69: Child and Adolescent Psychiatric Disorders

CHAPTER 69 Child and Adolescent Psychiatric Disorders



Jeff Q. Bostic, MD, EdD, Jefferson B. Prince, MD




KEY POINTS



• Psychopathology often begins and manifests, sometimes differently, in childhood and adolescence.

• Assessment of children and adolescents requires developmentally sensitive adjustments to diagnostic criteria.

• Co-morbidities and symptoms from other disorders require consideration and sometimes targeted treatment interventions.

• Despite the resilience of children and adolescents, treatments are necessary and appropriate to minimize the effects of psychopathology on the child’s development.

• Treatment-planning for children and adolescents requires attention to configuring the environment to match the child’s needs and existing skills, as well as consideration of biological and psychological therapies.


OVERVIEW


Children and adolescents bring diverse genetic, temperamental, perceptual, and sociological backgrounds to the environments in which they are raised. The unique constellations of these background variables match, some better and some worse, to fluctuating environmental pressures that are often outside of the control of the young person. Sometimes significant biological factors, other times significant environmental factors, can stress the fit between the child and the environment, increasing vulnerability to expressions of psychopathology. Childhood and adolescence may alter expression of psychopathology, but young people are increasingly recognized as suffering psychiatric symptoms. Such symptoms can emerge in children, particularly those who face intense stress, loss of a caregiver, chronic illness, or a personal or family history of psychiatric disorders.


Epidemiological research has illuminated the prevalence of psychopathology in children and adolescents. Table 69-1 summarizes the prevalence of psychiatric disorders during childhood.


Table 69-1 Prevalence of Psychiatric Disorders in Children Ages 9 to 17
























Psychiatric Disorder Prevalence Past 6 Months (%)
Any psychiatric disorder 20.9
Anxiety disorders (includes generalized anxiety, separation anxiety, acute stress disorder, posttraumatic stress disorder, obsessive-compulsive disorder) 13
Disruptive behavior disorders (includes attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder) 10.3
Mood disorders (includes depression, dysthymia, bipolar disorder) 6.2
Substance abuse (includes abuse or dependence with any substance, including alcohol, marijuana, opiates, stimulants) 2.0
Pervasive developmental disorders (includes autism, Asperger’s, PDD NOS) < 1%

PDD NOS, Pervasive developmental disorder not otherwise specified.


Table 69-1 illuminates that anxiety disorders are the most common psychopathology of childhood. Disruptive behaviors, which include attention-deficit/hyperactivity disorder (ADHD), as well as oppositional defiant disorder (ODD) and conduct disorder, are less prevalent than anxiety disorders. Mood disorders are less prevalent in juveniles than anxiety or disruptive behaviors, and substance abuse appears still less often than mood disorders. While pervasive developmental disorders (including autism, Asperger’s, and milder forms of autism) have recently received much more attention, and appear to be more prevalent than described in previous decades, the pervasive developmental disorders are still much less common than are these other psychiatric disorders. Some psychiatric disorders occur most commonly in childhood, and these, while most are uncommon, are summarized in Table 69-2.


Table 69-2 Psychiatric Disorders Usually Occurring during Childhood



































































































Disorder Primary Symptom(s) Detection
Mental retardation Decreased intellectual function and impairments in adaptive function (e.g., self-care, independence) Intelligence testing less than approximately 70 and adaptive functioning impaired reported by others or testing (e.g., Vineland)
Learning disorders Achievement in reading, writing, math is below that expected based on intelligence Discrepancy on achievement test compared to intelligence tests
Motor skills disorders Impairments in motor coordination that affect daily living Coordination not because of specific medical disorder or pervasive developmental disorder
Communication disorders Communication difficulties including expressing self, stuttering, reception of language, articulation Usually by functional assessment of language by clinician; instruments available for expression/reception
Pervasive developmental disorders (PDDs): autism Impairments in social interaction and communication, and restricted interests Clinical interview and observations of delayed/unusual language; often nonfunctional routines or unusual interests
PDD: Rett’s disorder Deceleration in head circumference; deterioration of hand function to handwringing; loss of interest in social environment Clinical interview and observation; comparisons with earlier growth charts
PDD: childhood disintegrative disorder Marked regression in multiple areas of function after 2 years of apparently normal development Clinical interview and observation; comparisons with earlier growth data
PDD: Asperger’s disorder Autism symptoms except normal language development in infancy Clinical interview and observations of unusual social connection to others; sometimes unusual prosody, narrow interests
Attention-deficit/hyperactivity disorder Inattention and possibly hyperactivity and impulsivity Clinical interview and observation/description (often by others) of distractible, restless, impatient behaviors
Conduct disorder Persistent pattern of violating rights of others or social norms Description (often by others) of aggressive, destructive, antisocial/criminal, and runaway/truancy behaviors
Oppositional defiant disorder Persistent pattern of defiance toward authority figures Description (often by others) of argumentativeness, resentment, and hostility toward adults, teachers
Pica Eating of nonnutritive substances Description of eating dirt, paint, hair, for example; occasionally, imaging reveals ingested agents
Rumination disorder Repeated regurgitation, rechewing of food after normal feeding accomplished Observation or description by others of unusual pastural sounds while rechewing food
Feeding disorder of childhood Failure to eat adequately Detected by failure to gain weight in absence of medical etiologies
Tourette’s disorder Multiple motor tics and one or more vocal tics Clinical observation or description by others of tic sounds and movements
Chronic tic disorder Motor or vocal tics Clinical observation or description by others of tic sounds or movements
Transient tic disorder Motor and/or vocal tics that last more than 4 weeks but less than 12 months Clinical observation or description by others of tic sounds and/or movements
Encopresis Repeated passage of feces in inappropriate places monthly after reaching age 4 years Usually description by others; not because of a medical condition
Enuresis Repeated voiding of urine twice weekly while asleep or causing distress or impairing function after reaching the age of continence Usually description by others; not because of medical condition
Separation anxiety Excessive anxiety surrounding separations from caregivers or home Clinical interview and description from caregivers of efforts to avoid separations
Selective mutism Persistent failure to speak in specific social situations where speaking expected, yet speaking in other situations Clinical interview, observation, and report from others of patient’s reluctance to speak in some places while speaking in other places
Reactive attachment disorder Markedly disturbed, inappropriate social relatedness before age 5 and associated with pathological care Clinical interview and observation; often indiscriminate connection to strangers
Stereotypic movement disorder Driven, nonfunctional motor behaviors; may be self-harming Observation or description of motor activities interfering with normal activities or resulting in self-inflicted injuries that require treatment

Psychopathology often becomes detected as the child grows and then faces new developmental challenges. For example, children learn to watch and to emulate their caregivers, to ambulate, to speak, to play with other children, to separate from parents to attend school, to adhere to the structure of schools where these children can learn from others, to find their place among their peers, to construct their identity different from that of their parents, and to bond with others as they prepare themselves to have and to raise their own children. As the child faces each of these developmental hurdles, those hurdles may exceed the child’s abilities and increase the child’s vulnerability for developing psychopathology. Different anxiety disorders are therefore more prevalent at different times, consistent with the developmental demand at that point. So separation anxiety more commonly emerges early in childhood (when the child transitions from home to school, or to a different school, or community), while obsessive-compulsive disorder (OCD) more commonly occurs later in childhood or during adolescence. Similarly, mood disorders are diagnosed more commonly during adolescence, as the challenge to fit in among peers may prove too difficult and loneliness and isolation increase risks of depression.


A number of instruments are available to screen for the presence of psychopathology in children and adolescents (see Appendix 69-1). Commonly employed general instruments include the Pediatric Symptom Checklist, now available in multiple languages. This and other general and specific screening tools are available online at www.schoolpsychiatry.org.


Treatments continue to evolve, and psychosocial interventions increasingly are examined to clarify which components benefit and match to certain types of symptoms and to certain types of patients. Child psychiatry also has witnessed the proliferation of medication treatments. While medications have become a valuable part of the treatment armamentarium for children, special considerations are required in the medication of children (Table 69-3).


Table 69-3 Use of Psychotropics in Pediatric Patients






1. The use of psychotropic medications should follow a careful evaluation of the child and the family, including psychiatric, medical, and social considerations. Children who manifest transient symptoms related to an adjustment to medical illnesses or to losses should be considered for nonpharmacological treatment; pharmacological care should be reserved for refractory cases.

2. Pharmacotherapy should be considered as part of a comprehensive treatment plan that includes individual and family psychotherapy, educational and behavioral interventions, and careful medical management; it should not be presented as an alternative to these other interventions.

3. If a patient has a psychiatric disorder that may respond to psychotropic medications, the clinician should decide which psychotropic medication to use, and take into consideration the age of the child and the severity and nature of the symptomatic picture. Diagnosis and target symptoms should be defined before initiating pharmacotherapy.

4. The family and the child should be familiarized with the risks and benefits of this intervention, the availability of alternative treatments, the possible adverse effects, the potential for interaction with other medications, the realization of possible unforeseeable adverse events, and the prognosis with and without treatment. Providing patients choices in treatments, including medications, may improve adherence to treatments. Permission to use medications should be obtained from the custodial parent or the patient’s legal guardian. Standard use of antipsychotics in children and adolescents who are in the custody of the state may require a legal hearing; however, antipsychotics can be used in these patients in emergency situations.

5. Ongoing pharmacological assessment is necessary. When a medication is thought to be either ineffective or inappropriate to the current clinical situation, these agents should be tapered and discontinued under careful clinical observation. Appropriate alternative interventions should be reviewed with the family and then initiated.

6. The Food and Drug Administration (FDA) approves the use of medications in specified clinical situations. However, the FDA allows practitioners to use medications in clinical situations not included in the official labeling. That is, practitioners may use a medication for clinical situations other than the “approved” use or the use of medications in age-groups not formally studied. Often, medical advances are made with use of drugs in conditions that are not as yet included on the package insert.

7. Previously the law of parsimony dictated a single cause for each symptom complex; this led to the use of large doses of individual agents for a given disorder, which can often result in intolerable adverse effects. In contrast, the use of combined pharmacotherapy has permitted more targeted treatment and greater efficacy, often achieved with lower doses and fewer adverse effects.


DEVELOPMENTAL VARIATIONS IN PSYCHOPATHOLOGY


The diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) sometimes require developmentally sensitive adjustments to detect symptoms in patients at different ages.1 Table 69-4 compares different symptom presentations of DSM-IV-TR disorders in pediatric versus adult patients.


Table 69-4 Developmental Considerations in DSM-IV-TR Criteria















































Disorder DSM-IV-TR Criteria* Age-Related Adjustments
Obsessive-compulsive disorder Either obsessions: (1) intrusive anxiety-provoking recurrent, persistent thoughts, impulses, or images that (2) are not excessive worries about real-life problems that (3) person tries to ignore or neutralize, which (4) are a product of his or her own mind; OR, compulsions: (1) repetitive behaviors in response to an obsession or according to rules that must be rigidly applied, which (2) prevent or reduce distress or some dreaded situation Children may not acknowledge symptoms, and symptoms may not be ego-dystonic to young children. Children do not have to recognize obsessions or compulsions as excessive or unreasonable.
Generalized anxiety disorder Excessive anxiety and worry more days than not for at least 6 months about multiple things the person finds difficult to control. Three or more of the following symptoms: (1) restlessness or being keyed up; (2) easily fatigued; (3) difficulty concentrating or having one’s mind going blank; (4) irritability; (5) muscle tension; (6) sleep disturbance Children may describe more somatic complaints and even deny worries or fears. Child anxieties more often concern competence or performance at school/sports, or improbable catastrophic events.
Acute stress disorder; posttraumatic stress disorder (PTSD) Person is exposed to a traumatic event where actual or threatened physical integrity of self or others and person’s response involved intense fear, helplessness, or horror; associated symptoms of numbing, detachment, lack of emotional responsiveness; reduced awareness of surroundings, derealization, depersonalization, dissociative amnesia, reexperiencing in images, dreams, flashbacks, or distress when reminded; marked avoidance of stimuli that arouse recollections of the trauma; marked anxiety or hyperarousal Children may or may not be able to describe distressing events, and may fear betraying adults so that they resist description of traumatic events; distressing dreams of the event may turn into generalized nightmares of monsters, rescues, or threats; children may exhibit repetitive play of the event rather than perceive reliving it. Foreshortened futures, belief in abilities to foretell pending negative events, and somatic complaints are more common in children with PTSD.
Attention-deficit/hyperactivity disorder Inattention (six or more of the following): (1) careless mistakes; (2) difficulty sustaining attention; (3) does not seem to listen; (4) does not follow through or finish tasks; (5) difficulty organizing; (6) dislikes/avoids mental tasks; (7) loses things; (8) easily distracted; (9) forgetful Hyperactivity is often more visible in younger patients, who may be difficult to contain. For adolescents and adults, hyperactivity may manifest as restlessness, jitteriness, or internal urges to move about.
  Hyperactive/impulsive (six or more of the following): (1) often fidgets or squirms; (2) leaves seat when expected to sit; (3) runs or climbs excessively/feels restless; (4) difficulty doing leisure acts quietly; (5) often “on the go” or “driven by a motor”; (6) talks excessively; (7) blurts out; (8) difficulty waiting turn; (9) often interrupts or intrudes  
  Some symptoms impairing by age 7, impair in two or more settings (school, home, peers)  
Oppositional defiant disorder Pattern of defiant behavior (not conduct disorder or antisocial personality disorder) over 6 months and often doing four or more of the following: (1) loses temper; (2) argues with adults; (3) refuses to comply with adult requests/rules; (4) deliberately annoys others; (5) blames others for own mistakes; (6) acts touchy or easily annoyed; (7) gets angry and resentful; (8) behaves spiteful or vindictive Oppositionality is common in children at age 2 and again during adolescence; symptoms should increase and persist in children rather than represent persisting conflict around toilet training or dating; instead, resistance to multiple authority figures over various issues rather than “fit” between child and particular adult.
Depression Mood symptoms (five or more): (1) depressed or irritable mood most of day nearly every day for at least 2 weeks accompanied most days by (2) diminished interest or pleasure; (3) significant weight loss or loss of appetite; (4) insomnia or hypersomnia; (5) psychomotor agitation or retardation; (6) fatigue or energy loss; (7) worthlessness or inappropriate guilt; (8) loss of concentration or indecisive; (9) recurrent thoughts of death or suicide; not bereavement (symptoms following loss of loved one beyond 2 months) Children may appear irritable rather than complain of sadness. Children may avoid activities, complain of somatic symptoms, or be negative about activities or peers rather than report loss of energy, increased self-criticism or guilt, or lack of pleasure or changes in libido. Symptoms of dysthymia need only be present for 1 year (instead of 2 years) in juveniles.
Bipolar disorder Mania, with elevated, expansive, or irritable mood lasting at least 1 week, accompanied by three or more of the following symptoms (four if irritable mood): (1) inflated self-esteem or grandiosity; (2) decreased need for sleep; (3) more talkative or pressured speech; (4) racing thoughts or flight of ideas; (5) distractibility; (6) increase in goal-directed activity/agitation; (7) excessive involvement in pleasurable activities with high potential for painful consequences Episodes in children are more commonly “ultra-rapid,” happening multiple times per day, and exclusively manic intervals lasting multiple days or weeks are uncommon. Irritability or silliness is more common among children than grandiosity or hyperreligiosity.
Psychosis (schizophrenia) Two or more for a significant time during a 1-month period: (1) delusions; (2) hallucinations; (3) disorganized speech (derailment or incoherence); (4) grossly disorganized or catatonic behavior; (5) negative symptoms (i.e., affective flattening, alogia, or avolition) Functional impairment or loss of self-care Children may report hypnopompic or hypnagogic hallucinations; children may report fantasy characters and wishes even into elementary school years. Failure to achieve (rather than deterioration from) an expected level of interpersonal, academic or occupational achievement is more common in children with psychosis.

* In all cases, symptoms must cause marked impairment and not be due to another disorder, intoxication (except substance abuse disorders), or other medical condition.



CHILDHOOD ANXIETY DISORDERS


When unremitting anxiety impairs the child across family, peer, and school/work domains, anxiety disorders should be considered. Anxiety problems often manifest in children as multiple somatic complaints (such as headaches, stomachaches, and nervous twitches of unknown physiological nature). Further inquiry of the child or caregivers may reveal multiple fears or incapacitating worries. The most common anxiety disorders requiring treatment in children are separation anxiety, generalized anxiety disorder (GAD) of childhood, and acute stress disorder (ASD). Other anxiety disorders, such as posttraumatic stress disorder (PTSD) or OCD, may cause substantial impairment, but are characterized by symptoms less often acknowledged by children or detected by the adults in their lives. Often the child has a parent with an anxiety disorder. Childhood anxiety disorders are relatively common and may persist into adult life.



Separation Anxiety


In separation anxiety, the predominant disturbance is a developmentally inappropriate excessive anxiety on separation from familial surroundings. A certain level of separation anxiety is an expected and healthy part of normal development that occurs in all children to varying degrees between infancy and age 6. Healthy separation anxiety is typically seen around 8 to 10 months of age, when an infant becomes anxious when meeting strangers (stranger anxiety). Children also may become mildly anxious around 18 to 24 months of age, when they are increasingly exploring their world but wanting to return to their caregiver frequently for security. In contrast, approximately 2% to 5% of children will experience separation anxiety disorder at some point with separation worries that are excessive and overwhelm the child for even brief separations (such as leaving to go to school, going to sleep, or staying behind at home when a parent runs an errand). The child’s fears usually appear to be irrational (such as a fear that the parent may suddenly die or become ill). People with separation anxiety disorder often go to great extremes to avoid being apart from their home or caregivers. They may protest against leaving a parent’s side, refuse to play with friends, or complain about physical illness at the time of separating. When separation occurs or is even anticipated, the child may experience severe anxiety to the point of panic. It may develop during the preschool age, but more commonly appears in elementary school–age children.



Treatment of Separation Anxiety



Psychosocial Treatments for Separation Anxiety.


Environmental modifications are often important in the management of separation anxiety. Planned efforts to minimize the magnitude of separations (e.g., having the child transition between familiar adults [such as preferred school staff], constructing check-in notes from parents provided at various points during the preschool or school day, providing planned distracting or attractive activities as the child makes the transition) may all decrease separation fears.


Psychotherapy interventions, matched to the developmental level of the child, are often helpful. For younger children, identifying fears (that something may happen to their parent or to them, or to other adults or children) may provide clarity about the nature of the specific fear so that desensitization or successive approximations can be used to diminish anxiety. For example, for young children unable to sleep in their own rooms, sleeping on the floor, in the hall, or with a light or sibling proximate may prove viable once the child’s particular distress becomes clear. Reinforcement for efforts toward sleeping alone are often needed to sustain the child’s effort. Similarly, assessment of evidence that supports or negates fears, and steps to combat these fears (from relaxation techniques to keeping transitional objects, sometimes imbued with “special powers” to provide the child with strength or special skills) can replace the child’s existing anxiety response. Sometimes a parent of the child with separation anxiety may similarly feel anxious around separations, so mindfulness about parent efforts and responses for separations may illuminate needs for reassurance and de-escalating acts for parents to decrease the cascade of anxiety that surrounds separations.



Pharmacotherapy for Separation Anxiety.


Antidepressants and benzodiazepines are frequently used together to enable children to both separate and tolerate separations. Selective serotonin reuptake inhibitors (SSRIs) are often initiated, while benzodiazepines are simultaneously provided for several weeks until the medication exerts significant effects. Low-dose, short-acting alprazolam or lorazepam is often used to enable the child to separate and to acclimate to the parent-absent environment. In addition, some patients require evening doses of benzodiazepines initially to counter overwhelming anxiety as they anticipate separations at bedtime or the next day. Tricyclic antidepressants (TCAs) have also been useful, primarily as second-line agents, for management of separation anxiety. Several controlled studies with imipramine have demonstrated efficacy for separation anxiety and for school-refusal.2



Obsessive-Compulsive Disorder


Obsessive-compulsive disorder (OCD) is among the best studied of the juvenile anxiety conditions. OCD often develops early in life; nearly one-third of adults with obsessions report the onset of their symptoms before age 15 years, and cases of the disorder have been described as early as age 3. However, less than 25% of patients with OCD seek treatment or admit having OCD before adulthood. OCD is characterized by persistent ideas or impulses (obsessions) that are intrusive and senseless (e.g., thoughts of having caused violence, becoming contaminated, or severely doubting oneself) that may lead to persistent repetitive, purposeful behaviors (compulsions) (e.g., handwashing, counting, checking, or touching in order to neutralize the obsessive worries). Within the medical setting, this disorder is often associated with an exaggerated, persistent, and impairing obsession with an organ, disease process, or treatment. This disorder has been estimated to affect 1% to 2% of the adult population; it has been shown to be familial and associated with Tourette’s syndrome (TS) and ADHD.


Interest has grown in a syndrome that resembles both OCD and tic disorders called pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Investigators have studied plasma exchange, intravenous (IV) immunoglobulin, and penicillin to treat OCD/tics associated with PANDAS.3,4 These treatments appear to be effective only for those patients (less than 10%) whose OCD/tics were associated with streptococcal infections.



Treatment of OCD



Psychosocial Treatment of OCD.


Therapy treatments have been beneficial in the management of OCD. Cognitive-behavioral treatments, both with individuals and with groups of children having OCD, have proven efficacious, including “personifying” the obsessions (e.g., “Germy”), and identifying steps to “boss back Germy,” to recognize how much time the child plays with “Germy” instead of with peers (to make the obsessions more dystonic). Practicing compulsions differently to make them more uncomfortable and com-peting responses to replace existing compulsions have been useful.5



Pharmacotherapy of OCD.


Pharmacotherapy with SSRI antidepressants remains the cornerstone of pharmacological treatments for OCD. Studies suggest that children with OCD respond in a fashion similar to adults, and may require doses up to four times the normal doses used to treat depression (i.e., 80 mg fluoxetine instead of 20 mg daily). The SSRI antidepressants are FDA-approved for OCD in the pediatric population (e.g., sertraline [Zoloft, initiated at 12.5 to 25 mg daily and titrated to 50 to 200 mg daily], fluvoxamine [Luvox, a more sedating drug that is initiated at 25 mg at bedtime and increased to 25 to 150 mg twice per day], and fluoxetine [Prozac, initiated at 5 to 10 mg and increased to 60 mg/day]). In addition, controlled studies have shown the TCA clomipramine (Anafranil) to be effective for pediatric OCD.



Generalized Anxiety Disorder


Generalized anxiety disorder (GAD) of childhood is more frequently seen in boys than in girls. Similar to GAD in the adult patient, the essential feature is excessive worry and fear that is not focused on a specific situation or object and not as a result of psychosocial stressors. Children may manifest an exaggerated or unrealistic response to the comments or criticisms of others. Less commonly, some children and adolescents experience panic attacks.



Treatment of Generalized Anxiety Disorder



Psychosocial Treatments for GAD.


Patient education about the chronic nature of GAD and the fluctuating course of symptoms often associated with the emergence or decrease in stressors may provide reassurance to patients and decrease general stress levels. Psychotherapeutic support using relaxation, deep breathing, and progressive muscle relaxation may help children counter escalations of anxiety. Cognitive-behavioral techniques for appraising situations more completely and logically, and for accessing other input from others or evaluating all the evidence (e.g., the likelihood of a terrorist attack in a rural county), may enable children to control anxiety with cognitive skills.



Pharmacotherapy for Pediatric GAD.


Treatment of GAD in children is similar to the treatment of GAD in adults; SSRIs, benzodiazepines, TCAs, or beta-blockers appear to be effective. Buspirone, a non-benzodiazepine anxiolytic without anticonvulsant, sedative, or muscle-relaxant properties, may provide some benefit alone or by using it in combination with an SSRI. The effective daily buspirone dose is estimated to range from 0.3 to 0.6 mg/kg.



Acute Stress Disorder/Posttraumatic Stress Disorder


Acute stress disorder (ASD) develops within days of a traumatic event and is manifest by anxiety, dissociative symptoms, persistent re-experiencing of the trauma, and avoidance of stimuli that raise recollections of the trauma. This disorder is likely to be observed in pediatric patients or their parents after acute injuries. The severity, duration, and proximity to the trauma are factors that influence the development of ASD, and approximately 15% to 33% of individuals in severe accidents or observing significant harm to others develop an ASD. In addition to the nature (e.g., burns, self-injurious behaviors, or abuse) and extent of the injuries, pre-existing psychiatric illness increases the risk of ASD.


If the stressful symptoms surrounding the trauma last beyond 1 month, the diagnosis changes to posttraumatic stress disorder (PTSD). PTSD may occur following a traumatic event that continues to haunt a person months later, beyond the “acute” reaction to a trauma. Children, like adults, may experience nightmares months to years after a traumatic event, as well as flashbacks or distressing recollections sometimes suppressed successfully for years. Sometimes patients will not have symptoms immediately following the traumatic event, but months or years later. Events resembling a past trauma may rekindle the trauma, culminating in anxiety symptoms, or sometimes a person will experience a PTSD reaction when reaching a developmental point related to the trauma. For example, when children reach high school or college, have their own children, or experience the loss of someone, their distress may emerge as the trauma is re-experienced from a different role (e.g., older sibling or parent instead of child). While ASD and PTSD are not genetic disorders, vulnerabilities to anxiety reactions do have genetic components; in addition, some individuals live in more dangerous or chaotic environments, as do their children, so that PTSD may occur more commonly in some families. Approximately 8% of Americans have been reported to experience PTSD at some point in their lives, although susceptibility to traumatic events increases one’s risk of developing PTSD.



Treatment of Acute Stress Disorder/Posttraumatic Stress Disorder



Psychosocial Treatments of ASD/PTSD.


Efforts to help children separate themselves from the traumatic event, and from the victim role, are usually helpful. Environmental changes to reduce further risks for the child often require intervention by adults to create safety for the child. Cognitive-behavioral techniques to help the child resist traumatic recollections, and to counter recurrent distressing thoughts, to de-escalate anxiety, and to distinguish time or setting variables that surrounded the event to diminish generalization of fears can allay symptoms. Anticipatory planning with family members for reactions to settle the child if nightmares or flashbacks occur can diminish retraumatization during the child’s recollection of past events.



Pharmacotherapy for ASD/PTSD.


Treatment has relied on multiple “off-label” agents reported to be effective for various ASD/PTSD symptoms. High-potency benzodiazepines (e.g., alprazolam 0.25 to 1 mg three times per day or clonazepam 0.25 to 1 mg three times per day) or medium-potency benzodiazepines (e.g., lorazepam 0.25 to 1 mg three times per day) can be effective. While the clinical toxicity of benzodiazepines is low, higher rates of disinhibition are observed in the pediatric population than in adults. The most commonly encountered short-term adverse effects of benzodiazepines are sedation, disinhibition, and depression. With the exception of the theoretical potential risk for tolerance and dependence that appears to be low in children, no known long-term adverse effects are associated with benzodiazepines. Adverse effects of withdrawal can occur, and benzodiazepines should be tapered slowly.


Long-acting benzodiazepines (such as clonazepam) may be preferable when long-term treatment with a benzodiazepine is warranted. For clonazepam, an initial dose of 0.25 to 0.5 mg can be given at bedtime. The dose can be increased by 0.5 mg every 5 to 7 days depending on the clinical response and the side effects. Typically, doses between 0.25 and 2 mg/day are effective. Clinicians should monitor for signs of disinhibition, which may manifest as either excessively silly behavior or as agitation. Children who become disinhibited on high-potency benzodiazepines may respond more favorably to the mid- or low-potency agents (such as clorazepate). Potential benefits of the longer-acting compounds are single-daily dosage and a decreased risk of withdrawal symptoms after discontinuation of treatment.


Beta-blockers, in particular propranolol, have been studied as a means of reducing arousal symptoms of PTSD. Similarly, alpha-adrenergic agents (such as clonidine or guanfacine) may likewise reduce anxiety, hyperarousal, and impulsivity and improve attention. In patients with dissociation, medications that enhance gamma-aminobutyric acid (GABA), such as gabapentin (Neurontin), may reduce the severity of anxiety. In patients with fear or terror, the short-term use of atypical antipsychotics in low doses may be useful.


The SSRIs have been shown to be useful in reducing symptoms of anxiety, depressed mood, rage, and obsessional thinking in adults with PTSD. The SSRIs may be used for similar target symptoms in pediatric patients with PTSD.6



TIC DISORDERS


Perhaps as many as 15% of boys between 8 and 12 years of age have transient tics, often excessive eye-blinking or facial grimacing. These tics usually wax and wane over several years and manifest most frequently when the child is anxious or fatigued. Tics, however, can intensify and become conspicuous, such that the child may feel ostracized or distressed, thus necessitating treatment. Perhaps the best-known persisting tic disorder is Tourette’s syndrome (TS), a childhood-onset neuropsychiatric disorder afflicting up to 3 of every 1,000 children that usually begins with motor tics around age 6; it is manifest by both multiple motor and phonic tics, and is accompanied by other behavioral and psychological symptoms. TS is commonly associated with OCD (in about 30% of cases) and ADHD (in about 50% of cases). It is notewor thy that in many cases it is not the tics but the co-morbid disorders that are the major source of distress and disability. Some interesting associations include the findings that ADHD appears earlier in life than tics and that stimulants may exacerbate tics. For many patients with tics and ADHD, the symptoms of ADHD appear to be associated with the most severe impairment.

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Jun 8, 2016 | Posted by in PSYCHIATRY | Comments Off on 69: Child and Adolescent Psychiatric Disorders

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