Clinical Assessment and Management of Childhood Psychiatric Disorders, Third Edition
Savita Malhotra
Contents
Foreword to the Third Edition by N Sartorius v
Foreword to the Third Edition by Anthony PS Guerrero vii
Foreword to the Second Editon by Myron L Belfer ix
Preface to the Third Edition xi
Development of the Brain and Mind 1
Risk and Resilience: The Role of Family, School and Environment 18
Approach to Psychiatric Assessment and Interview 24
Interview Technique 38
Neurodevelopmental Assessment 48
Psychological Assessment of Children 57
Structured Assessment and Some Indian Scales 80
Diagnosis and Classification 107
Management Planning 131
Treatments 138
Special Issues in Adolescence 165
Infant Mental Health 175
Psychiatric and Behavioural Emergencies 184
Sexual Abuse in Children and Adolescents 201
Alcohol and Substance Abuse in Children and Adolescents 209
Glossary of Terms 219
Appendices
Appendix 1. Child and Adolescent Psychiatry Case History 235
Appendix 2. Temperament Measurement Schedule 240
Appendix 3. Childhood Psychopathology Measurement Schedule 247
Appendix 4. Life Events Scale for Indian Children 252
Appendix 5. Parental Handling Questionnaire 256
Appendix 6. Designs of Gesel’s Drawing Test 258
Appendix 7. Guidelines for Healthy Parenting 260
Index 265
Preface to the Third Edition
Children can suffer from mental disorders much like adults, rather many psychiatric disorders begin in childhood. Early treatment is the key to promote healthy development and socio-emotional well-being. It has been reported that about 50% of all mental disorders begin before 14 years of age and 75% begin before 25 years of age. Developing brain during fetal, infancy and early childhood phase is the most sensitive to environmental influences and becomes conditioned/patterned accordingly, incorporating the lived experience, and gets built in the process leading to a unique constellation of behavior, emotions and personality. Importance of child mental health has been amply understood by researchers, professionals and societies. In India too in recent years awareness is increasing and the need and demand for professional psychiatric services for children is rising. However, there is great dearth of qualified mental health professionals, i.e. psychiatrists, psychologists, social workers, special educators, speech and language therapists, and occupational therapists in India. Problem is further compounded by the very few training facilities available in the country.
As the theory and practice of child psychiatry is deeply enmeshed in the sociocultural milieu of the child’s life, it becomes necessary that approaches and clinical tools for assessments and interventions are ethnosensitive. In my experience of practicing psychiatry and child psychiatry for 50 years, I have felt that the knowledge derived from the work done in the Western countries cannot be directly applied to the Indian population and there is a definite need to adapt such knowledge to make it applicable to the local situation. As a postgraduate teacher of psychiatry, I have often felt that the students find themselves at crossroads due to mismatch between clinical approaches given in the Western textbooks and the practical realities experienced in every day’s professional work.
This book has been written to help and guide clinicians such as child psychiatrists, general adult psychiatrists, psychologists and pediatricians to systematically and comprehensively assess and manage psychiatric disorders in children and adolescents. The book is intended to serve as a clinical guide or a manual to provide perspective and assist the clinicians in doing their job effectively. General adult psychiatrists feel a sense of unease or difficulty in approaching children or in psychologically engaging with them in their diagnostic and therapeutic work. The book is written in a simple, descriptive style, providing reasoning for the suggested approach, enabling the reader to understand the frame of reference. As a child psychiatrist deals as much with adults (parents, family, teachers, etc.) all the clinical skills required of a general adult psychiatrist are also required in a child psychiatrist. An introductory chapter on child development outlining various theoretical viewpoints is given to serve as the backdrop within which the clinical assessment, interpretation of signs and symptoms, and planning and execution of interventional approaches can be understood. As the diagnostic process is not merely a labeling exercise, and as the factors contributing towards pathology are equally important for diagnosis, the chapter on family, school, environment and resilience has been given for the reader to know about the most crucial aspects of the child’s life that have a bearing on his/her mental health. Chapters on psychiatric assessment and interviewing techniques predominantly provide a skilloriented flexible system of guidance in conducting a comprehensive examination.
Neurodevelopmental assessment is a crucial component of examination, particularly in disorders of neurodevelopment, and a psychiatrist should be well-equipped to carry it out. Psychological assessments in the form of various psychological tests, performed usually by psychologists, provide important supplementary information. However, the psychiatrist needs to know the types of questions that can be answered through psychometry, the types of tests available and their scope and limitations, so as to make most judicious and appropriate use of such tests in clinical practice. Psychological tests can be used for assistance in diagnosis, for assessing the degree of disability or for planning intervention or monitoring effectiveness, etc. After clinical assessment, the next step of diagnosis and differential diagnosis involves a process of thinking and analyzing the assessment data, interpretation of the signs and symptoms and its summarization into a diagnostic category. A basic knowledge of various diagnostic entities and the rules for diagnosis and classification becomes imperative. The chapter on diagnosis and classification provides a broad framework as well as detailed listing of diagnostic entities and criteria as per International Classification of Diseases (ICD) 10th revision and the Diagnostic and Statistical Manual (DSM) IV revision currently in use that a busy clinician can quickly refer. Introduction has also been made to ICD 11 and DSM 5, with listing of corresponding diagnostic categories keeping the reader updated and well-informed about the latest developments. It is equally important to know about the available Indian scales or tools for assessment even though these are very few and far between.
An effort has been made to enlist as many scales as possible and to provide the complete instructions and manual for scoring and administration for those scales that have been developed by me to give an easy and free access to students, researchers and clinicians. These scales have been extensively used in India and remain much in demand. Management has been described in two chapters, one outlining the principles of management and planning process, and the second gives specific treatment methods and guidelines to undertake actual treatment. A separate chapter on psychiatric and behavioral emergencies covering commonly encountered emergent situations in pediatric medicine or psychiatry and their handling has been included to deal with emergencies even if uncommonly encountered. Issues of adolescence primarily focusing on the special considerations applicable to them have been handled in another chapter.
With growing evidence about the importance of brain development and its psychiatric consequences during fetal stage and infancy stage, a new chapter on ‘infant mental health’ has been added. This is done to emphasize that the clinician must pay attention to the intrauterine and infancy phase of life in order to understand the earliest neurodevelopmental influences on mental health and illness. Two other major challenges have emerged recently, one is child sexual abuse and the other is substance addiction. Separate chapters have been added to help the clinicians understand and manage these otherwise complex problems. In recent times, there is a great deal of public awareness and outcry about these issues. Drug abuse among children is not only increasing but also occurring at younger age and with newer and synthetic compounds.
Keeping in mind the needs of a practicing clinician rather than that of an intellectual academician, emphasis on practical, realistic and feasibility aspects of treatments is deliberate. Insights gained through my experience of working with children and their families for 50 years in clinical practice has provided the inspiration and quintessence for the book.
Considering the pre-eminence of psychological methods of treatment in child psychiatry, effort has been made to describe various forms of psychological interventions in simple and practical format enabling the clinician to undertake these therapies without much doubt or hesitation. It has been my endeavor to present psychological therapies in the most usable form allowing even the nonmental health clinicians to practice extending the benefits to children and families in need. Unpopularity of psychological interventions with the clinicians on account of these as essentially time consuming or labour intensive, or often difficult or poorly understood interventions, compromising the legitimate interests of child psychiatric patients, is a huge impediment that needs to be addressed and resolved. Throughout the book, effort has been made to include the latest and well-accepted, theories and practices. The term ‘child’ has been used mostly generically to include infancy and adolescence as well, unless there was a need to specify.
The book was first published in 2002 and the second edition came out in 2013. Now, after 11 years, the book had gone out of print, and it had become necessary to revise and update it. Working on this book has been pleasurable and also challenging. I owe it to my patients and their families who gave me the needed experience and insights and honed in me the clinical art of practicing child psychiatry. I am also indebted to my students for their inquisitiveness and faith, evoking and keeping alive in me a quest for knowledge and excellence.
Savita Malhotra