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Child and adolescent psychiatry and psychotherapy comprises the diagnosis, treatment, prevention, and rehabilitation of neuropsychiatric and developmental disorders as well as behavior disturbances during childhood and adolescence. The need for a separated psychiatric discipline for children and adolescents results from age-dependent characteristics of mental disorders, strongly influenced by rapidly alternating stages of neurobiological and social development in this period of life. The discipline of child and adolescent psychiatry is now acknowledged as a medical speciality or subspecialty in many countries; however it will still need much effort to offer a specialized child mental health service worldwide.
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This research paper provides an overview of the historical development of child psychiatry in different cultural regions, focusing on the development in Europe and the USA. A necessary distinction is made regarding the diagnostical classification system for mental disorders in childhood and adolescence in comparison to the classification system in general psychiatry. Principles of child-specific assessment and treatment are described. Further, some future perspectives in the development of a more biologically influenced child psychiatry are discussed as well as the needs for a modern child psychiatry in developing countries.
1. History
The clinical discipline of psychiatry was formed in the nineteenth century, in a situation of an increasing interest in and knowledge of psychological phenomena. In 1899, the term ‘child psychiatry’ was first used by the French psychiatrist M. Manheimer, who called his book Les troubles mentaux de l’ enfance, subtitled Precis de psychiatrie infantile.
Four main traditions have made substantial contributions to the current body of knowledge in the field of child and adolescent psychiatry, and influenced the structure and the actual treatment concepts of child psychiatric institutions. The formerly unified disciplines of psychiatry and neurology have given rise to the tradition of neuropsychiatry, especially in some European countries. Several scientific associations still include reference to neurology. Increasing research activity in the areas of neuropsychobiology and neuropsychology confirms the need of a close linkage between these two ‘brain disciplines’ for a better understanding of psychiatric disorders.
A movement based on a remedial clinical tradition, promoted by Hans Asperger in Austria and Paul Moor in Switzerland, still plays a role in pediatric departments with activities in the field of child psychosomatics. In general, remedial education is an important part of the multidisciplinary children’s mental healthcare service.
Developed by the pioneers of psychoanalytical work with children, like Anna Freud, Alfred Adler and Melanie Klein, the psychodynamic-psychoanalytic tradition influences etiological concepts of behavioral and personality disorders and gives implications on psychotherapeutic treatment strategies; however, behavioral therapy, often in combination with family therapy interventions, is predominant in the clinical use of psychotherapy nowadays.
The empirical, epidemiological, and statistical tradition has been established in a number of European countries, mainly the UK, Scandinavian countries, and Germany. It has been strongly influenced by the work of Michael Rutter and by research influences from the USA. This tradition created the basis of the currently used classification systems in psychiatry.
Although first considerable activities in the field of child psychiatry started in Europe in the early twentieth century, it was not until 1954 that the first European symposium of child psychiatry took place in Magglingen (Switzerland), a consequence of World War II and the ensuing political situation. At this meeting, first attempts were made to establish a unifying scientific association, which was founded in 1960 as the Union of European Pedopsychiatrists at the first European congress in Paris. Later, at a congress in Madrid in 1979, the name of the society was changed to the European Society for Child and Adolescent Psychiatry (ESCAP) (Remschmidt and van Engeland 1999).
The crystallization of child psychiatry in the USA was influenced by the growing knowledge in the field of psychiatry in Europe. A sociocultural reform, beginning in the year 1900, was the main factor contributing to the establishment of child psychiatry in the USA. The desire to protect children from social hardship resulted in the need for mental healthcare institutions. William Healy founded the first Institute of Juvenile Research in 1909 to handle child problems occurring in association with delinquency and traumatic injuries. The Orthopsychiatric Association, founded in 1924, integrated the different medical and sociopsychological professionals working in the psychiatric field. The psychiatrist Adolf Meyer installed the first department of child psychiatry at the Johns Hopkins University in the early 1930s. Leo Kanner, an immigrant from Austria, was the first chairman and published his textbook of child psychiatry in 1935. Child psychiatry was accepted as a clinical discipline in its own right in 1950. Since then, the American Academy of Child and Adolescent Psychiatry (AACAP) has made a marked contribution to the global development of a modern child and adolescent psychiatry (Schwab and Schwab-Stone 1999).
The different professionals working in the field of child psychiatry have been organized in the International Association of Child and Adolescent Psychiatry and Allied Professions (IACAPAP), founded as an umbrella organization in the 1930s. Countries from East Asia and the Pacific region present a remarkable level of medical supply and research in the field of child and adolescent psychiatry. In recent years South America, African countries, and Australia have also contributed with increasing activities to the specialization of child mental health services.
2. Epidemiology And Classification
The prevalence rates of all mental disturbances in children are estimated at about 15 percent. However, mental disorders in need of treatment occur in about half of these cases. In children with primary neurological brain dysfunctions, the prevalence of psychiatric disorders increases with the degree of the brain damage or the metabolic alteration. So, children with epilepsy suffer five times more from mental problems than unaffected children.
Psychiatric classification systems are compilations of diagnostic criteria, based on clinical experience, to define and differentiate mental disorders and establish agreement and common language among healthcare professionals and researchers. The classification of mental disorders is essential for the development of treatment concepts and a necessary precondition for epidemiological, clinical, and biological research in this field.
The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), published by the World Health Organisation (WHO) in 1992, is a comprehensive classification system of medical conditions and mental disorders, used in official medical and psychiatric nosology throughout most of the world. However, some countries (e.g., France and the USA) use compatible or modified classifications. The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ), published in 1994 by the American Psychiatric Association (APA), is the official psychiatric coding system used in the USA and is in part compatible with the ninth revision of the International Classification of Diseases (ICD-9).
The mental development of children and adolescents, in contrast to that of adults, is strongly influenced by brain maturation processes and social environment. Considering this fact, the classification system in child and adolescence psychiatry is based on a multiaxial diagnostical view. The approach of the actual classification systems is atheoretical according to etiological concepts. Due to the limited knowledge about etiology and pathomechanism of the mental disorders, it is mainly the symptoms and course of a disorder that are used to define and classify the mental disorders. An approach to predict the clinical course of the disorder is associated with the description of a clinical feature. Additional contributing factors, like the intelligence level, the parent–child relationship, and the social environment are assembled by using different diagnostical axes. The impact of the disorder on psychosocial functions is assessed on Axis VI of the multiaxial diagnostic system (Remschmidt and Schmidt 1994).
ICD-10, regardless of the use of a multiaxial system, does not consider age of disease onset consistently. Apart from that, the predicted clinical course is basically used for many clinical decisions including treatment concepts (Rutter 1989). Taking into account these important facts, an appropriate version of the classification system for child and adolescent psychiatry has been developed, where age of onset and typical clinical course has been integrated. The disorders have been divided into early-onset disorders with a persistent course (e.g., autism), early-onset disorders with transient manifestation (e.g., enuresis), age-related interactional disorders (e.g., separation anxiety), young age-related disorders with sometimes recurrent episodes or chronical course (e.g., eating disorders), early-onset adult-type disorders (e.g. schizophrenia).
Even though specified diagnostic criteria are provided for each mental disorder, increasing the reliability of clinicians process of diagnosis, the professionals have to pay attention to existing mixed forms or comorbid disorders (Caron and Rutter 1991), like attention deficit hyperactivity disorder (AD HD) with conduct disorder or eating disorder with depressive disorder (Biederman et al. 1991).
3. Developmental Psychopathology And Pathogenesis
Mental disorders in children and adolescents are manifested in behavioral problems, affective and cognitive disturbances, and somatic concerns. The quality and severity of these problems are influenced by the developmental state. The rapid development, simultaneously on the biological and on the social level, has a strong impact on the diverse developmental tasks of a minor (Munir and Beardslee 1999).
Biological maturation, particularly in early childhood, plays a key role in the etiology of mental problems. With increasing age social adaptation and social learning becomes more prominent. The maturation of the brain and gender-specific role taking are two main factors of becoming adult. Acceleration or retardation of the biological and social maturation results in an alteration of the developmental process with behavioral problems and social disintegration in the case of existing permanent deficits.
Developmental psychopathology describes age-related aspects of mental disorders, especially the formation and alternating pattern of symptoms over time (Cicchetti and Cohen 1995). In early childhood the ability of autonomous behavior is acquired. For that, an inner representation and judgment of the child’s cognitive and behavioral activities is an important precondition. Older children compare their self-image with an imagined ideal as a kind of self-control, which modifies and limits the outcome of the social learning process. Although there is an interaction between these different components, mental disorders in childhood and adolescence can be interpreted as deficits in maturation or learning processes or in their autonomous efforts. Parallel to the differentiation of cognitive, emotional, and social functions there are increasing demands on the child. Sexual development, gender-related role taking, and academic achievement all which have to be coped with adequately.
During certain periods of development, the child and adolescent have specific responsibilities. Functions according to these specific developmental demands can be easily disrupted, because they are not well established due to the rapid developmental process. Infants suffer from regulation disorders, which are often induced by the behavior of caregivers. Preschool-age children suffer from somatic, physiological dysfunction in the area of sleep, eating, speech, and elimination control, whereas in school-age children communication problems in peer groups and in the school situation appear (Esser et al. 1990). Separation anxiety, insufficient affect control, and learning disabilities are characteristic problems with increasing age. Adolescents then have to develop self-confidence, to deal with authorities and to accept their sexual identity.
Risk and protective factors, in addition to the developmental process, are effective in the pathogenesis of mental disorders. Genetically determined factors are the somatic constitution, particularly the brain function, and the pattern of personality, the temperamental factors (Rothenberger 1990).
Pervasive developmental disorders like autism have a high genetic risk (Rutter et al. 1999). Traumatic brain injuries prenatal, perinatal, or postnatal, or chronic metabolic dysfunction increase the risk of developing a mental problem. A lack of sociocultural stimulation, socioemotional deprivation, or high pressure as a result of people’s inadequate expectations could be summarized as sociogenic risk factors (Rutter 1999). Language acquisition in particular strongly depends on a sociogenic balance. Intrapsychic conflicts are a result of chronic problems, like sexual or physical abuse, mental disease of a parent, delinquency in the family, distorted familiar communication. The interactive process between parents and child can amplify or otherwise reduce behavior in both directions, to a normalization or to an increased disturbance. Life events, as acute stress factors, in general play a minor role in the pathogenesis of mental disorders of children and adolescents. In the case of strong traumatic impairment, like being a victim of a rape or having a bad accident, a posttraumatic stress disorder can appear (Costello et al. 1998).
Protective factors, like social attractiveness, verbal skill, appropriate problem-solving strategies, self-consciousness, creative intelligence and interests, a pleasant life and family situation, and stable peergroup relationships can act successfully against other biological or psychosocial stress factors to reduce the risk of developing a mental disorder or in the case of manifestation to reduce symptom severity and improve clinical outcome (Laucht et al. 1997).
4. Assessment
To provide a diagnosis, child and adolescent psychiatrists examine the mental status, the psychopathological profile, and behavior of the patient; ascertain the social and biological development, and evaluate the prior medical and psychiatric history. Further useful information can be obtained by parental interviews and school reports. Different sources of information reflect different point of views, experiences, and insights (Jensen et al. 1999). Depending on the type of disorder and the age of the child, the reliability of this information is quite different as well. The summary of information from different sources, including the child, the parents, teachers, peer group members, doctor, pediatrician, and sometimes the youth welfare department, provides the most reliable and complete picture of symptoms, functional level of the child, and influencing environmental factors.
Recognizing the level of social functioning and the performance of developmental tasks related to the child’s age is a key assessment for the estimation of severity and prognosis of the disorder. Structured psychiatric interviews, rating scales, and self-report forms can be used to observe, quantify, and categorize the evaluated symptoms, for example, the Diagnostic Interview Schedule for Children-Revised (DISC-R), the Child Behavior Checklist, scales for the assessment of psychotic symptoms (Positive and Negative Symptom Rating Scale—PANS) or mood disorders (Beck Depression Inventory).
Cognitive and intellectual abilities, basic factors of a healthy mind, are age-related functions. To ascertain alterations of these functions, it is necessary to determine the social level and the state of the biological maturation. Particularly in children with mental retardation, learning disabilities, or pervasive developmental disorders a comprehensive assessment of the intellectual function (examples are Kaufman-ABC and WISC-III) is necessary to create an optimized educational and treatment program (Ollendick and Hersen 1993).
In a subgroup of patients, a defined somatic dysfunction, mainly neurological diseases, is the primary cause of mental diseases. Brain diseases (tumor, epilepsy), metabolic dysfunctions (phenylketonuria, hypothyroidism) and diseases with defined chromosomal aberrations (like Down, Angelman, and PraderWilli syndrome) can be associated with a varied picture of mental disturbances. Therefore physical examinations and technical investigations (brain computerized scan, radiology, electroencephalography, and blood and genetic screening) are standard procedures to rule out somatic disorders and to determine the developmental state of a child. The analysis of genetic mutations, polymorphisms, and associated molecularbiological dysfunctions will provide more insight into the etiology of a psychiatric disorder which is always manifested on a neurobiological level. The early assessment of a genetically caused metabolic dysfunction (like phenylketonuria) can help to prevent the emergence of a disorder or will help, in some cases of known genetic defects (like Prader-Willi syndrome) or relevant polymorphisms associated with a disorder (like in AD HD), to develop better treatment strategies in the near future.
Assessment of the neuropsychological functions should be done routinely in children and adolescents with AD HD (Barkley 1998). The core symptoms— inattention, hyperactivity, and impulsivity—need to be quantified by neuropsychological tests, in part with support of computerized methods (e.g., Continuous Performance Task, CPT). Learning disabilities, often associated with developmental or attention deficit disorders, need further examination by questionnaires and psychological tests. To rule out sensory dysfunction, visual and acoustic perception has to be assessed in cooperation with departments of ophthalmology, phonetics, and pediatric audiology.
If children are younger than four years, the psychopathological assessment is oriented on findings regarding the child’s development and interactional behavior. This information can be received mainly from parental reports or, in the case of some early onset diseases, by the medical records. Semistandardized play situations and the observation of peer group and parent–child interactions provide further information about the child’s intellectual function, capacity for emotional reactions, attachment, and behavior.
5. Treatment
Psychiatric therapy in general is based on three major treatment pillars: psychotherapy, psychopharmacology, and psychosocial and family interventions. Each kind of mental disorder or disease needs a typical combination of these three therapy forms to get an optimal therapy effect. In children and adolescents the family and school environment particularly has to be taken into consideration.
For a sophisticated mental healthcare network, the cooperation of the various professional groups, including psychiatrists, psychologists, social workers, teachers, and members of administrative institutions of the government, responsible for children and adolescents, is a necessary precondition (Simeon 1990).
The treatment of mental disorders can be divided into three main groups: treatment mainly by psychotherapy, treatment mainly by a psychopharmacological intervention, and combined psycho-therapeutical and pharmacological approaches. Psychosocial interventions, specially in childhood and adolescence, are in general a part of the treatment program.
A follow-up assessment over a longer time period provides information about the course of the disease. It is necessary to react early to changes in the symptomatology, to observe the social functioning of the child and adolescent, to control possible side effects of the treatment, and not to overlook the best moment to stop the treatment.
There is a group of early-onset disorders with a persistent course like mental retardation, pervasive developmental disorders, and transient developmentally dependent disorders like learning disorders, communication disorders, selective mutism, attachment and elimination disorders (encopresis, enuresis). Treatment plans are based on behavioral therapy concepts. Contingency management, self-monitoring by protocols, training of social skills and communication, and principles of classical and operant conditioning are expanded by family therapy, educational programs and cooperation with teachers, social interventions, psychomotoric and coordinative training, and in many cases additional parental guidance (Noshpitz 1981).
At the present time, there is no disorder-specific medication on the market; however, there are some substances which are successful in the reduction of single symptoms belonging to these disorders (Houts et al. 1994), like antipsychotics in autistic children (McDougle et al. 1997). An efficient medication exists only for single early-onset disorders. In the case of AD HD, the core symptoms can be reduced about 70–80 percent by medication, mainly by the use of psychostimulants. However, children with AD HD need an intensive behavioral and educational treatment program as well, particularly, if they suffer from an associated oppositional defiant or conduct disorder. Often their parents need additional support from parental guidance (Barkley 1998, Kazdin 1997).
The main emphasis in the treatment of mood and schizophrenic disorders, summarized as early-onset adult–type disorders, which get manifested mainly in adolescence and early adulthood, is the psychopharmacological therapy. The exception is that younger children with mood disorders often gain a clinical improvement just from psychotherapy. Antidepressive and antipsychotic medication acts quite specifically on the disturbed brain metabolism, which is, as a primary mechanism or a biological reaction on permanent psychosocial stress, the main causal factor for the disorder. Neurotransmitters like serotonin, noradrenalin, and dopamine are regulated by these substances and neuroplastical processes, which are important for the structural function of brain, are regenerated and stabilized over a longer time. Therefore the intake of most of these medications should be continued over a longer time, if there is no contraindication by serious side effects, which might occur in some cases. Although medication is necessary and the first choice of treatment, these patients need an intensive psychosocial support and training program to prevent them from social disintegration and to cover their academic achievement.
Another large group of mental diseases can be described as behavioral, emotional, age-specific interaction disorders and personality disorders. Examples are eating, anxiety and obsessive-compulsive disorders, stress reactions, and emotionally unstable personalities, called borderline personality disorder. Various behavioral therapy methods in combination with family therapy and psychosocial interventions, continued in an outpatient therapy setting, are established as the most successful kind of treatment. In a few cases, the additional use of medication can improve or accelerate the treatment success (Piccinelli et al. 1995).
Controlled clinical trials are the basis for the development of effective treatment approaches (Vitiello and Jensen 1997). Performing clinical trials in children and adolescents, either to investigate the efficacy and safety of psychotherapeutic treatment strategies or of newer psychopharmacological substances, is difficult from the legal and ethical point of view. There is the need to get a written consent from the prob-and or patient before starting any investigation. The prob-and has to be informed about targets, efficacy, and expected side effects of the planed therapy. In the case of children, especially those suffering from mental problems, an adapted, comprehensible form of information needs to be presented, and the parental authorities have to give their written consent as well. Although double-blind placebocontrolled clinical trials are the highest standard to study the efficacy and safety of newer treatment concepts, it is quite difficult from ethical point of view to carry out such a design in children.
Further aggravating circumstances hinder a fast performance of clinical trials in children and adolescents: First, the brain of a minor is not completely maturated. Brain dysfunction and resulting mental disturbances may be transient, like separation anxiety and sleep problems in early childhood. The child psychiatrist has to be aware of this fact, especially regarding the duration of medical and psychotherapeutic treatment interventions. Further, risks of pharmacological side effects and unintentional reactions to psychotherapeutic interventions are higher in children and adolescents than in adults as a consequence of the unstable somatic and mental system. Secondly, some mental disorders in children and adolescents may be triggered by an altered familiar environment with communication problems, may be with violence or sexual abuse. In these cases the treatment of the family system and not exclusively the individual therapy is the primary aim. Unintended reactions, like separation of the parents, should be mentioned as a kind of side effect.
6. Future Directions
In developing countries the scarcity of trained personnel has prevented a higher specialization of child mental health services. For professionals in developing countries the term ‘child mental health’ therefore covers a broad range of problems, including neurological and developmental disorders, mental retardation, educational difficulties, and psychiatric disorders. Worldwide prevalence rates, an estimation of the persons with a disorder in relation to the whole population, of about 15 percent for children with mental problems, emphasize that developing countries need support in the training and further specialization of their professionals who are responsible for child mental healthcare. Cooperative research projects, under the patronage of the WHO and of the local psychiatric associations, may be one strategy for analyzing the quantity and the quality of child mental health problems in developing countries. It is necessary to recognize characteristic patterns of mental health problems, to describe risk factors (like malnutrition, war and displacement, political oppression, poverty, child labor, urbanization, and social changes) and to develop treatment concepts in consideration of the specific sociocultural background of the community (Rahman et al. 2000).
Although the establishment of specialized mental health services in developing countries is a primary goal, improvement of the child and adolescent psychiatry in developed countries remains a permanent task. Growing insight in molecular biology increases knowledge about brain function and improves the understanding of the mind–body relation (Deutsch 1990). Genetic factors will be described, which have responsibility for the manifestation of mental diseases. Biotechnology will offer new therapeutic strategies, which have to be examined in clinical trials by child and adolescent psychiatrists.
Going one step back from the future perspectives to present problems, child and adolescent psychiatrists need to perform more controlled clinical trials assessing the efficacy and security of psychotherapeutic and psychopharmacological interventions and both in combination. It is necessary to know more about long-term courses and outcome of mental diseases in children to young adulthood and to control the efficacy of pharmacological and psychotherapeutic treatment over a longer time range. A comprehensive neuroscience research especially will increase the knowledge about disorders with an early onset and a persistent pattern of symptoms and about specific developmental-related disorders.
Some mental disorders are quite rare in children and adolescents, like manic affective disorder, so multicenter studies in many hospitals have to be designed to investigate the efficacy of therapies in a sufficient number of child and adolescent patients. Other early onset problems in children, like the different kinds of learning disabilities, need to be investigated more exactly for the development of treatment concepts with higher efficacy. Especially in developing countries with a weak school network, knowledge about learning disabilities, about efficient treatment approaches and perhaps about their prevention, might be very helpful (Schmidt and Remschmidt 1989).
At the least the vision of child psychiatry is the prevention of diseases (Greenfield and Shore 1995). Universal prevention, comparable to vaccination strategies, is hardly reachable in psychiatry. Even selective prevention by early assessment, provisional diagnoses and early therapeutic and psychosocial interventions in identified risk groups is difficult and comprises the problem of false positive assignments with the risk of stigmatizing people. Before acute clinical symptoms occur, there is mainly the registration of unspecific problems, giving some evidence of the later manifestation of a specific mental disorder. Defined criteria of premorbid symptomatology associated with prevention concepts have not yet been established. Probably the progress in biotechnology by detecting disease-specific genetic patterns, will improve the chance of a selective prevention. A more realistic concept is that of an indicated prevention in the earliest stage of a manifested disorder with minor clinical symptoms (McGuire and Earls 1991).
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