Behavioral or Psychiatric Problems

Basics
DESCRIPTION
Behavioral, developmental, or psychosocial problems requiring medical or psychiatric treatment, or causing significant
impairment
EPIDEMIOLOGY
BASICS-EPIDEMIOLOGY-Prevalence

1420% of American children have a moderate to severe psychiatric disorder(s).

8% of high school students attempt suicide, 25% of whom require medical attention.

Depression: 510% (conservative estimate)

Eating disorders: 0.51%, but 515% mortality rate

RISK FACTORS

Genetics

Strong evidence for heritable/genetic risk of bipolar disorder (manic depression), schizophrenia, and depression

Anxiety, attention deficit/hyperactivity (ADHD), pervasive developmental, and tic disorders also appear to be
genetically transmissible.

Personality disorders have a significant genetic component (twin studies).

Many disorders, e.g., ADHD (3:19:1) and depression (1:2), have distinct male/female preponderance.

Diagnosis

Frequently unrecognized by primary care providers:

1. 5080% of children with mental health problems
2. 30% of children with mental retardation/other developmental disabilities

50% of suicide attempters seek medical care in the month preceding their attempt, 25% in the preceding week.

Many patients with psychiatric disorders present with vague physical complaints. All such patients should be
screened for psychiatric problems.

General goals:
1. Goal 1: Assess for safety, i.e., suicidality, homicidality, and adequate support/supervision at home.
2. Goal 2: Rule out organic causes.
3. Goal 3: Establish psychiatric/psychologic causes as possible diagnosis.
4. Goal 4: Work with family to accept possibility of psychiatric/psychologic diagnosis and facilitate referral
to mental health services.

Screening hints:
1. Parents/children are often reluctant to discuss psychosocial issues; they consider them stigmatizing.

2. Standard developmental checklists are often inadequate.

3. Asking Do you have any concerns about your childs behavior or emotional well-being? may increase
the likelihood of identifying psychiatric problems.

Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent version:
1. Collaborative effort of pediatricians and child psychiatrists, psychologists, and neurologists
2. Concise, user-friendly guide for diagnosing mental disorders
SIGNS AND SYMPTOMS

History

Psychobehavioral assessment includes:

1. History of presenting complaint past medical, developmental, and behavioral/psychiatric history
2. Complete family history and review of systems

SHADSSS mnemonic.

Useful inventory of psychosocial functioning (least threatening topics asked first, most intimate questions asked
last)
All of these areas should be assessed in all patients:
1. School (in school? grades? relationship with peers? teachers?)
2. Home (living situation? relationship with parents? siblings?)
3. Activities (how is free time spent?)
4. Depression
5. Substance abuse (including alcohol/tobacco)
6. Sexuality (including abuse, sexually transmitted diseases, and pregnancy)
7. Safety (suicidality, homicidality, revenge or violent plans)

All families require a family assessment. Families/support systems are crucial to the ultimate success of any
treatment plan.

Family assessment includes:

1. Constitution of household, custody/visitation arrangements
2. Who supervises child/provides child care
3. Family stressors, e.g., emotional, financial, interpersonal, violence within the family, involvement with
law enforcement/social services, etc.
4. Familys coping strategies for conflicts, problems, stressors, etc.
Physical Exam

All patients require a thorough physical examination.

Goal is to detect any organic causes for patients symptoms (see Differential Diagnosis).

TESTS

No standard battery of laboratory tests. Tests should be ordered based on clinical suspicion.

Specific resources:
1. Screening questionnaires (see Bibliography):

Parent monitoring forms/diaries, direct observation of parentchild interactions can be used,

depending on the practitioners practice setting, experience, familiarity, and confidence with these
modalities.

Screening for maternal depression may also be important in detecting psychosocial dysfunction.

2. The Pediatric Symptom Checklist:

Well-validated 35-item parent report

Can be completed in 5 minutes, easily administered in waiting area

Easily scored

3. The Child Behavior Checklist:

More in-depth assessment

More difficult to administer/score

4. Conners Rating Scales:

Adjunct to diagnosing ADHD

Rating scales alone insufficient to diagnose ADHD

CLINICAL:
Pitfalls:

Not asking about behavioral or psychiatric problems

Missed psychiatric diagnosis, especially suicidality, homicidality, plans for revenge/violence

Equating the degree of medical severity of a suicide attempt with the severity of suicide intent:
1. Children/adolescents often misjudge the lethality of their suicide methods.
2. All attempts must be taken seriously.

Making diagnosis/treatment plan without comprehensive evaluation:

1. Many psychiatric disorders present in similar fashion (see Differential Diagnosis).
2. Successful treatment depends on accurate diagnosis, based on a thorough biopsychosocial evaluation.

Delay in diagnosis/referral for treatment (e.g., prognosis for learning disabilities and hearing impairment is
associated with timely intervention)
DIFFERENTIAL DIAGNOSIS

Organic causes:
1. CNS infections or parainfectious syndromes

2. Substance abuse, toxic ingestions, medication adverse effects

3. Intracranial trauma or other injury
4. CNS tumors
5. Endocrine disorders: Thyroid or adrenal dysfunction
6. Metabolic disorders, abnormality of:

Glucose

Sodium

Potassium

Calcium

7. Migraines
8. Seizure disorders
9. Hematologic disorders:

Porphyria

Severe anemia

10. Hypoxia
11. Cardiopulmonary disturbances

Psychobehavioral disorders (many disorders have similar symptoms):

1. ADHD Ddx:

Mood disorders: Depression/bipolar disorder

Anxiety disorders: School phobia, posttraumatic stress

Tic disorders

Substance abuse

Hearing or vision impairment

Learning disabilities

2. Social withdrawal Ddx:

Depression

Neglect

Pervasive developmental disorder, sensory impairment (e.g., deafness)

Learning disability

3. Psychotic symptoms Ddx:

Psychotic disorders

Mood disorders (depression, bipolar disorder)

Borderline personality disorder

Substance abuse

Treatment
MEDICATIONS
Contraindications, precautions, and significant possible interactions

Patients on psychotropic medications need close monitoring for adverse effects.

Stimulants:
1. Assessment of growth, heart rate, and BP every 36 months
2. Patients on pemoline should have liver function checked every 612 months.

Tricyclic antidepressants (TCAs): Baseline ECG (before starting TCAs), ECG 1 month after starting TCAs and
every 6 months thereafter

Antipsychotics: Reassessment at 2, 4, and 12 weeks after starting medication, and every 36 months thereafter for
adverse effects, especially dystonia, anticholinergic symptoms, movement disorders

Atypical antipsychotics:
1. Frequently cause significant weight gain and may cause impaired glucose tolerance and prolong QTc
2. Patients weight should be closely monitored, as well as any signs of diabetes mellitus.
3. An ECG should be obtained before and after starting ziprasidone.
Frequently Asked Questions

Q: When should a child be referred to a specialist?

A: Whenever there is uncertainty about diagnosis or management, or when the treatment needs of the patient
exceed the practitioners capacity to provide them.

Q: How do you get children and families to talk about their problems?

A: There is no trick. Being a patient, empathetic, nonjudgmental listener is the best strategy.

Q: What constitutes a psychiatric emergency?

A: Any situation where the safety or functioning of the child, family, or another person is endangered.