Locomotor skills An infant initially becomes mobile, usually by crawling, but some will bot - tom shuf \202 e and others will commando crawl (creep). \200 \200 By By 12mths range for this is broad. 10mths infants are usually cruising round the edge of furniture. 50% of infants are walking independently; however, the age Children not walking by 18mths must be referred for evaluation Further development of motor skills Children learn to run and jump and by 24mths they start to kick a ball \200 Age 3yrs: pedal a tricycle. Age 4yrs: stairs one leg at a time, and pedal a bicycle with st abilizers. Age can jump from a bottom step, stand on one leg brie \202 y, and can balance on one leg for a few seconds, go up and down 5yrs: can skip on both feet. 15_McClure_15.indd 558 11/14/2012 3:37:33 PM FINE MOTOR DEVELOPMENT 559 Fine motor development Fine motor development and vision Fine motor skills are dependent on good vision. Therefore \201 ne motor skills are usually assessed alongside visual develo pment. Early visual alertness A \200 newborn infant will \201 x and follow a near face or light moving across the \201 eld of view. By follow an object. By (i.e. hand regard). 6wks infant is more alert and will turn the head through 90 to 3 \200\2234mths a baby will spend a lot of time watching their hands Note: Some infants may demonstrate an intermittent squint. Fixed squints and all those pers isting beyond the 8-week check must be referred to an ophthalmologist (see b Chapter 24 pp. 908 \200\223910). Early \201 ne motor skills As the primitive grasp re \202 ex starts to decrease infants will start to reach for objects. \200 6mths: grip is usually with the whole palm (palmar grasp); holds objects with both hands and will bang them together; transfers objects betwee n hands. 10mths infant is developing a pincer grip using thumb and \201 rst At \200 \200 \200 By \201 nger. By 12mths infant will use index \201 nger to point to objects. Preschool \201 ne motor development Fine motor skills can be assessed with pencil control and with building bricks (Table 15.1). Table 15.1 Fine motor skill developmental milestones Age Pencil skills Brick building 18mths Scribbles 2yrs Builds 6-brick tower 2.5yrs Copies a circle Builds 8-brick tower or train with 4 carriages 3yrs Draws a circle Copies/makes bridge 4yrs Draws a cross Copies/makes steps 4.5yrs Draws a square 5yrs Draws a triangle 15_McClure_15.indd 559 11/14/2012 3:37:33 PM CHAPTER 15 Child development 560 Speech and language development Speech is assessed in conjunction with hearing (b p.896). I mpaired hear- ing will affect language development. Age of acquisition of language is very varied. Early signs of normal hearing and vocalization \200 \200 \200 Newborn By By \200 \200 will quieten to voices and startle to loud noises. 6wks: responds to mother \200\231s voice. 12wks: will vocalize alone or when spoken to; beg ins to coo and laugh. Early language development \200 \200 At 6mths By 8mths \200\230dada \200\231. By 13mths understanding of other single words (e. g. \200\230drink \200\231 or \200\230no \200\231). By 18mths: \200 \200 will use consonant monosyllables, e.g. \200\230ba \200\231 or \200\230da \200\231. will u se non-speci \201 c two-syllable babble, e.g. \200\230mama \200\231 or two-syllable words become appropriate and develops vocabulary of 10 words; demonstrate 6 parts of the body. Phrase and conversation development Conversation becomes increasingly complex with sentence development in the 2nd year. \200 By24mths phrases by the age of 2yrs (e.g. \200\230Giv e me toy \200\231 or \200\230get me drink \200\231). By 3yrs begin to combine 2 words together progressing to 3-words knows age, name and several colors. 15_McClure_15.indd 560 11/14/2012 3:37:33 PM SOCIAL, EMOTIONAL, AND behavioral DEVELOPMENT 561 Social, emotional, and behavioral development Early social development \200 At \200 \200 At 10mths an increased wariness of strangers. By 10mths 6wks: starts smiling; becomes increasingly responsive socially. shows separation anxiety when separated from parent and begins to wave \200\230good-bye \200\231. Social and self-help skills development \200 \200 \200 \200 At 8mths At 12mths At 18mths By 2yrs begins to start to feed self using \201 ngers. will drink from a cup. uses spoon to feed self. removes some clothes and will soon start to try to dress self. Bladder and bowel training Very variable. Some children are potty trained by 2yrs, but others can be much older when t hey develop this behavior. Night-time dryness always takes longer. 10% of 5-year-olds still wet the bed at night. Symbolic play \200 By 24mths children start to copy actions and activities that they see around them (e.g. feeding a doll, making tea, dusting, and cleaning). They progress in the 2nd year to play on their own or alongside peers in parallel play. From 3yrs simple rules. they start to have interactive play, taking turns and following Cognitive function Cognition refers to higher mental function. \200 Pre-school \200 children: thought processes are called pre-operational; children are at the center of their world; \200\230magical \200\231 thinking and play with toys as if they were alive. Junior are more practical and orderly. Teenage abstract thought and complex reasoning. school age: thoughts become operational and thought processes years: formal operational thought has developed including 15_McClure_15.indd 561 11/14/2012 3:37:33 PM CHAPTER 15 Child development 562 Developmental assessment The Denver Developmental Screening test (Box 15.2) is used as a re lative- ly quick test of children \200\231s abilities and as an assessment of whether they have achieved their age-appropriate developmental milestones (Fig. 15.1). Box 15.2 How to use the Denver Developmental Screening test \200 \200 A vertical line is drawn at the child \200\231s chronological age If premature, subtract th e month chronological age (up until the age of 2yrs) s of prematurity from the Developmental assessment should always consider developmental prog- ress over time within e ach area of skill. The pattern and rate of attainment of developmental milestones may also vary. 15_McClure_15.indd 562 11/14/2012 3:37:34 PM DEVELOPMENTAL ASSESSMENT 563 Percent of children passing PR = Prone SIT = Sitting 25 50 75 90 TEST ITEM Months 1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 PR LIFTS HEAD 1 BEAR SOME WEIGHT ON LEGS STANDS MOMENTARILY 2 PULL TO SIT NO HEAD LAG PRE HEAD UP 45 WALKS HOLDING ON FURNITURE PR HEAD UP 90 PULL TO SIT NO HEAD LAG STANDS ALONE WELL PR CHEST UP ARM SUPPORT STOOPS & RECOVERS STANDS HOLDING ON SIT HEAD STEADY WALKS WELL PULLS SELF TO STAND Gross Motor GETS TO SITTING ROLLS OVER 9 10 11 FOLLOWS TO MIDLINE GRASPS RATTLE SIT, LOOKS FOR YARN REGARDS RAISIN SIT, TAKES 2 CUBES SYMMETRICAL MOVEMENTS 9 FOLLOWS PAST MIDLINE REACHES FOR OBJECT BANGS 2 CUBES HELD IN HANDS 13 9 FOLLOWS 180 TAKES RAISIN ATTAINS NEAT PINCER GRASP OF RAISIN 12 HANDS TOGETHER THUMBS, FINGER GRASP Fine Motor-adaptive TRANSFERS CUBE HAND TO HAND RESPONDS TO BELL DADA OR MAMA NONSPECIFIC VOLCALIZES NOT CRYING TURNS TO VOICE DADA OR MAMA SPECIFIC LAUGHS SQUEALS 12 IMITATES SPEECH SOUNDS Language REGARDS FACE SMILES RESPONSIVELY INITIALLY SHY WITH STRANGERS 26 PLAYS PAT A CAKE SMILES SPONTANEOUSLY PLAYS BALL WITH EXAMINER INDICATES WANTS (NOT CRY) FEEDS SELF CRACKER 27 RESISTS TOY PULL 50% 90% pass at 1 month DRINK FROM CUP PLAYS PEEK-A-BOO WORKS FOR TOY OUT OF REACH Personal \200\223social 1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 Months Fig. 15.1 Denver developmental screening. 15_McClure_15.indd 563 11/14/2012 3:37:34 PM CHAPTER 15 Child development 564 Neurodevelopmental delay Common presentations Delayed walking Children may show early delay in the acquisition of motor milestones, with a failure to crawl or sit unsupported at the appropriate age. A child who is not walking at the age of 18mths should be referred for a f urther opinion, and may need to see a physiotherapist or a specialist paediatri- cian. It i s important to exclude the following conditions: \200 b p.550). \200 Cerebral palsy (see Duchenne muscular dystrophy (DMD) or other muscular disorders (b p.546) . Global neurodevelopmental delay as part of a syndrome or other unidenti \201 ed cause (b pp.537, 564 \200\223565, 942, 956, 960). Delayed speech Delayed speech may be an isolated \201 nding, either in the production of actual sounds or in the use of language. Language is divided into receptive language (langu age comprehension) and expressive language (speech to communicate). A speech and language t herapist should assess language delay. A hearing test should be considered especially if th e child has not had their hearing screened as a neonate or there are other concerns (see b pp.560, 896). The causes of delayed speech development are shown in Box 15.3. Box 15.3 Causes of delayed speech development \200 Familial: late in developing language skills or have had speech therapy Hearing impairment: chronic otitis media (glue ear) is a common cause for delayed or poor clarity of speech in the pre-school age Environmental: poor social interaction/deprivation Neuropsychological: \200 \200 a family history of language delay where parents have been \200 global developmental delay autistic spectrum disorder Global neurodevelopmental delay See also b pp.537, 565, 942, 956, 960. Global developmental delay indicates a delay in all skill areas. Often it is more pronounce d in \201 ne motor, speech, and social skills. The degree of gross motor de \201 cit is variable. There are many causes of developmen- tal delay (see Box 15.4), although in some c ases the cause will remain unknown. If the delay is severe or profound then it is more like ly that a cause will be found. 15_McClure_15.indd 564 11/14/2012 3:37:34 PM NEURODEVELOPMENTAL DELAY 565 Box 15.4 Causes of global neurodevelopmental delay Genetic \200 \200 \200 Chromosomal disorders, e.g. Down syndrome, fragile X Duchenne muscular dystrophy Metabolic syndromes, e.g. phenylketonuria Congenital brain anomalies e.g. hydrocephalus or microcephaly Prenatal insult \200 \200 \200 Teratogens, e.g. alcohol and drugs Congenital infections, e.g. rubella, CMV, or toxoplasmos is Hypothyroidism Perinatal insult \200 Complication of extreme prematurity, e.g. intraventricular hemorrhage; periventricular leuc omalacia Birth asphyxia Metabolic disorder, e.g. hypoglycaemia or hyperbilirubinaemia \200 Postnatal events \200 Brain injury: \200 CNS infection: \200 Metabolic: trauma; anoxia, e.g. suffocation or drowning e.g. encephalitis/meningitis e.g. hypoglycaemia 15_McClure_15.indd 565 11/14/2012 3:37:34 PM CHAPTER 15 Child development 566 Learning dif \201 culties/disabilities \200 \200 Learning dif \201 culty categorized as mild, moderate, severe, or profound. Cognitive func tion can be assessed by an IQ (intelligence quotient) test (Table 15.2), but it may be dif \201 cult to assess all skill areas, especially in preschool age group \200\224assessment can be signi \201 cantly affected by language problems and motor skills. Table 15.2 Cognitive function assessment using an IQ test Assessment IQ Normal 70 Mild learning dif \201 culty 50 \200\22369 Moderate learning dif \201 culty 35 \200\22349 Severe learning dif \201 culty 20 \200\22334 Profound learning dif \201 culty <20 Mild learning disability may only be detected once a child is in school. A child with moder ate learning dif \201 culty will need signi \201 cant support in their education. One wit h severe dif \201 culties will learn basic personal care and develop simple speech, but wi ll always need supervision. A child with profound dif \201 culty is unlikely to develop sp eech and will always be dependent. Developmental co-ordination disorder See also b p.988. Previously known as dyspraxia Developmental co-ordination disorder (DCD) is where there are dif \201 culties in learning speci \201 c motor and \201 ne motor skills There are often associated problems with mo tor planning, proprioception and sensation(maybe hypo/hypersensitive to touch, taste, smell ) Children tend to be clumsy and poorly co-ordinated, but may also have speci \201 c dif \201 cul- ties in writing, learning to dress, and remembering daily routine. DCD may also a ffect reading. Physiotherapists and occupational therapists will assess the child and the nature of their dif \201 culties and provide appropriate supportive strategies and training programs to he lp the child manage in school. Communication dif \201 culties Children may have an isolated language disorder and dif \201 culty with social skills. However, when these two development problems are present on a background of other dif \201 culties (limited play, obsessions and lack of social awaren ess), autism must be considered (see b p.602). 15_McClure_15.indd 566 11/14/2012 3:37:34 PM 567 Chapter 16 Child and family psychiatry Prevalence 568 Classi \201 cation, categories, and dimensions 569 Comorbidity and causatio n 570 Developmental perspective 571 Systemic thinking 572 Assessment 573 History taking 574 Communicating 575 Asking the dif \201 cult questions 576 Depression 578 Suicide and non-f atal deliberate self-harm 580 Bipolar disorder 582 Anxiety disorders 584 Post-traumatic str ess disorder 586 Obsessive compulsive disorder 588 Attachment disorder 589 Schizophrenia 59 0 Somatoform disorders and typical consultation \200\223liaison presentations 592 Anorexia nervosa 594 Bulimia nervosa 596 Oppositional de \201 ant and co nduct disorders 598 Attention de \201 cit hyperactivity disorder 600 Autism spectrum disor ders 602 Individual psychotherapy 604 Family therapy 605 Psychopharmacotherapy 606 16_McClure_16.indd 567 11/14/2012 3:42:45 PM CHAPTER 16 Child and family psychiatry 568 Prevalence \200 The prevalence of child and adolescent mental health problems is similar across many Wester n countries (714 \200\22320%). 7 \200 50% of those meeting symptom requirements for a diagnosis are also experiencing signi \201 cant functional impairment. As a consequence at any one time aroun d 10% of children and adolescents are suffering from a clinically signi \201 cant diagnosa ble mental health disorder (based on ICD-10 diagnostic criteria).1 Mental disorders are mor e common in boys than girls (11% compared with 8%), and in teens compared with preteens 5 \200\22310yr olds \200\22410% boys, 6% girls; 11 \200\22315yr olds \200\22413% boys, 10% gi rls).1 <20% children with mental health dif \201 culties actually receive specialist care and most remain undiagnosed. Applying the disability-adjusted life year (DALY) methodology, the burden of neuropsychiatric conditions affecting children is predicted to double by the year 2020.2 The then US Surgeon General, David Satcher, summarized in 2001, \200\230the b urden of suffering experienced by children with mental health needs and their families has created a health crisis in this country \200\231.3 Anybody can suffer from a mental health problem. However, adverse mental health is more commonly experienced by individuals from de prived or abusive backgrounds, from families that are \201 nancially disadvantaged or emo tionally troubled. Single parent families and members of ethnic minority groups are over re presented. These groups may also experience speci \201 c barriers to accessing child and a dolescent mental health services that are predominantly clinic- or hospital-based. References 1 Department of Health (2000) The Mental Health of Children and Adolescents in G reat Britain. London: Stationery Of \201 ce. 2 World Health Organization (1999). Making a difference. Geneva: WHO. 3 Report of the US Su rgeon General \200\231s Conference on Children \200\231s Mental Health (2001). A national action agenda. Washington DC: Department of Health and Human Services. 16_McClure_16.indd 568 11/14/2012 3:42:46 PM CLASSIFICATION, CATEGORIES, AND DIMENSIONS 569 Classi \201 cation, categories, and dimensions As is the case in general medicine and pedi atrics diagnosis is used in child and adolescent psychiatry to; \200 \200 \200 Collect and organize information collected at assessment. To guide treatment planning. To i nform about prognosis. Classi \201 cation systems assist with the standardization of the diagnostic process and t he use of a reliable and effective classi \201 catory system can serve several important f unctions; \200 Their use results in a greater precision in planning treatment at both the individual and p opulation levels. They are a prerequisite for the conduct of many types of clinical researc h and facilitate the communication of research \201 ndings. They allow for the collection of epidemiological data a process which is central to health-care planning at internationa l, national, and local levels. The two most in \202 uential diagnostic systems are the World Health Organization \200\231 s International Classi \201 cation of Diseases (ICD) and the American Psychiatric Associat ion \200\231s Diagnostic and statistical manual (DSM) system. Current versions are ICD-10 a nd DSM-V, although revisions are underway for both. Both are categorical systems. They both include sec- tions describing disorders \201 rst diagnosed in childhood and adolescence, but also allow children and adolescents to meet criteria for most \200\230adult \200\231 mental health disorders. A key requirement of both systems is that they insist that both sy mptoms and associated impairments be present in order for a diagnosis to be made. Notwithstanding these clear bene \201 ts there has been some resistance to the introductio n of standardized diagnostic systems into routine clinical practice in child and adolescent mental health. Some clinicians believe this categorical approach is overly restrictive and propose that a dimensional approach whereby \200\230cases \200\231 represent the extreme end of a continuum is more appropriate. Supporters of the dimensional view suggest it is le ss stigmatizing for children, evoke a more holistic management strategy than a limited medi cal model, and, for some presentations, has more predictive validity than the categorical/d iagnostic model. Drawbacks of the dimen- sional approach include dif \201 culties deciding when to treat and an over reli- ance on symptoms at the expense of impairment. Unfortunate ly debates over \200\230categorical \200\231 versus \200\230dimensional \200\231 often be come unnecessarily polar- ized and it is important to remember that they are not mutually e xclusive from each other. 16_McClure_16.indd 569 11/14/2012 3:42:46 PM CHAPTER 16 Child and family psychiatry 570 Comorbidity and causation The etiology of most common mental health problems is poorly under- stood. In most cases th ere appears to be interplay between genes and environment with polygenic pathways, multiple potential environmental risk factors and complex gene x environment interactions and assoc ia- tions (Fig. 16.1). As a consequence the simple relationship depicted by example 1 is ra re. Example 1 does, however, remind us that one condition may develop into another, e.g. th e progression of oppositional de \201 ant disorder to conduct disorder. Reverse causality is also possible e.g. head injury caused by impulsive risk taking behaviors s to ADHD. It i s also the case that the presenting condition, for instance depression, may be s to earlier struggles with an eating disorder (example 2). The co-occurrence of disorders is common in child and adolescent mental health. Disorders A and B in examples 3 and 4 above are comorb id. An example of 3 is sexual abuse acting as a non-speci \201 c risk factor for later dru g and alcohol use and deliberate self-harm. In example 4, the two conditions may co-occur, but are aetiologically unrelated. Other potential relationships between A and B are possibl e and indeed most cases will be much more complex than depicted here. 1. Direct causation A B 2. Reverse causation A B 3. Shared causation A C B 4. Co-occurrence but no causal relationship A C C B Fig. 16.1 Comorbidity and causation. 16_McClure_16.indd 570 11/14/2012 3:42:46 PM DEVELOPMENTAL PERSPECTIVE 571 Developmental perspective A cross-sectional understanding, effectively a snap-shot in time, is not usu- ally informative about the child \200\231s pre-presentation strengths and vuln er- abilities, and has been shown to have little predictive validity about future developme nt. A developmental model acknowledges that the individual \200\231s needs, demands, skills and contributions change over time. Infant, child, and adolescent stages of development ar e described, as being embed- ded within the, also changing, emotional and material resource s of the primary caregivers, which in turn exist within evolving social and com- munity res ources and cultural factors such as a given group \200\231s typical way of expressing emoti on, reaction to adversity, and morals about acceptable behavior. \200 Some factors, such as a genetic vulnerability, act continuously, but variably across time. Some care giving in \202 uences, such as coercive parenting styles, are often seen as deve lopmental continuities, unless an active process of change is undertaken. Children can be d escribed as being on a normal, or abnormal, trajectory, either globaly or for a range of co nstructs such as regulation of mood, impulsivity, emotional reciprocity, etc. The usefulness of this perspective lies in understanding whether a recent presentation is a continuation of a long-standing behavioral or emotional state or a recent discontinuity fr om a normal trajectory. The former usu- ally involves continuity of causative factors. Such presentations require more complex interventions, over longer periods and generally have a more guarded prognosis. The heuristic bio-psychosocial is another framework that helps the clinician avoid reductio nist and simple formulations for complex presentations. 16_McClure_16.indd 571 11/14/2012 3:42:46 PM CHAPTER 16 Child and family psychiatry 572 Systemic thinking No child is an island. No family should be one. Children and families pre - sent within the context of systems; nuclear and extended families as well as the local an d school communities. They are also affected by regional and national phenomena such as emp loyment and poverty gradients and access to services. Systemic thinking involves viewing the child within the context of the family and these bro ader systems. Such understanding is especially impor- tant when treatment systems intersect around complex psychosocial presentations. The dif \201 culties some physicians caring fo r adolescents with anorexia nervosa experience in balancing the various inputs from mental health therapists, dieticians, school teachers and heads, the child, and par- ents is a goo d example. Understanding the family system is essential: whether the parents work together or undermin e the other one \200\231s parenting; the function of sibling subsystems; whether there are typical alliances (i.e. father and son going to the football) or unhealthy alliances (i.e. cross-generation grouping to remove someone from family activities). Other types of questio ns that could be asked include; \200 \200 \200 Has a child been elevated into a decision-making role? Has one parent been demoted? Is a ch ild an \200\230identi \201 ed \200\231 rather than actual patient, e.g. the child is pres ented with withdrawn behavior when the real problem is an imminent parental separation? Hav e healthcare staff been unwittingly triangulated by some family members to exclude others f rom carer roles? There are a number of schools of systemic thinking, but all tend to focus on understanding a number of key issues about the family and their rela- tionship with the environment; \200 \200 \200 \200 \200 \200 Family functioning, roles, and relationships. Attitudes and beliefs within the family. Patt erns of communication and interaction. Problem solving abilities. Strengths within the fami ly. Social and cultural backgrounds. 16_McClure_16.indd 572 11/14/2012 3:42:46 PM ASSESSMENT 573 Assessment A thorough assessment and understanding of the presenting dif \201 culties form s the basis for any treatment interventions offered for children, young people, and their f amilies or carers. As mental health problems rarely occur in isolation, with comorbidity th e norm, it is essential that any assessment is suf \201 ciently comprehensive to ensure th at a clear and com- plete formulation of the presenting problems has been made. An assessment will usually have 4 major components: Identi \201 cation of problems, histor y, signs and symptoms. The information gathering stages. Evaluation/synthesis. Care/treatme nt planning. \200 \200 \200 The psychiatric history and examination of child and adolescent mental health problems bear s many similarities to that of adults. However, there are several differences in detail and emphasis. The assessment will usually be conducted as part of a joint interview with paren ts and the child/young person and will often require more than one visit. The general proce sses include; \200 \200 Clinical interview with the parent(s)/carers. Clarify presenting complaints with systematic evaluation of psychopathological symptoms and description of how problems developed over t ime. Developmental history. Pre and post-natal factors. Early developmental history (e.g. m ilestones, language, attachment, sleep, feeding problems, early temperament). Medical histo ry (esp. tics and epilepsy, and psychosis for adolescents). Medication (esp. anticonvulsant s, antihistamines, sympathomimetics, steroids). Family history, functioning, problems copin g styles, warmth and hostility, social networks and other resources. Interview with the chi ld/young person. Functioning in the family, the school and the peer group. Emotional proble ms and self-esteem. Self report rating scales may be useful as supplement especially for em otional symptoms in those 9yrs and older. Behavioral observation during clinical examinatio n can be very useful when problems are seen, but an absence of observed problems during ass essment does not mean they are not there. Also look for social disinhibition and evidence o f language disorder during observation. Systematic screening for psychiatric symptoms/disor ders. Physical examination. \200 \200 \200 \200 \200 \200 \200 Preschool or school information is invaluable \200\223if parents \200\231 consent. Whilst c lassroom observation may be helpful a narrative report of behavior and behavior problems se en within school setting is often adequate. 16_McClure_16.indd 573 11/14/2012 3:42:46 PM CHAPTER 16 Child and family psychiatry 574 History taking Why have multiple informants? Neither parents nor their children and adolesc ents may, be aware of or see the whole picture. They may also withhold information from you . Which of us does not on occasion operate a need to know policy? As an example, the teenag e girl with anorexia nervosa who wants to avoid admission may exaggerate the amount she is eating and minimize her level of exercise. Whom to get information from? This is a balance between \200\230the more sources the bette r \200\231 and the demands of con \201 dentiality and time. \200 A good starting point is the referral details and information from both the young person an d members of the family. Information from the school should also be sought though this may not be practicable in an emergency situation. Where relevant, others should be approached, e.g. social services, child and adolescent mental health services, youth offending teams. Example The child is brought to Accident and Emergency with an unex- plained and suspicious injury. Collaboration with other agencies is essential if child protection concerns exist. Local information-sharing protocols pro- tect practitioners and expedite this work (see b pp.1005 \200\2231009, 1038). Interviewing the family To an extent the family interview is an ef \201 cient way of gathe ring informa- tion and hearing the views of the patient, siblings, and parents all at one g o. However, to see it this way is missing the point. It is an opportunity to learn so much more. \200 \200 \200 Are there obvious tensions or con \202 icts? Is tension between the parents diffused by th e child \200\231s behavior? Are the children allowed appropriate autonomy, or do they rule the roost? Is one parent a \200\230switchboard \200\231 through which all communication is routed? Are family members able to listen to each others \200\231 views? Is disagreement t olerated? Is there a family \200\230story \200\231 that informs how they interact around t he presenting problem? Examples include, \200\230no-one listens to us \200\231, \200\230w e have tried our best and can \200\231t do any more \200\231, \200\230it is all this child \200\231s fault \200\231, and \200\230he/she cannot be helped, but at the same time someo ne has to do something about her/him \200\231. This sort of mixed message around a scapegoa ted child can often be very dif \201 cult to work with. \200 \200 Family structures are variable. Often times the interview is with one par- ent. Sometimes i t can be illuminating if grandparents are also present. Are there coalitions across generat ions (e.g. grandparent and child), in effect combining forces to undermine one of the paren ts? A further area to note is how the family responds to you. Are you treated as a threat, a me ssiah, a parent/grandparent, or just a doctor? Do you feel pulled to take sides in a disput e? 16_McClure_16.indd 574 11/14/2012 3:42:46 PM COMMUNICATING 575 Communicating See also b pp.20, 794, 1034 \200\2231035. Tips for communicating with children \200 Children \200\231s anxiety is often decreased if \201 rst interviewed with an adult they trust. Assume children do not fully understand why they are being seen. Often children assu me they are \200\230in trouble \200\231. Often children equate doctors with physical illne ss, often with painful procedures such as injections. Rarely have they met a \200\230talki ng doctor \200\231. Be prepared to see a child several times to gain trust and rapport. Lea rn and/or practice child-appropriate communication, i.e. drawing, coloring, storytelling, p retending, building, making, exploring, appreciating tall tales, talking about current TV, technology, books. Do not take over play; follow the child \200\231s lead and still behave like a sensible adult. Practice age-appropriate language. Do not undermine the parents \200 \231 efforts by appearing too competent. \200 \200 \200 \200 Tips for communicating with adolescents \200 Don \200\231t assume they have chosen to be there. \200 Understand they may be ambivalent about recognizing they have a problem, deal ing with, or denying it. They may see you as a source of help or as a threat \200\224or bot h. Discuss the context of your conversation \200\224why are you meeting? Discuss what you w ill do with what she/he tells you (con \201 dentiality and its limits may be crucial). It may be helpful to ask about neutral areas \201 rst. Be prepared to ask closed questions a ccepting a yes or no answer. Speak plainly. Avoid talking like an adult pretending to be a teenager. Convey your desire to understand by checking whether you are getting it right. \200\230I am hearing that unless something changes pretty quick you are not going to be abl e to go to school any more. Have I got it right? \200\231 Do ask the adolescent what she/he would like to happen, but as above accept they may have mixed feelings. Be patient. Unless it is an acute situation consider continuing your assessment over more than one session. D o see the adolescent alone as well as with his/her parents. \200 \200 \200 \200 16_McClure_16.indd 575 11/14/2012 3:42:46 PM CHAPTER 16 Child and family psychiatry 576 Asking the dif \201 cult questions About sexual abuse See also b pp.801, 1002. Sexual and other forms of abuse are common speci \201 c and non-speci \201 c vulnerability factors f ors poor mental health and must be excluded as aetiological factors. The clinician \200\231 s task is to \201 nd an approach to asking about abuse that they are comfortable with and appear to the child to be comfortable with. One approach is a hierarchical set of question s. \200 \200 \200\230I ask these questions to all children I see. \200\231 Introductory comment: Ask child to respond to a broad, non-leading statement: tell me somet hing has happened to them that they wish had never happened. \200\231 Child \200\231s respo nse may be verbal or non-verbal af \201 rmation, denial, or looking perplexed; they may no t understand the question at all. Ask more speci \201 c questions: \200\230Some things ar e done by other people \200\231 or \200\230 are touched in places they wished t hey had not been touched. \200\231 Ask very speci \201 c questions: \200\230Some people a re touched in places like their private parts/vagina/penis (language depends on age, may al so point or draw picture), has this happened to you? \200\231 \200\230Some children Partial af \201 rmation or non-verbal cues that suggest possible abuse should be followed up during later appointments. One caveat is there are differ- ences between a purely forens ic and a clinical interview. In both settings open, non-leading questions are preferable. L ocal protocols will also guide assessments. About suicidal ideation and intent Clinicians must ask about suicidal thinking, especially in adolescents with any depressive features. Asking does not create or promote suicidal thi nk- ing. Again, a hierarchical approach is used effectively by many clinicians. \200 \200 Introductory comment: Ask adolescent to respond to a broad statement: \200\230Some young p eople tell me that they feel life is not worth living anymore. \200\231 Again look for resp onses that may be verbal or non-verbal af \201 rmation or denial. Ask more speci \201 c q uestions: to not be alive \200\231 or \200\230Some people think it would be better to be d ead. \200\231 Ask very speci \201 cally to clarify risk and extent of planning: thought of killing yourself? \200\231; \200\230Have you ever made a plan to kill yourself? \200\230 Have you ever lost control and started your plan? \200\231 \200\230I ask these questions to everyone I see. \200\231 \200\230Have you considered what it would be like \200\230Have you As above, partial af \201 rmation or non-verbal cues that suggest possible abuse should be followed up during later appointments. 16_McClure_16.indd 576 11/14/2012 3:42:46 PM ASKING THE DIFFICULT QUESTIONS 577 16_McClure_16.indd 577 11/14/2012 3:42:46 PM CHAPTER 16 Child and family psychiatry 578 Depression Loose usage of the words \200\230depression \200\231 and \200\230depressed \200\231 causes much con- fusion. They can refer to a mood, which may be appropriate, a sym ptom, or a mental disorder. Prevalence Approximately 10% of 10-yr-olds are reported by parents and teachers, and 20% of 14-yr-olds report themselves to be often miserable. However, the rate of diagnosable depre ssive disorder in a community sample of 11 \200\22316-yr-olds is closer to 3%. The discrepa ncy is due to those who suffer low moods, but do not meet full diagnostic criteria. Etiology Genes increase both the risk of developing depression and of experiencing negative life events. Post-pubertally females are twice as likely as males to become depressed and possible links to estrogen levels, either in utero or post-puberty, have been suggested. Fe males may also be more in \202 uenced by lack of positive relationships, close friendships , or a supportive peer network. Environmental factors include; early adversity and attachme nt dif \201 culties, negative or traumatic life events or abuse, death of a parent, drug a nd alcohol abuse, and bullying. Psychosocial factors include; social isolation and negative interpersonal relationships, poor academic achieve- ment, unstable family environment, par ental drug and alcohol abuse. Clinical features Diagnosis of depressive disorder requires that mood is persistently lower ed and accompanied by a loss of interest and enjoyment and/or increased fatigability for mo re than 2wks with a signi \201 cant effect on func- tioning. There should also be at least two of the following symptoms; \200 \200 \200 \200 \200 \200 \200 Reduced concentration and attention. Reduced self-esteem and self-con \201 dence. Ideas of guilt and unworthiness. Bleak and pessimistic views of the future. Ideas or acts of self-h arm. Diminished appetite. Disturbed sleep. Depressive disorders are frequently recurrent so it is always important to ask about past e pisodes. Dysthymia is a chronic enduring depressed state lasting for over a year, but without the intensity of a depressive episode. Amongst those referred to child psychiatric clinics, comorbidity is com- mon, e.g. conduct disorder, obsessive compulsive disorder. Management1 Initial assessment should identify: \200 \200 \200 Signi \201 cant risk of self-harm or suicide. Signi \201 cant lack of self-care or neglec t. Symptoms of manic episode or psychotic disorder. 16_McClure_16.indd 578 11/14/2012 3:42:46 PM DEPRESSION 579 \200 Comorbid psychiatric disorder. Previous history of moderate or severe depressive episodes. When these are present, referral to a specialist child and adolescent men- tal health servi ce is appropriate First line treatment for mild depressive disorder with symptom duration less than 4wks Supp ortive therapy and psychoeducation about depressive disorders are effective \201 rst line interventions in 30% of children and adolescents with recent onset of mild to moderate dep ressive symptoms. Advice should be given on sleep hygiene, nutrition, activity, and exercis e. If there is no response to supportive management after 2 \200\2233mths, young people sho uld be referred to Tier 2/3 CAMHS services for more intensive psychological therapy. Treatment for moderate to severe depressive disorders Psychological therapies are recommend ed as \201 rst line treatments for treating child and adolescent depressive disorders. Re commended prac- tice is that a block of psychological therapy should be undertaken prior to consideration of antidepressant medication. Supported approaches are cognitive behavioral therapy (CBT) and interpersonal therapy. Brief fam- ily therapy may be effective in some ca ses. Response to treatment should be reviewed after 12wks If there is a good response to treatme nt the course of therapy should be completed and follow up should be provided for 12mths af ter remission of symptoms (or 2yrs if the patient has had one or more previous episode of d epression).