Clinical cases in child psychiatry
Silvio Saidemberg, M.D.
Disclosures
Nothing to disclose
After completing this presentation you
should be able to:
• Describe the relationship of ADHD to other psychiatric
and medical conditions.
• Acknowledge the possible treatments for ADHD
• Describe the relationship of psychosis to psychiatric
and medical conditions.
• Describe the relationship of mood disorders to
psychiatric and medical conditions.
After completing this presentation you
should be able to:
• Describe the relationship of separation anxiety to school phobia or
school refusal.
• Explain the developmental appropriateness of separation anxiety in the
preschool child and during the first months of school.
• Discuss the family dynamics of separation anxiety disorder.
• Distinguish between separation anxiety disorder and truancy as a cause
of school absence.
• Describe the etiologic role of the parent (often the mother) in
separation anxiety disorder.
• Develop a therapeutic plan for abnormal separation anxiety.
Epidemiology
Table 2-7. Children and adolescents ages 9 to 17 with mental or addictive disorders,*
combined MECA sample
Anxiety disorder
13.0%
Disruptive disorders 10.3 %
Mood disorders
6.2%
Substance disorders
2.0%
Any disorder
20.9 %
* Disorders include diagnosis-specific impairment and Child Global Assessment Scale <or=70
(mild global impairment).
Source: Shaffer et al., 1996
Epidemiology
Not all mental disorders identified in childhood and adolescence persist into adulthood, even
though the prevalence of mental disorders in children and adolescents is about the same as
that for adults (i.e., about 20 percent of each age population). While some disorders do
continue into adulthood, a substantial fraction of children and adolescents recover or “grow
out of” a disorder, whereas, a substantial fraction of adults develops mental disorders in
adulthood.
Epidemiology
Children and Adolescents
The annual prevalence of mental disorders in children and adolescents is not as well
documented as that for adults. About 20 percent of children are estimated to have mental
disorders with at least mild functional impairment (see Table 2-7).
Federal regulations also define a sub-population of children and adolescents with more severe
functional limitations, known as “serious emotional disturbance” (SED).4 Children and
adolescents with SED number approximately 5 to 9 percent of children ages 9 to 17 (Friedman
et al., 1996b).
Link between antidepressants and
suicide
1. 4% of youth treated with an antidepressant had
some episode of suicidality COMPARED WITH
2. 2% of youth treated with a placebo (sugar pill)
3. FDA concluded that suicidality is a potential SIDE
EFFECT for youth treated with antidepressant
medication
Link between suicidality and
antidepressants
1. Risk likely to be greater in the first few months of
treatment
2. FDA recommends screening youth carefully for
bipolar disorder
3. Findings resulted in a BLACK BOX Warning for use
of this med in youth
4. Age of warning expanded to young adults 18 to 24
Determination of suicide risk is still
evolving
1. Data from 27 pediatric research studies for youth
< 19 years old
2. Included treatment studies for depression, OCD,
and anxiety disorders
3. No suicide completions
4. Pooled risk difference within each psychiatric
indication were not statistically significant
JAMA 2007, Apr 297(15): 1683 96 - -
Medication Monitoring
FDA has recommended frequent monitoring for
suicidality early in treatment
Month 1 assess weekly –
Month 2 assess every 2 weeks –
Month 3 reassess at week 12 –thereafter reIncrease frequency of monitoring as necessary
Epidemiology- ADHD
Results of long-term follow-up studies showed that in
adolescence, most patients (70%-80%) continue to show
symptoms of the disorder and continue to meet the
diagnostic criteria for ADHD.
Epidemiology- ADHD
. In adulthood, many patients continue to be symptomatic
(60%), but fewer meet the diagnostic criteria for ADHD.
Research in this area is plagued by a number of
methodological difficulties. In addition to the
reclassification of the disorder over the years, differences
in study designs have made it difficult to replicate key
findings.
Epidemiology- ADHD
The core symptoms of hyperactivity-impulsivity tend to
decrease over time, although inattention may persist.
Additional difficulties resulting from secondary problems
often develop in later life. These difficulties include low
self-esteem, poor academic performance, and poor
interpersonal skills. Antisocial behavior and substance
abuse in late adolescence and adulthood are important
problems in some of these patients.
Epidemiology- ADHD
The prognosis for these patients is influenced by the
severity of symptoms, comorbidity, I.Q., family situation
such as parental pathology, family adversity, socioeconomic
status, and treatment. Treatment, particularly stimulant
medication, can be helpful in the short term for these
patients, but the long-term impact of treatment is unclear.
MRDD Research Reviews 1999;5:243-250. © 1999 WileyLiss, Inc.
ADHD
Attention Deficit Hyperactivity Disorder (ADHD) is a
developmental manifestation of inattention and
distractibility, with or without accompanying
hyperactivity and impulsivity.
ADHD
Either (1) or (2): (DSM –IV TR)
(1) Six (or more) of the symptoms of inattention have
persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental
level.
(2) Six (or more) of the symptoms of hyperactivityimpulsivity have persisted for at least 6 months to a
degree that is maladaptive and inconsistent with
developmental level.
(1) inattention:
1.
2.
3.
4.
5.
6.
7.
8.
9.
often fails to give close attention to details or makes careless mistakes in schoolwork,
work, or other activities
often has difficulty sustaining attention in tasks or play activities
often does not seem to listen when spoken to directly
often does not follow through on instructions and fails to finish schoolwork, chores, or
duties in the workplace (not due to oppositional behavior or failure to understand
instructions)
often has difficulty organizing tasks and activities
often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental
effort (such as schoolwork or homework)
often loses things necessary for tasks or activities (e.g., toys, school assignments,
pencils, books, or tools)
often easily distracted by extraneous stimuli
often forgetful in daily activities
(2)
symptoms of hyperactivity-impulsivity :
Hyperactivity
1. often fidgets with hands or feet or squirms in seat
2. often leaves seat in classroom or in other situations
in which remaining seated is expected
3. often runs about or climbs excessively in situations
in which it is inappropriate (in adolescents or
adults, may be limited to subjective feelings of
restlessness)
4. often has difficulty playing or engaging in leisure
activities quietly
5. often "on the go" or often acts as if "driven by a
motor"
(2)
symptoms of hyperactivity-impulsivity:
Impulsivity
1.
2.
3.
often blurts out answers before questions have been
completed
often has difficulty awaiting turn
often interrupts or intrudes on others (e.g., butts into
conversations or games)
ADHD DIAGNOSIS
(1)or (2):
1. Some hyperactive-impulsive or inattentive symptoms that
caused impairment were present before age 7 years.
2. Some impairment from the symptoms is present in two or
more settings (e.g., at school [or work] and at home).
3. There must be clear evidence of clinically significant
impairment in social, academic, or occupational
functioning.
ADHD DIAGNOSIS
(1)or (2):
DIFERENTIAL:
The symptoms do not occur exclusively during the course of a
Pervasive Developmental Disorder, Schizophrenia, or other
Psychotic Disorder and are not better accounted for by
another mental disorder (e.g., Mood Disorder, Anxiety
Disorder, Dissociative Disorder, or a Personality Disorder).
ADHD Differential Diagnosis
1. Age-appropriate behaviors in active children
2. ODD (Oppositional defiant Disorder)
3. Mood Disorders: anxiety, depression, bipolar,
4. Psychotic Disorders
5. Thyroid disorders
6. Tourette’s Syndrome
7. Mental Retardation/ Pervasive Developmental Disorder
8. Understimulating or overstimulating environments
9. Substance Abuse Spectrum
10. Dual and multiple diagnoses
ADHD - Specify Type:
1. Attention-Deficit/Hyperactivity Disorder, Combined Type:
if both Criteria 1 and 2 are met for the past 6 months
2. Attention-Deficit/Hyperactivity Disorder, Predominantly
Inattentive Type: if Criterion 1 is met but Criterion 2 is not
met for the past 6 months
3. Attention-Deficit/Hyperactivity Disorder, Predominantly
Hyperactive-Impulsive Type: if Criterion 2 is met but
Criterion 1 is not met for the past 6 months
4. "In Partial Remission”: For individuals (especially
adolescents and adults) who currently have symptoms
that no longer meet full criteria, "In Partial Remission"
should be specified.
ADHD
Epidemiology:
Incidence in school-age children is estimated to be 3-7%.
ADHD is 3-5 times more common in boys than in girls. The
predominantly inattentive type of ADHD is found more
commonly in girls than in boys.
The prevalence rate in adults has been estimated at 2-7%.
At least an estimated 15-20% of children with ADHD maintain
the full diagnosis into adulthood. As many as 65% of these
children will have ADHD or some residual symptoms of ADHD
as adults.
ADHD Treatment
Psychostimulants facilitate dopamine release. Commonly used ADHD
medications include:
Methylphenidate (Ritalin) based
Concerta
Daytrana (patch)
Focalin and Focalin XR
Metadate CD
Metadate ER
Methylin Chewable Tablets
Methylin Oral Solution
Ritalin
Ritalin LA on some days simply by taking it off early.
ADHD Treatment
Psychostimulants facilitate dopamine release. Commonly used
ADHD medications include:
Amphetamine based
Adderall and Adderall XR
Dexedrine
Vyvanse
Nonstimulants
Strattera norepinephrine reuptake inhibitor.
Alpha 2 adrenoreceptor agonists
Clonidine
Tenex
ADHD Treatment
Psychostimulants facilitate dopamine release. Commonly
used ADHD medications include:
These medications differ in how long they last (short
acting vs. long acting)
Short-Acting ADHD medications can last from 3 to 6 hours.
Adderall
Dexedrine
Focalin
Methylin Chewable Tablets and Oral Solution
Ritalin
ADHD Treatment
Psychostimulants facilitate dopamine release. Commonly
used ADHD medications include:
Intermediate-Acting ADHD medications can last
about 4 to 6 hours.
Dexedrine Spansule
Metadate ER
Ritalin SR
ADHD Treatment
Psychostimulants facilitate dopamine release. Commonly used ADHD
medications include:
Long-Acting ADHD medications can last from 8 to 12
Adderall XR
Concerta
Focalin XR
Metadate CD
Ritalin LA
Strattera
Vyvanse
Daytrana (This Ritalin patch basically works as long as your child
wears it, so it can be used as a short-acting ADHD medication
ADHD Treatment
Therapeutic Interventions:
1. Nutritional
2. Sleep
3. Motivation assessment and approach
4. Limit setting skills
5. Coping skills development assessment
6. Classroom Behavior Monitoring
7. School Accomodations
8. Behavior Modification
9. Individual Therapy
10.Family Therapy
ADHD Treatment
Case 1 is a 10-year-old male who was referred to the
ADHD clinic for an assessment of attentional
difficulties. He was diagnosed with NF-1 at the age of
5. Clinical evaluation confirmed a diagnosis of
Attention Deficit Hyperactivity Disorder,
Predominantly Inattentive Type. He met all 9 criteria
for Inattention, all 3 Impulsivity criteria, and 2 out of
the 6 criteria for Hyperactivity..
Case 1
The Conners’ Parent Rating Scale revealed clear
impairment in ADHD related realms, and the
Conners’ Teaching rating scale suggested problems
with anxiety, emotional lability, and social difficulties.
Case 1
Conners’ Parent Rating Scales Revised
Long Version (CPRS-R:L)
The CPRS-R:L contains 80 items. It’s typically used
with parents or caregivers when comprehensive
information and DSM-IV consideration are required.
Case 1
Conner’s Parent Rating Scales include:
1. Oppositional
2. Cognitive Problems/Inattention
3. Hyperactivity
4. Anxious-Shy
5. Perfectionism
6. Social Problems
7. Psychosomatic
8. Conners’ Global Index
9. DSM-IV Symptom Subscales
10.ADHD Index
Case 1
A psychoeducational assessment conducted
demonstrated that intellectual abilities were overall
below the mean for the general population, but
within one standard deviation. Working memory was
more severely impaired. There was no discrepancy
between verbal and nonverbal domains.
Case 1
Academic testing demonstrated low average
performance on spelling and reading. Memory was
also impaired, with verbal memory scores almost
one standard deviation below the mean, and visual
memory scores almost two standard deviations
below the mean. Difficulties with fine motor and
visuospatial skills were also evident
Case 1
WISC-IV = Wecschler Intelligence Scale etc, WRAT =
Wide Range Achievement Test; WRAML = Wide
Range Assessment of Memory and Learning; Beery =
Beery Developmental Test of Visual Motor
Integration.
Case 1
J Can Acad Child Adolesc Psychiatry. 2006 May; 15(2): PM
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87–90.
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Clinical Case Rounds in Child and Adolescent
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Psychiatry: Neurofibromatosis Type 1, Cognitive
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Impairment, and Attention Deficit Hyperactivity
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Disorder
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Nicola Keyhan, MA, MD FRCPC,1 Debbie Minden, PhD, 27
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CPsych,2 and Abel Ickowicz, MD, FRCPC1
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Case 1
Further evidence suggesting a link between brain
pathology and attentional deficits includes the
findings of Kayl et al.’s (2000) MRI study which
compared 36 children with NF-1 to 18 controls and
revealed that teacher and parent reports of
attentional difficulties were associated with a smaller
splenium and smaller total corpus collosum. Clearly,
the limited number of studies and small sample sizes
makes it is impossible to draw conclusions about this
data at this point in time.
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Case 2
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A 25-year-old female presented with a long-term
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history of TTM. She also suffered from post partum CI
depression which had been effectively treated with D
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sertraline. There was no family history of TTM and
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she had not previously received psychiatric care for M
this disorder. She reported that she was twelve years C2
old when she started to pull hair from the top of her 27
head. The urge to pull her hair intensified in her early 7
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twenties.
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Case 2
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The patient was using hair extensions to cover her
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hair loss at the time of assessment, and replaced
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them every six weeks due to ongoing pulling. Despite D
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attempts to resist pulling and to distract herself, she
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continued to pull out her hair. Her symptoms
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worsened during periods of marked stressors, such as C2
times of serious illness and the hospitalization of her 27
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infant. When asked about other triggers, she
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expressed great distress and cried when disclosing
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that seeing her child’s hair precipitated strong urges 0
that led to pulling of his hair.
Case 2
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Clinical Case Rounds in Child and Adolescent
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Psychiatry: Trichotillomania-by-Proxy: A Possible Cause CI
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of Childhood Alopecia
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Katherine C. Beattie, Dianne M. Hezel, BA, and S.
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Evelyn Stewart, MD
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1 Psychiatric & Neurodevelopmental Genetics Unit,
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Massachusetts General Hospital, Boston,
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Massachusetts, USA
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2 Obsessive-Compulsive Disorder Institute, McLean
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Hospital, Belmont, Massachusetts, USA
3 Harvard Medical School, Boston, Massachusetts, USA
Case 2
Corresponding email: dhezel@pngu.mgh.harvard.edu; PM
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Email: stewart@pngu.mgh.harvard.edu
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Received August 12, 2008; Accepted January 11, 2009. D
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Keywords: Trichotillomania-by-proxy, trichotillomania,
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childhood alopecia, hair loss, Munchausen-by-proxy M
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Case 3
Case Report
Alice, a 16-year-old African American girl with no prior
psychiatric history, came to the emergency room with a
chief complaint of hallucinations. Her symptoms had
developed 5 days previously and included fever and a
cough. She was taken to a local emergency room, diagnosed
with an upper respiratory infection, and given azithromycin.
Her condition worsened over the next 2 days. She was again
taken to the emergency room, given an injection of
promethazine, and discharged with a prescription for oral
promethazine with codeine.
Case 3
Case Report
Alice began acting strangely the next day; she started telling
her mother that she looked different. Later, she developed
auditory and visual hallucinations and was unable to
recognize her younger sister. Her symptoms worsened, and
she was taken to the emergency room for the third time and
told to discontinue promethazine. Her hallucinations
continued to worsen. She was taken to a different hospital,
admitted to the pediatric unit, and a psychiatric
consultation was obtained. intervention.
Case 3
Case Report
Upon a mental status examination, she appeared alert,
confused, and anxious. She reported auditory and visual
hallucinations and was extremely paranoid. Alice heard and
saw demons, thought she was in bound in chains, and
would not look at anyone's face because the faces appeared
to have no eyes. She reported seeing dead people without
eyes in tree trunks and believed that when she was alone in
her room, the devil appeared in the form of her mother.
The results of Alice's laboratory and imaging tests were
normal, with the exception of a positive test for influenza A
Case 3
Case Report
She and her mother reported no history of mental disorders
or substance abuse in Alice or in her family. Both believed
the onset of her symptoms correlated with the
promethazine injection and worsened with oral
promethazine and codeine.
Alice was given 1 mg of risperidone and 1 mg of lorazepam
orally. Upon reevaluation the next day, she was calm and no
longer psychotic. She was discharged 2 days after admission
without any further psychiatric intervention.
Case 3
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It was not until 1919, that
Kraeplin introduced the concept of
dementia praecox and noted its onset in
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late childhood and adolescence (6). Given M
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the insidious onset of the disorder,
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Kraeplin cautiously suggested that 3.5% of7
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patients with schizophrenia had the onset 29
of their illness before the age of 10 years. 0
1. List the patient's target symptoms.(Positive and Negative)
Symptoms
+ Symptoms
- Symptoms
Paranoid Delusions
Poor hygiene and grooming
Grandiosity
Blunted affect
Ideas of reference
Withdrawal
Hallucinations
Agitation with violence and
increased motor activity
Looseness of Associations
Responding to internal stimuli
Case 3
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Psychotic symptoms can be attributed to distinct
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mental illnesses (functional psychoses), which are CI
contrasted with the psychotic symptoms that usually D
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result from a demonstrable underlying pathologic
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mechanism and organic origin (organic psychoses), M
such as delirium. Cognitive impairments, particularly C2
impaired concentration and ability to focus, usually 27
accompany psychosis in children. However, when the 7
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psychosis is secondary to an organic origin, there is 9
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often accompanying impairment in the sensorium
presenting as confusion and disorientation, as is
typical of delirium.
Case 3
Schizophrenic psychoses with onset before age 11 years are
rare. The prevalence in this age group is about 0.01 to 0.05
per 1,000. In addition, developmental status can affect the
expression of the disorder. The earliest descriptions by DeSanctis (5), Bleuler (49), and Kraeplin (6) reported the onset
and occurrence during childhood and considered
schizophrenic psychoses to be an early onset of the same
disease.
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Neuroimaging
findings include a progressive increase in ventricular size
and a fourfold greater decrease in cortical gray matter
volume during adolescence, with the greatest differences
occurring in the frontal and temporal regions (64–67).
Others findings reported in the literature are a smaller total
cerebral volume, correlated with negative symptoms (37),
and frontal lobe dysfunction (68).
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Brief Reactive Psychosis
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Occasionally, children and adolescents suddenly develop
psychotic symptoms that can last from a few hours or days.
The child experiences these symptoms when under tremendous
stress, such as after a death in the family, witnessed acts of violence or
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destruction, or physical or sexual abuse.
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The acute psychotic symptoms often resolve quickly, with total
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recovery in a few days. These youngsters may suddenly become
disorganized, confused, agitated, or withdrawn. At times, their speech 2
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becomes nonsensical and incomprehensible.
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They may also experience delusions and hallucinations.
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These, too, are usually short-lived.
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Case 3
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Organic Psychoses
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Neurologic Conditions
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Seizure Disorder
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Children with seizure disorders can experience hallucinations :
as part of the seizure activity. Complex partial seizures,
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especially those with a temporal focus, may be associated M
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with interictal psychotic symptoms of delusions,
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hallucinations, and unusual preoccupations. Caplan and co- 2
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workers described a formal thought disorder in children with 7
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partial complex seizures (78,79), although their way of
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defining thought disorder makes it intertwine closely with 0
language organization deficits.
Case 3
Organic Psychoses
Neurologic Conditions
Seizure Disorder
However, they did emphasize that these epileptic children
usually do not display negative symptoms such as those
seen in schizophrenia. Hallucinations in children with
epilepsy typically are brief. Therefore, these children
experience mainly positive symptoms, which are often
short-lived.
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Organic Psychoses
Neurologic Conditions
Seizure Disorder
Caplan and co-workers also described a higher incidence of
formal thought disorder in those children who have lower
IQs, earlier onset of the seizure disorder, and poor seizure
control. They postulated that these symptoms may either
reflect the underlying neuropathology that produces the
seizures or result from the ‘‘kindling phenomenon’’ as a
secondary effect of the seizure activity.
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Organic Psychoses
Neurologic Conditions
Metabolic and Hormonal Disturbances
Various metabolic and hormonal conditions can be
responsible for psychotic symptoms in children.
Endocrinopathies may include disorders of the
adrenal, thyroid, or parathyroid glands. Exogenous
metabolic disturbances leading to psychotic
symptoms can include exposure to heavy metals.
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Organic Psychoses
Neurologic Conditions
Toxic Psychoses
Toxic psychosis or delirium usually occurs secondary
to bacterial or viral infections, high fevers, and
exogenous toxins including medications, illicit drugs,
alcohol, and poisonings.
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Organic Psychoses
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Neurologic Conditions
Toxic Psychoses
Unlike childhood schizophrenia or other psychotic
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disorders, in which impaired thinking and
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communication are the most salient symptoms, toxic C2
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psychosis is more likely to cause vivid, disturbing
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visual or tactile hallucinations and other perceptual 7
problems. Auditory hallucinations can also occur, but 29
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their content is qualitatively different from those
experienced in childhood schizophrenia or mood
disorders.
Case 3
Organic Psychoses
Neurologic Conditions
Toxic Psychoses
These sensory experiences may be extremely
frightening and may be accompanied by agitation or
by uncontrolled or even aggressive behaviors.
Children and adolescents often describe the
experience as ‘‘losing their mind’’—a frightening
concept, and they can become disoriented, unable
to orient to person or place, or comprehend why
they are behaving in an unusual manner.
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Case 4
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Abraham (not his real name) first came to the McLean
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outpatient department at the age of 13.5 years. He had just C
been discharged from inpatient hospitalization and required ID
ongoing outpatient pharmacologic management. His mother :
stated that he had been diagnosed with Asperger’s disorder P
and despite numerous placements in therapeutic schools, M
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hospitalizations, and medication trials, he continued to be 2
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violent and aggressive.
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Case 4
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None of the medications that he had tried had been
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effective, except thioridazine. Abraham had been treated
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with thioridazine, 125 mg/day, for an extended period. Both ID
parents, who were well educated, felt that their son did not :
simply have Asperger’s disorder, and they wanted to know P
what other diagnoses could be made. In addition, Abraham’sM
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parents were concerned about his current medication
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regimen because he had recently developed an unusual
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tongue movement, which was most prominent when he
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missed a dose of thioridazine.
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Case 4
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At the initial evaluation, Abraham had ongoing sleep
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disturbances, obsessions, sadness, irritability, and racing
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thoughts. He spoke in a loud, anxious manner. He washed all ID
the clothes in the house in a frenzied and intense manner :
late into the night, even if the items were clean. Abraham P
obsessed about a girlfriend who he reported was enrolled at M
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a local public high school, although the girlfriend did not, in 2
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fact, exist. Abraham also felt that God could transfer
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thoughts from one person to another and that God and
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other people could read his mind.
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Case 4
Abraham stated that something was "haywire" and that he
felt like he was "unraveling." He could not follow his own
thoughts and felt disorganized. Abraham also stated that he
felt he could see his dead uncle. He admitted to biting
himself when he was upset.
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Case 4
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His mother said that Abraham had become more aggressive C
over the past few months. Without provocation, he had hit ID
his younger siblings and struck out at people. In addition, his :
mother described him as being more perseverative than
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usual. He was extremely intrusive physically and engaged in M
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some inappropriate touching. His mother stated that
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Abraham’s whole family was gravely affected by his
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behavior. His siblings were afraid of him. His mother, who 7
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was a graduate student at the time, had missed many
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classes, and his father often had to leave work early in order 0
to help with Abraham. stopped.
Case 4
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His parents described him as quite silly and anxious at age
2.5 years. At age 4, Abraham had become aggressive and
had engaged in bizarre talk using repetitive nonsensical
words. Abraham was first hospitalized when he was 8 years P
old. Psychological testing at that time showed that he had M
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some looseness of association and some breaks with reality. 2
Psychotherapy notes at that time stated that he had "manic- 2
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like behaviors."
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Case 4
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Since the age of 8, he had undergone numerous evaluations. C
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He had a history of being fidgety, having grandiose and
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racing thoughts, exhibiting disorganized behavior, and being :
aggressive. Abraham showed mood lability and had discrete
episodes of hypomania, evidenced by silliness,
hypersexuality, poor sleep, and perseverative and pressured
obsessive ritualistic behaviors, such as washing clothes all
night.
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Case 4
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He had received numerous diagnoses in the past, including
conduct disorder, attention deficit hyperactivity disorder
(ADHD), social learning disability, anxiety disorder, pervasive
developmental disorders not otherwise specified, and
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Asperger’s disorder. The most consistent historical diagnosis M
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given to Abraham was pervasive developmental disorders 2
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not otherwise specified or Asperger’s disorder. However,
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none of the historical diagnoses had captured his symptom 7
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complex completely.
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One treating psychiatrist had entertained the possibility that
Abraham might have mood dysregulation and tried lithium
to treat his symptoms, but no formal diagnosis of bipolar or
affective disorder had been made.
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The results of past neurologic evaluations, including an EEG M
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and magnetic resonance imaging, had all been within
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normal limits. A test for fragile X syndrome had been
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negative. At 6 years old, Abraham had psychological testing; 7
his verbal IQ was 111, and his performance IQ was 97. He 29
had difficulty grasping a pencil and was noted to have
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trouble placing pegs in a Peg-Board with only one hand.
Case 4
He had difficulty "reading" the emotional content in pictures PM
in the Children’s Apperception Test (which contains drawings C
of familiar social situations, such as a father sitting in a chair ID
:
with a boy next to him). Abraham routinely had difficulty
labeling the feelings shown in the pictures accurately and P
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had difficulty perceiving the social interactions that were
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taking place. The examiner felt that his inability to identify 2
the feelings of others was causing Abraham to misperceive 2
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what was going on socially in his environment.
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In addition, Abraham was highly anxious and inattentive and PM
had difficulty with self-control. He was seen as managing his C
anxiety by trying to control social situations in an effort to ID
counter some of the social rejection he faced. The examiner :
concluded that Abraham had a "social learning disability." At P
numerous subsequent psychological evaluations, Abraham M
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was noted to have disorganized thinking.
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He had been prescribed a number of medications over the PM
years. He was initially given imipramine but developed a
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glazed look and stomach aches, so it was discontinued. He ID
:
had tried four selective serotonin reuptake inhibitors
(SSRIs)—fluoxetine, clomipramine, sertraline, and
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paroxetine—all of which led to an increase in sleep
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disturbances, agitation, aggression, and, at times, homicidal 2
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ideation. In addition, he was given a low dose of
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methylphenidate (10 mg/day), which increased his
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agitation.
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A trial of perphenazine, up to 9 mg/day, caused side effects
but no improvement. The psychiatrist who suspected an
underlying mood disorder tried lithium, up to 600 mg/day.
Lithium decreased Abraham’s impulsivity and motor
agitation; however, it was discontinued because it caused
diarrhea.
Abraham had been hospitalized just before his outpatient
visit at McLean Hospital because of his worsening
depressive symptoms and suicidal ideation. He was sad,
could not concentrate, and did not want to attend his new
school.
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Abraham was given the following diagnoses: bipolar PM
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disorder (mixed, with psychotic features) and
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Asperger’s disorder, with features of OCD. Shortly D
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after his initial outpatient evaluation, Abraham was
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hospitalized at McLean because of ongoing agitation M
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and unsafe behavior
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His thioridazine and clonidine doses were slowly
tapered, and he was given other medications,
including valproate and propranolol. Both trials
were of short duration and limited efficacy owing to
side effects.
Eventually, a combination of 1 mg b.i.d. of oral
clonazepam, 2100 mg/day of lithium (1.0 mM), and
3 mg/day of risperidone led to a marked reduction
in his behavioral symptoms. Over the next few
months his mood normalized and his aggressive,
extreme compulsive and disruptive behaviors
stopped.
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Diagnosing Bipolar Disorder in Childhood
Healthy children often have moments when they have
difficulty staying still, controlling their impulses, or dealing
with frustration. The Diagnostic and Statistical Manual IV
(DSM-IV) still requires that, for a diagnosis of bipolar
disorder, adult criteria must be met. There are as yet no
separate criteria for diagnosing children.
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Diagnosing Bipolar Disorder in Childhood
Some behaviors by a child, however, should raise a red flag:
destructive rages that continue past the age of four
talk of wanting to die or kill themselves trying to jump out
of a moving car
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To illustrate how difficult it is to use the DSM-IV to diagnose ID
children, the manual says that a hypomanic episode requires :
Diagnosing Bipolar Disorder in Childhood
a "distinct period of persistently elevated, expansive, or
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irritable mood lasting throughout at least four days." Yet
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upwards of 70 percent of children with the illness have mood 2
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and energy shifts several times a day.
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Diagnosing Bipolar Disorder in Childhood
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Since the DSM-IV is not scheduled for revision in the
immediate future, experts often use some DSM-IV criteria as P
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well as other measures. For example, a Washington
C
University team of researchers uses a structured diagnostic 2
2
interview called Wash U KIDDE-SADS, which is more
7
sensitive to the rapid-cycling periods commonly observed in 7
2
children with bipolar disorder
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Diagnosing Bipolar Disorder in Childhood
What is the need for Diagnosis of Childhood Bipolar
Disorder?
Tragically, after symptoms first appear in children, years
often pass before treatment begins, if ever. Meanwhile, the
disorder worsens and the child's functioning at home,
school, and in the community is progressively more
impaired.
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Diagnosing Bipolar Disorder in Childhood can have a
preventive impact:
1.
2.
3.
4.
5.
6.
7.
8.
9.
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removal from school,
placement in a residential treatment center,
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hospitalization in a psychiatric hospital,
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incarceration in the juvenile justice system
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development of personality disorders such as
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narcissistic, antisocial, and borderline personality
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a worsening of the disorder due to incorrect medications 29
drug abuse,
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accidents,
suicide.
Case 4
Diagnosing Bipolar Disorder in Childhood:What are the
various types of Bipolar Affective Disorder?
Bipolar I Disorder
Children with this disorder have episodes of mania and
episodes of depression. Sometimes there are fairly longer
periods of normality between the episodes. Usually people
spend much more time depressed than Manic. However,
some children will have Chronic Mania and rarely get
depressed.
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Diagnosing Bipolar Disorder in Childhood:What are the
various types of Bipolar Affective Disorder?
Bipolar II Disorder
In this form of the disorder, the adolescent experiences
episodes of hypomania between recurrent periods of
depression. Hypomania is a markedly elevated or irritable
mood accompanied by increased physical and mental
energy. Hypomania can be a time of great creativity.
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Hypomania :
Bipolar Affective Disorder - Cyclothymia
This variant is characterized by many episodes of
and occasional episodes of mild depression only. A child may P
have quite a few episodes of Hypomania over the span of a M
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year.
2
The less severe form of high in bipolar disorder is
hypomania.
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Mixed states of Bipolar Affective Disorder
In these conditions, a child will show signs of depression and
mania at the same time. Most often, the mood is depressed
and there are thoughts of suicide and hopelessness. The rest P
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of the picture is however mania. Depressive and manic
C
symptoms sometimes occur at the same time. Patients who 2
2
are overactive and over-talkative may be having profoundly 7
depressive thoughts. In other patients, mania and
depression follow each other in a sequence of rapid
changes; eg, a manic patient may become intensely
depressed for a few hours and then return quickly to his
manic state.
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Rapid cycling Bipolar Affective Disorder
This means there are many cycles of mania and depression
each year. These recurrent episodes may be depressive,
manic, or mixed. The main features are that recurrence is
frequent and that episodes are separated by a period of
remission or a switch to an episode of opposite polarity.
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Childhood Onset Bipolar Affective Disorder
Children with this picture have episodes of mania and
depression just like adult bipolar disorder but there are three
differences:
1- The cycling is fast. Often a child will cycle between mania
(or hypomania) and depression many times a day
2- The episodes are short. Rarely there will have days of any
one state.
3- Often mania and depression are mixed up together at the
same time.
Case 4
Mood disorders such as major depression and acute mania
can often be accompanied by psychotic symptoms. Over
the past several decades, the prevalence of mood disorders
appears to have been increasing (69). Although information
on the epidemiology of psychotic depression in children is
limited, Chambers et al. described the occurrence of
psychotic depression in children (61). The psychotic
symptoms usually are mood congruent, but at times they
can be quite like those seen in childhood schizophrenia
(20,70–72).
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This overlap in symptoms increases the likelihood of
M
incorrect diagnosis, especially at the time of onset.
C
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Sometimes, the negative symptoms of schizophrenia in
D
children can be mistaken for those of depression. However, :
it has been shown that children with schizophrenia have
P
poorer premorbid adjustments, lower IQs, and more chronic M
C
dysfunction, when compared with children who suffer from 2
a depressive disorder (50). It is therefore prudent to make 2
7
only a tentative diagnosis at the outset that must be
7
2
confirmed longitudinally. Careful follow-up of psychotic
9
patients is needed to detect diagnostic errors.
0
TREATMENT
Tricycle antidepressants (nortriptyline, imipramine,
desipramine)
Selective serotonergic reuptake inhibitors (fluoxetine,
paroxetine, sertraline, fluvoxamine, citalopram)
Nonselective serotonergic reuptake inhibitors (nefazodone,
mirtazapine)
Monoamine oxidase inhibitors (phenelzine,
tranylcypromine) (seldom used currently)
Others: bupropion, venlafaxine.
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TREATMENT
Mood stabilizers that have been used for the treatment
of manic-depressive illness in children include the
following:
Anticonvulsants (divalproex sodium, carbamazepine,
gabapentin)
Lithium
Often, the use of antipsychotic medications in addition
to the use of antidepressants or mood stabilizers is
indicated in functional psychosis.
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JC is a 9-year-old boy who lives with his mother and
attends the third grade, where he is an A student.
During the last 2 weeks, he has refused to go to
school and has missed 6 school days. He is awake
almost all night worrying about going to school. As
the start of the school day approaches, he cries and
screams that he cannot go, chews holes in his shirt,
pulls his hair, digs at his face, punches the wall,
throws himself on the floor, and experiences
headaches, stomachaches, and vomiting.
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If he attends school, he is less anxious until bedtime.
As his separation anxiety has increased, he has
become gloomy, has stopped reading for fun, and
frequently worries about his mother’s tachycardia.
JC was seen once by a psychiatrist at age 3 years for
problems with separation anxiety. He did well in
preschool and kindergarten.
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He was seen at a community mental health center
during the first grade for school refusal, but did well
again during the second grade. In addition to having
recurrent symptoms of separation anxiety disorder,
he is phobic of dogs, avoids speaking and writing in
public, and has symptoms of generalized anxiety
disorder and obsessive-compulsive disorder. His
mother has a history of panic disorder.
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Anxiety Disorders
Children who experience acute anxiety or who have a
history of maltreatment, abuse or neglect report
significantly higher rates of psychotic symptoms when
compared with controls (75). Several studies have
documented psychotic-like symptoms in children with
posttraumatic stress disorder. In such instances, the
psychotic symptoms actually represent intrusive
thoughts or worries regarding the traumatic event (73,
76,77).
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Anxiety Disorders
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Mental status examination usually reveals the lack
of a formal thought disorder, and the psychotic-like
symptoms are more akin to derealization or
P
depersonalization, as is often observed in traumatized
M
children. Furthermore, there is often a qualitative difference C
in the way children with anxiety disorders and those with 2
2
childhood-onset schizophrenia relate. The former have
7
better-developed relationship and prosocial skills compared 7
2
with the socially isolated, awkward, and odd behaviors of a 9
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child with schizophrenia.
Case 5
Anxiety Disorders
An identifiable traumatic event, abuse, or neglect
in the child’s history, in and of itself, does not necessarily
rule out a psychotic disorder, because children with both
schizophrenia and mood disorders may have had such
experiences (73).
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Anxiety Disorders
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NEUROBIOLOGICAL FACTORS. There is some evidence as of
2002 that social phobia can be inherited. A group of
researchers at Yale has identified a genetic locus on human
P
chromosome 3 that is linked to agoraphobia and two
M
genetic loci on chromosomes 1 and 11q linked to panic
C
2
disorder. Because social phobia shares some traits with
2
panic disorder, it is likely that there are also genes that
7
govern a person's susceptibility to social phobia. In addition, 7
2
researchers at the National Institute of Mental Health
9
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(NIMH) have identified a gene in mice that appears to
govern fearfulness.
Case 5
P
Anxiety Disorders
M
Positron emission tomography (PET) scans of patients
C
I
diagnosed with social phobia indicate that blood flow is
D
increased in a region of the brain (the amygdala) associated :
with fear responses when the patients are asked to speak in P
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public. In contrast, PET scans of control subjects without
C
social phobia show that blood flow during the public speaking 2
2
exercise is increased in the cerebral cortex, an area of the
7
brain associated with thinking and evaluation rather than
7
2
emotional arousal. The researchers have concluded that
9
patients with social phobia have a different neurochemical
0
response to certain social situations or challenges that
activates the limbic system rather than the cerebral cortex.
Case 5
Anxiety Disorders
P
TEMPERAMENT. A number of researchers have pointed to M
inborn temperament (natural predisposition) as a broad
C
vulnerability factor in the development of anxiety and mood I
disorders, including social phobia. More specifically, children D
who manifest what is known as behavioral inhibition in early :
infancy are at increased risk for developing more than one
anxiety disorder in adult life, particularly if the inhibition
P
remains over time.
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Anxiety Disorders
P
Behavioral inhibition refers to a group of behaviors that are M
displayed when the child is confronted with a new situation C
or unfamiliar people. These behaviors include moving
I
around, crying, and general irritability, followed by
D
withdrawing, seeking comfort from a familiar person, and :
stopping what one is doing when one notices the new
person or situation. Children of depressed or anxious
P
parents are more likely to develop behavioral inhibition. One M
study of preadolescent children diagnosed with social
C
phobia reported that many of these children had been
2
identified as behaviorally inhibited in early childhood.
2
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Anxiety Disorders
P
PSYCHOSOCIAL FACTORS. The development of social phobiaM
is also influenced by parent-child interactions in a patient's C
family of origin. Several studies have found that the children I
of parents with major depression, whether or not it is
D
comorbid with panic disorder, are at increased risk of
:
developing social phobia. Children of parents with major
depression and comorbid panic disorder are at increased P
risk of developing more than one anxiety disorder. A family M
pattern of social phobia, however, is stronger for the
C
generalized than for the specific or circumscribed subtype. 2
2
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Case 5
Anxiety Disorders
PSYCHOSOCIAL FACTORS. .
It is highly likely that the children of depressed parents may
acquire certain attitudes and behaviors from their parents
that make them more susceptible to developing social
phobia. One study of children with social phobia found that
their cognitive assessment of ambiguous situations was
strongly negative, not only with regard to the dangerousness
of the situation but also in terms of their ability to cope with
it. In other words, these children tend to overestimate the
threats and dangers in life and to underestimate their
strength, intelligence, and other resources for coping. This
process of learning from observing the behavior of one's
parents or other adults is called social modeling .
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CONCLUSION
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“From the clinical perspective, the rapid
change and development of childhood have
immediate implications for diagnosis and
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intervention. When one is treating children, it C
2
is important to maintain diagnostic fluidity and 2
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to tolerate the pressure of uncertainty”.
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Recommended Reading:
Neuropsychopharmacology: The Fifth Generation of Progress. Edited by Kenneth L.
Davis, Dennis Charney, Joseph T. Coyle, and Charles Nemeroff. American College of
Neuropsychopharmacology 2002.
Letter: Promethazine-Induced Psychosis in a 16-Year-Old Girl
Charles Timnak, M.D., and Ondria Gleason, M.D., Tulsa, Okla.
Psychosomatics 45:89-90, February 2004
© 2004 The Academy of Psychosomatic Medicine
Separation Anxiety Disorder and School Refusal in Children and Adolescents
Gregory L. Hanna, MD*; Daniel J. Fischer, MSW; Thomas E. Fluent, MD
* Associate Professor of Psychiatry; Director, Section of Child and Adolescent
Psychiatry, University of Michigan Medical School, Ann Arbor, Mich
Chief Social Worker, Section of Child and Adolescent Psychiatry, University of
Michigan Medical School, Ann Arbor, Mich
Clinical Assistant Professor; Director, Child and Adolescent Psychiatry Training
Program, University of Michigan Medical School, Ann Arbor, Mich
Recommended Reading:
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Read more: Social phobia - children, causes, DSM, functioning, therapy, adults, drug, person, I
people, used, medication, brain, skills, effect, women, health, traits, mood
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http://www.minddisorders.com/Py-Z/Social-phobia.html#ixzz0m4hs93KC
:
Treating a child with Asperger’s disorder and comorbid bipolar disorder. Jean A. Frazier, M.D.,
Robert Doyle, M.D., Sufen Chiu, M.D., Ph.D., and Joseph T. Coyle, M.D.
From the Consolidated Department of Psychiatry, Harvard Medical School, Boston; the
McLean Division of Massachusetts General Hospital; and the Department of Psychiatry,
Massachusetts General Hospital, Boston. Address reprint requests to Dr. Coyle, McLean
Hospital, 115 Mill St., Belmont, MA 02478; joseph_coyle@hms.harvard.edu (e-mail).
Supported by an NIMH Clinical Scientist Award (MH-01573) to Dr. Frazier. The authors thank
Abraham and his parents for allowing us to share his story.
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