Case Studies in Child and Adolescent Metal Health

M.S. Thambirajah

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315345178
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The case studies in this book provide a unique source of material suitable for all practitioners and trainers. The book gives detailed descriptions of common cases seen in specialist child and adolescent mental health services (CAMHS) including depression, learning disabilities, Asperger's syndrome, anorexia, deliberate self harm and schizophrenia. Subject reviews and summaries in each chapter aid comprehension, and explanatory figures, boxed text and lists make the content easy to recall. The book illustrates practical ways of managing and treating cases in an evidence-based manner. This resource is vital for child and adolescent mental health services practitioners, including psychiatrists, psychologists, specialist child health nurses and social workers. Trainee child and adolescent mental health services practitioners will also find the information invaluable.

Chapter 1

Oppositional defiant behaviour

It was a routine referral from the GP. The parents had taken Adam to the GP to get help with his behaviour problems. The referral letter was brief: ‘I would be grateful if you could see this 7 year old boy. His parents describe him as a defiant and angry child with a bad temper. He does not do what he is told. This is worse at meal times and when he gets ready to go to school in the mornings. He talks back to his parents, uses bad language and is aggressive especially towards his mother. Parents describe him as “hard work”. Other problems: surgical repair of VSD and coarctation of aorta (congenital heart conditions) soon after birth. I would be much thankful if you could see him fairly soon because the problems at home have been getting worse recently.’

Clinical presentation and background

Adam and his family were offered a routine appointment. Adam and his parents, Mr and Mrs Jones, attended the first assessment session. According to his father, Adam’s behaviour was causing a great deal of problems in the family. He refused to obey simple instructions and argued over every small thing. For example, when asked to do things like putting his toys away after playing with them in the drawing room he simply refused to comply. Getting him to obey day-to-day parental requests and commands was extremely difficult. He defied parental authority and every simple request was met with defiance. His parents were experiencing great difficulty in getting him to abide by house rules. For example, the back garden of the house was small and was considered unsafe, but Adam demanded that he be allowed to play in the garden. Any attempt to get him to abide by the rules resulted in arguments or temper tantrums. Mrs Jones summarised the problems as: ‘He would not do as he is told’.

In addition to challenging his parents’ authority, Adam wanted to have his way in most things. He dominated the household and fought with his older brother Lee over wanting to watch his favourite television programmes or to play on the computer. He took things from Lee’s room without his permission and insisted that he had the right to keep them. On one occasion he had taken the remote control for the television with him to the toilet so that others could not watch the programmes they wanted. This had lead to a major incident in which he and his father got into a physical struggle to recover the TV remote control. Mr Jones felt that Adam deliberately annoyed everyone in the family. During family times he would push, elbow or prod his brothers and provoke them. This usually led to retaliation by them, resulting in physical fights.

What concerned parents most was his aggressiveness. He was easily provoked and when he lost his temper he would go into a rage, attack his brothers, kick doors and throw things. Temper tantrums were a daily occurrence; it could take two hours for the temper to subside. On one occasion he had urinated on the carpet when sent to his room. During family times he would play up over small matters and one of the parents would end up taking him away from the scene. Getting him ready for school in the morning was a hard task. He would delay, obstruct or quibble over going to the bathroom, brushing his teeth and getting dressed. His mother had to be behind him all the time to get even the simplest task seen through. He could not be taken out to the shops because he caused severe disruption by meddling with things in the shelves.

Developmental history: Adam was born full term and the delivery was normal. But 36 hours after the delivery he had difficulty in breathing and was placed in intensive care. He was later transferred to the regional children’s hospital for investigations. He was diagnosed as having congenital heart disease (ventricular septal defect and coarctation of aorta). He underwent surgery soon after and was in hospital for four weeks. When he returned home he continued to cry at nights and took a long time to settle. He was followed up at the hospital till the age of five. His parents had been told that his heart defects had been completely corrected and that he had made a full recovery. He had no other medical problems.

Adam’s developmental milestones were normal. He started walking at 14 months and he spoke his first word by his first birthday, He was described as a difficult baby; he cried a lot and was a very irritable child. Mrs Jones recalled that soon after his discharge from hospital he was very demanding and did not settle down for a long time. Parents attributed this to the surgery and hospitalisation. Mrs Jones felt tired all day and even confused through loss of sleep. He started having his first temper tantrums around the age of 2 years and, contrary to parent’s experience with his older brother, the tantrums had got worse as he had grown older. They had tried to ignore the tantrums at the beginning but now he had about two to three tantrums a day.

Adam did not experience much difficulty when he started nursery. After some initial aggression directed towards other children he settled down, made friends and enjoyed going to school. In his present school he was good at games and was popular with peers. Asked about Adam’s strengths, both parents were quick to say that in spite of all that they had said about him he was a caring and loving boy.

Family history: The family consisted of Mr Jones, a plumber, Mrs Jones, a parttime shop assistant, and three boys. Adam was 7½, his older brother Lee 9 and the younger brother Mathew was 5. The parents had been married for 13 years. Both sets of grandparents lived locally and were supportive. The maternal grandparents had offered to keep Adam with them over weekends to provide respite for the family. But, of late, they had found Adam very difficult to manage and were now making excuses not to have him. The family history was unremarkable. There was no psychiatric illness or learning disability in the family.

Examination: During the interview Adam was initially well behaved and pleasant but when parents were describing his difficult behaviours he began contesting their version of events, often saying ‘it was not my fault’ and blamed others for the problems. He disagreed that he was being difficult and often turned to his mother for support. Mrs Jones did not overtly take his side but appeared to be close to tears during these exchanges. Mr Jones said that he could manage Adam on his own but it was his mother who experienced difficulties. Mr Jones appeared to be in some physical pain at the time of interview and on enquiry he revealed that he had been suffering with low backache for some time. During the interview Mr Jones raised his voice several times to get Adam to stop arguing.

Adam was seen on his own later. He was a somewhat slim boy with a mischievous smile. He was cooperative and amiable. He liked school because it was fun. He talked a great deal about his friends and the birthday parties to which he had been invited. When asked about his difficulties at school he said, that his class teacher hated him and blamed him for things that other kids did. He said that his father shouted at him ‘all the time’ and he was ‘always in trouble’ meaning that he was ‘always sent to his room’ and he commented that ‘it was unfair’. He agreed that he lost his temper often and threw things or punched holes in the door. As for the things that he would like to see changed, he said that he would like

1. his father not to shout at him
2. to be a good boy and
3. to get his older brother to share his computer games with him.

He was not sure why he had been brought to the clinic. He had thought he was coming to a clinic similar to the regional cardiac clinic but the clinician had been ‘only just asking questions’. Later in the examination he asked, ‘Are you a real doctor?’

Adam’s drawings were colourful and detailed. In the draw-a-man test (Harris, 1963), a rough method of assessing cognitive development in children, he produced a detailed picture of a man with glasses wearing a tie. But his writing was rather poor; he just managed to write his name. He made numerous spelling mistakes and there were many lateral inversions (for example, he would confuse the letters b and d). A short reading test (Schonell graded word reading test) was administered to assess reading. The test consists of a list of words of increasing difficulty that the child is asked to read. The number of words the subject is able to read is compared with the ‘norms’ provided for each age group. Adam’s could not read even one word in the list. This gave him a reading age of 6.0 minus (his chronological age was 7 years 6 months). In a later session Mrs Jones recollected that Adam had had difficulties naming colours till very recently. He could choose a red felt pen if asked to do so, but, if asked to name the colour of the pen, he could not do so.

Permission was obtained from parents to contact school and ask for a report. The school report arrived sometime later. Adam’s level of general intelligence was reported to be above average, confirming the clinician’s initial impression that he was sharp and witty. But it also confirmed the initial impression that Adam did indeed have significant difficulties in reading and writing. He was soon to be assessed by the educational psychologist.

Case conceptualisation and formulation

Conceptualisation of the case and making a formulation of the problem in a coherent and meaningful way is central to any therapeutic activity. This is especially so in child mental health where the problems have multiple dimensions and are complex both in their presentations and causations. Essentially a case formulation consists of answering two basic questions:

1. The what question: what is the problem and how is it best characterised? This involves describing the essential features of the clinical picture. It may consist of a brief description of the psychological presentation or a psychiatric diagnosis. It is important to remember that psychiatric diagnoses are purely descriptive and do not impute a biological dysfunction in the person nor do they ascribe any particular causation. Another necessary step in the assessment process is to consider the other possible reasons (not causations) for the clinical picture. In medical jargon this is called differential diagnosis but what it means is rather simple: the exclusion of other possibilities.
2. The why question: why is the problem occurring in this child and family at this particular time? This stage of assessment involves an attempt at explaining the causative or aetiological factors that may have lead to the problem including factors that maintain it. As a rule mental health problems in children and adolescents are caused by multiple factors and any adequate assessment involves the identification of factors in the child, family and environment that may be contributing to the causation and maintenance of the problem/s.

It is important to stress that the above two steps, describing the problem and ascribing causative and maintaining factors, necessarily involve the construction of hypotheses that need to be confirmed, changed or refuted from information gathered from subsequent sessions. The important point though is that these are only hypotheses and the clinician should be prepared to revise, modify and, at times, replace them with new ones and not ‘fall in love’ with their favourite hypothesis!

Thus, the formulation represents the essential links between aetiological factors and clinical picture; it connects theory and practice and encapsulates the idea of how we view the difficulties presented by the child and the family and, therefore, forms the basis of treatment planning and interventions. The approach adopted here is not associated with a particular (e.g. psychodynamic, cognitive behavioural or systemic) model of conceptualisation and treatment; rather it is empirically oriented and incorporates the following:

• Available research evidence.
• Making simple (but not simplistic) formulations that encompass aetiological factors in the child, family and environmental (especially school and peer) factors.
• A multi-level and multi-dimensional approach. Most of the problems referred to CAMHS are sufficiently complex and often warrant more than one form of intervention.

In the case of Adam, on the basis of the first assessment session, the main problem was described as follows: Adam showed a considerable degree of noncompliant and defiant behaviours; these behaviours occurred both at home and school but the situation at home was worse than that at school. At home the difficult behaviours were of high frequency and moderate intensity. This constellation of behaviours is commonly described as oppositional defiant behaviour. On the basis of the findings in the first interview it was felt that Adam’s behaviours met the criteria for Oppositional Defiant Disorder (ODD).

Although Adam’s case looks rather simple and straightforward, it was essential that the clinician considered other possible descriptions to the clinical picture and not bypass the stage of differential diagnosis. In Adam’s case the other possibilities were:

1. conduct disorder
2. hyperkinetic disorder and
3. adjustment disorder.

The defining feature of conduct disorder (see Chapter 12) is the presence of rule-breaking behaviour, i.e. the behaviours that violate the law or basic rights of others; this includes behaviours such as theft, cruelty, bullying, fighting, assault and destructiveness. Adam’s pattern of behaviour, as bad as it was, was confined to being negativistic, defiant and disobedient towards authority figures, rather than the violation of rights of others or societal norms. Hyperkinetic disorder (see Chapter 9) is characterised by impulsivity, lack of concentration and general overactivity occurring in various situations. There was little indication of these features in Adam. Lastly, some children react to difficulties in adjustment to change in life situations such as parental illness or divorce (see Chapter 5) with disturbance in behaviour. In the case of Adam there were no such major life events.

The next step was to consider the possibility of any coexisting developmental problems. The commonest developmental problems seen in children presenting to CAMHS are: general intellectual (learning) disability (see Chapter 4), specific developmental disorders (sLD) and autism spectrum disorder (ASD, see Chapter 7). In Adam’s case he was judged to be a bright boy and there was no evidence of autistic features. However, he did show considerable difficulties in reading indicating he had specific reading disorder.

A number of aetiological fact...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Preface
• About the author
• Abbreviations
• Author’s note
• Dedication
• 1 Oppositional Defiant Behaviour
• 2 Adolescent Depression
• 3 School Refusal
• 4 Intellectual (Learning) Disability
• 5 Parental Divorce and Separation
• 6 Looked After Child
• 7 Asperger’s Syndrome
• 8 Anorexia Nervosa
• 9 Hyperkinetic Disorder
• 10 Obsessive Compulsive Disorder
• 11 Somatisation
• 12 Conduct Disorder
• 13 Post-traumatic Stress Disorder
• 14 Deliberate Self-harm I: Overdose
• 15 Deliberate Self-harm II: Self-injury
• 16 Adolescent Schizophrenia
• Index