Behavioral or Psychiatric Problems
Thomas H. Chun, MD
Behavioral or Psychiatric Problems - BASICS
Behavioral or Psychiatric Problems - description
Behavioral, developmental, or psychosocial problems requiring medical or psychiatric treatment, or causing significant impairment
Behavioral or Psychiatric Problems - epidemiology
Behavioral or Psychiatric Problems - prevalence
- 14–20% 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: 5–10% (conservative estimate)
- Eating disorders: 0.5–1%, but 5–15% mortality rate
Behavioral or Psychiatric Problems - risk factors
Behavioral or Psychiatric Problems - 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 (3:1–9:1) and depression (1:2), have distinct male/female preponderance.
Behavioral or Psychiatric Problems - DIAGNOSIS
- Frequently unrecognized by primary care providers:
- 50–80% of children with mental health problems
- 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:
- Goal 1: Assess for safety, i.e., suicidality, homicidality, and adequate support/supervision at home.
- Goal 2: Rule out organic causes.
- Goal 3: Establish psychiatric/psychologic causes as possible diagnosis.
- Goal 4: Work with family to accept possibility of psychiatric/psychologic diagnosis and facilitate referral to mental health services.
- Screening hints:
- Parents/children are often reluctant to discuss psychosocial issues; they consider them stigmatizing.
- Standard developmental checklists are often inadequate.
- Asking “Do you have any concerns about your child’s 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:
- Collaborative effort of pediatricians and child psychiatrists, psychologists, and neurologists
- Concise, user-friendly guide for diagnosing mental disorders
Behavioral or Psychiatric Problems - signs & symptoms
Behavioral or Psychiatric Problems - history
Behavioral or Psychiatric Problems - physical exam
- All patients require a thorough physical examination.
- Goal is to detect any organic causes for patient’s symptoms (see “Differential Diagnosis”).
Behavioral or Psychiatric Problems - tests
- No standard battery of laboratory tests. Tests should be ordered based on clinical suspicion.
- Specific resources:
- Screening questionnaires (see “Bibliography”):
- Parent monitoring forms/diaries, direct observation of parent–child interactions can be used, depending on the practitioner’s practice setting, experience, familiarity, and confidence with these modalities.
- Screening for maternal depression may also be important in detecting psychosocial dysfunction.
- The Pediatric Symptom Checklist:
- Well-validated 35-item parent report
- Can be completed in 5 minutes, easily administered in waiting area
- Easily scored
- The Child Behavior Checklist:
- More in-depth assessment
- More difficult to administer/score
- Conners Rating Scales:
- Adjunct to diagnosing ADHD
- Rating scales alone insufficient to diagnose ADHD
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:
- Children/adolescents often misjudge the lethality of their suicide methods.
- All attempts must be taken seriously.
- Making diagnosis/treatment plan without comprehensive evaluation:
- Many psychiatric disorders present in similar fashion (see “Differential Diagnosis”).
- 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)
Behavioral or Psychiatric Problems - differencial diagnosis
- Organic causes:
- CNS infections or parainfectious syndromes
- Substance abuse, toxic ingestions, medication adverse effects
- Intracranial trauma or other injury
- CNS tumors
- Endocrine disorders: Thyroid or adrenal dysfunction
- Metabolic disorders, abnormality of:
- Glucose
- Sodium
- Potassium
- Calcium
- Migraines
- Seizure disorders
- Hematologic disorders:
- Hypoxia
- Cardiopulmonary disturbances
- Psychobehavioral disorders (many disorders have similar symptoms):
- ADHD Ddx:
- Mood disorders: Depression/bipolar disorder
- Anxiety disorders: School phobia, posttraumatic stress
- Tic disorders
- Substance abuse
- Hearing or vision impairment
- Learning disabilities
- Social withdrawal Ddx:
- Depression
- Neglect
- Pervasive developmental disorder, sensory impairment (e.g., deafness)
- Learning disability
- Psychotic symptoms Ddx:
- Psychotic disorders
- Mood disorders (depression, bipolar disorder)
- Borderline personality disorder
- Substance abuse
Behavioral or Psychiatric Problems - TREATMENT
Behavioral or Psychiatric Problems - medication
Contraindications, precautions, and significant possible interactions
- Patients on psychotropic medications need close monitoring for adverse effects.
- Stimulants:
- Assessment of growth, heart rate, and BP every 3–6 months
- Patients on pemoline should have liver function checked every 6–12 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 3–6 months thereafter for adverse effects, especially dystonia, anticholinergic symptoms, movement disorders
- “Atypical” antipsychotics:
- Frequently cause significant weight gain and may cause impaired glucose tolerance and prolong QTc
- Patient’s weight should be closely monitored, as well as any signs of diabetes mellitus.
- An ECG should be obtained before and after starting ziprasidone.
Behavioral or Psychiatric Problems - bibliography
- Achenbach TM, Ruffle TM. The child behavior checklist and related forms for assessing behavioral/emotional problems and competencies. Pediatr Rev. 2000;21:265–271.
- American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adol Psychiatry. 2001;40(suppl):24S–51S.
- American Academy of Pediatrics, ADHD Subcommittee. Clinical practice guideline: Diagnosis and evaluation of the child with ADHD. Pediatrics. 2000;105:1158–1170.
- Cantwell DP. Attention deficit disorder: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1996;35:978–987.
- Casidy LJ, Jellinek MS. Approaches to recognition and management of childhood psychiatric disorders in pediatric primary care. Pediatr Clin North Am. 1998;45:1037–1052.
- Clark LR, Ginsburg KR. How to talk to your teenage patients. Contemp Adolesc Gynecol. 1995;Winter:23–27.
- Glascoe FP. Early detection of developmental and behavioral problems. Pediatr Rev. 2000;21:272–279.
Green WH. Child and Adolescent Clinical Psychopharmacology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001.- McClellan JM, Werry JS. Evidence-based treatments in child and adolescent psychiatry: An inventory. J Am Acad Child Adolesc Psychiatry. 2003;42:1388–1400.
- Roberts RE, Attkisson C, Rosenblatt A. Prevalence of psychopathology among children and adolescents. Am J Psychol. 1998;155:715–725.
- Stancin T, Palermo TM. A review of behavioral screening practices in pediatric settings: Do they pass the test? J Dev Behav Pediatr. 1997;18:183–194.
- Wolralch ML. Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version: Design, intent, and hopes for the future. J Dev Behav Pediatr. 1997;18:171–182.
Behavioral or Psychiatric Problems - CODES
Behavioral or Psychiatric Problems - icd9
V79.0 Depression
296.3 Major depressive disorder, recurrent episode
300.4 Dysthymic disorder
309.28 Adjustment disorder with mixed anxiety and depressed mood
309.0 Adjustment disorder with depressed mood, grief reaction
Behavioral or Psychiatric Problems - FAQ
- 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 practitioner’s 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.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
Other Book Chapters Related to Behavioral symptoms
Read excerpts from these other book chapters related to Behavioral symptoms:
Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.
More About Causes of Behavioral symptoms
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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