13 – Child Psychiatry and Neurodevelopmental Disorders




Abstract




Given that children and adolescents can never be thought of simply as “little adults” but rather as patients with their own unique developmental, psychological, and biological characteristics, it is crucial that clinicians recognize how psychopathology presents differently in this population. Key differences between children, adolescents, and adults regarding epidemiology, diagnostic criteria, and treatment are described below for mood disorders, anxiety disorders, trauma and stressor-related disorders, and psychotic symptoms.





13 Child Psychiatry and Neurodevelopmental Disorders


Scott Shaffer and Steven c. Schlozman



Child and Adolescent Psychiatry


Given that children and adolescents can never be thought of simply as “little adults” but rather as patients with their own unique developmental, psychological, and biological characteristics, it is crucial that clinicians recognize how psychopathology presents differently in this population. Key differences between children, adolescents, and adults regarding epidemiology, diagnostic criteria, and treatment are described below for mood disorders, anxiety disorders, trauma and stressor-related disorders, and psychotic symptoms.



Depression


Prior to the 1960s, depression was rarely recognized in children. However, growing research and clinical experience has revealed that children can indeed experience depression although it sometimes presents differently than in adults (Shatkin, 2009). The criteria for major depressive disorder in the DSM-V differ for children and adolescents in two key ways. In children and adolescents, an irritable mood can substitute for a depressed mood. In order to meet these alternate criteria, the irritable mood must be present most of the day, nearly every day rather than simply during specific moments of frustration. Along with significant weight loss when not dieting, failure to make expected weight gain is an acceptable vegetative symptom of depression in children. In addition to these differences in DSM-V criteria, it has been observed that children and adolescents frequently demonstrate less impairment in sleep, energy, appetite, and concentration than depressed adults typically do (Birmaher, Brent, et al., 2007). In addition, depressed young children may report somatic symptoms such as stomach aches or headaches (Engle, Winiarski, et al., 2018).



Epidemiology

The Center for Disease Control and Prevention (CDC) estimates the incidence of depression in children 3–5 years old to be 0.5 percent, 2 percent for 6–11-year-olds, and up to 12 percent for 12–17-year-olds. The gender ratio is 1:1 for children, but becomes 2:1 female:male in adolescence (Perou, Winiarski, et al. 2013).



Treatment

The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter indicates that “it is reasonable, in a patient with a mild or brief depression, mild psychosocial impairment, and the absence of clinically significant suicidality or psychosis, to begin treatment with education, support, and case management related to environmental stressors in the family and school. It is expected to observe response after 4 to 6 weeks of supportive therapy” (Birmaher, Brent, et al., 2007). Cognitive-behavioral therapy (CBT) and interpersonal psychotherapy are both evidence based therapies for depression in adolescents. CBT provides the patient with skills and strategies to identify and connect their thoughts, feelings, and behaviors. Interpersonal psychotherapy targets the adolescent’s interpersonal skills as a way to improve their relationships, which then improves depressive symptoms.


Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment in children and adolescents with moderate to severe major depressive disorder (Birmaher, Brent, et al., 2007). Fluoxetine is FDA approved for children eight years and older, and escitalopram is FDA approved for children twelve years and older. Other SSRIs, while off-label, are frequently used to treat depression in children and adolescents as well, though the evidence base is weaker. Following a review of all studies of antidepressants in children and adolescents, a pooled analysis demonstrated that about 4 percent of patients taking medication reported thoughts of suicide compared to 2 percent of patients taking placebo. As a result, in 2003 the FDA issued a black box warning stating that children and adolescents treated with antidepressants “should be observed closely for clinical worsening, suicidality, or unusual changes in behavior” (Noel, 2015). Since depression itself increases the likelihood of experiencing suicidal ideation, proving the link between SSRIs and increased suicidality has been challenging. While close monitoring when prescribing SSRIs to youth is important, SSRIs are considered safe medications that have the potential of providing improvement in symptoms when prescribed appropriately.



Bipolar Disorder


A significant current controversy in child and adolescent psychiatry is the approach to the diagnosis of bipolar disorder in children and adolescents. Symptoms associated with mania, such as aggression, impulsivity, irritability, and risk-taking behavior, can be seen in children diagnosed with behavioral disorders such as ADHD and Conduct Disorder (Parems & Johnston, 2010).


It is rare for children and young adolescents to demonstrate discrete episodes of depression and mania with clear change from baseline that is consistent with Bipolar I Disorder (Parems & Johnston, 2010). Bipolar disorder is thought of as a spectrum, and behavioral dysregulation and “mood swings” in youth have been used to justify a diagnosis of bipolar disorder. However, the DSM-V criteria for a manic episode are the same in children, adolescents, and adults.


The diagnostic criteria for cyclothymic disorder differ for children and adolescents compared with adults. Young patients require only one year rather than two years of numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. It is crucial that children and adolescents receive a thorough and comprehensive psychiatric evaluation to determine whether their symptoms can best be explained by bipolar disorder.



Epidemiology

The prevalence of bipolar disorder in clinical populations in the United States has ranged from 0.6 percent to 15 percent and varies depending on the setting, referral source, and methodology in defining the diagnosis. Whether this increase is due to overdiagnosis or a heightened awareness on the part of clinicians is a current controversy in the field. Patients with bipolar disorder have a high rate of comorbid diagnoses, including disruptive behavior disorders (30 percent to 70 percent), ADHD (50 percent to 80 percent), and anxiety disorders (30 percent to 70 percent) (International Association for Child and Adolescent Psychiatry and Allied Professions [IACAPAP], 2015).



Treatment

Lithium was the first medication to be approved by the FDA for the treatment of mania in children ages twelve to seventeen years. Several atypical antipsychotics are FDA approved for the acute treatment of manic or mixed episodes in children and adolescents: risperidone for ten- to seventeen-year-olds, olanzapine for thirteen- to seventeen-year-olds, aripiprazole for ten- to seventeen-year-olds, and quetiapine for ten- to seventeen-year-olds. Lurasidone is the only medication that is FDA approved to treat bipolar depression in children and adolescents.


It is important that children and families receive psychotherapy in addition to psychopharmacologic treatments. Patients and families can benefit from recognizing triggers and early signs of mood changes, and to receive emotional support for coping with a chronic mental illness. Child and family focused cognitive-behavior therapy (CFF-CBT) was specifically designed for eight- to eighteen-year-olds with bipolar disorder. CFF-CBT consists of twelve 60-minute sessions that are delivered weekly over 3 months. The intervention is designed to be employed across multiple domains – individual, family, peers, and school – to address the impact of bipolar disorder on the child’s psychosocial functioning (IACAPAP, 2015).



Disruptive Mood Dysregulation Disorder


Throughout the 1990s and early 2000s, researchers observed that children and adolescents who demonstrated severe nonepisodic irritability were frequently diagnosed with bipolar disorder. Ellen Liebenluft, MD, captured these patients with her description of severe mood dysregulation, which she defined as “severe, nonepisodic irritability and the hyperarousal symptoms characteristic of mania but who lack the well-demarcated periods of elevated or irritable mood characteristic of bipolar disorder.” Children with severe mood dysregulation were compared to those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples demonstrated that nonepisodic irritability in youth was common and was associated with an increased risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adults. Data also suggested that children with severe mood dysregulation had lower familial rates of bipolar disorder than did those with bipolar disorder (Liebenluft, 2011). These important findings led to a new diagnosis in the DSM-V called disruptive mood dysregulation disorder. The diagnostic criteria include severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation. The temper outbursts are inconsistent with developmental level, and they occur on average three or more times per week. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others. Symptoms are present for twelve or more months, and throughout that time, the patient should not have a period lasting three or more consecutive months without all of the symptoms. The symptoms are also present in at least two of three settings. The diagnosis should not be made for the first time before age six years or after age eighteen years, and the age at onset is before ten years. In addition, the full symptom criteria for a manic or hypomanic episode have not been met, and the diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder.


Since this is a new diagnosis, information regarding epidemiology and treatment is limited. Based on prevalence estimates of chronic and severe irritability, the prevalence likely falls in the 2 to 5 percent range. Rates are expected to be higher in males and school-age children than in females and adolescents (APA, 2013).



Anxiety Disorders


Anxiety disorders are of particular interest in child and adolescent psychiatry because of their early onset. About 5 percent of children and adolescents in Western countries meet the criteria for an anxiety disorder. As in adults, there is about a 1.5–2 times difference in the presence of anxiety disorders in females compared to males. Of all psychiatric disorders seen in children, they are often the most early to appear but often go untreated due to a cycle of avoidance on behalf of the patient and families. Similarly to adults, evidence-based treatment of anxiety disorders in children and adolescents consists of selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT). For patients experiencing mild anxiety that is causing minimal impairment, a trial of cognitive-behavioral therapy alone is recommended. For patients who are experiencing more moderate-severe symptoms and greater levels of impairment, and/or who have failed a trial of cognitive-behavioral therapy, combined treatment consisting of CBT and an SSRI is recommended (Connolly, Sucheta, et al., 2007).



Separation Anxiety Disorder

The diagnostic criteria for separation anxiety disorder are the same as adults with one exception: the fear, anxiety, or avoidance lasts at least four weeks in children and adolescents rather than six months in adults. In children, six- to twelve-month prevalence is around 4 percent, and in adolescents, the twelve-month prevalence is 1.6 percent. It is the most prevalent anxiety disorder in children younger than twelve years old (APA, 2013). School refusal is a frequent manifestation of separation anxiety disorder, which leads to significant academic and social impairment.

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Jul 27, 2021 | Posted by in PSYCHIATRY | Comments Off on 13 – Child Psychiatry and Neurodevelopmental Disorders

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