Child and adolescent psychiatry

Specialty

Anatomy or system affected: All

Specialties and related fields: Critical care, family medicine, neurology, pharmacology, preventive medicine, public health

Definition: The branch of psychiatry concerned with the mental and emotional health and development of infants and teenagers.

Science and Profession

Specialists in child and adolescent psychiatry are responsible for the physical and mental health of the individuals whom they treat. They must be acute observers of individual and family behavior, as well as knowledgeable about how certain nutritional, physical, and situational conditions can manifest themselves as mental or emotional problems. Particularly with infants, this requires keen knowledge of normal and abnormal development, both mental and physical. Additionally, these specialists must be able to consult with a variety of medical and other professionals—from psychologists, who provide behavioral and diagnostic assessments, to social work professionals and lawyers, when child abuse or neglect enters into the clinical picture.

Practitioners in child or adolescent psychiatry receive extensive training. First, they must complete medical school in order to obtain a doctorate in medicine. Next, they must complete a four-year residency in psychiatry and a two-year specialty residency in child psychiatry. Finally, they must go through licensing and certification procedures in order to practice independently.

This training prepares them to diagnose and treat the wide variety of psychiatric disorders experienced by children and adolescents. Anxiety, attention deficit hyperactivity disorder, autism spectrum disorder, social (pragmatic) communication disorder, conduct disorder, specific learning disabilities, intellectual disabilities, mood disorders, oppositional defiant disorder, and addiction and substance-related disorders are some of the most well researched disorders in children. Other problems include asthma, elimination disorders (such as bedwetting or bedsoiling), child abuse and neglect, child sexual abuse, feeding and eating disorders, selective mutism, gender dysphoria, personality disorders, disorders of arousal (such as sleepwalking and sleep terrors), childhood-onset fluency disorder (formerly called stuttering), and disruptive mood dysregulation disorder. Disorders such as these are described in detail in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed., 2013).

Diagnostic and Treatment Techniques

Practitioners of child and adolescent psychiatry are generally introduced to their patients via the parents or an intervening medical professional or agency. In most cases, these specialists diagnose disorders through clinical interviews with the patient, the patient’s parents, and sometimes even schoolteachers or other observers of relevant problems. Additionally, diagnoses are sometimes confirmed via a patient’s response to drugs (such as Ritalin, antidepressants, or lithium carbonate) or via test results from a psychological or behavioral assessment. Some assessments are based on structured, pencil-and-paper tests that measure intelligence or other personal attributes. Others are based on direct observations of the patient and/or family interactions.

Once a diagnosis is made, practitioners provide therapy to the individual child or adolescent and/or to family members. Acute or severe problems might be treated in a hospital setting, while chronic or mild problems might be treated on an outpatient basis. Therapies typically selected include medicinal and psychotropic drugs, dietary recommendations, behavioral therapies and parent training, family therapy, play therapy, and individual psychotherapy. In these situations, a good practitioner will try to involve the child in the process of consent to treatment so as to facilitate trust and gain compliance from the child.

Finally, practitioners in this specialty area perform two other important functions. First, in some cases, no disorder is present, and the psychiatrist provides normative information about child and adolescent growth and development. Second, these professionals must provide protection to suspected victims of abuse or neglect. In such cases, the psychiatrist must report these suspicions to the appropriate authorities, initiate referral to social service agencies, and protect the children or adolescents as necessary.

Perspective and Prospects

Work by Sigmund Freud, the Austrian physician and founder of psychoanalysis, marked the birth of this field of study. By focusing his work on the relationship between childhood experiences and adult functioning, Freud was able to foster interest in child development and welfare. Issues such as family relationships; the emotional, physical, and sexual mistreatment of children; and differences in the way that children and adults perceive and experience the world became highlighted through his work and that of those who followed. Finally, in 1959, child psychiatry became a specialty certified by the American Board of Psychiatry and Neurology, adding credibility and importance to this growing field of practice and research.

Today, child and adolescent psychiatry remains in its infancy compared to other specialties. Relationships between childhood and adult disorders continue to be explored through a variety of epidemiological, genetic, psychiatric, and behavioral studies. Prime topics include connections among attention deficit hyperactivity disorder, mood, learning, and a broad spectrum of developmental disorders. Similarly, interest in understanding how trauma, neglect, and family influences relate to childhood mood, learning, and substance use disorders is also increasing.

Innovative drug and psychotherapeutic strategies are being explored for the disorders described above. The greatest treatment advances should be expected in the development and application of new drug therapies for childhood and adolescent psychiatric disorders. Further, refinement of behavioral assessment and management strategies for both school and home environments are likely to contribute greatly to this progress. Finally, because this specialty faces growing challenges posed by long-term childhood medical disorders, such as cancer, it is likely that interventions will be improved specifically to meet these needs.

Key terms:

• development: the process of progressive change that takes place as one matures from birth to death; development can be gradual, as on a continuum, or ordered, as in distinctly different stages
• disorder: a persistent or repetitive maladaptive pattern in thinking, behaving, or feeling that necessitates treatment
• intellectual disability: also called intellectual developmental disorder; a disorder characterized by deficits in adaptive functioning before the age of eighteen years and a below-average intelligence quotient (IQ); the degree of disability ranges from mild to severe
• normal: a term of reference that can mean average (as in statistically normal), functional (as in adaptive), or socially appropriate (as in within cultural bounds of acceptability)

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed., American Psychiatric Association, 2013. Provides comprehensive descriptions of mental disorders, as well as a glossary of technical terms.

Andreasen, Nancy C., and Donald W. Black. Introductory Textbook of Psychiatry. 4th ed. Washington, D.C.: American Psychiatric Press, 2006. Designed for use by medical and other students, this book provides basic information on psychiatry, various psychiatric disorders, treatments, and special topics such as suicide, acquired immunodeficiency syndrome (AIDS), and disorders of childhood and adolescence.

Keck, Gregory C., and Regina M. Kupecky. Parenting the Hurt Child: Helping Adoptive Families Heal and Grow. Rev. ed. Colorado Springs, Colo.: NavPress, 2009. Past physical abuse or psychological trauma in adopted children can greatly impact the child’s new family. This book details how to recognize problems and the kind of counseling or psychiatric treatment to seek.

Koplewicz, Harold S. More than Moody: Recognizing and Treating Adolescent Depression. New York: Penguin, 2003. A leading clinician and researcher helps parents distinguish between normal teenage angst and depression, examining the warning signs, risk factors, and key behaviors, as well as treatment options.

Lewis, Melvin, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007. Covers such topics as child and adolescent development, theories of development, and psychiatric disorders.

Martin, Andrés, et al., eds. Pediatric Psychopharmacology: Principles and Practice. New York: Oxford University Press, 2003. A thorough discussion of the biological bases of pediatric psychopharmacology, including topics such as the various drugs routinely used in child psychiatry, complementary and alternative medicine approaches, and epidemiological, research, and methodological considerations. Includes an appendix of generic and commercial drug name equivalencies, preparations, and available dosages.

Turecki, Stanley, and Leslie Tonner. The Difficult Child. Rev. ed. New York: Bantam Books, 2000. Provides information on childhood behavior problems.