Child and adolescent psychiatry

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Child and adolescent psychiatry (or pediatric psychiatry) is a branch of

biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions.[1]
Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the pediatric population.

Classification of disorders

Main article: Mental disorders diagnosed in childhood

There are many classifications of disorders. Developmental disorders include

persistent depressive disorder, and disruptive mood dysregulation disorder
are under the classification of mood disorders.

A wide range of disorders that are classified as eating disorders include

alcohol use disorder or cannabis use disorder
.

Disorders are often comorbid. For example, an adolescent can be diagnosed with both major depressive disorder and generalized anxiety disorder. The incidence of psychiatric comorbidities during adolescence may vary by race, ethnicity and socioeconomic status, among other variables.[2]

Clinical practice

Assessment

The

adolescent starts with obtaining a psychiatric history by interviewing the young person and his/her parents or caregivers. The assessment includes a detailed exploration of the current concerns about the child's emotional or behavioral problems, the child's physical health and development, history of parental care (including possible abuse and neglect), family relationships and history of parental mental illness. It is regarded as desirable to obtain information from multiple sources (for example both parents, or a parent and a grandparent) as informants may give widely differing accounts of the child's problems. Collateral information is usually obtained from the child's school with regards to academic performance, peer relationships, and behavior in the school environment.[3]

Psychiatric assessment always includes a

mental state examination of the child or adolescent which consists of a careful behavioral observation and a first-hand account of the young person's subjective experiences. This assessment also includes an observation of the interactions within the family, especially the interactions between the child and his/her parents.[4]

The assessment may be supplemented by the use of behavior or symptom rating scales such as the Achenbach Child Behavior Checklist or CBCL, the Behavioral Assessment System for Children or BASC,

intellectual impairment or other cognitive problems which may be contributing to the child's difficulties.[6]

Diagnosis and formulation

The child and adolescent psychiatrist makes a diagnosis based on the pattern of behavior and emotional symptoms, using a standardized set of diagnostic criteria such as the

case formulation is standard practice for child and adolescent psychiatrists and can be defined as a process of integrating and summarizing all the relevant factors implicated in the development of the patient's problem, including biological, psychological, social and cultural perspectives (the "biopsychosocial model").[10] The applicability of DSM diagnoses have also been questioned with regard to the assessment of very young children: it is argued that very young children are developing too rapidly to be adequately described by a fixed diagnosis, and furthermore that a diagnosis unhelpfully locates the problem within the child when the parent-child relationship is a more appropriate focus of assessment.[11]

The child and adolescent psychiatrist then designs a treatment plan which considers all the components and discusses these recommendations with the child or adolescent and family.

Treatment

Treatment will usually involve one or more of the following elements: behavior therapy,[12] cognitive-behavior therapy,[13] problem-solving therapies,[14] psychodynamic therapy,[15][16] parent training programs,[17] family therapy,[18] and/or the use of medication.[19] The intervention can also include consultation with pediatricians,[20] primary care physicians[21] or professionals from schools, juvenile courts, social agencies or other community organizations.[22]

In a review of existing meta-analyses and disorders on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder), only for ADHD was the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders.[23][24]

Training

In the United States, Child and adolescent psychiatric training requires 4 years of medical school, at least 4 years of approved residency training in medicine, neurology, and general psychiatry with adults, and 2 years of additional specialized training in psychiatric work with children, adolescents, and their families in an accredited residency in child and adolescent psychiatry.[25] Child and adolescent sub-speciality training is similar in other Western countries (such as the UK, New Zealand, and Australia), in that trainees must generally demonstrate competency in general adult psychiatry prior to commencing sub-speciality training.

Certification and continuing education

In the US, having completed the child and adolescent psychiatry residency, the child and adolescent psychiatrist is eligible to take the additional certification examination in the subspecialty of child and adolescent psychiatry from the American Board of Psychiatry and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP).[26] Although the ABPN and AOBNP examinations are not required for practice, they are a further assurance that the child and adolescent psychiatrist with these certifications can be expected to diagnose and treat all psychiatric conditions in patients of any age competently. Training requirements are listed on the web site of The American Academy of Child & Adolescent Psychiatry.[27]

Shortage of child and adolescent psychiatrists in the United States

The demand for child and adolescent psychiatrists continues to far outstrip the supply worldwide. There is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced.[28] As of 2016, there are 7991 child and adolescent psychiatrists in the United States. A report by the US Bureau of Health Professions (2000) projected a need by the year 2020 for 12,624 child and adolescent psychiatrists, but a supply of only 8,312. In its 1998 report, the Center for Mental Health Services estimated that 9-13% of 9- to 17-year-olds had serious emotional disturbances, and 5-9% had extreme functional impairments. In 1999, however, the Surgeon General reported that "there is a dearth of child psychiatrists." Only 20% of emotionally disturbed children and adolescents received any mental health treatment, a small percentage of which was performed by child and adolescent psychiatrists. Furthermore, the US Bureau of Health Professions projects that the demand for child and adolescent psychiatry services will increase by 100% between 1995 and 2020.[29]

Cross-cultural considerations

Steady growth in migration of immigrants to higher-income regions and countries has contributed to the growth and interest in cross-cultural psychiatry. Families of immigrants whose child has a psychiatric illness must come to understand the disorder while navigating an unfamiliar health care system.[30][31]

Criticisms

Subjective diagnoses

One criticism against psychiatry is that psychiatric diagnoses lack complete "objectivity," particularly when compared with diagnoses in other medical specialties. However, for several major psychiatric disorders

interrater reliability, which shows the degree to which psychiatrists agree on the diagnosis, is generally similar to those in other medical specialties.[32] In 2013, Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests."[33][34]

Traditional deficit and disease models of child psychiatry have been criticized as rooted in the medical model which conceptualizes adjustment problems in terms of disease states. It is said by these critics that these normative models explicitly characterize problematic behavior as representing a disorder within the child or young person and these commentators assert that the role of environmental influences on behavior has become increasingly neglected, leading to a decrease in the popularity of, for example, family therapy. There are criticisms of the medical model approach from within and without the psychiatric profession (see references): it is said to neglect the role of environmental, family, and cultural influences, to discount the psychological meaning of behavior and symptoms, to promote a view of the "patient" as dependent and needing to be cured or cared for and therefore undermines a sense of personal responsibility for conduct and behavior, to promote a normative conception based on adaptation to the norms of society (the ill person must adapt to society), and to be based on the shaky foundations of reliance on a classificatory system that has been shown to have problems of validity and reliability (Boorse, 1976; Jensen, 2003; Sadler et al. 1994; Timimi, 2006).[full citation needed]

Prescription of psychotropic medications

Since the late 1990s, use of psychiatric medication has become increasingly common for children and adolescents. In 2004 the U.S.

Black Box Warning on antidepressant prescriptions to alert patients of a research link between use of medication and apparent increased risk of suicidal thoughts, hostility, and agitation in pediatric patients. The most common diagnoses for which children receive psychiatric medication are ADHD, ODD, and conduct disorder.[35]

Some research suggests that children and adolescents are sometimes given antipsychotic drugs as a first-line treatment for mental health problems or behavioral issues other than a psychotic disorder.[36] In the United States, the usage of these drugs in young people has greatly increased since 2000, especially among children from low-income families.[36] More research is needed to specifically assess the efficacy and tolerability of antipsychotic medications in pediatric populations. Because of the risk of metabolic syndrome and cardiovascular events with long-term antipsychotic use, use in pediatric populations is highly scrutinized and recommended in combination with psychotherapy and effective parent-training interventions.[36]

Electroconvulsive therapy

In 1947, child neuropsychiatrist

Rockland State Hospital, a psychiatric facility now known as the Rockland Psychiatric Center.[41]

History

When psychiatrists and pediatricians first began to recognize and discuss childhood psychiatric disorders in the 19th century, they were largely influenced by literary works of the Victorian era.

Brontë sisters, George Eliot, and Charles Dickens, introduced new ways of thinking about the child mind and the potential influence early childhood experiences could have on child development and the subsequent adult mind. When the Journal of Psychological Medicine and Mental Pathology, the first psychiatric journal in English, was published in 1848, child psychiatry didn't exist as its own field yet. However, some of the earliest works on the possibility of nervous disorders and "insanity" in children were published in the Journal and several medical writers directly referenced works such as Jane Eyre (1847), Wuthering Heights (1847), Dombey and Son (1848), and David Copperfield (1850), to illustrate this new conceptualization of the child mind. Until that time, it was generally accepted that children were free from nervous disorders and the "passions" that affected the adult mind.[42]

As early as 1899, the term "child psychiatry" (in French) was used as a subtitle in Manheimer's monograph Les Troubles Mentaux de l'Enfance.

autism, otherwise known as Kanner Syndrome.[46]

Maria Montessori together with It:Giuseppe Ferruccio Montesano and Clodomiro Bonfigli, two distinguished child psychiatrists, created in 1901 in Italy the "Lega Nazionale per la Protezione del Fanciullo" (National League for the Protection of Children). She gradually developed her own pedagogic method, initially based on the "intuition that the question of the 'mentally deficient' was more pedagogic than medical".[47] In 1909, Jane Addams and her female colleagues established the Juvenile Psychopathic Institute (JPI) in Chicago, later renamed as the Institute for Juvenile Research (IJR), the world's first child guidance clinic.[48] Neurologist William Healy, M.D., its first director, was charged with not only studying the delinquent's biological aspects of brain functioning and IQ, but also the delinquent's social factors, attitudes, and motivations, thus it was the birthplace of American child psychiatry.[49]

From its establishment in February 1923, the Maudsley Hospital, a South London-based postgraduate teaching and research psychiatric hospital, contained a small children's department.[50] Similar overall early developments took place in many other countries during the late 1920s and 1930s.[51] In the United States, child and adolescent psychiatry was established as a recognized medical speciality in 1953 with the founding of the American Academy of Child Psychiatry, but was not established as a legitimate, board-certifiable medical speciality until 1959.[52][53]

The use of medication in the treatment of children also began in the 1930s, when

hyperactive children.[54] But it was not until the 1960s that the first NIH grant to study paediatric psychopharmacology was awarded. It went to one of Kanner's students, Leon Eisenberg, the second director of the division.[45]

The discipline has relatively flourished since the 1980s, in large part, because of contributions made in the 1970s, even if the outcomes for patients have been disappointing at times. It was a decade during which child psychiatry witnessed a major evolution as a result of the work carried out by,

depression in mid-adolescence and the frequent co-morbidity with conduct disorder, and explored the relationship between various mental disorders and scholastic achievement.[56]

It was paralleled similarly by work on the

childhood or adolescence (DSM-IV).[citation needed
]. The American Psychiatric Association's DSM is now on its fifth edition (DSM-5).

People in the field are sometimes referred to as "neurodevelopmentalists".[59][60] As of 2005 there was debate in the field as to whether "neurodevelopmentalist" should be made a new speciality.[61]

In terms of patient outcomes, there is evidence that, in the United Kingdom at least on the 70th anniversary of the NHS, mental health remains a medical "Cinderella" (low priority) and the more so Child and Adolescent Health services which have been through repeated reorganisations and underinvestment all of which leads to disruption and loss of adequate provision.[62]

"Modern neuroscience, genetics, epigenetics, and public health research has presented the tantalizing possibility that it can now be said with relative certainty that much (certainly not all) is understood about why some children struggle and others soar. Although it is an oversimplification, it can now be suggested that it is possible to understand how environmental factors, both negative and positive, influence the genome or epigenome, which in turn influence the structure and function of the brain and thus human thoughts, actions, and behaviors."[63]

See also

Notes

  1. ISBN 9780781793872
  2. S2CID 29157841
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  3. ^ Rutter, Michael and Taylor, Eric. Chapter 2, Clinical assessment and diagnostic formulation. In Rutter and Taylor (2002)
  4. ^ Angold, Adrian. Chapter 3, Diagnostic interviews with parents and children. In Rutter and Taylor (2002)
  5. ^ Verhulst, Frank and Van der Ende, Jan. Chapter 5, Rating scales. In Rutter and Taylor (2002)
  6. ^ Sergeant, Joseph and Taylor, Eric. Chapter 6, Psychological testing and observation. In Rutter and Taylor (2002)
  7. ISBN 978-0-89042-555-8. {{cite book}}: |website= ignored (help
    )
  8. ^ "ICD-11". icd.who.int.
  9. PMID 18516309
  10. PMID 17141121
  11. PMID 19486838
  12. ^ Herbert, Martin. Chapter 53, Behavioural therapies, in Rutter and Taylor (2002)
  13. ^ Brent, David, Gaynor, Scott and Weersing, Robin. Chapter 54, Cognitive-behavioural approaches to the treatment of depression and anxiety. In Rutter and Taylor (2002)
  14. ^ Compas, Bruce, Benson, Molly et al. Chapter 55, Problem-solving and problem-solving therapies, in Rutter and Taylor (2002)
  15. PMID 16292115
    .
  16. PMID 19242290
    .
  17. ^ Scott, Stephen. Chapter 56, Parent training programmes, in Rutter and Taylor (2002)
  18. ^ Jacobs, Brian and Peaarse, Joanna.Chapter 57, Family therapy, in Rutter and Taylor (2002)
  19. ^ Heyman, Isobel and Santosh, Paramala. Chapter 59, Pharmacological and other physical treatments, in Rutter and Taylor (2002)
  20. ^ Rauch, Paula and Jellinek, Michael. Chapter 62, Paediatric consultation, in Rutter and Taylor (2002)
  21. ^ Garralda, Elena. Chapter 65, Primary health care psychiatry, in Rutter and Taylor (2002)
  22. ^ Nicol, Rory. Chapter 64, Practice in non-medical settings, in Rutter and Taylor (2002)
  23. PMID 20671900
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  24. PMID 18791982
    .
  25. ^ "What is Child and Adolescent Psychiatry?". www.aacap.org. Retrieved 2021-03-19.
  26. ^ "Specialties & Subspecialties". American Osteopathic Association. Archived from the original on 2015-08-13. Retrieved 18 September 2012.
  27. ^ AACAP Archived 2007-09-29 at the Wayback Machine
  28. S2CID 17187044
  29. ^ "Child and Adolescent Psychiatry as a Career". www.aacap.org. Retrieved 2021-03-19.
  30. ^ Wintrob R. Cross-cultural psychiatry. Psychiatric Times. 2010;27:27.
  31. ^ Measham T, Guzder J, Rousseau C, Nadeau L. Cultural considerations in child and adolescent psychiatry. Psychiatric Times. 2010;27:38-40.
  32. PMID 20428307
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  33. S2CID 8486296
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  34. PMID 23737411
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  35. ^ Webber, Jo., Plotts, Cynthia A. Emotional and Behavioral Disorders Theory and Practice 5th Edition. 2008. Pearson Education: New York, NY. p. 98.
  36. ^
    ABIM Foundation, American Psychiatric Association
    , retrieved 30 December 2013, which cites
  37. PMID 9137112.{{cite journal}}: CS1 maint: multiple names: authors list (link
    )
  38. ISBN 978-0-8135-4169-3.{{cite book}}: CS1 maint: multiple names: authors list (link
    )
  39. ^ Boodman, Sandra G. (24 September 1996). "Shock therapy: it's back". Washington Post.
  40. ^ Sullivan, Valerie (30 October 1982). "General news: Berkeley, California". United Press International.
  41. ^ Hill, Gladwin (31 October 1982). "Now therapy by the ballot". The New York Times. Retrieved 23 March 2011.
  42. ^
    S2CID 35218208
  43. doi:10.1192/bjp.46.193.342
    .
  44. PMID 14154770
  45. ^ a b c d "Child and Adolescent Psychiatry at the Johns Hopkins Hospital". Archived from the original on 2009-08-21. Retrieved 2009-07-22.
  46. S2CID 2513608
  47. ISBN 978-3-642-96005-5
  48. ^ Beuttler, Fred and Bell, Carl (2010). For the Welfare of Every Child – A Brief History of the Institute for Juvenile Research, 1909 – 2010. University of Illinois: Chicago
  49. ^ Schowalter, John E. (2000). Child and Adolescent Psychiatry Comes of Age, 1944-1994. In Menninger RW and Nemiah JC (Eds). American Psychiatry After World War II – 1944 – 1994. Washington, D.C.: American Psychiatric Press, p. 461 – 480
  50. PMID 19397089
  51. PMID 19397089
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  52. ^ "About Us". AACAP. Archived from the original on 21 April 2011. Retrieved 25 March 2011.
  53. ISBN 978-0-202-30431-1
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  54. PMID 21451781
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  55. ^ Green, Jonathan; Yule, William (2001), "Foreword", in Jonathan Green and William Yule (ed.), Research and Innovation on the Road to Modern Child Psychiatry: Festschrift for Professor Sir Michael Rutter, London, p. vii{{citation}}: CS1 maint: location missing publisher (link); Stevenson, Jim (2001), "The Significance of Genetic Variation for Abnormal Behavioural Development", in Jonathan Green and William Yule (ed.), Research and Innovation on the Road to Modern Child Psychiatry: Festschrift for Professor Sir Michael Rutter, London, p. 20{{citation}}: CS1 maint: location missing publisher (link)
  56. ISBN 978-0-87630-602-4
  57. PMID 24014081
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  58. ^ Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington DC: American Psychiatric Association, 1994
  59. PMID 11153486
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  60. doi:10.1016/S0887-8994(97)90006-0
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  61. doi:10.1176/appi.ajp.162.6.1234
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  62. doi:10.4000/rfcb.4138
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  63. ^ Child Adolesc Psychiatric Clin N Am 26 (2017) 611–624

References

External links

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