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 AdolescentsThe 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 completions4. 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 re-Increase 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 Wiley-Liss, Inc.

ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is a developmental manifestation of inattention and distractibility, with or without accompanying hyperactivity and impulsivity.

ADHDEither (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 hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.

(1) inattention:1. often fails to give close attention to details or makes

careless mistakes in schoolwork, work, or other activities

2. often has difficulty sustaining attention in tasks or play activities

3. often does not seem to listen when spoken to directly 4. 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)

5. often has difficulty organizing tasks and activities 6. often avoids, dislikes, or is reluctant to engage in

tasks that require sustained mental effort (such as schoolwork or homework)

7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

8. often easily distracted by extraneous stimuli 9. often forgetful in daily activities

(2) symptoms of hyperactivity-impulsivity : Hyperactivity1. 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"

6. often talks excessively

(2) symptoms of hyperactivity-impulsivity:

Impulsivity1. often blurts out answers before

questions have been completed 2. often has difficulty awaiting turn 3. 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 children2. ODD (Oppositional defiant Disorder)3. Mood Disorders: anxiety, depression, bipolar, 4. Psychotic Disorders 5. Thyroid disorders6. Tourette’s Syndrome7. Mental Retardation/ Pervasive Developmental Disorder8. Understimulating or overstimulating environments9. Substance Abuse Spectrum10. 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.

ADHDEpidemiology: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

ClonidineTenex

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. Nutritional2. Sleep3. Motivation assessment and approach4. Limit setting skills5. Coping skills development assessment6. Classroom Behavior Monitoring7. School Accomodations8. Behavior Modification9. Individual Therapy10.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 RevisedLong 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. Oppositional2. Cognitive Problems/Inattention3. Hyperactivity4. Anxious-Shy5. Perfectionism6. Social Problems7. Psychosomatic8. Conners’ Global Index9. DSM-IV Symptom Subscales10.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): 87–90. Clinical Case Rounds in Child and Adolescent Psychiatry: Neurofibromatosis Type 1, Cognitive Impairment, and Attention Deficit Hyperactivity DisorderNicola Keyhan, MA, MD FRCPC,1 Debbie Minden, PhD, CPsych,2 and Abel Ickowicz, MD, FRCPC1

PMCID: PMC2277290

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

A 25-year-old female presented with a long-term history of TTM. She also suffered from post partum depression which had been effectively treated with sertraline. There was no family history of TTM and she had not previously received psychiatric care for this disorder. She reported that she was twelve years old when she started to pull hair from the top of her head. The urge to pull her hair intensified in her early twenties.

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Case 2

The patient was using hair extensions to cover her hair loss at the time of assessment, and replaced them every six weeks due to ongoing pulling. Despite attempts to resist pulling and to distract herself, she continued to pull out her hair. Her symptoms worsened during periods of marked stressors, such as times of serious illness and the hospitalization of her infant. When asked about other triggers, she expressed great distress and cried when disclosing that seeing her child’s hair precipitated strong urges that led to pulling of his hair.

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Case 2

Clinical Case Rounds in Child and Adolescent Psychiatry: Trichotillomania-by-Proxy: A Possible Cause of Childhood AlopeciaKatherine C. Beattie,1 Dianne M. Hezel, BA,1,2 and S. Evelyn Stewart, MD1,2,3

1 Psychiatric & Neurodevelopmental Genetics Unit, Massachusetts General Hospital, Boston, Massachusetts, USA2 Obsessive-Compulsive Disorder Institute, McLean Hospital, Belmont, Massachusetts, USA3 Harvard Medical School, Boston, Massachusetts, USA

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Case 2

Corresponding email: dhezel@pngu.mgh.harvard.edu; Email: stewart@pngu.mgh.harvard.eduReceived August 12, 2008; Accepted January 11, 2009.Keywords: Trichotillomania-by-proxy, trichotillomania, childhood alopecia, hair loss, Munchausen-by-proxy

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Case 3

Case ReportAlice, 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 ReportAlice 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 ReportUpon 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 ReportShe 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

It was not until 1919, thatKraeplin introduced the concept of dementia praecox and noted its onset in late childhood and adolescence (6). Given the insidious onset of the disorder, Kraeplin cautiously suggested that 3.5% of patients with schizophrenia had the onset of their illness before the age of 10 years.

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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 Psychotic symptoms can be attributed to distinct

mental illnesses (functional psychoses), which are contrasted with the psychotic symptoms that usually result from a demonstrable underlying pathologic mechanism and organic origin (organic psychoses), such as delirium. Cognitive impairments, particularly impaired concentration and ability to focus, usually accompany psychosis in children. However, when the psychosis is secondary to an organic origin, there is often accompanying impairment in the sensorium presenting as confusion and disorientation, as is typical of delirium.

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Case 3 Schizophrenic psychoses with onset before age 11 years are

rare. The prevalence in this age group is about 0.01 to 0.05per 1,000. In addition, developmental status can affect theexpression of the disorder. The earliest descriptions by De-Sanctis (5), Bleuler (49), and Kraeplin (6) reported the onsetand occurrence during childhood and considered schizophrenic psychoses to be an early onset of the same disease.

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Case 3 Neuroimaging

findings include a progressive increase in ventricular sizeand 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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Case 3 Brief Reactive Psychosis

Occasionally, children and adolescents suddenly developpsychotic symptoms that can last from a few hours or days.The child experiences these symptoms when under tremendousstress, such as after a death in the family, witnessed acts of violence or destruction, or physical or sexual abuse.The acute psychotic symptoms often resolve quickly, with totalrecovery in a few days. These youngsters may suddenly becomedisorganized, confused, agitated, or withdrawn. At times, their speech becomes nonsensical and incomprehensible.They may also experience delusions and hallucinations.These, too, are usually short-lived.

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Case 3 Organic Psychoses

Neurologic ConditionsSeizure DisorderChildren with seizure disorders can experience hallucinationsas part of the seizure activity. Complex partial seizures, especially those with a temporal focus, may be associated with interictal psychotic symptoms of delusions, hallucinations, and unusual preoccupations. Caplan and co-workers described a formal thought disorder in children with partial complex seizures (78,79), although their way of defining thought disorder makes it intertwine closely with language organization deficits.

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Case 3 Organic Psychoses

Neurologic ConditionsSeizure DisorderHowever, 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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Case 3 Organic Psychoses

Neurologic ConditionsSeizure DisorderCaplan 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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Case 3 Organic Psychoses

Neurologic ConditionsMetabolic and Hormonal DisturbancesVarious 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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Case 3 Organic Psychoses

Neurologic Conditions

Toxic PsychosesToxic 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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Case 3 Organic Psychoses

Neurologic ConditionsToxic PsychosesUnlike childhood schizophrenia or other psychotic disorders, in which impaired thinking and communication are the most salient symptoms, toxic psychosis is more likely to cause vivid, disturbing visual or tactile hallucinations and other perceptual problems. Auditory hallucinations can also occur, but their content is qualitatively different from thoseexperienced in childhood schizophrenia or mood disorders.

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Case 3 Organic Psychoses

Neurologic ConditionsToxic PsychosesThese 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 frighteningconcept, 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 Abraham (not his real name) first came to the McLean

outpatient department at the age of 13.5 years. He had just been discharged from inpatient hospitalization and required ongoing outpatient pharmacologic management. His mother stated that he had been diagnosed with Asperger’s disorder and despite numerous placements in therapeutic schools, hospitalizations, and medication trials, he continued to be violent and aggressive.

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Case 4 None of the medications that he had tried had been

effective, except thioridazine. Abraham had been treated with thioridazine, 125 mg/day, for an extended period. Both parents, who were well educated, felt that their son did not simply have Asperger’s disorder, and they wanted to know what other diagnoses could be made. In addition, Abraham’s parents were concerned about his current medication regimen because he had recently developed an unusual tongue movement, which was most prominent when he missed a dose of thioridazine.

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Case 4 At the initial evaluation, Abraham had ongoing sleep

disturbances, obsessions, sadness, irritability, and racing thoughts. He spoke in a loud, anxious manner. He washed all the clothes in the house in a frenzied and intense manner late into the night, even if the items were clean. Abraham obsessed about a girlfriend who he reported was enrolled at a local public high school, although the girlfriend did not, in fact, exist. Abraham also felt that God could transfer thoughts from one person to another and that God and 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

His mother said that Abraham had become more aggressive over the past few months. Without provocation, he had hit his younger siblings and struck out at people. In addition, his mother described him as being more perseverative than usual. He was extremely intrusive physically and engaged in some inappropriate touching. His mother stated that Abraham’s whole family was gravely affected by his behavior. His siblings were afraid of him. His mother, who was a graduate student at the time, had missed many classes, and his father often had to leave work early in order to help with Abraham. stopped.

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Case 4

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 old. Psychological testing at that time showed that he had some looseness of association and some breaks with reality. Psychotherapy notes at that time stated that he had "manic-like behaviors."

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Case 4

Since the age of 8, he had undergone numerous evaluations. He had a history of being fidgety, having grandiose and 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

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 Asperger’s disorder. The most consistent historical diagnosis given to Abraham was pervasive developmental disorders not otherwise specified or Asperger’s disorder. However, none of the historical diagnoses had captured his symptom complex completely.

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Case 4

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.The results of past neurologic evaluations, including an EEG and magnetic resonance imaging, had all been within normal limits. A test for fragile X syndrome had been negative. At 6 years old, Abraham had psychological testing; his verbal IQ was 111, and his performance IQ was 97. He had difficulty grasping a pencil and was noted to have trouble placing pegs in a Peg-Board with only one hand.

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Case 4 He had difficulty "reading" the emotional content in pictures

in the Children’s Apperception Test (which contains drawings of familiar social situations, such as a father sitting in a chair with a boy next to him). Abraham routinely had difficulty labeling the feelings shown in the pictures accurately and had difficulty perceiving the social interactions that were taking place. The examiner felt that his inability to identify the feelings of others was causing Abraham to misperceive what was going on socially in his environment.

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Case 4 In addition, Abraham was highly anxious and inattentive and

had difficulty with self-control. He was seen as managing his anxiety by trying to control social situations in an effort to counter some of the social rejection he faced. The examiner concluded that Abraham had a "social learning disability." At numerous subsequent psychological evaluations, Abraham was noted to have disorganized thinking.

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Case 4 He had been prescribed a number of medications over the

years. He was initially given imipramine but developed a glazed look and stomach aches, so it was discontinued. He had tried four selective serotonin reuptake inhibitors (SSRIs)—fluoxetine, clomipramine, sertraline, and paroxetine—all of which led to an increase in sleep disturbances, agitation, aggression, and, at times, homicidal ideation. In addition, he was given a low dose of methylphenidate (10 mg/day), which increased his agitation.

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Case 4 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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Case 4 Abraham was given the following diagnoses: bipolar

disorder (mixed, with psychotic features) and Asperger’s disorder, with features of OCD. Shortly after his initial outpatient evaluation, Abraham was hospitalized at McLean because of ongoing agitation and unsafe behavior

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Case 4 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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Case 4 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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Case 4 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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Case 4 Diagnosing Bipolar Disorder in Childhood

To illustrate how difficult it is to use the DSM-IV to diagnose children, the manual says that a hypomanic episode requires a "distinct period of persistently elevated, expansive, or irritable mood lasting throughout at least four days." Yet upwards of 70 percent of children with the illness have mood and energy shifts several times a day.

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Case 4 Diagnosing Bipolar Disorder in Childhood

Since the DSM-IV is not scheduled for revision in the immediate future, experts often use some DSM-IV criteria as well as other measures. For example, a Washington University team of researchers uses a structured diagnostic interview called Wash U KIDDE-SADS, which is more sensitive to the rapid-cycling periods commonly observed in children with bipolar disorder

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Case 4 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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Case 4 Diagnosing Bipolar Disorder in Childhood can have a

preventive impact:

1. removal from school, 2. placement in a residential treatment center, 3. hospitalization in a psychiatric hospital, 4. incarceration in the juvenile justice system 5. development of personality disorders such as narcissistic,

antisocial, and borderline personality 6. a worsening of the disorder due to incorrect medications 7. drug abuse, 8. accidents, 9. suicide.

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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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Case 4 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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Case 4

Bipolar Affective Disorder - Cyclothymia This variant is characterized by many episodes of Hypomania and occasional episodes of mild depression only. A child may have quite a few episodes of Hypomania over the span of a year.

The less severe form of high in bipolar disorder is hypomania.

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Case 4

Mixed states of Bipolar Affective DisorderIn 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 of the picture is however mania. Depressive and manic symptoms sometimes occur at the same time. Patients who are overactive and over-talkative may be having profoundly 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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Case 4

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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Case 4 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. Overthe past several decades, the prevalence of mood disordersappears to have been increasing (69). Although informationon the epidemiology of psychotic depression in children islimited, 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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Case 4 This overlap in symptoms increases the likelihood of

incorrect diagnosis, especially at the time of onset. Sometimes, the negative symptoms of schizophrenia in children can be mistaken for those of depression. However, it has been shown that children with schizophrenia have poorer premorbid adjustments, lower IQs, and more chronic dysfunction, when compared with children who suffer from a depressive disorder (50). It is therefore prudent to make only a tentative diagnosis at the outset that must be confirmed longitudinally. Careful follow-up of psychotic patients is needed to detect diagnostic errors.

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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)LithiumOften, the use of antipsychotic medications in additionto the use of antidepressants or mood stabilizers is indicated in functional psychosis.

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Case 5 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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Case 5 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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Case 5 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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Case 5 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 intrusivethoughts or worries regarding the traumatic event (73,76,77).

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Case 5 Anxiety Disorders

Mental status examination usually reveals the lackof a formal thought disorder, and the psychotic-like symptoms are more akin to derealization or depersonalization, as is often observed in traumatized children. Furthermore, there is often a qualitative difference in the way children with anxiety disorders and those with childhood-onset schizophrenia relate. The former have better-developed relationship and prosocial skills compared with the socially isolated, awkward, and odd behaviors of a child with schizophrenia.

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Case 5 Anxiety Disorders

An identifiable traumatic event, abuse, or neglectin the child’s history, in and of itself, does not necessarilyrule out a psychotic disorder, because children with bothschizophrenia and mood disorders may have had such experiences (73).

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Case 5 Anxiety Disorders

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 chromosome 3 that is linked to agoraphobia and two genetic loci on chromosomes 1 and 11q linked to panic disorder. Because social phobia shares some traits with panic disorder, it is likely that there are also genes that govern a person's susceptibility to social phobia. In addition, researchers at the National Institute of Mental Health (NIMH) have identified a gene in mice that appears to govern fearfulness.

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Case 5 Anxiety Disorders

Positron emission tomography (PET) scans of patients diagnosed with social phobia indicate that blood flow is increased in a region of the brain (the amygdala) associated with fear responses when the patients are asked to speak in public. In contrast, PET scans of control subjects without social phobia show that blood flow during the public speaking exercise is increased in the cerebral cortex, an area of the brain associated with thinking and evaluation rather than emotional arousal. The researchers have concluded that patients with social phobia have a different neurochemical response to certain social situations or challenges that activates the limbic system rather than the cerebral cortex.

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Case 5 Anxiety Disorders

TEMPERAMENT. A number of researchers have pointed to inborn temperament (natural predisposition) as a broad vulnerability factor in the development of anxiety and mood disorders, including social phobia. More specifically, children 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 remains over time.

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Case 5 Anxiety Disorders

Behavioral inhibition refers to a group of behaviors that are displayed when the child is confronted with a new situation or unfamiliar people. These behaviors include moving around, crying, and general irritability, followed by 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 parents are more likely to develop behavioral inhibition. One study of preadolescent children diagnosed with social phobia reported that many of these children had been identified as behaviorally inhibited in early childhood.

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Case 5 Anxiety Disorders

PSYCHOSOCIAL FACTORS. The development of social phobia is also influenced by parent-child interactions in a patient's family of origin. Several studies have found that the children of parents with major depression, whether or not it is 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 risk of developing more than one anxiety disorder. A family pattern of social phobia, however, is stronger for the generalized than for the specific or circumscribed subtype.

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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

“From the clinical perspective, the rapid change and development of childhood have immediate implications for diagnosis and intervention. When one is treating children, it is important to maintain diagnostic fluidity and 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, MichChief Social Worker, Section of Child and Adolescent Psychiatry, University of Michigan Medical School, Ann Arbor, MichClinical Assistant Professor; Director, Child and Adolescent Psychiatry Training Program, University of Michigan Medical School, Ann Arbor, Mich

Recommended Reading:

Read more: Social phobia - children, causes, DSM, functioning, therapy, adults, drug, person, people, used, medication, brain, skills, effect, women, health, traits, mood 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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