CHILD AND ADOLESCENT ASSESMENT AND DSM DISORDERS

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CHILD AND ADOLESCENT ASSESMENT AND DSM DISORDERS

• Basic needs of all children are
• Nurturance
• Responsiveness
• Predictability
• Support
• Safety
• Guidance

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MOST COMMON DISORDERS FOR CHILDREN UNDER AGE 12

• ADHD
• Attachment DO
• PTSD
• Depression
• Pervasive developmental DO
• Anxiety
• Developmental Delay FAS, birth trauma, meth.,
  genetic
• Enuresis, encopresis

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MOST COMMON DISORDERS FOR ADOLESCENTS BETWEEN 13
18

• Depression
• OCD
• ADHD, combined
• Conduct DO
• PTSD
• Anxiety
• Substance abuse/dependency
• Psychosis mixed D/D

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ETIOLOGY OF MENTAL ILLNESS IN CHILDREN

• Multiple interactive processes
• Environmental factors exposure to stressful
  events and trauma can lead to psychological and
  somatic disorders
• The childs innate temperament and its effect on
  the childs responses to the world and of adult
  response to the child
• Temperament and trauma interactions
• Exposure to drugs

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• Genetic factors depression, ADHD, schizophrenia,
  autism, alcoholism, learning disorders
• Psychosocial adversity poverty, abuse and
  neglect

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RESILIENCE IN CHILDREN

• Risk factors are not fate factors
• Role of protective factors
• Role of Validation
• Role of strengths

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ADJUSTMENT AND MALADJUSTMENT

• Adjustment and strengths in children can be
  measured through spontaneity, creativity,
  self-awareness, curiosity, care for others,
  autonomy and a positive self construct
• Maladjustment can be measured by withdrawn
  behaviors, impulsiveness, self destructiveness,
  inability to get positive reinforcers from
  significant others and environment, negative self
  construct and lack of initiative

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• A warm and supportive environment with
  consistency, even discipline and open respectful
  communication is more likely to promote an
  adjusted child
• As noted maladjustment may occur as a consequence
  of constitutional factors, disturbed familial
  environment, life crisis, natural disasters and
  faulty social constructionism

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INITIAL INTERVIEW

• Anxiety about interview can be expected
• Structured vs. unstructured
• Divide first interview parent(s)/child and child
  alone
• Establishing rapport through flexibility and
  finding interests
• Interview style the younger the person the more
  non directive you should be
• Assurance of confidentiality and safety

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THE PLAY INTERVIEW

• Rationale and materials use of transformative
  objects, board games, puppet shows, stuffed
  animals, and art (both expressive and copy). Get
  down to the childs level if possible
• Invite the child to explore and play. The child
  will then verbalize play actions which can be
  questioned by interviewer
• Resistance is seen in play disruption
• Often times parent(s) can be present

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INTERACTIONAL ENGAGEMENT STRATEGIES

• Engagement building a relationship, let the
  child set the pace, sit at their level, keeping
  the child informed, listening rather than
  directing play
• Exploration use of imaginary possibilities
• Continuity/deepening comment on a drawing rather
  than ask what it is
• Remembering through play children guide us
  through play and or often unaware that they are
  reenacting
• Limit setting use of guidelines

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• How to deal with strong negative feeling, such as
  I hate (parent, sib or relative) Often a
  projection of self-hatred, suicidal ideation, or
  abuse
• The child or adolescent who only says I dont
  know usually means a fear of answering or
  discussing issues that may involve abuse
• Touch? Or no touch? touching is provocative and
  should be avoided. What if child is out of
  control?
• Lying? fear of consequences

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• Focus on interpersonal issues
• Interests
• Fears and worries
• Self image
• Moods and feelings
• Somatic concerns
• Aspirations, expectations and fantasies

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THE CHILD MENTAL STATUS EXAM

• Size and general appearance
• Health, nutrition, distinguishing features,
  apparent habits, dress, grooming, apparent vs.
  stated age, gender attributes, mannerisms
• Motility
• Involuntary movements, tics, autoerotic
  movement. Does the child sit for 3 mins. if asked
  to?

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CHILD MSE

• Coordination Posture, gait, balance, gross and
  fine motor movement, writing, drawing. Ask child
  to walk stairs or throw a ball to an object while
  hopping. Pick up sticks, make a fist, play jacks
  or unwrap candy
• Speech Articulation, grammar, infantilism,
  neologisms, pitch, mutism or aphasia (absence of
  speech). Have the child name things around the
  room. Have child repeat a sentence or give
  meaning of a sentence

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CHILD MSE

• Intellectual functions Vocabulary, math, general
  fund of knowledge, social awareness.
• Modes of thinking and perception Orientation,
  fantasy, hallucinations, human/animal references,
  suspicious, obsessive, lapse in attention,
  bizarreness. Name and then hide objects. Have
  child find them sequentially

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CHILD MSE

• Social/emotional reactions Fear, apathy,
  sadness, oppositional, friendly, happy, range of
  affect and maturity for age. Does child engage
  easily in conversation? How does child handle
  separation from parents?
• Manner of relating Open/closed, aggressive,
  fearful
• Fantasies and dreams symbolic interactions

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CHILD MSE

• Sensory/acuity Vision, hearing, taste, agnosia
  (difficulty in tactile recognition). Hold up
  fingers at various distances and not ocular
  muscle. Negative feelings about foods. Scary
  experiences, Close eyes and identify common
  objects by touch.
• Character of Play Formal, gender appropriate,
  transactional aspects, content.

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DSM AND CA EMOTIONAL DISORDERS

• Mental Retardation
• Mild MR DSM 317, FSIQ level 50-70
• Moderate MR DSM 318.0, FSIQ level 35-55
• Severe MR DSM 318.1, FSIQ level 20-40
• Profound MR DSM 318.2, FSIQ level 20-25
• MR, severity unspecified DSM 319
• Limitations in (at least two) communication,
  intelligence, social skills, functional academic
  skills, occupational, health and safety
• Problems in adaptive functioning
• Life time diagnosis in adults often Developmental
  Delay

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• Pervasive Developmental Disorders
• Autistic DSM 299
• Retts Disorder DSM 299.80
• Childhood Disintegrative Disorder DSM 299.10
• Aspergers Disorder 299.80

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• Autistic DO
• Unable to regulate social interaction, no
  interest in friendships, little understanding of
  social convention (adults), unfazed by needs of
  others, delay in language, oddities in spoken
  language, unable to integrate words, restrictive,
  preoccupied, attachments to inanimate objects,
  odd responses to sensory stimulation, some self
  injury, EEG abnormalities
• 4 to 5 higher rate in boys
• Prevalence 5 in 10K
• Onset before age 3, language is predictor of
  lifetime course
• Criteria page 75

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• Retts Disorder
• Multiple deficits following period of normal
  functioning after birth (5 month)
• 5-48 months deceleration of head circumference
• Loss of nearly all acquired skills up to that
  time
• Hard wringing
• Disinterest in social environment

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• Disintegrative DO
• Loss of language, social skill, motor skills
• Bowel and bladder control
• EEG abnormalities as in injury to CNS
• Very rare disorder. Onset preceded by 2 years of
  normal development. Onset between 3 and 4 with a
  continuous course through age

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• Aspergers Disorder
• Impairment in social interaction. No reciprocity
  in interaction, aloof, one-sided in relating to
  others, no empathy.
• Restricted behaviors and presentation
• No cognitive delays
• 5X more common in boys
• Some skills may increase with age
• Increased genetic risks

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• ADHD Attention Deficit/Hyperactivity Disorder
• ADHD Combined type 314.01
• ADHD Inattentive type 314.00
• ADHD Hyperactive/impulsive 314.01
• ADHD NOS 314.9
• 3-5 of school aged children usually first
  identified when child enters school or makes a
  grade advancement.
• Characterized by inattention, impulsivity,
  inattention, impulsivity, distractibility
• Problems in school, work and social settings

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• ADHD Inattentive
• Messy and careless, difficulty in sustaining
  attention, lack of follow through
• Poor organizational skills, easily distracted
• Attention to irrelevant stimuli
• Poor with rules of conduct or games
• Increased pain tolerance
• Problems in personal space
• Often well liked
• Chronic into adulthood
• Need accommodations

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• ADHD, Hyperactive
• Fidgety and unable to hold still or remain
  seated. Excessive activity. Feel driven inside.
  Impatient and a blurted. Interruptive. Fails to
  listen. Grabs.
• Accidental, fails to recognize consequences.
• False confidence. Little consideration for
  behaviors.
• Difficulties in peer relations and poor self
  esteem.

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• Symptoms are multiple and worsen with age unless
  exposed to intense structure
• Frustration, stubbornness, moody, depression,
  blaming, family discord
• Onset before age 7
• Parent with ADHD 55 chance for offspring
• Differential Dx Depression, MR, PTSD, psychosis,
  Bipolar, ODD
• Four part assessment Medical, Academic, Home and
  DSM Interview

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• Conduct DO
• CD, Childhood Onset 312.81
• CD, Adolescent Onset 312.82
• CD, Unspecified 312.89
• Subtypes and Specifiers
• Childhood gt10
• Adolescent 10
• Unspecified (onset unknown)
• Mild minor harm to others
• Moderate mild to severe
• Severe considerable

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• Conduct DO
• Repetitive pattern of behaviors in which the
  basic rights of others are violated.
• Four behaviors Aggression, destruction of
  property, theft and deceit, serious rule
  violation.
• Absence of guilt or regard for concerns of
  others.
• 6-16 Boys and 2-9 Girls
• Differentials PTSD, ADHD, Mood DO, AOD,
  Schizophrenia.
• Earlier the worse the prognosis

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• Oppositional Defiant DO
• DSM 313.81
• 2-16 of school age children
• Recurrent patterns of negativistic, defiant,
  disobedient and hostile behavior toward
  authority. Regarded as less severe that CDO but
  develop into it later
• Significant impairment in academic and social
  functioning.
• Differentials PTSD, Bi Polar, Depression, AOD

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OTHER CHILDHOOD DISORDERS

• Separation Anxiety DO 309.21
• Recurrent distress upon separation, somatic
  complaints, disaster fears, reunion fantasy,
  school refusal, clingy, fear of animals, death
  concerns, depression, agoraphobia
• 4 with development following stress in as early
  as preschool
• Mothers Dx panic and anxiety DO

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• Reactive Attachment DO 313.89
• Inhibited or disinhibited type
• gt5 inappropriate social relatedness associated
  with pathological care
• Inhibited frozen, resistant, avoidant
• Disinhibited everyone is mommy
• Growth delay
• Differentials MR, Autistic, Phobia, ADHD

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ADULT DX SEEN IN CHILDREN

• Adjustment DO
• PTSD
• Dysthymia
• Eating DO
• Schizophrenia
• Bi Polar DO