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Practical Child Psychiatry: the Clinician's Guide Practical Child Psychiatry: The Clinician's Guide Bryan Lask Sharon Taylor Kenneth P Nunn BMJ PUBLISHING GROUP Practical Child Psychiatry: The clinician’s guide This Page Intentionally Left Blank This Page Intentionally Left Blank Practical Child Psychiatry: The clinician’s guide Bryan Lask Professor of Child and Adolescent Psychiatry, St George's Hospital Medical School, University of London, London, UK and Huntercombe Hospital, Maidenhead, UK Sharon Taylor Specialist Registrar in Child Psychiatry, Academic Unit of Child and Adolescent Psychiatry, Imperial College of Science, Technology and Medicine, St Mary’s Campus, London, UK Kenneth P Nunn Professor of Child Psychiatry, University of Newcastle and Director of Inpatient Child Psychiatry, John Hunter Hospital, Newcastle, New South Wales, Australia © BMJ Publishing Group 2003 BMJ Books is an imprint of the BMJ Publishing Group All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 2003 by BMJ Books, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 7279 1593 2 Typeset by SIVA Math Setters, Chennai, India Printed and bound in Spain by Graphycems, Navarra Contents Preface vii Foreword ix Acknowledgements xiii Section I: A bird’s eye view 1 1. Background 3 2. Assessment 14 Section II: The clinical picture 19 3. Fears and anxieties 21 4. Post-traumatic stress disorder 34 5. The disruptive disorders 39 6. Depression and suicidality 54 7. Substance misuse 69 8. Feeding and eating problems 78 9. Habits, mannerisms, tics, obsessions and compulsions 90 10. Sleep problems 98 11. Enuresis and encopresis 106 12. Psychosis 113 13. Somatisation 127 14. Psychiatric aspects of the medically ill child 134 15. Psychological aspects of learning disability 152 16. Autistic spectrum disorders 175 17. Neurodevelopmental disorders 189 18. The maltreated child 209 19. The bereaved child 224 20. The dying child 236 Section III: Treatment 241 21. Treatment overview 243 22. Parental and family treatment 253 23. Psychotherapy 266 v Practical Child Psychiatry 24. Cognitive behavioural therapy 281 25. Psychopharmacology 290 Section IV: The last word 351 26. The child’s view 353 Index 361 vivi Preface This book is written for the busy clinician who sees children and adolescents in distress. It aims to offer a practical guide to the assessment and treatment of emotional and behavioural problems, however they may present. Throughout we have tried to offer a perspective that will be of immediate value to the busy clinician. We have deliberately avoided learned theoretical discussions, slavish adherence to disease classification, and exhaustive reviews of the literature. Rather we have aimed to imagine ourselves in the clinics of the busy clinician and addressed what we believe to be of most relevance. The first section offers a bird's eye view of psychiatric disorders, including definitions, demography, aetiology, and assessment. Section II describes the clinical picture of the more common disorders and overviews their treatment. The finer details of the most commonly used treatments are presented in section III. We hope that this book will be of interest and value to all those working with troubled children and adolescents, whatever their professional background and regardless of their level of experience. However it is not for those who want a learned critique of the literature nor a detailed review of the very latest research findings. There are many other texts for such purposes. For an exhaustive and scholarly overview of the literature we suggest Rutter et al. or Noshpitz. For a developmental perspective use Graham et al. Practical advice on treatment planning can be found in Klykylo et al. For those sitting specialist exams Goodman and Scott and for those working in primary care Spender et al. will be of interest. But for busy clinicians who want a concise, practical, and accessible guide to the assessment and treatment of the child in distress we hope this book will be just what they need. Further reading Goodman R, Scott S. Child psychiatry. Oxford: Blackwell Science, 1997. Graham P, Turk J, Verhulst F. Development and developmental psychopathology. In: Child psychiatry: a developmental approach. Oxford: Oxford Medical Publications/Oxford University Press, 1999. vii Practical Child Psychiatry Klykylo WM, Kay J, Rube D. Clinical child psychiatry. Philadelphia: WB Saunders, 1998. Noshpitz J. Handbook of child & adolescent psychiatry. Chichester: John Wiley, 1997. Rutter M, Taylor E, Hersov L. Child and adolescent psychiatry. Modern approaches, 3rd edn. Oxford: Blackwell Science, 1994. Spender Q, Salt N, Dawkins J, Kenderick T, Hill P. Child mental health in primary care. Oxford: Radcliffe Medical Press, 2001. viii Foreword As knowledge in the specialties of medicine has expanded, textbooks have become longer in length and often narrower in focus so that authors can provide more in depth discussions of the various aspects of diseases included in the specialty. At the same time, clinicians practicing medicine seem to have less time to read for a variety of reasons, including the increase in administrative duties and paper work, seeing patients with more complicated problems, the need to help patients get appropriate services, and the frequent pressure to see ever more patients. What these busy clinicians often need is not another textbook focused on diseases, but rather a textbook focused on the practice of medicine. Practical Child Psychiatry: The clinician’s guide by three eminent child psychiatrists from two different continents is just that book for the busy mental health clinician. The authors provide the reader with a guide to caring for children and adolescents with mental health problems. The authors’ focus is on the actual work of seeing patients and providing care, from the initial assessment to the treatment of the child and family. In this book, sections I and III, which cover the topics of assessment and treatment, offer much practical advice both to the trainee and the seasoned clinician. The authors provide many helpful suggestions about what to do, how to think and behave, and what pitfalls to avoid. Much of this information is encapsulated in the form of short lists and outlines, which provide an excellent starting point for examining one’s style of practice and clinical work. Reading these lists will remind the reader of various patients and, perhaps, of some successes and failures. For me, these lists also are a reminder of the challenges of providing quality mental health care and how helpful such summaries can be in highlighting effective and ineffective care. Section II provides 18 chapters on common clinical problems related to children’s behaviours and emotions. For each problem, the authors provide a brief review, which ix Practical Child Psychiatry addresses the salient clinical issues related to making the correct diagnosis. The chapters are focused on types of symptoms and conditions, rather than diseases; thus, the chapter on disruptive behaviours (chapter 5) helps the reader distinguish between ADHD (Attention Deficit Hyperactivity Disorder), CD (Conduct Disorder), and ODD (Oppositional Defiant Disorder). Chapters also are included on common problems of child health, such as child maltreatment, enuresis and encopresis, and medical illness. A striking feature of this book is that much of the advice and recommendations are not, strictly speaking, supported by evidence-based medicine. While evidence-based medicine can provide data about the use of certain diagnostic tests or whether a certain medication or procedure is helpful for a specific condition, data from clinical trials are unlikely to inform how a clinician interacts with a patient, makes clinical decisions for the individual patient’s problems, or provides the humanistic or therapeutic aspects of care.1 What is extraordinarily helpful about this book is that the advice and recommendations are from experts who have extensive experience as clinicians and teachers. The reader, therefore, is getting advice that has been practiced, assessed, and revised. This is the best kind of information to help fill the large void left by all the questions that cannot or will not be answered through evidence-based medicine. Lask, Nunn, and Taylor challenge the clinician to practice medicine in a more thoughtful, self-reflective manner. Their goal of improving the mental health care of children, adolescents, and families can be reached if the reader attends to the many pearls of wisdom in this book and translates these into effective practice. A well known American child psychiatrist, Robert Coles wrote “A clinician must try to see what is strong as well as what is weak, what is sound as well as what ails, what might be struggling for expression in a person’s life as well as what is lacking”.2 Practical Child Psychiatry: The clinician’s guide will help clinicians provide better care by seeing the strengths and weaknesses of their patients and families. x Foreword 1. Leventhal JM. Editorial: A continuing theme of taking stock – Clinical challenges for the new millennium. Clinical Child Psychology and Psychiatry 2000;5:309–311. 2. Coles R. The South Goes North: Volume
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