Clinical Child Psychiatry

William M. Klykylo, Jerald Kay, William M. Klykylo, Jerald Kay

• Publisher: Wiley-Blackwell
• Year: 2012
• Print ISBN: 9781119993346
• eBook ISBN: 9781119967705
• Edition: 3
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Clinical Child Psychiatry
THIRD EDITION

Making a psychiatric diagnosis in children can be challenging: some clinicians say the incidence of some childhood disorders, such as bipolar disorder and ADHD, is over-diagnosed while others say they are undiagnosed, undertreated, and are a large burden on society. The drug treatment of child psychiatric disorders can also be controversial in children and adolescents. This book fulfills the need for an objective, clinically relevant source to dispel this confusion.

Clinical Child Psychiatry is a textbook of current clinical practice in child and adolescent psychiatry. It is designed as a reference for clinicians that is both easily usable and authoritative, a "chairside" reference for the consultation room.

This book addresses a defined series of clinical entities that represent the bulk of current treatment modalities and disorders encountered in 21st century practice. It is authoritative in the areas addressed while at the same time being rapidly accessible in format. To facilitate access, it presents disorders in declining order of frequency. The authors believe that worthwhile clinical work must be informed by both evidence-based practice and by psychiatry's traditional attention to internal and interpersonal dynamics. They are committed to an approach that is broadly biopsychosocial while based on current clinical evidence for a pragmatic, clinical focus. The book is divided into four sections. The first, Fundamentals of Child and Adolescent Psychiatric Practice, addresses assessment, treatment modalities, and planning. Common Child and Adolescent Psychiatric Disorders and Developmental Disorders cover the diagnosis and treatment of the large majority of disease entities encountered in practice. The final section, Special Problems in Child and Adolescent Psychiatry, includes a variety of topics such as foster care and adoption, loss and grief, and forensics.

• New evidence relating to the areas of depression, psychosis, trauma.
• New insights from genetics, genomics, and proteomics cleverly integrated into chapters on the individual disease with focus on their clinical application.
• New chapter on consultation and collaboration within systems of care.

The book addresses a need for clinicians, many of whom are beginners, non-psychiatrists, or psychiatrists entering unfamiliar territory, to come up to speed rapidly in providing more than perfunctory service to needy populations. This challenge grows ever greater.

Section II

Common Child and Adolescent Psychiatric Disorders

10

Attention-Deficit Hyperactivity Disorder

David M. Rube, Tejal Kaur

Introduction

Attention-deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric conditions of childhood and adolescence, and is also one of the best researched neurobiological conditions in medicine, with over 200 placebo-controlled medication trials displaying acute response [1]. The core symptoms of ADHD are manifest throughout the life cycle, from preschool through adult life; they interfere with a child's family and peer interactions, academic attainment, emotional development, self-esteem, and overall quality of life. Given the high prevalence, impairment, and societal cost of ADHD, treatment is not only essential, but also practical and efficacious.

History

In North America, children who survived the great encephalitis epidemics of 1917 and 1918 were noted to have many behavioral problems similar to those constituting what we call ADHD [2, 3]. The cases that were reported and others that have arisen due to birth trauma, head injury, exposure, or infections gave rise to the idea of a “brain-injured child syndrome.” This concept evolved into that of minimal brain damage and eventually minimal brain dysfunction. Many challenges were raised to this label, however, because of the lack of evidence of brain injury in many of the children who exhibited the symptoms.

In the late 1950s and early 1960s, the “hyperactive child syndrome” was described by Burks and Chess [4, 5]. That syndrome was typified by daily movement that was greater than that of normal children of the same age. In the late 1960s, under the influence of the psychoanalytic movement, the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) [6] described all childhood disorders as “reactions,” and the hyperactive child syndrome became the “hyperkinetic reaction of childhood.” It was defined as a disorder of overactivity, restlessness, distractibility, and short attention span. It was asserted that the behavior usually diminishes in adolescence, leading to the ongoing myth that ADHD “disappears in adolescence.”

In the revised edition of DSM-III (DSM-III-R) [7], the disorder was renamed ADHD (attention deficit hyperactivity disorder), with a single list of items incorporating all three symptoms and a single threshold for diagnosis. Since the publication of the DSM-III-R, researchers have found that the problems with hyperactivity and impulsivity were not separate but formed a single dimension of behavior. These conclusions led to the creation of two separate symptom lists when DSM-IV was published in 1994 [8]. The establishment of the inattention list once again permitted the diagnosis of a subtype of ADHD. The DSM-IV currently permits diagnosis of subtypes of attention-deficit hyperactivity disorder: inattentive type, hyperactive impulsive type, and, for children with problems from both lists, ADHD combined type.

Core Clinical Criteria

For a diagnosis of ADHD, DSM-IV requires an early age of onset (prior to age 7 years), the presence of impairment for 6 months or longer, and the presence of impairment in two or more settings (see Table 10.1). Inattention includes failing to give close attention to details, difficulty sustaining attention, not listening, not following through, difficulty organizing, losing things, becoming easily distracted, and forgetfulness. Hyperactivity includes fidgeting, being out of seat, running or climbing excessively, having difficulty playing quietly, being “on the go” or as if “driven by a motor,” and talking excessively. The impulsivity symptom criteria include blurting out answers, having difficulty awaiting a turn, and often interrupting or intruding on others [8]. Core deficits include impairment in rule-governed behavior across a variety of settings and relative difficulty for age in inhibiting an impulsive response to internal wishes, needs, or external stimuli.

Table 10.1 Criteria for the diagnosis of attention-deficit hyperactivity disorder (ADHD).

The diagnosis requires evidence of inattention or hyperactivity and impulsivity or both

Inattention

Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

Often fails to give close attention to details and makes careless mistakes

Often has difficulty sustaining attention

Often does not seem to listen

Often does not seem to follow through

Often has difficulty organizing tasks

Often avoids tasks that require sustained attention

Often loses things necessary for activities

Often is easily distracted

Often is forgetful

Hyperactivity and impulsivity

Six or more of the following symptoms of hyperactivity and impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

Often fidgets

Often leaves seat

Often runs about or climbs excessively

Often has difficulty with quiet leisure activities

Often is ‘on the go’ or ‘driven by a motor’

Often talks excessively

Often blurts out answers

Often has difficulty awaiting turn

Often interrupts or intrudes

Symptoms that cause impairment:

Are present before seven years of age

Are present in two or more settings (e.g., home, school, or work)

Do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or another psychotic disorder

Are not better accounted for by another mental disorder (e.g., a mood disorder or an anxiety disorder)

The criteria are adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision.

While the syndrome may manifest itself differently throughout the life cycle, school-age children are the most common presenting population to pediatricians, child psychiatrists, and psychologists. Weiss [9, 10] points out that these children typically present with:

• inappropriate or excessive activity, unrelated to the task at hand, which generally has an intrusive or annoying quality;
• poor sustained attention;
• difficulties in inhibiting impulses in social behavior and cognitive tasks;
• difficulties getting along with others;
• school underachievement;
• poor self-esteem secondary to difficulties getting along with others and school underachievement;
• other behavior disorders, learning disabilities, anxiety disorders, and depression.

Restlessness is measured by well-standardized rating scales and direct and indirect observation [11, 12]. Teachers and parents may not agree with one another, owing to the likelihood that children may act differently in different situations, particularly as the full range of ADHD symptoms are less likely to emerge in settings where a child likes a teacher or tries harder at home to please his or her parents. Consequently, a child being evaluated in a physician's office could sit perfectly still during the examination, and the clinician may use rating scales in settings where the child spends the majority of his time. Whalen and Henker [13] suggest that “each measure reflects a unique child × perceiver × setting example.”

Bewildered parents will report their child's difficulties with attention. A common complaint is “he can play video games for hours but to do 20 minutes worth of homework requires 1 to 2 hours worth of screaming and temper tantrums.” It seems that when a particular activity interests a child, he or she can pay attention for hours. However, these same children can have a poor attention span when attending to tasks they find boring, repetitive, or difficult and that give them no satisfaction.

Poor attention span should be carefully assessed, as it can also be very similar to the poor concentration seen in anxiety and mood disorders. Moreover, as many of the core symptoms of ADHD can appear cross-sectionally to mimic other Axis I psychiatric diagnoses, and vice versa, a thorough assessment should begin with a broad-based differential (see “Differential Diagnoses” and Table 10.2).

Table 10.2 Mental health conditions that mimic or coexist with attention-deficit hyperactivity disorder (ADHD).

Difficulty Getting Along with Others

Peers often quickly reject children with ADHD because of their aggression, impulsivity, and noncompliance with rules [14]. Children with ADHD may be unpopular with their peers and may have difficulties with parents, siblings, and teachers [15]. These children may have few “best friends” and few enduring friendships, and this unpopularity and inability to establish and maintain friendships may be replaced in life by social isolation. In childhood, sometimes the only person willing to play with a hyperactive child is a younger child or a child with some other similar difficulty.

The negative effect of hyperactive children on others has been observed with respect to their teachers and ability to participate in both dyads and groups of children. Parents may also interact with a hyperactive child in a more negative and intrusive way. Furthermore, as ADHD often runs in families, one often discovers the likelihood that the parent may also have significant ADHD symptoms, which contribute to general disorganization in the household, which in turn often exacerbates ADHD and concomitant behavioral symptoms. Although working with parents to increase structure and behavioral modification strategies at home can prove beneficial, simultaneous addition of medication can lead to improved relationships with peers, teachers, and parents.

School Underachievement

Cantwell and Baker [16] showed that even when intelligence was controlled for, hyperactive children were behind normal children in their grade level in reading, spelling, and arithmetic. Even in the absence of comorbid learning disorder, t...

Table of contents

• Cover
• Series Page
• Title Page
• Copyright
• Dedication
• List of Contributors
• Preface to Clinical Child Psychiatry, Third Edition
• Section I: The Fundamentals of Child and Adolescent Psychiatric Practice
• Section II: Common Child and Adolescent Psychiatric Disorders
• Section III: Developmental Disorders
• Section IV: Special Problems in Child and Adolescent Psychiatry
• Index