CURRENT Diagnosis and Treatment Pediatrics, (Current Pediatric Diagnosis & Treatment) 22nd Edition

7. Child & Adolescent Psychiatric Disorders & Psychosocial Aspects of Pediatrics

Adam Burstein, DO

Ayelet Talmi, PhD

Brian Stafford, MD, MPH

Kimberly Kelsay, MD

Mental illness affects between 14% and 20% of children and adolescents. The prevalence is higher for those juveniles living in poor socioeconomic circumstances. Unfortunately, the shortage of mental health providers, stigma attached to receiving mental health services, chronic underfunding, institutional barriers of the public mental health system, and disparate insurance benefits have contributed to the fact that only 2% of these children are actually seen by mental health specialists. About 75% of children with psychiatric disturbances are seen in primary care settings, and half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. Parents and children often prefer discussing these issues with someone they already know and trust. As a result, pediatric primary care providers are compelled to play an important role in the prevention, identification, initiation, management, and coordination of mental health care in children and adolescents.

Despite being strategically positioned as the gatekeeper for identifying these concerns, primary care providers identify fewer than 20% of children with emotional and behavioral problems during health supervision visits when these concerns are also present. In addition, these problems are not identified when they begin (and are more readily amenable to treatment). This gatekeeper role has become more important over the past decade as advances in mental health awareness and treatment have improved opportunities for early identification and intervention. This role is especially critical since child psychiatry remains an underserved medical specialty, with only 7400 board-certified child and adolescent psychiatrists in the United States. In contrast, the more than 50,000 board-certified pediatricians and innumerable midlevel pediatric providers in the United States are in a unique position to identify issues affecting the emotional health of children and to initiate treatment or referrals to other providers.

Emotional problems that develop during childhood and adolescence can have a significant impact on development and may continue into adulthood; in fact, most “adult” psychiatric disorders have their onset during childhood. Most disorders do not present as an “all-or-none” phenomenon; rather, they progress from adjustment concerns to perturbations in functioning to significant disturbances and severe disorders. Pediatricians have the capacity to manage emotional problems and behavioral conditions early on, when improvement can be achieved with less intensive interventions. If pediatricians and schools do not appropriately identify mental health problems, provide education about the benefits of intervention, and encourage and initiate intervention, childhood-onset disorders are more likely to persist, cause worsening impairment, and lead to a downward spiral of school and social difficulties, poor employment opportunities, and poverty in adulthood, as well as increased health care utilization and costs as adults.

Pediatricians and other pediatric care providers may be the first or sometimes only medical professional in a position to identify a mental health problem. This chapter reviews prevention, surveillance, and screening for mental illness; situations that may arise in the context of such assessments; illnesses that are often diagnosed during childhood or adolescence; current recommendations for interventions and use of psychotropic medications; and indications for referral to mental health professionals.

Belfer ML: Child and adolescent mental disorders: the magnitude of the problem across the globe. J Child Psychol Psychiatry 2008;49(3):226–236 [PMID: 18221350].

Costello EJ, Egger H, Angold A: 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden. J Am Acad Child Adolesc Psychiatry 2005;44:972–986 [PMID: 16175102].

Costello EJ, Foley DL, Angold A: 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: II. Developmental epidemiology. J Am Acad Child Adolesc Psychiatry 2006;45(1):8–25 [PMID: 16327577].

Roberts RE, Roberts CR, Xing Y: Prevalence of youth-reported DSM-IV psychiatric disorders among African, European, and Mexican American adolescents. J Am Acad Child Adolesc Psychiatry 2006;45(11):1329–1337 [PMID: 17075355].

Given the many barriers to receiving mental health care, new approaches to identifying concerns and providing mental health professional services have been recently explored.

Usual or typical pediatric care of emotional and behavioral problems is related to the comfort level of the individual pediatric provider and available resources. The efficacy of surveillance in the form of developmentally appropriate anticipatory guidance and counseling is variable; the average time spent on surveillance is 2.5 minutes. However, as stated earlier, the majority of emotional and behavioral problems are not identified in this model of care. In addition, when they are identified, the logistics of referral can be problematic. Although pediatricians often refer to mental health providers, only 50% of families will actually attend an appointment and the average number of appointments attended is only slightly greater than one. Based on level of comfort and training, the primary clinician in this model is more likely to be responsible for psychiatric medications if prescribed.

Among the technological interventions that can enhance identification of problems and target specific symptoms for assessment is the Child Health & Development Interactive System (CHADIS)(http://www.childhealthcare.org). In this system, parents use a computer kiosk to note their level of concern about various behaviors, which triggers algorithmic interviews for each concern based on psychiatric diagnostic criteria. The CHADIS system provides an electronic worksheet of analyzed results, school communication tools, as well as other resources.

Enhanced care is a model of care in which a pediatric developmental or behavioral specialist is embedded in the clinic, thus making for improved referral and communication and management. This “colocation” creates easier access for patients and improved communication with mental health professionals.

Telephonic consultation or telepsychiatry with mental health consultation teams in a stepped care approach allows enhanced access to mental health providers, especially for children in rural communities. The provision of consultation to pediatric care providers also allows pediatric providers ongoing education with the eventual goal of pediatric providers learning to manage these concerns on their own.

Collaborative care provides high-quality, multidisciplinary, and collaborative care through the colocation of educators, consultants, or direct service mental health providers in the clinic. Successful collaborative care results in greater specialist involvement by negating identification and referral and other system-of-care barriers. Successful components include a leadership team, primary clinicians, mental health and developmental specialists, administrators, clinical informatics specialists, and care managers. Collaborative care implies that nearly all visits are done jointly and that mental health professionals are always available for consultation, in contrast to the approach in the enhanced care model, which requires the scheduling of an appointment with a mental health specialist in the practice. These interventions can be accomplished through collaboration among mental health and primary care providers, mental health systems and primary care practices, and in academic settings with interdepartmental collaboration. Typically, philanthropic or other foundation grants are necessary to start a collaborative program so that reimbursement and sustainability concerns can be identified and remedied.

Brito A et al: Bridging mental health and medical care in under-served pediatric populations: three integrative models. Adv Pediatr 2010;57(1):295–313 [PMID: 21056744].

Chenven M: Community systems of care for children’s mental health. Child Adolesc Psychiatr Clin N Am 2010;19(1):163–174 [PMID: 19951815].

Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health: Policy statement—the future of pediatrics: mental health competencies for pediatric primary care. Pediatrics 2009;124(1):410–421 [PMID: 19564328].

Connor DF et al: Targeted child psychiatric services: a new model of pediatric primary clinician—child psychiatry collaborative care. Clin Pediatr 2005;45:423–434 [PMID: 16891275].

Foy J et al: Improving mental health services in primary care: reducing administrative and financial barriers to access and collaboration. Pediatrics 2009;123(4):1248–1251 [PMID: 19336386].

Kelleher KJ, Campo JV, Gardner WP: Management of pediatric mental disorders in primary care: where are we now and where are we going? Curr Opin Pediatr 2006;18:649–653 [PMID: 17099365].

Kelleher KJ, Stevens J: Evolution of child mental health services in primary care. Acad Pediatr 2009;9(1):7–14 [PMID: 19329085].

Williams J, Shore SE, Foy JM. Co-location of mental health professionals in primary care settings: three North Carolina models. Clin Pediatr (Phila) 2006;45;537–543 [PMID: 16893859].

Yellowlees PM, Hilty DM, Marks SL, Neufeld J, Bourgeois JA. A retrospective analysis of a child and adolescent mental health program. J Am Acad Child Adolesc Psychiatry 2008;47(1):103–107 [PMID: 18174831].

The role of the primary care pediatrician continues to expand to include public health, mental health, and community concerns. The American Academy of Pediatrics (AAP) policy statement on community pediatrics addresses the fact that today’s children and families live in a period of rapid social change and declining economic circumstances. In addition, the economic organization of the healthcare and social service systems in the United States is undergoing profound changes. For many pediatric providers, efforts to promote the health of children have been directed at attending to the needs of particular children in a practice setting, on an individual basis, and providing them with a medical home. This approach, in combination with pediatricians’ own personal community interests and commitments, has been dramatically successful. Increasingly, however, the major threats to the health of US children—the new morbidity—arise from problems that cannot be adequately addressed by the practice model alone. These problems include unacceptably high infant mortality rates in certain communities, extraordinary levels of intentional and unintentional injuries, chemical dependency, behavioral and developmental consequences of inappropriate care and experience, family dysfunction, sexually transmitted diseases, unplanned pregnancies and out-of-wedlock births, and lack of a medical home. The policy statement concludes, “We must become partners with others, or we will become increasingly irrelevant to the health of children.”

Today’s community pediatrician seeks to provide a far more realistic and complete clinical picture by taking responsibility for all children in a community, providing preventive and curative services, and understanding the determinants and consequences of child health and illness, as well as the effectiveness of services provided.

Bright Futures

Bright Futures is a national health promotion and disease prevention initiative that addresses children’s health needs in the context of family and community. In addition to use in pediatric practice, many states implement Bright Futures principles, guidelines, and tools to strengthen the connections between state and local programs, pediatric primary care, families, and local communities. The Bright Futures Guidelines, now in its third edition, was developed to provide comprehensive health supervision guidelines, including recommendations on immunizations, routine health screenings, and anticipatory guidance. In addition, Bright Futures for Mental Health provides numerous guidelines, tools, and strategies for improving mental health identification, assessment, initiation, management, and coordination.

Surgeon General’s National Action Plan

The Office of the Surgeon General (OSG) also recommends that pediatrics continue to evolve and include lifestyle, health system, and other psychosocial areas. The OSG’s National Action Agenda on Mental Health includes several calls to primary care pediatricians, including the following: engage other professional organizations in educating new frontline providers in various systems (eg, teachers, physicians, nurses, hospital emergency personnel, day care providers, probation officers, and other child healthcare providers) in child development; equip them with skills to address and enhance children’s mental health; and train them to recognize early symptoms of emotional or behavioral problems for proactive intervention. Such training must focus on developmental and cultural differences in cognitive, social, emotional, and behavioral functioning, and understanding these issues in familial and ecological context.

Partnership Access Line

In this chapter, various clinical tools from the Partnership Access Line (PAL) Washington website (www.palforkids.org) are used to assist the primary care provider in diagnosis and treatment of the more common psychiatric conditions. The PAL algorithms are useful for treatment of specific diagnoses, considering alternative diagnoses in the differential, and reviewing medication treatment tables for specific information regarding psychopharmacologic treatments.

American Academy of Pediatrics: Children’s Mental Health in Primary Care: http://www.aap.org/mentalhealth/index.html.

American Academy of Pediatrics Committee on Community Health Services: The pediatrician’s role in community pediatrics. Pediatrics 2005;115:1092–1094 [PMID: 15805396].

Bright Futures Mental Health: http://www.brightfutures.org/mentalhealth/pdf/index.html; http://www.brightfutures.org/mentalhealth/pdf/tools.html.

Hacker KA, Arsenault LN, Williams S, Digirolamo AM: Mental and behavioral health screening at preventive visits: opportunities for follow-up of patients who are nonadherent with the next preventive visit. AMJ Pediatr 2011;158(4):666–671.e2 [Epub 2010 Nov 11] [PMID: 21074180].

Massachusetts Child Psychiatry Access Project: http://www.mcpap.com/.

Sheldrick RC, Merchant S, Perrin EC: Identification of developmental-behavioral problems in primary care: a systematic review. Pediatrics 2011;128(2):356–363 [Epub 2011 Jul 4] [PMID: 21727101].

U.S. Surgeon General’s National Action Agenda: http://www.surgeongeneral.gov/cmh/childreport.htm.

Zero to Three: http://www.zerotothree.org.

Summary of the Pediatrician’s Role

Given these calls for a new pediatric role as the gatekeeper for socioemotional health, the expanding role of the primary care pediatric provider encompasses the following broad categories: prevention, identification, assessment, initiation, management, coordination, and collaboration (Table 7–1).

Most families seek help from their primary care providers when they are concerned about a child’s health, growth, or development. Historically, the most efficient indicator in eliciting psychosocial problems is the history provided by parents or guardians and interview and observation of the child. The possible approaches to identification of problems include surveillance, screening, and assessment.

Surveillance consists of the following elements: checking in, eliciting concerns, asking open-ended questions, watching and waiting, listening for red flags, identifying risk factors, and monitoring closely over time. Like vital signs, which represent an essential component of the physical evaluation, the essential components of the primary care surveillance for mental health concerns should generally include a review of the youth’s general functioning in different aspects of their life. Five questions forming the mnemonic PSYCH can be addressed to parents and youth as a surveillance means of uncovering areas of concern.

1. Parent-child interaction: How are things going with you and your parents? Or you and your infant (or toddler)?

2. School: How are things going in school (or child care; academically, behaviorally, and socially)?

3. Youth: How are things going with peer relationships/friendships (how does child get along with same-aged peers)?

4. Casa: How are things going at home (including siblings, family stresses, and relationship with parents)?

5. Happiness: How would you describe your mood? How would you describe your child’s mood?

Many pediatric practices are hampered by lack of continuity and not enough time for in-depth surveillance. In addition, surveillance is notoriously tied to office and provider characteristics. Given current time constraints for current pediatric visits, and the fact that only 18% of parents reporting elevated behavior problems in children actually told their providers about it, surveillance is currently considered nonoptimal. Although part of the clinical interview with families, surveillance is not a separate and billable service under current Medicaid and insurance reimbursement plans, whereas formal screening is.

Screening is the process of using standardized instruments to identify areas of risk, delay, or concern. Newborn hearing, vision, and developmental screenings are common in today’s pediatric practice. However, the morbidity associated with developmental, emotional, and psychosocial problems requires that socioemotional screening also be performed to identify the presence of symptoms of emotional, behavioral, or relationship disorders. Screening tools are brief, easy to use, and can be administered as a questionnaire or using an interview format. A positive screen warrants a more complete assessment. The use of screening tools can also lead to early identification and interrupt the adjustment-perturbation-disturbance-disorder pathway. Newer methods of eliciting socioemotional and behavior concerns have been developed (see section below on Tools). Helpful information can also be obtained from broad screening checklists and symptom-specific questionnaires (such as depression or anxiety self-report inventories). Questions can be incorporated into the general pediatric office screening forms, or specific questionnaires can be used.

Tools for Mental Health Screening in the Office Setting

Given the low rates of identification of psychosocial problems by pediatric surveillance, the use of standardized screening tools has become standard practice. Typically, broad screeners that elicit information regarding multiple domains are employed first and are followed by targeted screens to address symptomatology, severity, impairment, and context of specific psychosocial problems.

Multiple Screening Tools:

http://www.mcpap.com/tools_index.asp.

http://www.brightfutures.org/mentalhealth/pdf/tools.html.

http://www.palforkids.org.

http://www.schoolpsychiatry.org.

http://www.wpic.pitt.edu/research.

A. General or Broad Screening Tools

1. Strengths and Difficulties Questionnaires (SDQs)—The SDQs are brief behavioral screening questionnaires targeting patients 3–16 years old with parent, teacher, and child self-report versions available. Several versions are available and can readily be used by researchers, clinicians, and educators. They have been well validated and are available on the Internet without cost. The SDQs are available in over 40 languages. The domains assessed include: emotional problems, conduct problems, hyperactivity/inattention, peer-relationship problems, and prosocial behaviors. For further information, refer to the following web site: http://www.sdqinfo.org.

Vostanis P: Strengths and Difficulties Questionnaire: research and clinical applications. Curr Opin Psychiatry 2006 Jul;19(4):367–372 [PMID: 16721165].

2. Pediatric Symptoms Checklist (PSC)—The PSC is a one-page questionnaire listing a broad range of children’s emotional and behavioral problems that reflects parents’ impressions of their children’s psychosocial functioning. An adolescent self-report version is also available for children ages 11 and older. The PSC was developed initially for children older than age 5, but cutoff scores for preschool and school-aged children indicating clinical levels of dysfunction have been empirically derived. The questionnaire is easy to score, is free of charge, and is available in English and Spanish from the following web sites: http://www.brightfutures.org/mentalhealth/pdf/professionals/ped _sympton_chklst.pdf.

Kostanecka A et al: Behavioral health screening in urban primary care settings: construct validity of the PSC-17. J Dev Behav Pediatr 2008 Apr;29(2):124–128 [PMID: 18408533].

3. Parents’ Evaluation of Developmental Status (PEDS)—The PEDS is a validated screener for socioemotional, developmental, and behavioral concerns in children aged 1 month to 8 years. Parents answer yes/no about their concerns in various areas of their child’s development. Scoring the PEDS is more labor intensive than other general screeners and the instrument must be purchased. Its benefits include extensive validity data and useful pathways for level of concern and referral. It is available in English, Vietnamese, and Spanish. For further information, see the following web site: http://www.pedstest.com.

Brothers KB, Glascoe FP, Robertshaw NS: PEDS: developmental milestones—an accurate brief tool for surveillance and screening. Clin Pediatr (Phila) 2008;47(3):271–279 [Epub 2007 Dec 5] [PMID: 18057141].

4. Ages and Stages, Socioemotional (ASQ: SE)—The Ages and Stages, SE is a companion to the Ages and Stages Developmental Screen. It is an easy-to-use tool with a deep, exclusive focus on infant, toddlers, and younger children’s social and emotional behavior. After a one-time cost, the instrument is reproducible, making it cost-effective. It is culturally sensitive for use across diverse pediatric populations. Screens are available for the 6-, 12-, 18-, 24-, 36-, 48-, and 60-month visits, and in English, French, Spanish, and Korean.

Ages and Stages, SE (technical data): http://archive.brookespublishing.com/documents/asq-se-technical-report.pdf.

Briggs-Gowan MJ, Carter AS: Social-emotional screening status in early childhood predicts elementary school outcomes. Pediatrics 2008;121(5):957–962 [PMID: 18450899].

5. Family Psychosocial Screen—Pediatric Intake Form, Bright Futures, Retrieved November 19, 2013, from http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdf. Form adapted, with permission, from Kemper KJ, Kelleher KJ: Family psychosocial screening: Instruments and techniques. Ambulatory Child Health 1996;1:325–339.

6. WE CARE—Available in appendix of article. (Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR: Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE Project. Pediatrics 2007;120(3):547–558 [PMID: 17766528].)

Assessment of Behavioral & Emotional Signs & Symptoms

When an emotional problem or mental illness is mentioned by the patient or parents, elicited by an interview, or identified by a screening instrument, a thorough evaluation is indicated. At least 30 minutes should be scheduled, and additional appointments may be necessary to gather information or perform tests to determine a mental health diagnosis. Examples of more thorough questions and observation are given in Table 7–2. Targeted assessment screening tools are also useful in determining severity, comorbidity, and context of impairment.

It is useful to see both parents and the child first together, then the parents alone, and then the child alone (for school-aged children and adolescents). This sequence enables the provider to observe interactions among family members, allows the child to feel more comfortable with the provider, and offers the parents and the child an opportunity to talk confidentially about their concerns. Parents and children often feel shame and guilt about some personal inadequacy they perceive to be causing the problem. The provider can facilitate the assessment by acknowledging that the family is trying to cope and that the ultimate task of assessment is to seek solutions and not to assign blame. An attitude of nonjudgmental inquiry can be communicated with supportive statements such as, “Let’s see if we can figure out what might be happening here and find some ways to make things better.”

A. History of the Presenting Problem

First, obtain a detailed description of the problem.

• When did it start?

• Where and with whom does it occur?

• Were there unusual stresses, changes, or life events at that time?

• How is the child’s life and the family’s functioning affected?

• What does the child say about the problem?

• What attempts have been made to alleviate the problem?

• Do the parents have any opinions about the cause of the problem?

B. Techniques for Interviewing Children and Adolescents

1. Interviewing the preschool child—Preschool children should be interviewed with their parents. As the parents discuss their concerns, the provider can observe the child’s behavior, including their activity level and any unusual behaviors or symptoms. It is helpful to have toy human figures, animals, or puppets, and crayons and paper available that the child can use to express him- or herself. After hearing the history from the parents and observing and talking with the child, the provider can begin to develop an impression about the problem and formulate a treatment plan to discuss with the family.

2. Interviewing the school-aged child—Most school-aged children have mastered separation anxiety sufficiently to tolerate at least a brief interview alone with the provider. In addition, they may have important information to share about their own worries. The child should be told beforehand by the parents or provider (or both) that the doctor will want to talk to the child about his or her feelings. School-aged children understand and even appreciate parental concern about unhappiness, worries, and difficulty in getting along with people. At the outset, it is useful to explore the child’s thoughts about certain issues raised by the parents and ask whether the child thinks that a problem exists (eg, unhappiness, anxiety, or sleep disturbance) and any other concerns the child may have. The provider should ask the child to describe the problem in his or her own words and ask what he or she thinks is causing the problem. It is important to ask the child how the problem affects the child and the family. At the end of the interview with the child, it is important to share or reiterate the central points derived from the interview and to state that the next step is to talk with the parents about ways to make things better for the child. At that time, it is good to discuss any concerns or misgivings the child might have about sharing information with parents so that the child’s right to privacy is not arbitrarily violated. Most children want to make things better and thus will allow the provider to share appropriate concerns with the parents.

3. Interviewing the adolescent—The provider usually begins by meeting briefly with the parents and adolescent together to define the concerns. Because the central developmental task of adolescence is to create an identity separate from that of the parents, the provider must show respect for the teen’s point of view. The provider should then meet alone with the adolescent or, at least, give the teen the option. After the provider has interviewed the adolescent and talked further with the parents, he or she should formulate thoughts and recommendations. Whenever possible, it is helpful to discuss these with the adolescent before presenting them to the parents and teen together. The issue of confidentiality must be discussed early in the interview: “What we talk about today is between you and me unless we decide together that someone should know or unless it appears to me that you might be in a potentially dangerous situation.”

The interview with the adolescent alone might start with a restatement of the parents’ concerns. The teen should be encouraged to describe the situation in his or her own words and say what he or she would like to be different. The provider should ask questions about the adolescent’s primary concerns, predominant mood state, relationships with family members, level of satisfaction with school and peer relationships, plans for the future, drug and alcohol use, and sexual activity.

In concluding the interview, the provider should summarize his or her thoughts and develop a plan with the teenager to present to the parents. If teenagers participate in the solution, they are more likely to work with the family to improve the situation. This should include a plan either for further investigation or for ways of dealing with the problem and arranging subsequent appointments with the provider or an appropriate referral to a mental healthcare provider.

C. Targeted Screening Tools and Assessment Measures

As with broad screening tools, targeted screening tools or assessment instruments can be very valuable in the clinic since they are standardized and allow for the assessment of current symptoms and severity. They can also be useful for following or reassessing a patient’s progress after initiation of treatment.

1. Vanderbilt Assessment Scales for Attention-Deficit/Hyperactivity Disorder—These scales are included in the American Academy of Pediatrics/National Initiative for Children’s Health Quality (AAP/NICHQ) Attention-Deficit/Hyperactivity Disorder Practitioner’s Toolkit, available at: http://www.nichq.org/toolkits_publications/toolkits _landingpage.html. http://www.schoolpsychiatry.org.

2. Center for Epidemiologic Studies Depression Scale for Children (CESD-C)—Available at: http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf.

3. Self-Report for Childhood Anxiety-Related Emotional Disorders (SCARED)—Available at: http://www.wpic.pitt.edu/research/.

4. Patient Health Questionnaire-9 Modified for Teens (PHQ-Modified)—Available at: http://www.lfmp.com/Portals/8/PHQ-9%20(Depression%20Screener%20for%20Adolescents%2012-18).pdf.

5. Other Tools

A. BRIGHT FUTURES—The Bright Futures Tool Kit has numerous guidelines, tools, and other resources for identifying mental health concerns. Available at: http://www.brightfutures.org/mentalhealth/pdf/tools.html.

B. CHADIS—See earlier discussion of models of health care.

C. DISORDER-SPECIFIC SCREENING TOOLS—Useful tools for evaluating other mental health concerns, such as obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and pervasive developmental disorder (PDD), can be found at the following websites: http://www.schoolpsychiatry.org and http://www.mcpap.com/.

The Mental Status Examination

The mental status examination (MSE) is a tool equivalent to the physical examination. It includes some standard aspects to help evaluate an individual including observation of an individual’s overall cognitive, emotional, and behavioral presentation. Through observations, interaction, and questions, the MSE identifies current behavioral presentation and areas of clinical concern (eg, suicidal thinking, hallucinations). A well-documented MSE details the patient’s behavioral and clinical presentation. Please refer to standard elements of MSE (Table 7–3).

Diagnostic Formulation & Interpretation of Findings

Diagnosis, the final product of the assessment, starts with a description of the presenting problem, which is then evaluated within the context of the child’s age, developmental needs, the stresses and strains on the child and the family, and the functioning of the family system.

The provider’s first task is to decide whether a problem exists. For example, how hyperactive must a 5-year-old child be before he or she is too hyperactive? When a child’s functioning is impaired in major domains of life, such as learning, peer relationships, family relationships, authority relationships, and recreation, or when a substantial deviation from the trajectory of normal developmental tasks occurs, a differential diagnosis should be sought based on the symptom profile. The provider then develops an etiologic hypothesis based on the information gathered:

1. The behavior falls within the range of normal given the child’s developmental level.

2. The behavior is a temperamental variation.

3. The behavior is related to central nervous system impairment (eg, prematurity, exposure to toxins in utero, seizure disorder, or genetic disorders).

4. The behavior is a normal reaction to stressful circumstances (eg, medical illness, change in family structure, or loss of a loved one).

5. The problem is primarily a reflection of family dysfunction (eg, the child is the symptom bearer, scapegoat, or the identified patient for the family).

6. The problem indicates a possible psychiatric disorder.

7. The problem is complicated by an underlying medical condition.

8. Some combination of the above.

Sharing of the diagnosis is also the beginning of initiating treatment. The provider’s interpretation of the complaint and diagnosis is then presented to the family. The interpretive process includes the following components:

1. Psychoeducation: An explanation of how the presenting problem or symptom is a reflection of a suspected cause and typical outcomes both with and without intervention.

2. A discussion of possible interventions, including the following options:

a. Close monitoring

b. Counseling provided by the primary care provider

c. Referral to a mental health professional

d. Initiation of medication

e. Some combination of the above

3. A discussion of the parent’s and adolescent’s response to the diagnosis and potential interventions.

A joint plan involving the provider, parents, and child is then negotiated to address the child’s symptoms and developmental needs in light of the family structure and stresses. If an appropriate plan cannot be developed, or if the provider feels that further diagnostic assessment is required, referral to a mental health practitioner should be recommended.

Kelleher KJ, Campo JV, Gardner WP: Management of pediatric mental disorders in primary care: where are we now and where are we going? Curr Opin Pediatr 2006;18:649–653 [PMID: 17099365].

Richardson LP, Katzenellenbogen R. Childhood and adolescent depression: the role of primary care providers in diagnosis and treatment. Curr Probl Pediatr Adolesc Health Care 2005;35: 6–24 [PMID: 15611721].

Situations Requiring Emergent or More Extensive Psychiatric Assessment

If there is any concern about the child’s safety, the provider must also evaluate the risk of danger to self (suicidal attempts or ideation), danger to others (assault, aggression, or homicidal ideation), and screen for other factors that could heighten the risk of danger to self or others, such as physical or sexual abuse or illicit substance use or abuse. The presence of drug or alcohol abuse in adolescent patients may require referral to community resources specializing in the treatment of these addictive disorders.

The following questions should be asked of the youth. The parents should be asked similar questions about what they have observed. Specific details about the circumstances should be asked if any question below is answered with “yes.”

1. Have you ever been sad for more than a few days at a time such that it affected your sleep or appetite?

2. Have you ever been so sad that you wished you weren’t alive?

3. Have you ever thought of ways of killing yourself or made a suicide attempt?

4. Have you ever thought about killing someone else, or tried to kill someone?

5. Has anyone ever hit you and left marks? (If yes, ask who, when, and under what circumstances, and if it was reported.)

6. Has anyone ever touched your private areas when they weren’t supposed to, or in a way that made you feel uncomfortable? (If yes, ask who, when, and under what circumstances, and if it was reported.)

7. Do you use alcohol, tobacco, or illicit drugs? (If yes, ask what, when, with whom, and how much.)

A. Civil Commitment and Involuntary Mental Health “Holds”

If further assessment indicates a need for inpatient hospitalization, it is optimal if the patient and guardian give consent for this care. In a situation in which the guardian is unwilling or unable to give consent for emergency department (ED)–based assessment or inpatient hospitalization of a child or adolescent, an involuntary mental health “hold” may become necessary.

The term involuntary mental health “hold” refers to a legal process that can be initiated by providers, police officers, and certified mental health professionals, which allows the individual to be prevented from leaving the ED or hospital for up to 72 hours. This allows the provider to establish a safe environment and prevent the individual from harming themselves or others, and allows sufficient time to determine if the individual is a risk to him- or herself or others due to mental illness. Each state has laws specifying rules and regulations that must be followed as part of this process. A specific form must be completed and the patient and family informed of their rights. As this involves revoking the civil rights of a patient or their guardian, it is critical to implement the procedure correctly. All providers should be familiar with their state laws regulating this process.

Although the precise wording and conditions of involuntary mental health holds may vary slightly from state to state, they are generally quite similar. A 72-hour involuntary mental health hold is obtained for the purpose of acute evaluation and determination of the patient’s safety when the evaluator elicits sufficient information to confirm a significant risk exists of danger to self or others. Additional criteria for involuntary psychiatric admission include a determination that the patient is “gravely disabled” by virtue of impaired judgment, which renders the patient unable to provide food, clothing, or shelter for him- or herself, or in the case of a child or adolescent, that he or she is unable to eat and perform normal activities of daily living. In addition, patients that have a medical condition(s) requiring urgent or emergent treatment do not require a mental health hold. In this case, the primary team/provider should conduct a capacity evaluation.

Baren JM, Mace SE, Hendry PL. Children’s mental health emergencies—part 3: Special situations: child maltreatment, violence, and response to disasters. Pediatr Emerg Care 2008;24(8):569–577 [PMID: 18708906].

Baren JM, Mace SE, Hendry PL, Dietrich AM, Goldman RD, Warden CR: Children’s mental health emergencies—part 2: Emergency department evaluation and treatment of children with mental health disorders. Pediatr Emerg Care 2008;24(7):485–498 [PMID: 18633314].

Baren JM, Mace SE, Hendry PL, Dietrich AM, Grupp-Phelan J, Mullin J: Children’s mental health emergencies—part 1:Challenges in care: definition of the problem, barriers to care, screening, advocacy, and resources. Pediatr Emerg Care 2008;24(6):399–408 [PMID: 18562887].

Dolan MA, Fein JA: Committee on Pediatric Emergency Medicine. Pediatric and adolescent mental health emergencies in the emergency medical services system. Pediatrics 2011;127(5): e1356–e1366 [Epub 2011 Apr 25] [PMID: 21518712].

B. Mandatory Reporting of Abuse or Neglect or Threat to Others

Mandatory reporting by a provider of suspicion of physical or sexual abuse or neglect to the local human services agency is discussed in greater detail in Chapter 8. The “Tarasoff Rule” refers to a California legal case that led to a “duty to warn”: Providers are mandated to warn potential victims of harm when plans are disclosed to them about serious threats to harm specific individuals. Documentation of a phone call and registered letter to the individual being threatened are mandated. Under such circumstances, arrangement for the involuntary civil commitment of the potential perpetrator of harm is likely to be in order as well.

C. Referral of Patients to Mental Healthcare Professionals

Primary care providers often refer patients to a child and adolescent psychiatrist or other qualified child mental health professional when the diagnosis or treatment plan is uncertain, or when medication is indicated and the pediatrician prefers that a specialist initiate or manage treatment of the mental illness (Table 7–4). For academic difficulties not associated with behavioral difficulties, a child educational psychologist may be most helpful in assessing patients for learning disorders and potential remediation. For cognitive difficulties associated with head trauma, epilepsy, or brain tumors, a referral to a pediatric neuropsychologist may be indicated.

The diagnosis is not clear The pediatrician feels that further assessment is needed The pediatrician believes medication may be needed, but will not be prescribing it The pediatrician has started medications and needs further psychopharmacologic consultation Individual, family, or group psychotherapy is needed Psychotic symptoms (hallucinations, paranoia) are present Bipolar affective disorder is suspected Chronic medical regimen nonadherence has a risk of lethality Delirium is suspected

Patients with private mental health insurance need to contact their insurance company for a list of local mental health professionals trained in the assessment and treatment of children and adolescents who are on their insurance panel. Patients with Medicaid or without mental health insurance coverage can usually be assessed and treated at their local mental healthcare center. The referring pediatrician or staff should assist the family by providing information to put them in touch with the appropriate services. Personal relationships with community mental health administrators and clinicians improve the success of referrals. Additionally, new delivery systems in which mental health professionals are “colocated” in the clinic remove barriers and improve access and care (see earlier discussion). In addition, the distant poles of involuntary inpatient psychiatric hospitalization and outpatient treatment have been filled in by other levels of treatment to provide a spectrum of care and include the following: inpatient psychiatric hospitalization, day treatment hospitalization, residential treatment, home-based care, intensive outpatient, outpatient treatment, primary care management.

Pediatricians who feel comfortable implementing the recommendations of a mental health professional with whom they have a collaborative relationship should consider remaining involved in the management and coordination of treatment of mental illness in their patients. The local branches of the American Academy of Child and Adolescent Psychiatry and the American Psychological Association should be able to provide a list of mental health professionals who are trained in the evaluation and treatment of children and adolescents.

The field of consultation-liaison psychiatry was developed to address the need for mental health assessment and intervention of medically hospitalized pediatric patients. Psychiatric consultation on the medical floor and in the intensive care units can be complex and often requires assessment and intervention beyond the individual patient. The psychiatric consultation, in addition to evaluating the patient’s symptom presentation, should also include assessment of family dynamics as related to the patient, and may include evaluation of how the medical team is addressing care of the patient and family. The psychiatric consultation focuses on the various hierarchies related to the interaction of the patient and staff, or staff and staff, in addition to the patient per se; this evaluation can be quite enlightening and may lead to more productive interventions.

When requesting a psychiatric consultation, as with any medical specialty, it is critical that the concern and focus of the consultation request be as specific as possible. The liaison role of the psychiatrist is to often assist in clarifying or formulating the specific reason for the consult. Psychiatric consultation on the medical floor is often requested when the patient’s emotional state is affecting his or her response to medical care, or when an underlying mental illness may be contributing to the presenting symptoms. Patients admitted to the intensive care unit or a medical floor after a suicide attempt or supposed unintentional overdose should be evaluated by a psychiatric consultant before discharge.

Another common reason for requesting a psychiatric consultation on the medical floor is change in mental status. Be alert to the likelihood that acute mental status changes in the medical setting can represent delirium, as this has significant assessment and treatment implications. Delirium is defined as an acute and fluctuating disturbance of one’s alertness and orientation. Delirium can be manifested by a variety of psychiatric symptoms including paranoia, hallucinations, anxiety, and mood disturbances. However, aside from dementia and possibly dissociation and malingering, primary psychiatric presentations do not typically involve disturbances of alertness and orientation that are, by definition, always present in delirium.

Hindley P: Pediatric consultation-liaison psychiatry. J Psychosom Res 2010;68(4):325–327 [PMID: 20307698].

Shaw RJ, Wamboldt M, Bursch B, Stuber M: Practice patterns in pediatric consultation-liaison psychiatry: a national survey. Psychosomatics 2006;47(1):43–49 [PMID: 16384806].

Advances in the treatment of pediatric and adolescent illness have transformed several previously fatal conditions into life-threatening but potentially survivable conditions. These include advances in the fields of neonatal medicine, cardiac surgery, pulmonology, and hematology-oncology, including bone marrow transplantation. Additionally, solid organ transplantation, including heart, liver, kidney, and lung, among others, has revolutionized the potential treatment options for a whole host of once-fatal illnesses.

However, the intensity of treatment can in itself be highly stressful and even traumatic physically, financially, and psychologically, for children as well as their parents and siblings. Survivors are at risk of long-term medical and psychological sequelae. Those who are fortunate enough to survive the initial treatment of a potentially life-threatening condition often exchange a life-threatening biologic illness for a chronic emotional condition and physical disability.

Phase-Oriented Intervention

Psychosocial interventions should vary, depending on the developmental level of the patient, siblings, and family, and the phase of the illness. A first crisis is dealt with differently than interventions made during a long course of illness, or a period of stabilization or remission. With this in mind, the Organ Procurement and Transplantation Network/United Network for Organ Sharing established new bylaws in August 2004 which set minimum requirements for the psychosocial services available as part of an accredited solid organ transplant program. These guidelines include: (1) the establishment of a team comprising a transplantation psychiatrist, psychologist, nurse practitioner, and psychiatric social worker; (2) a formal psychiatric and substance abuse evaluation of prospective transplantation candidates; (3) evaluation of any potential renal or hepatic living donors; and (4) the availability of individual supportive counseling, crisis intervention, support groups, and death, dying, and bereavement counseling to transplantation patients and their families.

Reactions to Chronic Physical or Mental Illness & Disability

Between 5% and 10% of individuals experience a prolonged period of medical illness or disability during childhood and another 5%–10% experience the onset of mental illness in childhood. The psychosocial effects for the child and the family are often profound. Although the specific effect of illness on children and their families depends on the characteristics of the illness, the age of the child, and premorbid functioning, it can be expected that both the child and the parents will go through stages toward eventual acceptance of the disease state. It may take months for a family to accept the diagnosis, to cope with the stresses, and to resume normal life to the extent possible. These stages resemble those that follow the loss of a loved one. If anxiety and guilt remain prominent within the family, a pattern of overprotection can evolve. Likewise, when the illness is not accepted as a reality to be dealt with, a pattern of denial may become prominent. The clinical manifestations of these patterns of behavior are presented in Table 7–5.

Children are very observant and intuitive when it comes to understanding their illness and its general prognosis. At the same time, their primary concerns usually are the effects of the illness on everyday life (eg, routines), feeling sick, and limitations on normal, age-appropriate activities. Children are also keenly aware of the family’s reactions and may be reluctant to bring up issues they know are upsetting to their parents. Whenever possible, parents should be encouraged to discuss the child’s illness and to answer questions openly and honestly, including exploration of the child’s fears and fantasies. Such interactions promote closeness and relieve the child’s sense of isolation. Even with these active attempts to promote effective sharing between the child and the family, ill children frequently experience fear, anxiety, irritability, and anger over their illness, and guilt over causing family distress. Sleep disturbances, tears, and clinging, dependent behavior are not infrequent or abnormal. Parents frequently need support in an individual or group format to help them cope with the diagnosis and stress caused by the disease, its treatments, and its affect on the afflicted child and other family members.

Overprotection Persistent anxiety or guilt Few friends and peer activities Poor school attendance Overconcern with somatic symptoms Secondary gain from the illness Effective coping Realistic acceptance of limits imposed by illness Normalization of daily activities with peers, play, and school Denial Lack of acceptance of the illness Poor medical compliance Risk-taking behaviors Lack of parental follow-through with medical instructions General pattern of acting-out behavior

The Psychosocial Impact of Living With Illness

Chronic disease and long-term illnesses disrupt family cycles, routines, and daily living. Children and families face numerous challenges including extended contact with the medical system; painful procedures and painful conditions; feelings of fear, worry, and grief; and significant lifestyle disruptions. Discussions and interventions that take into account both emotional and medical symptoms will help the child and family better understand their experiences and attitude toward illness and life. The family and child will benefit from discussions about such questions as “What is the real nature of this illness? How has it affected us? What will be our future? What does the treatment do to me?” Such discussions can be quite enlightening and empowering, as they encourage open discussion for the child and parents and an active role in treatment.

Patient- and parent-reported outcome tools, known either as health status or health-related quality of-life (HRQOL) measures, can also be routinely used in pediatric specialty clinics. These measures adopt the World Health Organization’s definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease.” Health-related quality of life refers to the subjective and objective impact of dysfunction associated with an illness or injury and is multidimensional, including four core domains: (1) disease state and physical symptoms, (2) functional status, (3) psychological functioning, and (4) social functioning. A team approach is often necessary when providing care to complex and chronically ill children. Including these measures during annual visits and incorporating a mental health professional on the team can improve overall adjustment and quality of care.

Davis E et al: Paediatric quality of life instruments: a review of the impact of the conceptual framework on outcomes. Dev Med Child Neurol 2006;48(4):311–318 [Review] [PMID: 16542522].

The diagnosis of a potentially fatal illness in a child is a severe blow even to families who have reason to suspect that outcome. The discussion with parents and the child about terminal illness is one of the most difficult tasks for a provider working with children and adolescents. Although parents want and need to know the truth, they are best told in stepwise fashion beginning with temporizing phrases such as “The news is not good” and “This is a life-threatening illness.” The parents’ reactions and questions can then be observed for clues about how much they want to be told at any one time. The provider must also attempt to gauge how much of the information the parents are able to comprehend during the initial discussion and consider involvement of appropriate support services. Some parents may dissociate during the sharing of frightening and overwhelming news, and crucial information may need to be addressed again when the parents are less shocked or traumatized and in a more receptive state. Parents may prefer to discuss difficult news when supportive people in their lives are present for the conversation as these supportive others can often retain information, ask clarifying questions, and review it with parents at a later point in time. Parents’ reactions may follow a grief sequence, including initial shock and disbelief lasting days to weeks, followed by anger, despair, and guilt over weeks to months, and ending in acceptance of the reality of the situation. These responses vary in their expression, intensity, and duration for each member of the family. Even when the illness is cured, some parents may continue to suffer from post-traumatic stress symptoms related to the diagnosis and treatment.

Developmental and phase-oriented perspectives of patients, siblings, parents, and caretakers are reviewed in Table 7–6. Although most children do not fully understand the permanency of death until about age 8, most ill children experience a sense of danger and doom that is associated with death before that age. Even so, the question of whether to tell a child about the fatal nature of a disease should in most cases be answered in the affirmative unless the parents object. When the parents object, this should alert the provider to involve the unit social worker, who can work with the family to ensure their decision is in the best interest of the child. Refusal of the adults to tell the child, especially when the adults themselves are very sad, leads to a conspiracy of silence that increases fear of the unknown in the child and leads to feelings of loneliness and isolation at the time of greatest need. In fact, children who are able to discuss their illness with family members are less depressed, have fewer behavior problems, have higher self-esteem, feel closer to their families, and adapt better to the challenges of their disease and its treatment.

The siblings of dying children are also significantly affected. They may feel neglected and deprived because of the time their parents must spend with the sick child. Anger and jealousy may then give rise to feelings of guilt over having such feelings about their sick sibling. Awareness of the emotional responses, coping abilities, and available resources for support of other family members can diminish these feelings and make a significant difference in the family’s overall ability to cope with the illness.

After the child dies, the period of bereavement may last indefinitely. Family members may need help in dealing with their grief through supportive counseling services or peer-support groups. Bereavement usually does not substantially interfere with overall life functioning for more than 2–3 months. Most parents and siblings are able to return to work and school within a month, although their emotional state and thoughts may continue to be dominated by the loss for some time. Grief responses may resurface around anniversaries (eg, of the diagnosis, medical procedure, death) or birthdays of the deceased child. When the individual is unable to function in his or her societal and family role beyond this time frame, a diagnosis of complicated bereavement, major depression, PTSD, or adjustment disorder should be considered and appropriate interventions recommended, such as referral for counseling or psychotherapy and possibly antidepressant medication. For additional information on this topic, please refer to Chapter 32.

Long-Term Coping

The process of coping with a chronic or terminal illness is complex and varies with the dynamics of each individual child and family. Each change in the course of illness and each new developmental stage may present different challenges for the child and family. It is important for healthcare providers to continually assess the family’s and child’s needs and coping abilities over time and to provide appropriate support, information, and access to interventions.

Assistance From Healthcare Providers

A. Educate the Patient and Family

Children and their families should be given information about the illness, including its course and treatment, at frequent intervals. Factual, open discussions minimize anxieties. The explanation should be comprehensible to all, and time should be set aside for questions and answers. The setting can be created with an invitation such as “Let’s take some time together to review the situation again.”

B. Prepare the Child for Changes and Procedures

The provider should explain, in an age-appropriate manner, what is expected with a new turn in the illness or with upcoming medical procedures. This explanation enables the child to anticipate and in turn to master the new development and promotes trust between the patient and the healthcare providers.

C. Encourage Normal Activities

The child should attend school and play with peers as much as the illness allows. Individual education plans should be requested from the school if accommodation beyond the regular classroom is necessary. At the same time, parents should be encouraged to apply the same rules of discipline and behavior to the ill child as to the siblings.

D. Encourage Compensatory Activities, Interests, and Skill Development

Children who experience disability or interruption of their usual activities and interests should be encouraged to explore new interests, and the family should be supported in adapting the child’s interests for their situation, and in presenting new opportunities.

E. Promote Self-Reliance

Children often feel helpless when others must do things for them, or assist with their daily needs. The healthcare provider should guide and encourage parents in helping ill children assume responsibility for some aspects of their medical care and continue to experience age-appropriate independence and skills whenever possible.

F. Periodically Review Family Coping

Families are often so immersed in the crisis of their child’s illness that they neglect their own needs or the needs of other family members. From time to time, the provider should ask “How is everyone doing?” The feelings of the patient, the parents, and other children in the family are explored. Parents should be encouraged to stay in touch with people in their support system, and to encourage their children in such efforts as well. Feelings of fear, guilt, anger, and grief should be monitored and discussed as normal reactions to difficult circumstances. If these experiences are interfering with the family’s functioning, involvement of the pediatric social worker or a therapist can be helpful.

Appropriate lay support groups for the patient and family should be recommended. Many hospitals have such groups, and hospital social workers can facilitate participation for the patient and family.

Lewis M, Vitulano LA: Biopsychosocial issues and risk factors in the family when the child has a chronic illness. Child Adolesc Psychiatr Clin N Am 2003;12(3):389–399 [PMID: 12910814].

Pao M, Bosk A: Anxiety in medically ill children/adolescents. Depress Anxiety 2011;28(1):40–49. doi: 10.1002/da.20727 [Epub 2010 Aug 18] [PMID: 20721908].

Pediatric Medical Traumatic Stress Toolkit: http://www.nctsn.org/trauma-types/pediatric-medical-traumatic-stress-toolkit-for-health-care-providers.

Vitulano LA: Psychosocial issues for children and adolescents with chronic illness: self-esteem, school functioning and sports participation. Child Adolesc Psychiatr Clin N Am 2003;12(3): 585–592 [PMID: 12910824].

PSYCHIATRIC DISORDERS OF CHILDHOOD & ADOLESCENCE

A psychiatric disorder is defined as a characteristic cluster of signs and symptoms (emotions, behaviors, thought patterns, and mood states) that are associated with subjective distress or maladaptive behavior. This definition presumes that the individual’s symptoms are of such intensity, persistence, and duration that the ability to adapt to life’s challenges is compromised.

Psychiatric disorders have their origins in neurobiologic, genetic, psychological (life experience), or environmental sources. The neurobiology of childhood disorders is one of the most active areas of investigation in child and adolescent psychiatry. Although much remains to be clarified, data from genetic studies point to heritable transmission of attention-deficit/hyperactivity disorder (ADHD), schizophrenia, mood and anxiety disorders, eating disorders, pervasive developmental disorders, learning disorders, and tic disorders, among others. About 3%–5% of children and 10%–15% of adolescents will experience psychiatric disorders.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) is the formal reference text for psychiatric disorders and includes the criteria for each of the mental illnesses, including those that begin in childhood and adolescence. Psychiatric diagnoses are given on five axes to allow the provider to address the developmental, medical, psychosocial, and overall adaptive issues that contribute to the primary diagnosis on axis I or II.

Axis I: Clinical disorders

Axis II: Personality disorders, mental retardation, learning disabilities

Axis III: General medical conditions

Axis IV: Psychosocial and environmental problems

Axis V: Global assessment of functioning (on a scale of 0–100, with 100% being the highest level of functioning)

Unfortunately, available mental health classification systems are infrequently used in pediatric primary care settings since they address the more severe and extensive conditions. As previously stated, primary care providers frequently see a spectrum of disturbances in their clinical practice, many not achieving full DSM-IV-TR criteria. In order to combat the fact that current nosologies do not provide enough detail about common problems and situations that primary care pediatric providers come across, the AAP and the American Psychiatric Association (APA) collaboratively developed the DSM-IV Primary Care (DSM-PC), including a child and adolescent version (C&A). The key assumptions of the DSM-PC (C&A) are based on the fact that children’s environments have an impact on their mental health, and that children demonstrate a continuum of symptoms from those seen in typical children to those in children with severe disorders. The DSM-PC is compatible with the DSM-IV-TR, is clear and concise, and is available for research testing and subsequent refinement. It is organized into sections covering environmental situations, child manifestations, and severity (Table 7–7). Categories of the major environmental factors that may affect a child, ranging from economic issues to family violence, are described and given V codes. Specific behavioral manifestations are listed under broad groupings and include complaints, definitions, symptoms, differential diagnosis, developmental variation, and etiology. Severity, in the DSM-PC, has several dimensions, including symptoms, functioning, burden of suffering, and risk and protective factors. The DSM-PC has a great deal of promise, not only as a mechanism to classify the complexities of children’s behavior problems, but also as a mechanism for the future to facilitate financial reimbursement for early identification of and intervention for children’s behavioral problems. Pediatricians should find this manual to be a valuable tool in the care of children and their families. A revised DSM-PC is being developed.

Unfortunately, the current knowledge base regarding disorders described by the DSM-PC is limited. The descriptions of disorders in this chapter therefore follow the DSM-IV-TR nosology in order to reference current knowledge regarding epidemiology, course, and treatment of specific disorders. The DSM-IV-TR has been revised, and the DSM-V was released in May 2013. Major changes in diagnostic criteria include updates to autism spectrum disorders, attention-deficit hyperactivity disorder, and tic disorders. Newly added diagnoses include social communication disorder, which describes children who have language and communication deficits. Specific learning disorders, also a new category, has modifiers in reading, written expression, and/or mathematics. Three new communication disorders—language disorder, childhood-onset fluency disorder (ie, stuttering), and speech sounds disorder—have replaced expressive language disorder, stuttering, and phonologic disorder, respectively. Lastly, intellectual disability replaces “mental retardation” and requires both adaptive-functioning assessments and IQ scores for diagnosis.

PEDIATRIC PRIMARY CARE BEHAVIORAL HEALTH SERVICES

Delivering mental health and behavioral services in the context of pediatric primary care provides a mechanism for improving access, quality, and effectiveness of services (Guevara & Forrest, 2006; Trupin, 2011) within a medical home for children. In the ideal, medical homes provide children and families with comprehensive, coordinated, individualized, strength-based, culturally sensitive, and family centered care that is inclusive of physical, mental, and oral health (Strickland et al, 2011). Mental health and behavioral services span the continuum from colocating a behavioral health provider within a primary care setting and offering traditional outpatient mental health services in isolation of primary care services but at the same clinic to integrating of behavioral health clinicians into the routine practice of a pediatric primary care clinic. Behavioral health services include direct clinical interventions, consultation to pediatric providers on challenging cases, joint visits, and trainings (Strohm et al, 2009). Colocated services primarily target children and families while integrated services target children, families, pediatric providers, and systems of care in which services are being delivered.

Behavioral health providers working in pediatric primary care settings must be prepared to address a wide range of presenting problems, health conditions, and family circumstances. Difficulties span daily routine disruptions (eg, eating and sleeping), developmental delays, management of chronic illness (eg, asthma, obesity), adjustment to life events and stressors (eg, moving, divorce), acute traumas (eg, accidents, episodes of abuse), chronic family circumstances (eg, family violence, financial hardship, parental mental illness), academic challenges, relationship disruptions, and mental health disorders. Consequently, behavioral health providers utilize numerous strategies to address the varied and often complex presentations.

First and foremost, behavioral health providers strive to establish a relationship with the child and family. Rapport and relationship building are essential to engaging families in treatment and, importantly, to having families return to the primary care setting for ongoing treatment and support. Once a strong relationship is established, behavioral health providers strive to identify challenges and concerns through screening and assessment, diagnose and treat those issues that can be managed in primary care, triage and refer families to external resources, and ultimately, improve child and family outcomes. In integrated models, behavioral health providers work collaboratively with pediatric primary care providers to develop and implement care plans.

Interventions that have successfully addressed development, psychosocial factors, and to a more limited extent, mental health and behavioral issues in pediatric primary care settings, have typically targeted specific behavioral concerns including sleep disruptions, discipline techniques, obesity, and pain (Allen, Elliott, & Arndorfer, 2002) with the goals of symptom reduction, improved adaptive behaviors and functioning, decreased family distress, and increased adherence to medical regimens. Behavioral health clinicians frequently manage prevalent mental health disorders including anxiety (Saklosky & Birmaher, 2008), depression, and attention-deficit/hyperactivity by adapting outpatient treatments for use in primary care. Exposures, relaxation techniques, and cognitive skills are among the many that can be readily taught. Educational interventions including counseling sessions, written information, and videotapes have been used to enhance parent-child interactions and bolster parental confidence (Pinilla & Birch, 1993; Wolfson, Lacks & Futterman, 1992). Behavioral health clinicians often coordinate screening and identification efforts (Simonian, 2006; Weitzman & Leventhal, 2006) by implementing procedures and developing protocols for successful screening, identification, referral, and feedback.

The Healthy Steps for Young Children Program incorporated developmental specialists and enhanced developmental services into pediatric primary care settings. Findings from an evaluation of the program suggest that participating families received more developmental services, were more satisfied with the quality of care provided, were more likely to attend well-child visits and receive vaccinations on time, and were less likely to use severe discipline techniques with their children (Minkovitz et al, 2003). Participation in the program also increased the likelihood that mothers at risk for depression would discuss their sadness with someone in the pediatric setting.

In reviewing the literature, Regalado and Halfon (2001) found that methods of identifying children with developmental difficulties in primary care settings were not adequate and assessment approaches for behavioral problems in the first 3 years of life were particularly lacking. This review also noted that physicians underestimate the extent of psychosocial challenges faced by families and their impact on behavior problems in children. Although a compelling case can be made for providing access to behavioral health services in pediatric primary care, particularly in infancy and early childhood (Talmi et al, 2009; Zeanah & Gleason, 2009), further studies are needed to assess whether early access to behavioral services can prevent mental health issues and long-term developmental sequelae. Importantly, without behavioral health supports in pediatric primary care settings, the burden of addressing mental health, developmental, and behavioral issues falls on the pediatric provider who has neither adequate time (Cooper et al, 2006) nor the ability to bill and receive reimbursement for such services (Meadows et al, 2011). Moreover, despite the recognition that clinical skills are needed to identify and address children’s and parent’s complex behavioral health needs, developmental and psychosocial issues have only recently become more central in pediatric training (American Academy of Pediatrics, 2009).

Special Considerations in Prescribing Psychotropic Medications

As mentioned previously, pediatricians will likely be managing mental health issues in the primary care setting. A large portion of the management will likely consist of medication treatment. Each primary care provider must establish their comfort level in prescribing psychotropic medications. Table 7–8 may be helpful in guiding prescribing psychotropic medications within the primary care setting. More complete information regarding medication is detailed throughout the chapter. In addition, a list of FDA-approved medication for various psychiatric disorders is included in Table 7–18. For a current alphabetical listing of FDA-approved psychotropic medications, please refer to the NIMH website at http://www.nimh.nih.gov/health/publications/mental-health-medications/nimh-mental-health-medications.pdf.

Allen, KD, Elliott, AJ, Arndorfer, RE, Behavioral pain management for pediatric headache in primary care. Children’s Health Care, 2002; 31, 175–189.

American Academy of Pediatrics: Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. The future of pediatrics: mental health competencies for pediatric primary care. Pediatrics 2009;124:410–421 [PMID: 19564328].

American Academy of Pediatrics: Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. American Academy of Pediatrics; 1996.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.

Anstiss T: Motivational interviewing in primary care. J Clin Psychol Med Settings (1068–9583) 2009;16(1):87 [PMID: 19253016].

Cooper S, Valleley R J, Polaha J, Begeny J, Evans J H: Running out of time: physician management of behavioral health concerns in rural pediatric primary care. Pediatrics 2006;118(1):e132 [PMID: 16818528].

Dilallo JJ, Weiss G: Motivational interviewing and adolescent psychopharmacology. J Am Acad Child Adolesc Psychiatry (0890–8567) 2009;48(2):108 [PMID: 20040823].

Guevara JP, Forrest CB: Modernizing pediatric primary care to better manage children’s behavioral health. Curr Opin Pediatr 2006;18(6):639 [PMID: 17099363].

Meadows T, Valleley R, Haack MK, Thorson R, Evans J: Physician “costs” in providing behavioral health in primary care. Clinical Pediatrics 2011;50(5):447 [PMID: 21196418].

Minkovitz CS, Hughart N, Strobino D, et al. A practice-based intervention to enhance quality of care in the first three years of life: results from the Healthy Steps for Young Children Program. JAMA. 2003 Dec 17; 290(23):3081–3091 [PMID: 14679271].

Moran M. DSM-5 provides new take on developmental disorders. Psychiatric News, January 18, 2013, p 6.

Pinilla T, Birch LL: Help me make it through the night: behavioral entrainment of breast-fed infants’ sleep patterns. Pediatrics 1993;91:436–444 [PMID: 8424024].

Regalado M, Halfon N: Primary care services promoting optimal child development from birth to age 3 years. Arch Pediatr Adolesc Med 2001;155:1311–1322 [PMID: 11732949].

Strickland B, Jones J, Ghandour R, Kogan M, Newacheck P: The medical home: health care access and impact for children and youth in the United States. Pediatrics 2011;127:604–611 [PMID: 21402643].

Strohm J et al: Pediatric behavioral health in primary care: a collaborative approach. 2009. J Am Psychiatr Nurses Assoc 2005 Oct;11(5):276–282.

Talmi A, Stafford B, Buchholz M: Providing perinatal mental health services in pediatric primary care. Zero to Three 2009 May;29(5):10–16.

Trupin E: Behavioral health screening and intervention in primary care. Arch Pediatr Adolesc Med 2011;165(7):669 [PMID: 21383257].

Weitzman CC, Leventhal JM: Screening for behavioral health problems in primary care. Curr Opin Pediatr 2006;18(6): 641–648 [PMID: 17099364].

Whitlock EP, Orleans CT, Pender N, Allan J: Evaluating primary care behavioral counseling interventions. Am J Preventative Med 2002;22(4):267–284 [PMID: 11988383].

Woflson A, Lacks P, Futterman A, Effects of parent training on infant sleeping patterns, parents’ stress, and perceived parental competence. J Consult Clinical Psychol, 1992 Feb;60(1):41–8 [PMID: 1556284].

Zeanah PD, Gleason MM: Handbook of Infant Mental Health, 3rd ed. New York, NY: Guilford Publications; 2009.

1. Anxiety-Based School Refusal (School Avoidance)

 ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

 A persistent pattern of school avoidance related to symptoms of anxiety.

 Somatic symptoms on school mornings, with symptoms resolving if the child is allowed to remain at home.

 No organic medical disorder that accounts for the symptoms.

 High levels of parental anxiety are commonly observed.

 General Considerations

Anxiety-based school refusal should be considered if a child presents with a medically unexplained absence from school for more than 2 weeks. Anxiety-based school refusal is a persistent behavioral symptom rather than a diagnostic entity. It refers to a pattern of school nonattendance resulting from anxiety, which may be related to a dread of leaving home (separation anxiety), a fear of some aspect of school, or a fear of feeling exposed or embarrassed at school (social phobia). In all cases, a realistic cause of the fear (eg, an intimidating teacher or a playground bully) should be ruled out. In most cases, anxiety-based school refusal is related to developmentally inappropriate separation anxiety. The incidence between males and females is about equal, and there are peaks of incidence at ages 6–7 years, again at ages 10–11 years, and in early adolescence.

 Clinical Findings

In the preadolescent years, school refusal often begins after some precipitating stress in the family. The child’s anxiety is then manifested either as somatic symptoms or in displacement of anxiety onto some aspect of the school environment. The somatic manifestations of anxiety include dizziness, nausea, and stomach distress. Characteristically, the symptoms become more severe as the time to leave for school approaches and then remit if the child is allowed to remain at home for the day. In older children, the onset is more insidious and often associated with social withdrawal and depression. The incidence of anxiety and mood disorders is increased in these families.

 Differential Diagnosis

The differential diagnosis of school nonattendance is presented in Table 7–9. Medical disorders that may be causing the somatic symptoms must be ruled out. Children with learning disorders may wish to stay home to avoid the sense of failure they experience at school. Children may also have transient episodes of wanting to stay at home during times of significant family stress or loss. The onset of school avoidance in middle or late adolescence may be related to the onset of schizophrenia. Children who are avoiding school for reasons related to oppositional defiant disorder or conduct disorder can be differentiated on the basis of their chronic noncompliance with adult authority and their preference for being with peers rather than at home.

I. Emotional or anxiety-based refusalb A. Separation anxiety disorder (50%–80% of anxious refusers) B. Generalized anxiety disorder C. Mood or depressive disorder (with or without combined anxiety) D. Social phobia E. Specific phobia F. Panic disorder G. Psychosis II. Truancyc behavior disorders A. Oppositional defiant disorder, conduct disorder B. Substance abuse disorders III. Situation-specific school refusal A. Learning disability, unaddressed or undetected B. Bullying or gang threat C. Psychologically abusive teacher D. Family-sanctioned nonattendance 1. For companionship 2. For child care 3. To care for the parent (role-reversal) 4. To supplement family income E. Socioculturally sanctioned nonattendance (school is not valued) F. Gender concerns IV. Undiagnosed medical condition (including pregnancy)

^aMedically unexplained absence of more than 2 weeks.

^bSubjectively distressed child who generally stays at home.

^cNonsubjectively distressed and not at home.

 Complications

The longer a child remains out of school, the more difficult it is to return and the more strained the relationship between child and parent becomes. Many parents of nonattending children feel tyrannized by their defiant, clinging child. Children often feel accused of making up their symptoms, leading to further antagonism between the child, parents, and medical caregivers.

 Treatment

Once the comorbid diagnoses and situations related to school avoidance or refusal have been identified and interventions begun (ie, educational assessment if learning disabilities are suspected, medication if necessary for depression or anxiety, or addressing problems in the home), the goal of treatment is to help the child confront anxiety and overcome it by returning to school. This requires a strong alliance between the parents and the healthcare provider. The parent must understand that no underlying medical disorder exists, that the child’s symptoms are a manifestation of anxiety, and that the basic problem is anxiety that must be faced to be overcome. Parents must be reminded that being good parents in this case means helping a child cope with a distressing experience. Children must be reassured that their symptoms are caused by worry and that they will be overcome on return to school.

A plan for returning the child to school is then developed with parents and school personnel. Firm insistence on full compliance with this plan is essential. The child is brought to school by someone not likely to give in, such as the father or an older sibling. If symptoms develop at school, the child should be checked by the school nurse and then returned to class after a brief rest. The parents must be reassured that school staff will handle the situation at school and that school personnel can reach the primary healthcare provider if any questions arise.

If these interventions are ineffective, increased involvement of a therapist and consideration of a day treatment program may be necessary. For children with persistent symptoms of separation that do not improve with behavioral interventions, medications such as selective serotonin reuptake inhibitors (SSRIs) should be considered. Comorbid diagnoses of panic disorder, generalized anxiety disorder, or major depression should be carefully screened for, and if identified, treated appropriately.

 Prognosis

The vast majority of preadolescent children improves significantly with behavioral interventions and return to school. The prognosis is worsened by the length of time the child remains out of school. Long-term outcomes are influenced by comorbid diagnoses and responsiveness to behavioral or medication interventions. A history of school refusal is more common in adults with panic and anxiety disorders and agoraphobia than in the general population.

Bailey KA, Chavira DA, Stein MT, Stein MB: Brief measures to screen for social phobia in primary care pediatrics. J Pediatr Psychol 2006;31(5):512–521 [PMID: 16034004].

Bowen R, Chavira DA, Bailey K, Stein MT, Stein MB: Nature of anxiety comorbid with attention deficit hyperactivity disorder in children from a pediatric primary care setting. Psychiatry Res 2008;157(1–3):201–209 [Epub 2007 Nov 19] [PMID: 18023880].

Chavira DA, Stein MB, Bailey K, Stein MT: Child anxiety in primary care: prevalent but untreated. Depress Anxiety 2004; 20(4):155–164 [PMID: 15643639].

Gardner W, Lucas A, Kolko DJ, Campo JV: Comparison of the PSC-17 and alternative mental health screens in an at-risk primary care sample. J Am Acad Child Adolesc Psychiatry 2007;46(5):611–618 [PMID: 17450052].

Khalid-Khan S, Santibanez MP, McMicken C, Rynn MA: Social anxiety disorder in children and adolescents: epidemiology, diagnosis, and treatment. Paediatr Drugs 2007;9(4):227–237 [PMID: 17705562].

Ross WJ, Chan E, Harris SK, Goldman SJ, Rappaport LA: Pediatrician-psychiatrist collaboration to care for children with attention deficit hyperactivity disorder, depression, and anxiety. Clin Pediatr (Phila) 2011;50(1):37–43 [Epub 2010 Aug 19] [PMID: 20724316].

Sakolsky D, Birmaher B: Pediatric anxiety disorders: management in primary care. Curr Opin Pediatr 2008;20(5):538–543 [PMID: 18781116].

Wren FJ, Bridge JA, Birmaher B: Screening for childhood anxiety symptoms in primary care: integrating child and parent reports. J Am Acad Child Adolesc Psychiatry 2004;43(11):1364–1371 [PMID: 15502595].

2. Generalized Anxiety Disorder & Panic Disorder

 General Considerations

Anxiety can be manifested either directly or indirectly, as shown in Table 7–10. The characteristics of anxiety disorders in childhood are listed in Table 7–11. Community-based studies of school-aged children and adolescents suggest that nearly 10% of children have some type of anxiety disorder. The differential diagnosis of symptoms of anxiety is presented in Table 7–12.

Psychological Fears and worries Increased dependence on home and parents Avoidance of anxiety-producing stimuli Decreased school performance Increased self-doubt and irritability Frightening themes in play and fantasy Psychomotor Motoric restlessness and hyperactivity Sleep disturbances Decreased concentration Ritualistic behaviors (eg, washing, counting) Psychophysiologic Autonomic hyperarousal Dizziness and lightheadedness Palpitations Shortness of breath Flushing, sweating, dry mouth Nausea and vomiting Panic Headaches and stomach aches

I. Normal developmental anxiety A. Stranger anxiety (5 mo-2½ years, with a peak at 6–12 mo) B. Separation anxiety (7 mo–4 y, with a peak at 18–36 mo) C. The child is fearful or even phobic of the dark and monsters (3–6 y) II. “Appropriate” anxiety A. Anticipating a painful or frightening experience B. Avoidance of a reminder of a painful or frightening experience C. Child abuse III. Anxiety disorder (see Table 7–11), with or without other comorbid psychiatric disorders IV. Substance abuse V. Medications and recreational drugs A. Caffeinism (including colas and chocolate) B. Sympathomimetic agents C. Idiosyncratic drug reactions VI. Hypermetabolic or hyperarousal states A. Hyperthyroidism B. Pheochromocytoma C. Anemia D. Hypoglycemia E. Hypoxemia VII. Cardiac abnormality A. Dysrhythmia B. High-output state C. Mitral valve prolapsed

The evaluation of anxiety symptoms in children must consider the age of the child, the developmental fears that can normally be expected at that age, the form of the symptoms and their duration, and the degree to which the symptoms disrupt the child’s life. The family and school environment should be evaluated for potential stressors, marital discord, family violence, harsh or inappropriate disciplinary methods, sexual abuse, neglect, and emotional overstimulation. The child’s experience of anxiety and its relationship to life events should be explored. Please refer to treatment algorithm for anxiety disorders (Figure 7–1).

 Figure 7–1. Treatment algorithm for children and adolescents with anxiety. (Reproduced with permission from Hilt R: Primary Care Principles for Child Mental Health, summer 2013. version 4.1).

 Complications

Some adolescents with panic disorder can develop agoraphobia, a subsequent fear that a panic attack may occur in public or other places where help or escape may not be available.

 Treatment

Therapy to incorporate specific cognitive and behavioral techniques to diminish anxiety should be recommended for children and adolescents struggling with both generalized anxiety as well as panic disorder. Cognitive, behavioral, environmental, and virtual treatments are typically available in both the privately insured as well as in community mental health settings. Parent-child and family interventions are also very useful techniques in treating the anxious child. When panic attacks or anxiety symptoms do not remit with cognitive, behavioral, and environmental interventions, and they significantly affect life functioning, psychopharmacologic agents may be helpful. SSRIs may be effective across a broad spectrum of anxiety symptoms including panic and generalized anxiety, although no SSRIs are approved for this indication. Occasionally, short-term use of benzodiazepines can be helpful for severe impairment and for treatment relief while waiting for the SSRI to achieve benefit (usually within 3–4 weeks). Alternatively, alpha agonists can be used in place of benzodiazepines, on a scheduled or as-needed based, and usually are better tolerated without concern for physiologic dependence. Please refer to medication used for treatment of anxiety disorders (Table 7–13).

 Prognosis

The average age of onset for an anxiety disorder is 5 years of age. In addition, there is continuity between high levels of childhood anxiety and anxiety disorders in adulthood. Anxiety disorders are thus likely to be lifelong conditions, yet with effective interventions, individuals can minimize their influence on overall life functioning.

Alfano CA, Ginsburg GS, Kingery JN: Sleep-related problems among children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 2007 Feb;46(2):224–232 [PMID: 17242626].

Ipser JC et al: Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2009 Jul 8;(3):CD005170 [PMID: 19588367].

Keeton CP, Kolos AC, Walkup JT: Pediatric generalized anxiety disorder: epidemiology, diagnosis, and management. Paediatr Drugs 2009;11(3):171–183 [PMID: 19445546].

Lavigne JV et al: The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. J Clin Child Adolesc Psychol 2009 May;38(3):315–328 [PMID: 19437293].

Manassis K: Silent suffering: understanding and treating children with selective mutism. Expert Rev Neurother 2009 Feb; 9(2):235–243 [PMID: 19210197].

Roy AK et al: The CAMS Team: attention bias toward threat in pediatric anxiety disorders. J Am Acad Child Adolesc Psychiatry 2008 Aug 8;47(10):1189–1196 [PMID: 18698266].

Rynn MA et al: Efficacy and safety of extended-release venlafaxine in the treatment of generalized anxiety disorder in children and adolescents: two placebo-controlled trials. Am J Psychiatry 2007 Feb;164(2):290–300 [PMID: 17267793].

3. Social Anxiety Disorder

 General Considerations

Social Anxiety Disorder is characterized by significant, persistent fear in social settings or performance situations. The disorder results in overwhelming anxiety and inability to function when exposed to unfamiliar people and/or scrutiny. As at least one-third of children with anxiety disorders meet criteria for two or more anxiety disorders, it is important to evaluate the other possible causes of anxiety. Overall, this is usually a complication of older children and adolescents.

Anxiety symptoms in children with social anxiety disorder are related specifically to the social setting and not better accounted for any other anxiety disorder. Common manifestations of this disorder include ongoing avoidance of social functions, and persistent somatic complaints which occur in a social setting and resolve in the absence of social exposure. The symptoms significantly disrupt the child’s—and frequently the family’s—life, and parents often describe a pattern of overly accommodating their child’s avoidance and/or incentivizing their child to attend routine social, extracurricular, or family functions.

 Complications

Children with social anxiety disorder are at increased risk for depression and school avoidance. Children with social anxiety disorder can also experience panic attacks, and furthermore it is important to be aware of the high comorbidity between substance use disorders and anxiety disorders, especially social anxiety disorder.

 Treatment

Similar to the other anxiety categories, the mainstay of treatment for social anxiety disorder is therapy. The goal is to modify behavior and diminish the anxiety in social settings through the use of specific cognitive and behavioral techniques. As with other anxiety disorders, if ongoing therapy is not effective at mitigating the anxiety, then psychopharmacologic agents may be helpful. SSRIs are the only class of medication to have demonstrated efficacy for children with social anxiety disorder.

 Prognosis

As previously mentioned, since there is continuity between high levels of childhood anxiety and anxiety disorders in adulthood, anxiety disorders are likely to persist for years. However, with effective interventions, individuals can significantly lessen the impact of the disorder and improve overall functioning.

Connolly SD, Bernstein GA; Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 2007 Feb;46(2): 267–283 [PMID: 17242630].

Gail A Bernstein, Shaw K. Practice parameters for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry, 1997;36(10 Suppl):S69–S84 [PMID: 9334566].

4. Specific Phobias

 General Considerations

Specific phobia is an intense fear of a particular thing, experience, or situation. This object or situation is a cause of great distress. To handle the distress, the child avoids the object or situation, therefore reinforcing the anxiety. The perceived harm or threat is well out of proportion to the actual stimulus. A specific fear can develop into a specific phobia if symptoms are significant enough to result in extreme distress or impairment related to the fear. While children commonly experience more than one specific phobia, this alone does not constitute the diagnosis of generalized anxiety disorder.

 Treatment

The mainstay of treatment for specific phobias is psychotherapy. Again, cognitive behavioral therapy is the most effective approach, with a major emphasis on the development of stress reduction techniques, coping skills, and exposure-response therapy.

 Prognosis

While some specific phobias usually lessen in severity over time, others may require more active and continual interventions. Overall, the purpose is to minimize the distress and improve functioning.

Connolly SD, Bernstein GA; Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 2007 Feb;46(2): 267–283 [PMID: 17242630].

5. Obsessive-Compulsive Disorder

 ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

 Recurrent obsessive thoughts, impulses, or images that are not simply excessive worries about real-life problems.

 Obsessions and compulsions cause marked distress, are time-consuming, and interfere with normal routines.

 Repetitive compulsive behaviors or mental acts are performed to prevent or reduce distress stemming from obsessive thoughts.

 General Considerations

Obsessive-compulsive disorder (OCD) is an anxiety disorder that often begins in early childhood but may not be diagnosed until the teenage or even young adult years. The essential features of OCD are recurrent obsessions or compulsions that are severe enough to be time-consuming or cause marked distress and functional impairment. Obsessions are persistent ideas, thoughts, or impulses that are intrusive and often inappropriate. Children may have obsessions about contamination or cleanliness; ordering and compulsive behaviors will follow, such as frequent hand washing, counting, or ordering objects. The goal of the compulsive behavior for the individual with OCD is to reduce anxiety and distress. There may be significant avoidance of situations due to obsessive thoughts or fears of contamination. OCD is often associated with major depressive disorder. OCD is a biologically based disease and has a strong genetic/familial component. Pediatric autoimmune disorders associated with group B streptococci have also been implicated in the development of OCD for some children. The prevalence of OCD is estimated to be around 2%, and the rates are equal between males and females.

Trichotillomania, while technically classified as an impulse disorder, is also thought to be related to OCD. It involves the recurrent pulling out of hair, often to the point of bald patches, and can also involve pulling out eyelashes, eyebrows, and hair from any part of the body. Trichotillomania should be considered in the differential diagnosis for any patient with alopecia. Treatment often includes the same medications used to treat OCD, and behavior therapy to decrease hair pulling and restore normal social functioning.

 Treatment

OCD is best treated with a combination of cognitive-behavioral therapy specific to OCD and medications in more severe cases. SSRIs are effective in diminishing OCD symptoms. Fluvoxamine and sertraline have FDA approval for the treatment of pediatric OCD. The tricyclic antidepressant (TCA) clomipramine has FDA approval for the treatment of OCD in adults.

 Prognosis

Although OCD is usually a lifelong condition, most individuals can achieve significant remission of symptoms with the combination of cognitive-behavioral therapy and medications. A minority of individuals with OCD are completely disabled by their symptoms.

Gilbert AR, Maalouf FT: Pediatric obsessive-compulsive disorder: Management priorities in primary care. Curr Opin Pediatr 2008 Oct;20(5):544–550 [PMID: 18781117].

Reinblatt SP, Walkup JT: Psychopharmacologic treatment of pediatric anxiety disorders. Child Adolesc Psychiatr Clin N Am 2005 Oct;14(4):877–908 [PMID: 16171707].

Seidel L, Walkup JT: Selective serotonin reuptake inhibitor use in the treatment of the pediatric non-obsessive-compulsive disorder anxiety disorders. J Child Adolesc Psychopharmacol 2006 Feb-Apr;16(1–2):171–179 [PMID: 16553537].

Stafford B, Troha C, Gueldner BA: Intermittent abdominal pain in a 6-year-old child: the psycho-social-cultural evaluation. Curr Opin Pediatr 2009 Oct;21(5):675–677 [PMID: 19521239].

Storch EA et al: Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches. J Am Acad Child Adolesc Psychiatry 2007 Apr;46(4):469–478 [PMID: 17420681].

6. Post-Traumatic Stress Disorder

 ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

 Signs and symptoms of autonomic hyperarousal such as easy startle, increased heart rate, and hypervigilance.

 Avoidant behaviors and numbing of responsiveness.

 Flashbacks to a traumatic event such as nightmares and intrusive thoughts.

 Follows traumatic events such as exposure to violence, physical or sexual abuse, natural disasters, car accidents, dog bites, and unexpected personal tragedies.

 General Considerations

Factors that predispose individuals to the development of post-traumatic stress disorder (PTSD) include proximity to the traumatic event or loss, a history of exposure to trauma, preexisting depression or anxiety disorder, and lack of an adequate support system. PTSD can develop in response to natural disasters, terrorism, motor vehicle crashes, and significant personal injury, in addition to physical, sexual, and emotional abuse. Natural disasters such as hurricanes, fires, flooding, and earthquakes, for example, can create situations in which large numbers of affected individuals are at heightened risk for PTSD. Individuals who have a previous history of trauma, or an unstable social situation are at greatest risk of PTSD.

Long overdue, attention is now being paid to the substantial effects of family and community violence on the psychological development of children and adolescents. Abused children are most likely to develop PTSD and to suffer wide-ranging symptoms and impaired functioning. As many as 25% of young people exposed to violence develop symptoms of PTSD.

Heightened concern about terrorism in the United States has created increased awareness of PTSD and community-based interventions to decrease the risk of PTSD. Studies after the terrorist attacks of September 11, 2001, and the Oklahoma City bombing reported up to 40% of children and adolescents who experienced PTSD symptoms. Studies after Hurricane Katrina also identified PTSD rates up to 60% in young children after the disaster.

 Clinical Findings

Children and adolescents with PTSD show persistent evidence of fear, anxiety, and hypervigilance. They may regress developmentally and experience fears of strangers, the dark, and being alone, and avoid reminders of the traumatic event. Children also frequently reexperience elements of the events in nightmares and flashbacks. In their symbolic play, one can often notice a monotonous repetition of some aspect of the traumatic event. Children with a history of traumatic experiences or neglect in infancy and early childhood are likely to show signs of reactive attachment disorder and have difficulty forming relationships with caregivers.

 Treatment

The cornerstone of treatment for PTSD is education of the child and family regarding the nature of the disorder so that the child’s emotional reactions and regressive behavior are not mistakenly viewed as manipulative. Support, reassurance, and repeated explanations and understanding are needed. It is critical for the child’s recovery, that the child is living in a safe environment, and if caregivers have been abusive, concerns must be reported to social services. Efforts should be made to establish or maintain daily routines as much as possible, especially after a trauma or disaster that interrupts the family’s environment. In the case of media coverage of a disaster or event, children’s viewing should be avoided or limited. Interventions to maintain safety of the child are imperative. Individual and family psychotherapy are central features of treatment interventions. Specific fears usually wane with time, and behavioral desensitization may help. Cognitive-behavioral therapy is considered first-line treatment for PTSD, and there is some preliminary evidence that eye movement desensitization and reprocessing (EMDR) may also be useful.

A supportive relationship with a caregiving adult is essential. Frequently caregivers also have PTSD and need referral for treatment so that they can also assist in their child’s recovery.

For children with more severe and persistent symptoms, assessment for treatment with medication is indicated. Sertraline has approval for the treatment of PTSD in adults. Target symptoms (eg, anxiety, depression, nightmares, and aggression) should be clearly identified and appropriate medication trials initiated with close monitoring. Some of the medications used to treat children with PTSD include clonidine or guanfacine (Tenex), mood stabilizers, antidepressants, and neuroleptics. Children who have lived for an extended time in abusive environments or who have been exposed to multiple traumas are more likely to require treatment with medications. Occupational therapy for sensory integration can also be effective in decreasing reactivity to stimuli and helping the child and caregivers develop and implement self-soothing skills. Individuals who have suffered single-episode traumas usually benefit significantly from psychotherapy and may require limited treatment with medication to address symptoms of anxiety, nightmares, and sleep disturbance.

 Prognosis

At 4- to 5-year follow-up investigations, many children who have been through a traumatic life experience continue to have vivid and frightening memories and dreams and a pessimistic view of the future. The effects of traumatic experiences can be far-reaching. The ability of caregivers to provide a safe, supportive, stable, empathic environment enhances the prognosis for individuals with PTSD. Timely access to therapy and use of therapy over time to work through symptoms also enhance prognosis. Evidence is growing to support a connection between victimization in childhood and unstable personality and mood disorders in later life.

Banh MK et al: Physician-reported practice of managing childhood posttraumatic stress in pediatric primary care. Gen Hosp Psychiatry 2008 Nov-Dec;30(6):536–545 [PMID: 19061680].

Cohen JA, Kelleher KJ, Mannarino AP: Identifying, treating, and referring traumatized children: the role of pediatric providers. Arch Pediatr Adolesc Med 2008 May;162(5):447–452 [PMID: 18458191].

Cohen JA, Scheeringa MS: Post-traumatic stress disorder diagnosis in children: challenges and promises. Dialogues Clin Neurosci 2009;11(1):91–99 [PMID: 19432391].

Kirsch V, Wilhelm FH, Goldbeck L: Psychophysiological characteristics of PTSD in children and adolescents: a review of the literature. J Trauma Stress 2011 Apr;24(2):146–154. doi: 10.1002/jts.20620 [Epub 2011 Mar 24] [Review] Erratum in: J Trauma Stress. 2011 Jun;24(3):370–372 [PMID: 21438015].

National Child Traumatic Stress Network. Multiple invaluable resources available at: http://www.nctsn.org.

Scheeringa MS, Zeanah CH: Reconsideration of harm’s way: onsets and comorbidity patterns of disorders in preschool children and their caregivers following Hurricane Katrina. J Clin Child Adolesc Psychol 2008 Jul;37(3):508–518 [PMID: 18645742].

7. Selective Mutism

 General Considerations

This disorder is most common in early childhood, with high levels of stress. Time of onset usually coincides with a child leaving home for the first time, either to preschool, kindergarten, or first grade.

 Clinical Findings

Children and adolescents with selective mutism do not speak in one or more settings despite the ability to comprehend spoken language and speak in other settings. Many of these children have comorbid disorders, including elimination disorders, OCD, school phobia, and depression.

 Treatment

The mainstay for treatment of selective mutism is cognitive behavioral therapy. If the condition is severe, use of SSRI is indicated.

 Prognosis

The prognosis is usually very good, especially with therapy and/or use of medication.

Dulcan MK, Martini DR: Concise Guide to Child & Adolescent Psychiatry, 2nd ed. Washington, DC: American Psychiatric Association; 1999.

Inattentive, Hyperactive, & Combined Type

 General Considerations

ADHD is one of the most commonly seen and treated psychiatric conditions in children and adolescents. Although there is no definitive cause or cure for this disorder, with adequate screening and monitoring, it can be identified and effectively treated.

 Clinical Findings

Symptoms of ADHD fall into two categories: hyperactive and impulsive or inattentive. If a child has a significant number of symptoms in both categories, a diagnosis of ADHD, combined type is given. There is growing controversy about the diagnosis and treatment of ADHD. As with all psychiatric diagnoses, functional impairment is a required feature, as is presentation across multiple settings and relationships (eg, home and school). It is important to keep in mind that intermittent symptoms of hyperactivity and/or inattention without functional impairment does not warrant a diagnosis of ADHD.

 Differential Diagnosis

As discussed later in this chapter, not all hyperactivity and/or inattention can be attributed to ADHD. Some of the most common psychiatric conditions that have similar presenting problems to ADHD include mood disorder (ie, bipolar and depression), anxiety disorders, oppositional defiant disorder, adjustment disorder, PTSD, and learning disorders. There are also a number of medical diagnoses with presenting problems similar to ADHD, including head injury, hyperthyroidism, fetal alcohol syndrome, and lead toxicity. Inadequate nutrition and sleep deprivation including poor quality of sleep can also manifest with symptoms of inattention. It is important to have the correct diagnosis prior to initiating treatment for ADHD. Refer to the algorithm in this section on diagnosis, evaluating conditions on the differential and selecting treatment for ADHD (Figure 7–2).

 Figure 7–2. Treatment algorithm for children and adolescents with ADHD. (Reproduced with permission from Hilt R: Primary Care Principles for Child Mental Health, summer 2013. version 4.1).

 Complications

ADHD comorbidities are common and include cooccurring anxiety disorders, mood disorders, oppositional defiant disorder, and conduct disorder. While stimulant medication, the first-line treatment for ADHD, has the potential for abuse, literature indicates that individuals who are treated for ADHD are significantly less likely to abuse substances compared to those who have not been treated. Also, a large majority of children and adolescents with ADHD are not formally diagnosed, and of those who are diagnosed, only 55% actually receive ongoing treatment.

 Treatment

Medication is a primary treatment for ADHD. Stimulants are the most effective and most commonly prescribed medications. Approximately 75% of children with ADHD experience improved attention span, decreased hyperactivity, and decreased impulsivity when given stimulant medications. Children with ADHD who do not respond favorably to one stimulant may respond well to another. Children and adolescents with ADHD without prominent hyperactivity (ADHD, predominantly inattentive type) are also likely to be responsive to stimulant medications. When stimulants are not well tolerated or effective, nonstimulants may be used as an alternative. Among nonstimulant medications, atomoxetine, a selective noradrenergic reuptake inhibitor and guanfacine ER, a central alpha-2A-adrenergic receptor agonist, both have FDA approval for the treatment of ADHD in children. Please refer to table of stimulants and nonstimulants when considering which medication to use (Tables 7–14 and 7–15).

 Special considerations regarding the use of stimulant medication

For general considerations on the use of stimulant medications, refer to Table 7–14.

Common adverse events include anorexia, weight loss, abdominal distress, headache, insomnia, dysphoria and tearfulness, irritability, lethargy, mild tachycardia, and mild elevation in blood pressure. Less common side effects include interdose rebound of ADHD symptoms, emergence of motor tics or Tourette’s syndrome, behavioral stereotypy, tachycardia or hypertension, depression, mania, and psychotic symptoms. Reduced growth velocity can occur, however, for individual patient’s ultimate height is not usually noticeably compromised. Treatment with stimulant medications does not predispose to future substance abuse. Young children are at increased risk for side effects from stimulant medications.

Reports in the medical literature and to the FDA of sudden death and of serious cardiovascular adverse events among children taking stimulant medication raised concerns about the safety of these medications. In fact, the labels for methylphenidate and amphetamine medications were changed in 2006 to note reports of stimulant-related deaths in patients with heart problems and advised against using these products in individuals with known serious structural abnormalities of the heart, cardiomyopathy, or serious heart rhythm abnormalities. There continues to be, however, insufficient data to confirm whether taking stimulant medication causes cardiac problems or sudden death. The FDA is advising providers and other providers to conduct a thorough physical examination, paying close attention to the cardiovascular system, and to collect information about the patient’s history and any family history of cardiac problems. If these examinations indicate a potential problem, providers may want to consider a screening electrocardiogram (ECG) or an echocardiogram. In addition, stimulants should also be used cautiously in individuals with a personal or family history of motor tics or Tourette’s syndrome, as these medications may cause or worsen motor tics. Caution should also be taken if there is a personal or family history of substance abuse or addictive disorders, as these medications can be abused or sold as drugs of abuse. Students attending college/university may be at increased risk to divert their stimulants to peers. Stimulants are also contraindicated for individuals with psychotic disorders, as they can significantly worsen psychotic symptoms. Stimulants should be used with caution in individuals with comorbid bipolar affective disorder and ADHD and consideration of concurrent mood stabilization is critical. Providers should be aware that additive stimulant effects are seen with sympathomimetic amines (ephedrine and pseudoephedrine).

FDA statement available at: http://www.fda.gov/Drugs/DrugSafety/
PostmarketDrugSafetyInformationforPatientsandProviders/
DrugSafetyInformationforHeathcareProfessionals/ucm165858.htm.

Initial medical screening—should include observation for involuntary movements and measurement of height, weight, pulse, and blood pressure. (See also Chapter 3.)

Pulse, blood pressure, height, and weight should be recorded every 3–4 months and at times of dosage increases and abnormal movements such as motor tics should be assessed at each visit.

 Prognosis

Research indicates that 60%–85% of those diagnosed with ADHD in childhood continue to carry the diagnosis into adolescence. The literature varies greatly about progression of ADHD into adulthood. Most studies show that in adulthood, a majority of adolescents diagnosed with ADHD in adolescence continue to have functional impairment, whether or not they meet full criteria for the disorder. While many have devised ways to cope with their symptoms in a manner that does not require medication, about one-third of adults previously diagnosed with ADHD in childhood require ongoing medication management.

AACAP Practice Parameter for ADHD: http://www.aacap.org/
AACAP/Resources_for_Primary_Care/Practice_Parameters_and_
Resource_Centers/Practice_Parameters.aspx.

Barzman DH, Findling RL: Pharmacological treatment of pathologic aggression in children. Int Rev Psychiatry 2008 Apr; 20(2):151–157 [Review] [PMID: 18386205].

Biederman J et al: Treatment of ADHD with stimulant medications: response to Nissen perspective in the New England Journal of Medicine. J Am Acad Child Adolesc Psychiatry 2006 Oct;45(10):1147–1150 [PMID: 16840880].

Correll CU, Kratochvil CJ, March JS: Developments in pediatric psychopharmacology: focus on stimulants, antidepressants, and antipsychotics. J Clin Psychiatry 2011 May;72(5):655–670 [PMID: 21658348].

Daughton JM, Kratochvil CJ: Review of ADHD pharmacotherapies: advantages, disadvantages, and clinical pearls. J Am Acad Child Adolesc Psychiatry 2009 Mar;48(3):240–248 [PMID: 19242289].

Gilbert D: Treatment of children and adolescents with tics and Tourette syndrome. J Child Neurol 2006 Aug;21(8):690–700 [PMID: 16970870].

Hammerness P, McCarthy K, Mancuso E, Gendron C, Geller D: Atomoxetine for the treatment of attention-deficit/hyperactivity disorder in children and adolescents: a review. Neuropsychiatr Dis Treat 2009;5:215–226 [PMID: 19557116].

http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/index.shtml.

McVoy M, Findling R: Child and adolescent psychopharmacology update. Psychiatr Clin North Am 2009 Mar;32(1):111–133 [PMID: 19248920].

Nevels RM, Dehon EE, Alexander K, Gontkovsky ST: Psychopharmacology of aggression in children and adolescents with primary neuropsychiatric disorders: a review of current and potentially promising treatment options. Exp Clin Psychopharmacol 2010 Apr;18(2):184–201 [PMID: 20384430].

Posey DJ, McDougle CJ: Guanfacine and guanfacine extended release: treatment for ADHD and related disorders. CNS Drug Rev 2007 Winter;13(4):465–474 [PMID: 18078429].

Vitiello B: An international perspective on pediatric psychopharmacology. Int Rev Psychiatry 2008 Apr;20(2):121–126 [PMID: 18386201].

1. Depression in Children & Adolescents

 ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

 Dysphoric mood, mood lability, irritability, or depressed appearance, persisting for days to months at a time.

 Characteristic neurovegetative signs and symptoms (changes in sleep, appetite, concentration, and activity levels).

 Suicidal ideation, feeling of hopelessness.

 General Considerations

The incidence of depression in children increases with age, from 1% to 3% before puberty to around 8% for adolescents. The rate of depression in females approaches adult levels by age 15. The lifetime risk of depression ranges from 10% to 25% for women and 5% to 12% for men. The incidence of depression in children is higher when other family members have been affected by depressive disorders. The sex incidence is equal in childhood, but with the onset of puberty the rates of depression for females begin to exceed those for males by 5:1.

 Clinical Findings

Clinical depression can be defined as a persistent state of unhappiness or misery that interferes with pleasure or productivity. The symptom of depression in children and adolescents is as likely to be an irritable mood state accompanied by tantrums or verbal outbursts as it is to be a sad mood. Typically, a child or adolescent with depression begins to look unhappy and may make comments such as “I have no friends,” “Life is boring,” “There is nothing I can do to make things better,” or “I wish I were dead.” A change in behavior patterns usually takes place that includes social isolation, deterioration in schoolwork, loss of interest in usual activities, anger, and irritability. Sleep and appetite patterns commonly change, and the child may complain of tiredness and nonspecific pain such as headaches or stomach aches (Table 7–16).

 Differential Diagnosis

Clinical depression can usually be identified by asking about the symptoms. Children are often more accurate than their caregivers in describing their own mood state. When several depressive symptoms cluster together over time, are persistent (2 weeks or more), and cause impairment, a major depressive disorder may be present. When depressive symptoms are of lesser severity but have persisted for 1 year or more, a diagnosis of dysthymic disorder should be considered. Milder symptoms of short duration in response to some stressful life event may be consistent with a diagnosis of adjustment disorder with depressed mood.

The American Academy of Pediatrics recommends annual screening for depression in children age 12 and older using a standardized measure. The Center for Epidemiologic Study of Depression–Child Version (CESD-C), Child Depression Inventory (CDI), Beck Depression Rating Scale, and Reynolds Adolescent Depression Scale and Patient Health Questionnaire-9 modified for teens (PHQ-9) are self-report rating scales that are easily used in primary care to assist in assessment and monitoring response to treatment.

Depression often coexists with other mental illnesses such as ADHD, conduct disorders, anxiety disorders, eating disorders, and substance abuse disorders. Medically ill patients also have an increased incidence of depression. Every child and adolescent with a depressed mood state should be asked directly about suicidal ideation and physical and sexual abuse. Depressed adolescents should also be screened for hypothyroidism and substance abuse. Please refer to treatment algorithm on depression regarding diagnosis and treatment recommendations (Figure 7–3).

 Complications

The risk of suicide is the most significant risk associated with depressive episodes. In addition, adolescents are likely to self-medicate their feelings through substance abuse, or indulge in self-injurious behaviors such as cutting or burning themselves (without suicidal intent). School performance usually suffers during a depressive episode, as children are unable to concentrate or motivate themselves to complete homework or projects. The irritability, isolation, and withdrawal that often result from the depressive episode can lead to loss of peer relationships and tense dynamics within the family. Please refer to section on identifying and addressing suicide risk for additional information.

 Figure 7–3. Treatment algorithm for child and adolescents with depression. (Reproduced with permission from Hilt R: Primary Care Principles for Child Mental Health, summer 2013. version 4.1).

 Treatment

Treatment includes developing a comprehensive plan to treat the depressive episode and help the family to respond more effectively to the patient’s emotional needs. Referrals should be considered for individual and possibly adjunctive family therapy. Cognitive-behavioral therapy has been shown to effectively improve depressive symptoms in children and adolescents. Cognitive-behavioral therapy includes a focus on building coping skills to change negative thought patterns that predominate in depressive conditions. It also helps the young person to identify, label, and verbalize feelings and misperceptions. In therapy, efforts are also made to resolve conflicts between family members and improve communication skills within the family.

When the symptoms of depression are moderate to severe and persistent, and have begun to interfere with relationships and school performance, antidepressant medications may be indicated (Table 7–19). Mild depressive symptoms often do not require antidepressant medications and may improve with psychotherapy alone. A positive family history of depression increases the risk of early-onset depression in children and adolescents and the chances of a positive response to antidepressant medication. Depression in toddlers and young children is best approached with parent-child relational therapies.

It is important to be cognizant of evidence-based medical practice when prescribing for any indication. A major source of clinic guidelines regarding the treatment of depression in child and adolescents stems from the carefully conducted Treatment of Adolescent Depression Study (TADS). The authors of this study found that cognitive-behavioral therapy combined with fluoxetine led to the best outcomes in the treatment of pediatric depression during the first 12 weeks of treatment. Although our knowledge is still evolving, these findings suggest that when recommending or prescribing an antidepressant, the provider should consider concurrently recommending cognitive-behavioral or interpersonal therapy. Providers should discuss the options for medication treatment, including which medications have FDA approval for pediatric indications (Table 7–18). Target symptoms should be carefully monitored for improvement or worsening, and it is important to ask and document the responses about any suicidal thinking and self-injurious behaviors.

In 2005, the FDA issued a “black box warning” regarding suicidal thinking and behavior for all antidepressants prescribed for children and adolescents. The FDA compiled data from 24 short term trials of 4–16 weeks that included the use of antidepressants for major depressive disorder and obsessive compulsive disorder. Across these studies, the average risk of suicidal thinking and behavior during the first few months of treatment was 4% or twice the placebo risk of 2%. No suicides occurred in these trials. Although children face an initial increased risk of increased suicidal thinking and behaviors during the first few months of treatment, there is now substantial evidence that antidepressant treatment, over time, is protective against suicide. For example, following the addition of the “black box warning” for all antidepressants in October 2005, a 20% decrease in prescriptions for those younger than age 20 occurred. During the same time period, there was an 18% increase in suicides. Furthermore, the suicide rates in children and adolescents were lowest in areas of the country that had the highest rate of selective serotonin reuptake inhibitor (SSRI) prescriptions. This suggests best practice is to educate the family regarding both the risks and benefits of antidepressant treatment and monitor carefully for any increase in suicidal ideation or self-injurious urges, as well as improvement in target symptoms of depression, especially in the first 4 weeks and subsequent 3 months.

Special Considerations Regarding the Use of Antidepressant Medication

A. Selective Serotonin Reuptake Inhibitors

There are some special considerations when prescribing the various classes of antidepressant medication. Table 7–19 outlines the distinct differences between some of the most commonly used antidepressant medications. In addition to the information provided in the table, providers should be aware that each SSRI has different FDA indications. Providers can choose to treat with an SSRI that has not received FDA approval for a specific indication or age group, most typically in consideration of side effect profile, or familial response to a specific medication, but should inform the patient and family that they are using a medication off-label.

The therapeutic response for SSRIs should be expected 4–6 weeks after a therapeutic dose has been reached. The starting dose for a child younger than 12 years old is generally half the starting dose for an adolescent. SSRIs are usually given once a day, in the morning with breakfast. One in ten individuals may experience sedation and prefer to take the medication at bedtime. Caution should be used in cases of known liver disease or chronic or severe illness where multiple medications may be prescribed, because all SSRIs are metabolized in the liver. In addition, caution should be used when prescribing for an individual with a family history of bipolar disorder, or when the differential diagnosis includes bipolar disorder, because antidepressants can induce manic or hypomanic symptoms.

Adverse effects of SSRIs are often dose-related and time-limited: gastrointestinal (GI) distress and nausea (can be minimized by taking medication with food), headache, tremulousness, decreased appetite, weight loss, insomnia, sedation (10%), and sexual dysfunction (25%). Irritability, social disinhibition, restlessness, and emotional excitability can occur in approximately 20% of children taking SSRIs. It is important to systematically monitor for side effects. SSRIs other than fluoxetine should be discontinued slowly to minimize withdrawal symptoms including flulike symptoms, dizziness, headaches, paresthesias, and emotional lability.

All SSRIs inhibit the efficiency of the hepatic microsomal enzyme system. The order of inhibition is: fluoxetine > fluvoxamine > paroxetine > sertraline > citalopram > escitalopram. This can lead to higher-than-expected blood levels of other drugs, including antidepressants, antiarrhythmics, antipsychotics, β-blockers, opioids, and antihistamines. Taking tryptophan while on an SSRI may result in a serotonergic syndrome of psychomotor agitation and GI distress. A potentially fatal interaction that clinically resembles neuroleptic malignant syndrome may occur when SSRIs are administered concomitantly with monoamine oxidase inhibitors. Fluoxetine has the longest half-life of the SSRIs and should not be initiated within 14 days of the discontinuation of a monoamine oxidase inhibitor, or a monoamine oxidase inhibitor initiated within at least 5 weeks of the discontinuation of fluoxetine. One should be cautious of fluoxetine and ibuprofen and other NSAIDs for concerns of GI bleeding.

B. Serotonin Norepinephrine Reuptake Inhibitors

Serotonin norepinephrine reuptake inhibitors (SNRIs), which include venlafaxine, duloxetine, desvenlafaxine, and milnacipran, are antidepressants that primarily inhibit reuptake of serotonin and norepinephrine. Desvenlafaxine is the major active metabolite of the antidepressant venlafaxine. It is approved for the treatment of major depression in adults. Contraindications for this class of medication include hypertension. The most common adverse effects are nausea, nervousness, and sweating. Hypertension is typically a dose-related response. SNRIs should be discontinued slowly to minimize withdrawal symptoms: including flulike symptoms, dizziness, headaches, paresthesias, and emotional lability.

C. Other Antidepressants

Bupropion is an antidepressant that inhibits reuptake of primarily serotonin, but also norepinephrine and dopamine. It is approved for treatment of major depression in adults. Like the SSRIs, bupropion has very few anticholinergic or cardiotoxic effects. The medication has three different formulations, and consideration for use is based on tolerability and compliance. Bupropion can interfere with sleep, so dosing earlier in the day is paramount to adherence and decreasing side effects. Contraindications of this medication include history of seizure disorder or bulimia nervosa. The most common adverse effects include psychomotor activation (agitation or restlessness), headache, GI distress, nausea, anorexia with weight loss, insomnia, tremulousness, precipitation of mania, and induction of seizures with doses above 450 mg/d.

Mirtazapine is an α₂-antagonist that enhances central noradrenergic and serotonergic activity. It is approved for the treatment of major depression in adults. Mirtazapine should not be given in combination with monoamine oxidase inhibitors. Very rare side effects are acute liver failure (1 case per 250,000–300,000), neutropenia, and agranulocytosis. More common adverse effects include dry mouth, increased appetite, constipation, weight gain, and increased sedation.

Tricyclic antidepressants (TCAs) are an older class of antidepressants, which include imipramine, desipramine, clomipramine, nortriptyline, and amitriptyline. With the introduction of the SSRIs and alternative antidepressants, use of the TCAs has become uncommon for the treatment of depression and anxiety disorders. The TCAs have more significant side-effect profiles and require more substantial medical monitoring, including the possibility of cardiac arrhythmias. Overdose can be lethal. For these reasons, in general, SSRIs or alternative antidepressants should be considered before recommending a TCA. In some countries, where access to newer and more costly medications is difficult, TCAs are still frequently employed for certain behavioral, emotional, and functional conditions. TCAs are still to treat individuals with medical and psychiatric issues, for example, chronic pain syndromes, migraines, headache, or enuresis as well as depression, anxiety, bulimia nervosa, OCD, and PTSD. Imipramine and desipramine are FDA approved for the treatment of major depression in adults and for enuresis in children age 6 years and older. Contraindications include known cardiac disease or arrhythmia, undiagnosed syncope, known seizure disorder, family history of sudden cardiac death or cardiomyopathy, and known electrolyte abnormality (with bingeing and purging). Initial medical screening includes taking a thorough family history for sudden cardiac death and the patient’s history for cardiac disease, arrhythmias, syncope, seizure disorder, or congenital hearing loss (associated with prolonged QT interval). Other screening procedures include serum electrolytes and blood urea nitrogen in patients who have eating disorders, cardiac examination, and a baseline ECG. Ongoing medical follow-up includes monitoring pulse and blood pressure (ie, screening for tachycardia and orthostatic hypotension) with each dosage increase, and obtaining an ECG to monitor for arteriovenous block with each dosage increase; after reaching steady state, record pulse, blood pressure, and ECG every 3–4 months. Note: TCAs may potentiate the effects of central nervous system depressants and stimulants; barbiturates and cigarette smoking may decrease plasma levels while phenothiazines, methylphenidate, and oral contraceptives may increase plasma levels. SSRIs given in combination with TCAs will result in higher TCA blood levels due to inhibition of TCA metabolism by liver enzymes (eg, cytochrome P-450 isoenzymes). Please refer to Table 7–20 on upper limits of cardiovascular parameters with tricyclic antidepressants.

 Prognosis

A comprehensive treatment intervention, including psychoeducation for the family, individual and family psychotherapy, medication assessment, and evaluation of school and home environments, often leads to complete remission of depressive symptoms over a 1- to 2-month period. If medications are started and prove effective, they should be continued for 6–12 months after remission of symptoms to prevent relapse. Early-onset depression (before age 15) is associated with increased risk of recurrent episodes and the potential need for longer-term treatment with antidepressants. Education of the family and child/or adolescent will help them identify depressive symptoms sooner and decrease the severity of future episodes with earlier interventions. Some studies suggest that up to 30% of preadolescents with major depression manifest bipolar disorder at 2-year follow-up. It is important to reassess the child or adolescent with depressive symptoms regularly for at least 6 months and to maintain awareness of the depressive episode in the course of well-child care.

Cheung AH et al: GLAD PC Steering Committee Expert survey for the management of adolescent depression in primary care. Pediatrics 2008 Jan;121(1):e101–e107 [PMID: 18166529].

Cheung AH et al: GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics 2007 Nov; 120(5):e1313–e1326. Erratum in: Pediatrics 2008 Jan; 121(1):227 [PMID: 17974724].

Cheung AH et al: Pediatric depressive disorders: management priorities in primary care. Curr Opin Pediatr 2008 Oct;20(5): 551–559 [Review] [PMID: 18781118].

http://www.thereachinstitute.org/files/documents/GLAD-PCToolkit.pdf.

Richardson L, McCauley E, Katon W: Collaborative care for adolescent depression: a pilot study. Gen Hosp Psychiatry 2009 Jan–Feb;31(1):36–45 [Epub 2008 Nov 18] [PMID: 19134509].

Richardson LP et al: Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics 2010 Dec;126(6):1117–1123 [Epub 2010 Nov 1] [PMID: 21041282].

The Guidelines for Adolescent Depression in Primary Care Toolkit: http://www.thereachinstitute.org/guidelines-for-adolescent-depression-in-primary-care-glad-pc.html.

US Preventive Services Task Force Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics 2009 Apr;123(4):1223–1228. Erratum in: Pediatrics. 2009 Jun;123(6):1611 [PMID: 19336383].

Williams SB et al: Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics 2009 Apr;123(4):e716–e735 [Review] [PMID: 19336361].

Zuckerbrot RA et al: GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007 Nov;120(5):e1299–e1312 [PMID: 17974723].

2. Bipolar Disorder

 ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

 Periods of abnormally and persistently elevated, expansive, or irritable mood, and heightened levels of energy and activity.

 Associated symptoms: grandiosity, diminished need for sleep, pressured speech, racing thoughts, impaired judgment.

 Not caused by prescribed or illicit drugs.

 General Considerations

Bipolar disorder (previously referred to as manic-depressive disorder) is an episodic mood disorder manifested by alternating periods of mania and major depressive episodes or, less commonly, manic episodes alone. Children and adolescents often exhibit a variable course of mood instability combined with aggressive behavior and impulsivity. At least 20% of bipolar adults experience onset of symptoms before age 20 years. Onset of bipolar disorder before puberty is uncommon; however, symptoms often begin to develop and may be initially diagnosed as ADHD or other disruptive behavior disorders. The lifetime prevalence of bipolar disorder in middle to late adolescence approaches 1%.

 Clinical Findings

In about 70% of patients, the first symptoms are primarily those of depression. In the remainder, manic, hypomanic, or mixed states dominate the presentation. Patients with mania display a variable pattern of elevated, expansive, or irritable mood along with rapid speech, high energy levels, difficulty in sustaining concentration, and a decreased need for sleep. The child or adolescent may also have hypersexual behavior, usually in the absence of a history or sexual abuse. It is critical to rule out abuse, or be aware of abuse factors contributing to the clinical presentation. Patients often do not acknowledge any problem with their mood or behavior. The clinical picture can be quite dramatic, with florid psychotic symptoms of delusions and hallucinations accompanying extreme hyperactivity and impulsivity. Other illnesses on the bipolar spectrum are bipolar type II, which is characterized by recurrent major depressive episodes alternating with hypomanic episodes (lower intensity manic episodes that do not cause social impairment and do not typically last as long as manic episodes) and cyclothymic disorder, which is diagnosed when the child or adolescent has had 1 year of hypomanic symptoms alternating with depressive symptoms that do not meet criteria for major depression.

It is also common for individuals diagnosed with bipolar spectrum disorders to have a history of inattention and hyperactivity problems in childhood, with some having a comorbid diagnosis of ADHD. While ADHD and bipolar disorder are highly comorbid, inattention and hyperactivity symptoms accompanied by mood swings can be an early sign of bipolar disorder before full criteria for the disorder have emerged and clustered together in a specific pattern.

 Differential Diagnosis

Differentiating ADHD, bipolar disorder, and major depressive disorder can be a challenge even for the seasoned clinician, and confusion about the validity of the disorder in younger children still exists. The situation is further complicated by the potential for the coexistence of ADHD and mood disorders in the same patient.

A history of the temporal course of symptoms can be most helpful. ADHD is typically a chronic disorder of lifelong duration. However, it may not be a problem until the patient enters the classroom setting. Mood disorders are typically characterized by a normal baseline followed by an acute onset of symptoms usually associated with acute sleep, appetite, and behavior changes. If inattentive, hyperactive, or impulsive behavior was not a problem a year ago, it is unlikely to be ADHD. Typically, all of these disorders are quite heritable, so a positive family history for other affected individuals can be informative in formulating a diagnosis. Successful treatment of relatives can offer guidance for appropriate treatment.

In prepubescent children, mania may be difficult to differentiate from ADHD and other disruptive behavior disorders. In both children and adolescents, preoccupation with violence, decreased need for sleep, impulsivity, poor judgment, intense and prolonged rages or dysphoria, hypersexuality, and some cycling of symptoms suggest bipolar disorder. Table 7–21 further defines points of differentiation between ADHD, conduct disorder, and bipolar disorder.

Physical or sexual abuse and exposure to domestic violence can also cause children to appear mood labile, hyperactive, and aggressive, and PTSD should be considered by reviewing the history for traumatic life events in children with these symptoms. Diagnostic considerations should also include substance abuse disorders, and an acute organic process, especially if the change in personality has been relatively sudden, or is accompanied by other neurologic changes. Individuals with manic psychosis may resemble those with schizophrenia. Psychotic symptoms associated with bipolar disorder should clear with resolution of the mood symptoms, which should also be prominent. Hyperthyroidism should be ruled out. The Young Mania Rating Scale and The Child Mania Rating Scale may be helpful in eliciting concerning symptoms and educating families and patients, and in aiding timely referral to local mental health resources. Please refer to treatment algorithm for bipolar mood disorder (Figure 7–4).

 Figure 7–4. Treatment algorithm for child and adolescents with bipolar mood disorder. (Reproduced with permission from Hilt R: Primary Care Principles for Child Mental Health, summer 2013. version 4.1).

 Complications

Children and adolescents with bipolar disorder are more likely to be inappropriate or aggressive toward peers and family members. Their symptoms almost always create significant interference with academic learning and peer relationships. The poor judgment associated with manic episodes predisposes individuals to dangerous, impulsive, and sometimes criminal activity. Legal difficulties can arise from impulsive acts, such as excessive spending, and acts of vandalism, theft, or aggression, that are associated with grandiose thoughts. Affective disorders are associated with a 30-fold greater incidence of successful suicide. Substance abuse may be a further complication, often representing an attempt at self-medication for the mood problem.

 Treatment

Most patients with bipolar disorder respond to pharmacotherapy with either mood stabilizers, such as lithium, or atypical antipsychotics. The recent data on the mood stabilizers carbamazepine and valproate have been less promising. Lithium, risperidone, aripiprazole, quetiapine, and olanzapine have all been approved by the FDA for the treatment of acute and mixed manic episodes in adolescents. In addition, lithium and aripiprazole have been approved for preventing recurrence. In cases of severe impairment, hospitalization is required to maintain safety and initiate treatment. Supportive psychotherapy for the patient and family and education about the recurrent nature of the illness are critical. Family therapy should also include improving skills for conflict management and appropriate expression of emotion.

Please refer to table listing common medication used in treating bipolar mood disorder (Table 7–22).

Specific Considerations: Medication for Treating Bipolar Mood Disorder

In addition to prescribing medications that have FDA approval for use in children with bipolar disorder (lithium and the atypical antipsychotic medications), providers may choose to use other medications off label after nonresponse to first-line treatment or side effect profiles. These medications include valproic acid, carbamazepine and oxcarbazepine, lamotrigine, topiramate, and gabapentin.

A. Lithium and Antiepileptics

Lithium remains a frontline drug in the treatment of bipolar disorder and has been shown to have an augmenting effect when combined with SSRIs for treatment-resistant depression and OCD. Lithium is contraindicated in patients with known renal, thyroid, or cardiac disease; those at high risk for dehydration and electrolyte imbalance (eg, vomiting and purging); and those who may become pregnant (teratogenic effects). Initial medical screening includes general medical screening with pulse, blood pressure, height, and weight; complete blood cell count (CBC); serum electrolytes, blood urea nitrogen, and creatinine; and thyroid function tests, including thyroid-stimulating hormone levels. For children the starting dose is usually 150 mg once or twice a day, with titration in 150- to 300-mg increments. Dose may vary with the brand of lithium used; consult a psychopharmacology textbook for medication-specific information. Oral doses of lithium should be titrated to maintain therapeutic blood levels of 0.8–1.2 mEq/L. The drug is generally given in two doses. Blood samples should be drawn 12 hours after the last dose (ie, trough).

Lithium has a narrow therapeutic index. Blood levels required for therapeutic effects are close to those associated with toxic symptoms. Mild toxicity may be indicated by increased tremor, GI distress, neuromuscular irritability, and altered mental status (confusion), and can occur when blood levels exceed 1.5 mEq/L. Moderate to severe symptoms of lithium toxicity are associated with blood levels above 2 mEq/L. Acute renal failure can occur at levels over 2.5–3 mEq/L. Given its low therapeutic index, a provider should be cautious in patients with a known overdose history or current risk. Lithium toxicity is a medical emergency and hemodialysis may be indicated for supertoxic levels.

Common side effects of lithium include intention tremor, GI distress (including nausea and vomiting and sometimes diarrhea), hypothyroidism, polyuria and polydipsia, drowsiness, malaise, weight gain, acne, and agranulocytosis. Individuals should maintain adequate hydration and excessive salt intake or salt restriction should be avoided. Thiazide diuretics and nonsteroidal anti-inflammatory agents (except aspirin and acetaminophen) can lead to increased lithium levels. Ibuprofen should be avoided by individuals who take lithium due to combined renal toxicity. Precautions against dehydration are required in hot weather and during vigorous exercise.

The ongoing monitoring of lithium includes measuring serum lithium levels 5–7 days following a change in dosage and then quarterly at steady state. In addition, serum creatinine and thyroid-stimulating hormone concentrations should be monitored every 3–4 months.

Valproate has FDA approval for the treatment of bipolar disorder in adults. Its efficacy in acute mania equals that of lithium, but it is generally better tolerated. Valproate is more effective than lithium in patients with rapid-cycling bipolar disorder (more than four cycles per year) and in patients with mixed states (coexisting symptoms of depression and mania). Valproate may be more effective than lithium in adolescents with bipolar disorder because they often have rapid cycling and mixed states.

The primary contraindication is known liver dysfunction. Initial medical screening consists of baseline CBC and liver function tests (LFTs). Ongoing monitoring includes checking LFTs monthly for 3–4 months; subsequently, LFTs, a CBC, and trough valproate levels should be obtained every 3–4 months.

The starting dose of valproate is usually 15 mg/kg/d. Doses are usually increased in increments of 5–10 mg/kg/d every 1–2 weeks to a range of 500–1500 mg/d in two or three divided doses. Trough levels in the range of 80–120 mg/mL are thought to be therapeutic.

Between 10% and 20% of patients on valproate experience sedation or anorexia, especially early in treatment or if the dose is increased too rapidly. GI upset occurs in 25% of patients, and when severe, can usually be treated with cimetidine. Increased appetite and weight gain can be troublesome for children and adolescents. Blurred vision, headache, hair loss, and tremor occur occasionally. Slight elevations in aminotransferases are frequent. Severe idiosyncratic hepatitis, pancreatitis, thrombocytopenia, and agranulocytosis occur only rarely.

Carbamazepine. Similar to lithium and valproate, carbamazepine may be effective for treating bipolar disorder or for the target symptoms of mood instability, irritability, or behavioral dyscontrol. Some data suggest that it is more effective than valproate for the depressive phases of bipolar disorder. A new form of carbamazepine—oxcarbazepine (Trileptal)—is also rarely being used for pediatric mood disorders; however, its efficacy has not been established. Reportedly, oxcarbazepine does not have the worrisome side effects of bone marrow suppression and liver enzyme induction. Blood levels cannot be monitored, and the dose range is similar to that of carbamazepine.

Both of these medications should be avoided in individuals with a history of previous bone marrow depression or adverse hematologic reaction to another drug; history of sensitivity to a TCA.

Initial medical screening includes getting a baseline CBC with platelets, reticulocytes, serum iron, and blood urea nitrogen; LFTs; urinalysis.

The drug is usually started at 10–20 mg/kg/d, in two divided doses, in children younger than 6 years; 100 mg twice daily in children aged 6–12 years; and 200 mg twice daily in children older than 12 years. Doses may be increased weekly until there is effective symptom control. Total daily doses should not exceed 35 mg/kg/d in children younger than 6 years; 1000 mg/d in children aged 6–15 years; and 1200 mg/d in adolescents older than 15 years. Plasma levels in the range of 4–12 mg/mL are thought to be therapeutic.

Some of the more common adverse effects include nausea, dizziness, sedation, headache, dry mouth, diplopia, and constipation, which reflect the drug’s mild anticholinergic properties. Rashes are more common with carbamazepine than with other mood stabilizers. Aplastic anemia and agranulocytosis are rare. Leukopenia and thrombocytopenia are more common, and if present, should be monitored closely for evidence of bone marrow depression. These effects usually occur early and transiently and then spontaneously revert toward normal. Liver enzyme induction may significantly change the efficacy of medications given concurrently.

Medical follow-up includes hematologic, hepatic, and renal parameters should be followed at least every 3 months for the first year. White blood cell counts (WBCs) below 3000/mL and absolute neutrophil counts below 1000/mL call for discontinuation of the drug and referral for hematology consultation.

Lamotrigine is approved for the treatment of bipolar depression in adults. The most concerning side effects of this medication are serious rashes that can require hospitalization and can include Stevens-Johnson syndrome (0.8% incidence). The starting dose is 25 mg, with a slow titration of increasing the dose by 25 mg/wk to a target dose (as clinically indicated) of 300 mg/d.

Gabapentin. Like valproate and carbamazepine, gabapentin is an anticonvulsant that has been used as a mood stabilizer in some adult populations. It may be used along with either valproate or carbamazepine in individuals with treatment-resistant disorders. The usual adult dose range for seizure disorders is 900–1800 mg/d in three divided doses and may need to be adjusted downward in individuals with renal impairment. Although its use among adolescents and even children is increasing, gabapentin is not approved for this indication, and reports of its efficacy remain largely anecdotal. Some reports suggest it may worsen behavioral parameters in children with underlying ADHD.

For additional information on mood stabilizer medications, please refer to section on psychotic disorders (ie, atypical antipsychotics and neuroleptics).

 Prognosis

It is not uncommon for the patient to need lifelong medication. In its adult form, bipolar disorder is an illness with a remitting course of alternating depressive and manic episodes. The time span between episodes can be years or months depending on the severity of illness and ability to comply with medication interventions. In childhood, the symptoms may be more pervasive and not fall into the intermittent episodic pattern until after puberty.

Chang K: Challenges in the diagnosis and treatment of pediatric bipolar depression. Dialogues Clin Neurosci 2009;11(1):73–80 [PMID: 19432389].

Cummings CM, Fristad MA: Pediatric bipolar disorder: recognition in primary care. Curr Opin Pediatr 2008 Oct;20(5): 560–565 [PMID: 18781119].

Demeter CA et al: Current research in child and adolescent bipolar disorder. Dialogues Clin Neurosci 2008;10(2):215–228 [PMID: 18689291].

Miklowitz DJ, Chang KD: Prevention of bipolar disorder in at-risk children: theoretical assumptions and empirical foundations. Dev Psychopathol 2008 Summer;20(3):881–897 [PMID: 18606036].

Miklowitz DJ et al: Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry 2008 Sep;65(9):1053–1061 [PMID: 18762591].

Youngstrom EA, Birmaher B, Findling RL: Pediatric bipolar disorder: validity, phenomenology, and recommendations for diagnosis. Bipolar Disord 2008 Feb;10(1 Pt 2):194–214 [PMID: 18199237].

The suicide rate in young people has remained high for several decades. In 2007, suicide was the third leading cause of death among children and adolescents aged 10–24 years in the United States. The suicide rate among adolescents aged 15–19 years quadrupled from approximately 2.7 to 11.3 per 100,000 since the 1960s. It is estimated that each year, approximately 2 million US adolescents attempt suicide, yet only 700,000 receive medical attention for their attempt. Suicide and homicide rates for children in the United States are two to five times higher than those for the other 25 industrialized countries combined, primarily due to the prevalence of firearms in the United States. For children younger than 10 years, the rate of completed suicide is low, but from 1980 to 1992, it increased by 120%, from 0.8 to 1.7 per 100,000.

Adolescent girls make three to four times as many suicide attempts as boys of the same age, but the number of completed suicides is three to four times greater in boys. Firearms are the most commonly used method in successful suicides, accounting for 40%–60% of cases; hanging, carbon monoxide poisoning, and drug overdoses each account for approximately 10%–15% of cases.

Suicide is almost always associated with a psychiatric disorder and should not be viewed as a philosophic choice about life or death or as a predictable response to overwhelming stress. Most commonly it is associated with a mood disorder and the hopelessness that accompanies a severe depressive episode. Suicide rates are higher for Native American and Native Alaskan populations than for white, black, and Latinos/Hispanic populations. Although suicide attempts are more common in individuals with a history of behavior problems and academic difficulties, other suicide victims are high achievers who are temperamentally anxious and perfectionistic and who commit suicide impulsively after a failure or rejection, either real or perceived. Mood disorders (in both sexes, but especially in females), substance abuse disorders (especially in males), and conduct disorders are commonly diagnosed at psychological autopsy in adolescent suicide victims. Some adolescent suicides reflect an underlying psychotic disorder, with the young person usually committing suicide in response to auditory hallucinations or psychotic delusions.

The vast majority of young people who attempt suicide give some clue to their distress or their tentative plans to commit suicide. Most show signs of dysphoric mood (anger, irritability, anxiety, or depression). Over 60% make comments such as “I wish I were dead” or “I just can’t deal with this any longer” within the 24 hours prior to death. In one study, nearly 70% of subjects experienced a crisis event such as a loss (eg, rejection by a girlfriend or boyfriend), a failure, or an arrest prior to completed suicide.

Assessment of Suicide Risk

Any clinical assessment for depression must include direct questions about suicidal ideation. If a child or adolescent expresses suicidal thinking, the treating provider must ask if he or she has an active plan, intends to complete that plan, and has made previous attempts. Suicidal ideation accompanied by any plan warrants immediate referral for a psychiatric crisis assessment. This can usually be accomplished at the nearest emergency department (ED).

Assessment of suicide risk calls for a high index of suspicion and a direct interview with the patient and his or her parents or guardians. The highest risk of suicide is among white, adolescent boys. High-risk factors include previous suicide attempts, a suicide note, and a viable plan for suicide with the availability of lethal means, close personal exposure to suicide, conduct disorder, and substance abuse. Other risk factors are signs and symptoms of major depression or dysthymia, a family history of suicide, a recent death in the family, and a view of death as a relief from the pain in the patient’s life.

Intervention

Suicidal ideation and any suicide attempt must be considered a serious matter. The patient should not be left alone, and the treating provider should express concern and convey a desire to help. The provider should meet with the patient and the family, both alone and together, and listen carefully to their problems and perceptions. It is helpful to explicitly state that with the assistance of mental health professionals, solutions can be found.

The majority of patients who express suicidal ideation and all who have made a suicide attempt should be referred for psychiatric evaluation and possible hospitalization. Most providers feel uncomfortable and have little experience in evaluating suicidality and risk. In addition, this evaluation frequently takes considerable time and requires contact with multiple informants for information gathering and treatment planning. The provider should err on the side of caution as referral for further assessment is always appropriate when there is concern about suicidal thinking and behavior.

An evaluation in a psychiatrist’s office or the ED will help determine level of risk and disposition. If the patient has suicidal ideation without a plan, has a therapist he or she can see the same or next day, is able to “contract for safety,” and the family is able to provide supervision and support, then the evaluating provider can consider sending the patient and family home that day from the office or ED without need for immediate hospitalization. If there appears to be potential for suicide as determined by suicidal ideation with a plan, there are no available resources for therapy, and the patient is not able to cooperate with a plan to ensure safety; if the patient is severely depressed or intoxicated; if the family does not appear to be appropriately concerned; or if there are practical limitations on providing supervision and support to ensure safety, the individual should be hospitalized on an inpatient psychiatric unit. Any decision to send the patient home from the ED without hospitalization should be made only after consultation with a mental health professional. The decision should be based on lessening of the risk of suicide and assurance of the family’s ability to follow through with outpatient therapy and provide appropriate support and supervision. As part of safety planning for discharge, guns, knives, and razor blades should be removed from the home, and, to the extent possible, access to them outside the home should be prohibited. Medications and over-the-counter drugs should be kept locked in a safe place with all efforts made to minimize the risk of the patient having access (eg, key kept with a parent, or use of combination lock on the medicine chest). The patient should be restricted from driving for at least the first 24 hours and likely longer to lessen the chance of impulsive motor vehicle crashes. Instructions and phone numbers for crisis services should be given, and the family must be committed to a plan for mental health treatment.

Suicide prevention efforts include heightened awareness in the community and schools to promote identification of at-risk individuals and increasing access to services, including hotlines and counseling services. Restricting young people’s access to firearms is also a critical factor, as firearms are responsible for 85% of deaths due to suicide or homicide in youth in the United States.

Finally, the treating provider should be aware of his or her own emotional reactions to dealing with suicidal adolescents and their families. Because the assessment can require considerable time and energy, the provider should be on guard against becoming tired, irritable, or angry. Although understandable, provider fears about precipitating suicide by direct and frank discussions of suicidal risk are unfounded. Reviewing difficult cases with colleagues, developing formal or informal relationships with psychiatrists, and attending workshops on assessment and management of depression and suicidal ideation can decrease the anxiety and improve competence for primary care providers.

Bursztein C, Apter A: Adolescent suicide. Curr Opin Psychiatry 2009 Jan;22(1):1–6 [PMID: 19122527].

Carballo JJ et al: The role of the pediatrician in preventing suicide in adolescents with alcohol use disorders. Int J Adolesc Med Health 2007 Jan–Mar;19(1):61–65 [PMID: 17458325].

Dervic K, Brent DA, Oquendo MA: Completed suicide in childhood. Psychiatr Clin North Am 2008 Jun;31(2):271–291 [PMID: 18439449].

Dudley M et al: New-generation antidepressants, suicide and depressed adolescents: how should clinicians respond to changing evidence? Aust N Z J Psychiatry 2008 Jun;42(6):456–466 [PMID: 18465372].

Gardner W et al: Screening, triage, and referral of patients who report suicidal thought during a primary care visit. Pediatrics 2010 May;125(5):945–952 [Epub 2010 Apr 12] [PMID: 20385642].

Goldstein TR: Suicidality in pediatric bipolar disorder. Child Adolesc Psychiatr Clin N Am 2009 Apr;18(2):339–352, viii [PMID: 19264267].

Greydanus D, Patel D, Pratt H: Suicide risk in adolescents with chronic illness: implications for primary care and specialty pediatric practice: a review. Dev Med Child Neurol 2010 Dec;52(12):1083–1087 [Epub 2010 Aug 31] [PMID: 20813018].

Kim YS, Leventhal B: Bullying and suicide. Int J Adolesc Med Health 2008 Apr–Jun;20(2):133–154 [PMID: 18714552].

Prager LM: Depression and suicide in children and adolescents. Pediatr Rev 2009 Jun;30(6):199–205; quiz 206 [PMID: 19487428].

Steele MM, Doey T: Suicidal behaviour in children and adolescents. Part 1: Etiology and risk factors. Can J Psychiatry 2007 Jun;52(6 Suppl 1):S21–S33 [PMID: 17824350].

Steele MM, Doey T: Suicidal behaviour in children and adolescents. Part 2: Treatment and prevention. Can J Psychiatry 2007 Jun;52(6 Suppl 1):S35–S45 [PMID: 17824351].

Wintersteen MB, Diamond GS, Fein JA: Screening for suicide risk in the pediatric emergency and acute care setting. Curr Opin Pediatr 2007 Aug;19(4):398–404 [PMID: 17630602].

 ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

 A persistent pattern of behavior that includes the following:

• Defiance of authority.

• Violating the rights of others or society’s norms.

• Aggressive behavior toward persons, animals, or property.

 General Considerations

Disorders of conduct affect approximately 9% of males and 2% of females younger than 18 years. This is a very heterogeneous population, and overlap occurs with ADHD, substance abuse, learning disabilities, neuropsychiatric disorders, mood disorders, and family dysfunction. Many of these individuals come from homes where domestic violence, child abuse, drug abuse, shifting parental figures, and poverty are environmental risk factors. Although social learning partly explains this correlation, the genetic heritability of aggressive conduct and antisocial behaviors is currently under investigation.

 Clinical Findings

The typical child with conduct disorder is a boy with a turbulent home life and academic difficulties. Defiance of authority, fighting, tantrums, running away, school failure, and destruction of property are common symptoms. With increasing age, fire-setting and theft may occur, followed in adolescence by truancy, vandalism, and substance abuse. Sexual promiscuity, sexual perpetration, and other criminal behaviors may develop. Hyperactive, aggressive, and uncooperative behavior patterns in the preschool and early school years tend to predict conduct disorder in adolescence with a high degree of accuracy, especially when ADHD goes untreated. A history of reactive attachment disorder is an additional childhood risk factor. The risk for conduct disorder increases with inconsistent and severe parental disciplinary techniques, parental alcoholism, and parental antisocial behavior.

 Differential Diagnosis

Young people with conduct disorders, especially those with more violent histories, have an increased incidence of neurologic signs and symptoms, psychomotor seizures, psychotic symptoms, mood disorders, ADHD, and learning disabilities. Efforts should be made to identify these associated disorders because they may suggest specific therapeutic interventions. Conduct disorder is best conceptualized as a final common pathway emerging from a variety of underlying psychosocial, genetic, environmental, and neuropsychiatric conditions.

 Treatment

Effective treatment can be complicated by the psychosocial problems often found in the lives of children and adolescents with conduct disorders, with related difficulty achieving compliance with treatment recommendations. Efforts should be made to stabilize the environment and improve functioning within the home, particularly as it relates to parental functioning and disciplinary techniques. Identification of learning disabilities and placement in an optimal school environment is also critical. Any associated neurologic and psychiatric disorders should be addressed.

Residential treatment may be necessary for individuals whose symptoms do not respond to lower level interventions, or whose environment is not able to meet their needs for supervision and structure. Juvenile justice system involvement is common in cases where conduct disorder behaviors lead to illegal activities, theft, or assault.

Medications such as mood stabilizers, neuroleptics, stimulants, and antidepressants have all been studied in youth with conduct disorders, yet none has been found to be consistently effective in this population. Refer to the treatment algorithm (Figure 7–5) and list of suggested medication for additional information (Table 7–23). Early involvement in programs such as Big Brothers, Big Sisters, scouts, and team sports in which consistent adult mentors and role models interact with youth decreases the chances that the youth with conduct disorders will develop antisocial personality disorder. Multisystemic therapy (MST) is being used increasingly as an intervention for youth with conduct disorders and involvement with the legal system. Multisystemic therapy is an intensive home-based model of care that seeks to stabilize and improve the home environment and to strengthen the support system and coping skills of the individual and family.

 Figure 7–5. Treatment algorithm for disruptive behavior and aggression in children and adolescents. (Reproduced with permission from Hilt R: Primary Care Principles for Child Mental Health, summer 2013. version 4.1).

 Prognosis

The prognosis is based on the ability of the child’s support system to mount an effective treatment intervention consistently over time. The prognosis is generally worse for children in whom the disorder presents before age 10 years; those who display a diversity of antisocial behaviors across multiple settings; and those who are raised in an environment characterized by parental antisocial behavior, alcoholism or other substance abuse, and conflict. Nearly half of individuals with a childhood diagnosis of conduct disorder develop antisocial personality disorder as adults.

1. Oppositional Defiant Disorder

 ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

 A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months.

 Loses temper, argues with adults, defies rules.

 Blames others for own mistakes and misbehavior.

 Angry, easily annoyed, vindictive.

 Does not meet criteria for conduct disorder.

Oppositional defiant disorder usually is evident before 8 years of age and may be an antecedent to the development of conduct disorder. The symptoms usually first emerge at home, but then extend to school and peer relationships. The disruptive behaviors of oppositional defiant disorder are generally less severe than those associated with conduct disorder and do not include hurting other individuals or animals, destruction of property, or theft.

Oppositional defiant disorder is more common in families where caregiver dysfunction (eg, substance abuse, parental psychopathology, significant psychosocial stress) is present. It is also more prevalent in children with a history of multiple changes in caregivers, inconsistent, harsh, or neglectful parenting, or serious marital discord.

Interventions include careful assessment of the psychosocial situation and recommendations to support parenting skills and optimal caregiver functioning. Assessment for comorbid psychiatric diagnoses such as learning disabilities, depression, and ADHD should be pursued and appropriate interventions recommended.

2. Aggression & Violent Behavior in Youth

The tragic increase in teenage violence, including school shootings, is of particular concern to health professionals, as well as to society at large. There is strong evidence that screening and initiation of interventions by primary care providers can make a significant difference in violent behavior in youth. Although the prediction of violent behavior remains a difficult and imprecise endeavor, providers can support and encourage several important prevention efforts.

The vast majority of the increase in youth violence including suicides and homicides involves the use of firearms. Thus, the presence of firearms in the home, the method of storage and safety measures taken when present, and access to firearms outside the home should be explored regularly with all adolescents as part of their routine medical care.

It is important to note that violent behavior is often associated with suicidal impulses. In the process of screening for violent behavior, suicidal ideation should not be overlooked. Any comment about wishes to be dead or hopelessness should be taken seriously and assessed immediately.

Interventions for parents include encouraging parents and guardians to be aware of their child’s school attendance and performance. Parents should be encouraged to take an active role and learn about their children’s friends, be aware of who they are going out with, where they will be, what they will be doing, and when they will be home. Most students involved in school violence might have been identified earlier and potentially may have benefited from interventions to address problems in social and educational functioning in the school environment. Communities and school districts nationwide have increased their efforts to identify and intervene with students whom teachers, peers, or parents recognize as having difficulty.

Threats & Warning Signs Requiring Immediate Consultation

Any and all threats that children make can be alarming. However, it is important to be aware of some of the more serious and potentially lethal threats. These threats should be taken with the utmost seriousness and parents/guardians should see a mental health provider immediately. Such threats include threats/warnings about hurting or killing someone or oneself, threats to run away from home and/or threats to damage or destroy property.

Factors Associated With Increased Risk of Violent and/or Dangerous Behavior

Not all threats signify imminent danger, and there are several factors to consider when assessing the dangers of a child or adolescent. A past history of violence or aggressive behavior, including uncontrollable angry outbursts, access to guns or other weapons, history of getting caught with a weapon in school and family history of violent behaviors are likely predictors of future violent behavior. In addition, children who witness abuse and violence at home and/or have a preoccupation with themes and acts of violence (eg, TV shows, movies, music, violent video games, etc.) are also at high risk of such behavior. Victims of abuse (ie, physical, sexual, and/or emotional) are more susceptible to feeling shame, loss, and rejection. The difficulty of dealing with abuse can further exacerbate an underlying mood, anxiety, or conduct disorder. Children who have been abused are more likely to be perpetrators of bullying and engage in verbal and physical intimidation toward peers. They also may be much more prone to blame others and are unwilling to accept responsibility for their own actions. Substance use is another major factor frequently associated with violent, aggressive, and/or dangerous behavior, particularly because it impacts judgment and is often associated with decreased inhibition and increased impulsivity. Socially isolated children also carry a high risk for violent and dangerous behavior. These include children with little to no adult supervision, poor connection with peers, and little to no involvement in extracurricular activities. These individuals may be more likely to seek out deviant peer groups for a sense of belonging.

How Providers and Parents Can Respond to Concerns of Violence and/or Dangerous Behavior

If a provider or parent suspects that a child is at risk for violent and/or dangerous behavior, the most important intervention is to talk with the child immediately about alleged threat and/or behavior. One should consider the child’s past behavior, personality, and current stressors when evaluating the seriousness and likelihood of them engaging in a destructive or dangerous behavior. If the child already has a mental health provider, he/she should be contacted immediately. If they are not reachable, the parent(s)/guardian(s) should take the child to the closest ED for a crisis evaluation. It is always acceptable to contact local police for assistance, especially if harm to others is suspected. Another indication that warrants a crisis evaluation is if a child refuses to talk, is argumentative, responds defensively, or continues to express violent or dangerous thoughts/plans. Continuous, face-to-face adult supervision is essential while awaiting professional intervention. After evaluation, it is imperative to follow up with recommendations from mental health provider(s) to ensure safety and ongoing management.

Barker ED, Maughan B: Differentiating early-onset persistent versus childhood-limited conduct problem youth. Am J Psychiatry 2009 Aug;166(8):900–908 [Epub 2009 Jul 1] [PMID: 19570930].

Boylan K et al: Comorbidity of internalizing disorders in children with oppositional defiant disorder. Eur Child Adolesc Psychiatry 2007 Dec;16(8):484–494 [Epub 2007 Sep 24] [PMID: 17896121].

Dretzke J et al: The effectiveness and cost-effectiveness of parent training/education programmes for the treatment of conduct disorder, including oppositional defiant disorder, in children. Health Technol Assess 2005 Dec;9(50):iii, ix–x, 1–233 [PMID: 16336845].

Eyberg SM, Nelson MM, Boggs SR: Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. J Clin Child Adolesc Psychol 2008 Jan;37(1):215–237 [PMID: 18444059].

Fazel S, Doll H, Långström N: Mental disorders among adolescents in juvenile detention and correctional facilities: a systematic review and metaregression analysis of 25 surveys. J Am Acad Child Adolesc Psychiatry 2008 Sep;47(9):1010–1019 [PMID: 18664994].

From AACAP Facts For Families: http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Childrens_Threats_When_Are_They_Serious_65.aspx.

Hamilton SS, Armando J: Oppositional defiant disorder. Am Fam Physician 2008 Oct 1;78(7):861–866 [PMID: 18841736].

Henggeler SW et al: Mediators of change for multisystemic therapy with juvenile sexual offenders. J Consult Clin Psychol 2009 Jun;77(3):451–462 [PMID: 19485587].

Jensen PS: The role of psychosocial therapies in managing aggression in children and adolescents. J Clin Psychiatry 2008; 69(Suppl 4):37–42 [PMID: 18533767].

Loeber R, Burke J, Pardini DA: Perspectives on oppositional defiant disorder, conduct disorder, and psychopathic features. J Child Psychol Psychiatry 2009 Jan;50(1–2):13342 [PMID: 19220596].

Moffitt TE et al: DSM-V conduct disorder: research needs for an evidence base. J Child Psychol Psychiatry 2008 Jan;49(1):3–33 [PMID: 18181878].

Ogden T, Amlund HK: What works for whom? Gender differences in intake characteristics and treatment outcomes following Multisystemic Therapy. J Adolesc 2009 Dec;32(6): 1425–1435 [PMID: 19619894].

Turgay A: Psychopharmacological treatment of oppositional defiant disorder. CNS Drugs 2009;23(1):1–17 [PMID: 19062772].

 ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

 A symptom suggesting physical dysfunction.

 No physical disorder accounting for the symptom.

 Symptoms causing distress, dysfunction, or both.

 Symptoms not voluntarily created or maintained, as in malingering.

 Clinical Findings

Hypochondriasis, somatization, and conversion disorders involve an unhealthy overemphasis and preoccupation with somatic experiences and symptoms. Somatoform disorders are defined by the presence of physical illness or disability for which no organic cause can be identified, although neither the patient nor the caregiver is consciously fabricating the symptoms. The category includes body dysmorphic disorder, conversion disorder, hypochondriasis, somatization disorder, and somatoform pain disorder (Table 7–24).

Conversion symptoms most often occur in school-aged children and adolescents. The exact incidence is unclear, but in pediatric practice they are probably seen more often as transient symptoms than as chronic disorders requiring help from mental health practitioners. A conversion symptom is thought to be an expression of underlying psychological conflict. The specific symptom may be symbolically determined by the underlying conflict; the symptom may resolve the dilemma created by the underlying wish or fear (eg, a seemingly paralyzed child need not fear expressing his or her underlying rage or aggressive retaliatory impulses). Although children can present with a variety of symptoms, the most common include neurologic and gastrointestinal complaints. Children with conversion disorder may be surprisingly unconcerned about the substantial disability deriving from their symptoms. Symptoms include unusual sensory phenomena, paralysis, vomiting, abdominal pain, intractable headaches, and movement or seizure-like disorders.

In the classic case of conversion disorder, the child’s symptoms and examination findings are not consistent with the clinical manifestations of any organic disease process. The physical symptoms often begin within the context of a family experiencing stress, such as serious illness, a death, or family discord. On closer examination, the child’s symptoms are often found to resemble symptoms present in other family members. Children with conversion disorder may have some secondary gain associated with their symptoms. Several reports have pointed to the increased association of conversion disorder with sexual overstimulation or sexual abuse. As with other emotional and behavioral problems, healthcare providers should always screen for physical and sexual abuse.

 Differential Diagnosis

It is sometimes not possible to rule out medical disease as a source of the symptoms. Medical follow-up is required to monitor for changes in symptoms and response to recommended interventions.

Somatic symptoms are often associated with anxiety and depressive disorders (see Tables 7–7 and 7–11). Occasionally, psychotic children have somatic preoccupations and even somatic delusions.

 Treatment

In most cases, conversion symptoms resolve quickly when the child and family are reassured that the symptom is a way of reacting to stress. The child is encouraged to continue with normal daily activities, knowing that the symptom will abate when the stress is resolved. Treatment of conversion disorders includes acknowledging the symptom rather than telling the child that the symptom is not medically justified and responding with noninvasive interventions such as physical therapy while continuing to encourage normalization of the symptoms. If the symptom does not resolve with reassurance, further investigation by a mental health professional is indicated. Comorbid diagnoses such as depression and anxiety disorders should be addressed, and treatment with psychopharmacologic agents may be helpful.

Somatoform disorder is not associated with the increased morbidity and mortality associated with other psychiatric disorders such as mood disorders or psychotic illness. Somatoform patients are best treated with regular, short, scheduled medical appointments to address the complaints at hand. In this way they do not need to precipitate emergencies to elicit medical attention. The medical provider should avoid invasive procedures unless clearly indicated and offer sincere concern and reassurance. The provider should also avoid telling the patient “it’s all in your head” and should not abandon or avoid the patient, as somatoform patients are at great risk of seeking multiple alternative treatment providers and potentially unnecessary treatments.

 Prognosis

Patients presenting with somatoform disorders are often resistant to mental health treatment, in part fearing that any distraction from their vigilance will put them at greater risk of succumbing to a medical illness. Psychiatric consultation is often helpful, and for severely incapacitated patients, referral psychiatric consultation is always indicated.

Andresen JM et al: Physical symptoms and psychosocial correlates of somatization in pediatric primary care. Clin Pediatr (Phila) 2011 Oct;50(10):904–909 [PMID: 21576182].

Campo JV et al: Physical and emotional health of mothers of youth with functional abdominal pain. Arch Pediatr Adolesc Med 2007 Feb;161(2):131–137 [PMID: 17283297].

Ginsburg GS, Riddle MA, Davies M: Somatic symptoms in children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 2006 Oct;45(10):1179–1187 [PMID: 17003663].

Goldbeck L, Bundschuh S: Illness perception in pediatric somatization and asthma: complaints and health locus of control beliefs. Child Adolesc Psychiatry Ment Health 2007 Jul 16;1(1): 5 [PMID: 17678524].

Kozlowska K et al: A conceptual model and practice framework for managing chronic pain in children and adolescents. Harv Rev Psychiatry 2008;16(2):136–150 [PMID: 18415885].

Kozlowska K et al: Conversion disorder in Australian pediatric practice. J Am Acad Child Adolesc Psychiatry 2007 Jan;46(1): 68–75 [PMID: 17195731].

Masia WC et al: CBT for anxiety and associated somatic complaints in pediatric medical settings: an open pilot study. J Clin Psychol Med Settings 2009 Jun;16(2):169–177 [PMID: 19152057].

Mulvaney S et al: Trajectories of symptoms and impairment for pediatric patients with functional abdominal pain: a 5-year longitudinal study. J Am Acad Child Adolesc Psychiatry 2006 Jun;45(6):737–744 [PMID: 16721324].

Plioplys S et al: Multidisciplinary management of pediatric non-epileptic seizures. J Am Acad Child Adolesc Psychiatry 2007 Nov;46(11):1491–1495 [PMID: 18049299].

Seshia SS, Phillips DF, von Baeyer CL: Childhood chronic daily headache: a biopsychosocial perspective. Dev Med Child Neurol 2008 Jul;50(7):541–545 [PMID: 18611206].

Walker LS et al: Appraisal and coping with daily stressors by pediatric patients with chronic abdominal pain. J Pediatr Psychol 2007 Mar;32(2):206–216 [PMID: 16717138].

The most common and most disturbing stressors in the lives of children and adolescents are the death of a loved one, marital discord, separation and divorce, family illness, a change of residence or school setting, experiencing a traumatic event, and, for adolescents, peer-relationship problems. When faced with stress, children can experience many different symptoms, including changes in mood, changes in behavior, anxiety symptoms, and physical complaints. Key findings for the diagnosis of an adjustment disorder include the following:

• The precipitating event or circumstance is identifiable.

• The symptoms have appeared within 3 months after the occurrence of the stressful event.

• Although the child experiences distress or some functional impairment, the reaction is not severe or disabling.

• The reaction does not persist more than 6 months after the stressor has terminated.

 Differential Diagnosis

When symptoms emerge in reaction to an identifiable stressor but are severe, persistent, or disabling, depressive disorder, anxiety disorder, and conduct disorders must be considered.

 Treatment

The mainstay of treatment involves genuine empathy and assurance to the parents and the patient that the emotional or behavioral change is a predictable consequence of the stressful event. This validates the child’s reaction and encourages the child to talk about the stressful occurrence and its aftermath. Parents are encouraged to help the child with appropriate expression of feelings, while defining boundaries for behavior that prevent the child from feeling out of control and ensure safety of self and others. Maintaining or reestablishing routines can also alleviate distress and help children and adolescents adjust to changing circumstances by increasing predictability and decreasing distress about the unknown.

 Prognosis

The duration of symptoms in adjustment reactions depends on the severity of the stress; the child’s personal sensitivity to stress and vulnerability to anxiety, depression, and other psychiatric disorders; and the available support system.

The incidence of schizophrenia is about 1 per 10,000 per year. The onset of schizophrenia is typically between the middle to late teenage and early thirties, with onset before puberty being relatively rare. Symptoms usually begin after puberty, although a full “psychotic break” may not occur until the young adult years. Childhood onset (before puberty) of psychotic symptoms due to schizophrenia is uncommon and usually indicates a more severe form of the spectrum of schizophrenic disorders. Childhood-onset schizophrenia is more likely to be found in boys.

Schizophrenia is a biologically based disease with a strong genetic component. Other psychotic disorders that may be encountered in childhood or adolescence include schizoaffective disorder and psychosis not otherwise specified (psychosis NOS). Psychosis NOS may be used as a differential diagnosis when psychotic symptoms are present, but the cluster of symptoms is not consistent with a schizophrenia diagnosis.

 ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

 Delusional thoughts.

 Disorganized speech (rambling or illogical speech patterns).

 Disorganized or bizarre behavior.

 Hallucinations (auditory, visual, tactile, olfactory).

 Paranoia, ideas of reference.

 Negative symptoms (ie, flat affect, avolition, alogia).

 Clinical Findings

Children and adolescents display many of the symptoms of adult schizophrenia. Hallucinations or delusions, bizarre and morbid thought content, and rambling and illogical speech are typical. Affected individuals tend to withdraw into an internal world of fantasy and may then equate fantasy with external reality. They generally have difficulty with schoolwork and with family and peer relationships. Adolescents may have a prodromal period of depression prior to the onset of psychotic symptoms. The majority of patients with childhood-onset schizophrenia have had nonspecific psychiatric symptoms or symptoms of delayed development for months or years prior to the onset of their overtly psychotic symptoms.

 Differential Diagnosis

Obtaining the family history of mental illness is critical when assessing children and adolescents with psychotic symptoms. Psychological testing, particularly the use of projective measures, is often helpful in identifying or ruling out psychotic thought processes. Psychotic symptoms in children younger than age 8 years must be differentiated from manifestations of normal vivid fantasy life or abuse-related symptoms. Children with psychotic disorders often have learning disabilities and attention difficulties in addition to disorganized thoughts, delusions, and hallucinations. In psychotic adolescents, mania is differentiated by high levels of energy, excitement, and irritability. Any child or adolescent exhibiting new psychotic symptoms requires a medical evaluation that includes physical and neurologic examinations (including consideration of magnetic resonance imaging and electroencephalogram), drug screening, and metabolic screening for endocrinopathies, Wilson disease, and delirium.

 Treatment

The treatment of childhood and adolescent schizophrenia focuses on four main areas: (1) decreasing active psychotic symptoms, (2) supporting development of social and cognitive skills, (3) reducing the risk of relapse of psychotic symptoms, and (4) providing support and education to parents and family members. Antipsychotic medications (neuroleptics) are the primary psychopharmacologic intervention. In addition, a supportive, reality-oriented focus in relationships can help to reduce hallucinations, delusions, and frightening thoughts. A special school or day treatment environment may be necessary, depending on the child’s or adolescent’s ability to tolerate the school day and classroom activities. Support for the family emphasizes the importance of clear, focused communication and an emotionally calm climate in preventing recurrences of overtly psychotic symptoms.

The antipsychotics, formerly known as neuroleptics, are indicated for psychotic symptoms in patients with schizophrenia. They are also used for acute mania and as adjuncts to antidepressants in the treatment of psychotic depression (with delusions or hallucinations). The antipsychotics may be used cautiously in refractory PTSD, in refractory OCD, and in individuals with markedly aggressive behavioral problems unresponsive to other interventions. They may also be useful for the body image distortion and irrational fears about food and weight gain associated with anorexia nervosa.

The “atypical antipsychotics” differ from conventional antipsychotics in their receptor specificity and effect on serotonin receptors. Conventional antipsychotics are associated with a higher incidence of movement disorders and extrapyramidal symptoms (EPS) due to their wider effect on dopamine receptors. The introduction of the atypical antipsychotics has significantly changed neuroleptic prescribing patterns. The atypical antipsychotics have a better side-effect profile for most individuals and comparable efficacy for the treatment of psychotic symptoms and aggression. Atypical antipsychotics have a decreased incidence of EPS and tardive dyskinesia (TD). Significant side effects can include substantial weight gain and sedation. Because of their increased use over conventional antipsychotics, this section focuses primarily on the atypical antipsychotics.

The following adverse effects of antipsychotics apply to both typical and atypical antipsychotics, but are thought to have a significantly lower incidence with the atypical antipsychotics.

1. Initial medical screening—Providers should obtain baseline height, weight, and waist circumference observe and examine for tremors and other abnormal involuntary movements and establish baseline values for CBC and LFTs, lipid profile and cholesterol. Obtain an ECG if there is a history of cardiac disease or arrhythmia, and to establish a baseline QT interval (cardiac repolarization) prior to initiation of the antipsychotics that have a greater effect on the QT interval (eg, ziprasidone and thioridazine). Antipsychotics can cause QT prolongation leading to ventricular arrhythmias, such as torsades de pointes. Medications that affect the cytochrome P-450 isoenzyme pathway (including SSRIs) may increase the neuroleptic plasma concentration and increase risk of QTc prolongation.

2. Adverse effects—The most troublesome adverse effects of the atypical antipsychotics are cognitive slowing, sedation, orthostasis, and weight gain. The conventional antipsychotics have an increased incidence of EPS and TD. Sedation, cognitive slowing, and EPS all tend to be dose-related. Because of the risk of side effects, neuroleptic medications should be used with caution and monitored regularly. The risk-benefit ratio of the medication for the identified target symptom should be carefully considered and reviewed with the parent or guardian.

A. WEIGHT GAIN, HYPERGLYCEMIA, HYPERLIPIDEMIA, AND DIABETES MELLITUS—In postmarketing clinical use, there have been significant reports of weight gain, hyperglycemia, and diabetes mellitus. This led to a consensus statement by concerned professional societies about how best to monitor and manage these significant side effects. Table 7–25 presents the currently recommended monitoring calendar. Baseline and ongoing evaluations of significant markers are considered standard clinical practice.

B. EXTRAPYRAMIDAL SIDE EFFECTS—EPS and acute dystonic reactions are tonic muscle spasms, often of the tongue, jaw, or neck. EPS symptoms can be mildly uncomfortable or may result in such dramatically distressing symptoms as oculogyric crisis, torticollis, and even opisthotonos. Onset is usually within days after a dosage change and symptoms may occur in up to 25% of children treated with conventional antipsychotics. Acute neuroleptic-induced dystonias are quickly relieved by anticholinergics such as benztropine (Cogentin) and diphenhydramine.

C. TARDIVE DYSKINESIAS—Tardive dyskinesias (TDs) are involuntary movement disorders that are often irreversible and may appear after long-term use of neuroleptic medications. Choreoathetoid movements of the tongue and mouth are most common, but the extremities and trunk may also be involved. The risk of TD is small in patients on atypical antipsychotics, and those on conventional antipsychotics for less than 6 months. There is no universally effective treatment.

D. PSEUDOPARKINSONISM—Pseudoparkinsonism is usually manifested 1–4 weeks after the start of treatment. It presents as muscle stiffness, cogwheel rigidity, masklike facial expression, bradykinesia, drooling, and occasionally pill-rolling tremor. Anticholinergic medications or dosage reductions are helpful.

E. AKATHISIA—Akathisia is usually manifested after 1–6 weeks of treatment. It presents as an unpleasant feeling of driven motor restlessness that ranges from vague muscular discomfort to a markedly dysphoric agitation with frantic pacing. Anticholinergic agents or β-blockers are sometimes helpful.

F. NEUROLEPTIC MALIGNANT SYNDROME—Neuroleptic malignant syndrome is a very rare medical emergency associated primarily with the conventional antipsychotics, although it has also been reported with atypical antipsychotics. It is manifested by severe muscular rigidity, mental status changes, fever, autonomic lability, and myoglobinemia. Neuroleptic malignant syndrome can occur without muscle rigidity in patients taking atypical antipsychotics and should be considered in the differential diagnosis of any patient on antipsychotics who presents with high fever and altered mental status. Mortality as high as 30% has been reported. Treatment includes immediate medical assessment and withdrawal of the neuroleptic and may require transfer to an intensive care unit.

G. WITHDRAWAL DYSKINESIAS—Withdrawal dyskinesias are reversible movement disorders that appear following withdrawal of neuroleptic medications. Dyskinetic movements develop within 1–4 weeks after withdrawal of the drug and may persist for months.

H. OTHER ADVERSE EFFECTS—These include cardiac arrhythmias, irregular menses, gynecomastia, and galactorrhea due to increased prolactin, sexual dysfunction, photosensitivity, rashes, lowered seizure threshold, hepatic dysfunction, and blood dyscrasias.

3. Drug interactions—Potentiation of central nervous system depressant effects or the anticholinergic effects of other drugs may occur, as well as increased plasma levels of antidepressants.

4. Medical follow-up—The patient should be examined at least every 3 months for signs of the side effects listed. An Abnormal Involuntary Movement Scale can be used to monitor for TD in patients taking antipsychotics. Most antipsychotic treatments seem to be associated with relevant weight gain, which increases the risk of the development of metabolic syndrome and future cardiovascular morbidity and mortality. New recommendations include quarterly monitoring of blood pressure, weight gain, abdominal circumference, dietary and exercise habits, and, if indicated, fasting blood glucose and lipid panels. In cases of significant weight gain or abnormal laboratory values, patients should either be switched to an agent with a decreased risk for these adverse events or should receive additional treatments to reduce specific adverse events in cases in which discontinuation of the offending agent is clinically contraindicated or unfeasible.

A. Atypical Antipsychotics

Aripiprazole (Abilify), a partial dopamine blocker and a serotonin agonist, has FDA approval for treating acute mania or mixed mania use in children and adolescents with bipolar I disorder. (see Table 7–18 for other indications). It also has approval for maintenance therapy in adults. Side effects include nausea and vomiting and fatigue. It is associated with less weight gain than other atypical antipsychotic medications, although for some individuals, weight gain from treatment with aripiprazole can still be substantial. Doses over 30 mg are more likely to be associated with EPS. The dose range is 5–30 mg, and pills can be split.

Olanzapine (Zyprexa) is FDA approved as a second-line treatment for mania and mixed mania in adolescents with bipolar I disorder. This is due to the increased risk of weight gain and hyperlipidemia with olanzapine. It has greater affinity for type 2 serotonin receptors than dopamine-2 receptors and also has an effect on muscarinic, histaminic, and α-adrenergic receptors. The starting dose for children is usually 2.5 mg with a goal of 10 mg/day. Doses over 20 mg have not been studied.

Quetiapine (Seroquel) also has FDA approval for acute manic and mixed episodes in children and adolescents with bipolar I disorder and also has approval for maintenance therapy in adults with bipolar I disorder. It is an antagonist at multiple receptor sites, including serotonin (5-HT_1A and 5-HT₂), dopamine (D₁ and D₂), histamine, and adrenergic receptors. Quetiapine is given in 25- to 50-mg increments up to 600 mg. It is thought to be a weight-neutral medication, and the primary side effect is sedation, especially at lower doses. It also comes in an extended-release preparation (XR).

Risperidone (Risperdal) has FDA approval for acute manic and mixed episodes in children and adolescents with bipolar I disorder also has approval for maintenance therapy in adults with bipolar I disorder as well as other indications; see Table 7–18. It blocks type 2 dopamine receptors (similar to haloperidol) and type 2 serotonin receptors. The initial dose is 0.5 mg/d. It is typically titrated up in 0.5- to 1-mg increments to a maximum dose of 6 mg. Side effects include weight gain and sedation. A dissolvable tablet (m-tab) and a long-acting OROS version of the major active metabolite of risperidone is also available (paliperidone). An intramuscular injectable form (Consta) is available for long-term management of bipolar disorder and schizophrenia in adults and is given every 2 weeks.

Ziprasidone (Geodon) does not have FDA approval for use in children or adolescents. It has affinity for multiple serotonin receptors (5-HT₂, 5-HT_1A, 5-HT_1D, and 5-HT_2C) and dopamine-2 receptors, and it moderately inhibits norepinephrine and serotonin reuptake. It also has moderate affinity for H₁ and α₁ receptors. Ziprasidone has a greater effect on cardiac QT intervals and requires a baseline ECG and ECG monitoring when a dose of 80 mg is reached and with each dose change above 80 mg to monitor for QT prolongation. Ziprasidone is reported to cause minimal weight gain. The initial dose is 20 mg, with dose changes in 20-mg increments to a total daily dose of 140 mg for the treatment of psychotic symptoms in adults.

B. Conventional Neuroleptics

Conventional or “typical” antipsychotics have been used successfully for decades and are notable for the first category of antipsychotic medication to be used for individuals with severe mood and psychotic disorders. Some of neuroleptics still used today include Haldol, Thorazine, and Perphenazine. This medication class has largely fell out of favor in common practice due to the significant difference and concern for adverse effects. Specifically, these medications—while effective—are notorious for causing previously described adverse effects to include akathisia, dystonia, EPS, and tardive dyskinesia. Occasionally, these medications are used in an acute setting, as needed, for treatment of out-of-control, aggressive, and/or manic behavior.

Clozapine (Clozaril) is usually reserved for individuals who have not responded to multiple other antipsychotics due to its side effect of agranulocytosis. Clozapine blocks type 2 dopamine receptors weakly and is virtually free of EPS, apparently including TD. It was very effective in about 40% of adult patients with chronic schizophrenia who did not respond to conventional antipsychotics.

Non-dose-related agranulocytosis occurs in 0.5%–2% of subjects. Some case reports note benefit from clozapine in child and adolescent schizophrenic patients who were resistant to other treatment. Contraindications are concurrent treatment with carbamazepine and any history of leukopenia. Initial medical screening should include a CBC and LFTs. The daily dose is 200–600 mg in two divided doses. Because of the risk of neutropenia, patients taking clozapine must be registered with the Clozapine Registry and a WBC must be obtained biweekly before a 2-week supply of the drug is dispensed. If the white count falls below 3000/mL, clozapine is usually discontinued. Other side effects include sedation, weight gain, and increased salivation. The incidence of seizures increases with doses above 600 mg/d.

 Prognosis

Schizophrenia is a chronic disorder with exacerbations and remissions of psychotic symptoms. Generally, earlier onset (prior to age 13 years), poor premorbid functioning (oddness or eccentricity), and predominance of negative symptoms (withdrawal, apathy, or flat affect) over positive symptoms (hallucinations or paranoia) predict more severe disability, while later age of onset, normal social and school functioning prior to onset, and predominance of positive symptoms are associated with better outcomes and life adjustment to the illness.

There is a handout for monitoring the side effects of atypical antipsychotics available at: http://webspace.psychiatry.wisc.edu/walaszek/geropsych/docs/atypical-antipsychotic.doc.

Bhangoo RK, Carter RS: Very early interventions in psychotic disorders. Psychiatr Clin North Am 2009 Mar;32(1):81–94. doi: 10.1016/j.psc.2008.10.003 [PMID: 19248918].

Cantor-Graae E: The contribution of social factors to the development of schizophrenia: a review of recent findings. Can J Psychiatry 2007 May;52(5):277–286 [PMID: 17542378].

Carlisle LL, McClellan J: Psychopharmacology of schizophrenia in children and adolescents. Pediatr Clin North Am 2011 Feb; 58(1):205–218, xii [PMID: 21281857].

Family resources: http://www.nami.org/template.cfm? section= your_local_nami http://www.mentalhealthamerica.net/go/faqs.

Kennedy E, Kumar A, Datta SS: Antipsychotic medication for childhood-onset schizophrenia. Cochrane Database Syst Rev 2007 Jul 18;(3):CD004027 [PMID: 17636744].

Masi G, Mucci M, Pari C: Children with schizophrenia: clinical picture and pharmacological treatment. CNS Drugs 2006;20(10):841–866 [PMID: 16999454].

Sprong M et al: Pathways to psychosis: a comparison of the pervasive developmental disorder subtype Multiple Complex Developmental Disorder and the “At Risk Mental State.” Schizophr Res 2008 Feb;99(1–3):38–47 [PMID: 18055179].

Thomas LE, Woods SW: The schizophrenia prodrome: a developmentally informed review and update for psychopharmacologic treatment. Child Adolesc Psychiatr Clin N Am 2006 Jan;15(1):109–133 [PMID: 16321727].

Several psychiatric conditions are covered elsewhere in this book. Refer to the following chapters for detailed discussion:

• Attention-deficit/hyperactivity disorder (ADHD): see Chapter 3.

• Autism and pervasive developmental disorders: see Chapter 3.

• Enuresis and encopresis: see Chapter 3.

• Eating disorders: see Chapter 6.

• Intellectual disability/mental retardation: see Chapter 3.

• Substance abuse: see Chapter 5.

• Sleep disorders: see Chapter 3.

• Tourette’s syndrome and tic disorders: see Chapter 25.