Child and adolescent psychiatry

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CHAPTER 16 Child and adolescent psychiatry

Alessandra Radovini

About one in ten young people suffer from mental symptoms sufficiently distressing to justify seeking professional help. Australian studies suggest that as many as one in seven (14%) have symptoms of emotional and behavioural disturbance.

Mental heath problems and disorders in children and young people can damage self-esteem, impede relationships with peers, decrease school performance and impact on the quality of life of the child, parents/carers and families.

This chapter provides an overview of psychiatric disorders in childhood and adolescence. We begin with a general overview of aetiology, and then turn to general principles of assessment and management. We then give consideration to specific disorders afflicting young people.

Aetiology

Mental illnesses in children and adolescents share many aetiological factors with those that pertain to adults. However, there are unique factors that impact on the young person and their world and these can of themselves, or through interaction effects, lead to the manifestation and perpetuation of emotional and behavioural problems. Such factors encompass biological, psychological, social and developmental factors in the context of the child’s family and school environment.

Genetic factors

Increasingly, research is discovering the role of genetic factors in the aetiology of several disorders such as autism, intellectual disability, attention deficit hyperactivity disorder (ADHD), conduct disorder, anxiety and depression. This may result from the influence of single or multiple gene abnormalities or the complex interaction between genes, brain function and environment.

Trauma

An alarming number of children are direct victims of abuse and neglect, or witness domestic violence. Research has established the direct deleterious effect of child abuse and neglect on the growth and development of the brain. This impacts on the child’s sense of self, ability to develop trust, ability to form relationships and ability to learn. All of these can have long-term consequences.

Educational factors

The school environment is an important influence on children. Normal transition points and multiple school changes can be stressful. Poor peer relationships, bullying, and underachievement in academic or sporting areas, can cause significant stress/distress for children, leading to behavioural or emotional difficulties. Further, children with disruptive behaviours and/or unrecognised learning difficulties may end up in a negative cycle of conflict and punishment, making school an aversive experience.

Family factors

Family factors include parental separation and divorce, parental mental illness, and social and economic hardship.

Parental separation and divorce

In many Western cultures, around one in two marriages ends in divorce. The impact on children can be very significant, including: fear and confusion regarding the threat to their security; the actual or perceived loss of a parent; self-blame and feeling responsible for the parental conflict; the deleterious effect of exposure to ongoing conflict; and the ongoing uncertainty of long custody disputes.

Parental mental illness

This can adversely impact on a child not only in relation to inherited genetic vulnerability, but also through modelling behaviours and learnt maladaptive strategies for dealing with stress, in addition to the impact of mental illness on the availability and ability of the adult to parent adequately.

Social and economic hardship

Many families struggle with a variety of challenges such as poverty, unemployment and unstable housing. These challenges place significant stress on the family unit and family wellbeing.

Assessment

The main aims of the psychiatric assessment of children and adolescents are shown in Box 16.1. Assessment of young people differs from that of adults in a number of ways, including:

image Children are not usually help-seeking, but are brought to attention by others.
image Parents rather than children are often the primary source of information. Collateral history from other professionals such as teachers and school counsellors is vital in understanding the overall functioning of the child.
image The presenting problem needs to be understood in the context of the expected developmental level of the child.
image Assessment of the child and the family and school situation takes longer.
image Psychiatric comorbidity is common (around 50% in those referred to mental health services). This needs to be both thought of and looked for when children present to services.

BOX 16.1 Aims of psychiatric assessment in children and adolescents

• Understanding the presenting problems. The predisposing, precipitating and perpetuating factors and family beliefs need to be understood.
• Assessing the impact on functioning at home and school. Relationships with others, academic performance and social functioning need to be assessed.
• Assessing the development of the child. Particular note should be paid to early infancy and the quality of the bond between infant and mother, any disruptions in primary care giver, attainment of milestones, transitions to preschool and primary school, cognitive and physical development, and medical history.
• Understanding the family context, the stresses and strengths. This includes understanding the relationship with siblings, the parental and marital relationship, the parental medical, psychiatric, drug and alcohol history, and the influence of significant others (e.g. grandparents).

Clinicians vary in who they see at the first appointment. It is often the parents and the child, but during the course of the assessment the clinician will commonly meet with the child separately, with the parents (together and individually) and with the family unit as a whole. In some circumstances, this does not occur (e.g. during a crisis assessment or single session therapy). Also, older adolescents may not wish to involve their parents.

Assessing children

The interview needs to be adjusted taking into account the appropriate developmental and cognitive level of the child. Younger children will be assessed by observation of their play and interactions, and less so via language. From about the age of 7 or 8, children can be directly interviewed in addition to engaging them in play. They can be asked questions such as whether they know why they have been brought to the appointment, their likes and dislikes regarding school, their friends and interests. They can be asked about things that make them sad, happy, worried or angry. Asking children to draw themselves, their family, a happy and sad/scary dream, or three wishes they would make, can offer further insights into a child’s world. A playful and curious approach to the child and their world is helpful. Children are usually seen initially with their parents and then on their own.

Assessing adolescents

Adolescence is a time of increasing independence and moving towards adult functioning. Adolescents are often seen by themselves first, to obtain a history directly from them and to begin to form a therapeutic relationship directly with the young person by demonstrating that the clinician is interested in their point of view as well as that of their parents. Parents are then asked to join the interview, or joint sessions are separately arranged. Engagement with an adolescent is facilitated by being transparent and clear about the limits of confidentiality and issues of safety and risk (where appropriate) and how the clinician will deal with these. A collaborative stance where the adolescent is given some choice where possible and appropriate (e.g. appointment times or venues) is helpful.

Physical examination and investigations

Conducting physical examinations and the extent of investigations will vary depending on the clinical context, the presenting problem and who else is involved (e.g. a paediatrician). The use of laboratory investigations depends on the nature of the problem. Specific testing such as cognitive, speech and language, and occupational therapy assessments, are commonly requested where there are any concerns regarding a child’s attainments.

Formulation and feedback

The formulation seeks to answer the question: ‘Why does this child present with these problems at this time?’ The task is to synthesise the wealth of information from various sources and to provide feedback and recommendations for treatment to the child and family. This is sometimes done in written format as well as in discussion.

Management

The management plan needs to identify and prioritise the areas of possible intervention. An agreed initial focus of intervention needs to be established with both the family and the child/adolescent. Families especially are the agents of change for younger children and need to be actively involved in the treatment plan. The management plan is often multimodal (individual, family and system work) reflecting the need to intervene at a number of levels when working with children, adolescents and families who often present with multiple and complex needs.

Medication

While the use of psychotropic medication has increased for children and adolescents, this needs to be done with due caution and as part of a broader management plan. Relatively few drug trials exist for this population and much less is known about the metabolism, efficacy and long-term side effects than in adults. Information regarding medication needs to be provided to families together with careful ongoing monitoring. Where risk of overdose exists, then issues of supervision and access to medication need to be addressed.

Specific disorders

Psychiatric disorders of childhood and adolescence can be grouped into a number of broad categories. They can be thought of as disturbances of normal development, aspects of functional mastery, learning, emotions and behaviour (see Table 16.1).

TABLE 16.1 Classification of psychiatric disorders of childhood and adolescence

Disturbance of: Group Specific disorders
Normal development Developmental disorders
Intellectual disability
Autism
Asperger’s disorder

Function Elimination disorders
Enuresis
Encopresis
Learning Learning disorders
Speech disorders
Motor skills disorders
Specific learning disorders (e.g. reading, maths)
Emotions Internalising disorders
Anxiety
Depression
Behaviour Disruptive disorders
Attention deficit hyperactivity disorder (ADHD)
Oppositional defiant disorder (ODD)
Conduct disorder

It is further useful to group disorders that commonly present at particular developmental stages. This is to be taken as a rough guide as there is of course significant overlap between these groupings. Children with any of these disorders can first present to services at any time (e.g. Asperger’s disorder being diagnosed in late adolescence) or the disorder can arise at any age (e.g. anxiety and depression). Onset of ‘adult-like disorders’ such as psychosis, schizophrenia, bipolar disorder, eating disorders and personality disorders can also emerge particularly in mid to late adolescence. The reader is referred to disorder-specific chapters for details.

Detailed below are the individual disorders according to developmental life phase.

Infancy and early childhood: 0–5 years

Disorders of infancy and early childhood are listed in Box 16.2.

BOX 16.2 Disorders of infancy and early childhood

Disorders of infancy and early childhood include:

• intellectual disability
• autism
• Asperger’s disorder, and
• elimination disorders.

Intellectual disability

Intellectual disability is defined at below average intelligence (IQ < 70) together with significant problems in everyday functioning. It usually presents in young children as global delay in milestones (i.e. delays in motor skills, language, social skills or play).

A comprehensive multidisciplinary evaluation is required, including general physical, neurological, hearing, vision, psychological/psychiatric and special education. Particular attention should be given to emotional, behavioural and psychiatric comorbidities, as these are common and need to be addressed in their own right.

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