What is a Child and Adolescent Psychiatrist?
As a child and adolescent psychiatrist, my job is to evaluate and treat individuals with psychiatric disorders. Child and Adolescent Psychiatry is a specialty of Psychiatry, which is, in turn, a specialty of medicine and therefore requires a medical degree (M.D. or D.O.). My patients often ask me how much education it takes to become a C/A psychiatrist. The minimum training includes four years of college (except in rare cases), four years of medical school, three to four years of general psychiatry residency, and two additional years of child and adolescent psychiatry training. That adds up to thirteen to fourteen years! At the end of this time period, C/A psychiatrists are educated in multiple areas including general medicine, neurology, child development, research and statistics, diagnosing psychiatric disorders by understanding the symptoms of each illness, and treating them using a variety of interventions including psychotherapies (individual, group, and specialized) and the use of medications to treat psychiatric illnesses. Child Psychiatry trainees must observe children in a variety of settings and understand how the environment impacts their functioning in addition to learning about the biology and genetics of psychiatric illnesses.
In 1999, the Surgeon General reported that “there is a dearth of child psychiatrists.” Only 20% of emotionally disturbed children and adolescents received any mental health treatment, a tiny percentage of which was performed by child and adolescent psychiatrists. Furthermore, the U.S. Bureau of Health Professions projects that the demand for child and adolescent psychiatry services will increase by 100% between 1995 and 2020.
How do child and adolescent psychiatrists diagnose a psychiatric disorders?
People often wonder how a psychiatrist diagnoses a psychiatric illness. A diagnosis is achieved after a careful psychiatric and medical evaluation during which a list of symptoms and signs are elicited by the patient (and in the case of a child, the family and others, such as teachers, care providers, and coaches). These sets of symptoms are correlated with disorders that are found in the Diagnostic and Statistical Manual, also known as the “DSM.” There have been several editions of this manual, and the current one is DSM-IV-TR. A description of this manual from the American Psychiatric Association is as follows:
Diagnostic and Statistical Manual
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. It is intended to be applicable in a wide array of contexts and used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) has been designed for use across clinical settings (inpatient, outpatient, partial hospital, consultation-liaison, clinic, private practice, and primary care), with community populations. It can be used by a wide range of health and mental health professionals, including psychiatrists and other physicians, psychologists, social workers, nurses, occupational and rehabilitation therapists, and counselors. It is also a necessary tool for collecting and communicating accurate public health statistics.
While the DSM-IV-TR is not a perfected method of diagnosis, it is the best tool available at this time. The next version of DSM – DSM-V – is in process and will be published in the next two to three years. As we learn more about psychiatric disorders, taking into account both biology and the environment, our ability to accurately diagnose psychiatric disorders should continue to improve.
To better understand how the DSM-IV-TR is used, I will use Mikey, a seven year old Caucasian male who presented for evaluation with his mother. Mikey is having is disruptive behavior at school and at home. Mother reports that Mikey was always an active child and states that once he learned to walk; he would take physical risks, like jumping off furniture, fences, and other structures, sustaining two broken bones by the age of 5. He often ignored requests both at home and at school. In Kindergarten, he would not sit still during structured activities and needed constant reminders to sit in his seat and would bother the other children by talking and poking them. In first grade the demands of a full school day made his behavior escalate. He did not listen in class and would not do his assignments, or if he did his homework, would not turn it in. He was behind academically due to this. Also, other children wanted to avoid him because he angered easily and would impulsively push them or tease them during playtime. He also distracted them during class by making noises or moving too much in his seat. He would get upset both at home and at school when he asked to do something he does not want to do and often “forgot” to do his chores or do activity of daily living (like showering and brushing teeth). He has great difficulty enjoying any leisure activity as he is constantly restless.
Other than this, Mikey is a happy boy who eats and sleeps well. He does not have any health problems, and his home life is stable. He has been tested by the school, and to their surprise, he has a very high IQ, but is behind about six months in his academics.
His psychiatrist diagnoses Attention Deficit Hyperactivity Disorder, Combined Type. Let’s look at the DSM-IV-TR for Attention Deficit Hyperactivity Disorder and see how the doctor came to this conclusion. Mikey’s symptoms are starred to the left of the items listed.
Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder
A. Either (1) or (2):
(1) inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
**(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
**(b) often has difficulty sustaining attention in tasks or play activities
**(c) often does not seem to listen when spoken to directly
**(d) often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace
(not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
**(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
**(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
**(i) is often forgetful in daily activities
**Mikey has the required SIX symptoms of INATTENTION
(2) hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
**(a) often fidgets with hands or feet or squirms in seat
**(b) often leaves seat in classroom or in other situations in which remaining seated is expected
**(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
**(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often “on the go” or often acts as if “driven by a motor”
(f) often talks excessively
**(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
**(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
**Mikey has more than the required SIX symptoms of HYPERACTIVITY/IMPULSIVITY
**B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
**Mikey’s symptoms started by the age of TWO.
**C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
**Mikey has trouble both at home and at school.
**D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
**Mikey’s school testing shows he is six months behind in school, and he is not functioning at an age appropriate level at home.
Based on the above, Mikey is diagnosed with Attention Deficit Hyperactivity Disorder, Combined Type. “Combined Type” indicates that he has problems in all three areas – attention, hyperactivity, and impulsivity.
Treatment of Psychiatric Disorders in children and adolescents
Now that Mikey has been diagnosed with ADHD, what is the next step?
The American Academy of Child and Adolescent Psychiatry has developed guidelines for physicians to follow in deciding to treat children/adolescents with psychiatric disorders. Although C/A psychiatrists are physicians who are able to prescribe medication, it is not necessarily the first and only recommendation they make. Many psychiatric disorders respond well to psychotherapy, modifications to the child’s environment, and other interventions based on the diagnosis and its severity. A good C/A psychiatrist will present the best available options for treatment. Many parents are reluctant to consider medications as a first line treatment, so discussions about treatment often include a plan that includes trying certain interventions before starting a medication. In Mikey’s case, his parents felt that some behavioral modifications at home and school should be given a chance as well as some tutoring to help Mikey catch up in school.
When are medications indicated and how do C/A psychiatrists monitor them?
Medications are indicated when the psychiatric disorder is severe enough that the child needs to be hospitalized because cannot function or are dangerous to themselves or others in their normal environment, when other interventions have failed over a certain time period, or when the physician and family feel that the benefits of using psychotropic medications outweighs the risks. The American Academy of Child and Adolescent Psychiatry takes the issue of using psychotropic medications in children very seriously and has developed the following thirteen principles or guidelines to ensure the safety of the patient.
- Principle 1. Before Initiating Pharmacotherapy, a Psychiatric Evaluation Is Completed.
- Principle 2. Before Initiating Pharmacotherapy, a Medical History Is Obtained, and a Medical Evaluation Is Considered When Appropriate.
- Principle 3. The Prescriber Is Advised to Communicate With Other Professionals Involved With the Child to Obtain Collateral History and Set the Stage for Monitoring Outcome and Side Effects During the Medication Trial.
- Principle 4. The Prescriber Develops a Psychosocial and Psychopharmacological Treatment Plan Based on the Best Available Evidence.
- Principle 5. The Prescriber Develops a Plan to Monitor the Patient, Short and Long Term.
- Principle 6. Prescribers Should Be Cautious When Implementing a Treatment Plan That Cannot Be Appropriately Monitored.
- Principle 7. The Prescriber Provides Feedback About the Diagnosis and Educates the Patient and Family Regarding the Child’s Disorder and the Treatment and Monitoring Plan.
- Principle 8. Complete and Document the Assent of the Child and Consent of the Parents Before Initiating Medication Treatment and at Important Points During Treatment.
- Principle 9. The Assent and Consent Discussion Focuses on the Risks and Benefits of the Proposed and Alternative Treatments.
- Principle 10. Implement Medication Trials Using an Adequate Dose and for an Adequate Duration of Treatment.
- Principle 11. The Prescriber Reassesses the Patient if the Child Does Not Respond to the Initial Medication Trial as Expected.
- Principle 12. The Prescriber Needs a Clear Rationale for Using Medication Combinations.
- Principle 13. Discontinuing Medication in Children Requires a Specific Plan.
In Mikey’s case, six months of therapy and tutoring were not effective and he continued to have difficulties at home and school. He and his parents agreed to a trial of medication for ADHD, and he showed a good response to it without side effects.
Child and adolescent psychiatrists are medical specialists whose goal is to improve the lives of children through the correct evaluation, diagnosis and treatment of psychiatric disorders.