Child and adolescent psychiatry
The branch of psychiatry that specializes in the study, diagnosis, treatment, and prevention of psychopathological disorders of children, adolescents, and their families, child and adolescent psychiatry encompasses the clinical investigation of phenomenology, biologic factors, psychosocial factors, genetic factors, demographic factors, environmental factors, history, and the response to interventions of child and adolescent psychiatric disorders (Kaplan and Saddock).
- 1 History
- 2 Classification of disorders
- 3 Clinical practice
- 4 Training
- 5 Criticisms
- 6 See also
- 7 Notes
- 8 References
- 9 External links
An important antecedent to the specialty of child (pediatric) psychiatry was the social recognition of childhood as a special phase of life with its own developmental stages, starting with the neonate and eventually extending through adolescence. Kraepelin's psychiatric taxonomy published in 1883, ignored disorders in children.
Johannes Trüper founded a famous approved school on Sophienhöhe close to Jena in 1892 and was a co-founder of "Die Kinderfehler"(1896), one of the leading journals for research in pedagogy and child psychiatry in its time. The psychiatrist and philosopher Theodor Ziehen, regarded as one of the pioneers of child psychiatry, gained practical child psychiatric experience as a consultant liaison psychiatrist at the approved school which was run by Johannes Trüper. Wilhelm Strohmayer, another psychiatrist from Jena, also belongs to the founding fathers of child psychiatry in Germany with his book Vorlesungen uber die Psychopathologie des Kindesalters für Mediziner und Pädagogen (1910) which is based on his consultant work on Sophienhöhe.
As early as 1899, the term "child psychiatry" (in French) was used as a subtitle in Manheimer's monograph Les Troubles Mentaux de l'Enfance. However, the Swiss psychiatrist Moritz Tramer (1882–1963) was probably the first to define the parameters of child psychiatry in terms of diagnosis, treatment, and prognosis within the discipline of medicine, in 1933. In 1934, Tramer founded the Zeitschrift für Kinderpsychiatrie (Journal of Child Psychiatry), which later became Acta Paedopsychiatria. The first academic child psychiatry department in the world was founded in 1930 by Leo Kanner (1894–1981), an Austrian émigré and medical graduate of the University of Berlin, under the direction of Adolf Meyer at the Johns Hopkins Hospital, Baltimore. Kanner was the first physician to be identified as a child psychiatrist in the US and his textbook, Child Psychiatry (1935), is credited with introducing both the specialty and the term to the Anglo-phone academic community. In 1936, Kanner established the first formal elective course in child psychiatry at the Johns Hopkins Hospital. In 1944 he provided the first clinical description of early infantile autism, otherwise known as Kanner's Syndrome.
In 1909, Jane Addams and her female colleagues established the Juvenile Psychopathic Institute (JPI) in Chicago, later renamed as the Institute for Juvenile Research (IJR), the world's first child guidance clinic. Neurologist William Healy, M.D., its first director, was charged with not only studying the delinquent’s biological aspects of brain functioning and IQ, but also the delinquent’s social factors, attitudes, and motivations, thus it was the birthplace of American child psychiatry.
From its establishment in February 1923, the Maudsley, a London-based postgraduate teaching and research psychiatric hospital, contained a small children's department. Similar overall early developments took place in many other countries during the late 1920s and 1930s. In the United States, child and adolescent psychiatry was established as a recognized medical speciality in 1953 with the founding of the American Academy of Child Psychiatry, but was not established as a legitimate, board-certifiable medical speciality until 1959.
The use of medication in the treatment of children also began in the 1930s, when Charles Bradley opened a neuropsychiatric unit and was the first to use amphetamine for brain-damaged and hyperactive children. But it wasn't until the 1960s that the first NIH grant to study pediatric psychopharmacology was awarded. It went to one of Kanner's students, Leon Eisenberg, the second director of the division.
The era since the 1980s flourished, in large part, because of contributions made in the 1970s, a decade during which child psychiatry witnessed a major evolution as a result of the work carried out by Michael Rutter. The first comprehensive population survey of 9- to 11-year-olds, carried out in London and the Isle of Wight, which appeared in 1970, addressed questions that have continued to be of importance for child psychiatry; for example, rates of psychiatric disorders, the role of intellectual development and physical impairment, and specific concern for potential social influences on children's adjustment. This work was influential, especially since the investigators demonstrated specific continuities of psychopathology over time, and the influence of social and contextual factors in children's mental health, in their subsequent re-evaluation of the original cohort of children. These studies described the prevalence of ADHD (relatively low as compared to the US), identified the onset and prevalence of depression in mid-adolescence and the frequent co-morbidity with conduct disorder, and explored the relationship between various mental disorders and scholastic achievemment.
It was paralleled similarly by work on the epidemiology of autism that was to enormously increase the number of children diagnosed with autism in future years. Although attention had been given in the 1960s and '70s to the classification of childhood psychiatric disorders, and some issues had then been delineated, such as the distinction between neurotic and conduct disorders, the nomenclature did not parallel the growing clinical knowledge. It was claimed that this situation was altered in the late 1970s with the development of the DSM-III system of classification, although research has shown that this system of classification has problems of validity and reliability. Since then, the DSM-IV and DSM-IVR have altered some of the parsing of psychiatric disorders into "childhood" and "adult" disorders, on the basis that while many psychiatric disorders are not diagnosed until adulthood, they may present in childhood or adolescence (DSM-IV).
Classification of disorders
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Disorders of attention and behaviour
Gender identity disorder
The psychiatric assessment of a child or adolescent starts with obtaining a psychiatric history by interviewing the young person and his/her parents or caregivers. The assessment includes a detailed exploration of the current concerns about the child's emotional or behavioral problems, the child's physical health and development, history of parental care (including possible abuse and neglect), family relationships and history of parental mental illness. It is regarded as desirable to obtain information from multiple sources (for example both parents, or a parent and a grandparent) as informants may give widely differing accounts of the child's problems. Collateral information is usually obtained from the child's school with regards to academic performance, peer relationships, and behavior in the school environment.
Psychiatric assessment always includes a mental state examination of the child or adolescent which consists of a careful behavioral observation and a first-hand account of the young person's subjective experiences. The assessment also includes an observation of the interactions within the family, especially the interactions between the child and his/her parents.
The assessment may be supplemented by the use of behavior or symptom rating scales such as the Achenbach Child Behavior Checklist or CBCL, the Behavioral Assessment System for Children or BASC, Connors Rating Scales (used for diagnosis of ADHD), Millon Adolescent Clinical Inventory or MACI, and the Strengths and Difficulties Questionnaire or SDQ. These instruments bring a degree of objectivity and consistency to the clinical assessment. More specialized psychometric testing may be carried out by a psychologist, for example using the Wechsler Intelligence Scale for Children, to detect intellectual impairment or other cognitive problems which may be contributing to the child's difficulties.
Diagnosis and formulation
The child and adolescent psychiatrist makes a diagnosis based on the pattern of behavior and emotional symptoms, using a standardized set of diagnostic criteria such as the Diagnostic and Statistical Manual (DSM-IV-TR) or the International Classification of Diseases (ICD-10). While the DSM system is widely used, it may not adequately take into account social, cultural and contextual factors and it has been suggested that an individualized clinical formulation may be more useful. A case formulation is standard practice for child and adolescent psychiatrists and can be defined as a process of integrating and summarizing all the relevant factors implicated in the development of the patient's problem, including biological, psychological, social and cultural perspectives (the "biopsychosocial model"). The applicability of DSM diagnoses have also been questioned with regard to the assessment of very young children: it is argued that very young children are developing too rapidly to be adequately described by a fixed diagnosis, and furthermore that a diagnosis unhelpfully locates the problem within the child when the parent-child relationship is a more appropriate focus of assessment.
The child and adolescent psychiatrist then designs a treatment plan which considers all the components and discusses these recommendations with the child or adolescent and family.
Treatment will usually involve one or more of the following elements: behavior therapy, cognitive-behavior therapy, problem-solving therapies, psychodynamic therapy, parent training programs, family therapy, and/or the use of medication. The intervention can also include consultation with pediatricians, primary care physicians or professionals from schools, juvenile courts, social agencies or other community organizations.
In the United States, Child and adolescent psychiatric training requires 4 years of medical school, at least 3 years of approved residency training in medicine, neurology, and general psychiatry with adults, and 2 years of additional specialized training in psychiatric work with children, adolescents, and their families in an accredited residency in child and adolescent psychiatry. Child and adolescent sub-speciality training is similar in other Western countries (such as the UK, New Zealand, and Australia), in that trainees must generally demonstrate competency in general adult psychiatry prior to commencing sub-speciality training.
Certification and continuing education
In the US, having completed the child and adolescent psychiatry residency, the child and adolescent psychiatrist is eligible to take the additional certification examination in the subspecialty of child and adolescent psychiatry from the American Board of Psychiatry and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP). Although the ABPN and AOBNP examinations are not required for practice, they are a further assurance that the child and adolescent psychiatrist with these certifications can be expected to diagnose and treat all psychiatric conditions in patients of any age competently. Training requirements are listed on the web site of The American Academy of Child & Adolescent Psychiatry.
Shortage of child and adolescent psychiatrists
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The demand for child and adolescent psychiatrists continues to far outstrip the supply worldwide. There is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced. There are currently only approximately 6,500 practicing child and adolescent psychiatrists in the United States. A report by the US Bureau of Health Professions (2000) projected a need in the year 2020 for 12,624 child and adolescent psychiatrists, but a supply of only 8,312. In its 1998 report, the Center for Mental Health Services estimated that 9-13% of 9- to 17-year-olds had serious emotional disturbances, and 5-9% had extreme functional impairments. However, in 1999, the Surgeon General reported that "there is a dearth of child psychiatrists." Only 20% of emotionally disturbed children and adolescents received any mental health treatment, a tiny percentage of which was performed by child and adolescent psychiatrists. Furthermore, the US Bureau of Health Professions projects that the demand for child and adolescent psychiatry services will increase by 100% between 1995 and 2020.
Steady growth in migration of immigrants to higher-income regions and countries has contributed to the growth and interest in cross-cultural psychiatry. Families of immigrants whose child has a psychiatric illness must come to understand the disorder while navigating an unfamiliar health care system.
One criticism against psychiatry is that psychiatric diagnoses lack "objectivity", particularly when compared with diagnosis in other medical specialties. However, for several major psychiatric disorders interrater reliability, which shows the degree to which psychiatrists agree on the diagnosis, is generally similar to those in other medical specialties. In 2013, Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests".
Traditional deficit and disease models of child psychiatry have been criticized as rooted in the medical model which conceptualizes adjustment problems in terms of disease states. It is said by these critics that these normative models explicitly characterize problematic behavior as representing a disorder within the child or young person and these commentators assert that the role of environmental influences on behavior has become increasingly neglected, leading to a decrease in the popularity of, for example, family therapy. There are criticisms of the medical model approach from within and without the psychiatric profession (see references): it is said to neglect the role of environmental, family, and cultural influences, to discount the psychological meaning of behavior and symptoms, to promote a view of the "patient" as dependent and needing to be cured or cared for and therefore undermines a sense of personal responsibility for conduct and behavior, to promote a normative conception based on adaptation to the norms of society (the ill person must adapt to society), and to be based on the shaky foundations of reliance on a classificatory system that has been shown to have problems of validity and reliability (Boorse, 1976; Jensen, 2003; Sadler et al. 1994; Timimi, 2006).[full citation needed]
Unnecessary use of psychoactive drugs as treatment
There are concerns about over-prescription of psychiatric medications to young people. In the late 1990s, more children and adolescents were taking prescription drugs than ever before; Prozac and Zoloft being commonly used for more older children while younger youth took prescription drugs for a diagnosis of ADHD. In 2004 the U.S. Food and Drug Administration (FDA) issued the Black Box Warning. The warning posted on prescriptions all around the country gave information regarding risk of suicidal thoughts, hostility, and agitation, mostly common on antidepressant packages. The most common diagnosis that would end up with a child having prescriptions drugs are ADHD, ODD, and conduct disorder. More than half of these children are also on some type of psychotropic medication.
Children or adolescents are sometimes given antipsychotic drugs as a first-line treatment for mental health problems or behavioral issues other than a psychotic disorder, which is contrary to the intended use of the drugs. In a concerning trend, in the United States since 2000 the usage of these drugs in young people has greatly increased especially among children from low-income families. Evidence for the efficacy and tolerability of antipsychotic medications is not sufficient to be able to anticipate all the risks, which include young peoples' tendency toward weight gain, metabolic side effects, and cardiovascular changes, and thus the use of the drugs beyond their indication is discouraged and controversial.
Various people and organizations have sought to challenge overuse of psychoactive drugs as treatment for young people. Lawyer James Gottstein sought to check the growth in the administration of psychotropics, particularly to children, and raise awareness of alternatives. Peter Breggin, in his book Reclaiming Our Children, calls for the ethical treatment of children. Breggin argues that the child abuse includes the administration of psychoactive drugs to young people whose medical needs and behavioral problems would be better addressed through non-pharmaceutical treatment. David Healy says that children in the United States, covered by Medicaid due to low family income, are four times more likely to receive psychotropic drugs than children with private health insurance. A British documentary called America's Medicated Kids also covered these issues.
Rebecca Riley, the daughter of Michael and Carolyn Riley and resident of Hull, Massachusetts, was found dead at age 4 in her home after prolonged exposure to various medications, her lungs filled with fluid. The medical examiner's office determined the girl died from "intoxication due to the combined effects" of prescription drugs. Police reports state she was taking 750 milligrams a day of Depakote, 200 milligrams a day of Seroquel, and .35 milligrams a day of Clonidine. Rebecca had been taking the drugs since the age of two for bipolar disorder and ADHD, diagnosed by child psychiatrist Kayoko Kifuji of the Tufts-New England Medical Center.
In 1947, child neuropsychiatrist Lauretta Bender published a study on 98 children aged between four and eleven years old who had been treated in the previous five years with intensive courses of electroconvulsive therapy (ECT). These children received ECT daily for a typical course of approximately twenty treatments. This formed part of an experimental trend amongst a cadre of psychiatrists to explore the therapeutic impact of intensive regimes of ECT, which is also known as either regressive ECT or annihilation therapy. In the 1950s Bender abandoned ECT as a therapeutic practice for the treatment of children. In the same decade the results of her published work on the use of ECT in children was discredited after a study showing that the condition of the children so treated had either not improved or deteriorated. Commenting on his experience as part of Bender's therapeutic program, Ted Chabasinski said that, "It really made a mess of me ... I went from being a shy kid who read a lot to a terrified kid who cried all the time." Following his treatment, he spent ten years as an inmate of Rockland State Hospital, a psychiatric facility now known as the Rockland Psychiatric Center.
- Biological psychiatry
- Childhood psychiatric disorders
- Child psychopathology
- Child and adolescent mental health services
- Developmental disorders
- Medical model
- Biopsychiatry controversy
- Controversy about ADHD
- Rennie v. Klein - right to refuse treatment
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