Child and Adolescent Psychiatry

Brain, Behavior, and Movement: 2017

Dr. Ellen House

I. Why should we care about childhood mental health?

a. Child Psychiatry is a focus on healthy development of the child and family – it’s all about
function
b. Sound mental health provides the essential foundation for all aspects of human development
(relationships, capacity for learning, ability to cope with adversity, etc)
c. Untreated childhood mental illness is associated with significant long-term impairments in
functioning and health across many domains
d. It’s easier to intervene early with children and family then try to address issues later in life
II. Children exemplify the importance of the biopsychosocial model of health and illness.
a. Childhood adverse experiences raise the risk for mental and physical health sequelae
b. Fryers and Brugha (2013) childhood determinants of mental illness
i. Psychological disturbances in childhood and adolescence
ii. Genetic influences
iii. Neurologic vulnerability in childhood
iv. Disturbed behaviors in childhood/adolescence
v. Features of personality
vi. Poor school performance/educational achievement
vii. Childhood/family adversity
viii. Child maltreatment
ix. Parenting concerns
x. Disrupted families
c. Resilience is typical development in spite of having a risk factor, not all those at risk will have
difficult outcomes
d. Protective Factors: Characteristics or qualities of individuals or environments that protect
(moderate) the expected negative effects of risk factors. Ex: high IQ, high self-esteem, certain
personality types (autonomous, active, outgoing and warm), high quality parenting, social
support, higher household income, good schools, biological factors
III. Mental illnesses are chronic diseases of the young
a. National Comorbidity Survey Replication: ½ of lifetime cases of mental illness begin by age 14
and ¾ by age 24
b. Approximately 12-22% of children and adolescents struggle with a psychiatric disorder and
youth have the highest prevalence of illness
c. However, there is often a delay in accessing care
IV. Children’s health and symptoms must be understood and evaluated in the context of development
a. Knowing normative development helps us to identify behaviors that are atypical or delayed
b. Age norms are the normative behaviors expected at certain ages
i. Diagnosticians increasingly use age norms to evaluate psychiatric problems rather than
using theoretical, absolute, or population-wide standards.
1. Ex: temper tantrums are normal for a 2 year old but for a 30 year old might
indicate a psychiatric disorder
ii. Age norms can also be useful for identifying symptoms that are age-specific
1. Ex: major depression in early adolescence may present as irritability and
somatization instead of the sad mood and lethargy common in adulthood.
c. Developmental trajectories are the pathways or courses of development over time – helping to
understand behavior as typical or problematic
i. Ie school avoidance or separation anxiety depending on age
d. A critical period is a point in the lifespan during which an individual is acutely sensitive to the
effects of risk and protective factors (e.g., disease, toxin, trauma, enriched environment)
i. Early childhood is considered a critical period because
1. Rapid development of the nervous system during this time
2. Relatively less neural plasticity in later years
 3. Ex: Attachment to the mother during early infancy predicts later social behaviors
in adolescence and parenting skills during adulthood. Alcohol exposure in utero
can cause fetal alcohol syndrome vs impact on adolescence
e. Transition points: Critical periods may also be defined by psychosocial events, or critical points
of transition between life stages (starting school, puberty, college, birth of child, death of parent)
V. Theories of Development:
a. Freud’s Stage Theory of Psychosexual Development: Freud proposed that healthy adult
function requires successful resolution of the core tasks of each developmental stage. Failure to
resolve the tasks of a particular stage leads to a specific pattern of neurosis in adult life
Stage Age Primary Action Conflict Psychopathology

Oral Birth – mouth, rooting, eating, sucking; weaning oral fixation (drinking, eating, smoking,
18 mos develops trust and comfort nail biting), depression or aggression,
over-dependence on others;
dependent personality disorder

Anal 18 mos - 3 control of bladder and bowel toilet-training “anal-retentive” personality (stringent,
yrs movements; develops orderly, rigid, obsessive) or “anal
competence, productivity and expulsive” personality (messy and
creativity disorganized); obsessive compulsive
personality disorder
Phallic 3 yrs – focus on genitals; learn to Oedipus complex sexual deviancies (avoidance or
6 yrs differentiate between males and (wanting to be the father overindulging) or sexual identity
females and have sex with the issues; histrionic personality disorder
mother); Electra complex
for girls
Latent 6 yrs – libido interests are suppressed;
puberty ego and superego develop;
important for development of
social and communication skills
Genital Puberty – strong sexual interest develops;
adult goal of this stage is to establish
balance between different life
areas

b. Erikson’s Theory of Psychosocial Development: personality develops in stages based on social

experiences across the lifespan. In each stage, people experience a primary conflict that serves
to develop a psychological quality

Stage Age Important Positive Outcome Negative Outcome

Basic Conflict Events

Trust Vs Mistrust birth – 1yr feeding gains confidence and inability to trust; fear about the
security in the world around inconsistent world; anxiety, heightened
him insecurities, mistrust

Autonomy vs. 1-3 yrs toilet training confident and secure in their feelings of inadequacy; overly
Shame and Doubt own ability to survive in the dependent upon others, lack self-
world esteem

Initiative vs. Guilt 3-6 yrs exploration sense of initiative; security in guilt; nuisance to others; lack self-
ability to make decisions and initiative; followers
lead others
Industry vs. 6 yrs - puberty school industrious; confident in inferiority; doubt abilities; may not reach
Inferiority ability to achieve goals his potential
Identity vs. Role adolescence social form their own identity sense of confusion about themselves
Confusion relationships and their role in the world.

Intimacy vs. young relationships comfortable relationships avoiding intimacy; fearing commitment
Isolation adulthood and a sense of commitment, and relationships; isolation, loneliness,
safety, and care within a and depression
relationship
Generativity vs. middle work and productive members of stagnant and feel unproductive
Stagnation adulthood parenthood society and community
Ego Integrity vs. older reflection on develop integrity dissatisfaction with life; despair,
Despair adulthood life depression, hopelessness

c. Piaget’s Theory of Cognitive Development: Piaget was the major architect of cognitive theory,
and his ideas provided a comprehensive framework for understanding cognitive development.
Each period has specific features that enable a child to comprehend certain kinds of knowledge
and understanding. Piaget believed that although children pass through these stages at different
rates, they all follow the same sequence.

Stage Age Cognitive Skill Milestone

Sensorimotor birth – 2 infant uses senses and motor skills to infant learns the concept of object
years obtain information and an understanding permanence, that is, that an object still
about the world around him or her. exists when is it not in the visual field
Preoperational 2 years – child begins to develop symbolic thinking, child will begin to understand and to
7 years including language; egocentric thinking-- coordinate several points of view; learn
child sees the world from his/her own conservation of number, mass,
perspective; unable to consider more than and substance
one dimension
Concrete 7 years – able to understand and to apply logic, can child can perform mental operations and
Operations 12 years interpret experiences objectively, can use logic, although still restricted to
coordinate several perspectives tangibles
Formal 12 years - able to consider hypothetical and abstract young adult is able to discern the
Operations adulthood thought, can consider several possibilities underlying motivations or principles
or outcomes, and has the capacity to of something (such as an idea, a theory, or
understand concepts as relative rather an action)
than absolute and can apply them to novel situations

I. How does psychiatric treatment differ in kids?

a. Multidisciplinary, team-oriented approach
b. Family and school involvement (DCS)
c. Strong importance of therapy, rare medication alone
d. Developmental Context
e. Importance of the milieu/level of care
f. Compliance
g. Informed Consent/Assent
h. Reasons for presentation
II. Suicide:
a. CDC 2015 – Suicide is third leading cause of death for children 5-14 and second leading cause
of death for adolescents 14-24 year olds
b. 9-12th graders in the prior 12 months: 17% seriously contemplated suicide, 13.6% made a plan,
8% attempted suicide one or more times, 2.7% had a suicide attempt that resulted in injury/need
for medical attention
III. Resources:
a. For teens and families
i. http://www.halfofus.com
ii. https://www.jedfoundation.org
iii. http://jasonfoundation.com
iv. https://twloha.com/learn/vision/
 v. http://www.crisistextline.org
b. For clinicians
i. http://www2.massgeneral.org/schoolpsychiatry/index.asp
ii. DSMV, CDC, NIMH, National Comorbidity Research Survey