Introduction

1 INTRODUCTION

The Concise Guide to Child and Adolescent Psychiatry, 5th Edition, offers an introduction to mental health care in children and adolescents to be used in conjunction with clinical supervision and consultation. This book was written to be used as a primer on child and adolescent psychiatry for medical and other health or mental health students or clinical trainees and as a brief update for practicing physicians, nurses, and advanced practice nurses in general psychiatry, child and adolescent psychiatry, pediatrics, neurology, and family medicine. It may also be useful for professionals in special education, child welfare, and juvenile justice, as well as parents. In the interest of brevity, complex theoretical notions, new research, and areas of controversy have been simplified. Each section on a disorder or clinical situation includes a listing of relevant treatment methods. Treatment techniques are described in Chapters 17 (“Psychopharmacology”) and 18 (“Psychosocial Treatments”). Each chapter has suggested additional reading for those who wish more detail. For more in-depth, comprehensive coverage of child mental health, see Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition (Dulcan 2016). The American Academy of Child and Adolescent Psychiatry practice parameters—clinical guidelines that are based on the scientific literature and the wisdom of experienced clinicians—are published in the Journal of the American Academy of Child and Adolescent Psychiatry. They are cited in the corresponding chapters.

Throughout this book, children refers to both prepubertal children and adolescents, unless otherwise specified. Parent is used for the child’s primary adult caregiver(s), whoever that may be.

CHANGE IN CHILDREN AND ADOLESCENTS

The primary “work” of children is to grow and change in multiple dimensions. Rigid descriptions of mental disorders and psychiatric symptoms do not capture the liveliness and energy of children as they develop and cope with internal and external difficulties. A child’s tendency to change is a therapeutic ally. As clinicians, we work with the natural dynamics of the interaction among our interventions, environmental influences, and developmental processes.

Disorders in childhood can exert lasting effects beyond the primary psychiatric disorder. Developmental complications are often cumulative and may disrupt a wide range of functions. Social, cognitive, and psychological development, and even physical growth (Pine et al. 1996), may be impaired. Progressive learning delays, school failure, low self-esteem, demoralization, impaired relationships with family members, and rejection or neglect by peers are common complications of childhood-onset disorders. Prompt intervention can reduce these developmental consequences.

Regardless of the etiology of the primary disorder, biological, cognitive, psychological, familial, social, economic, and cultural factors are critical in determining the course of illness. Genes can interact with environment to increase vulnerability or to reduce risk. The effects of early developmental deficits may be compensated for or exacerbated by later opportunities or barriers. The family or social environment can amplify strengths or aggravate weaknesses. The adult outcome of a childhood disorder in a specific patient is a result of the interaction among therapeutic forces and risk and protective factors. The ultimate prognosis may depend more on the ability of the child and family to learn to cope with the illness than on the severity of the disorder. Resilient individuals may even turn childhood symptoms such as excessive sensitivity (separation anxiety disorder), unrelenting stubbornness (oppositional defiant disorder), or uncontrolled activity and enthusiasm (attention-deficit/hyperactivity disorder) into strengths in adulthood. Compensatory abilities and an enhancing environment can result in achievement and adaptation far above that predicted from early deficits.

OVERVIEW OF DIAGNOSIS

Use of DSM-5 for Children and Adolescents

DSM-5 (American Psychiatric Association 2013) introduced significant changes in the organization of disorders. No longer are some disorders of youth relegated to a separate chapter. The new neurodevelopmental disorders chapter includes many disorders that typically are first diagnosed in childhood. The former DSM multiaxial structure has been eliminated, and all psychiatric and “other medical diagnoses” are placed in a single list. Any diagnosis can be used for a child if the criteria are met. A few disorders have slightly adapted criteria for children. Some disorders include behavior or emotions that may be normal at certain developmental stages but become pathological if they persist (becoming, e.g., separation anxiety disorder, enuresis, encopresis, or oppositional defiant disorder). Most disorders, however, are not “normal” at any age. In this book, key DSM-5 criteria for disorders are highlighted. For full details, refer to DSM-5 (American Psychiatric Association 2013).

DSM-5 contains an expanded list of clinical circumstances, classified as “V codes” or “Other Conditions That May Be a Focus of Clinical Attention,” that are not psychiatric diagnoses but may prompt assessment and treatment. They include psychosocial and environmental problems relevant to diagnosis, treatment, and prognosis. Many of these codes are especially relevant to children, and the major categories are listed in Table 1–1 (see DSM-5 for detailed list).

TABLE 1–1. DSM-5 conditions relevant to children and adolescents that may be a focus of clinical attention
Relational problems
Problems related to family upbringing
Other problems related to primary support group
Abuse and neglect
Child maltreatment and neglect problems
Child physical abuse
Child sexual abuse
Child neglect
Child psychological abuse
Educational and occupational problems
Housing and economic problems
Other problems related to the social environment
Problems related to crime or interaction with the legal system
Problems related to other psychosocial, personal, and environmental circumstances
Other circumstances of personal history (includes child or adolescent antisocial behavior)
Nonadherence to medical treatment
Borderline intellectual functioning
Source. American Psychiatric Association 2013.

All DSM-5 diagnoses (except for tic disorders) require evidence that the symptoms are causing significant distress or impairment in social, academic, and/or occupational functioning.

“Other” medical conditions (new terminology to indicate that psychiatric disorders are also medical conditions) are now included in the single list of the patient’s diagnoses. Many medical problems, from a fever or earache to a brain tumor, may be signaled first by behavioral or emotional symptoms or declining school performance. Children with chronic medical disorders or physical disabilities are at increased risk for psychiatric disorders (see Chapter 16).

Replacing the former Axis V, DSM-5 includes separate measures of symptom severity and disability for individual disorders.

Comorbidity

Psychiatric disorders typically occur in combinations. This is true not only in young people treated in the most intensive settings, such as inpatient units and residential treatment facilities, but also in outpatients. Comorbidity is common even in community epidemiological surveys, although less so than in children who have been referred for clinical services. Combinations of disorders may be unexpected, such as a teenager with impulsive hyperactivity or aggressive conduct problems who also suffers from depression or anxiety. Broad-spectrum rating scales are a useful supplement to the diagnostic process, to avoid overly narrow focus on the presenting problem.

OVERVIEW OF TREATMENT

Contemporary treatment planning includes use of evidence-based interventions selected with consideration of biological, psychological, and social factors; multimodal treatment approaches; and multidisciplinary teams. As diagnostic criteria have been refined, evaluation techniques have become more precise, both therapy models and medications have been more rigorously designed and tested for specific disorders or symptoms, and treatment selection has a stronger empirical foundation.

In contrast to treatment in adults, a child is typically brought to the clinical setting by someone else. Although the child is identified as “the patient,” each case has at least two clients: a parent or guardian and the child, whose needs and goals may conflict. In addition, treatment often involves other family members; teachers and school counselors; government agencies, such as child protective services or the juvenile court; community organizations; and financial providers, such as Medicaid or insurance companies, and state-funded services. Because children depend on adults for their basic needs and have little autonomy in choosing caregivers, residence, schools, or activities, the clinician must work in partnership with the parents and other support systems to reestablish developmental progress and maximize adaptive outcome.

REFERENCES

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013

Dulcan MK (ed): Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Arlington, VA, American Psychiatric Association Publishing, 2016

Pine DS, Cohen P, Brook J: Emotional problems during youth as predictors of stature during early adulthood: results from a prospective epidemiologic study. Pediatrics 97(6, Pt 1):856–863, 1996 8657527