs has resulted in panics or aborted outings, while the child's own claim never to be scared of anything seems to be due to a mixture of bravado and a desire to get the interview over with as soon as possible. Alternatively, an adolescent's own account may make it clear that she experiences a level of anxiety that interferes with her sleep and concentration even though her parents are unaware of this because she does not confide in them and spends much of her time in her room. In other instances, it is harder to know who to believe – and perhaps it is more sensible to accept that there are multiple perspectives rather than one single truth.

The behavioural problems that dominate much of child and adolescent psychiatric practice are less familiar territory for most mental health trainees since adults with comparable symptoms are more likely to appear in courts than clinics. Enquiry should focus on three main domains of behaviour: defiant behaviour, often associated with irritability and temper outbursts; aggression and destructiveness; and antisocial behaviours such as stealing, fire setting and substance abuse. Reports from parents and teachers are likely to be the main source of information on behavioural problems, though children and adolescents sometimes tell you about misdeeds that their parents or teachers do not know about. There is only limited value in asking children and adolescents about their defiant behaviours since they, like adults, often find it hard to recognise when they are being unreasonable, disruptive or irritable, however good they may be at recognising these traits in others.

Evaluating developmental delay can be particularly hard for new trainees who do not have children of their own or a background in child health. Development complicates what, in adults, would be a simple assessment. Consider a physical analogy. An adult height of 1 metre is small, whereas a childhood height of 1 metre may be small, average or large; it obviously depends on the age of the child and, unless you have a growth chart handy, you could easily fail to spot children who were unusually small or tall for their age. The same problem is even more pronounced in the psychological domain. What are you going to make of an attention span of five minutes at different ages? Are you missing children whose speech is immature or excessively grown up for their age? How long should a 5-year-old sit still without fidgeting? In the absence of good published norms, you will mostly have to rely on experienced colleagues until you ‘get your eye in’. Remember, too, that experienced parents or teachers are rarely concerned without good reason.

The areas of development that are of particular relevance to child and adolescent psychiatry are: attention and activity regulation; speech and language; play; motor skills; bladder and bowel control; and scholastic attainments, particularly in reading, spelling and mathematics. When judging current levels of functioning, you will be able to draw on direct observations of the child or adolescent as well as reports from parents and teachers. Asking parents about developmental milestones can tell you about their child's previous developmental trajectory.

Assessing children's and adolescents’ difficulties in social relatedness is another taxing task, partly because relationships change with development. In addition, it is not always clear whether children's problems getting on with other people reflect primarily on them or on the other people. For example, if a child with cerebral palsy is unable to make or keep friends, how far might this reflect the child's lack of social skills, and how far might it reflect the prejudice of other children?

The most striking impairments in relatedness are seen in the autistic disorders, generally taking one of three forms: (1) an aloof indifference to other people as people; (2) a passive acceptance of interactions when others take the initiative and tell them what to do; and (3) an awkward and rather unempathic social interest that tends to put others off because of its gaucheness. Disinhibition and lack of reserve with strangers are prominent in some autistic, hyperactivity and attachment disorders, and may also be seen in mania and after severe bilateral head injury. The disinhibition may be accompanied by a pestering, importuning style. In small doses, some of these traits can seem quite charming. For example, after a few minutes acquaintance, you may judge a boy to be delightfully frank or open or eccentric. However, this sort of charm generally palls with longer acquaintance and the history usually makes it clear that his manner soon becomes very wearing for all those in regular contact with him.

Some children and adolescents have difficulty relating to most social partners, whether young or old, strangers or friends. Other children and adolescents have problems with specific types of social relationship, for example, with attachment or friendship relationships. The problems may even be specific to one important social partner. Thus, most children and adolescents are specifically attached to a relatively small number of key people, and the quality of their attachment (secure, resistant, aloof, disorganised) may vary, depending on which of these key people they are relating to. For example, the attachment may be insecure with the main caregiver but secure with the other caregivers (see Chapter 32). Similar specificity can be seen in sibling relationships.

You can gather information on a child or adolescent's social relationships from several sources. Observing the family interactions in the waiting room or consulting room can be very helpful. See how the child or adolescent relates to you during the physical and mental state examinations. If your assessment follows a fairly standardised pattern, it is all the more striking that one child is shy and monosyllabic throughout while another child of the same age greets you as a best friend and wants to climb onto your lap. Also note what might in other circumstances be called the counter-transference, for example, did you find them irritati...