PSYCHIATRIC EXAMINATION OF CHILDREN
Consult multiple sources:
Child: Young children usually report information in concrete terms but give accurate details about their emotional states.
Parents.
Teachers.
Child welfare/justice.
Methods of gathering information:
Play, stories, drawing.
Kaufman Assessment Battery for Children (K-ABC): Intelligence test for ages 2½ to 12.
Wechsler Intelligence Scale for Children–Revised (WISC-R): Intelligence quotient (IQ) for ages 6–16.
Peabody Individual Achievement Test (PIAT): Tests academic achievement.
MENTAL RETARDATION (MR)
See Neurologic Disease chapter.
LEARNING DISORDERS
See Neurologic Disease chapter.
BEHAVIORAL DISORDERS
DEFINITION
Behavioral disorders include oppositional defiant disorder and conduct disorder.
Oppositional Defiant Disorder (ODD)
A 9-year-old boy’s mother has been called to school because her son is defiant toward the teacher and does not comply with her requests to follow the rules. His parents reports similar scenarios at home, and he often becomes argumentative with them. Think: Oppositional defiant disorder.
ODD is a common mental health condition in children. It is more common in boys. A certain degree of oppositional behavior may be normal in childhood. However, normal defiance should not impair significant social relationship or academic performance. Children with this condition have substantially impaired relationships with parents, teachers, and peers. They might not show oppositional behavior in the pediatrician office. The diagnosis is therefore based on reports from the parents or teachers. Attention deficit/hyperactivity disorder (ADHD) and other mood disorders may coexist.
DIAGNOSIS
Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSMIV) definition: Recurrent pattern of negativistic, defiant, disobedient, and hostile behavior for 6 months.
Consistent pattern of disobedience toward parent or teacher
Four or more of the following criteria are usually present:
Loses temper.
Argues with adults.
Refuses to follow rules.
Deliberately annoys others.
Does not take responsibility for mistakes or behavior.
Sensitive, touchy, easily annoyed.
Angry, resentful.
Spiteful, vindictive.
Behavior causes impairment in social and academic functioning.
Rule out other causes of clinical presentation.
Temper tantrums and breath holding are manipulative behaviors.
PATHOPHYSIOLOGY
Low self-esteem, low frustration tolerance, precocious use of substances.
EPIDEMIOLOGY
Prevalence: 2–16%.
May be a precursor of a conduct disorder.
↑ incidence of substance abuse, mood disorders, disorder (ADHD).
ODD can be a developmental antecedent to conduct disorder. The former does not involve violation of the basic rights of others.
TREATMENT
Behavioral therapy, problem-solving skills.
Early intervention is more effective than waiting for a child to grow out of it.
Parental management training.
Conduct Disorder
A 9-year-old boy’s mother has been called to school because her son has been hitting other children and stealing pens. She reports that he often pokes their family cat with sharp objects. Think: Conduct disorder.
This disorder involves a variety of problematic behaviors, including oppositional and defiant behaviors and antisocial activities such as lying, stealing, running away, and physical violence. It is a pattern of behavior that violates the basic rights of others. The basic problem is a chronic conflict with parents, teachers, and peers. It is two to three times more common in boys. Conduct disorder is difficult to treat, and these behaviors are more likely to persist into adulthood.
DIAGNOSIS
Chronic conflict with parents, teachers, or peers.
A repetitive and persistent pattern of behavior that involves violation of the basic rights of others or of social norms and rules, with at least three of the following in 1 year:
Aggression toward people and animals.
Destruction of property.
Deceitfulness or theft.
Serious violation of rules.
The change in behavior causes significant impairment in social, academic, or occupational functioning.
A closely linked behavior is juvenile delinquency, which is a tendency to break the law or engage in illicit behavior.
ETIOLOGY
Lack of empathy is an important risk factor.
Involves genetic and psychosocial factors.
EPIDEMIOLOGY
Prevalence: 6–16% in boys, 2–9% in girls.
Up to 40% risk of developing antisocial personality disorder in adulthood.
↑ incidence of ADHD, learning disorders, mood disorders, substance abuse, and criminal behavior in adulthood.
Conduct disorder is one of the most difficult mental health problems during adolescence.
TREATMENT
Multimodal:
Structured environment, firm rules, consistent enforcement.
Psychotherapy: Behavior modification, problem-solving skills.
Adjunctive pharmacotherapy may help: Antipsychotics, lithium, selective serotonin reuptake inhibitors (SSRIs).
Conduct disorder is the most common diagnosis in outpatient psychiatry clinics.
ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD)
A 9-year-old boy’s mother has been called to school because her son has not done his homework. He claims that he did not know about the assignments. He interrupts other kids and is always getting up during class. His parents report that he cannot sit still at the dinner table. Think: ADHD.
ADHD is a common psychiatric disorder present in up to 10% of school-age children. Onset of symptoms occurs before age 7 yr. Inattention and distractibility is the hallmark. Classic triad: impaired attention, impulsivity, and excessive motor activity. Symptoms must be present in two or more situations, such as school and home. The diagnosis of ADHD is clinical.
DEFINITION
Three types predominantly:
Inattentive.
Hyperactive-impulsive
Combined: Most children have the combined type.
DIAGNOSIS
Six or more of the following for 6 months:
Inattention: Problems listening, concentrating, paying attention to details, organizing tasks, easily distracted, forgetful.
Hyperactivity-impulsivity: Unable to inhibit impulses in social behavior, → blurting out, interrupting, fidgeting, leaving seat, talking excessively.
Combined subtype: Six or more symptoms of inattention and hyper-activity-impulsivity.
Onset before age 7 yr.
Behavior inconsistent with age and development.
Impairment in two or more social settings.
Evidence of impairment in functioning.
The above may →:
Difficulty getting along with peers and family.
School underachievement secondary to poor organizational skills.
Poor sequential memory, deficits in fine motor skills.
Medical conditions and sleep conditions must be ruled out before a diagnosis of ADHD is made.
Important to rule out other situations that can trigger ADHD-type behaviors, such as death in the family, divorce, inner ear infection that causes temporary hearing problems, anxiety or depression, learning disability, child abuse.
The diagnosis of ADHD is clinical.
Onset of ADHD occurs no later than age 7 yr.
The three cardinal signs of ADHD:
Inattention
Hyperactivity
Impulsivity
Symptoms must be present in two or more situations for a diagnosis of ADHD.
ETIOLOGY
Genetic predisposition.
Environmental factors.
Perinatal complications, maternal nutrition and substance abuse, obstetric complications, viral infections.
Neurochemical/neurophysiologic factors.
Psychosocial factors, including emotional deprivation and parental anxiety and inexperience.
Family dysfunction.
PATHOPHYSIOLOGY
Catecholamine hypothesis, ↓ in norepinephrine metabolites.
Hypodopaminergic function, low levels of homovanillic acid.
Up to 15–20% continue to have ADHD in adulthood.
EPIDEMIOLOGY
Prevalence: 3–10% among young and school-age children.
Male-to-female ratio: 3:1.
↑ incidence of mood disorders, personality disorders, conduct disorder, and ODD.
Most cases improve in adolescence; 20% have symptoms into adulthood.
Stimulants used appropriately for ADHD do not cause addiction.
ADHD is the most common significant behavioral syndrome in childhood.
TREATMENT
Pharmacotherapy:
Psychostimulants (first-line drugs): Methylphenidate (Ritalin), dextro-amphetamine, pemoline.
Atomoxetine (second-line drug).
Atypical antipsychotics: On the rise; work by blocking dopamine.
Clonidine: Caution when using in combination with methylphenidate.
Psychotherapy:
Behavior modification, cognitive behavioral therapy.
Parental counseling: Positive reinforcement, firm nonpunitive limit setting, reduce external stimulation.
Group therapy: Social skills, self-esteem.
Two-thirds of children with ADHD also have conduct disorder or ODD.
PERVASIVE DEVELOPMENTAL DISORDERS (PDDs)
DEFINITION
Group of conditions that involve problems with social skills, language, and behaviors.
Apparent early in life with developmental delay involving multiple areas of development.
Include autistic disorder, Asperger syndrome, Rett syndrome, and childhood disintegrative disorder.
Pervasive developmental disorder not otherwise specified (PDD-NOS; atypical autism): Diagnosed when criteria are not met for any of the above.
The most efficacious pharmacotherapeutic agents for ADHD are psychostimulants, though behavioral modification and firm limit setting should also be used. Seventy-five percent of patients have significant improvement on Ritalin.
TREATMENT
There is no cure, but goal of treatment is to manage symptoms and improve social skills.
Remedial education.
Behavioral therapy.
Neuroleptics such as haloperidol to control self-injurious and aggressive behavior and mood lability.
SSRIs to help control stereotyped and repetitive behaviors.
Autistic Disorder
A 3-year-old boy is brought in by his parents because they think he is deaf. He shows no interest in them or anyone around him and speaks only when spoken to directly. He often lines his toys up in a straight line. Hearing tests are normal. Think: Autism.
Autism is a spectrum of behaviors that include abnormalities in social interactions, aberrant communication, and restricted repetitive and stereotyped behaviors. The onset is usually before age 3 yr. Speech is typically delayed or may regress. It is often associated with mental retardation.
Spectrum of pervasive developmental disorders characterized by various degrees of impaired social interaction and communication and repetitive, stereotyped patterns of behavior.
Seventy percent of children with autistic disorder are mentally retarded, though a few have narrow remarkable abilities (savants). Only 1–2% can function completely independently as adults.
Autism is not caused by thimerosal-containing vaccines.
DIAGNOSIS
Diagnosis made within the first 3 yr and other causes of the clinical presentation ruled out.
It is based on behavior, not cause.
Parents usually notice signs in the first 2 yr of the child’s life.
Characteristic triad: Impairments in social interaction, impairments in communication, and restricted interests and repetitive behaviors.
At least six of the following (with at least two from qualitative impairment in social interaction, one from qualitative impairments in communication, and one from patterns of behavior):
Qualitative impairment in social interaction (at least two):
Marked impairment in the use of multiple nonverbal behaviors, including poor eye contact.
Failure to develop peer relationships and attachments.
Lack of spontaneous seeking to share enjoyment, interests, achievements.
Lack of emotional or social reciprocity.
Qualitative impairments in communication (at least one):
Delay or lack of spoken language (expressive language deficit).
Marked impairment in the ability to initiate or sustain a conversation with others.
Stereotyped and repetitive use of language or idiosyncratic language.
Lack of spontaneous make-believe play or social initiative.
Repetitive and stereotyped patterns of behavior and activities (at least one):
Inflexible rituals: Unvarying pattern of daily activities.
Preoccupations.
Highly responsive to intimate environment, stimulus overselectivity, unable to cope with change in routine.
Standard developmental screening tests have poor sensitivity for autism.
Two areas are particularly affected in autistic disorder:
Communication
Social interactions
Computed tomography (CT) and magnetic resonance imaging (MRI) in autistic disorder show ventricular enlargement; polymicrogyria; and small, densely packed, immature cells in the limbic system and cerebellum.
ETIOLOGY
Genetic predisposition (36% concordance rate in monozygotic twins, 0% in dizygotic twins).
Prenatal neurologic insult.
Immunologic and biochemical factors.
PATHOPHYSIOLOGY
Neuroanatomic structural abnormalities.
Abnormalities in dopamine and serotonin system: ↑ in serotonin.
Half of children with autistic disorder never speak.
EPIDEMIOLOGY
Prevalence: 10–15:10,000.
Male-to-female ratio: 4:1.
Diagnosis first year (25%), second year (50%), after 2 years (25%).
Significant comorbidity with fragile X syndrome, tuberous sclerosis, mental retardation, and seizures.
PROGNOSIS
No effective treatment.
Depends on presence or absence of underlying disorder and speech.
Those with autistic disorder who do speak exhibit echolalia, pronoun reversal, inappropriate cadence or intonation, impaired semantics, and failure to use language for social interaction.
Asperger Syndrome
DIAGNOSIS
Impaired social interaction (at least two, similar to autistic disorder).
Restricted or stereotyped behaviors, interests, or activities.
No substantial delay in language development (unlike autistic disorders).
EPIDEMIOLOGY
Male > female.
Rett Syndrome
A 4-year-old girl with prior history of severe mental retardation is brought in for evaluation. She has been developing normally until 18 months of age, when she acquired dementia and her head circumference plateaued. She wrings her hands and has ataxia and marked loss of gross motor skills. Think: Rett syndrome.
Rett syndrome is a pervasive developmental disorder. It is a genetic disorder in which developmental arrest typically occurs between 6 and 18 months. Parents may report gross motor development delay, disinterest in play, and loss of eye contact. Hand wringing is a hallmark of this condition. Rapid deterioration may occur. This diagnosis should be considered in a previously healthy child with normal development who develops deceleration of head growth.
Unlike those with autistic disorder, children with Asperger syndrome have normal language and cognitive development.
DIAGNOSIS
Normal pre-and perinatal development until between 6 and 18 months of age.
Normal head circumference at birth, but ↓ rate of growth between the ages of 6 and 18 months.
Loss of previously learned purposeful hand skills between the ages of 6 and 30 months, followed by the development of stereotyped hand movements.
Early loss of social interaction, usually followed by subsequent improvement.
Problems with gait or trunk movements: 50% of females are not ambulatory.
Severely impaired language and psychomotor development.
The diagnosis is also supported by a positive mutational analysis of MECP2.
Prone to seizure disorders and gastrointestinal complaints (constipation).
Generally, autistic disorders more common in boys except Rett syndrome (more common in girls).
EPIDEMIOLOGY
Classically restricted to females; males are beginning to be recognized due to genetic testing.
The gene for Rett syndrome is located on the X chromosome.
PROGNOSIS
Females can live up to 40 years of age.
Currently, there is no cure.
Childhood Disintegrative Disorder
DIAGNOSIS
Normal development in the first 2 years of life.
Loss of previously acquired skills in at least two of the following:
Language.
Social and self-care skills.
Bowel or bladder control.
Play skills.
Motor skills.
At least two of the following:
Impaired social interaction.
Impaired use of language.
Restricted, repetitive, and stereotyped behaviors and interests.
Regression can be very sudden.
EPIDEMIOLOGY
Onset ages 2–10 yr.
Four to eight times higher incidence in boys.
Rare.
TREATMENT
No permanent cure.
Behavior therapy: Aims to teach child how to relearn skills that are lost.
TIC DISORDERS
Tics
Sudden, repetitive, stereotyped movements (motor tics) and utterances (phonic tics).
Most common motor tics involve the face and head (eg, blinking of eyes).
Examples of vocal tics include coprolalia (repetitive speaking of obscene words) and echolalia (exact repetition of words).
Tourette Syndrome
A 13-year-old boy has had uncontrollable blinking since he was 9 years old. Recently, he has noticed that he often involuntarily makes a barking noise that is embarrassing. Think: Tourette syndrome.
It is characterized by motor and phonic (or vocal) tics. Tics are defined as involuntary, sudden, intermittent, repetitive movements (motor tics) or sounds (phonic tics). Comorbidities, such as ADHD and obsessive-compulsive disorder, are common. The age of onset is before 18 yr but most children shows readily identifiable symptoms by age 7 yr.
DIAGNOSIS
Multiple motor and vocal tics occurring multiple times per day, almost daily for > 1 yr (no tic-free period for > 3 months).
Onset before age 18.
Distress or impairment in social functioning.
EPIDEMIOLOGY
Three times more common in boys.
Onset usually between the ages of 7 and 8 yr.
High comorbidity with obsessive-compulsive disorder (OCD) and ADHD.
Tics in Tourette syndrome may be consciously repressed for short periods of time.
ETIOLOGY
Genetic: 50% concordance rate in monozygotic twins, 8% in dizygotic.
Neurochemical: Impaired regulation of dopamine in the caudate nucleus.
TREATMENT
Most cases are mild and do not require drug therapy.
Supportive psychobehavioral therapy, education, and reassurance.
Pharmacotherapy when symptoms interfere with functioning: Haloperidol or pimozide.
ELIMINATION DISORDERS
Enuresis
DIAGNOSIS
Lack of involuntary urinary continence beyond age 4 for diurnal enuresis and age 6 for nocturnal enuresis.
Occurs at least twice per week for at least 3 consecutive months.
Types:
Primary: Child never established continence.
Secondary: Most commonly occurs between ages 5 and 8 yr.
Rule out the influence of a medical condition (eg, urethritis, diabetes, seizures).
ETIOLOGY
Genetic predisposition.
Physical factors: Small bladder, low nocturnal levels of antidiuretic hormone (ADH).
Delayed or stringent toilet training.
Psychosocial stressors.
EPIDEMIOLOGY
Prevalence: 7% male and 3% female at age 5 yr; 3% male and 2% female prevalence at age 10 yr.
SIGNS AND SYMPTOMS
Urination during the day, night, or both on the individual.
Nocturnal (nighttime only) is the most common subtype.
Diurnal (daytime only) is more common in females.
TTREATMENT
According to specific causative factors suggested by an adequate psychosocial evaluation.
Enlist child in cure, offer positive reinforcement, do not punish; older children participate in cleaning up.
No liquids after dinner; urinate before going to bed.
Behavior modification therapy (eg, buzzer to wake up child when wetness is detected).
Pharmacotherapy: Antidiuretics (desmopressin [DDAVP]) or tricyclic antidepressants (imipramine).
Most cases of enuresis spontaneously remit by age 7.
Encopresis
DIAGNOSIS
Repeated passage of feces into inappropriate places (eg, clothing or floor) whether involuntary or intentional.
Behavior must occur once a month for 3 months.
Individual must be at least 4 years old.
Rule out the influence of a medication or a general medical condition (eg, hypothyroidism, lower gastrointestinal [GI] problems, dietary factors).
ETIOLOGY
Anxiety about defecating in a particular place.
A more generalized anxiety in response to stressful environmental factors.
Oppositional behavior.
Physiologic conditions: Lack of sphincter control, constipation with overflow incontinence.
EPIDEMIOLOGY
Prevalence: 1% in 5-year-old children (less common than enuresis).
Incidenc ↓ with age.
More common in males than females.
Associated with other conditions such as conduct disorder and ADHD.
Encopresis in a 7-year-old child likely indicates a more serious disturbance than thumb-sucking in a 4-year-old, which is more serious than a nightmare in a 5-year-old, breath-holding spells in a 2-year-old, and nocturnal enuresis in a 6-year-old.
TREATMENT
According to the specific causative factors suggested by an adequate psychosocial evaluation.
Enlist child in cure, positive reinforcement; do not punish.
Older children participate in cleaning up.
Choose a specific time every day to attempt bowel movement.
Stool softeners: Majority of encopresis cases involve constipation.
Psychotherapy, family therapy, and behavioral therapy.
MOOD DISORDERS
Depressive disorders can be classified into three types:
Major depressive disorder (MDD).
Dysthymic disorder (DD).
Depressive disorder not otherwise specified (NOS).
Dysthymic disorder: Symptoms are less intense but last longer than major depressive disorder. Characterized by chronically depressed or irritable mood (at least 1 year) and must have two of the following symptoms: appetite disturbance, sleep disturbance, fatigue, low self-esteem, poor concentration, difficulty making decisions, or feelings of hopelessness.
Depressive disorder NOS: Clinically significant depressive symptoms but does not meet criteria for any specific mood disorder or adjustment disorder with depressed mood.
Fifty to sixty percent of individuals with a single depressive episode can be expected to have a second episode.
Major Depressive Disorder (MDD)
DEFINITION
Pathologic sadness or despondency not explained as a normal response to stress and causing an impairment in function.
Recurrent condition that generally continues into adulthood.
Electroencephalography (EEG) in depression shows ↓ slow-wave (delta) sleep, shortened time before onset of rapid eye movement (REM), and longer duration of REM.
ETIOLOGY/PATHOPHYSIOLOGY
Genetic predisposition.
Catecholamine hypothesis: Depression is caused by a deficit of norepinephrine at nerve terminals throughout the brain.
Cortisol hypothesis: Larger quantities of cortisol metabolites in blood and urine, abnormal diurnal variation.
In suspected cases of depression, be sure to look for other signs or risk factors such as school failure or family history of mental health disorders.
EPIDEMIOLOGY
Prevalence: 2% of children; 4–8% of adolescents.
Twenty-eight percent of child psychiatry clinic patients.
Fifteen to twenty percent incidence in adolescents.
Two to three times higher in postpubertal girls than boys.
Other mental disorders frequently co-occur with major depressive episode including anxiety/panic disorders, OCD, eating disorders, substance abuse, borderline personality disorder, ADHD, and ODD.
A combination of treatments for depression may be necessary. Childhood depression should be treated with behavior modification before medication.
DIAGNOSIS
Depressed mood with at least five of the following signs lasting more than 2 weeks:
Depressed mood.
Loss of interest in activities.
Plus, four or more of the following for 2 weeks or longer:
Sleep disturbance.
Weight change or appetite disturbance.
↓ concentration.
Suicidal ideation.
Psychomotor agitation or retardation.
Fatigue or loss of energy.
Feelings of worthlessness or inappropriate guilt.
Always rule out other causes of the clinical presentation (eg, hypothyroidism, nutritional deficiency, chronic infection/systemic disease, substance abuse).
Use of antidepressant medications in adolescents may ↑ risk of suicidal thoughts and behaviors during initial weeks due to disinhabition.
COMPLICATIONS
Can persist into adulthood.
Up to 15% of patients with depression commit suicide each year.
TREATMENT
If suicidal or homicidal, admit to the hospital.
Biopsychosocial approach.
Cognitive behavior therapy (CBT).
Individual and/or group therapy.
Family intervention.
TCAs, SSRIs. TCAs have risk of lethal overdose—look for convulsions, coma, and cardiac arrythmias in toxicity.
Electric shock therapy: Catatonic syndrome or intractable depression.
For adolescents, CBT and SSRIs appear to be most effective.
One percent of suicide gestures are lethal.
Suicide
DEFINITION
Suicide is a complex human behavior with biologic, sociologic, and psychological roots that results in a self-inflicted death that is intentional rather than accidental.
Suicide ideation, with or without a plan.
Suicide gesture—for attention, without intent for death.
Suicide attempt.
Seventy-five percent of those who go on to attempt suicide convey their suicidal intentions directly or indirectly.
ETIOLOGY
Genetic predisposition.
Psychiatric disorders: Correlations of suicidal behavior and mood or disruptive disorders, substance abuse.
Environmental factors: Stressful life events; family disruption due to death or separation, illness, birth, or siblings; peer pressure; physical or sexual abuse.
Parental influence: Psychiatric illness, substance abuse, violence, physical or sexual abuse.
Girls attempt suicide more but boys are more successful.
Thirty to seventy percent of suicides occur with significant alcohol or drug abuse. Substance abuse disinhibits the individual to complete the act.
EPIDEMIOLOGY
Attempted suicides account for 6% of deaths in 10- to 14-year-olds, 11% of deaths in 15- to 19-year-olds.
Third leading cause of death for young adults aged 10–19.
In the United States, there are about 50–100 attempts for each complete suicide; 8–9% of U.S. adolescents attempt suicide.
Boys more frequently complete suicide, but girls attempt more often. (Girls tend to choose less lethal methods like overdose, cutting; boys will choose firearms, hanging).
The rate of suicide is higher in Alaskan, Asian-American, and Native American youth.
Of the 1–2% of those who attempt suicide, 10% will eventually complete the act.
Risk factors: Look for psychiatric disorders, prior attempts, family clustering of suicides, substance use/abuse, history of sexual abuse, or serotonin abnormalities.
DIAGNOSIS
Even though risk factors for suicide are known, it is not possible to predict who will commit suicide.
Assess signs and symptoms, correlate with other clinical variables such as psychiatric and substance abuse history, gender, age, race, prior history of suicide attempts, and recent traumatic life events.
Key questions: Are you having any thoughts about harming yourself or taking your life? Have you developed a plan? What is your plan?
Suicidal ideation, when accompanied by a specific plan, must be taken seriously, and these patients need to be hospitalized for assistance and suicide precautions.
TREATMENT
Immediate hospitalization; remove all potentially lethal items.
Psychotherapeutic intervention, trustful atmosphere, coping strategies; remove motivation for suicide; involve parents and relatives, guidance counselor.
Pharmacotherapy depends on the accompanying diagnosis.
Suicide completers: Male, older, history of depression, alcoholism, schizophrenia, careful planning, high lethality, firearms.
VIOLENT BEHAVIOR
EPIDEMIOLOGY
Homicide is the second leading cause of death among 15- to 19-year-olds and the leading cause of death in African-American adolescents.
Rates of homicide are higher in males than in females.
Death by firearm homicide is highest in the 15- to 24-year-old age group.
Suicide attempters: Female, younger, history of depression, alcoholism, personality disorder, impulsive, no planning, low lethality, drug overdose.
RISK FACTORS
Look for clinical entities associated with violent behavior such as mental retardation, moderate to severe language disorder, learning disorder, ADHD, mood disorders, anxiety disorders, personality disorders, conduct disorders, and ODD.
Other risk factors: Substance abuse, gang involvement, history/exposure to domestic/child abuse, and access to firearms.
SCREENING
Ask about recent involvement in physical fights, carrying a weapon, firearms in household, concerns that an adolescent has about his/her safety, past episodes of trauma, and social problems in school or neighborhood.
SUBSTANCE ABUSE
EPIDEMIOLOGY
Alcohol and cigarettes are the most prevalent drugs among school-age young adults.
Marijuana is the most commonly reported illicit drug used.
The prevalence of substance abuse varies according to age, gender, geographic region, race, and other demographic factors.
SIGNS AND SYMPTOMS
See Table 21-1 for signs and symptoms of intoxication and withdrawal due to substances of abuse.
TREATMENT
Group therapy.
Narcotics Anonymous.
Hospitalizations may be necessary for acute withdrawal.
Alcohol abuse: Rule out medical complications, start benzodiazepine for withdrawal symptoms, and give thiamine before glucose to prevent Wernicke’s encephalopathy.
TABLE 21-1. Substances of Abuse—Intoxication and Withdrawal
ANXIETY DISORDERS
Separation Anxiety
DEFINITION
Excessive anxiety beyond that expected for the child’s developmental level related to separation or impending separation from the attachment figure.
Separation anxiety is normal until age 3–4 yr.
EPIDEMIOLOGY
Prevalence: 4% of school-age children.
Males and females are affected equally.
ETIOLOGY
Contribution by parental anxiety/excessive concern expressed.
SIGNS AND SYMPTOMS
May refuse to sleep alone or go to school.
May complain of physical symptoms in order to avoid anxiety-provoking activities.
Become extremely distressed when forced to separate, and may worry excessively about losing their parents forever.
TREATMENT
Family therapy.
Supportive psychotherapy.
Low-dose antidepressants.
School Phobia
DEFINITION
A child who develops emotional upset at the prospect of going to school in the absence of severe antisocial behavior.
Related to separation anxiety.
ETIOLOGY
Environmental, hostile, or dependent relationship between a parent and child; stressful events at home or school.
Concurrent psychiatric disorders, depression, separation anxiety, generalized anxiety, posttraumatic stress, somatoform disorder, avoidant personality disorder.
EPIDEMIOLOGY
More common in lower socioeconomic classes, younger children in the family, early teenage years, lack of parental interest or education.
Equal in both males and females.
Most frequent among younger children.
Prevalence: 5% of elementary school children, 2% of junior high school children.
SIGNS AND SYMPTOMS
Avoidance behavior in relation to school; seeks situations that provide comfort and security; once in school, comfortable and productive, fear of school recurs the next day despite positive experience the day before.
Physical complaints secondary to anxiety: Anorexia, headache, abdominal pain.
DIAGNOSIS
Marked and persistent fear that is excessive and unreasonable, instigated by the anticipation of the school situation.
Exposure to school provokes an immediate anxiety response.
School is avoided.
School phobia interferes with academic and social functioning.
Duration of at least 6 months.
Other mental disorders ruled out.
TREATMENT
Mainstay of treatment is returning the child to regular school attendance.
Behavioral therapy, recognize and control anxiety symptoms.
Anxiolytics or antidepressants for a short period of time when the symptoms are most severe.
Obsessive-Compulsive Disorder (OCD)
DEFINITIONS
Obsessions: Persistent, intrusive thoughts, images, impulses involuntarily intruding into consciousness, causing distress and functional impairment. Common themes are contamination and fear of harm to self or others.
Compulsions: Actions that are responses to a perceived internal obligation to follow certain rituals and rules, which may be motivated directly by obsessions or efforts to ward off certain thoughts or fears.
DIAGNOSIS
Impaired social, academic, or vocational functioning with four or more of the following:
Preoccupied with details, rules, lists, order, organization, or schedules, resulting in loss of the goal of activity.
Perfectionism that prohibits task completion.
Social impairment secondary to preoccupation with work and level of productivity.
Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values.
Unable to discard objects of no worth or sentimental value.
Preference to work as an individual and not in a group.
Miserly spending in order to save for future catastrophes.
Inflexible, rigid, stubborn.
Characteristics must be ego-dystonic and functionally disruptive versus ego-syntonic and functionally adaptive in OCD.
ETIOLOGY
Genetic predisposition, higher concordance among monozygotic versus dizygotic twins.
EPIDEMIOLOGY
High comorbidity with ADHD and tic disorders.
SIGNS AND SYMPTOMS
Unproductive because of preoccupation with details, rules, lists, schedules, organization, order.
Uncompleted tasks secondary to perfectionist tendencies.
Work habits interfere with social interactions.
Impossible standards of morals, ethics, or values.
Inflexible, stubborn, cheap; prefers to work as an individual and not in a group.
TREATMENT
Long-term therapy is required.
Maintain a professional distance from the patient.
Establish ground rules for therapy.
Behavioral therapy such as self-observation, extinction, operant conditioning, and modeling.
Pharmacotherapy:
First-line agents are SSRIs (ie, fluoxetine, fluvoxamine, paroxetine, sertraline).
Clomipramine is a second-line agent.
Habit
DEFINITION
Repetitive patterns of movement used to discharge tension.
ETIOLOGY
A stressful environment at home or school.
Concurrent psychiatric disorders including anxiety or depression.
PATHOPHYSIOLOGY
Purposeful movement loses original meaning and becomes repetitive and a means to discharge anxiety or provide comfort.
EPIDEMIOLOGY
Highest prevalence among 7- to 11-year-olds.
Males: 1–13%.
Females: 1–11%.
SIGNS AND SYMPTOMS
Bruxism (teeth grinding or clenching).
Tics, repetitive movement, gesture or utterance that mimics some aspect of normal behavior.
Stuttering, impairment in speech fluency characterized by frequent repetitions or prolongations of sounds or syllables.
Thumb-sucking, self-nurturing, and comforting behavior.
Individual is often unaware of habitual behavior.
TREATMENT
Behavior therapy: Identify habit, under what circumstances it most often occurs, work on habit reversal.
Habit reversal: Substituting another, more benign behavior for the previous habit.
Selective Mutism
DEFINITION
Not speaking in certain situations (eg, school).
EPIDEMIOLOGY
Onset usually around age 5 or 6.
Girls > boys.
May be preceded by a stressful life event.
TREATMENT
Supportive psychotherapy, behavior therapy, family therapy.
GENDER IDENTITY DISORDER
DEFINITION
Intense, persistent, and pervasive preoccupation with becoming a member of the opposite sex.
Patients exhibit a strong and persistent cross-gender identification and a sense of inappropriateness about their assigned sex.
EPIDEMIOLOGY
Prevalence: 1 in 30,000 males, 1 in 100,000 females.
Coexisting separation and/or generalized anxiety disorder or depression is common.
↑ risk of suicide.
Onset for boys is usually between ages 2 and 4; less clear for girls because cross-gender behaviors are more often tolerated in girls.
SIGNS AND SYMPTOMS
For genetic men: Overidentification with the mother, overtly feminine behavior, little interest in usual male pursuits, peer relationships primarily with girls.
DIAGNOSIS
Persistent discomfort with his or her sex.
Four or more of the following:
Stated desire to be or that he or she is the other sex.
Wearing clothes appropriate to the opposite sex.
Persistent role-playing or fantasies of being the opposite sex.
Interest in the habits of the opposite sex.
Preference for playmates of the opposite sex.
TREATMENT
Psychotherapy aimed at helping individual to accept his or her anatomic sex, adjustment in social and occupational areas, increasing self-esteem, and building social skills with peers.
Social and occupational adjustment is usually no better after surgery for gender identity disorder.
EATING DISORDERS (EDs)
DEFINITION
Two subtypes:
Restricting
Binge eating/purging
Anorexia Nervosa
A 16-year-old girl has a 6-month history of amenorrhea and a 25-lb weight loss. She is thin, with Tanner stage 4 development of breasts and pubic hair. She also reports constipation and feeling of bloating. When you ask her about the weight loss, she states that she is “overweight.” She had no menstruation in last 6 months. Think: Anorexia nervosa.
Anorexia nervosa is an eating disorder that is characterized by a triad of amenorrhea, weight loss, and psychiatric disturbance. Common presenting symptoms include constipation, intolerance to cold, dry skin, and hair loss. It predominantly affects females. Anorexia nervosa is associated with multiple hormonal abnormalities resulting in amenorrhea. Electrolyte abnormalities such as hyponatremia, hypokalemia, hypophosphatemia, and hypoglycemia may be present.
DIAGNOSIS
Refusal to maintain body weight at or above 85% of ideal weight for age and height.
Even though underweight, an intense fear of gaining weight.
Disturbance in self-perception of body weight and lack of insight into the seriousness of physical condition.
The absence of at least three consecutive menstrual cycles in women.
ETIOLOGY
Genetic predisposition (6–10% of female relatives of anorexic patients have the condition, twin studies confirm).
Psychological need to control, perfectionism.
Conforming to society’s ideal of beauty.
Stressful life events such as leaving home for college or death in the family.
The most common cause of death in anorexia nervosa is cardiac arrhythmias due to electrolyte disturbances, particularly hypokalemia.
PATHOPHYSIOLOGY
A primary hypothalamic disturbance secondary to ↑ corticotropin-releasing factor.
Central neurotransmitter dysregulation affecting dopamine, serotonin, and norepinephrine.
Reduced norepinephrine activity and turnover.
Endocrine abnormalities, ↑ growth hormone levels, loss of cortisol diurnal variation, reduced luteinizing hormone (LH), follicle-stimulating hormone (FSH), impaired response to luteinizing hormone–releasing hormone (LHRH), abnormal glucose tolerance test.
Electrocardiography (ECG) in anorexia nervosa may show low-voltage T-wave inversion and flattening, ST depression, supraventricular or ventricular arrhythmias, and/or prolonged QT intervals.
EPIDEMIOLOGY
Predominance in females (female-to-male ratio 10:1).
One percent prevalence among women.
Bimodal onset at 14 and 18 yr.
More common in industrialized countries.
Incidence has ↑ over the past two decades.
More common in activities such as ballet, gymnastics, and modeling.
The long-term mortality of anorexia nervosa is 10%.
SIGNS AND SYMPTOMS
Extreme dieting, special diets such as vegetarianism.
Refusal to eat meals with family members or in public.
Rituals surrounding meals.
Preoccupation with food and its preparation.
Intense fear of becoming obese, which does not diminish as weight loss progresses.
Disturbance in the way in which one’s body, weight, size, and/or shape is experienced, such as “feeling fat” although one may be emaciated.
Denial of hunger.
Obsessive interest in physical exercise.
Abuse laxatives, diuretics, or stimulants in an effort to enhance weight loss.
Studiousness and academic success.
Multiorgan involvement:
Amenorrhea.
Hypothermia.
Constipation.
Low blood pressure, bradycardia.
Lanugo, hair loss.
Petechiae.
Pedal edema, dry skin.
Osteopenia.
Electrolyte abnormalities: Alkalosis, hypokalemia.
Lab abnormalities: Leukopenia, elevated liver function tests (LFTs), elevated triglycerides, carotenemia.
TREATMENT
Anorexic patients deny health risks associated with their behavior, making them resistant to treatment.
Individual and family psychotherapy: Target abnormal and destructive thought processes.
Behavior modification techniques to restore normal eating behavior, set specific weight goals.
Nutritional rehabilitation: Restore nutritional state and weight.
Pharmacologic therapy (SSRIs have been used successfully).
Beware of complications occurring during rehabilitation for anorexia nervosa, including congestive heart failure (CHF), cardiac arrhythmias, and overcorrection of electrolyte abnormalities.
Bulimia Nervosa
A 15-year-old girl has bilateral parotid gland swelling and erosion of the posterior aspect of the dental enamel of her upper incisors. She reports frequent vomiting after her meal. Think: Bulimia nervosa.
Bulimia nervosa is characterized by recurrent episodes of binge eating defined as the rapid consumption of a large amount of food in a reasonably short period of time. The hallmark of bulimia is a fear of not being able to stop eating when the binge is in progress. Self-induced vomiting and excessive exercise are the compensatory behaviors. Parotid enlargement, dental problems, and abrasions of knuckles are due to biting down on them during self-induced vomiting. The typical age of presentation is during the teenage year.
DIAGNOSIS
Recurrent episodes of eating within a 2-hr period of larger-than-normal proportions accompanied by a sense of lack of control over actions (binge eating).
Unlike anorexia, these patients are at or above their expected weight.
Recurrent compensatory behavior in order to prevent weight gain—self-induced vomiting, laxatives, diuretics, enemas, excessive exercise.
Episodes occur at least twice a week for 3 months.
Body shape and weight is the basis of self-evaluation.
Does not occur exclusively during episodes of anorexia nervosa.
ETIOLOGY
Biopsychosocial.
PATHOPHYSIOLOGY
A primary hypothalamic disturbance secondary to ↑ corticotropin-releasing factor.
Central neurotransmitter dysregulation affecting dopamine, serotonin, and norepinephrine.
Reduced norepinephrine activity and turnover.
Endocrine abnormalities, low triiodothyronine (T3), high T3 receptor uptake (T3RU), impaired thyrotropin-releasing hormone (TRH) responsiveness, abnormal dexamethasone suppression test.
EPIDEMIOLOGY
Predominantly found in women (4% prevalence).
Predominant in whites.
More common in industrialized countries.
Culturally dependent.
SIGNS AND SYMPTOMS
Secretive binge-eating and purging behaviors.
Abuse laxatives, diuretics, or stimulants in an effort to enhance weight loss.
Obsessive interest in physical activity.
Physical manifestations include parotid gland enlargement, dental caries, scars on dorsum of fingers (due to teeth scraping during self-induced vomiting).
Laboratory abnormalities include dehydration, hypokalemia, hypochloremia, hypomagnesemia, elevated blood urea nitrogen (BUN), and amylase.
TREATMENT
Group therapy is the most effective treatment.
Eating Disorder Not Otherwise Specified (NOS)
DEFINITION
Abnormal eating behaviors or exhibits characteristics of other eating disorders without meeting all criteria. Examples include:
Meets all criteria for anorexia nervosa except weight falls within normal range or does not have amenorrhea.
Meets all criteria for bulimia nervosa but binge eating does not meet duration/frequency criteria.
Binge eating in the absence of purging activities.
Rumination
DIAGNOSIS
Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning.
Onset is between 3 and 12 months in normal infant; later in the mentally retarded.
Other medical and psychiatric conditions have been ruled out.
Rumination comes from the Greek root, ruminare, meaning “to chew the cud.”
ETIOLOGY
Adverse psychosocial environment.
Mental retardation.
PATHOPHYSIOLOGY
Unsatisfactory mother-infant relationship that causes the infant to seek an internal source of gratification.
Positive reinforcement when attention follows rumination.
Negative reinforcement when rumination reduces anxiety.
EPIDEMIOLOGY
Highest prevalence in normal infants and mentally retarded adults.
SIGNS AND SYMPTOMS
Presents with “spitting up” or frequent vomiting.
Effortless regurgitation, does not involve retching.
Infants are irritable and hungry between episodes of regurgitation.
Malnutrition, weight loss, failure to thrive.
Up to 25% mortality rate.
TREATMENT
Counseling to improve parent-child dynamics.
Behavioral intervention.
Aversive techniques, noxious stimulus is paired with rumination.
Nonaversive techniques, differential reinforcement or other incompatible responses.
In infants, the disorder frequently remits spontaneously.
Pica
DIAGNOSIS
Persistent eating of nonnutritive substances for a period of at least 1 month (eg, clay, dirt, etc.).
The eating of nonnutritive substances is inappropriate to the level of development.
Behavior is not culturally sanctioned.
Rule out other psychiatric disorders.
ETIOLOGY
Mental retardation.
Vitamin or mineral deficiencies (eg, iron deficiency anemia, particularly in pregnancy).
Poverty, neglect, lack of parental supervision, developmental delays.
Cultural belief.
Pica is found commonly in PDD and schizophrenia.
EPIDEMIOLOGY
In children aged 18 months to 2 yr, the ingestion and mouthing of nonnutritive substances is normal behavior.
Most common during the second and third years.
The prevalence ↑ with the severity of mental retardation.
SIGNS AND SYMPTOMS
Presenting complaint—“puts everything in his or her mouth.”
Direct observation of pica.
Complications:
Ingestion of paint chips can → lead poisoning.
Hair or large objects can cause bowel obstruction.
Sharp objects such as pins or nails can cause intestinal perforation.
Ingestion of feces or dirt can result in parasitic infections.
TREATMENT
Often remits spontaneously.
Treat underlying vitamin deficiency, if present.
Psychotherapy—assess why pica is occurring.
Behavior modification.
Direct observation and removal of potential pica.
SOMATOFORM DISORDERS
See Table 21-2 comparing somatoform disorders, factitious disorders, and malingering.
DEFINITION
Symptoms without physical cause.
Symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
Includes somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, and somatoform disorder NOS.
TABLE 21-2. Somatoform Disorders versus Factitious Disorders versus Malingering
TREATMENT
Psychodynamic therapy: Gain insight into unconscious conflicts and understand how psychological factors have influenced maintenance of the symptoms.
Identify and eliminate sources of secondary gain in order to avoid reinforcing the symptoms.
Improve self-esteem, promoting assertiveness, and teach nonsomatic ways to express distress.
Group therapy: Learn better coping strategies and improved social skills.
Somatization Disorder
History of many physical complaints, including at least:
Pain symptoms at more than four sites that are not intentionally produced.
Two nonpain GI symptoms.
One sexual or reproductive complaint.
One pseudoneurologic complaint.
Age of onset < 30 years old.
Conversion Disorder
DIAGNOSIS
Sensory symptoms, motor deficits, or pseudoseizures that are not intentionally produced.
Cannot be explained by an organic etiology.
Initiation of the symptom or deficit preceded by a psychological stressor.
Unintentional and involuntary.
Appropriate investigation leaves no medical explanation of symptoms.
Symptoms cause impairment in social functioning.
Other etiologies for the clinical presentation are ruled out.
Favorable prognosis for conversion disorder is associated with acute onset, definite precipitation by a stressful event, good premorbid health, and the absence of previous psychiatric illness.
Conversion disorder may be associated in some cases with history of a traumatic brain injury.
ETIOLOGY
Psychodynamic theory: Certain developmental predispositions respond to particular types of stress with conversion symptoms.
Behaviorists: A learned excess or deficit that follows a particular event or psychological state and is reinforced by a particular event or set of conditions.
Sociocultural: Predisposition of various ethnic and social groups to respond to stress with conversion symptoms.
A proportion of patients diagnosed with conversion disorder go on to develop demonstrable organic pathology (eg, multiple sclerosis or seizure nidus).
EPIDEMIOLOGY
More common in women, rural areas, and lower socioeconomic classes.
Rare in children < 10 years.
Incidence ↑ in children who have experienced physical or sexual abuse and in those whose parents are seriously ill or have chronic pain.
SIGNS AND SYMPTOMS
Paralysis, abnormal movements, inability to speak, see, hear; pseudoseizures.
Usually occurs within the context of a primary illness such as major depression, schizophrenia, or somatization disorder.
La belle indifference, the lack of interest in potentially life-altering symptoms, is common in adults, but rarely occurs in children.
Hypochondriasis
A 17-year-old girl becomes very concerned that a small lump in her left breast is “malignant cancer.” Her histopathology report showed it to be entirely benign. Despite reassurance by her physician she remains excessively worried. What is the cause of her excessive fear and what is the best possible treatment?
She has hypochondriasis, which is defined as a preoccupation with fears of having, or the belief that one has, a serious disease based on misinterpretation of bodily symptoms. The key feature in this condition is an abnormal concern that one is developing or has a serious illness. Psychotherapy that includes exploration of current life problems often result in symptom resolution.
DIAGNOSIS
Preoccupation over > 6 months with fear of having a disease based on the individual’s misinterpretation of normal bodily sensations.
Persistent preoccupation despite adequate medical evaluation and assurance.
Causes impairment in social functioning.
Other psychiatric diseases ruled out.
ETIOLOGY
Associated with anxiety, depression, and narcissistic traits.
Past experience with serious illness as a child or of a family member.
EPIDEMIOLOGY
There is a 1–9% prevalence in young adults.
Affects males and females equally.
The most common age of onset is early adulthood.
Hypochondriasis can → strained social relationships because of preoccupation with perceived condition and the patient’s expectation of receiving special treatment.
SIGNS AND SYMPTOMS
Complaints involving most organ systems.
Multiple visits to different doctors and deterioration of doctor-patient relationships.
Individuals often believe that they are not receiving proper care so they pursue more opinions.
Receive many evaluations and unnecessary surgeries.
May become addicted to drugs as a result of their chronic ongoing physical complaints.
TREATMENT
The primary aim of therapy is to help the patient identify and manage the fear of serious illness.
In addition to techniques helpful for somatoform disorders:
Behavior modification techniques: Earn points to participate in daily routine despite feeling sick.
Educate about physiologic mechanisms.
Body Dysmorphic Disorder
Preoccupation with imagined defect in appearance or excessive concern about a slight physical anomaly (eg, large nose, small muscles).
Multiple visits to plastic surgeons or dermatologists are common.
Pain Disorder
DIAGNOSIS
Pain in one or more anatomic sites of sufficient severity to warrant medical attention but with no physical findings to account for the pain or its intensity.
Pain causes impairment in social functioning.
Psychological factors are directly related to the onset, severity, exacerbation, or maintenance of the pain.
Pain is not intentionally produced or feigned.
Rule out other causes of the clinical presentation.
ETIOLOGY
Psychiatric—common in conditions such as schizophrenia, somatization disorder, anxiety, dissociation, conversion, and depression.
PATHOPHYSIOLOGY
A defect in ego function underlying the experience and expression of feelings.
Psychologically stressful events are converted into somatic symptoms rather than the development and appropriate expression of emotions.
EPIDEMIOLOGY
Affects males and females equally.
Alexithymia is the inability to express emotion.
FACTITIOUS DISORDERS
Munchausen Syndrome
DEFINITION
Intentional production or feigning of symptoms (eg, thermometer manipulation, self-injury, ingestion, injection) for primary gain (eg, relief of anxiety, assuming the sick role).
ETIOLOGY
Children who make themselves sick may have been victims of Munchausen by proxy.
Experience of misuse of illness to get attention and reinforcement of these actions.
TREATMENT
Younger children are more likely than older children/adolescents to admit to deception if approached in a direct and concerned (not accusatory) way.
Family therapy: Recognize how family communicates through illness and identify more effective ways of communication and getting what they need from family members.
Involvement of primary care doctor/pediatrician in confrontation.
Munchausen Syndrome by Proxy (MBP)
DEFINITION
Intentional fabrication or actual production of symptoms in a child by a caregiver (usually the mother) in order to gain attention for themselves.
A form of child abuse.
EPIDEMIOLOGY
Adults who commit MBP may have a history of factitious disorders themselves.
Ninety-eight percent of perpetrators are women.
Mortality rate is 9%.
Up to 75% of the morbidity involved relates to physicians trying to treat the unknown conditions.
SIGNS AND SYMPTOMS
Conditions that do not respond to treatment or whose courses are puzzling and persistent, often:
Vomiting/diarrhea (ingestion, syrup of ipecac).
Rashes (due to scrubbing with solvents).
Failure to thrive.
Seizures.
Infections.
Adding blood or other substances to urine specimens.
Physical or laboratory findings that are unusual, discrepant, or clinically impossible or do not occur in the absence of the parent.
Medically knowledgeable/fascinated mother who appears to enjoy the hospital setting, who is reluctant to leave child, and herself is dramatic and desires attention.
Family history of similar problems or unexplained death in sibling.
Signs or history of factitious disorder in mother.
TREATMENT
Appropriate physician suspicion, good medical records, and reporting of abuse (often multiple doctors have been visited, with little continuity).
Caregiver requires psychiatric therapy, such as for other factitious disorders.
Malingering
DEFINITION
Intentional creation of symptoms for secondary gain (eg, getting out of going to school or doing chores).
PSYCHOLOGICAL IMPACT OF ADOPTION AND FOSTER CARE
DEFINITION
Adoption: Acquiring legal guardianship of an individual.
Foster care: Temporary placement of an individual who has been removed from an unsafe environment.
Kinship: Placement with relatives.
ETIOLOGY
Questions of who the other parents are and why they left him or her and the subsequent impact of the perceived abandonment.
Parental assumptions of the behavior and personalities of the people whose union produced the child causes them to be hypervigilant.
PATHOPHYSIOLOGY
A narcissistic injury resulting in the assumption that they were unlovable, dirty, bad, or unrewarding to the biological parents.
Some blame the biological parents, assuming they were bad, alcoholic, or mentally ill.
Assume abandonment could happen again.
Unconscious rage at having been abandoned.
EPIDEMIOLOGY
Adoption is common among individuals who are unable to have children and want a family.
Two percent of population is adopted.
Foster care is common among children who have been abandoned by their parents or were removed from a dysfunctional environment.
SIGNS AND SYMPTOMS
Adolescent curious about his or her origins and early life creates conflict within the individual.
Continually search strangers’ faces for resemblances.
Expression of feelings of abandonment and the desire to find biological parents.
Foster child relationships may have been disrupted several times before, so the child is ambivalent toward the parents.
Rage, stemming from initial abandonment, causes aggressive and antagonist behavior.
Child could be coached to say, “I am adopted—so what! So was President Ford!”
TREATMENT
Individual and family therapy.
Address disruptive behavior and the etiology.
Address issues of abandonment.
Enhance communication between child and parents.
When to tell the child he or she is adopted?
Controversial.
Sooner is better (age 3–4 or earlier).
How to tell the child he or she is adopted? According to development level.
PERSONALITY DISORDERS
Patterns of behavior that deviate from cultural standards, can begin in adolescence or early adulthood.
Cluster A: “Weird”
Paranoid: Distrustful and suspicious.
Schizoid: Isolated, a “loner” type with limited emotional expression.
Cluster B: “Wild”
Borderline: Unstable mood, impulsive.
Histrionic: Sexually provocative, attention seeking.
Narcissistic: Needs to be admired, has sense of entitlement.
Antisocial: Lacks remorse, violates laws of society, breaks the law.
Cluster C: “Worried”
Obsessive-compulsive: See above.
Avoidant: Socially inhibited, intense fear of ridicule and being disliked.
Dependent: Submissive, needs to be taken care of, cannot be on their own.