Info Centre Home | Contents | Search | eMJA Home
|
Info Centre Home | Contents | Search | eMJA Home |
|
11 Common child and adolescent psychiatric problems and their
management in the community
Bruce J Tonge Solving the psychological problems of children is often a matter of family medicine |
Short course-->
|
Synopsis - Introduction - Assessment - Childhood psychopathology - Anxiety disorders - Depression - Conduct disorder - Attention deficit hyperactivity disorder (ADHD) - Somatoform disorders - Principles of management - Psychological treatments - Cognitive-behavioural therapy - Play and psychodynamic psychotherapy - Family therapy - Pharmacotherapy - Internalising disorders - Externalising disorders - The role of the general practitioner - When to refer - References - Authors' details - Box 1: Assessment components - Box 2: Timeline of psychopathology in childhood - Box 3: Anxiety disorders - Box 4: Depression - Box 5: Conduct disorder - Box 6: Attention deficit hyperactivity disorder - Case history 1: Separation anxiety presenting as school refusal - Case history 2: planning positive events and cognitive restructuring in the treatment of childhood depression - Case history 3: Family violence presenting as conduct disorder in a boy with ADHD - Case history 4: Asthma and an overprotective family - Short course - Contents list Synopsis |
|
Introduction |
Worldwide, the prevalence of clinically significant psychiatric
disorder in children is at least 7%.1 This rate rises in socially
disadvantaged and densely populated urban areas. It also increases
by 3%-4% after puberty. Childhood psychopathology presents
as: |
Assessment
|
Assessment and diagnosis takes a biopsychosocial approach, with
consideration of the contribution made by biological development
and medical illness, cognitive and personality characteristics and
the family, school and social environment. The components of a child
psychiatric assessment are shown in Box 1.
| The use and interpretation of play and drawing in the psychological treatment of children requires special training, but in general clinical practice children should be encouraged to play and draw to assist them to communicate. This may confirm information already gained or generate possibilities that need to be confirmed in further discussion with the child, parents or others, such as teachers. For example, recurring play themes arising from real life experiences may occur in free play with toys. The child may communicate emotional or relationship problems when drawing a picture of a person, the family, or a dream.3 This process is facilitated when the child experiences the clinician as non-judgemental and has heard the parents explain their concerns to the clinician and why help is being sought. Motor clumsiness, problems with handedness and fine motor difficulties (e.g., gripping a pencil) might indicate neurodevelopmental problems. These are often associated with attention deficit hyperactivity disorder (ADHD), learning problems and low self-esteem and therefore require further neurological assessment. Psychopathology checklists completed by parents, such as the Child behaviour checklist4 or the Developmental behaviour checklist,5 take 10 to 15 minutes to complete and are an effective and efficient means of providing the clinician with a broad survey of emotional and behavioural problems, some of which may be missed in a clinical interview. Selected questions or the entire questionnaire can also be used to follow response to treatment. At a more detailed level, answers on the Child behaviour checklist can be scored in reference to the manual,4 to give a measure of the child's psychopathology relative to a general population of children of the same age and sex. There are also two broad subscales rating disturbance with emotional (internalising) problems and behavioural (externalising) problems and more detailed problem domains, such as anxiety and aggression. Childhood psychopathology
|
Several psychopathological conditions mainly occur, or have their
onset, during childhood. These are specifically recognised in the
major classification systems of the DSM-IV6 and ICD-10.7 The peak ages of
onset for various childhood psychiatric disorders are shown in Box 2.
The four most common psychiatric disorders in childhood presenting
in the community are anxiety, depression, conduct disorder and ADHD.
These will each be described to highlight the general approach to the
treatment of psychiatric disorder in children.
| Anxiety disorders
Box 3: Anxiety disorders
|
The most common manifestation of anxiety in children is fear to be
separated from parents and home and refusal to attend
school.9
The common symptoms of anxiety are shown in Box 3.
The prevalence of anxiety is highest at times of transition: moving
from preschool to primary school, and from primary to secondary
school. Children who refuse to attend school are usually capable but
self-critical students, and mostly have separation anxiety, being
frightened to leave home. The prognosis is good with treatment, but
persistent anxiety disorder predicts the development of panic
disorder in adulthood.9
| Depression
|
Box 4:
Case history 2:
Contrary to earlier beliefs, persistent depression occurs in
children and becomes progressively more common after puberty. Up to
24% of adolescents will have had a major depression by the age of
18.11 It seriously affects
social, emotional and educational development, and is the most
important predictor of suicidal behaviour in young people aged 15-24
years.11
| Although the symptoms of depression in children are similar to those seen in adults, they also usually have irritable mood, may fail to make expected weight gain, and tend to keep secret their depressive thoughts and crying (Box 4).3,12 Depression can also occur in combination with another disorder such as anxiety, conduct disorder or ADHD, which require assessment and consideration in planning treatment.10,12 The prognosis is good when the depression is secondary to a life stress and responds to psychological treatment. A positive family history of mood disorder and a good response to antidepressant medication indicate an increased risk of further depressive or bipolar disorder in adult life. The National Health and Medical Research Council has released a comprehensive clinical practice guidelines booklet on Depression in young people, with accompanying booklets for general practitioners and their patients.11 Conduct disorder
|
Box 5:
Case history 3:
Serious and persistent patterns of disturbed conduct and antisocial
behaviour predominantly affect boys and comprise the largest group
of childhood psychiatric disorders.13 Conduct disturbance may
begin early in childhood, manifesting as oppositional, aggressive
and defiant behaviour becoming established during the primary
school years and amplifying after puberty. The presence of other
psychological disorders is common in these children, with about 30%
showing ADHD and learning problems.13 Clinical depression is
also found in about 20% of young people with conduct disorder, and,
although controversial, a prospective study suggests that this
emotional disturbance is secondary to the conduct
disorder.13
| The clinical features are shown in Box 5. This group of childhood disorders requires vigorous early intervention, assessment and management because, although about a third make a reasonable adjustment, there is evidence that at least half of the young people with serious conduct disorder will continue to experience mental health and psychosocial problems in adult life, such as personality disorder, criminality and alcoholism, and about 5% develop schizophrenia.13 Attention deficit hyperactivity disorder (ADHD)
|
Controversy exists regarding the prevalence of this condition,
which is now being more frequently diagnosed in Australia. Using
international diagnostic criteria, the prevalence is probably
about 1%, being three times more common in boys than girls.14 There is
usually a history of difficult and uneven development from infancy.
It is likely that the disorder has a neurobiological basis that is
complicated by family interactions and the progressive
consequences of associated learning problems.14 The clinical
features are described in Box 6.
| More recent evidence indicates that the young person does not necessarily grow out of the problem. Symptoms tend to persist, although adolescents usually become more goal-directed and less impulsive, channelling activity into sport or work if the opportunity is available. The outcome is less favourable for those who have an associated conduct disorder. In these cases, there is a significantly increased risk of continuing to have mental health, personality and social adjustment problems.14 Somatoform disorders
|
Of particular importance for general practitioners are those
disorders in which there is an interaction between physical illness
and psychological factors. In some children with a chronic illness
(e.g., asthma, diabetes or ulcerative colitis), emotional
distress, anxiety or anger can combine with family interactions
(e.g., overprotection, enmeshment and unresolved conflict) to lead
to poor compliance with treatment and deterioration in the illness
(see Case history 4).15,16 Clear and open
education of parents and children about the illness and its treatment
and working with the parents to communicate more effectively and
resolve conflicts helps to reduce overprotectiveness and secondary
emotional problems. If these measures fail, referral for more
intensive family and individual psychological treatment is
indicated to prevent worsening illness.
| General practitioners have an important role in the prevention and early intervention of eating disorders. At any time, anorexia nervosa now affects up to 1% of otherwise healthy young 15-18-year-old young women. Girls who are having difficulty with peer group and family relationships (including sexual abuse) are vulnerable to the disorder, which is initiated through peer group and media pressure regarding the desirability of a thin prepubertal body and pressure to diet and exercise. Girls with anorexia nervosa develop an intense preoccupation with dieting, a fear and perceptual disturbance regarding fatness, and bodily changes caused by starvation.17 Their expression of emerging independence and self-control becomes focused on food intake.17 Early intervention is vital to prevent a chronic psychiatric disorder, which is associated with ill-health and a mortality from inanition and suicide of about 5%. Both parents and the child need education on healthy eating and normal adolescent development. Other mental health problems, such as the treatment of depression in the mother, need attention. These measures, together with frequent review, can be effective in preventing the development of anorexia nervosa. Once established, anorexia nervosa requires specialist referral for individual psychological and family therapy, hospitalisation for refeeding, and pharmacotherapy. The potential adverse consequences of obesity (body weight exceeding ideal weight for height by 20%) justify early intervention. Obesity is based on constitutional and early feeding practices, but is usually aggravated by a sedentary lifestyle, watching television, low self-esteem and self-comforting eating. Early intervention leading to reduced calorie intake and increased activity levels requires peer and family support and is necessary by puberty, because about 80% of obese adolescents will become obese adults. Principles of management |
The key to effective management of childhood psychopathology is a
comprehensive assessment and diagnosis upon which to base the
treatment plan. This process can of itself provide families with an
understanding of the problem and generate possible solutions. Even
if the child receives an individually focused treatment, involving
the parents helps to improve outcome and facilitates treatment
compliance.9,13
| Psychological treatments are the most effective, with drugs having a limited role in childhood but an increasingly important role during adolescence as more adult psychiatric conditions occur. The first consideration is to ensure that the child is safe. In depressed young people, suicide risk is assessed by determining a past history of suicide attempts and risk-taking behaviour, the experience of a sense of hopelessness, helplessness and having no future, and current suicidal ideas, plan and means.11 Referral to specialist services is required when the young person is suicidal. Children and adolescents need to know that what they tell you in private is confidential, unless they are a risk to themselves or others, or if they are being abused. Most children, provided they were present when information was gathered from the parents, are relieved to consent to the clinician sharing their concerns with parents. The young person usually wants to be present when feedback is given to parents and this process is often therapeutic. Psychological treatments
Cognitive-behavioural therapy |
Each treatment program is modified according to the symptoms, but
involves:
|
Play and psychodynamic psychotherapy |
These approaches rely on using play, discussion and the relationship
with the therapist to help children develop insight into their
problems and learn to understand and cope with their emotional
distress. There is growing evidence that these approaches do work,
but they are generally not as efficient and effective as
cognitive-behavioural therapy.18 The more recent
structured approach referred to as "interpersonal psychotherapy"
is providing results that are more equivalent to
cognitive-behavioural therapy when applied to the treatment of
internalising conditions.19
|
Family therapy |
There are a variety of different approaches to working with families,
but most are based on working with the family as a group, improving
communication and problem-solving skills, developing more
effective methods of discipline of behavioural control and the
expression of emotion, and encouraging new patterns of
interaction.20 Studies of family therapy
often have methodological problems, but, overall, it has been shown
to be useful in treating a range of child psychiatric problems
including conduct disorder and delinquency, anxiety and depression
and bereavement.19
| Pharmacotherapy |
Drugs have a limited role in managing psychopathology in children.
Even in cases where they have a clear therapeutic benefit, they should
be used as an adjunct to a more broadly based management plan which
involves the parents and, when appropriate, the school.
|
Internalising disorders |
The role of drug treatment for anxiety and depression in childhood has
still to be firmly established by controlled trials. There is limited
evidence that imipramine may reduce symptoms of anxiety in
separation anxiety disorder and school refusal.21 Some case
reports indicate a positive response to tricyclic antidepressants
in the treatment of depression in children and adolescents, but
systematic controlled studies have failed to demonstrate
significant efficacy compared with placebo.22
| A recent placebo-controlled outpatient study of young people (aged 7-17 years) with non-psychotic major depression found significant improvement in depression rating scale scores and clinical assessment in a group treated with the selective serotonin reuptake inhibitor fluoxetine (20 mg morning dose for eight weeks).23 This finding requires replication. The judicious use of antidepressants as a secondary treatment is justified with regular review and monitoring for side effects and compliance. There is no evidence that benzodiazepines have any role in the treatment of anxiety or depression in children, and they might even produce paradoxical responses.24 Due to potentially serious side effects, neuroleptic drugs such as thioridazine should only be used in consultation with a specialist.
Externalising disorders |
Conduct disorder: There is virtually no indication
for the use of drugs in the treatment of conduct disorder unless the
child also suffers from ADHD or a depressive disorder.13
| Attention deficit hyperactivity disorder: There is a large body of evidence that, for school-aged children with ADHD, psychostimulants such as dextroamphetamine and methylphenidate reduce motor activity, enhance attention in cognitive performance and improve social behaviour.14,25 The effective daily dose of methylphenidate is usually 0.3-0.5 mg per kg. Preschool children have a more unpredictable response and respond better to parent training and behavioural management programs. Although psychostimulants are generally safe, they can have a number of troublesome side effects, including anorexia and weight loss, sleep disturbance, abdominal pains and headaches, irritability and depressed mood. Growth can also be inhibited, but this is reversible on drug discontinuation. Drug dependence has not been demonstrated. Clonidine is an alpha-adrenergic agonist used primarily in the treatment of hypertension. It has also been shown to be effective in the treatment of ADHD (25-50 mg one to three times a day; monitor blood pressure), although sedation may be a troublesome side effect.14,24 Imipramine (25-50 mg in a single evening or divided dose; history of heart disease is a contraindication; check pulse) has also been shown to be effective, but whether this is more specifically in a group of children with ADHD who also have concurrent anxiety has not yet been determined.24 Consulting teachers and providing structured educational programs that address specific learning disabilities and facilitate and reward success are also an important adjunct to the treatment of childhood emotional and behavioural disorders. The role of the general practitioner |
Most childhood psychiatric disorders can be effectively managed in a
general practice and community setting. Brief
cognitive-behavioural therapy, family therapy and
parenting-skills training can be provided in 15-20-minute
consultations if the general practitioner has received
introductory skills training in these techniques. The necessary
regular monitoring of drug therapy for compliance, side effects and
therapeutic response is also appropriate for the general
practitioner.
|
When to refer |
Referral to a specialist paediatrician with an interest in
behavioural paediatrics or a child psychiatrist should occur if the
prescription of psychoactive drugs is contemplated, when simple
behavioural and family support interventions fail, when symptoms
persist, when there is suicidal risk, or when there is evidence of
psychosis. A clinical child psychologist can also provide cognitive
and psychopathology assessment and psychological treatments. If
child abuse is suspected, reporting to the relevant community
services agency is necessary (if not mandatory according to local
laws).
| Early and timely intervention produces the best chance of a favourable outcome and improves the prognosis for all childhood emotional and behavioural problems. References |
|
Authors' details | Monash University Centre for Developmental Psychiatry, Monash
Medical Centre, Melbourne, VIC.
| Bruce J Tonge, MD, FRANZCP, MRCPsych, CertChildPsych, Professor, and Head. Correspondence: Professor B J Tonge, Monash University Centre for Developmental Psychiatry, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168.
| ||||||||||||||||||||||||||||||