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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Child and Adolescent Psychiatry has been widely acclaimed since the publication of its first edition in 1997(originally titled Child Psychiatry). Each chapter has been designed to present the key facts, concepts and emerging facets of the area, drawing on clinical experience as well as the latest research findings. These guiding principles are followed in the third edition, which has been updated to reflect the varied advances in research and clinical practice that inform the subject.
Child and Adolescent Psychiatry is structured into four main parts: first, an introductory section on assessment, classification and epidemiology; second, a section covering each of the main specific disorders and presentations; third, a section on the major risk factors predisposing to child psychiatric disorders; and fourth, a section on the main methods of treatment, covering also prevention, service organization and interpersonal and family therapies as well as fostering and adoption.
- Spans child and adolescent psychiatry
- Includes many practical tips on successful assessment and treatment techniques
- Comprehensive coverage of topics, written in an accessible style by international experts in the field
- Up to date information on prevention issues
Written in an accessible style, the book will be of benefit to all those working with children and adolescents with mental health problems: as an invaluable resource for trainee psychiatrists, paediatricians and general practitioners; as a textbook for undergraduate students in medicine, nursing and related fields; and as a refresher for active clinicians.
Supported by a companion website featuring over 200 multiple choice questions and answers to assist those preparing for examinations, including MRCPsych.
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Veröffentlichungsjahr: 2012
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Contents
Cover
Dedication
Title Page
Copyright
Foreword to First Edition
Foreword to Third Edition
Preface
Part 1: Assessment, Classification and Epidemiology
Chapter 1: Assessment
Five key questions
Some ‘how to’ tips
Putting it all together: the formulation
Chapter 2: Classification
The underlying principles guiding diagnostic groupings
Classifying disordered individuals or disordered families?
Diagnostic groupings: current practice
Chapter 3: Epidemiology
Advantages of an epidemiological approach
Epidemiological studies are not always the best approach
Stages in an epidemiological study
Epidemiological findings in child and adolescent psychiatry
Part 2: Specific Disorders and Presentations
Chapter 4: Autistic Spectrum Disorders
Epidemiology
Characteristic features
Asperger syndrome
Associated features of ASDs
Assessment
Differential diagnosis
Aetiology and pathogenesis
Treatment
Prognosis
Chapter 5: Disorders of Attention and Activity
Epidemiology
Defining characteristics
Assessment of symptoms
Additional features commonly associated with ADHD
Differential diagnosis
Causation
Treatment
Prognosis
Chapter 6: Disruptive Behaviour
Psychiatric labelling and social control
Dimension or category?
Is disruptive behaviour a psychiatric problem?
Symptoms and signs
Associated features
Differential diagnosis
Epidemiology
Causes
Assessment
Treatment
Continuity and outcome
Type of adult outcome
Chapter 7: Juvenile Delinquency
Epidemiology
Associated factors
Risk assessment
Management
Chapter 8: School Refusal
Epidemiology
Characteristic features
Associated features
Differential diagnosis
Underlying psychiatric conditions in the child
Treatment
Prognosis
Chapter 9: Anxiety Disorders
Epidemiology
Causation
Prognosis
Varieties of anxiety disorder
Chapter 10: Depression
Depression as a single symptom
Depression as a symptom cluster
Depression as a disorder
Features of depression at different ages
Depressive equivalents
Epidemiology
Classification
Associated features
Differential diagnosis
Causation
Treatment
Prognosis
Chapter 11: Mania
Characteristic features
Classical and juvenile-specific criteria for bipolar disorder
Epidemiology
Causation
Treatment
Bipolar disorder diagnosed with juvenile-specific criteria
Chapter 12: Suicide and Deliberate Self-harm
Completed suicide
Deliberate self-harm (DSH)
Chapter 13: Stress Disorders
Assessment
Post-traumatic stress disorder (PTSD)
Acute stress disorder
Adjustment disorder
Bereavement
Chapter 14: Obsessive-compulsive Disorder
Epidemiology
Characteristic features
Associated features
Differential diagnosis
Causation
Treatment
Prognosis
Chapter 15: Tourette Syndrome and Other Tic Disorders
Classification
Epidemiology
Characteristic features
Associated features
Differential diagnosis
Causation
Treatment
Prognosis of Tourette syndrome
Chapter 16: Selective Mutism
Epidemiology
Associated features
Differential diagnosis
Causation
Treatment
Prognosis
Chapter 17: Attachment Disorders
Varieties of attachment disorder
Diagnosis
Differential diagnosis
Attachment disorders v. insecure attachment
Assessment of the child
Assessment of the care received
Management
Course and prognosis
Chapter 18: Enuresis
Nocturnal enuresis
Diurnal enuresis
The link with psychiatric problems
Chapter 19: Faecal Soiling
Types of soiling and their management
Prognosis of soiling
Associated psychiatric disorders
Chapter 20: Sleep Disorders
Normal sleep
Epidemiology of sleep problems
Presentation
Specific types of sleep disturbance
Medication
Chapter 21: Psychosomatics
Some general principles
Recurrent abdominal pain (RAP)
Chronic fatigue syndrome (CFS)
Conversion disorders
Chapter 22: Preschool Problems
Common problems
Outcome in later childhood
Outcome in adulthood
Treatment
Chapter 23: Introduction to Adolescence and Its Disorders
A potted history of adolescence
Rules and autonomy
Biological and social influences interact
Cognitive development
Identity
Solving problems and weathering stress
Epidemiology of adolescent psychiatric disorders
Chapter 24: Schizophrenia
Epidemiology
Characteristic features
Antecedents of schizophrenia
Differential diagnosis
Causation
Clinical course and treatment
Prognosis
Chapter 25: Eating Disorders
Anorexia nervosa
Bulimia nervosa
Binge eating disorder
Chapter 26: Substance Use and Abuse
Causation
Substance use disorders
Treatment
Prevention
Chapter 27: Maltreatment
Epidemiology
Clinical picture
Risk factors for maltreatment
Effects of maltreatment
Assessment
Intervention
Part 3: Risk Factors
Chapter 28: Intellectual Disability
Definition
Prevalence
The two-population model
Causes of intellectual disability
Diagnostic assessment of intellectual disability
Prevention of intellectual disability
Provision of services for children with intellectual disability
Psychiatric disorders in children and adolescents with intellectual disability
Chapter 29: Brain Disorders
A relatively rare risk factor
An extremely powerful risk factor
At risk for which psychiatric disorders?
Interaction with other risk factors
Mediating links
Prognosis
Treatment
Three specific points
Chapter 30: Language Disorders
Epidemiology
Causation
Varieties of language disorders
Differential diagnosis and assessment
Interventions for language disorders
Prognosis for language development
Associated scholastic difficulties
Associated psychiatric and personality problems
Chapter 31: Reading Difficulties
Background information about normal reading
Specific reading difficulties (SRD)
SRD and developmental dyslexia
Causation of SRD
Chapter 32: Insecure Attachment
The nature of attachment
Secure and insecure attachment
Attachment throughout life
Consequences of secure and insecure attachments
Chapter 33: Nature and Nurture
Association is not the same as causation
Genes, shared environment and non-shared environment
Genetic influence
Precautions required when interpreting behavioural genetic studies
Genes and environment interact
Epigenetics and the environmental modulation of gene expression
Chapter 34: Coping with Adversity
Common stressors
Coping and resilience
Resilience and protective factors
Mechanisms
Clinical implications
Chapter 35: School and Peer Factors
Bully-victim problems
Peer popularity and unpopularity
Institutional factors
Oldest/youngest in class
Part 4: Treatment and Services
Chapter 36: Intervention: First Principles
Engaging the family
When are labels useful?
Symptoms and social impairments both need to be addressed
Complex problems may need complex solutions
Working with other agencies
Treatment need not mirror aetiology
Selecting treatment approaches
Modify treatment according to outcome
Chapter 37: Prevention
Types of prevention
Conditions that make prevention feasible
Targeting risk and protective factors
The example of conduct disorder
Prevention of other disorders
Prevention of risky predicaments
The future
Chapter 38: Medication and Diet
Medication: general principles
Medication: specific groups of drugs
Diet
Other physical treatments
Chapter 39: Behaviourally-based Treatments
Behavioural methods in practice
Evaluation of behaviourally-based therapies
Chapter 40: Cognitive, Interpersonal and Other Individual Therapies
Cognitive therapy
Social problem-solving skills programmes
Interpersonal psychotherapy (IPT)
Individual counselling and psychotherapy
Chapter 41: Family and Systemic Therapies
Background
Structural family therapy
Strategic family therapy
Milan systemic family therapy
Evaluation of family therapy
Chapter 42: Fostering and Adoption
Fostering
Adoption
Psychopathology
Assessment
Issues in deciding placement
Identity and contact issues
Issues and therapeutic work with foster or adoptive parents
Specific interventions
Issues in selecting adoptive parents
Chapter 43: Organisation of Services
Why plan at all?
Inclusiveness
Clearly defined boundaries
Budgets that are fair to the young
High quality provision
Providing value for money
Built-in improvement
Index
We dedicate this book
to all children and parents,
especially our own.
Companion website
The book is accompanied by a companion resources site:
goodmanchildpsychiatry.com
with self-assessment material for each chapter.
This edition first published 2012 © 2012 by Robert Goodman and Stephen Scott
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Library of Congress Cataloging-in-Publication Data
Goodman, Robert, MRCPsych. Child and adolescent psychiatry / Robert Goodman and Stephen Scott. – 3rd ed. p.; cm. Rev. ed. of: Child psychiatry / Robert Goodman and Stephen Scott. 2nd ed. Oxford, UK : Blackwell, 2005. Includes bibliographical references and index. ISBN 978-1-119-97968-5 (pbk.) I. Scott, Stephen, MRCPsych. II. Goodman, Robert, MRCPsych. Child psychiatry. III. Title. [DNLM: 1. Mental Disorders. 2. Adolescent. 3. Child. WS 350] 618.92'89–dc23 2012011738
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover photos courtesy of Stephen Scott, Catherine Lincoln and iStockphoto.com
Foreword to First Edition
There is nothing quite like this gem of a book, which provides much the best introduction to child psychiatry that has been written. It is succinct, very easy to read, and immensely practical in the guidance it provides on conceptual issues, on diagnosis and on treatment. Most introductory textbooks achieve accessibility for practitioners at the cost of a lack of scientific rigour and questioning; this splendid volume shows well that this price need not be paid. It is thoroughly up to date in its distillation of research findings and it conveys, with both interest and clarity, how modern clinical work is being shaped by the products of scientific investigation. Quite appropriately, the details of the research are not described, but the spirit of scientific inquiry pervades the whole of the book. References to a well-selected, short list of key review papers and chapters are provided, so that readers may both extend their understanding and also assess the evidence for themselves. The account given here, however, does a remarkably good job of selecting from an immense literature the research findings that are of greatest clinical relevance now. I would be surprised if reading this book does not stimulate most people to read further. Equally, I am sure that they will be astonished to discover how little that is important has not already been well covered in this volume. Quite a feat!
Both the authors are experienced clinicians and their wealth of practical knowledge, together with their ‘feel’ for clinical issues and for patients’ needs, comes through on every page. All the major varieties of mental disorders are covered but the approach taken is distinctive in four main respects. To begin with, the book provides very helpful guidance on the details of how to do what is needed. This is as evident in the first chapter on assessment as in those dealing with different forms of treatment. Indeed, the description of how clinicians need to think about the questions involved in assessment is masterly despite (or perhaps because of) its brevity. Second, there is a particularly insightful description of the different kinds of risk and protective factors and of how they might operate. Third, the discussion of clinical issues involves an explicitly developmental focus with an accompanying consideration of just how overt disorders relate to the variations in normal development. Finally, the book is skilfully organised to be most helpful to those preparing for professional examinations (with a useful list of 200 multiple choice questions). Remarkably, it achieves this organisation without the drawback of unwarranted dogmatism that mars so many introductory texts. My only regret is that I did not write this excellent book!
Professor Sir Michael Rutter Honorary Director MRC Child Psychiatry Unit, Institute of Psychiatry
Foreword to Third Edition
This splendid new third edition retains all the strengths of its predecessors and it not only brings things up to date but it broadens the coverage through additional material on adolescence. The timing of the book coincides with a period during which DSM-5 and ICD-11, the new classifications from the American Psychiatric Association and the World Health Organisation, are currently being finalised. Nevertheless, it is very much to the authors' credit that they have finessed this very skillfully by presenting issues, concepts, findings and clinical matters in a way that deals with the big issues without getting bogged down in the details. As with the two previous editions, there is a very skilful integration of science and clinical practice. The main target audience is certainly clinicians but researchers, too, will find that there is much to learn here on areas of research that are a bit outside of their own interest.
The book is also very interesting to read. It is a bit like watching one of David Attenborough's marvellous TV programmes – you never feel lectured at, your interest is engaged throughout, but in the course of that engagement you actually learn a lot. Readers will not find here dogmatic assertions that are not supported by evidence. The suggested readings at the end of each chapter provide an easy way for readers to find out more of the detail if they wish but the book already contains an immense amount. There is no better book for those who want an accessible introduction to child and adolescent psychiatry as a whole, or as a means of keeping up to date with relevant scientific understanding and clinical practice.
Professor Sir Michael Rutter Honorary Director MRC Child Psychiatry Unit, Institute of Psychiatry
Preface
Aware that this is often our readers’ only book on the subject, we have aimed to get straight to the heart of child and adolescent psychiatry. Our goal has been to be brief, clear, practical, thoughtful, up-to-date, scientifically accurate, clinically sound, and relevant for examinations. We have been very encouraged by the exceptionally positive response to the first and second editions from trainees and senior colleagues from a variety of disciplines. We have renamed the book – it is now Child and Adolescent Psychiatry rather than just Child Psychiatry. The previous editions also covered adolescents as well as children, but we have strengthened the adolescent component, with new chapters on mania, schizophrenia, eating disorders and substance abuse. We have also thoroughly updated all the existing chapters.
The chapters are grouped into four Parts: Part 1, an introductory section on assessment, classification and epidemiology; Part 2, a section covering each of the main specific disorders and presentations; Part 3, a section on the major risk factors predisposing to child and adolescent psychiatric disorders; and, finally, Part 4, a section on the main methods of treatment. Each chapter presents the key facts, concepts and growing points in the area, drawing on clinical experience as well as the latest research findings.
It has been our good fortune to work alongside a diverse and talented group of clinicians and researchers at one of the world's leading centres of child and adolescent psychiatry. We hope we have communicated some of the excitement of being at the ‘cutting edge’ of a discipline that is increasingly benefiting from advances in subjects as varied as developmental psychology, neurobiology, genetics, social anthropology, linguistics and ethology. As practising clinicians, we have also been keen to make this a book about working with children and families, as well as theory. Because successful practitioners need to master techniques as well as concepts, we have included plenty of ‘how to’ tips on assessment and treatment.
To make the book read as easily as possible, we have not interrupted the text with references. Instead, each chapter ends with suggestions for further reading, providing convenient entry points into the current literature. In many instances, we recommend one or more chapters from the fifth edition of Rutter et al.'s Child and Adolescent Psychiatry – an outstanding source of detailed information and further references. We also suggest a mixture of recent journal articles and books.
The book has been written with several groups of readers in mind. Trainees in psychiatry, paediatrics and general practice should find it useful as an accessible introduction to the subject when they are first working with troubled children and adolescents; as a continuing source of practical and conceptual guidance when assessing and treating individual children and adolescents with unfamiliar disorders; and as a comprehensive textbook when preparing for professional examinations. Trainees from other disciplines (psychology, nursing, social work and education) should find this book meets their needs when working with troubled children and adolescents, and also helps them to understand psychiatric perspectives on problems that often require inter-disciplinary working. Finally, for established professionals in many fields, this book should be an easy way to keep abreast of current thinking, and a convenient source book for preparing teaching sessions and for reference.
Readers can access a special dedicated website (GoodmanScottchildpsychiatry.com) with over 200 multiple choice questions (MCQs) on child and adolescent mental health – plus the answers, of course. These are designed for trainees approaching professional examinations as well as for other readers who enjoy quizzes as a way of consolidating their knowledge. Our MCQs are modelled on Membership questions set by the various Royal Colleges, particularly emphasising the examiners’ favourite topics.
This book has been greatly strengthened by the comments and suggestions of many colleagues and trainees from a range of disciplines; we are extremely grateful to them all. We are keen to go on improving this book and look to you, our readers, for help. Please do write to us telling us what you liked and what needs changing. What should be cut and what should be expanded? How could we make the book more useful to you? We hope that your advice to us will benefit future readers and, through them, troubled children and their families.
Robert Goodman and Stephen Scott London
PART 1
Assessment, Classification and Epidemiology
CHAPTER 1
Assessment
Performing a thorough psychiatric assessment of a child or adolescent can all too easily become a long and dreary list of topics to be covered and observations to be made – turning the occasion into an aversive experience for all concerned. It is far better to start with a clear idea of the goals and then pursue them flexibly. Ends and means are different: this first part of the chapter deals with ends; the second half of the chapter deals with means, providing some ‘how to’ tips with suggestions about the order in which to ask things.
Five key questions
During an assessment you need to engage the family and lay the foundations for treatment while focusing on five key questions, given in the following list, and remembered by the mnemonic SIRSE. There is a lot to be said for carrying out a comprehensive assessment on the first visit, provided this does not result in such a pressured interview that it puts the family off coming again. As long as you are able to engage the family, it is not a disaster if the assessment is incomplete after the first session provided you recognise the gaps and fill them in during subsequent sessions. Indeed, all assessments should be seen as provisional, generating working hypotheses that have to be updated and corrected over the entire course of your contact with the family. Just as it is a mistake to launch into treatment without an adequate assessment, it is also a mistake to forget that your assessment may need to be revised during the course of treatment. Consider the need for a reassessment if treatment does not work.
SymptomsWhat sort of problem is it?ImpactHow much distress or impairment does it cause?RisksWhat factors have initiated and maintained the problem?StrengthsWhat assets are there to work with?Explanatory modelWhat beliefs and expectations do the family bring with them?Though child and adolescent psychiatrists and their colleagues may be involved in many types of assessment, these five key questions will be relevant in nearly all cases, albeit with variations in emphasis and approach. Most of the rest of this chapter focuses on an approach that seeks, where possible, to explain the presenting complaint in terms of the child or adolescent having one or more disorders – leading on to a fuller formulation involving aetiology, prognosis and treatment. For some referrals, however, it may be more appropriate to focus on parenting difficulties or problems of the family system as a whole rather than on the problems of the presenting individual.
Symptoms
Most of the psychiatric syndromes that affect children and adolescents involve combinations of symptoms (and signs) from four main areas: emotions, behaviour, development and relationships. As with any rule of thumb, there are exceptions, most notably schizophrenia and anorexia nervosa. The four domains of symptoms are:
The emotional symptoms of interest to child and adolescent psychiatrists will be very familiar to most mental health trainees. As with adults, it is appropriate to enquire about anxieties and fears (and also about any resultant avoidance). Ask, too, about misery and, if relevant, about associated depressive features including worthlessness, hopelessness, self-harm, inability to take pleasure in activities that are usually enjoyable (anhedonia), poor appetite, sleep disturbance and lack of energy. Classical symptoms of obsessive-compulsive disorder can be present in young children, even preschoolers. One difference in emphasis from adult psychiatry is the need to enquire rather more carefully about ‘somatic equivalents’ of emotional symptoms, for example, Monday morning tummy aches may be far more evident than the underlying anxiety about school or separation.
Parental reports are the primary source of information on the emotional symptoms of young children, with self-reports becoming increasingly important for older children and adolescents. Somewhat surprisingly, parents and their children often disagree with one another about the presence or absence of emotional symptoms. When faced with discrepant reports, it is sometimes straightforward to decide who to believe. Perhaps the parents have described in convincing detail a string of incidents in which their child's fear of dogs has resulted in panics or aborted outings, while the child's own claim never to be scared of anything seems to be due to a mixture of bravado and a desire to get the interview over with as soon as possible. Alternatively, an adolescent's own account may make it clear that she experiences a level of anxiety that interferes with her sleep and concentration even though her parents are unaware of this because she does not confide in them and spends much of her time in her room. In other instances, it is harder to know who to believe – and perhaps it is more sensible to accept that there are multiple perspectives rather than one single truth.
The behavioural problems that dominate much of child and adolescent psychiatric practice are less familiar territory for most mental health trainees since adults with comparable symptoms are more likely to appear in courts than clinics. Enquiry should focus on three main domains of behaviour: defiant behaviour, often associated with irritability and temper outbursts; aggression and destructiveness; and antisocial behaviours such as stealing, fire setting and substance abuse. Reports from parents and teachers are likely to be the main source of information on behavioural problems, though children and adolescents sometimes tell you about misdeeds that their parents or teachers do not know about. There is only limited value in asking children and adolescents about their defiant behaviours since they, like adults, often find it hard to recognise when they are being unreasonable, disruptive or irritable, however good they may be at recognising these traits in others.
Evaluating developmental delay can be particularly hard for new trainees who do not have children of their own or a background in child health. Development complicates what, in adults, would be a simple assessment. Consider a physical analogy. An adult height of 1 metre is small, whereas a childhood height of 1 metre may be small, average or large; it obviously depends on the age of the child and, unless you have a growth chart handy, you could easily fail to spot children who were unusually small or tall for their age. The same problem is even more pronounced in the psychological domain. What are you going to make of an attention span of five minutes at different ages? Are you missing children whose speech is immature or excessively grown up for their age? How long should a 5-year-old sit still without fidgeting? In the absence of good published norms, you will mostly have to rely on experienced colleagues until you ‘get your eye in’. Remember, too, that experienced parents or teachers are rarely concerned without good reason.
The areas of development that are of particular relevance to child and adolescent psychiatry are: attention and activity regulation; speech and language; play; motor skills; bladder and bowel control; and scholastic attainments, particularly in reading, spelling and mathematics. When judging current levels of functioning, you will be able to draw on direct observations of the child or adolescent as well as reports from parents and teachers. Asking parents about developmental milestones can tell you about their child's previous developmental trajectory.
Assessing children's and adolescents’ difficulties in social relatedness is another taxing task, partly because relationships change with development. In addition, it is not always clear whether children's problems getting on with other people reflect primarily on them or on the other people. For example, if a child with cerebral palsy is unable to make or keep friends, how far might this reflect the child's lack of social skills, and how far might it reflect the prejudice of other children?
The most striking impairments in relatedness are seen in the autistic disorders, generally taking one of three forms: (1) an aloof indifference to other people as people; (2) a passive acceptance of interactions when others take the initiative and tell them what to do; and (3) an awkward and rather unempathic social interest that tends to put others off because of its gaucheness. Disinhibition and lack of reserve with strangers are prominent in some autistic, hyperactivity and attachment disorders, and may also be seen in mania and after severe bilateral head injury. The disinhibition may be accompanied by a pestering, importuning style. In small doses, some of these traits can seem quite charming. For example, after a few minutes acquaintance, you may judge a boy to be delightfully frank or open or eccentric. However, this sort of charm generally palls with longer acquaintance and the history usually makes it clear that his manner soon becomes very wearing for all those in regular contact with him.
Some children and adolescents have difficulty relating to most social partners, whether young or old, strangers or friends. Other children and adolescents have problems with specific types of social relationship, for example, with attachment or friendship relationships. The problems may even be specific to one important social partner. Thus, most children and adolescents are specifically attached to a relatively small number of key people, and the quality of their attachment (secure, resistant, aloof, disorganised) may vary, depending on which of these key people they are relating to. For example, the attachment may be insecure with the main caregiver but secure with the other caregivers (see Chapter 32). Similar specificity can be seen in sibling relationships.
You can gather information on a child or adolescent's social relationships from several sources. Observing the family interactions in the waiting room or consulting room can be very helpful. See how the child or adolescent relates to you during the physical and mental state examinations. If your assessment follows a fairly standardised pattern, it is all the more striking that one child is shy and monosyllabic throughout while another child of the same age greets you as a best friend and wants to climb onto your lap. Also note what might in other circumstances be called the counter-transference, for example, did you find them irritating? Does the interview leave you feeling exhausted? These are often valuable clues to the feelings that this individual evokes in many other people. Direct observation is supplemented by the history. Parents can often tell you a lot about their child's relationships from the early years onwards. It can also be helpful to get a teacher's report on peer relationships at school, but remember that teachers are not always aware of peer problems, even when these are fairly substantial, particularly if teachers do not usually supervise the playground.
Most patients have symptoms from more than one domain
Only a minority of the children and adolescents attending child mental health services have symptoms restricted to just one domain, but such individuals do exist. Thus you may see pure emotional symptoms in generalised anxiety disorder, pure behavioural symptoms in socialised conduct disorder, and pure relationship difficulties in disinhibited attachment disorder. Pure developmental delays, such as primary enuresis, receptive language disorder or specific reading disorder are not usually seen by child and adolescent psychiatrists in the absence of other symptoms. However, children presenting with ADHD may seem to have fairly pure delays in the development of attention and activity control.
Most of the children and adolescents seen by psychiatrists have symptoms from two or more domains. For example, individuals with conduct disorder also commonly have emotional symptoms, peer problems, and developmental delays, such as specific reading disorder or hyperactivity (see Box 1.1).
Autism provides another illustration of symptoms in multiple domains. The core symptoms of autism span two domains, with characteristic patterns of relationship problems and developmental delays (as well as developmental deviance and rigidity). In addition, autistic individuals commonly display some behavioural problems, such as marked temper tantrums, and some emotional problems, such as unusual phobias.
Impact
Nearly all children and adolescents have fears, worries, periods of sadness and times when they misbehave, fidget or fail to concentrate. When do these sorts of symptoms represent a disorder rather than a normal variant? In general, you should only diagnose a disorder if the symptoms are having a substantial impact. DSM-III criteria for psychiatric disorders did not include the need for impact, and the result of that omission is illustrated by a study that found that half of a large representative sample of Puerto Rican children had a psychiatric disorder. This is a ridiculously high rate, and most of these children were not considered ‘cases’ on clinical grounds. This has since been rectified: DSM-IV and the research diagnostic criteria of ICD-10 generally include impact criteria. Impact is judged from:
The main measure of impact should be whether the symptoms result in significant social impairment, substantially compromising the child or adolescent's ability to fulfil normal role expectations in everyday life. The main areas of everyday life to consider are family life, class work, friendships and leisure activities, though interference with paid work or physical health is sometimes relevant. Two subsidiary measures of impact are also important: distress for the child or adolescent; and disruption for others. Like their adult counterparts, children and adolescents who are anxious or depressed can sometimes fulfil normal role expectations while experiencing considerable inner anguish. Equally, behavioural problems can sometimes lead to substantial disruption for others without resulting in much apparent distress or social impairment for the child or adolescent. For example, the parents of children with severe physical or intellectual problems are sometimes remarkably stoical in the face of marked defiance, tantrums, and destructiveness – suffering themselves, but making sure that the child does not ‘pay for it’. In these instances, it may be clinically sensible to diagnose a disorder as present, and treat it, even though the individual is not really socially impaired by the symptoms. Is this a slippery slope to labelling all ‘deviants’ as psychiatrically ill? We hope not.
Risk factors
Why does the individual you are assessing have his or her particular constellation of psychiatric problems? Though the world is full of people who think they do know the cause of particular psychiatric disorders (dietary allergy, lack of discipline, bad genes, poor teaching, hypothalamic damage, unresolved infantile conflicts, etc.), the identification of a single cause for a psychiatric disorder is rarely scientifically justifiable. There are exceptions. Thus, it seems reasonable to say that the compulsive self-biting behaviour in Lesch-Nyhan Syndrome (which can lead to affected children severing their own fingers and extensively damaging their lips and tongue) is caused by a specific genetic deficit resulting in complete deficiency of one of the enzymes involved in purine metabolism. The presence of this inborn error of metabolism seems to guarantee the characteristic behaviour, irrespective of other genetic or environmental factors.
By comparison, most of the ‘causes’ in child and adolescent psychiatry are best thought of as risk factors that increase the likelihood of a particular disorder without guaranteeing that it will occur. Thus, although exposure to a high level of parental conflict is a risk factor for conduct disorder, many of the children and adolescents who are exposed to marital conflict do not develop conduct disorder. Perhaps we need to explain psychiatric disorders in terms of particular combinations or sequences of risk factors. One such scheme invokes three types of risk factors: predisposing, precipitating and perpetuating factors. The window has a hole in it because the glass was particularly thin and brittle (the predisposing factors), it was hit by a piece of gravel (the precipitating factor), and no one has subsequently replaced the broken pane (the perpetuating factor). A child who has always been rather clingy and has never had many friends (the predisposing factors) refuses to return to school after a row with a friend and a few days off sick with a cold (the precipitating factors). His parents are so worried about his level of distress that they feel it would be harmful to force him to return to school, but every day off makes it harder for him to go back since he falls further behind with his schoolwork and his former playmates find new people to play with (the perpetuating factors). The presence of a disorder can be explained in terms of:
predisposing factorsprecipitating factorsperpetuating factors and the absence ofprotective factors.Even if you do train yourself to think in terms of multiple interacting causes, you will still need to remember how incomplete our present knowledge is. Our current understanding of aetiology will probably look ridiculously simplistic or misguided in a hundred years time (or much sooner). It often helps to admit this to parents: dogmatic insistence that you know the whole truth about causation may be less well received than the more defensible claim that you probably know enough about causation to provide some useful pointers to treatment.
In gearing your assessment to look for, or ask about, known risk factors, you will have to cover many areas. The traditional focus on family factors is partly justified since our family provides us with our genes and an important part of our environment. Thus, a family history of Tourette syndrome could be of genetic relevance, while a history of parental friction could be of environmental relevance, and a history of parental mental illness could have genetic or environmental consequences. Most children and adolescents inhabit three rather different social worlds: family, school and peer culture. Do not confine your interest in environmental factors to the social world of the family – school factors, such as scapegoating by a teacher and peer factors, such as bullying, may be at least as important. Also ask about adverse life events and more chronic social adversities. Physical and psychological examinations may also unearth previously unrecognised risk factors for psychiatric problems. For example, an adequate history and physical examination may suggest a dementing disorder, mild cerebral palsy, complex seizures or fetal alcohol syndrome – warranting referral to a specialist for a more definitive view. Psychometric assessment can detect low IQ and specific learning problems – risk factors for various psychiatric problems that may, sadly, have gone undetected in school.
Strengths
If you asked only about symptoms, impact and risk factors, your focus would be almost exclusively negative, dwelling on what is wrong with this individual and this family. It is also important to establish what is right about this individual and family. Identifying protective factors may make it clearer why this individual has a mild rather than a severe disorder. It may also be possible to identify protective factors that apply to siblings, but not to the referred individual, that help to explain why only one child in this family has developed a disorder. Relevant protective factors include a sense of worth stemming from being good at something, a close supportive relationship with an adult, and an easy temperament.
Your treatment plan needs to build on the strengths of the individual and the family – and also on the strengths of the school and wider social network. Though the aim of treatment is determined by what is wrong, the choice of treatment often depends on what is right. You should design the treatment to harness the strengths in the child or adolescent, such as the ability to make friends or respond to praise, and the strengths in the parents, such as an openness to trying new approaches in the family.
If you dwell exclusively on negatives, the family may leave the assessment feeling emotionally battered – and be correspondingly less willing to return. We live in a society that generally blames parents for their children's problems. If a child has a tantrum in the supermarket, most of the bystanders will look reproachfully rather than sympathetically at the accompanying parent. Parents stand accused, and often feel uncertain in their own minds whether they are to blame or not. On the one hand, they are likely to share society's view that parents cause their children's problems and most parents can identify many ways in which their child rearing has been less than perfect. On the other hand, most of the parents you see in clinic will also feel that they are neither better nor worse than many other parents whose children seem fine. Many parents are frightened that you will judge them ‘guilty as charged’ and may be defensive and prickly in anticipation of this. One of your key tasks is to convey that you see them not as fundamentally deficient people but as individuals who, like the rest of us, have strengths as well as weaknesses. An interview presents plenty of opportunities for registering in a non-patronising way the positive things parents and their children do. If parents come to feel that you are not judging them, they are much more likely to accept the treatment plan you recommend, including suggestions for change on their part. If you ally yourself with a child against the parents (which is a common temptation for beginners), you will probably only succeed in redoubling the parents’ criticisms of the child and discouraging the family from returning to the clinic.
When you meet parents who seem to have particularly glaring weaknesses, it is vital that you put even more effort into identifying their strengths. This is not to say that you should be blind to their difficulties with parenting (these difficulties may need to be the focus of treatment or even the grounds for initiating care proceedings), but you need to remember (for your own sake as well as theirs) that these parents have their own strengths, often despite harrowing personal backgrounds of their own. Parents have usually put a great deal of effort into parenting. Though successful parents may put in more effort, they also generally get much more back from their children, so failing parents may be putting in more effort per unit reward than successful parents!
It is sometimes helpful to identify the presenting problem as the opposite side of the coin to a valuable strength. For example, a strong-willed child who is seen at the clinic because of defiant and disruptive behaviour at home and at school may also show an impressive determination to succeed in the face of adversity. Similarly, a sensitive child who is prey to all manner of anxieties may show admirable empathy and consideration for others. In each case, identifying a trait as both good and bad rather than as entirely bad may make the trait easier to live with. In addition, the therapeutic task is redefined: it is not to abolish the trait (which is likely to be impossible anyway) but only to reduce the trait's troublesome consequences.
The family's explanatory model
The way we construe a child or adolescent's emotional and behavioural difficulties will depend on our cultural and professional backgrounds. This book draws on a set of explanatory models derived from empirically orientated child and adolescent psychiatry. Other professionals, such as social workers, educational psychologists or psychotherapists, may apply a different set of explanatory models, leading to radically different formulations even if they see the same child and family. It is easy to forget that colleagues from other disciplines have different explanatory models – an oversight that can severely hamper communication. The same can be said of communication between professionals and families, since professionals are often unaware that families may have distinctive explanatory models of their own, assuming instead that all right-thinking members of the public hold similar, albeit less detailed, views to their own.
Little is yet known about the range of explanatory models that influence the ways in which families from different social and cultural backgrounds think about their children's emotional and behavioural difficulties. Nevertheless, it is clear that members of the public often have complex explanatory models that differ substantially from those of doctors and other professionals – as regards aetiology, phenomenology, pathophysiology, natural history and treatment. In other words, families come to clinics with expectations that may differ radically from your own. You should not guess a family's views on the basis of your stereotypes about their class and culture; the only sensible way to find out what they believe is to ask them open-ended questions and listen carefully to their replies.
After you have asked the family about the presenting complaint, it flows naturally to enquire what they make of the problem; what they think it is due to; and how they think it might be investigated or treated. Some families will look puzzled and say that they don't know, that's for you to tell them. Many others will tell you things you could not easily have guessed. You may learn, for example, that the parents of a child with poor concentration fear he has a brain tumour, or think he needs a brain scan, or believe that you will be able to cure the symptoms with hypnosis. If you had not asked them, they might never have told you and they might have gone away disappointed, never to return again. It is also worth asking the parents whether other important people, including grandparents, friends, neighbours, teachers, have expressed strong opinions about causation, investigation or treatment. A child's mother may tell you, for instance, that her mother-in-law has been very insistent that the child's problems have arisen because the mother has always worked and has not spent enough time with her child.
Knowing about people's explanatory models gives you a chance at the end of the assessment to present your views in the way that will be most relevant to them. You can explain that the symptoms are not at all like those of a brain tumour; that a scan would not alter management; and that although you are not a trained hypnotist, even a professional hypnotist would be unlikely to be of much help in this instance. You can also mention that the quality of the day care that they have arranged for their child gives no reason for concern, and that there is no scientific basis for blaming ADHD on working mothers when the quality of alternative care is good. You can say, too, that you would be very happy to discuss this further with the child's grandmother if the family want you to. Some families hold to their explanatory models with great tenacity, but most families are willing to update their explanatory models if you take the time to present the facts. At the end of a careful assessment in which the family may have invested considerable hope, it would be a great shame if failure to explore the family's explanatory models left you and them at cross-purposes and mutually dissatisfied.
Some ‘how to’ tips
What means will you employ to answer the five key questions and engage the family? There are no hard and fast rules to suit all clinics, all clinicians, all families and all presenting complaints. This is where good clinical supervision is particularly helpful. Sitting in on assessments carried out by a range of senior colleagues can be very instructive. The rest of the chapter is taken up with a variety of ‘how to’ suggestions that are guides rather than fixed recipes.
How to: take the history from parents
As a trained clinical interviewer, you should not simply be a speaking questionnaire. If you only want the parents’ answers to a fixed series of predetermined questions, a questionnaire would be quicker and easier for them to complete, unless they are poor readers. One style of interviewing, which is known as ‘fully structured’ or ‘respondent-based’ interviewing, amounts to little more than a verbally administered questionnaire. The wording of questions is predetermined, and the style of questioning is ‘closed’, calling for a limited range of possible responses: often a yes/no answer, or a rating of frequency, duration or severity. Questionnaires and fully structured interviews are widely used as research and clinical tools, since they are quick, cheap and easy to administer in a standardised fashion. Their main limitation is that the parents’ answers sometimes tell you more about the parents’ beliefs (or misunderstandings of the terms used) than about the child or adolescent being described.
A different style of interviewing, known as ‘semi-structured’ or ‘interviewer-based’, can help you get beyond the parents’ views to the observations on which they are basing their views. The interviewer is expected to ask whatever questions are required to elicit from parents the information needed for the interviewer to decide whether a particular symptom (or impairment or risk factor) is present or not. In order to do this, the interviewer will often need to use ‘open’ questions that offer the parents the chance to make a wide range of possible responses. Obtaining detailed descriptions of recent instances of the behaviour in question is usually very helpful.
An example may make this clearer. One of the questions in a questionnaire or fully structured interview might be ‘Does your child have concentration problems?’ If the parents answered ‘Yes’, you would still not know whether the child's concentration was objectively poor or whether the parents were setting unrealistically high standards (or had misunderstood the question). A semi-structured approach would use a mixture of open and closed prompts to get the parents to describe, using recent examples, how long the child has been able to persist with specific activities without switching from one thing to another: playing alone, playing with friends, watching television, looking at a book, and so on. You could then make up your own mind from this evidence whether the child's concentration at home was age-appropriate or not.
Similar methods can be used to explore irritability, fearfulness or any other reported area of problems. It is also sometimes relevant to explore why parents are not concerned. For instance, if teachers report major problems with concentration but parents do not, it is important to explore whether the child really does concentrate adequately when out of school, or whether the parents simply have unusually low expectations.
Semi-structured interviewing is a valuable technique but you do have to be careful not to overdo it or the interview will go on for hours! One option is to use questionnaires or fully structured interviews to get an overall view and then use semi-structured interviewing to obtain more details about the most relevant aspects of the case. Finding the time to get parents to describe their child's typical day, perhaps yesterday, can often be a particularly illuminating window, not only on symptoms and any resultant impairment but also on family life, child-rearing tactics and expressed emotion.
Here is one possible scheme for taking a history from parents:
How to: see the child or adolescent alone
Do not rush into difficult topics – it is obviously best to engage with the individual first by focusing initially on pleasant and neutral topics or activities. Equally, do not become so focused on making the interview fun that you avoid difficult topics entirely (though you may want to postpone some difficult topics for a second interview).
Children under 5: observe play, play too, chat, use fewer directed questions.Over-5s: you should both sit down. It is often helpful to ask the child to do a drawing. Chat and use directed questioning.What to cover
How to: observe the family as a whole
Are the parents supervising the children and setting limits if necessary? How sensitive and supportive are the parents if their child shows signs of anxiety or distress? How much warmth and criticism do the parents express about this child? (NB: warmth and criticism are independent, not the opposite sides of the same coin.)
Is there overt friction between parents? Do they countermand or back one another up? Who does the talking? Do they notice if they disagree? If so, do they reach a consensus?
How do siblings relate to one another? Do the parents treat the children differently from one another? Are there particular alignments within the family? For example, a mother's child, or a father's child, or father and son ‘ganging up against’ mother?
What is the relationship between children and parents? Possibilities include exploring from a secure base, interrupting their conversation, ignoring or challenging their requests, and watching them at a distance.
If toys are present in the room, are they used? What can you note about the form of play? Is it imaginative? What developmental level does it suggest? Are there any notable themes in the content of the play (for example, sexualised doll play)? Beware of overhasty interpretation of brief episodes of play.
How to: obtain information from teachers
Behaviour in school is often markedly different from behaviour at home. Although parents can often tell you if teachers have relayed any complaints or concerns about their child, it is best to get the information first hand from the school if at all possible, provided parents are willing to agree to you contacting the school. Having identified someone to contact, you can write and ask for their comments and a copy of a recent school report. It is often helpful for the teacher to complete a brief behavioural screening questionnaire such as the Strengths and Difficulties Questionnaire (www.sdqinfo.org). Since teachers have considerable experience of what to expect of children of any given age, their views are generally accurate. Whereas parents’ answers to questionnaires often need to be explored through semi-structured interviewing, it is usually appropriate to take teachers’ answers at face value. It is sometimes helpful, though, to get back to the teacher by phone to explore one or two particular issues in greater depth. Though teachers are generally excellent observers, they may miss or misconstrue some symptoms. In a busy classroom, disruptive behaviours are generally a lot more obvious than emotional symptoms. Consequently, teachers may miss anxiety or depression unless these have resulted in a dramatic decrease in the quality or quantity of the child's work. Subdued children may even seem better behaved than before. Thus, in one study, the rate of problems reported by teachers on a standardised questionnaire went down in the aftermath of a disaster.
Recognising the symptoms of ADHD in the classroom can also pose problems when a pupil has learning difficulties or dislikes academic work. Imagine how any child would behave if placed in a class taught in a language they did not understand – they, too, might well appear distracted or wander round the room at any excuse! What you really want to know to make a diagnosis of ADHD is whether the individual is restless and inattentive when engaged in tasks that are within their capabilities and that interest them. Sadly, some children and adolescents are never engaged in any such tasks at school. Finally, as noted earlier, teachers are sometimes unaware of problems in peer relationships because a pupil who seems to be getting on with classmates in class may be isolated or victimised in the playground without teachers necessarily spotting this.
When a pupil is reported to have marked problems in school, it is often very useful to go to the school and observe that individual both in the classroom and playground. Much may be learned, say, from observing a high level of restless, inattentive and impulsive behaviour in the classroom and playground, even though he or she had been fairly well controlled with you and other adults in the clinic; or from discovering that the child is constantly being told off by a highly critical teacher with limited classroom-management skills.
How to: do a physical examination
Systematic observation of a child or adolescent's physical features and skills is an essential part of a complete psychiatric assessment. You are primarily looking for:
