Childhood and Adolescent Psyciatric Disorders



Childhood and Adolescent Psychiatric Disorders 8/30/05

1) Discuss the questions to be answered in the psychiatric evaluation of children

• Does child have a “recognized” (DSM) psychiatric disorder?

• Understand the reason the child has been referred for a psychiatric evaluation (why at this point in time and who made the referral). Also it is important to assess the attitude of the family toward psychiatric disorders and interventions.

• Determine the significance of intrapsychic, family, social-cultural, and biological factors (continue to evaluate if these factors are helping or hurting the disorder)

• Assess strengths and competencies of child and family and the outcome if left untreated

• Determine what treatment is necessary and most likely to be effective

2) Describe the principles of evaluating children

• 20% children and adolescent have diagnosable psychiatric disorder. Although developmental characteristics may influence psychiatric symptoms, children can be diagnosis with ANY psychiatric disorder for which they meet the criteria.

• Children under 12: boys suffer from psychiatric illness more than girls (ADHD). In adolescence (over 12) girls suffer more (mood disorders)

• Evaluations may take longer in children and it is important to get information from collateral sources (family members, school staff, friends, etc.)

• The physician must have a working understanding of the normal development of children to distinguish pathology and normalcy (i.e. bedwetting, separation anxiety and tantrums)

• Obtain info not only from direct questioning, but observation (especially with young children – may be best evaluated while playing or drawing)

• Children and adolescents often present with somatic complaints. A physical exam is an important tool to rule out medical causes of symptoms.

• Psychological testing (testing for learning disabilities or projective tests) can be helpful to clarify diagnosis, but should not take the place of a psychiatric evaluation.

3) Discuss issues involved in interviewing children

• Be prepared to bring up abuse, sexuality, substance abuse or other delicate subjects, but be aware of sensitivity and your patients discomfort

• Interview parents and children together and separately

• Open-ended questions and “non-structured” interviews often most effective. Start with non-threatening questions.

• Environment (comfortable & non-threatening, available toys and drawing materials)

• Confidentiality: clarify limits at beginning. Many parents will agree to confidentiality between child and doc. Info harmful to child or others needs to be shared with parents.

• Psychiatric interview should include History of present illness, past psychiatric, family psychiatric, medical and social histories (including education, developmental, legal, substance abuse histories, and families living and financial situation.) Interview should include mental status exam.

4) Describe common psychiatric disorders of children/adolescents: include treatment

Mood Disorders

• Unipolar and bipolar possible. Mania is rare prior to puberty and may be confused w/ ADHD. (However, Dr. Johnson worried children are being over diagnosed as bipolar)

• Prior to puberty, depression more common in boys that girls (changes @ puberty)

• 3X more likely to be depressed if parents suffer from depression

• Prevalence: Major depressive (2% pre-pubertal children, 5% adolescents)

Dysthymic disorder w/out major depression 3.3% adolescents

• Clinical Features: Essentially the same as for adults with following exceptions

o Mood can be irritable instead of depressed

o May not lose weight, but rather fail to make expected developmental weight gains

o Reduction of school performance or activities w/ friends, boredom, aches & pains

o Less likely to show anhedonia, psychomotor retardation, delusions, or insomnia. (however just as critical to assess suicide level)

• Treatment: individual and family psychotherapy first line (in non psychotic depression meds added if no improvement within 3-4 wks). Many antidepressants are not FDA approved for use in children, but still used. Formerly used tricyclic antidepressants (EKG monitoring and plasma level necessary), now use SSRIs and newer drugs

Anxiety Disorders Affect 2-8% children and adolescents. Overlap with depression common.

Simple Phobias – Often will go away without treatment, but treatment helpful if phobia is severe. Treatment: Desensitization, medication, individual and group psychotherapy

Separation Anxiety Disorder (SAD) – “excessive anxiety for patient’s age lasting for at least 4 wks concerning separation from parents or individual to whom the child is attached” Worry something will happen to parent or themselves if separated, reluctance to go to school, refusal to sleep alone or away from home, nightmares about separation, etc.

• Separation anxiety normal from age 7 months to early preschool (not a disorder)

• SAD is most common childhood anxiety disorder (related to adult agoraphobia)

• Treatment: Individual/parent/family therapy. Meds: Antidepressants commonly used. Sometimes use anti anxiety meds temporarily

Generalized Anxiety Disorder “Unrealistic worry in multiple areas (future events, past behavior, child’s competence, somatic complaints, self- consciousness, excessive need for reassurance)” Often see nail-biting, thumb sucking, and hair pulling or twisting

• More common in older children (may be associated with SAD, often seen w/ADHD)

• Treatment: Individual/parent/family therapy. Meds: Antidepressants

Obsessive-Compulsive Disorder – prevalence 3-4% (with some symptoms in 8% teens)

• Many go undiagnosed into adulthood (diagnostic criteria same in adults, although rituals more common in children). Symptoms may wax and wane.

• Perhaps associated with exposure to group A beta streptococci infection

• Treatment: Meds important (Clomipramine, Fluoxetine, Fluvoxamine, and other SSRIs) Behavioral modification and/or psychotherapy often helpful. Treatment needed for multiple years (can relapse if discontinue meds).

• Assoc. w/ depression, tics, developmental delays, anxiety disorders, and Tourette’s

Schizophrenia – in teens similar to adults, features in children different. Prevalencea in childhood 1/2000. Increases after puberty, reaching adult levels in late adolescence.

• Children – uneven development, language and social behavior delayed and different than normal children. Visual hallucinations more common in kids than adults.

• Evaluation : medical history, physical exam, vital signs, baseline lab tests, EEG and CT or MRI of brain

• Treatment: Psychotherapy, Meds often vital, Family psycho-educational treatment. Token economics (operant conditioning) helpful to shape behavior. Hospitalization and long term residential treatment may be necessary.

Eating Disorder – 20-40 % infants and toddlers have feeding problems. Often due to mismatch of child/ parents eating style, child’s independence & assertion, & changes in normal growth rate

• Estimated 25% teens have eating disorder (Only 14% teen girls satisfied w/ their weight). By Kindergarten kids choose thinness in girls and muscles in boys to measure popularity.

• Early childhood – Pica, feeding disorders, and rumination disorder

• Late childhood – Anorexia Nervosa and Bulimia Nervosa

• Treatment – Look for co-morbid psychiatric disorders. Behavioral management, psychotherapy, and environmental interventions. Meds helpful (SSRIs).

Mental Retardation – IQ ................
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