Special Clinical Circumstances


16


SPECIAL CLINICAL CIRCUMSTANCES


This chapter covers a wide variety of situations and conditions that are not psychiatric diagnoses but in which psychiatric clinical skills may be useful or even required. Emergencies require expert assessment and prompt intervention. The effects of family transitions or adolescent pregnancy may become apparent in pediatric or school settings. Childhood obesity and physical illness raise psychological issues. The children of parents with psychiatric disorders are often ignored by systems of care designed for adults.


EMERGENCIES


Assessment and Triage


Emergencies present most often in psychiatric, pediatric, or general hospital emergency rooms, but they also occur in other psychiatric and pediatric settings and in schools (Table 16–1). The clinician rapidly assesses the potential for physical danger or acute psychiatric deterioration, evaluates support systems, may initiate treatment, and makes a disposition for further evaluation and treatment. In situations that are potentially dangerous to the youth or to others, a delay in intervention may result in acute exacerbation or increased resistance to treatment or actual harm.








































TABLE 16–1. Common psychiatric emergencies in children and adolescents


Suicidal behavior, threats, or intent


Victim of physical abuse or severe neglect


Victim of sexual abuse or rape


Violent behavior or threats of violence


Delirium or other behavior or mental status changes secondary to medical illness or to prescribed medication


Nonpsychotic hallucinations in young children


Night terrors


Acute phobic hallucinations


Psychosis


Acute anxiety reactions, hyperventilation, panic attack


Acute school refusal


Misconduct/legal violations (i.e., fire setting, property destruction, theft)


Running away


Substance use


Anorexia nervosa or bulimia nervosa


Conversion symptoms


An emergency evaluation must be brief and focused (Table 16–2). The clinician should talk with the child or adolescent and the relevant adults both alone and together. Important collateral information can be gathered by telephone, from as many informants as possible (with appropriate consent). To ensure patient and staff safety and facilitate immediate intervention, the clinician must assess immediately for


















































































































TABLE 16–2. Outline of emergency history


Demographics


Age



Residence



School and current grade



Health insurance status



Primary caregiver



Legal guardian


Chief complaint


Who initiated the emergency visit?



What happened?



What did the patient intend to do?



How was the patient discovered?



How did the patient and others react?


Any past suicide attempts and intent


Overdose of prescribed or over-the-counter medication



Use of firearms



Hanging



Other self-injury



Use of alcohol or illicit drugs


History of present illness


Development of symptoms



Previous evaluations



Treatment attempts and their results



Involvement of social agencies or legal authorities


History of emotional or behavior problems


Depression


Aggression



Conduct disorder



Drug or alcohol use



Psychosis



Autism spectrum disorder


Adaptive functioning with family, school, and peers


Problem-solving skills, social skills, ability to ask for and obtain help


Stressors in patient and family


Recent romantic breakup, peer conflict, bullying, cyberbullying, academic disappointment, disciplinary action, family discord, family social stressors


Abbreviated developmental history


Intellectual disability


Developmental delay



Regression from previous level of functioning


Family situation


Family living arrangements



Other family or adults involved or who could be involved



Adult stability, competence, relationship with the patient, attitude toward the patient and his or her problems



Physical abuse, neglect, substance abuse


Family history of psychiatric illness or suicide



History of medical illness and review of symptoms




  • Medical illness or medication side effect.
  • Head trauma.
  • Intentional or accidental overdose.
  • Drug or alcohol intoxication or withdrawal.
  • Need for physical restraint or containment to prevent aggression or the child escaping.
  • Need to prevent a parent from removing the child from the emergency room.
  • Drugs or weapons carried by or available to the patient or accompanying adult(s).

A careful mental status examination is crucial in an emergency situation, with special focus on signs of psychosis, organicity, intoxication, suicidality, poor judgment, or impulsivity. Medical evaluation should be pursued as indicated (Table 16–3). The cause of a sudden change in behavior should be considered organic until proven otherwise. “Medical clearance” in the emergency room does not guarantee the absence of physical disorder as a cause of psychiatric symptoms.


































TABLE 16–3. Psychiatric emergency medical evaluation


Physical and neurological examination


Potential neurological causes


Evidence of drug ingestion


Evidence of physical or sexual abuse


Medical complications of an eating disorder


Laboratory tests—according to clinical indications


Follow-up findings from medical history and physical examination


Blood level of prescribed drug


Toxicology if overdose is suspected


Pregnancy test


Blood and urine drug screen


Blood alcohol level


Tests for sexually transmitted diseases


In a single evaluation in an emergency setting, especially if collateral information is limited, the clinician often has difficulty making a definitive DSM-5 (American Psychiatric Association 2013) diagnosis. It would be appropriate to use “unspecified” disorders until more definitive information is available. Only a triage decision regarding further evaluation and treatment may be possible. Abbreviated feedback, education, and explanation are appropriate in the emergency setting. When the disposition or treatment is uncertain, the primary issue is safety (Table 16–4). The decision whether to hospitalize a young person is often determined by the ability of supervising adults to tolerate the young person’s behavior or to ensure safety.



























TABLE 16–4. Options for emergency dispositions


Begin crisis intervention in emergency setting


Send home with outpatient or crisis center referral or appointment


Provide family members with information on outpatient referral or crisis center


Send home with return to emergency room as needed


Observe in the emergency department


Contact child welfare or protective services for evaluation for placement outside the home in a shelter or foster home or for supervision in the home (hospital protective services team may consult or assist)


If the patient is medically unstable, hospitalize in pediatric unit (may need constant observation by “sitter”) with psychiatric consultation


Partial hospitalization program (day hospital) or intensive outpatient program


Psychiatric hospitalization


Involve juvenile court



Suicide


Suicidal behavior is life threatening in all of its forms and should, therefore, be taken seriously regardless of age or circumstance. In pediatric patients, adults may assume that the intention of the youth’s suicidal behavior is not serious and may not seek treatment. Very young children may lack the cognitive and physical skills to act on suicidal ideation, but a preoccupation with self-destructive behavior suggests significant psychiatric disturbance. Even the most blatant “gesture” can prove fatal, especially in a child whose assessment of physical danger may be immature and unrealistic. The need for accurate and prompt identification of suicidal behaviors is essential given the tendency for these symptoms to recur within days or weeks.


Epidemiology


The National Youth Risk Behavior Survey, conducted every 2 years by the Centers for Disease Control and Prevention (CDC), found in 2015 that 17.7% of high school students had in the past year “seriously considered attempting suicide,” and 8.6% made a suicide attempt. In prepubertal children, the male-to-female ratio of completed suicide attempts is 3:1; a figure that increases to 5:1 in the 15- to 24-year age group. However, the prevalence of suicidal ideation and attempts is higher in females by a ratio of more than 2:1. Males choose the more lethal method of firearms to complete suicide, whereas the most used method in completed suicide in females is hanging. Suicide attempts using firearms are particularly lethal, especially when combined with substance use. In males, a history of suicidal behavior increases the risk of completed suicide. This prediction is not as strong in females, for whom a history of major depressive disorder is the strongest risk factor for suicide attempt. Gay, lesbian, bisexual, and transgender youth may be more likely to become suicidal because of multiple potential risk factors, including depression, substance abuse, sexual victimization, rejection by family, and bullying by peers.



Course and Prognosis


Psychiatric symptoms are a risk factor for serious and recurrent suicidal behavior. Nearly all suicide victims have a psychiatric disorder, particularly mood disorder, which in boys is often comorbid with substance abuse and/or conduct problems. Suicide in elementary school–age children is rare but is more often associated with attention-deficit/hyperactivity disorder (ADHD). Unfortunately, only one-third of suicide attempters are ever referred to a mental health service, and lack of treatment is common even in those referred. Additional risk factors include previous noncompliance with psychiatric treatment, social isolation, poor school performance, abuse and neglect, parental psychiatric illness, and family history of completed suicide. Medical illness increases suicide risk, especially epilepsy or central nervous system damage secondary to trauma, infection, or chemotherapy. Adolescent suicides are often preceded by stressful events, including the loss of a romantic relationship; reprimands in school or at home; or academic, family, or legal difficulties. Access to firearms greatly increases risk.


Evaluation


When evaluating a youth after a suicide attempt, the clinician should obtain a detailed history of the circumstances preceding and following the attempt; symptoms of mood disorder, substance abuse, or impulsive behavior; wishes to die or to influence others at the time of the attempt; whether a friend or family member has committed suicide (to identify “contagion”); amount of preparation and planning invested in the attempt; and coping skills and supports in the patient and family. Patients may present with a decline in social functioning characterized by isolation, legal problems, school suspensions, and running away from home. The seriousness of the attempt is determined by a consideration of both lethality and intention. Lethality is a measure of the likelihood of death and is based on method, location, and the likelihood of being found. Intention is a description of what the patient wished to happen and is based on information provided by the patient and the interpretation by the clinician. Patients with a previous history of suicide attempts or who use methods other than ingestion and superficial cutting should be considered at highest risk. Assessment of risk factors for subsequent suicide attempts is essential (Table 16–5). Information should be collected from multiple sources including the patient, caregiver, school, and any other individual close to the patient. The Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al. 2011) is a useful tool for structuring the assessment of suicidality (www.cssrs.columbia.edu).




































































TABLE 16–5. Risk factors for repeat suicide attempt


Patient history


Verbalization or threats regarding suicide


Substance abuse


Poor impulse control


A recent loss or other severe stressor


More than one previous suicide attempt


A friend or family member who has committed suicide


Exposure to recent news stories or movies about suicide


Poor social supports


Victim of physical or sexual abuse


Nature of the current attempt


Accidental discovery (versus attempt in view of others or telling others immediately)


Careful plans to avoid discovery


Hanging or gunshot


Family


Wishes to be rid of child or adolescent


Does not take child’s problems seriously


Overly angry and punitive


Depression or suicidality in family member


Unwilling or unable to provide support and supervision


Mental status examination


Depression


Hopelessness


Regret at being rescued


Belief that things would be better for self or others if dead


Wish to rejoin a dead loved one


Belief that death is temporary and pleasant


Unwillingness to promise to call before attempting suicide


Psychosis


Intoxication


Treatment


In determining disposition, safety is the first concern. A brief hospitalization may be useful to complete a more detailed assessment and begin treatment, even in youths who deny continuing suicidality. Compliance with outpatient treatment recommendations may be improved if an appointment date and time are provided and the therapist contacts the patient and family before the initial visit. Family involvement in treatment planning draws them into the therapy and educates them about psychiatric diagnoses, the lethality of the behavior, and the purposes of treatment. Caretakers should be told directly to remove firearms from the home (or at least lock them securely, with ammunition stored and locked in a separate location) and to securely lock up medications (prescribed and over-the-counter), sharp objects (e.g., knives, blades), ropes or cords, and household cleaners/chemicals, and to prevent access to alcohol or illicit drugs. Although “no-suicide contracts” do not eliminate risk, the discussion can provide insight into the thinking of both patient and caregivers. When a safety plan is being created, warning signals, triggers, and potential youth coping strategies and external supports are identified.


Subsequent treatment includes treating primary psychiatric disorders, improving problem solving and stress reduction skills, and stabilizing the home and school environment. Several models of cognitive-behavioral therapy (CBT) for suicidal youth, with or without medication added, have been developed (see the chapter by Goldstein and Brent [2016] in “Additional Reading”). Dialectical behavior therapy (DBT) has been shown to reduce suicidal ideation and suicidal behaviors in adolescents (MacPherson et al. 2013).


Child Maltreatment


In the psychiatric evaluation, clinicians should maintain a high index of suspicion and collect information about the possibility of physical or sexual abuse. All states have laws requiring professionals who suspect child abuse to report it to the designated authorities. Mandated reporting is not confined to confirmed abuse. If evidence is sufficient to raise a serious question, the situation must be reported in order to prompt an official investigation. Clinicians acting in good faith are immune from liability for reporting, but legal penalties may be assessed for failing to report. When the clinician suspects abuse, he or she should tell the parents that an investigation will ensue and that helpful services may be available from the child protection agency. Abusive parents are often frightened by their loss of control and remorseful for the injury to the child. They are overwhelmed by stressors and may be relieved to have aid in protecting the child. If the child is in immediate danger, he or she should be admitted to a pediatric service (by means of a court order, if necessary) until the investigation and determination of disposition are complete. In cases of significant abuse in which the parent is the suspected perpetrator or is unable to protect the child, the protective service agency should place the child in an emergency shelter or foster home. At times, security guards or police may be necessary to complete the disposition and keep the parent from absconding with an abused child.


Epidemiology


The U.S. Department of Health and Human Services National Child Abuse and Neglect Data System (NCANDS) reported that some form of maltreatment will be confirmed in one in eight children by age 18 years (Wildeman et al. 2014). Of the reported cases, 75% were due to neglect, 17% due to physical abuse, and 8% due to sexual abuse. In 2014, almost 1,600 childhood fatalities were caused by abuse or neglect. This figure is likely an underestimate, given the official tendency to report ambiguous deaths as accidental. Fatalities are more likely in younger children, with more than 75% in children younger than 3 years. More boys than girls died from abuse or neglect.


Physical and Emotional Abuse and Neglect


Clinical description and etiology. Physical abuse is defined as injury or risk of injury to a child younger than age 18 years as a consequence of being hit with a hand or object or being kicked, shaken, thrown, burned, stabbed, or choked by a parent or parent substitute. Children who are threatened, verbally abused, or given harsh but nonphysical forms of punishment are considered to be emotionally abused. Emotional abuse is defined as a “repeated pattern of caregiver behavior or extreme incident(s) that convey to children that they are worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another’s needs” (American Professional Society on the Abuse of Children 1995, p. 2). This abuse can include spurning behaviors or terrorizing, isolating, exploiting or corrupting, or denying appropriate emotional responsiveness to the child. The most common abuser is the child’s parent or guardian. Risk factors for abuse include social isolation of parents, violence between parents, management of behavior problems with corporal punishment, inappropriate expectations for the child’s developmental level, young parental age, parental history of abuse, caretaker use of alcohol and drugs, and stressors on the family such as unemployment and overcrowding. Children with a history of prematurity, intellectual disability, or physical disability may be at higher risk of victimization.


Neglect is more difficult to define than abuse, and clarification often requires a pediatric hospitalization with a comprehensive medical, psychiatric, and social evaluation. Neglect may be considered in five categories: 1) medical care neglect, 2) gross safety neglect (lack of supervision), 3) physical neglect (food and shelter), 4) emotional neglect, and 5) educational neglect (the latter two types are not recognized by all states). Emotional neglect applies when the patient is not given adequate attention and affection or is exposed to traumatic and inappropriate behaviors. Poverty contributes even more powerfully to neglect than to abuse. Many neglectful parents have not experienced or even witnessed appropriate parenting. Contributing factors may include cognitive limitation, drug or alcohol use, or mental illness.


Evaluation. Clinicians should have a high index of suspicion for abuse when evaluating an injured child whose presentation is atypical. The history may yield clues such as delayed seeking of medical care, an explanation that does not fit the injury or the child’s developmental level, and variable descriptions of how the injury occurred. Injuries characteristic of abuse include but are not limited to



  • Multiple injuries in various stages of healing.
  • Bruises in the pattern of fingers or belts.
  • Burns, especially from cigarettes or scalding by water.
  • Spiral bone fractures.
  • Head and eye injuries.
  • Ear injuries.
  • Abdominal injuries.
  • Chest injuries.

Evaluation of suspected abuse or neglect includes a complete physical examination (with imaging studies as indicated) and private interviews with the parents; the child (if old enough to talk) or adolescent; and other persons, such as siblings, babysitters, relatives, and neighbors. Youth may hide abuse because of fears of punishment or abandonment by peers or family members. Although corporal punishment of children by parents (and, in many states, by teachers or principals) is still accepted by many cultural groups in the United States, any injury inflicted by a hard object or by burning, shaking, or throwing should be considered abuse, as should prolonged or severe spanking.


Effects. Abused and neglected children are at risk for cognitive deficits, neurological impairment, blindness, physical disability, or even death. Psychological sequelae vary widely in severity and nature, commonly including low self-esteem, difficulty trusting others, impaired social relationships, increased impulsivity, irritability, anhedonia, aggression, poor school performance, and self-destructive activities, including suicide and a variety of risk-taking behaviors. Posttraumatic stress disorder (PTSD), attachment disorders, or symptoms of dissociation may ensue. Virtually any psychiatric disorder can be present in victims of abuse, whether as risk factor, comorbidity, or sequela.


Interventions. The initial goal of treatment is to prevent the recurrence of abuse. Interventions include hotlines and self-help groups (organized by Parents Anonymous) that are useful for motivated but socially isolated parents who have difficulty controlling their angry responses toward their children.


Victims need interventions for abuse-related symptoms, as well as a psychiatric evaluation with multimodal treatment as indicated. Day hospital programs provide a safe and nurturing environment to begin abuse-specific interventions. Group play therapy can encourage interaction with peers and avoid the solitary play that frequently develops in maltreated children.


Parents at high risk include teenagers, new parents, impoverished single parents, and individuals with histories of substance use or cognitive limitations. Perpetrators have high rates of depression, substance use, and antisocial behavior requiring assessment and treatment. Education in normal child development and principles of behavior management may be useful. Some parents need concrete assistance with housing, food, and medical care. Therapeutic and supportive services are often best provided in the home, because many families are both poorly motivated and insufficiently organized to make use of traditional outpatient services. Short-term placement of the child in foster care may be necessary while the home is stabilized and parents obtain treatment. Child welfare agencies and family courts should be encouraged to determine rapidly whether parents can be rehabilitated and the children returned or whether proceedings should be initiated to terminate parental rights. Too often a child is placed in a succession of foster homes, punctuated by unsuccessful returns to the parents.



Sexual Abuse


Clinical description. Sexual abuse refers to touching offenses (ranging from fondling to sexual penetration) and nontouching offenses (exposure to pornographic material). Although the reported incidence of sexual abuse and rape is increasing with mandatory reporting laws and heightened public awareness, it is still likely to be an underestimate. Females are more likely to be victimized than males by 4–5:1. The most common age of initial sexual abuse is 8–11 years. Most perpetrators are male and usually known to the victim. Although the offenders in most reported abuse cases are fathers or stepfathers (or boyfriends), retrospective studies also identify uncles or brothers as frequent perpetrators. Extrafamilial and intrafamilial sexual abuse of boys is less frequently reported and prosecuted, even though the psychological consequences may be debilitating.


Evaluation. Sexual abuse varies widely in degree of sexual contact; amount of physical or psychological coercion; single vs. repeated incidents; and whether the abuser is a member of the household, another person known to the child, or a stranger. The child may tell a parent, a friend, or a teacher, or there may be physical evidence such as prepubertal vaginal bleeding; recurrent urinary tract infections; inflammation, bruises, or lacerations of the genitals or anus; sexually transmitted disease; or pregnancy. Sudden onset of compulsive masturbation, precocious sexual knowledge or behaviors, oppositional behavior, fears, running away, depression, sleep disturbance, somatic symptoms, or decreased academic performance may raise suspicion.


Rape or sexual abuse by a stranger is usually reported by the victim immediately, although boys are less likely to acknowledge abuse. The child is often seen acutely in the emergency room. Sexual abuse by a relative or family friend is more difficult for children to report, is often discredited by the mother, and may result in a family crisis. In cases of father–daughter incest, the mother may suspect or be aware of the abuse, but fear of the father or a wish to “protect the family” prevents her from taking action. The mother may even tacitly encourage the abuse. In these families, a daughter takes on many aspects of the role of the mother and wife who is less available because of depression or physical illness.


The purposes of the initial evaluation are



  • To determine whether abuse is likely to have occurred.
  • To ensure that the child is protected.
  • To establish the need for medical and psychological treatment.

It is important that the evaluation itself does not further traumatize victims of sexual abuse. A team approach, in which health and mental health care professionals work together with the child protection agency and the legal system, avoids subjecting the child to repeated inquisitions. A complete physical examination is indicated, preferably by a pediatrician or pediatric gynecologist who has experience in evaluating abused children and who can carry out the procedures required for legal evidence. The clinician should interview (together and separately) the child, parents, and siblings. Questions about the specifics of the abuse are best saved for private or forensic interviews. For children who have difficulty verbally describing events, the opportunity to draw or use puppets may be helpful. The use of anatomically correct dolls is controversial. More complete evaluation of the patient’s psychiatric and developmental status should be deferred for a subsequent interview. If the alleged perpetrator is not a member of the immediate family, his or her interrogation is often best left to child welfare or legal officials.


Children rarely make false allegations of sexual abuse, except in the context of prompting by a parent embroiled in a custody dispute, adolescent vindictiveness (e.g., to remove a disliked stepfather), or a wish to disguise the teenager’s voluntary sexual activity. When false allegations are suspected, a child and adolescent mental health professional with special expertise should be consulted.


Effects. Victims of sexual abuse are at increased risk of behavioral and emotional problems, and are overrepresented in clinical psychiatric settings. Rates of psychiatric disorders increase as the children approach school age, probably because they begin to recognize the inappropriateness of the sexual contact. As adults, victims report higher rates of many psychiatric disorders. A history of sexual abuse increases the likelihood of attempted suicide 2- to 14-fold. Full or partial PTSD is common. Symptoms include fear, startle reactions, reenactment of the trauma, flashbacks, sleep disturbance, and depression. Children and adolescents who are victims of particularly severe or long-lasting abuse may experience dissociative reactions and conversion symptoms. The tendency to reenact the trauma may lead to sexual behavior problems. Among victims, risk factors for emotional and behavior problems include family disruption, economic hardship, preexisting psychiatric diagnosis, and scapegoating of the child for reporting the abuse. Psychological symptoms include suicidal ideation or behavior, fears, sleep disorder, low self-esteem, sexual precocity or preoccupation, impaired social adjustment, and subsequent sexual dysfunction as an adult. Promiscuity or, in contrast, a phobic reaction with sexual inhibition may develop.


Medical sequelae include damage to the genitals or rectum and/or acquisition of sexually transmitted diseases and their sequelae.


Interventions. The child must be protected from both further sexual abuse and the effects of reporting it, especially if the perpetrator is the father or the mother’s partner. The child should return home only if the abuser has been removed from and does not have access to the home and if the mother can and will protect the child.


Research on treatment for sexually abused children and adolescents is limited. Sexual abuse is an experience rather than a disorder and the treatment targets symptoms and dynamics. Symptoms resulting from abuse vary based on developmental level, with children more likely to experience anxiety and sleep disorders and adolescents more likely to experiment with drugs and delinquent behavior. There is an empirically supported model of CBT for sexual abuse–related PTSD symptoms in preschool-age children (Cohen et al. 2004).


Treatment interventions are “abuse-specific” and encourage the expression of abuse-related feelings, correct cognitive distortions regarding the abuse, teach prevention skills, and encourage support from other abuse victims. Specific symptoms may persist, however, and require targeted interventions that may include psychopharmacology. The therapist should select a treatment approach based on the characteristics of the child, the presence of psychiatric symptoms, and the family context. Intermittent treatment may be required for effects of abuse that may not appear for months or years. There is no evidence, however, that psychiatric treatment for asymptomatic victims of abuse will prevent future problems.


In incest cases, legal pressure may be required to initiate and maintain treatment of the perpetrator. Therapy models that aim at improving family functioning have not been particularly successful. Many parents (whether perpetrator or spouse) of sexually abused children have been abused themselves, making it difficult for them to deal with their child’s situation. These parents may benefit from a support group for adult victims of childhood incest. If alcohol is a precipitating factor, successful treatment of the alcoholism markedly decreases the risk of recidivism.


Out-of-Control Behavior


When a child or an adolescent is brought to an emergency room because his or her behavior is out of control (Table 16–6), the clinician must first use whatever physical means are necessary to ensure the safety of the patient, family, and staff.






































































TABLE 16–6. Causes of out-of-control behavior in children and adolescents


Temper outbursts


Attention-deficit/hyperactivity disorder


Oppositional defiant disorder


Conduct disorder


Intellectual disability


Autism spectrum disorder


Anxiety-provoked aggression


Separation anxiety disorder


Panic disorder


Obsessive-compulsive disorder


Acute phobic hallucinations (especially in children ages 2–6 years)


Organic delirium


Medical illness


Fever


Electrolyte imbalance


Central nervous system infection, tumor, trauma, or vascular accident


Seizures


Endocrine or autoimmune disorder


Hypoxia


Metabolic disorder


Adverse reaction to prescribed or over-the-counter medication


Toxic ingestion


Reaction to illicit substance


Acute intoxication or toxic reaction


Flashback


Withdrawal


Psychotic reaction to chronic drug use


Schizophrenia


Mania


Abuse or neglect


Posttraumatic stress disorder


Evaluation


If a patient has been aggressive, it is important to determine whether a person or object actually has been harmed or only threatened verbally or with gestures. Detailed description of the aggressive behavior includes: precipitants, warning signs, evidence of an altered mental state, actual damage, need for physical restraint, repetitive behaviors, lethality (including access to firearms), solitary vs. group action, and response to any previous treatment. Cultural factors may affect both the precipitant and the response. Predictors of violent behavior include male sex, emergency room arrival under police custody, and history of prior violence, violence victimization, substance use, and psychiatric illness (Marzullo 2014).


The mental status examination includes an assessment of current anger or violent intent, organic cognitive impairment, paranoia, delusions or hallucinations, and impulsivity.


Patients with intellectual disability, autism spectrum disorder, neurological disorders, or delayed expressive and receptive language are more likely to communicate distress through aggression. The older and larger the youngster, the more seriously aggression must be taken. If ADHD, conduct disorder, psychosis, intellectual disability, or drug use causes impulsivity and impaired judgment, a more restrictive environment may be needed.


Children and adolescents with a history of escalating violence and pervasive hostility are most problematic. Occasionally youth will show little guilt or remorse for their actions. The risk of aggressive behavior is increased by neuropsychological dysfunction and exposure to violence and/or physical abuse or witnessed violence between caregivers. In such instances, parents model the choice of aggression as a solution to problems. Family assessment is important because relationships among all family members are affected by violence.


Treatment


In the acute situation, medication is sometimes considered, although children have usually calmed and rarely require medication in the emergency department. Special caution in pharmacotherapy is needed if a medical disorder or drug ingestion is suspected. If necessary, acutely psychotic adolescents can be given an antipsychotic agent. The second-generation antipsychotics (see Chapter 17, “Psychopharmacology”), particularly risperidone and olanzapine, because of their comparable efficacy, rapid onset of action, sedative effects, rapid orally disintegrating form, and comparatively lower extrapyramidal effects, are becoming the preferred choice over haloperidol for the acutely agitated patient (Baeza et al. 2013). Benzodiazepines may cause paradoxical disinhibition and worsening of the agitation. Particular attention should be paid to the safe and appropriate use of seclusion and restraint, if needed, because of risk of harm to self or others and the failure of less restrictive interventions to control the patient’s behavior.


In considering disposition from the emergency room, the clinician must consider the safety of vulnerable persons in the home (e.g., a baby) and the ability of the adults to supervise. Even if the behavior resolves quickly in the emergency department, these youngsters often have multiple social, psychological, academic, and behavior problems that require psychiatric follow-up. The courts and child protective services are frequently involved in disposition planning.


After safety is ensured, the goal of treatment is to address the underlying cause of out-of-control behavior. Psychiatric hospitalization is not effective in the treatment of severe conduct disorders. Possibly more effective alternatives are extended partial hospitalization, residential treatment, therapeutic school placement, and comprehensive home-based treatment programs. The success of outpatient therapy depends on the patient’s and family’s cognitive abilities and motivation, the severity of antisocial behavior, and use of a systems approach. Cognitive-behavioral programs like anger management training encourage greater individual control. Social skills training increases alternatives to aggression, if the environmental contingencies can be managed to encourage their use. Family and, when necessary, the legal system should be involved to actively support the treatment process.


FAMILY TRANSITIONS


A substantial number of children spend some part of their life with just one parent, whether due to single motherhood, separation, divorce, or death of a parent. Children in single-parent households typically have more responsibility, not only for chores but also for management, decision making, babysitting for younger siblings, and emotional support of the parent. As a result, these children may be more independent, competent, and responsible than other children but at the expense of having less freedom, more worries, and less closeness with peers. The parent–child relationship can suffer when children resent the additional responsibility.


Divorce


Effects


Divorce affects nearly all aspects of a child’s life, but the long-term outcome varies depending on both risk and protective factors. Divorce is a process that often begins with marital strain and discord (that may last for years), is punctuated by the marital separation, and results in dramatic changes in family life. To the child, divorce represents the failure of a relationship that was to serve as a model of love and commitment. A conflict-ridden intact family is, however, more detrimental to children than a stable one-parent home. In fact, marital discord is a more important risk factor for child maladjustment than actual divorce or conflict following divorce (Buehler et al. 1998). High-intensity marital conflict during childhood is associated with attachment difficulties, externalizing and internalizing symptoms in childhood, and psychological disorders as young adults. Parental physical violence is more detrimental to children’s adjustment than verbal conflict. Rates of child abuse and sibling violence are increased in violent compared with nonviolent high-conflict marriages. Protective factors that have been identified for children in high-conflict marriages include a positive relationship with a caregiver and supportive siblings. In addition, for teenagers, peer relationships and a positive self-concept appear to be helpful. Another factor mediating the impact of high-conflict parental relationships is the manner in which the parents settle their disputes. Unresolved or chronic discord is associated with more difficulties for children. Parental conflict in which each parent criticizes the other to the child and attempts to gain the child’s alliance is particularly damaging, whether in an intact family or after divorce. Intense parental conflict may also reflect psychiatric symptoms in one or both adults. Children and adolescents commonly blame themselves for the divorce, view themselves as potential saviors, and harbor fantasies that their parents will reunite.


Reactions to parental divorce may vary with the age and developmental level of the child and the time since divorce. Infants may react with irritability and sleep and feeding difficulties. Children ages 2–6 years commonly experience separation anxiety and behavioral regression such as clinging or loss of toilet training. Children ages 5–9 years may be anxious, sad, and preoccupied with loss of their intact family and separation from their nonresidential parent, whatever the nature of the prior relationship. Slightly older children may feel shame and anger or complain of somatic symptoms, but they have somewhat better coping mechanisms to deal with their feelings. Disruptions in peer relationships and academic learning are common. Pre-teens may feel powerless, frightened, and intensely angry with one or both parents. They are more likely than younger children to take active sides in ongoing battles between their parents. Adolescents tend to react either with depression, acting out, and emotional and social withdrawal from friends and school or with a developmental spurt, showing unexpected maturity, empathy, and compassion and providing significant help to one or both parents. School social adjustment and academic performance may be negatively affected.


The relative effects of different custody options are difficult to study, although in one 12-year follow-up study of low-income families with contested custody in divorce who had been randomly assigned to mediation or litigation, mediation resulted in greater continuing involvement with the nonresidential parent without an associated increase in co-parenting conflict (Emery et al. 2001). Some research has found a positive correlation between joint legal custody and children’s adjustment; however, parents’ psychological well-being and the quality of the parent–child relationship are key variables. Divorcing parents who request joint custody are likely to be those who are better able to maintain a parental coalition and active involvement of both parents, despite the dissolution of the marriage. Fathers with joint custody are more likely to remain emotionally involved with and financially supportive of the children. If a judge awards joint custody against the wishes of one or both parents, severe conflict is likely to continue, to the detriment of the child. This is particularly true for infants and toddlers who are often forced into overnight visits at a time when separations may be traumatic. Single-parent custody relationships have been effective, particularly when contact with the noncustodial parent remains an option for the child. Even when the noncustodial parent has been unreliable or has acted violently, the child may continue to request visits. Unfortunately, divorce almost always has a detrimental effect on the relationship between the nonresidential parent and the child. Contacts become primarily social, and these parents rarely are partners in the child’s discipline or education. There is evidence, however, that for noncustodial fathers the quality of paternal parenting and the child–father relationship are more important than frequency of contact (Amato and Gilbreth 1999).


Marital separation and divorce create social upheaval for the child. The standard of living typically declines, due to spreading the family income over two households instead of one, inadequate child support payment, and mothers who may be poorly equipped to enter the job market. When a stay-at-home mother must return to work, children may be traumatized by yet another separation. Reduced income may lead to a move to a more modest neighborhood, with resulting separation from familiar peers, neighbors, and school.


Divorce has phases that require repeated adjustment. Some children do poorly during the first year after divorce, a time that forces change on the parent as well as the child. Many parents, coping with their own anger, grief, depression, anxiety, and loneliness, as well as struggling with the financial settlement and the practicalities of maintaining separate households, are emotionally unavailable to their children and unable to provide consistent routine and discipline. Typically, hostility between parents decreases over time. Long-term child adjustment is dependent on the ability of the custodial parent to maintain a functional household, continue the child’s relationship with the other parent, avoid severe economic hardship, and provide emotional support to the child.


Children of divorced families have more social, emotional, and behavioral difficulties, including substance use and difficulties with relationships, than those in intact families, although less so than previously believed. Age of the child, time since divorce, parenting styles, and degree of parental/family conflict likely influence these complex issues of postdivorce adjustment. Adolescents and young adults may experience delayed effects of divorce as they enter dating, falling in love, and marriage.


Most children of divorced parents eventually must readjust to one or more new families, as one or both of their parents find new partners or remarry. Remarriage by a custodial mother is associated with increased problems in the mother–daughter relationship but decreased behavioral symptoms in boys. Young adolescents who have functioned in parental roles often have special difficulty adjusting to a stepparent, who usurps some of their duties and privileges. Awareness of the parent’s sexual activity is acutely embarrassing to teenagers.


Although some young adults who have faced divorce as children have significant consequences, the majority have resilient outcomes.


Interventions


Education regarding typical reactions to divorce is useful for parents and children. A support group may reduce feelings of isolation and guilt, especially in communities where divorce is uncommon. Postdivorce groups or workshops based in schools offer services with less stigma. Parents Without Partners, a self-help group with chapters nationwide, offers companionship, advice, and support from adult peers, as well as educational programs and role models for children. Brief focused therapy can help children and parents deal with their feelings and aid parents in resolving conflict and establishing new lives. In a controlled trial with white, middle-class families undergoing divorce, a 6-year follow-up of a group and individual prevention program with mothers, with or without their school-age children, found that the adolescents from the intervention groups (compared with controls, who received reading material) had fewer mental disorders and fewer sexual partners. Among those initially at higher risk, the intervention subjects had fewer behavior problems and less substance use (Wolchik et al. 2002). Some states provide court-connected programs that offer or mandate evaluation, counseling, and crisis intervention and make recommendations to the judge regarding custody, visitation rights, and child support. Divorce and custody mediation is available as an effective alternative to the adversarial litigation process. However, in circumstances of abuse, violence, mental limitations or illness, or severe and unresolved parental conflict, the judicial system is appropriate for protection of children and parents. Children and parents with significant symptoms may require more extensive psychiatric evaluation including individual and/or family therapy. Parental psychiatric problems following divorce are associated with more difficulties for children; therefore, prompt treatment for these adults is critical.


Physical Illness in Parents or Siblings


When a family member is chronically or seriously ill, parental resources in time, money, and emotional energy available to other family members are reduced. In addition, nearly all children have at some time wished that something bad would happen to a parent or sibling. If that person then falls ill, the child may literally believe that he or she caused the illness. This “magical thinking” is normal in young children and appears under stress even at later developmental stages.


To the extent that an ill child receives special treatment, sibling rivalry is exacerbated. This may be overt or concealed by the child’s guilt or parental shaming. A child or an adolescent often must take on extra chores to substitute for a parent or sibling. Parents can help by equalizing chores, discipline, positive parental attention, privileges, and treats as much as developmental stages and physical condition permit.


Childhood disability and illness have an impact on the whole family system. The sibling of a disabled child may be teased by peers. Providing accurate information about the disability can facilitate coping. Some siblings of children with severe, chronic disabilities are more likely to have symptoms of aggression, depression, social isolation, and oppositional behavior. Families who are already stressed (e.g., by financial strain or single parenthood) are at higher risk for emotional or behavioral symptoms.


Death of a Family Member


The death of a family member, particularly a parent or primary caregiver, is a traumatic event for a child that can elicit strong emotional or behavioral responses. One in 20 children experiences the death of a parent. Bereaved children often experience depressed mood, sadness, longing for the deceased, appetite changes, irritability, social withdrawal, declining school performance, and sleep disturbances, although children’s expressions of grief tend to be more intermittent than those of adults. In the first 2 months after parental death, the effect can be profound and may lead to the development of major depression and suicidal ideation. However, the severity of these symptoms generally wanes over time. In a longitudinal study of the psychosocial functioning of bereaved children from stable families, the children appeared similar in function to healthy control subjects (Fristad et al. 1993). If the death occurred under traumatic circumstances, the expected anger and grief may escalate to childhood traumatic grief or persistent complex bereavement disorder. If the death involves a child, the siblings must face their own grief in addition to their grieving parents’ emotional withdrawal. Suicide-bereaved children have to address grief as well as the stigma and anguish surrounding suicide. Suicide-bereaved children experienced more anxiety, anger, and shame than children bereaved from parental death not caused by suicide (Cerel et al. 1999).


The terminal phase of the parental illness may, in fact, be more stressful for the child than the death. During this time, the child is exposed to the physical changes and painful consequences of life-threatening disease. The child also becomes aware of the irreversible nature of the illness and the likelihood of death. Parental illness changes the structure and organization of the family. Family roles and routines change, and family cohesiveness may suffer as the ill parent becomes less available physically and emotionally, and the other parent may be exhausted by caretaking and grief. Terminal phases of illness require more resources for care, which may jeopardize the family’s financial stability. When a parent has been ill, the death may mark the end of a tragic and difficult period for the family and begin the process of healing and reorganization.


When a family member dies, the child should be allowed some choice in whether to attend the funeral (if developmentally appropriate). One study (Weller et al. 1988) showed that attendance at funeral activities did not result in increased psychiatric symptoms 2 months later. Extra support, such as an adult friend or relative, can be helpful through the funeral process, because the surviving parent may be too preoccupied with his or her own grief to be available to the child. Children can mourn, although they may express their grief in behavior rather than verbally. If the child is especially vulnerable because of a psychiatric disorder or additional stressors, clinical judgment should influence the decision about how to handle the funeral, and extra therapeutic support may be needed.


Parents should explain death in a matter-of-fact, concrete way. Religious explanations should be used only if these are consistent with family beliefs. The magical thinking and egocentricity that are characteristics of young children may lead them to believe that they are responsible for the death. They will often be too frightened or guilty to mention this and should be spontaneously reassured that they had nothing to do with the cause of the death.


The child’s conceptualization of death plays a role in adjustment. As children mature, they gradually develop an understanding that death is universal and irreversible. Children younger than 2 or 3 years do not understand at all; they are simply made anxious by the separation. At ages 4–5 years, death seems reversible, like sleep or a long journey. For 5- to 10-year-olds, death can be personified. A more realistic concept of death develops in children ages 10–11 years. Although by then most understand that death is universal, more than half of fourth graders do not yet clearly understand the irreversibility of death. Elementary school–age children tend to view death as a punishment for bad behavior. Although most adolescents cognitively understand the meaning of death, some behave as though they do not accept their own mortality.


The long-term effects of family bereavement depend on how well the surviving parents cope and are able to restore family life functioning. Open and honest expressiveness among mutually supportive family members facilitates this process. If the child’s life is further disrupted by economic hardship or changes in school, home, and friends or the child’s relationship with the deceased parent had been conflictual, the risk of significant adjustment problems may be increased.


Adoption


Adopted children are overrepresented in psychiatric treatment settings because of factors such as genetic or prenatal risks from the birth parents; disruptions, trauma, or neglect in the child’s early life; adoptive home problems (such as unrealistic expectations by both the adoptive parents and the child, differential treatment by parents or grandparents); and the child’s unresolved feelings about being given up for adoption or identity issues. The understanding of temperament (see Chapter 2, “Evaluation and Treatment Planning”) emphasizes the importance of “goodness of fit” between parent and child. To the extent that there is a genetic contribution to temperament, adopted children may be more likely to be mismatched with one or both parents, increasing the risk of behavior and emotional problems.


Children adopted past infancy are at higher risk for psychiatric problems as a result of the experiences that led to placement for adoption. These children have endured not only the loss of their parent(s) or primary attachment figure, but perhaps also neglect, abuse, and frequent changes of caregiver. Some children adopted after spending their first years in a residential nursery or orphanage are capable of forming stable affectionate relationships with their adoptive parents, but many show significant social and attentional problems and attachment difficulties.


It is normal for children and adolescents, even those who have not been adopted, to go through stages of questioning whether they are with their “real” parents and whether another set of parents would be better. It is important for adoptive parents not to take these stages too seriously or personally. Although there is not a clear consensus of when the best time is to disclose to a child his or her adoption status, the child’s cognitive functioning should be taken into account. The trend is increasingly toward “open” adoption, where children are told early and there may be contact with the birth mother.


CULTURAL FACTORS FOR IMMIGRANT FAMILIES


Immigrant families face unique challenges, both within the family unit and in relation to the external environment, that can have a profound impact on the psychological well-being and functioning of children. Factors such as lack of social supports, financial strain, prior or current trauma associated with the immigration process, perceived racism or prejudice, ongoing concerns about immigrant status or risk of deportation, language barriers, and neighborhood crime and poverty can affect the family’s functioning and that of the children. In addition, children of immigrants often acculturate at a faster rate than their parents, leading to a phenomenon known as an “acculturation gap.” This can increase parent–child conflict, especially for adolescents, as their adoption of “American” values may be perceived by their parents as a rejection of their native culture. The children may feel that their parents are being unreasonable or unfair. Research has found that adoption of a “bicultural” identity, in which an individual integrates values from both the native and host cultures, is the most adaptive stance and produces the most favorable outcomes. Helping parents understand their bicultural children and helping children appreciate their parents’ immigration narrative can be beneficial in facilitating communication. In work with families, it is important for the clinicians to understand the immigration experience of the family and the cultural identity of the parents and children. Identifying the key decision-makers and caregivers within the family and recognizing the cultural factors impacting treatment seeking, understanding of illness, and attitudes toward mental health care can greatly improve rapport and treatment adherence.


ADOLESCENT PREGNANCY


Adolescent development includes exploration of new relationships, including attraction, dating, breaking up, and sexual activity. Mental health disorders in teenagers may significantly affect this aspect of social development. Teens with severe social anxiety or social skills deficits may be frustrated by their inhibition or difficulty in interacting with potential partners. Adolescents with depression, bipolar disorder, or impulsivity may be more likely to engage in unprotected sexual activity that puts them at risk for pregnancy or sexually transmitted diseases.


Mental health clinicians may be the health professionals with the most regular contact with youth. Psychiatric assessment and ongoing care should regularly address the emotional, developmental, and medical aspects of reproductive health in adolescents.


Demographics


By age 15, 15% of unmarried adolescents have had sexual intercourse; by age 19, 46% have. In 2015 data reported by the CDC, the birthrate among U.S. females ages 15–19 was 22.3 per 1,000, an all-time low, although remaining higher than in other industrialized nations. The recent sharp decline in American teenage pregnancy and birthrates is attributable to increased use of contraceptives, particularly use of highly effective methods (Lindberg et al. 2016). The proportion of teen pregnancies ending in abortion continued to decline, to 30% of pregnancies in 2010. There are large disparities by state of residence and by race, with adolescent girls of color at higher risk for unintended pregnancy.


The Mother


Adolescents who become pregnant are not a uniform group; they differ by race, socioeconomic status, and age. In studies controlled for academic aptitude and financial status, teenage mothers are less likely to complete high school, less likely to achieve a stable and well-paying job, more likely to be dependent on public assistance, and less likely to enter a stable marriage than their peers. Interestingly, those who are able to finish high school, avoid another pregnancy in their teens, and marry do not show negative effects at long-term follow-up when compared with peers who delayed their first pregnancy.


The Child


Lack of adequate prenatal care is a risk factor for prematurity, low birth weight, and neonatal mortality, especially for mothers younger than age 15 years. Children of teenage mothers have higher postneonatal mortality rates and more subsequent illnesses and injuries.


Children, especially sons, of teenage parents appear to be at a developmental disadvantage and may be at higher risk for emotional problems, ADHD, aggression, school failure, and incarceration. The daughters of adolescent mothers are more likely to become pregnant before age 18 years than offspring of mothers in their 20s. Poor prenatal care, genetic factors, parental limited education, and suboptimal parenting because of immaturity, financial stresses, and living in disadvantaged neighborhoods with low-quality schools may contribute to these outcomes.


Interventions


Mental health providers should regularly assess adolescents for high-risk sexual activity and provide guidance on abstinence, consent, contraception, and prevention of sexually transmitted disease. Potential effects of psychotropic medications on a developing fetus or newborn must be reviewed with all adolescents of reproductive potential.


Once an adolescent becomes pregnant, nonjudgmental support for the young woman and her family, along with practical and educational assistance, may facilitate making an informed decision among adoption, abortion, and raising the child. Young mothers are most satisfied with the outcome of their pregnancy when they receive parental support for their decision (Siegel and Brandon 2014). For teenage mothers raising a child, outreach programs offering prenatal care, child care, parenting training, assistance in completing high school, further academic or vocational training, and enrichment programs such as Head Start for the children can positively affect long-term outcome.


OBESITY


Clinical Description


Body mass index (BMI; weight in kg/height in m²), the most appropriate measure to screen for childhood obesity, has norms by age and gender. Overweight is defined as a BMI at or above the 85th percentile and below the 95th percentile of age- and sex-specific norms. Obesity is defined as a BMI greater than the 95th percentile.


Epidemiology


The prevalence of childhood obesity is increasing. Data from the 2011–2014 National Health and Nutrition Examination Survey (NHANES) found 17% of youth to be obese (Ogden et al. 2016). African American youth and Hispanic boys are at greatest risk for both obesity and overweight.


Etiology


Genetic, medical, family, and societal factors contribute to the development of obesity. Parental obesity greatly increases the risk. Feeding practices from infancy impact later weight gain. The ubiquitous presence of calorie-dense and nutrition-poor foods, the relative absence of fresh fruits and vegetables in urban “food deserts,” the challenges of exercise in many neighborhoods, and the increase in screen time for many children are all implicated in pediatric obesity.



Course and Prognosis


Obesity in middle childhood (especially if it persists through adolescence) predicts adult obesity. Childhood obesity can result in medical complications, including cardiovascular disease and diabetes. Severe liver disease with hepatitis and fibrosis may result. Obstructive sleep apnea as a consequence of weight gain can lead to nighttime hypoxemia, cardiac arrhythmias, and right heart failure. Obesity carries a social stigma as well. These children have more difficulty making and keeping friends, negatively affecting levels of self-esteem. However, there is increasing evidence that obesity is not always associated with poor health outcomes and that it is possible to be metabolically healthy at higher weights (Saul and Rodgers 2016).


Evaluation and Differential Diagnosis


The mental health provider may be part of a multidisciplinary team working with the obese child and his or her family. Comprehensive assessment should include medical, family, social, nutritional, physical activity, and sleep history, as well as a physical exam and laboratory tests as indicated to assess metabolic risk factors and possibly rare endocrine or genetic causes of obesity. The nutritional history includes not only what and how much the child consumes but behavioral patterns as well, including where the child eats and with whom; times of day; accompanying activities; emotional state before, during, and after eating; and family attitudes toward food, exercise, and weight. Clinicians must strive to avoid communicating weight bias or shame, respectfully taking into account cultural and socioeconomic factors that influence health and diet behaviors.


Treatment


The treatment team should emphasize family-based efforts rather than targeting the identified patient and make the primary goal healthy behaviors rather than weight change. For children, the medical recommendation is generally to stabilize weight and allow the child to grow into it, rather than weight loss. Prescribing dietary or behavioral changes is less effective than collaborative treatment. Collaboration begins with motivational interviewing, in which the clinician helps the child and family develop their goals and assess their readiness for, and obstacles to, meeting them.


Specific treatment plans vary based on the family presentation, the child’s needs, and resources available, but experts make the following general recommendations (Children’s Hospital Association 2012):


For individuals:



  1. Use a hunger scale to develop awareness of hunger and satiety.
  2. Review and encourage sleep hygiene, as poor sleep is associated with overeating.
  3. Recommend eating in a common area, such as the kitchen table, without television screens or other distractions.
  4. Consume five small meals per day.
  5. Recommend leaving the table after a normal meal and waiting 20 minutes before second helpings, giving time to experience satiety.
  6. Encourage regular exercise.
  7. Decrease sedentary activities.

For caregivers:



  1. Recommend that the whole family participate in health and exercise behaviors, and explore barriers to these.
  2. Show love and nurturing without using food as a reward.
  3. Create a positive family culture around eating.
  4. Foster mindfulness around eating, encouraging children to enjoy foods and to attend to the sensory experience of eating.
  5. Avoid buying foods that family members overeat.
  6. Avoid nagging or criticizing around food—this is likely to be counterproductive.

Certain behavioral patterns related to diet and nutrition may be best addressed in CBT, interpersonal psychotherapy, or DBT. These include boredom eating, emotional eating, binge eating, nighttime eating syndrome, hoarding or hiding foods, and food aversions.


Children who are treated with certain psychotropic medications, particularly the atypical antipsychotics and the mood stabilizers, are at risk for medication-induced weight gain. Counseling regarding dietary habits must be part of their care, and the continued need for treatment must be carefully balanced against the risks associated with development of obesity. Addition of metformin may mitigate medication-induced weight gain (Zheng et al. 2015).


Bariatric surgery is increasingly used to treat severe obesity in adolescents who have not responded to more conservative weight loss strategies, particularly when there is comorbid diabetes or metabolic syndrome. Bariatric surgery can reverse these disease processes (Mirensky 2016).


PHYSICALLY ILL CHILDREN AND ADOLESCENTS


Developmental Factors in Reaction to Acute Illness, Hospitalization, and Surgery


The emotional response to illness is dependent on the child’s stage of development, the amount of discomfort, the type of treatment and its side effects, the practical limitations that result from the illness, premorbid psychiatric problems in the patient, and the child’s level of understanding. Parents influence the child’s reaction through their own coping mechanisms and the support they are able to provide. Clinicians can often predict the most stressful times in the course of an illness and should take these opportunities to provide additional emotional support. Practices such as parental rooming-in, unlimited parental visiting, permitting parents to be present while the child is sedated preoperatively, and outpatient surgery to avoid hospital admissions have reduced emotional aftereffects. The use of primary nurses and child development specialists in the hospital has also facilitated children’s adjustment. Preparation, individualized to coping style and developmental level, may be done via talks explaining procedures, visits, books, puppet shows, and films.



Infancy


Hospitalized infants younger than 6 months are most upset by the change in the usual routine. It is helpful to have the parents do as much of the caregiving as possible and to arrange for consistent nurses. For the older infant who has formed strong differential attachments, separation is traumatic, and stranger anxiety adds to the infant’s distress. Infants respond to the emotional reactions of the primary caregivers. An anxious, tense parent will be less able to soothe and comfort her child than one who is calmer and in better control. Most pediatric hospital settings encourage parents to “live in” while their infant is hospitalized.


Early Childhood


Hospitalized children ages 1–3 years may react to separation from their parents by rejecting parents when they visit, being aggressive toward medical staff, regressing in bowel and bladder control, and/or refusing to eat. If parents are absent, children may develop depression, sleep disturbance, diarrhea, or vomiting. Maximizing parental presence and providing the child with familiar items from home, especially the child’s favorite toy or blanket (transitional object), are helpful. Developmentally, this is a time of increasing exploration and autonomy. Unfortunately, toddlers frequently attempt to master their environment by becoming more oppositional. Offering the child as much predictability, consistency, and control (choices) as possible can reduce distress and resistance.


For children ages 3–5 years, separation from parents by hospitalization is difficult, even for a child who is comfortably able to separate in other circumstances. Anesthesia and surgery are especially frightening because of normal developmental fears of bodily injury. Children believe that illness and painful treatments are punishment for real or fantasized misbehavior. When possible, preparation by simple explanations and a visit to the hospital may help. Frequent presence of a parent is important. Following the acute phase of illness, if understandably anxious parents attempt to protect the child’s health by limiting the child’s activities, including delaying school enrollment, unintended increased passivity, dependence, and fearfulness in the child may result.



School Age


Children ages 6–12 years usually tolerate acute illness and hospitalization relatively well, especially when they are prepared, their parents are present, and the child’s preceding development was on course. Even so, the child may have irrational explanations of illness (e.g., that she is being punished or that his parents were unable to protect him). Peer relationships become paramount during this period, and peers notice and may comment on physical appearance and capabilities. Medically ill children become aware of their differences and limitations; occasionally their friendships are affected. School attendance and participation are major developmental tasks of childhood; medically ill children have more academic problems than their non–medically ill peers. These problems may be caused by the effects of the illness and its treatment, decreased expectations in the classroom, school absences, or psychosocial stressors. Reactions often include regression or oppositional behavior.


Adolescence


Adolescents have more realistic fears regarding the outcome of illness, such as changes in appearance or inability to continue favorite activities. An injury may make impossible a planned career (e.g., sports, the military). Loss of autonomy and privacy is especially painful for adolescents. The adolescent should be given some control over treatment to avoid struggles between the patient and the caregiver and to convey that the adolescent’s opinions are important. Occasionally, lack of adherence to medical requirements can be an expression of suicidal ideation, particularly when the consequences could be life threatening. Physical appearance and sexuality emerge as priorities during adolescence, and patients with sequelae of illness, injury, or treatment may need additional support.


Chronic Illness


The Child’s Reaction


Chronic illness can lead to interference with academic, social, and recreational development. Autonomy and control of the child’s own body are jeopardized, and self-esteem may be lowered. Especially in adolescence, peers have little tolerance for differences in appearance or behavior. Children and adolescents with chronic illness without disability are twice as likely as control children to have a psychiatric disorder. Those with disability as well as chronic illness are even more likely to have emotional symptoms, ADHD, social isolation, and school performance problems. Central nervous system disorders are more likely to have psychiatric sequelae. Episodic illness is more stressful than persistent medical disorders because of the unpredictability of the problem and the need to respond to sudden changes in physical condition. Psychiatric distress may present as an increase in dependent, fearful behavior; an escalation in risk-taking or acting-out behaviors; or, in older children and adolescents, a tendency to become angry, hostile, and isolative. Somatic symptom disorder, manifested by headaches, recurrent abdominal pain, limb pain, chest pain, or fatigue that is affected by psychological factors, interacts with symptoms of medical disorders and may be difficult to distinguish. The combination can lead to increased physical disability. Catastrophic injury and devastating illness can lead to symptoms of PTSD in both the pediatric patient and the parent. Support should be provided to the child, parent, and medical staff. Psychiatric disorder is not inevitable in chronically ill children and adolescents. Knight et al. (2015) assessed mental health problems in matched pairs of youth with diabetes and systemic lupus erythematosus and found depression symptoms in 23%, suicidal ideation in 15%, and anxiety in 27% of participants.


The Parents’ Reaction


The most critical factor in the child’s ability to cope with chronic illness is the response of the family. Medical illness in a child tends to exaggerate all the strengths and weaknesses of the family. At the time of diagnosis, the parents must go through a period of mourning with stages similar to those following a death: anger, denial, grief, and resignation. Medical problems in a child may be viewed by the parent (and others) as a negative reflection on the parent. Parents feel guilty, especially for genetic diseases or pregnancy complications. The psychological status of parents is strongly related to their perception of the child’s illness. Clinicians must, therefore, attend to the parents’ understanding of the disorder and all of its implications. Additional caregiving and financial burdens may stress parents beyond their ability to cope. Chronic illness increases the strain on a marriage. The parents’ anger, resentment, guilt, and/or denial may interfere with their ability to communicate with each other and to work with the pediatric team. Parents may distance themselves from the child, become overly close or intrusive, or alternate between the two. Mothers of children with chronic illness are at increased risk for depression.


The Terminally Ill Child or Adolescent


When a young person is dying, parents or medical personnel may make misguided attempts to “protect” the child. These are perceived as in the best interests of the child but more often relate to the difficulties adults have with a child’s death. Although young patients may not fully understand their clinical situation, children are astute observers of emotions in their parents, nurses, and doctors. If the child is not dealt with honestly, his or her imagination can be even worse than the reality. Children understand the permanence of death by age 10 or 11 years, although they may not understand the relationship between it and the biological aspects of their illness. Parents or physicians may need to tell children about their terminal illness in stages, as understanding progresses and the child is able to cope with the knowledge. Children are often more concerned about immediate details of treatment and its effect on them than about ultimate survival. The child or adolescent should be given the opportunity, but not be forced, to talk about disease, disability, or death. Drawing, painting, or imaginative play may be useful symbolic outlets and means of communication.


The terminal phase of an illness leads to a recapitulation in parents of the feelings of denial, anger, grief, depression, and guilt that followed the initial diagnosis. Discussions about death between parent and child should be encouraged as a way to prepare the child, answer his or her questions and fears, and say good-bye. If a child is terminally ill for a long time, anticipatory mourning may be completed, and some parents gradually detach, leaving the child no emotional place in the family. Similarly, physicians may inadvertently avoid the child and family when aggressive treatment is no longer an option and the medical team is resigned to the patient’s death. Alternatively, if a child who is expected to die recovers, parents often experience a “Damocles syndrome,” living in constant fear of disease exacerbation and death. Other parents come into conflict with medical caregivers by demanding additional active treatments that are medically considered to be futile. A hospital ethics committee or palliative care consultation may be helpful.


Adherence to Treatment


Lack of adherence to or compliance with medical procedures and regimens can be a major problem in the care of children and adolescents. Factors in the child and parent, family dynamics, the nature of the treatment, and the relationship between the child and family and the medical team can all contribute to poor adherence. Severe nonadherence may warrant a full psychiatric evaluation and treatment of psychiatric disorder(s) and/or family dysfunction.


Adherence is facilitated by giving the child or adolescent as much responsibility for the treatment as appropriate, gradually increasing responsibility as interest, understanding, and behavior control improve. The child should participate in decision making and be offered as many choices as possible. Explanations can be targeted to the child’s ability to understand. The normal compulsiveness of children ages 6–12 years can be harnessed to develop a habit of charting or record keeping related to the treatment. If children or adolescents are able to develop their own relationships with medical personnel, adherence may be facilitated by avoiding the struggles for independence inherent in the parent–child relationship. Adults should minimize power struggles and, whenever possible, negotiate and solve problems with the young person. At times, a child’s nonadherence may signal a parent’s ambivalence about or even opposition to treatment.


Treatment


Psychotherapy


Supportive individual, family, and/or group education and psychotherapy are often valuable for the patient and parents. Instruction in social problem-solving and coping skills may be beneficial.


Support Groups


Support groups for children and adolescents and for parents, both separately and as families, may be helpful. These groups provide emotional support and education on challenges the disease is likely to present. Chronically ill children may benefit from disease-specific camps and recreation programs with medical supervision, which permit them more normal activities and provide a respite for parents.


Pharmacotherapy


Indications for the use of pharmacotherapy in medically ill children and adolescents do not differ from those in medically healthy children. Medication choice and management decisions are, however, affected by the illness and should be made in conjunction with the pediatric specialist. Risk of side effects is higher because of both medication interactions and illness. Disorders that are the direct consequence of medical illness, including delirium and organic affective states, should be addressed by treating the primary cause. Situational and anticipatory anxiety related to medical procedures may benefit from hydroxyzine, diazepam, or alprazolam if psychosocial intervention is insufficient. Because benzodiazepines may cause paradoxical agitation in children, a test dose may be indicated. Treatable depression should be actively sought, because depression is not an inevitable response to illness and may dramatically impede recovery.



Behavior Modification


Techniques such as behavior contracting with contingency management and self-monitoring with self-reinforcement are invaluable in improving medical and behavioral adherence. Children who refuse or are unable to swallow oral medication can be taught to take pills using instruction, modeling, contingent rewards, and a behavior-shaping protocol that involves successively larger candies or placebos (Patel et al. 2015).


Cognitive-behavioral techniques can be used to ameliorate a variety of chronic physical symptoms and symptom-related behaviors. For example, in treating headache, the antecedents and consequences of pain are determined (by keeping a pain diary, if the child is old enough), and attempts are made to modify events and situations that precipitate or positively reinforce pain. The clinician works with the patient, parents, teachers, pediatrician, and significant others to emphasize functioning normally despite pain as well as stress management techniques. Reductions in pain and pain-related behaviors give patients a sense of control and mastery and a return to age-appropriate activities. Stress inoculation helps to prevent anxiety in children before medical and dental procedures and reduces anxiety, pain, or discomfort connected to repeated procedures such as chemotherapy injections, bone marrow aspirations, and spinal taps in chronically ill children. Stress inoculation consists of multicomponent cognitive-behavioral approaches, including education, modeling procedures, systematic desensitization, hypnosis, contingency management, imagery, and breathing exercises.


Hypnosis is readily used in children, who are generally more hypnotizable than adults. Different techniques are appropriate for children of different ages. Hypnosis is used in treating physical symptoms with a psychological component or managing severe physical symptoms (pain, nausea) associated with a medical disorder or treatment.


Relaxation training for children and adolescents is used to manage pain in pediatric migraine, juvenile rheumatoid arthritis, and hemophilia. These techniques can result in decreased subjective experience of pain, reduced need for analgesics, and even improved mood, self-esteem, and physical and social functioning. Relaxation techniques are also used in treating asthma or cystic fibrosis in patients who hyperventilate.


CHILDREN OF PSYCHIATRICALLY ILL PARENTS


Risks and Resilience


Children of psychiatrically ill parents are at increased risk for developing a psychiatric disorder themselves, due to both genetic and environmental risk factors. Psychiatric illness in a parent can impact his or her parenting abilities, create marital discord, and disrupt the family environment. Poor decision making or decreased functioning may result in inadequate supervision or neglect. Family disruption may lead to divorce or placement of the child outside of the home. A population-based study in Denmark found that children of parents with schizophrenia, bipolar disorder, or depression were less likely to live in a nuclear family and more likely to live in a single parent–headed household. There was also an increased risk of living with neither parent, especially if a parent has schizophrenia (Ranning et al. 2016). The risk of psychopathology in the child is related to the severity and chronicity of psychiatric illness in the parent.


Children may be particularly distressed when their parents are admitted to a psychiatric hospital. Younger children may show sleep disturbance, decreased appetite, attention-seeking behavior, separation anxiety, crying (especially at bedtime), and social withdrawal. Adolescents are better able to verbalize their fears, guilt, and concerns about themselves and their parents.


Children whose parents are depressed are at increased risk for the development of psychopathology, as well as behavioral, academic, and health problems. Parents who are depressed may be less affectionate and emotionally unavailable to their children, often resulting in elevated rates of depression in their children. These children are more likely to experience a variety of internalizing symptoms, including recurrent feelings of guilt, interpersonal problems, and difficulties with attachment. Remission in maternal depression with treatment is associated with a decrease in symptoms in the child (Weissman et al. 2006).


A 7-year longitudinal study found that 75% of children of a parent with bipolar disorder qualified for a psychiatric diagnosis, most commonly bipolar spectrum disorder, substance use disorder, anxiety disorder, disruptive behavior disorder, or ADHD (Axelson et al. 2015). Children who have a parent with schizophrenia are more likely to have abnormalities in attention and information processing, even before any overt symptoms emerge. Children of patients with anxiety disorders are at increased risk of an anxiety disorder themselves, as well as fears and worries, school difficulties, somatic complaints, and social isolation.


A significant minority of children of alcoholic parents have increased behavior problems, especially conduct problems, hyperactivity, impulsivity, hypersensitivity to stimuli, poor self-control, inattention, and emotional symptoms such as anxiety and depression. Prenatal alcohol exposure is a common nongenetic cause of intellectual disability and can contribute to the development of learning, language, and behavioral disabilities. Children of alcohol abusers are more likely to develop alcohol use problems themselves, and the disinhibition associated with substance use places them at greater risk for suicide, accidents, unplanned pregnancy, HIV exposure, and school failure.


Some “resilient” children not only resist and cope with unusual stress but also thrive and succeed despite adversity. Protective factors include a cohesive and emotionally supportive family environment and external support systems, such as caring extended family members, other adults, and/or institutional supports (e.g., school or community agencies). These children often have a strong commitment to extracurricular activities and interpersonal relationships and tend to be confident and self-reliant. They are realistic in their assessment of the family and its limitations, and understand their own coping style when dealing with parental psychiatric illness.


Adolescence is a particularly high-risk period for the development of major depression in the offspring of parents with mood disorder. Successful adaptation is characterized by close, confiding relationships; persistence and success in school and work; and involvement in activities. They are able to separate themselves, cognitively and emotionally, from their parent and their parent’s illness, while often functioning as caregivers in the family. Coping skills include accurate cognitive appraisal of the stress to be dealt with, realistic assessment of their responsibilities and powers, and an understanding of the parent’s illness (especially that they are not responsible for their parent’s depression).


Interventions


Parents can promote resilient traits in their children and moderate the emotional consequences of their psychiatric illness. Communication between spouses and among family members can improve the level of understanding and reduces guilt and emotional distress. Children should be referred to appropriate support groups. Individual strengths in the child should be encouraged and nurtured. When parents are receiving psychiatric treatment, the treating clinician should be alert to possible effects of the illness on the children. Parental psychiatric hospitalization is particularly stressful. There should be at least one family session near the time of admission to explain the need for hospitalization and the anticipated treatment course. Optimally, a member of the treatment team interviews each child to assess developmental level, school performance, peer relationships, coping skills for dealing with and understanding parental illness, and the possible presence of psychiatric symptoms. Efforts can be made to enrich and strengthen the child’s support system. Placement with a relative or in foster care may be necessary until the parent can resume child-care responsibilities.


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ADDITIONAL READING


Beardslee WR, Martin JL: Children of parents with psychiatric and substance abuse disorders, in Dulcan’s Textbook of Child and Adolescent Psychiatry. Edited by Dulcan MK. Washington, DC, American Psychiatric Publishing, 2010, pp 623–635


Cohen JA, Mannarino AP: Posttraumatic stress disorder and persistent complex bereavement disorder, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 345–364


Cohen JA, Bukstein O, Walter H, et al; AACAP Work Group on Quality Issues: Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry 49(4):414–430, 2010 20410735


DeMaso DR, Martini DR, Cahen LA, et al; Work Group on Quality Issues: Practice parameter for the psychiatric assessment and management of physically ill children and adolescents. J Am Acad Child Adolesc Psychiatry 48(2):213–233, 2009 20040826


Giles LL, Martini DR: Psychiatric emergencies, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 621–635


Goldstein TR, Brent DA: Youth suicide, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 571–584


Joshi PT, Cullins LM, Southammakosane CA: Child abuse and neglect, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 539–558


Kelly JB: Children’s adjustment in conflicted marriage and divorce: a decade review of research. J Am Acad Child Adolesc Psychiatry 39(8):963–973, 2000 10939225


Martini DR, Lowry KW, Lavigne JV: Psychiatric aspects of chronic physical disorders, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 411–433


Miller AL, Rathus JH, Linehan MM: Dialectical Behavior Therapy With Suicidal Adolescents. New York, Guilford, 2007



Pumariega AJ, Rothe E, Mian A, et al; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI): Practice parameter for cultural competence in child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry 52(10):1101–1115, 2013


Walsh F: Family transitions: challenges and resilience, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 637–652

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Nov 25, 2018 | Posted by in PSYCHIATRY | Comments Off on Special Clinical Circumstances
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