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).

History

An important antecedent to the specialty of child 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.^{[citation needed]} Kraepelin's psychiatric taxonomy published in 1883, ignored disorders in children.^{[citation needed]}

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.^[1]

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.^[2] 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.^[3] The first academic child psychiatry department in the world was founded by Leo Kanner in 1930 under the direction of Adolf Meyer at the Johns Hopkins Hospital, Baltimore.^[4] Dr. 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 the specialty to the academic community.^[4] The first use in English of the term "child psychiatry" occurred when Leo Kanner published his textbook under that name in the US in 1935.^[4] Academic child psychiatry in US was born at Johns Hopkins University.^[4] Its founding father, Leo Kanner, a medical graduate of the University of Berlin, was brought to Johns Hopkins by Adolf Meyer in 1928.^[4] Eight years later, Kanner offered the first formal elective course in the subject here. 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.^[4]

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.^{[citation needed]}

Academic divisions of child psychiatry began to develop, particularly in the US, in the 1930s. The first "pediatric psychiatry clinic" was established in 1930 at Johns Hopkins Hospital, Baltimore, headed by Leo Kanner.^{[citation needed]} In 1933, The Maudsley Hospital in London opened a children's department under Mildred Creak, and research in child psychiatry began to increase.^{[citation needed]} Similar overall early developments took place in many other countries. 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.^{[citation needed]}

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.^{[citation needed]} 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.^[5]

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.^{[citation needed]} 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.^{[citation needed]} Since then, the DSM-IV^[6] and DSM-IVR have corrected some of the questionable parsing of psychiatric disorders into "childhood" and "adult" disorders, recognizing that while many psychiatric disorders are not diagnosed until adulthood, they may present in childhood or adolescence (DSM-IV).

Classification

Developmental disorders

• Autistic spectrum disorders including Asperger's disorder
• Learning disorders

Disorders of attention and behaviour

• Attention deficit hyperactivity disorder
• Oppositional defiant disorder
• Conduct disorder

Psychotic disorders

• Childhood onset schizophrenia

Mood disorders

• Depression
• Bipolar disorder

Anxiety disorders

• Panic disorder
• Phobias
• Obsessive Compulsive Disorder

Eating disorders

• Anorexia nervosa
• Bulimia nervosa

Gender identity disorder

• Gender identity disorder in children

Clinical practice

Assessment

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.^[7]

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.^[8]

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.^[9] 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.^[10]

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)^[11] or the International Classification of Diseases (ICD-10).^[12] 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.^[13] 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").^[14] The applicability of DSM diagnoses have also been questioned with regard to the assessmment 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.^[15]

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

Treatment will usually involve one or more of the following elements: behavior therapy,^[16] cognitive-behavior therapy,^[17] problem-solving therapies,^[18] psychodynamic therapy,^[19][20] parent training programs,^[21] family therapy,^[22] and/or the use of medication.^[23] The intervention can also include consultation with pediatricians,^[24] primary care physicians^[25] or professionals from schools, juvenile courts, social agencies or other community organizations.^[26]

Training

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.^{[citation needed]} 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 and successfully passing the certification examination in general psychiatry given by the American Board of Psychiatry and Neurology (ABPN), the child and adolescent psychiatrist is eligible to take the additional certification examination in the subspecialty of child and adolescent psychiatry. Although the ABPN 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.^{[citation needed]}

Shortage of child and adolescent psychiatrists

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.^[27] 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.^{[citation needed]}

Cross-cultural considerations

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.^[28][29]

Criticisms

Critics of psychiatry often argue that psychiatric diagnosis lacks "objectivity", particularly when compared with diagnosis in other medical specialties. However, when one examines interrater reliability—an important component of objectivity—the agreement among psychiatrists for several major psychiatric disorders are generally on a par with those in other medical specialties. Nonetheless, in psychiatry as in all of general medicine, there is an irreducible element of the subjective. That is part of the "art" of medical and psychiatric practice (Pies 2007).

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).

See also

• Biological psychiatry
• Childhood psychiatric disorders
• Child psychopathology
• Child and adolescent mental health services
• Developmental disorders
• Medical model
• Psychiatry
• Anti-psychiatry
• Biopsychiatry controversy
• Peter Breggin
• Controversy about ADHD
• Rennie v. Klein - right to refuse treatment

References

General references

• Rutter, Michael; Taylor, Eric (2002), Child and Adolescent Psychiatry, Blackwell, ISBN 0-632-05361-5 

Notes

1. ^ Gerhard, Uwe-Jens; Schönberg, Anke and Blanz, Bernhard (2008), "Johannes Trüper--mediator between child and adolescent psychiatry and pedagogy", Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie 36 (1): 55–63, doi:10.1024/1422-4917.36.1.55, https://www.researchgate.net/publication/5374193_Johannes_Trper--mediator_between_child_and_adolescent_psychiatry_and_pedagogy, retrieved 2008-07-04 
2. ^ Manheimer, Marcel (1900), "Les troubles mentaux de l'enfance (review)", Journal of Mental Science 46 (193): 342–343, doi:10.1192/bjp.46.193.342. 
3. ^ Eliasberg, WG (July 1964), "In memoriam: Moritz Tramer M.D.(1882-1963)", American Journal of Psychiatry 121: 103–4, PMID 14154770 
4. ^ ^{a b c d e f} Child and Adolescent Psychiatry at The Johns Hopkins Hospital
5. ^ Rutter, Michael (1990), Chapter 7, Isle of Wight Revisited, Twenty-five years of child psychiatric epidemiology. In Annual Progress in Child Psychiatry and Child Development. Chess, Stella and Herzig, Margaret (eds), Psychology Press, ISBN 978-0876306024 
6. ^ Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington DC: American Psychiatric Association, 1994 
7. ^ Rutter, Michael and Taylor, Eric. Chapter 2, Clinical assessment and diagnostic formulation. In Rutter and Taylor (2002)
8. ^ Angold, Adrian. Chapter 3, Diagnostic interviews with parents and children. In Rutter and Taylor (2002)
9. ^ Verhulst, Frank and Van der Ende, Jan. Chapter 5, Rating scales. In Rutter and Taylor (2002)
10. ^ Sergeant, Joseph and Taylor, Eric. Chapter 6, Psychological testing and observation. In Rutter and Taylor (2002)
11. ^ American Psychiatric Association (2000), Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition, American Psychiatric Publishing, ISBN 978-0890420256 
12. ^ International Classification of Diseases (ICD), World Health Organisation, http://www.who.int/classifications/icd/en/, retrieved 2008-07-02 
13. ^ Rousseau, Cécile; Measham, Toby and Bathiche-Suidan, Marie (2008), "DSM IV, Culture and Child Psychiatry", Canadian Academy of Child and Adolescent Psychiatry 17 (2): 69–75, PMC 2387108, PMID 18516309, http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2387108 
14. ^ Winters, Nancy; Hanson, Graeme and Stoyanova, Veneta (January 2007), "The Case Formulation in Child and Adolescent Psychiatry", Child and Adolescent Psychiatric Clinics of North America 16 (1): 111–132, doi:10.1016/j.chc.2006.07.010, PMID 17141121 
15. ^ Egger, Helen (July 2009), "Psychiatric assessment of young children", Child and Adolescent Psychiatric Clinics of North America 18 (3): 559–580, doi:10.1016/j.chc.2009.02.004, PMID 19486838 
16. ^ Herbert, Martin. Chapter 53, Behavioural therapies, in Rutter and Taylor (2002)
17. ^ Brent, David, Gaynor, Scott and Weersing, Robin. Chapter 54, Cognitive-behavioural approaches to the treatment of depression and anxiety. In Rutter and Taylor (2002)
18. ^ Compas, Bruce, Benson, Molly et al. Chapter 55, Problem-solving and problem-solving therapies, in Rutter and Taylor (2002)
19. ^ Lieberman, A.F., Van Horn, P., Ippen, C.G. (2005). Towards evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1241-1248.
20. ^ Schechter DS, Willheim E (2009). When parenting becomes unthinkable: Intervening with traumatized parents and their toddlers. Journal of the American Academy of Child & Adolescent Psychiatry, 48(3), 249-254.
21. ^ Scott, Stephen. Chapter 56, Parent training programmes, in Rutter and Taylor (2002)
22. ^ Jacobs, Brian and Peaarse, Joanna.Chapter 57, Family therapy, in Rutter and Taylor (2002)
23. ^ Heyman, Isobel and Santosh, Paramala. Chapter 59, Pharmacological and other physical treatments, in Rutter and Taylor (2002)
24. ^ Rauch, Paula and Jellinek, Michael. Chapter 62, Paediatric consultation, in Rutter and Taylor (2002)
25. ^ Garralda, Elena. Chapter 65, Primary health care psychiatry, in Rutter and Taylor (2002)
26. ^ Nicol, Rory. Chapter 64, Practice in non-medical settings, in Rutter and Taylor (2002)
27. ^ Thomas, Christopher; Holzer, Charles (2006), "The continuing shortage of child and adolescent psychiatrists", Journal of the American Academy of Child and Adolescent Psychiatry 45 (9): 1023–31, doi:10.1097/01.chi.0000225353.16831.5d, PMID 16840879 
28. ^ Wintrob R. Cross-cultural psychiatry. Psychiatric Times. 2010;27:27.
29. ^ Measham T, Guzder J, Rousseau C, Nadeau L. Cultural considerations in child and adolescent psychiatry. Psychiatric Times. 2010;27:38-40.

External links

• American Academy of Child and Adolescent Psychiatry
• International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP)
• European Psychiatric Association: Child and Adolescent Psychiatry
• NIMH Child Psychiatry Branch Homepage
• Encyclopedia Britannica
• Classification of psychiatric disorders in childhood and adolescence: building castles in the sand?
• Cultural Diversity in the Development of Child Psychopathology
• Resources For Outpatient Children's Mental Health Treatment