Children cannot be considered to be little adults. Child and adolescent psychiatry is a unique area and conceptualisations typical of adult mental health are often either not helpful such as the rubric of personality disorders, or fall short in terms of emphasis. For example whilst adult practitioners will consider the patient’s family, in childhood and adolescence the family may be a source of solutions that lead to symptom reduction, a barrier to change or indeed the cause of the child's presentation.
Child and adolescent psychiatrists conceptualise their patients and their patient’s challenges in a unique way. This focuses on the twin concepts of development, the changes that occur as part of growing up, and of the inter-relatedness of the child and those around them which as a shorthand can be called the systemic perspective.
To elaborate, a fundamental task of infants, children and adolescents is to grow and in so doing learn to regulate, or achieve mastery over physiological, behavioural and emotional systems such as the ability to sleep, eat, self-soothe and control the excesses of behaviour and impulsivity. As adults we do not, and cannot live life as ‘toddlers’ and few adults would tolerate temper tantrums in their work colleagues. A developmental perspective allows the child and adolescent psychiatrist to know that stranger danger in a baby is normal and separation anxiety for the first few days of school is also within the normal limits. Similarly, the child and adolescent psychiatrist knows there should be a gradual improvement in the young boy’s ability to sit still and attend in class. Not to do so may suggest pathology. A grounding in what abilities and limitations to expect of children and adolescents, by age, gender and influenced by cultural expectation is essential to working in this area.
The content of some child and adolescent conditions demonstrate a developmental presentation pattern. For example, an underlying vulnerability to anxiety may become manifest in different ways across the child and adolescent developmental span. Of the anxiety-related presentations early issues include prolonged and excessive stranger danger; in the older child prolonged school-related separation anxiety. In pre-school children phobias often manifest as a fear of animals, in early school-age children as fear of the dark and/or burglars, school phobia around the age of entry to high school, in adolescence social phobia and late adolescence sees the onset of agoraphobia and panic disorder.
A systemic perspective emphasises that infants, children and adolescents are not ‘islands’, indeed the very young cannot live without the care and protection of adults. Further, children develop within systems or social networks, most obviously the immediate and extended family and the school environment, the latter including peers and teachers. Included in such understandings will be culturally dependent rules such as how extended is the typical family. For example, is it the norm for grandparents to live with the child and parents; how open or closed is the family to non-familial influences such as the impact of religious or village leaders and the influence of the media. As well as the generally applicable culture within which the family sits there are patterns of interaction and belief which may be more individual to the particular family and not necessarily shared by their neighbours. The parents may be in conflict and the child caught in the middle. A parent may be chronically ill and the child adopting a carer role. Understanding of both individual family systemic issues and the wider cultural influences are important to the practice of child and adolescent psychiatry in a variety of ways. In terms of engagement for instance one must to know whether it is appropriate to conduct a home visit, how to address parents and grandparents and what sort of formulations are likely to make sense to the child and family. A systemic perspective is also important to management. This is universal in child and adolescent psychiatry, not restricted to cases where the treatment modality is family therapy. Clearly an intervention that contravenes a local or family belief is unlikely to be supported by the family, and is therefore unlikely to be successful.
Biological thinking, whilst in children less likely to lead to pharmacological interventions, is highly relevant to child and adolescent psychiatry. Biological constructs that may be important to a child's mental health presentation include a history of any pathological processes that may have affected the child’s developing brain. Examples include infections and toxic insults during pregnancy or anoxic brain damage during labour or the first minutes of life. The child and adolescent psychiatrist routinely takes a history about such issues, as well as considering the child's facial and body morphology for possible chromosomal or genetic abnormalities, and any evidence of developmental delay during the early years. Developmental delays may be circumscribed but more commonly may cross functional domains so a broad and comprehensive assessment is required. It will be found, for example, that many children with behavioural problems are also clumsy. Developmental problems, even though due to problems before or around birth, may not manifest themselves immediately. For example a lowered intelligence or specific learning or speech problems may not become obvious until the child enters the late preschool or early school period. In adolescence biological issues that arise are less likely to be developmental and more likely to be the adverse mental health effects of injury or misadventure, or related to the development of an acute or chronic medical illness such as diabetes or drug use and abuse.
Later in this chapter issues of disease classification relevant to child and adolescent psychiatry will be discussed. The preceding introductory comments may lead some readers away from classifications that are primarily categorical such as the ICD-10 and DSM systems. These classifications are important in child and adolescent psychiatry and facilitate good communication, research and service planning. However, child and adolescent psychiatrists are equally influenced by and comfortable with dimensional views of psychopathology. For example, where the child lies on a dimension of inattention is as important as is the question as to whether the child has Attention Deficit Hyperactivity Disorder. A dimensional view has the added benefit of potentially being less ‘pathologising’ in that embedded in this approach is the understanding that healthy children also have a degree of “whatever it is” (i.e. inattention) but either have a more “healthy” amount or are more able to cope with it. With this perspective, rather than seeking cure of a categorical disorder, the child and adolescent psychiatrist will work to help the child and family move towards a more functional developmental trajectory. An example of this might be, in the case of a child with attention deficit, to attend more to the need to achieve education and less to the treatment of symptoms. This might, for instance, lead to the planning of a medication regime in a way which gives maximal attentional enhancement when the child is in school.
A useful dimensional nosology often used in child and adolescent mental health is the distinction between internalizing and externalizing symptoms. Formally derived from the scoring system of the Child Behavior Checklist (CBCL: Achenbach, 1991) and related measures, this terminology has now entered more general usage. Externalising symptoms are clearly witnessed or reported, obvious to an observer whereby the child will ‘externalise’ an assumed feeling state, cognition or demonstrate lack of age-appropriate regulation. Typical symptoms include anger, aggression and hyperactivity. Internalising symptoms are less obvious, indeed may go unreported without appropriate questioning. Typical internalizing symptoms are depressed mood and specific and generalized fears.