No single cause can explain child and adolescent psychopathology. Risk factors that may cause a child to be more susceptible include: family history of a mental illness; immature development of the brain; brain abnormality; family problems and dysfunction; poverty; mentally ill or substance-abusing parents; teen parents; abuse; discrimination based on race, creed, or color; chronic parental conflict or divorced parents; and chronic illness or disability. The developmental ecological model of psychopathology and a discussion of risk and protective factors is more fully explained in Chapter 3 of this book.

The importance of the family environment and its influence in the life of children cannot be over-stated. Children cannot be understood in the absence of understanding their family context, and families are integral to successful treatment. Parent–child transactions are two-way, reciprocal relationships. Children largely acquire the coordination of affect, cognition, and behavior, which they need to relate successfully to others within the socializing context of the parent–child relationship.

Families do not operate in a vacuum – the behavior of each family member affects the others, and each member is affected by other contexts to which he or she is exposed. Therefore, many situations affect family dynamics, and those dynamics may change from more to less adaptive depending on the nature of contextual factors. For example, a family may function adaptively given one set of circumstances (e.g., death of a grandparent) but maladaptively given another (e.g., sudden unemployment).

Because they function within a family that helps to buffer the effects of social change, children are less susceptible to sociocultural influences than are adults. As they grow and mature, however, children increasingly come into contact with the larger society. Stable, nurturing forces in the child’s home protect him or her from noxious exogenous influences. If children do not have stable nurturing forces in the home, they may be at risk for maladjustment.

Parents’ fears, anxiety, depression, and aggression, as well as their love, nurturance, and concern, shape the youth’s developing sense of self and the world. What parents believe about their world is often reflected in their child’s skills or deficits.

Increasing recognition of the complexities of the etiologies of psychopathology have moved the field of child and adolescent psychiatry beyond a disease model and simple social explanations. Research into genetic, neurophysiologic, and environmental variables and their effects on behavior have provided understanding of adaptation and maladaptation (see Chapter 3). Although the knowledge base for child and developmental psychopathology has grown exponentially in the last decade, it has been and continues to be compromised by the atheoretical, unsystematic, and somewhat fragmented fashion in which research findings have accrued. That is changing to some degree, but change comes slowly to the practice arena, and clinicians may find interventions in place in service provision to children and their families that are not based in the current science.

11.4.1 Coordination of Care

Many mental health professionals participate in the care of a mentally ill child or adolescent. They include psychiatrists, advanced practice clinicians, social workers, psychologists, recreational therapists, and occupational therapists among others. Although some disciplines overlap in the care they provide, each discipline contributes a unique service. For example, reviewing psychological testing results helps the clinician develop a comprehensive picture of a patient’s diagnosis and condition.

11.4.2 Treatment Settings and Continuum of Care

Treatment for mentally ill children is provided in many different settings, from the most restrictive levels of care for a seriously disturbed youth to the least restrictive level. Treatment services within these levels include preventive services, early intervention, crisis stabilization, inpatient hospitalization, crisis in-home services, residential treatment, partial hospitalization, day treatment, therapeutic foster care, case management, family support services, outpatient counseling, and medication management. Discharge planning, a collaborative process involving the youth, family, and mental health team, begins with admission to the inpatient unit or other treatment service.

Current structures of service provision, known as systems of care (SOCs), are slowly replacing the former wrap-around services models. These SOCs are a comprehensive spectrum of mental health and other necessary services organized into a coordinated network. This network is dynamic and changes as the needs of the children and families change.

11.4.3 Early Identification

Early identification and treatment are the keys to reducing the harm caused by psychiatric disorders in children and adolescents. Clinicians play integral roles in detecting early symptoms, such as depression, and referring children and families to appropriate psychiatric care providers. Screening for, and prevention of, psychiatric disorders needs to start during infancy. In addition, early intervention with children and teens at risk can prevent more serious maladjustment and emotional turmoil later in life.

11.4.4 Types of Interventions and Therapies

Several different forms of therapy are available to treat the child or adolescent with a psychiatric disorder. Whichever type of therapy is used, it is important to consider the child’s and family’s culture (see Chapter 7).

Individual therapy focuses on the needs and problems of the child or adolescent. Individual therapy is often of the cognitive and behavioral types, as these have the greatest empirical support in terms of efficacy. Behavioral and cognitive therapy is based on the concept that psychiatric disorders represent learned behavior. Thus, learning principles are applied to modifying these behaviors. Behavioral techniques include the use of token economies, time-out (from positive reinforcement), and rewards for – and reinforcements of – desired behaviors (see Chapter 32). Participation in devising a written behavioral contract helps increase a youth’s adherence to the treatment plan. Cognitive therapy, which assists with problem-solving and stopping negative self-perceptions, is likely to work well with older adolescents who may view a behavioral management system as a type of adult control. Other forms of empirically validated individual therapies are cognitive problem skills training and multisystem therapy.

Brief psychotherapy addresses a central issue in a specified time. The provider and child do not discuss extraneous issues. The provider openly explores the central problem with the child and family.

Play therapy is a vehicle that offers children an opportunity to express their fears, anxieties, frustrations, and aggression. Play is the child’s work and natural medium for expression. Play therapy is, however, a misnomer. The play is the means for the therapy to take place. In play therapy, the assumption is that the child expresses and works out conflicts and problems through play. There is no support, however, for the supposition that play therapy can be used as a way to establish the truth of past events. Moreover, despite its ubiquity in many child settings, empirical evidence is not available to verify its effectiveness. Most research on play therapy consists of case reports and trials comparing play with other forms of therapy, but does not account for the effects of the intense attention that the child receives.

Family therapy is based on the premise that the behavior of one person in the family affects everyone else in the family. No behavior of an individual can be understood without understanding the behavior of other family members. Interventions are directed at the family as a whole and their behavior patterns, not at one member. The idea in family therapies is that treating a child or adolescent successfully necessitates modifying how the home environment is reinforcing his or her behavior.

Parent management training (PMT) refers to procedures in which parents are trained to alter their child’s behavior in the home on the premise that the child’s maladaptive behavior is inadvertently developed and sustained by maladaptive parent–child interactions. Altering those interactions is hypothesized to reduce these problem behaviors. PMT involves educating and coaching parents to change their child’s problem behaviors using principles of learning theory and behavior modification. The aim of PMT is to decrease or eliminate a child’s disruptive or inappropriate behaviors at home or school and to replace problematic ways of acting with positive interactions with peers, parents, and such authority figures as teachers. In order to accomplish this goal, PMT focuses on enhancing parenting skills. The goal is to replace coercive behavior with prosocial behavior between parent and child interchanges. This training has been extensively studied and is a promising treatment for children with a conduct disorder.

Group therapy is especially helpful for adolescents for whom the influence of peers is strong; adolescents are more likely to accept feedback and suggestions from their peers than from adults. The exception to this is with conduct-disordered children, in which negative behaviors may actually be reinforced by the group. Group therapy is less threatening than individual therapy and allows the adolescent to identify with others who have similar problems. Groups provide opportunities to learn to identify and dismiss defeating cognitions and practice new behaviors.

A therapeutic milieu is a planned treatment environment that should be flexible and normalizing, as well as geared toward helping children develop self-responsibility and healthy interdependence with others. Ideally, the milieu should be planned to support and guide children toward greater responsibility and a more robust locus of control within their individual capacities. In a therapeutic milieu, interactions become opportunities for therapeutic intervention, and open, clear communication is modeled. Through the day-to-day normalizing experiences the child or teen can learn how to manage activities, deal with feelings, and get along with others. Milieu staff members work to model supportive and respectful behavior. Inpatient or residential milieu settings must offer safety, security, clear and reasonable limits, behavioral consequences, age-appropriate activities, and 24-hour availability of mature, caring adults.

The collaborative problem-solving (CPS) model is an approach to communicating and interacting with children who are inflexible and often explosive. It is posited on the idea that a child’s capacity for complying with a caregiver’s directives or expectations is unique to each child, and if the caregiver’s demands exceed that capacity the child’s responses deviate from those expected. These deviations may increase frustration levels for both parties, and may result in response biases on the part of both. The CPS model assumes that children “do well if they can.” It aims at helping challenging children and their adult caregivers to learn to resolve conflicts, disputes, and disagreements in a collaborative, mutually satisfactory way. The approach consists of three steps. The first is to identify and understand a child’s concern about a given issue and to reassure the child that the issue will not be resolved through coercion. The second is identifying the adult caregiver’s perspective on the same issue or problem. The third is to invite the child to brainstorm possible solutions with the goal being to mutually agree upon a realistic course of action.

Special education describes an educational alternative that focuses on teaching students with academic, behavioral, health, or physical needs beyond those met by traditional educational programs or techniques. Ideally, this process involves the individually planned and systematically monitored arrangement of teaching procedures, adapted equipment and materials, accessible settings, and other interventions designed to help students with special needs achieve success in school and community than would be available if the student were only given access to a typical classroom education.

The goals of special education are as follows:

• Decrease the child’s disturbing behavior.
  
• Increase the child’s rate of learning to enable him or her to remediate and progress.
  
• Reintegrate the child into regular classes as soon as possible.

Coordination and collaboration between school and other care systems is critical.

Pharmacologic therapy is an important part of any treatment program. Medication does not solve all the child’s or teen’s problems. If it is combined with therapies, family education, parent guidance, and special education, medication improves the likelihood that the child’s symptoms will decrease and his or her functioning will improve. Psychotropic medication must be given cautiously to children and adolescents because of the idiosyncratic reactions they can have, and because their rates of metabolism may be quite different from that of adults (see Chapter 33).

Many psychiatric illnesses affect children and adolescents. Some of these illnesses are usually first diagnosed during infancy, childhood, or adolescence. Alternatively, some disorders develop in childhood or adulthood, but the manifestations, treatment, or both in children and adolescents may differ from that of the adult. The disorders discussed in this section include the most common child and adolescent mental disorders from each category.

11.5.1 Mental Retardation

In the DSM-IV-TR taxonomy, mental retardation is defined on the basis of three features:

• Intellectual functioning with an IQ of approximately 70 or below
  
• Concurrent deficits or impairments in present adaptive functioning in at least two of the following areas: communication, self-care, home living, social/interpersonal skills
  
• Onset before 18 years of age.

Mental retardation (MR) affects 2–3% of the general population, although some experts argue that only about 1% should receive the diagnosis. The large majority of retarded persons fall in the mild range of retardation (intelligence quotient, IQ = 50–70), and smaller numbers are moderately (IQ = 35–49), severely (IQ = 20–34), or profoundly (IQ < 20) retarded. Children with severe and profound MR come to attention earlier than those with borderline or mild MR. More males than females are affected, and retardation can coexist with psychological disorders and physical disabilities.

ICD-10 characterizes mental retardation as a condition resulting from a failure of the mind to develop completely. There are several hundred disorders associated with mental retardation. The most common factor associated with severe mental retardation (including the moderate, severe, and profound levels of mental retardation) has been chromosomal abnormality, particularly Down syndrome. In approximately 20–30% of the individuals identified with severe mental retardation the cause has been attributed to prenatal factors, such as chromosomal abnormality. Perinatal factors such as perinatal hypoxia account for about 11%, and postnatal factors such as brain trauma account for 3–12% of severe mental retardation. In 30–40% of cases, the cause is reported to be unknown.

Knowledge of the sequence of development traversed by normal children has proved useful in early behavioral interventions with mentally retarded children. Studies of programs serving retarded children aged below 5 years have shown that particular types of cognitive and social stimulation can increase levels of functioning.

Research on older retarded children has shown that motivational factors play the major role in determining how productive and independent the children ultimately become. As retarded children face increased failure experiences compared to normal children, however, they may develop traits that work against their becoming independent. They often become overly wary of adults and develop a lower expectancy of success (i.e., they do not expect to succeed at challenging tasks). At the same time, children with MR are more likely to become dependent on adult approval and to accept adult (as opposed to their own) solutions to difficult problems. The net effect is that these children frequently perform below the level of their intellectual abilities on a variety of experimental and real-life tasks.

The range of psychiatric disorders in people with MR is similar to that of “normal” populations. Appropriate assessment of psychopathology in patients with dual diagnosis is important because: (a) it can suggest the form of treatment; (b) it may ensure access to and funding for special services; and (c) it can be used to evaluate subsequent interventions. Brain damage, epilepsy and language disorders are risk factors for psychiatric disorders and are often associated with mental retardation. Social isolation, stigmatization, and poor social skills put individuals with mental retardation at further risk for affective disorders.

Because children with mental retardation often have other problems, it is necessary to involve a team of practitioners from different disciplines (e.g., child psychiatrist, social worker, child psychologist, special education teacher, speech and language specialist, and community agencies), in the comprehensive diagnosis and care. The involvement of the family in the decision-making processes is crucial. In the United States, Public Law 99–457 and Public Law 102–119 require the involvement of parents and professionals in early intervention services. A family-centered interdisciplinary approach involves an assessment of the child (including school history, obtained from parents and school records), family (family marital and parenting history), and community resources. Medical, developmental and psychiatric histories are obtained. Behavioral analysis, psycho-educational, speech and language testing are completed. Medical and neurological assessments are performed. The team presents these results to the parents who are actively involved in evaluating and implementing treatment recommendations.

11.5.2 Autism Spectrum Disorders

Autism spectrum disorders, also called pervasive developmental disorders, have as their core features impairments in socialization, impairments in communication, and restricted repertoire of behaviors.

In 2007, the Centers for Disease Control and Prevention (CDC) in Atlanta reported that across the US autism rates were in the range of 6.7 per 1000, with approximately 1 in 150 eight-year-old children affected by an autism spectrum disorder.

11.5.2.1 Autism

Autism is a genetic disorder of neuronal organization occurring more in boys than girls. Chromosomal abnormalities are present in 5–6% of children with autism, and the role of genetic mechanisms is suggested by the observation that siblings of affected people are at a 22-fold or greater risk of autism than the general population. Autims is not caused by vaccinations.

Children with autism develop language slowly or not at all. They may use words without attaching meaning to them or communicate with gestures or noises instead of words. They spend time alone and show little interest in making friends. Approximately 50–80% of people with autism also are classified as mentally retarded. Their most distinctive feature, however, is that they seem isolated from the world around them. This detachment and aloofness helps distinguish people with autism from those who are solely mentally retarded. Children with autism are less responsive to social cues such as smiles or eye contact. They often have some degree of sensory impairment, including sensitivity in the areas of sight, taste, hearing, touch, or smell.

Children with autism do not play spontaneously or imaginatively. They act socially aloof and indifferent. They do not imitate others’ actions or participate in pretend games. They may act aggressively and throw tantrums for no obvious reason. In addition, they may perseverate; that is, show an obsessive interest in some item or activity and engage in ritualistic behavior. They often adhere to routines and do not tolerate changes in routine well. These characteristics are evident in children with autism before the age of 3 years.

11.5.2.2 Asperger Syndrome

Asperger syndrome, a condition occurring more frequently in boys, is a severe developmental disorder characterized by major difficulties in social interaction and restricted and unusual interests and behavior. Although there is not a significant general delay in language, people with Asperger syndrome use monotone speech and rigid language. They tend to be concrete and naive. Despite not grasping nonverbal communication cues and an inability to show empathy to others, they want to meet people and make friends. Mental retardation usually is not observed with Asperger syndrome, although occasional cases of accompanying mild mental retardation have been noted.

People with Asperger syndrome have an obsession with facts about circumscribed and odd topics. For example, they may have a tremendous interest in, and talk incessantly about, a topic that would not have interest or appeal to others. They are often rigid and perfectionististic.

11.5.2.3 Childhood Disintegrative Disorder

Childhood disintegrative disorder is a rare condition that is characterized by the development of an “autistic-like” picture and a marked regression following a period of normal development. It is often mistaken for autism. In this condition, onset of skill deterioration begins between ages 3 and 4 years. Skills lost are usually those of communication and motor development. Males are more likely to be affected. Prevalence rates are approximately 1 in 100 000 children. The outcome for children with childhood disintegrative disorder is usually very poor, worse than for children with autism. The loss of language, cognitive, social and self-care skills tends to be severe and permanently disabling. As a result, children with the disorder may eventually need residential care in a group home or long-term care facility.

11.5.2.4 Treatments

Improved outcomes are achieved with early detection. An easy screening tool for 18-month-olds is the Checklist for Autism in Toddlers (CHAT), which is used to evaluate the child’s ability to pretend, enjoyment in peekaboo games, attempts to engage the parent, and eye contact.

Treatment for patients with autism, Asperger syndrome, and related disorders centers on behavioral interventions, particularly cognitive and behavior therapy, special education, social skills training in groups, language therapies, occupational therapy, and sometimes pharmacotherapy. Behavior modification techniques include those used to enhance and reduce certain behaviors.

Medication may be needed to manage the symptoms of hyperactivity, irritability, aggression, self-injury, ritualistic behavior, and obsessive–compulsive behavior. These can span a wide range of psychoactive medications, including the SGAs, anticonvulsants, and mood stabilizers.

Treatment needs change according to the age of the developing child. Speech and language therapy and assistance to parents are critical when the child is very young. An older child or adolescent may need cognitive–behavioral therapy and medication to deal with obsessive–compulsive symptoms. The child’s prognosis is more positive when language development and social interaction are less impaired.

Children with an autism spectrum disorder need a structured environment and social–emotional training. The goal may be to learn to imitate social behavior that other children learn intuitively. In addition, special education placement in public school settings with measurable goals and objectives for the child is necessary.

Parents require accurate information, training in becoming advocates for their child, respite programs, and inclusion in individualized, collaborative treatment planning to understand and help their child. Future needs of the child with autism spectrum disorder might include vocational training and placement, use of sheltered workshops, supported employment, and community-based programs such as group home or supervised apartment living.

11.5.3 Learning Disorders

A comprehensive discussion of learning disorders is beyond the scope of this chapter and book. Readers are directed to references contained at the end of this chapter for more in-depth information.