Child and Adolescent Psychiatry

CHILD AND ADOLESCENT PSYCHIATRY:

INTRODUCTION, CLASSIFICATION AND EVALUATION

Acknowledgements: Most of the information included in this chapter was obtained from the Handbook for Psychiatry, 2005, Mental Health Information Centre of SA, Department of Psychiatry, University of Stellenbosch.

Chapter by Professor Susan Hawkridge, Dr Linda Keyter and Dr Bennie Steyn

Child psychiatry was once regarded as a separate discipline: complex, highly specialised, and beyond the capacity of the general practitioner or even the general psychiatrist. In a privileged environment, any child who presented with a “non-organic” problem was referred directly to a child psychiatrist or child psychologist. The vast majority of underprivileged children with psychiatric or psychological problems received little or no assistance.

Changes in the economics of health care and the recognition of basic human rights have necessitated a more practical approach to child psychiatry. It is now internationally accepted that children with emotional, behavioural and developmental problems often have to be evaluated and sometimes treated at primary health care level. Therefore all general practitioners should be aware of psychiatric disorders that may occur in children, and the referral or treatment facilities available in their area.

REFERRAL OF CHILDREN TO CHILD PSYCHIATRY

Referral must first be discussed with the parents (and where appropriate with the child). Parents often feel threatened by the perceived implication that they are raising their child incorrectly, or that the child has a “problem”. The child also is often left with the impression that s/he “is” a problem. It is therefore sometimes not appropriate for the child to be “labelled” as a psychiatric patient.

Children should be referred to secondary or tertiary level when:

i)a psychiatric disorder is clearly present and the referring clinician does not feel competent to manage it

ii)a psychiatric disorder is suspected, but the diagnosis is unclear

iii)a general medical condition is complicated by a serious or complex psychiatric disorder

iv)academic problems are complicated by a serious or complex psychiatric disorder

v)trauma to or witnessed by the child has led to a psychiatric disorder (e.g., posttraumatic stress disorder)

vi)treatment of an apparently uncomplicated case at primary level has been unsuccessful.

Prevention of psychiatric morbidity

In certain cases, the general practitioner can play an important role in the prevention of psychiatric disorders, for example:

i)encouraging a healthy family lifestyle, especially during pregnancy

ii)early detection and referral or treatment of substance abuse by parents

iii)counselling and support after the birth of an “abnormal” child

iv)counselling when a diagnosis of serious illness or disability is made in a child, especially if the child has to be hospitalised

v)counselling and support when a family member dies or is diagnosed as terminally ill

vi)support to the family in which a parent or child has a psychiatric disorder.

By being aware of possible emotional reactions and allowing for outlets for those feelings, any health care worker can make a contribution to the prevention of psychiatric disorders or complications.

Normal development

The rate of development varies significantly from child to child, and in an individual child, one area of development is often more rapid than another. Development also does not happen at a constant rate, and with increased stress, a child may temporarily “regress” (return to a previous stage of development).

Anna Freud described the following “lines of development”, which are important in the evaluation of children and adolescents:

1. Dependence to emotional self-reliance and adult “object relations”

2. Feeding: Suckling to eating

3. Control of urine and faeces

4. Irresponsibility to responsibility in habits, self-care, etc.

5. Egocentricity to companionship

6. Play to work

1) Dependence

Following birth, the child is totally dependent, and his world consists of interaction with the mother figure. It is thought that he incorporates the mother’s body (e.g., her breast) into his internal world, and that this world is “good” when meeting his needs, and “bad” when he is hungry, cold or hot.

Only when the infant reaches the stage of "emotional object constancy", does he begin to react towards his mother as if he understands that the same person (the mother) sometimes causes him pleasure and sometimes distress. He is aware of her absence when she leaves, and pleased to see her again when she returns. This process is usually only completed by the age of three years.

Even before this stage is reached, the infant begins to play with his fingers and it also seems that he begins to experience himself as separate from his environment.

The toddler stage is a time of ambivalence in the relationship with the mother figure. He loves her intensely, but also wants to control her, and therefore reacts against her control over him. Gradually he learns to reason and begins to understand why he must not do certain things, which changes the nature of the relationship. There is less protest against her; he becomes more possessive and jealous when she pays attention to others (Sigmund Freud’s “Oedipal stage”).

The school age child becomes more involved in activities, and seeks approval and encouragement from his parents, and later from others, for instance, teachers and friends. If parents provide opportunities for him to develop his individuality, there will be less resistance to their authority. The more they dominate and control him, the earlier resistance will appear. Understanding parents will, in favourable circumstances, be able to manage each stage of the child’s development without major problems.

2) Feeding

Normal, healthy eating habits are learned when the mother manages the feeding of the child well and without emotional over-investment (e.g., when the child refuses to eat). Severe conflict about eating may predispose to later eating problems.

3) Control of bladder and faeces

Controlis acquired at varying rates in individual children. Anal sphincter control develops rapidly when the child begins to walk, but in this stage of normal oppositionality many children will offer resistance to toilet training. This is another area in which emotional reactions of the mother (or the primary care giver) can predispose to later problems.

4) Responsibility

An appropriate sense of responsibility is established when the child can be reasonably careful of his own safety, does not intentionally injure himself, and is not reckless or accident-prone. He should also not be overanxious about possible minor injury, which would limit his activities.

5) Egocentricity

It is important to realise that it is normal for an infant to be completely self-centred. He is not conscious of others’ feelings or needs, and it cannot be expected of the very young child to consider other children or adults. The one-year-old will normally push other children around as if they were toys. At a later stage he will be able to play together with or alongside them (“parallel play”) without seeing them as separate people or considering their opinions. Cooperative play, in which there is interaction with the other child as a separate person with his/her own ideas and with whom the child might compete, is a later development. This development occurs rapidly in children who are in stable day care with other children.

6) Play

The first playis with the child’s own body and his mother’s. Thereafter the stage of the “transitional object” follows. Soft toys, which may be treated tenderly or harshly by the child, become for a period of time the favourite companion. Later the child will only insist on the toy’s presence at bedtime or when stressed. In the daytime he will keep busy with various objects and activities. As he develops further, achievement and making things becomes of more importance. This creative energy is later channelled into school work and sport, and still later into the individual’s occupation.

Fears, fantasy and magical thinking

It is important to keep in mind that the normal preschool child has a very active imagination, and uses a great deal of fantasy and imaginative play. Magical thinking is a normal developmental phase, usually lasting until around 6 years of age. The child may believe that his/her actions magically influence or cause unrelated events.

This way of thinking plays an important role in the pathogenesis of certain immature cognitive schemata. The child, who is normally still somewhat egocentric, believes that s/he can change things in his/her environment as a result of his/her emotions, especially aggressive feelings. For example, if there is severe sibling rivalry, and the sibling becomes ill, the child may believe or fear that s/he has caused the illness.

At different developmental stages, the normal child may have certain central anxieties:

Fear of annihilation

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Fear of loss of the mother figure

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Fear of own aggression and other impulses

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Fear of damage to his body (so-called “castration anxiety”)

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Fear of punishment /fear that parents will cease to love him

ADOLESCENCE

Adolescence begins with puberty and lasts until adulthood. It is an important developmental phase in which many physical and emotional changes occur.

i) Physical development:

The teenager grows fast, and with the development of secondary sexual characteristics, his/her appearance changes significantly. The menarche is accompanied by an increase in body fat, and hormonal changes can cause skin problems in both sexes.

ii)Cognitive development:

According to Piaget,6 who regarded adolescence as the period of “formal operations”, the following properties are characteristic of intellectual development in this phase:

a) The individual can formulate and test hypotheses; he can accept propositions with the aim of arguing them.

b) He develops the capacity to seek general properties and rules in symbolic verbal material, to build imaginary systems, and to think about abstract, unknown and intangible concepts.

c) He becomes aware of his own thought patterns and uses these to strengthen his arguments.

d) He learns to understand and use complex ideas such as correlation and proportionality.

iii)Emotional development:

During adolescence the egocentricity of childhood should decrease. The teenager becomes moreinterested in others’ ideas and needs. He changes from a child who needs care and attention to an adult who can provide care and attention. Control over his own emotions becomes stronger, and the mechanisms by which he defends himself against criticism, etc, become more mature. He becomes more considerate and less selfish, particularly with respect to people outside his own family. In early adolescence this process is frequently disrupted by periods of regression, especially when stressful circumstances prevail.

iv)Moral development:

Basic moral standards are established in childhood; the child learns what his parents regard as right and wrong. The adolescent begins to think about broader issues and is often very idealistic; he seeks solutions for the whole world’s problems. His morality now incorporates wider philosophies, and can be influenced by the peer group. Moral maturity is achieved when decisions about what is right and wrong are based not on rules and laws but on well-considered individual values.7

v)Own identity:

The individual begins to look at himself and to question his ideals and personality traits. He compares himself with others and pays attention to his interpersonal relationships. He develops a sexual identity and an image of himself (his personality, character) in his mind. He becomes aware of himself as a unique individual.

The so-called 'TASKS' of adolescence thathave to be completed before adulthood is achieved are as follows:

(a) He must separate from his parents and become independent of them.

(b) He must establish his sexual identity.

(c) Preparedness to earn a living must be established.

(d) A personal moral system must be formulated.

(e) Stable lasting friendships with others must be made, as well as intimate relationships.

(f) A new relationship based on mutual respect must be negotiated with his parents.

Problems can be experienced in any of the above aspects of adolescent development. The child can become self-conscious because s/he has difficulty with the physical changes and new appearance of adolescence. Teenagers who are oversensitive about their weight can withdraw socially and be very unhappy. The child who does not develop as fast as his peer group can also become self-conscious or feel inadequate.

In other cases, conflict can develop between the child’s moral standards and those of his peers. Certain children will find it easier to “go with the group”, although they are uncomfortable with the behaviour this entails.

Incomplete developmental tasks

Problems can be experienced in any or all of six areas of development:

1)The young person remains emotionally and/or materially dependent on his parents beyond the stage at which this is culturally appropriate, or the parents will not allow him to separate from them.

2)Confusion about sexual identity.

3)The adolescent does not have the capacity to obtain or keep fixed employment, or he is fired for behavioural problems, substance abuse, etc., or he is unmotivated to work.

4)Risk-taking behaviour, conduct disorder and crime.

5)Adjustment disorder, depression and suicidal behaviour can be precipitated by relationship crises.

6)Many factors can influence the young person’s ability to develop an adult relationship with his parents. Sometimes the parents object to the youngster’s career choice, sometimes to his choice of partner. Some parents never manage to accept their child as an individual with his own personality and ideals.

Disorders during adolescence

A. Children who have been treated for psychiatric disorders before puberty will in all probability still need clinical attention during adolescence, e.g.:

1)Conduct disorder

2)Anxiety disorders

3)Scholastic problems and attention deficit/hyperactivity disorder

4)Disabled and autistic children often present with behavioural problems in adolescence

5)Gender identity disorder

6)Mood disorders

B. Children often present during adolescence with the onset of “adult” psychiatric disorders, e.g.:

SchizophreniaIncidence increases significantly during

Bipolar disorderadolescence in comparison to childhood

Major depressive episode

C. Disorders that can present at any age:

1)Adjustment disorders

2)Post-traumatic stress disorder

3)Psychiatric disorder secondary to a general medical condition

D. Disorders that characteristically begin in adolescence:

Anorexia Nervosa

Bulimia Nervosa

Substance-induced disorders (except glue sniffing, which is more common amongst younger children)

Para-suicidal behaviour (also presenting increasingly often in prepubertal children)

Social phobia

E. Traits suggestive of personality disorders may be seen during adolescence, although the diagnosis is not made until after the age of 18 years.

F. In South Africa it should be remembered that most new HIV-infections occur amongst adolescents and young adults.

Treatment of adolescent disorders

During this developmental stage, the young person’s experience of himself as a unique, separate and responsible individual is very important. Individual therapycan thus be effective for some adolescent disorders. Maturation of cognitive capacity makes it possible to use more abstract modalities. Group therapy is very effective during adolescence because relationships with peers are important to the teenager, and peer group feedback and pressure can be a valuable tool in altering views and behaviour.

Because the adolescent eventually has to separate from the family of origin, family therapy is often appropriate. The therapist can facilitate communication between the teenager and the parents, and when issues such as independence, recognition of the adolescent’s right to appropriate autonomy and negotiation of reasonable limits arise, the therapist can play an important role in defusing the tension and assisting the family to arrive at a conclusion. Parents are usually justifiably concerned with their adolescent child’s safety and future, and some protective rules are needed.

References

1. Rahman A, Mubbashar M, Harrington R, Gater R. Annotation: Developing child mental health services in developing countries. J Child Psychol Psychiatr 2000;41(5):539-46.
2. Diagnostic and Statistical Manual of Mental Disorders (4th Edition). Washington: American Psychiatric Association, 1994.
3. Epstein N, Bishop D, Baldwin LM. The McMaster Family Assessment Device. Journal of Family and Marital Therapy 1983;9:171-80.
4. Minuchin S. Families and family therapy. Cambridge: Harvard University Press, 1974.
5. Freud, A. Normality & Pathology in Childhood. International Universities Press, 1998.
6. Lewis M. Overview of Infant, Child and Adolescent Development. In: Wiener J, ed. Textbook of Child and Adolescent Psychiatry. Washington DC: American Psychiatric Press, 1997:39-66.
7. Kohlberg L. Revisions in the theory and practice of moral development. In: Damon W, ed. New Directions in Child Development: Moral Development. San Francisco: Jossey-Bass, 1978: 83-88.