Diagnosing and Treating Children and Adolescents

SECTION I

Hilt, Robert J., and Abraham M. Nussbaum. DSM-5® Pocket Guide for Child and Adolescent Mental Health, American Psychiatric Publishing, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=5108631. Created from waldenu on 2022-09-12 21:14:44.

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Chapter 1

Introduction

In the midst of an overbooked afternoon, you are asked to perform a mental health assessment of Sophie, a 14-year- old girl you have never met. You gather some materials, enter her examination room, and find a poorly groomed girl with her arms crossed over her chest, staring up at the ceiling rather than looking at you. She says to no one in particular, “There is nothing wrong, and I don’t need to be here.” Her mother then speaks for her, describing school struggles, argu- ments at home, losing friends, and saying “strange” things that include threats to hurt herself and talking to no one in particular whenever she is alone. She has a history of mal- treatment by her mother’s previous boyfriend, and in subse- quent years she has had “mood swings.” Sophie is picking at the scabs overlaying the linear lacerations on her left forearm.

That sinking feeling you just experienced—the time- stressed challenge of assessing mental health concerns in a pediatric population—is something we have experienced too. We want this book to help, to be the guide you take with you on these kinds of encounters.

What Is in This Book?

Like The Pocket Guide to the DSM-5™ Diagnostic Exam, this book emphasizes a person-centered approach to diagnosis along with practical tools and interview prompts to try with children and with their parents.

Because young people are more likely to receive an initial mental health diagnosis and medication management in a primary care setting than in a specialty care setting, we pay particular attention throughout this guide to what would be practical to perform in a primary care setting. Therefore, we describe things such as

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4 DSM-5 Pocket Guide for Child and Adolescent Mental Health

• How to diagnostically investigate common complaints (Chapter 3)

• How to perform either 15-minute (Chapter 4) or 30-minute (Chapter 5) versions of a diagnostic interview

• Abbreviated DSM-5 (American Psychiatric Association 2013) diagnostic descriptions and criteria (Table 4–1 and Chapter 7)

• Rating scales and suggested uses (Chapters 10 and 11) • Developmental milestones and red flags for referral

(Chapters 3 and 12) • Psychosocial (Chapter 14) and psychotherapeutic (Chap-

ter 15) intervention basics • Psychopharmacological intervention basics (Chapter 16)

We expect that different parts of this book will be used in different ways. Some sections of this book will be more help- ful when read in their entirety because they describe strate- gies to approach different aspects of caring for young people. Other sections may be used as in-the-moment references, such as interview questions to try when investigating a spe- cific DSM-5 diagnosis or a table that lists key age-specific de- velopmental milestones.

The following points highlight how this book differs from The Pocket Guide to the DSM-5™ Diagnostic Exam.

• ICD-10 codes for diagnoses are included. • Diagnoses not commonly made in childhood or adoles-

cence are not included. All content is focused specifically on children and adolescents.

• Discussion of the development of DSM-5 is reduced be- cause it is no longer novel.

• The practical aspects of the text are increased by shorten- ing chapters and adding tables.

• Assessment tools specifically for children and adolescents are introduced.

• Initial treatment strategies—psychosocial, psychotherapeu- tic, and psychopharmacological—for diagnosed disorders are added.

We certainly did not start out knowing how to interview young people and diagnose their mental and behavioral health problems. We remember struggling through encoun- ters, wondering how to organize the disparate symptoms

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Introduction 5

and concerns. Through our struggles, we eventually arrived at a variety of ways to simplify the diagnostic and treatment process and have learned how to organize our approach even in time-constrained circumstances.

As coauthors, we have served in different postresidency clinical roles that include being a rural pediatrician, a pediatric hospitalist, a pediatric emergency physician, a child psychia- trist, a child psychiatric consultant to both tertiary care and ru- ral pediatricians, and an adult inpatient psychiatrist. We have provided both psychotherapy and medication treatments for young people and have been required to adapt what we do for the shifting needs and structures of various care settings. In the course of this work, we have often been humbled by the challenges young people face and the challenges they present to a person who dares to provide them with mental health as- sistance. After all, few children and adolescents arrive on our doorsteps with neatly described symptoms that perfectly map onto a single DSM-5 disorder. We have both made many mis- takes and grown from those experiences.

This book is an experience-based guide to child mental health diagnosis and treatment, intended to provide a variety of practical approaches, tips, and skills to supplement the di- agnostic content of DSM-5. We cannot offer any rigid rules to follow when diagnosing or treating mental health disorders in young people because good care for young people cannot be reduced to a checklist. However, we make it easier for ev- eryone to provide excellent care. Whatever your specialty, your practice setting, and your experience level, we can assist you as you journey with children and adolescents in pursuit of mental health.

Therapeutic Alliance: The Place to Start

Working with young people can be very different from work- ing with adults. Young people are often reluctant partici- pants, often with developmentally limited communication skills, who have been presented for care that they did not seek on their own. In addition, the process of diagnosing dis- orders in a child typically involves gathering information from multiple informants and remembering an age- and de- velopmentally adjusted–diagnostic differential. Particularly when clinicians are working in primary care or other settings

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6 DSM-5 Pocket Guide for Child and Adolescent Mental Health

that artificially limit evaluation times, that sense of a ticking clock increases the challenges in order to efficiently reach a diagnosis and treatment plan for a young person.

The first step to successful diagnosis and treatment is to support the collaborative treatment relationship, what we hereinafter call the therapeutic alliance. Creating a therapeutic alliance with the caregiver at an appointment is compara- tively simple when compared with building an alliance di- rectly with a young person.

The 14-year-old girl in the vignette at the beginning of this chapter, Sophie, illustrates the problem with building an alliance. Sophie communicated that she disagreed with her mother’s assessment of the situation and was disinterested in your services. If you were to open DSM-5 and immediately begin asking Sophie a series of diagnostic questions, it would likely only increase her resistance. You must first engage So- phie to obtain reliable responses.

If we were in the examination room with you, we would hear out the concerns of Sophie’s mother, which also serves to solidify the parental therapeutic alliance; we would thank her for the guidance; and we would tell her that after hearing the concerns of caregivers, we speak with all of our adoles- cent patients alone. We would describe the rules for that dis- cussion—namely, that the conversation is confidential except for safety concerns—and then invite Sophie to sit alone with us. We do so because with adolescents in particular, you de- velop a better alliance and obtain more honest answers when you interview them without a parent or caregiver present (cf. Ford et al. 1997; Gold and Seningen 2009). However, this guidance must be adapted to each situation; a separation should not be forced on an adolescent who does not want her or his caregivers to leave the room. Younger children, or those adolescents who appear to be developmentally imma- ture, are usually interviewed more successfully with caregiv- ers present and reassuring them.

All young people will have a better therapeutic alliance if they feel noticed, heard, and appreciated, which can be called empathic engagement. Even for practitioners in a time-pressured situation, be reassured that holding back a recitation of tar- geted diagnostic questions in order to really notice the patient and build a little engagement does not take long. In our expe- rience, creating that engaged therapeutic alliance up front with a reluctant interviewee saves time overall through en- hanced cooperation with the diagnostic process.

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Introduction 7

Starting with a genuine reflecting statement that follows someone’s lead can initiate engagement with an adolescent, such as saying to Sophie, “You said that you feel fine and that there is nothing wrong. I would like to hear more about what is go- ing well for you right now… .” You could also start the conver- sation by asking about something that is important to the patient but relatively situation neutral, such as, “Your mom said that you go to ____ school; what is that school like?” School, friends, family, and favorite activities can all be appropriate and relatively low-stress conversation starters.

For young persons who seem really reluctant to even start talking, you may find that the conversation flows better after describing something you saw. This shows that you have been paying attention to them. For instance, “It looked as if it was really hard to just sit there and do nothing while your mom was talking. Am I right about that?” If there is a chance to comment on something you saw that relates to the diagnostic theme, you could also take that opportunity, saying, for example, “I saw you shake your head when your mom described what happened yesterday. Did she say something that wasn’t true for you?”

With a very young child, a conversation starter could be a simple observation, such as commenting about what she is wearing or brought with her, such as, “I see you have flowers on your shoes; did you pick those out yourself?” You can also com- ment on something the young person is currently doing, such as how she is playing with a toy or drawing a picture, to start a conversation.

A more subtle strategy to build the treatment alliance with a young person is shaping how you speak in a way that shows that you will be a responsive, problem-solving partner rather than an authority who will judge her. Metaphorically, this is about getting you and your young patient to sit side by side and to talk about a problem together. That way, the young person can talk about a problem that does not involve who she is as a person. For instance, Sophie may feel less de- fensive if you conversationally refer to her “mood” having led her to cut herself rather than “you cut yourself.”

A bit of humor can help to get young people talking. If humor does not come easily to you, be aware that showing some humility about yourself can be disarming and get your patient to chuckle a little. Both of us have children of our own who daily remind us that we have not been “cool” for a long time (if we ever were), and we find that openly acknowledg- ing our status as uncool adults can humanize us and put a

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8 DSM-5 Pocket Guide for Child and Adolescent Mental Health

young person at ease. For instance, “What is that band’s name on your shirt?.. . I have not heard about them before, but that prob- ably means they are cool because I am a bit of a square.”

Building a therapeutic alliance with a young person should lead to learning that young patient’s own true chief complaint. For Sophie, it could be “My mom is driving me crazy,” “My boyfriend is abusive,” “I hear voices,” or any of a number of complaints. This creates a context from which your subsequent and more detailed diagnostic inquiries will logically follow. Following conversational opportunities can go like this: “So, during those times when your mom is driving you crazy, do you ever have thoughts about hurting yourself?” Child and parent chief complaints do not have to align; we have performed many successful treatments from start to fin- ish with young people whose chief complaints never fully aligned with what their parents thought the problem was.

Once you have the young person engaged and talking with you, the diagnostic and treatment process as described throughout the rest of this book should follow along more easily. Once a reasonable therapeutic alliance has been started, it is our experience that asking your patient questions about what she sees as the challenges in her life will be more honestly answered.

In summary, we suggest the following techniques to initi- ate a therapeutic alliance with a child and set up a useful di- agnostic interview:

• When developmentally appropriate, offer to talk with the patient without a caregiver present.

• Start the conversation with an observation or a subject im- portant to the patient.

• Briefly convey that you have noticed, heard, and appreci- ated the patient’s perspective.

• Show that you are the child’s treatment partner rather than an adult-engaged adjudicator.

• Use a little humor to break the ice, such as confessing your “uncoolness.”

• Ask about the patient’s main concerns or frustrations. • Try shaping your initial diagnostic questions to reference

the child’s own chief complaint.

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Chapter 2

Addressing Behavioral and Mental Problems

in Community Settings

Children infrequently receive timely care for mental and behavioral health problems: the average time from the start of child mental health symptoms until a young person enters mental health treatment is 8–10 years (Kessler et al. 2005). In many systems of care, only about one in five chil- dren with a diagnosable mental health disorder will receive treatment during childhood (U.S. Public Health Service Of- fice of the Surgeon General 1999). For those children identi- fied in primary care to be in need of a behavioral health intervention, a little more than half of those referred to a spe- cialist will attend even a single treatment appointment (Rushton et al. 2002).

The reasons for this underuse of specific mental health treatments during childhood are numerous. Barriers include stigma, poor problem recognition, limited family or practitio- ner understanding of treatments, insurance coverage barri- ers, complicated referral processes, and limited availability of mental health specialists.

There are far more community issues to address than any of us as individual practitioners could change all at once. Thankfully, opportunities are now increasing for practitio- ners to participate in meaningful improvements in commu- nity behavioral health systems. Through payer supports and system redesigns, primary care practices may be able to de- velop collaborative or integrated care partnerships with mental health specialists. Doing so brings specialist support directly into sites where people are already receiving medical services. Research has determined that such arrangements can be clinically more effective and even save money for the overall care system, which has captured the attention of health systems and payers.

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10 DSM-5 Pocket Guide for Child and Adolescent Mental Health

Regardless of the specific system of care available in your community, we would like to point out certain general clini- cal steps that appear along the path of addressing child be- havioral health problems in community settings. If you are a primary care practitioner or a health system representative working to improve community behavioral health, identify- ing opportunities to improve any of the following areas is likely to improve the health of children:

• Recognition of mental distress • Screening for mental distress • Diagnosis of a particular mental disorder • Education about mental health treatment • Teaching patients and caregivers self-help strategies • Initiation of counseling and therapy • Appropriate prescription of medications

Recognition of Mental Distress

Before a child can receive services, he or she first must be rec- ognized as needing some form of assistance. We point this out because caregivers have wide variations in their view of what requires professional help. The same set of disruptive behav- iors may lead one caregiver to write it off as “Oh, he’s just be- ing a boy” but lead another caregiver to demand immediately to see a professional. Families may actively resist acknowl- edging or may simply fail to recognize when the child has a problem that treatment could help. Therefore, a key initial step in the process is for family members, friends, school rep- resentatives, and primary care practitioners to help parents recognize what can and cannot be helped through mental health treatment and overcome stigma barriers when neces- sary. Education about general signs of trouble to watch for— such as decreasing school performance or losing the ability to have fun—can aid with problem recognition.

Screening for Mental Distress

Proactively looking for mental health problems through di- rect questioning or evaluating symptoms with a behavioral health rating scale is worthwhile, but only if practitioners are

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Mental Health in Community Settings 11

available to interpret that information and recommend ap- propriate actions. Rating scales are very useful for their ease of administration and ability to identify unrecognized prob- lems, to obtain clinical data from multiple informants, and to provide assessments of symptom severity to follow.

Rating scales are also inherently imperfect; they should never be the sole basis for making a diagnosis. This is because questions might be misinterpreted, might be answered un- truthfully, or might simply have been the wrong questions to ask. For instance, an adolescent with recent-onset inattention problems may have a depressive disorder or an anxiety disor- der missed if the only diagnostic assessment was an attention- deficit/hyperactivity (ADHD) disorder symptom rating scale. An adolescent who denies having depressive symp- toms on a rating scale but is engaging in recurrent self-harm should still receive specialized care. Thus, the most valuable steps in a rating scale screening process are practitioners helping to select the correct scales, interpreting the results in the context of a person’s personal situation, and taking a helpful action for any positive screening results.

Diagnosis of a Particular Mental Disorder

Making a mental health diagnosis and developing a treatment plan can be challenging for a mental health care practitioner who has up to an hour to complete his or her assessment. For those who are less experienced or have only 15 minutes to as- sess a person, the task quickly becomes overwhelming. Within a strictly limited and very short time frame, all that we would reasonably ask of a clinician is to identify the child’s leading problem and its probable rather than definitive origin.

A well-supported DSM-5 (American Psychiatric Associa- tion 2013) diagnosis subsequently requires three things: 1) that a child’s clinical presentation fulfills the specific symptom- based diagnostic criteria, 2) that those symptoms are not caused by other diagnoses or stressors, and 3) that those symptoms are impairing a child’s functioning. Because chal- lenges occur at each step, we recommend breaking up the process into several steps. In an initial brief assessment with incomplete information, we recommend that clinicians con- sider using less specific diagnoses, such as disruptive behav- ior disorder, unspecified, or depressive disorder, unspecified.

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12 DSM-5 Pocket Guide for Child and Adolescent Mental Health

The diagnosis then can be clarified over time through gather- ing more information at subsequent appointments. This mul- tistep approach allows the time needed to gather collateral information, such as ADHD rating scales completed by both teachers and family members for subsequent review.

When multiple problems are identified in an initial very brief appointment, working with a young person and his or her caregivers to jointly identify the leading problem allows for a more practical use of time. For instance, if a child is hav- ing screaming tantrums, is hitting other children, is sleeping poorly, and sometimes appears anxious, the identified lead- ing problem may be the unsafe externalizing behaviors. In that case, the child’s sleep problems and intermittent anxiety might be set aside to explore further at the next appointment.

Education About Mental Health Treatment

Educating children and families about their diagnosed men- tal health disorders has intrinsic value. Besides fulfilling an inherent desire to better understand problems, the ultimate purpose of providing psychoeducation is to increase the child’s and his or her caregiver’s ability to achieve health. Re- sistance to bringing a child to see a mental health practitioner or to trying out an appropriate psychiatric medication is common. So even if you make the best diagnosis possible, it does little good unless you connect the diagnosis to treat- ment. We keep the timeless advice of the physician Henry Cohen (1943) in mind: “All diagnoses are provisional formu- lae designed for action” (p. 24).

Therefore, we follow referral recommendations with ed- ucating the family about the value of receiving mental health services. This helps a patient and his or her caregivers visual- ize the process of treatment, what is known about the antici- pated response to treatment, and what is likely to happen without treatment. For instance, we might help a caregiver with reluctance to see a mental health specialist understand that it takes an episode of untreated major depression a mean of about 8 months to self-resolve, which, if that happens, is a great deal of life and normal development for a child to miss out on (Birmaher et al. 2007). For a family who, because of the child’s dysfunction, has lost some of their empathy for their child (which can happen with externalizing problems such as

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Mental Health in Community Settings 13

oppositional defiant disorder), providing blame-free psycho- education about the condition and the likelihood of response to treatment can also help can also help to reestablish care- giver empathy and support.

Teaching Patients and Caregivers Self-Help Strategies

Even though a primary care practitioner might prefer to have a mental health practitioner initiate all forms of intervention for an identified disorder, this delays care. Delays can occur from stigma-related resistance to following through on a re- ferral, challenges in negotiating insurance restrictions, and having to wait for a local practitioner to become available. We prefer that some form of treatment plan initiation occur right away, through the kind of steps that would be appropriate for a family primary care practitioner to recommend.

What would be appropriate treatment to recommend without a mental health practitioner? The first step in treat- ment plan initiation could be coaching the child and family on self-help measures they can implement now. For example, the practitioner could address a young person’s poor sleep habits, which accompany many different mental and behav- ioral health problems. Coaching how to improve a child’s sleep hygiene, such as restricting access to text messaging af- ter a certain time at night, can reduce daytime irritability and initiate improvements in mood, as we discuss in Chapter 14, “Psychosocial Interventions.”

We also recommend a few situation-specific self-help readings or videos, which are known generically as bibliother- apy. Behavior management training for disruptive behavior is a prime example, because we know that a motivated parent can make significant changes in the child’s discipline plan and environment from such references alone, without a ther- apist’s involvement (Lavigne et al. 2008). Many high-quality books, Web sites, and videos are available that motivated parents can use to try implementing evidence-based disrup- tive behavior management or cognitive-behavior therapy in- formed skills. However, even when parents use high-quality self-help tools, this is less likely to make a difference with more severe symptoms, more overall family dysfunction, and more diagnostic complexity.

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14 DSM-5 Pocket Guide for Child and Adolescent Mental Health

Initiation of Counseling and Therapy

We recommend psychotherapy for any young person who meets criteria for a mental health diagnosis with moderate to severe symptoms or for mild symptoms that are persistent and dysfunctional enough to warrant the investment of a young person’s time. There are exceptions to this broad gen- eralization about when to recommend psychotherapy; for in- stance, even in severe cases of ADHD, the young person may be treated successfully with medications alone, but this situa- tion is an exception to the rule. The specific preferred forms of psychotherapy will differ by disorder type, so we encourage you to identify the diagnosis first and then consider the op- tions we describe in Chapter 15, “Psychotherapeutic Interven- tions.” Because many families avoid going to psychotherapy, you should learn their concerns and address them. For in- stance, “You looked like you weren’t very happy with the idea of working with a therapist…what comes to mind for you about this?”

One-on-one psychotherapy is not the only source of out- patient services for young patients. Locally available support groups, crisis intervention services, parenting classes, social skills groups, family therapy, special education services, and speech therapists are just a few other examples. Because care- givers’ own mental health difficulties may affect a young per- son’s mental health disorders, coaching a caregiver on his or her own appropriate use of psychotherapy may be a way to help a child or an adolescent. Use of a question such as the fol- lowing may help: “With everything going on, do you have some- one in your corner who is there just to help you?” Some primary care practitioners may choose to provide young people with motivational interviewing techniques to support their efforts to reduce substance abuse behaviors or learn to provide coaching on relaxation training or other cognitive-behavioral techniques during their own follow-up appointments.

Appropriate Prescription of Medications

Primary care practitioners often feel pressured to prescribe right away, in part because the prescription pad is one of the few treatment tools immediately available. This can be quite appropriate when the diagnosis is clear, significant rather than just mild symptoms are present, an evidence-supported

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Mental Health in Community Settings 15

medication option is available, and the practitioner has dis- cussed the risks and benefits. We otherwise advise resisting an immediate prescription.

A near-universal recommendation when prescribing psy- chiatric medications to children is that some form of psycho- social intervention—therapy or changes in the child’s environment—should accompany their use. Other prescrib- ing principles to keep in mind include starting with low doses and increasing slowly over time (“start low, go slow”) and changing only one medication at a time to avoid out- comes confusion.

In summary, here are suggestions for a primary care ap- proach to child mental health treatment:

• Instill appropriate hope, even in the initial interview. • Form a therapeutic alliance with the young person and his

caregivers. • Use rating scales to help gather more clinical information

but be aware of their limitations. • Ask for collateral information from other informants to

help ensure a correct diagnosis. • Interview adolescents alone to obtain a more complete

history, especially for internalizing disorders. • Note the child’s office behavior and interactions, which

supply much of your child mental status examination findings.

• For an initial brief assessment, make only a provisional DSM-5 “unspecified” diagnosis.

• Expect to use more than one appointment to refine your diagnoses.

• Coach the family on pursuing their next best steps in care while screening for any barriers to address.

• For mild conditions, start with self-help approaches, bib- liotherapy, and school interventions.

• Consider referring to specialist care anyone who is more ill or not improving.

• Use psychosocial interventions, such as psychotherapy, in most scenarios.

• If symptoms are moderate to severe, consider starting med- ication management with an evidence-supported strategy.

• Use your local specialists for support, to provide counsel- ing, and to manage your more challenging patients.

• Schedule a follow-up appointment, even if patients were referred to specialty care.

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16 DSM-5 Pocket Guide for Child and Adolescent Mental Health

Common Ages for Disorder Presentations

As we assess young people, we find it helpful to remember a maxim of clinical practice: “When you hear hoof beats, think horses, not zebras.”

We find it to easier to detect psychiatric conditions in young people by recognizing the typical ages when different mental health conditions are likely to appear. For instance, you are unlikely to diagnose anorexia nervosa, bipolar disor- der, or schizophrenia in a 4-year-old in a primary care clinic.

Still, there are not precise ages at which you should or should not consider a particular diagnosis. We can offer no firm rules. We can offer two pieces of prudent advice:

1. Remember the adage “Common things are common.” When you are seeing a 10-year-old, separation anxiety disorder is more likely than schizophrenia.

2. Consider that developmental delay can influence the age and appearance of a disorder. For instance, encopresis, which is rarely seen in teenagers, may be more likely in a 16-year-old with the approximate mental age of a 4- year-old.

We created Table 2–1 to help guide your diagnostic inqui- ries. You will notice that as children age, conditions such as encopresis and oppositional defiant disorder become less likely, whereas conditions such as bipolar disorder and schizophrenia become more likely. Overall, diagnosable con- ditions increase with age. We advise against diagnosing per- sonality disorders until at least late adolescence because, by definition, a child’s personality is developing and changing more actively than is an adult’s personality.

Another way to think of the predicted likelihood of de- tecting specific disorders in children is in regard to their ab- solute frequencies of occurrence. According to National Comorbidity Survey data (Merikangas et al. 2010), anxiety disorders have a much earlier age at onset than many practi- tioners realize. Half of individuals who develop an anxiety disorder will have had symptom onset by age 6, half of those with behavior disorders will have had onset by age 11, and half of those with mood disorders will have had onset by age 13 (among adolescents who have a mental health diagnosis). Table 2–2 includes the relative distribution of the lifetime ex-

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Mental Health in Community Settings 17

perience of mental health diagnoses in decreasing overall or- der of frequency among 13- to 18-year-old patients in this survey.

Age-Based Behavioral Health Screening

Knowing when different mental and behavioral health disor- ders typically appear in young people can help your diagnos- tic process. Any screening test or diagnostic inquiry has more positive predictive value the higher the overall prevalence of the condition being investigated. Therefore, on the basis of prevalence rates and our own clinical experiences, the fol- lowing are our suggestions for routine consideration in your differential diagnosis at different age ranges.

Ages 0–5: Developmental impairments and disruptive be- havior problems are the predominant issues at this age. Gen- eral screening rating scales to consider at this age therefore include general developmental assessments, autism spec- trum screens, and social-emotional learning measures.

Ages 6–12: Attention-deficit/hyperactivity disorder (ADHD), disruptive, impulse-control, and conduct disorders; intellec- tual disabilities; anxiety disorders; and mood disorders pre- dominate at this age. General screening rating scales to consider at this age therefore include ADHD symptom rating scales, anxiety rating scales, and depression and autism spec- trum measures.

Ages 13–18: Major depressive disorder, anxiety disorders, posttraumatic stress disorder, eating disorders, ADHD, sub- stance use disorder, and conduct disorder predominate at this age. General screening rating scales to consider at this age therefore include ADHD symptom rating scales, anxiety rating scales, and depression rating scales.

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18 D

S M

-5 P ocket G

uid e for C

hild and A

dolescent M ental H

ealth

TABLE 2–1. Selected DSM-5 disorders to be considered at different ages

Preschool (2–5 years) School age (6–12 years) Adolescence (13–17 years)

ADHD (age ≥ 3, if severe) ADHD ADHD

Autism spectrum disorder Adjustment disorder Adjustment disorder

Communication disorders Conduct disorder Anorexia nervosa

Encopresis Encopresis Bipolar disorders

Intellectual disability (intellectual developmental disorder)

Bulimia

Conduct disorder

Persistent depressive disorder (dysthymia)

Intellectual disability (intellectual developmental disorder)

Insomnia disorder

Generalized anxiety disorder

Specific learning disorder

Major depressive disorder

Oppositional defiant disorder Insomnia disorder and parasomnias

Selective mutism

Separation anxiety

Specific phobia

Specific learning disorder

Major depressive disorder

Obsessive-compulsive disorder

Oppositional defiant disorder

Posttraumatic stress disorder

Tourette’s disorder (tics)

Trichotillomania (hair-picking disorder)

H ilt, R

obert J., and A braham

M . N

ussbaum . D

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Social anxiety disorder Specific phobia Somatic symptom disorder

Obstructive sleep apnea hypopnea

Obsessive-compulsive disorder

Oppositional defiant disorder

Panic disorder

Posttraumatic stress disorder

Tourette’s disorder (tics)

Trichotillomania (hair-picking disorder)

Schizophrenia

Social anxiety disorder

Specific phobia

Somatic symptom disorder

Substance use disorders

Note. ADHD=attention-deficit/hyperactivity disorder. Source. American Psychiatric Association 2013.

TABLE 2–1. Selected DSM-5 disorders to be considered at different ages (continued)

Preschool (2–5 years) School age (6–12 years) Adolescence (13–17 years)

H ilt, R

obert J., and A braham

M . N

ussbaum . D

S M

-5® P

ocket G uide for C

hild and A dolescent M

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ealth, A m

erican P sychiatric P

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aldenu on 2022-09-12 21:14:44.

20 DSM-5 Pocket Guide for Child and Adolescent Mental Health

TABLE 2–2. Cumulative prevalence of DSM-IV disorders in adolescents, per the National Comorbidity Survey–Adolescent Supplement

Disorder Total

prevalence (%)

Presence of severe

impairment among those

with disorder (%)

Specific phobia 19.3 3

Oppositional defiant disorder

12.6 52

Major depressive disorder or dysthymia

11.7 74

Social phobia 9.1 17

Drug abuse or dependence

8.9 NR

Attention-deficit/ hyperactivity disorder

8.7 8

Separation anxiety disorder

7.6 8

Conduct disorder 6.8 32

Alcohol abuse or dependence

6.4 NR

Posttraumatic stress disorder

5.0 30

Bipolar disorder 2.9 89

Eating disorder 2.7 NR

Agoraphobia 2.4 100

Panic disorder 2.3 100

Generalized anxiety disorder

2.2 41

Note. NR=not reported. Source. Derived from Merikangas et al. 2010.

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Chapter 3

Common Clinical Concerns

Although every child or adolescent is unique, a hand- ful of common concerns account for most of the reasons young people come to clinical attention. You learn to recognize these patterns during training. You see hundreds of children and adolescents, discuss them with clinical supervisors, and de- velop a subconscious ability to quickly recognize the ways a particular child resembles common concerning patterns. For instance, you may quickly recognize a child’s presentation pattern as typical of an uncomplicated adjustment to a new school rather than an episode of major depression. These sub- conscious patterns are a tremendous benefit to a practitioner because they help her improve her clinical efficiency.

However, relying on experience to guide your current practice causes at least two problems.

First, even seasoned practitioners make mistakes. We as- sume that an adolescent has an ordinary case of unhappiness, so we neglect to consider whether her social isolation is the result of abuse or psychosis. We assume that a child’s inabil- ity to play well with others represents a neurodevelopmental disorder, so we neglect to ask about cultural expectations for interactive play in a family. Even an experienced practitioner needs to remain curious about a particular patient and vigi- lant about the eventuality of making mistakes.

Second, most young people are evaluated and treated for mental illness by primary care practitioners with limited mental health training. These practitioners often have re- markable stores of clinical experience in caring for children and adolescents, but their mental health training is often lim- ited to a few afternoons, a long-ago clinical rotation, or an oc- casional lecture. A practitioner whose training is not specialized for mental health can benefit from referencing prudent aids to decision making.

The following sections, and their accompanying tables, are prudent guides to common clinical concerns. Each table identifies a common clinical concern, provides diagnostic cat-

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22 DSM-5 Pocket Guide for Child and Adolescent Mental Health

egories to which these concerns can be mapped, and suggests questions to guide clinical inquiry. We designed most ques- tions to be asked of a young person. When a question is de- signed to be asked of a caregiver, we label it “for caregiver.”

Poor Academic Performance

To succeed in a work environment, a person needs the ability to succeed, the desire to succeed, and an environment that enables success. Major life distractions or impairing illnesses can unfortunately derail a person who would have otherwise found success. Although that simple description can be used to describe just about any adult workplace, the exact same points are true about children in school. School is where chil- dren and adolescents go to work.

When you see a child who is struggling to succeed in school, it is useful to think very broadly about what might be getting in her way (Table 3–1). Just like an adult who is hav- ing workplace difficulties, a young person may have prob- lems with 1) ability, 2) desire or effort, 3) work environment, 4) life distraction, or 5) an impairing mental health disorder or illness.

1. Ability challenges we consider right away to ensure we do not miss them. The most basic ability is our senses. Hear- ing and vision screens are easy to perform, and when needed, an intervention such as a hearing aid or a new pair of glasses can make a profound difference. Motor im- pairments, such as the physical ability to write or enunci- ate clearly, also can be managed effectively through physical, occupational, or speech therapy.

Intellectual disabilities, of course, influence school success. You can determine whether a young child has fallen behind on developmental milestones by compar- ing her traits with a list of normal range expectations. Caregiver-completed developmental rating scale mea- sures such as the Ages & Stages Questionnaires (ASQ) will aid this task, or you can simply ask a caregiver if she has had any concerns about the child’s speech, compre- hension, or physical ability development. We would suspect an intellectual disability when the child has multiple areas of delay. IQ test scores provide helpful

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Common Clinical Concerns 23

TABLE 3–1. Poor academic performance

Diagnostic category Suggested screening questions

First consider

Abuse “Has anything or anyone made you feel uncomfortable or unsafe?”

(for caregiver) “Has anything happened to your child that really shouldn’t have happened?”

Bullying “Have other kids been teasing you or making you feel afraid?”

Sensory impairment

“Have you ever noticed any trouble with hearing or vision?”

Common diagnostic possibilities

Attention- deficit/ hyperactivity disorder

(for caregiver) “Even when she wants to learn, is your child too inattentive or hyperactive to succeed?”

Intellectual disability (intellectual development al disorder)

(for caregiver) “Have there always been problems with learning? Were there early milestone delays such as speech delays?”

Specific learning disorder

“Are any specific subjects or activities such as reading particularly difficult?”

Mood or anxiety disorder

(for caregiver) “Did poor school performance come after an anxious or depressive change?”

Oppositional defiant disorder or conduct disorder

(for caregiver) “Is your child simply refusing to do schoolwork?”

Substance use disorder

“Have you been using drugs or alcohol?”

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24 DSM-5 Pocket Guide for Child and Adolescent Mental Health

data, but impairments in adaptive life functioning also must be present to diagnose an intellectual disability. Early intervention services or a local school district’s special education program should be engaged as early as possible to improve outcomes when global develop- mental delay or an intellectual disability is suspected.

Specific learning disabilities are often detected much later than a general intellectual disability because they may not become apparent until school demands increase. The three overall categories of specific learning disabili- ties are reading, writing, and computation. The hallmark of a specific learning disability is that the child has an area of much poorer school performance than expected on the basis of the child’s overall intellect and effort.

2. Desire or effort in school is about the motivation to achieve. A person with a low to average intellect but a strong mo- tivation to achieve can have greater school success than someone with high intellect but low motivation to achieve. There is no quick fix for motivation problems. For young children, motivation in school starts with healthy home relationships and regularly experienced positive parent-child time, which foster a desire to meet adult expectations. Clear and reasonable family expecta- tions for the child’s school achievement are also neces- sary. For older children, this desire ideally evolves into working hard in school because they want to please themselves.

3. Work environment affects performance because not every school and not every classroom will suit every child. For instance, an easily distracted child will not do well in a loud and overcrowded classroom, and a child with a spe- cific writing disability will not do well in a class that re- quires large volumes of daily written work completion. Asking about the class environment and the child’s home workspace may identify these issues.

4. Life distractions prevent success by taking a child’s mind off his or her schoolwork. Abuse, neglect, and bullying are the most important distractions for us to catch right away so that child protective services or school officials can intervene. Children may experience a decline in school performance because of family stressors such as parental separation or divorce or from struggling with peer relationships. It is useful to ask, “When you try to do your schoolwork but get distracted, what’s on your mind?”

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Common Clinical Concerns 25

5. Impairing mental health disorders or illnesses that are de- scribed in DSM-5 (American Psychiatric Association 2013) can create school problems. For instance, major depressive disorder, persistent depressive disorder (dysthymia), gen- eralized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), social anxiety disorder (social phobia), oppositional defiant disorder (ODD), conduct disorder, substance use disorder, and posttraumatic stress disorder (PTSD) all will reduce a child’s school performance. Chronic medical diseases, especially those that involve ex- periencing daily pain, also will reduce the ability to focus on school.

Attention-deficit/hyperactivity disorder (ADHD) is the main mental disorder that gets considered in terms of a high overall incidence (>5%) and common family requests for treatment. We would look for ADHD if attention and/or hy- peractivity-related schooling difficulties can be traced back to the early elementary school years and these difficulties are not readily attributed to any of the above causes. Sud- den-onset attention problems are thus unlikely to be caused by ADHD. Another key trait to look for is whether ADHD- like symptoms are present in multiple settings (such as both in school and at home). The good news is that by correctly identifying an impairing illness such as ADHD, you have an opportunity to treat and resolve the schooling problem.

Developmental Delay

A person’s development from infancy to adulthood is amaz- ing in its breadth and complexity. Because not every person develops at the same pace or in the same order of skill acqui- sition, detecting a significant developmental impairment may be challenging (Table 3–2). For instance, a child may learn to walk without ever crawling or may appear speech delayed at 18 months but speech advanced at 2 years. Fewer than half of the children with significant developmental de- lays are identified before starting school, which delays entry into treatment. Therefore, anything practitioners can do to help caregivers detect these problems can alter the trajectory of a child’s life. A key function of health maintenance care in the first 5 years of life is to detect developmental impairments that would benefit from an intervention. Any parental con- cerns expressed about a child’s speech, learning, sociability,

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26 DSM-5 Pocket Guide for Child and Adolescent Mental Health

TABLE 3–2. Developmental delay

Diagnostic category

Suggested screening questions for caregiver

First consider

Neurodegenerative conditions

“Has your child lost any previously acquired skills or abilities?”

Sensory impairment

“Have you ever noticed any trouble with your child’s hearing or vision?”

Common diagnostic possibilities

Autism spectrum disorder

“Does your child smile in response to your smile? Did your child respond to her own name before age 1? Does your child have restricted interests or behaviors?”

Communication disorder

“Does your child have problems with stuttering or with understanding words?”

Fragile X syndrome “Does your child have siblings or relatives on the mother’s side of the family with intellectual impairment?”

Intellectual disability (intellectual developmental disorder) or global developmental delay

“Was your child slow to develop speech and physical skills? Does your child have a harder time learning new things than other children?”

Neurobehavioral disorder associated with prenatal alcohol exposure

“What can you tell me about alcohol use during pregnancy? Has your child had difficulty regulating his or her mood or impulses?”

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Common Clinical Concerns 27

or physical skills should open the proverbial door for further examination.

Development can be broken down into three broad cate- gories: cognitive, motor, and social-emotional. Cognitive de- velopment refers to what most people think of as intelligence. Some measurable areas of cognition include problem solv- ing, language, memory, information processing, and atten- tion. Motor development refers to the acquisition of gross motor (e.g., run, throw) and fine motor (e.g., pincer grasp, drawing) physical motion skills. Social-emotional development refers to the acquisition of the ability to interact with others and manage the emotions of social interactions.

Because there is a very wide range of what can be consid- ered “normal” development, we look for developmental markers that are far enough outside the norm to justify refer- ral for developmental assessments or interventions. When parents express that they already have concerns about a spe- cific area of their child’s development, we will likely find a need for a developmental assessment referral. Speech thera- pists can help with suspected communication delays, physi- cal therapists can help with suspected motor skill delays, and special education–sponsored preschools can help with sus- pected socialization and general learning skill delays. All children with significant developmental delays should be re- ferred to early intervention services.

Detecting autism spectrum disorder before a child reaches age 3 years is aided by recognizing certain red flags in social- emotional development. These include not smiling in response to being smiled at, not making eye contact, not sharing attention with others, not responding to her own name by age 1 year, poor social interest, and a lack of interest in other children. Socially fo- cused interventions that foster communication as early as possi- ble are a cornerstone of autism care.

Every child with developmental impairment should be screened for hearing or vision impairments because sensory impairments can worsen or even cause developmental impair- ments. Another reason for early sensory assessments is that hearing and vision impairments can be relatively easy to treat.

A developmental impairment rarely worsens over time, so when we find any loss of previously acquired skills, we broaden our search for an etiology to include medical causes. For example, hypothyroidism, phenylketonuria, and recur- rent seizures are some of the many medical causes of regress- ing development.

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28 DSM-5 Pocket Guide for Child and Adolescent Mental Health

We recommend considering genetic testing if the clinical pattern might fit a genetic disorder. For instance, fragile X test- ing is particularly pertinent if other family members have in- tellectual disability. If no specific genetic disorder is suspected, the yield of genetic testing will be reduced. Developmental disorder laboratory tests for fragile X and chromosome micro- array should be ordered only after providing pretest counsel- ing to families. Family risks from genetic testing include finding an unknown significance mutation that creates more anxiety than answers or learning something the family did not wish to learn, such as misattributed paternity or a pessimistic prognosis that lowers current quality of life.

Diagnosing a child with neurobehavioral disorder associ- ated with prenatal alcohol exposure, included in Section III of DSM-5, can be a challenge to your therapeutic alliance with caregivers because it inherently assigns blame for some of a child’s problems on her mother’s behaviors during preg- nancy. Characteristic facial features (thin upper lip, smooth philtrum, short palpebral fissure length) might be present, but their absence does not rule out the diagnosis. Because these children do have a unique prognosis, it is worth explor- ing this possibility in a blame-free fashion.

In Chapter 12, “Developmental Milestones,” we further review developmental milestones and discuss developmen- tal red flags, signs that need further evaluation, ideally through specialized developmental assessments.

Disruptive or Aggressive Behavior

When we see a young person who is aggressive or disruptive, we receive that behavior as a form of communication. A child who is unable to effectively communicate verbally may use behaviors instead, such as lashing out at a peer who has just taken her toy. Hunger, pain, sadness, fear, and frustration are just a few examples of distress that may turn into tantrums, disruptive behavior, or aggression. For instance, if you can identify that hunger leads to a tantrum in a nonverbal child, the child can be coached to point at a picture of food to com- municate hunger and get something to eat (this is known as a picture exchange system).

A functional analysis of behavior is an overall approach that helps with most aggression problems in childhood. In a func- tional analysis, you identify the character, timing, frequency,

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Common Clinical Concerns 29

and duration of at least a few incidents of disruptive, aggres- sive behavior in great detail. Predisposing, precipitating, and perpetuating influences on behavior can be elicited by asking a series of questions such as “Tell me about the last time this hap- pened. What was happening right before? How had that day been going overall? What did you do while the behavior was happening? What happened right afterward?”

What you often discover from the unedited details of two or three incidents is that the aggressive and disruptive behav- iors begin to make a lot more sense. Examples include tan- trums inadvertently being rewarded with treats because caregivers want the child to stop in the moment or aggression that allows a child to successfully escape aversive situations.

Different DSM-5 disorders may be suggested by particular circumstances of the child’s disruptive behaviors (Table 3–3). Children with PTSD may become disruptive when situations remind them of past negative events. Children with a learn- ing disability may be disruptive when struggling at school or working on homework. A child with ADHD may have nearly continuous, disruptive hyperactivity that is not situational or vindictive. A child with social anxiety disorder (social pho- bia) or autism spectrum disorder may show disruptive be- havior when pushed to engage in social situations. A child who has been bullied at school may suddenly develop dis- ruptive, lashing-out behavior or become resistant to going to school. In summary, identifying the overall pattern and con- text of behaviors is key to the diagnostic process.

It is relatively easy to identify ODD, a diagnosis that de- scribes pervasively negativistic and defiant behavior to- ward authority figures in a developmentally inappropriate fashion (i.e., not just the “terrible twos”) that lasts for more than 6 months. The real challenge is knowing what to do about it.

ODD has a complex, multifactorial etiology. In simple terms, ODD represents a mismatch in fit between a child’s in- herent traits or temperament and how her caregivers and au- thority figures respond to them. Communicating to caregivers that they share responsibility with their child for the negative behavior patterns in ODD without this being perceived as blaming them for the problem is a tricky balance. One way to do so is to characterize the child’s personality or biology as re- quiring higher-than-usual parenting demands, so more highly skilled parenting strategies are needed to respond to ODD. Empathy for the challenge parents face goes a long way here.

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TABLE 3–3. Disruptive or aggressive behavior

Diagnostic category Suggested screening questions

First consider

Abuse “Has anything or anyone made you feel uncomfortable or unsafe?”

(for caregiver) “Has anything happened to your child that really shouldn’t have happened?”

Bullying “Have other kids been teasing you or making you feel afraid?”

Safety “Have you been thinking about or planning to hurt anyone?”

Common diagnostic possibilities

Attention- deficit/ hyperactivity disorder

(for caregiver) “Does your child consistently have trouble paying attention, or is she hyperactive or disruptive?”

Communication disorder

(for caregiver) “Is your child aggressive when she has needs she cannot communicate?”

Conduct disorder

(for caregiver) “Has your child been committing serious violations of rules and the rights of others for more than a year?”

Oppositional defiant disorder

(for caregiver) “Has your child been unusually defiant and oppositional for more than 6 months?”

Posttraumatic stress disorder

(for caregiver) “Does your child’s disruptive behavior primarily occur after reminders or memories of past trauma?”

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Common Clinical Concerns 31

Conduct disorder is a similar, but more concerning, ver- sion of defiant, aggressive behavior that has a greater risk of continuing into adulthood. Conduct disorder should be sus- pected when a child is committing serious violations of the rights of others, such as stealing, initiating fights, using a weapon to threaten others, destroying property, or running away from home.

Successful management of ODD and conduct disorder re- quires motivating authority figures in a child’s environment to make changes in how they interact with the child. The tra- ditional one-on-one psychotherapy approach rarely will be sufficient. Behavior management training is the best overall treatment strategy for both ODD and conduct disorder. There are many types of behavior management training, but they all share a focus on coaching parents and caregivers to set better limits and expectations for the child and a focus on the child and parents regularly spending positive times together, thus providing opportunities for the child to experience praise. Historically, this approach was referred to as parent training, but we think that term should be discarded for un- necessarily assigning fault to the parents, which reduces the therapeutic alliance and motivation for change. The more se- vere the symptoms, the more community inclusive the be- havior management approach should be, such as how multisystemic therapy also engages nonparental authority figures in the community for patients with conduct disorder.

Medications are generally not the preferred treatment for disruptive or aggressive behavior. However, if the child has a specific DSM-5 diagnosis that is known to be medication re- sponsive, such as ADHD or major depressive disorder, then medication treatment typically will improve disruptive or ag- gressive behavior. No medications are indicated for the treat- ment of ODD or conduct disorder, whose best treatment is via coaching and supporting the child’s authority figures. If a dis- ruptive or aggressive problem is considered to be highly im- pairing and other appropriate interventions have been tried and have failed, then a nonspecific medication to diminish mal- adaptive or impulsive aggression may be considered. If this is done, we would recommend a clonidine or guanfacine trial first because if they are helpful, their use presents few long- term medical risks. Second-generation antipsychotics such as risperidone may be effective in reducing aggression, but anti- psychotics have more significant adverse effects and should be reserved for the most severe scenarios (Loy et al. 2012).

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32 DSM-5 Pocket Guide for Child and Adolescent Mental Health

Withdrawn or Sad Mood

When a young person presents as withdrawn or sad (Table 3– 4), we always assess for the presence of a major depressive episode. Two or more weeks of depressed or irritable mood, along with multiple neurovegetative symptoms (decreased energy, concentration, interest, or physical activity; thoughts of self-harm; changes in appetite or sleep; and feelings of guilt or worthlessness), would suggest a major depressive episode. In contrast, persistent depressive disorder (dysthy- mia) is essentially a low-grade depression that has been pres- ent for more than a year in a child, without relief for more than 2 months during that time. If the sad mood was trig- gered by a stressful event within the past 3 months and nei- ther major depression nor dysthymia is diagnosable, an adjustment disorder with depressed mood may be present.

Regardless of whether a withdrawn or sad child has an active mood disorder, routinely asking about self-harm risks is important. Adolescents may see even a single disappoint- ment—such as a relationship breakup—as so catastrophic that they feel suicidal or begin to hurt themselves. This means that as practitioners we must ask about suicidal thoughts and self-harm urges even if we believe that a young person is experiencing only a time-limited adjustment disor- der. With practice, we find that asking about suicidality and self-harm comes as naturally as asking any other question. It helps to keep in mind that asking about suicidal thoughts does not create a risk of self-harm. Instead, it reduces risks by showing you care.

Although medically induced depression is uncommon in a young person, all practitioners must be alert to the possibil- ity. For instance, testing for hypothyroidism is reasonable if a patient experienced physical symptoms such as fatigue be- fore mood changes developed. Because anemia is a common problem in young people, a complete blood count should be considered to assess its presence in a patient who is fatigued. Iatrogenic origins of depression should be considered as well, such as when a child starting -blockers or isotretinoin subsequently experiences dysphoria.

Recurrent substance abuse can cause an adolescent to ap- pear depressed. Because we find that adolescents typically assert that they see their substance use as helping their mood, establishing a timeline of what came first may help you con-

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Common Clinical Concerns 33

TABLE 3–4. Withdrawn or sad mood

Diagnostic category Suggested screening questions

First consider

Abuse “Has anything or anyone made you feel uncomfortable or unsafe?”

(for caregiver) “Has anything happened to your child that really shouldn’t have happened?”

Bullying “Have other kids been teasing you or making you feel afraid?”

Medical conditions (anemia, hypothyroidism)

“Did all of your symptoms seem to start with fatigue?”

Self-harm “Have you been thinking about hurting yourself? Have you ever hurt yourself or attempted suicide? Do you have any plans to hurt yourself?”

Common diagnostic possibilities

Adjustment disorder with depressed mood

“Did your sad or down mood start right after a stressful event in the past few months?”

Bipolar disorder “Has there ever been a period of multiple days in a row when you were the opposite of depressed, with very high energy and little need for sleep? If so, can you tell me more about that time?”

Persistent depressive disorder (dysthymia)

“Have you been sad or gloomy most days of the week for more than a year?”

Major depressive disorder

“Have you felt really down, depressed, or uninterested in things you used to enjoy for more than 2 weeks?”

Substance use disorder

“Have you been using drugs or alcohol?”

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34 DSM-5 Pocket Guide for Child and Adolescent Mental Health

vince your patient to discontinue the substance at least tem- porarily and find out how she feels after a few weeks of being substance free.

Bipolar disorder is relatively uncommon in children but should be considered. To detect the possibility of bipolar de- pression, we ask caregivers if the child has ever had a history of discrete mood elevation and energy increase of multiple days’ duration with accompanying manic symptoms (e.g., racing thoughts or speech, unusual risk taking, and de- creased need for sleep). Notably, the presence of an irritable mood is not a reliable indicator of bipolar disorder in chil- dren. If you suspect that a young person with a withdrawn or sad mood has bipolar disorder, monotherapy with antide- pressants should be avoided because of their risk for induc- ing a manic episode.

Every child with a moderate to severe depressive disorder should be referred for an evidence-based psychotherapy, such as cognitive-behavioral therapy (CBT) or interpersonal ther- apy. Because the level of family motivation to use psychother- apy is a common problem, we often address this up front by informing families that psychotherapy is the most effective strategy available to reduce the risks of suicidality. Caregivers of a young person can also take the safety steps of restricting impulsive access to firearms and dangerous pills and main- taining increased awareness and monitoring. In the presence of active suicide plans or the inability to maintain immediate safety, practitioners should consider admission to a crisis sta- bilization unit, day treatment program, or psychiatric inpa- tient treatment. Families also can help the child by promoting “behavioral activation” treatment for depression at home through scheduling desirable exercise and social activities.

The current view on selective serotonin reuptake inhibi- tor (SSRI) use for depression is that some young patients might experience an increase in suicidal thoughts during the first few months of SSRI use, but most do not, and overall, the benefits of use outweigh potential risks for a moderate to se- vere depression. A prudent practitioner will warn patients about the possible risk, stay connected with patients and the patient’s caregivers after the initial prescription to inquire specifically about increased irritability or suicidal thoughts at least twice in the first month of use, and strongly consider stopping the medication should increased irritability or sui- cidality occur (Bridge et al. 2007).

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Because of its large research evidence base indicating benefits in young people, fluoxetine is widely considered the first-line choice for adolescent major depressive disorder. Second-line SSRI choices based on the evidence include ser- traline and escitalopram or citalopram. Usual adolescent de- pression starting doses are 10 mg for fluoxetine, 25–50 mg for sertraline, 10 mg for citalopram, and 5 mg for escitalopram; about half of these amounts are used in preadolescents. Doses should be increased after 4–6 weeks if the medications are well tolerated but have insufficient benefits. SSRIs are most effective when used in combination with psychotherapy, which is another reason to promote the family’s engagement with psychotherapy. Persistent depressive disorder (dysthy- mia) would be treated with the same medications but is nota- bly slower to respond (McVoy and Findling 2013).

Irritable or Labile Mood

A young person may experience an irritable or labile mood for several reasons (Table 3–5). Several mental disorders— bipolar disorders, depressive disorders, anxiety disorders, PTSD, and ODD—should be considered because irritability can be a symptom of a mental disorder. It also can be a symp- tom of substance abuse, a reaction to challenging life situa- tions or maltreatment, or a normal variation in mood. When irritability is the primary complaint, we counsel a broad search for clues as to “why.”

Unfortunately, there has been a major misdiagnosis prob- lem during the past two decades because chronically irritable, labile moods in children were being interpreted as being pathognomonic of a childhood bipolar disorder. This was usu- ally incorrect, in that few (if any) chronically irritable children were later found to have bipolar disorder as young adults (Birmaher et al. 2014). Unless a child has multiday duration manic symptoms occurring during a discrete episode that rep- resents a break from baseline functioning, we counsel against diagnosing bipolar disorder in children and adolescents.

In part because of this perceived need to have a diagnosis that better characterizes children with life dysfunction be- cause of chronically irritable moods, a new diagnosis was created. Disruptive mood dysregulation disorder is a new DSM-5 diagnosis for children who have more than a year of

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TABLE 3–5. Irritable or labile mood

Diagnostic category Suggested screening questions

First consider

Abuse “Has anything or anyone made you feel uncomfortable or unsafe?”

(for caregiver) “Has anything happened to your child that really shouldn’t have happened?”

Substance abuse “Have you been using drugs or alcohol?”

Suicidality “Have you had thoughts about hurting yourself?”

Common diagnostic possibilities

Bipolar disorder “Has there ever been a period of multiple days in a row when you were the opposite of depressed, with super high energy and little need for sleep? If so, can you tell me more about that time?”

Disruptive mood dysregulation disorder

(for caregiver) “Has your child had severe and persistent irritability along with frequent temper outbursts?”

Major depressive disorder

“Have you felt really down, depressed, or uninterested in things you used to enjoy for more than 2 weeks?”

Oppositional defiant disorder

(for caregiver) “Has your child been unusually defiant and oppositional for more than 6 months?”

Posttraumatic stress disorder

(for caregiver) “Does the irritability or moodiness worsen after reminders or memories of past trauma?”

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significant daily dysphoric mood symptoms and temper out- bursts three or more times a week that are not better ex- plained by other conditions. However, this is a new diagnosis, so we know very little about prognosis or best treatments (Roy et al. 2014). Practically speaking, we believe disruptive mood dysregulation disorder could be considered as a variant of ODD in which mood symptoms predominate.

Even if a young person’s irritability cannot ultimately be traced to a specific DSM-5 diagnosis with a known treatment, a generalized approach to managing irritable moods can still be helpful. We recommend enhancing family supports and providing behavior management training as appropriate for most types of irritable mood care. Creating calm, consistent, and caring limits and expectations within the household will typically improve behavior problems and irritability from a wide variety of causes.

Families with significant internal conflict can benefit from family therapy or from caregivers seeking their own individ- ual supports. You may be able to motivate parents who re- port feeling exasperated with a child by using a “put your own mask on first” analogy, as with airline travel. An unnur- tured parent who receives individual supports or profes- sional help may greatly improve interactions with her child. For those children who are found to lack positive experiences with their caregivers, creating opportunities for praise and positive attention is a key to treatment success.

One-on-one counseling therapy is indicated for all mood disorders and anxiety-related conditions (including PTSD) with an irritability component. Medication is never indicated for irritable mood without a specific diagnosis.

Anxious or Avoidant Behavior

When a child is struggling with being worried or anxious, we first check if something in a child’s world is directly causing this feeling. Anxiety from being bullied, from experiencing a major traumatic event, or from living in an abusive house- hold should appropriately generate self-protective avoidance behaviors. Only after we know that no realistic threat to the child exists and have determined that the child’s anxiety causes significant life dysfunction do we consider an anxiety disorder diagnosis (Table 3–6).

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TABLE 3–6. Anxious or avoidant behavior

Diagnostic category Suggested screening questions

First consider

Abuse “Has anything or anyone made you feel uncomfortable or unsafe?”

(for caregiver) “Has anything happened to your child that really shouldn’t have happened?”

Bullying “Have other kids been teasing you or making you feel afraid?”

Trauma “Have you been hurt recently or been in any accidents?”

Self-harm “When you feel overwhelmed, do you think about hurting yourself?”

Common diagnostic possibilities

Generalized anxiety disorder

“Do you feel tense, restless, or worried most of the time? Do these worries affect your sleep or performance at school?”

Obsessive- compulsive disorder

“Do you frequently have unwanted thoughts, images, or urges in your mind? Do you check or clean things to avoid those unwanted thoughts?”

Panic disorder

“Do you get sudden surges of fear that make your body feel shaky or your heart race? Do you change what you do in order to avoid having a panic experience?”

Posttraumatic stress disorder

“Do you startle easily or have frequent nightmares? Do you avoid reminders of traumatic events in your past?”

(for caregiver) “Does the irritability or moodiness worsen after reminders or memories of past trauma?”

Separation anxiety disorder

“Is it hard to leave your house or hard to leave your mom or dad because of worries?”

Specific phobia

“Is there something in particular or a situation that makes you immediately afraid?”

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Children have worries during the course of their normal development, such as fears of strangers, separation, injury, or failure. Learning how to cope with anxious feelings by facing them directly is an important developmental task that, once mastered, enables future achievements. Parental anxiety may interfere with this process if it reinforces a child’s fears or en- courages avoidance behavior. For instance, inadvertent pa- rental reinforcement of normal separation anxiety may turn this problem into a disorder unless the parent is taught more helpful strategies.

Children who feel anxious often struggle to find words to express how they feel. A child reporting stomachaches, nau- sea, chest pain, fatigue, or headaches may be functionally dis- closing that she feels anxious, but through a biological mechanism such as autonomic nerves altering intestinal motil- ity or arterial smooth muscle tone. In fact, the chief complaint of children and adolescents seeking mental health treatment in primary care settings often will be a physical ailment. When listening alertly for any meaning behind a physical ailment, practitioners should think about timing. Severe stomach cramps before attending school or headaches before perform- ing in a sporting event will help identify anxiety disorders.

Common anxiety disorders for children include GAD, panic disorder, specific phobia, and separation anxiety disor- der. These conditions could appear in a developmental trajec- tory, such as separation anxiety disorder during the elementary school years being replaced by specific phobias in middle school and then a GAD in the adolescent years. For some children, their anxiety trait persists, but the expressed form of that anxiety varies over time. Isolated panic attacks are a short-term anxiety symptom that may appear with other disorders such as depression. Panic disorder is differ- ent, involving a disabling fear of experiencing future panic episodes.

Anxiety disorders commonly run in families; thus, when a child is given an anxiety disorder diagnosis, either or both parents likely have struggled with anxiety disorders them- selves. This familial tendency can occur through shared ge- netic traits, through children absorbing the anxious sentiments a parent generates within the household, or both. In some situations, the most effective way to help an anxious child is to help her parent to more effectively manage her own anxiety and thus create a more stable and supportive home environment for the child.

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Strategies shown to be effective for anxiety treatment in children include different forms of psychotherapy in which exposure to feared thoughts or ideas is their most common el- ement (Chorpita and Daleiden 2009). Repeated exposure to feared situations or memories that do not have any negative consequences, through repetition and reframing, will help the child’s mind to unlearn that fear. However, if that fear is still a “real” one, such as a traumatized child at risk for future abuse, then psychotherapy alone will not be as beneficial un- til the child’s safety is secured. CBT is the most commonly available modality for anxiety treatment that uses exposure.

Parents also must challenge or restrict the avoidance be- haviors in their child because avoidance of a feared situation leads to a temporary relief of anxiety that over time reinforces the fear and worsens the severity of the anxiety. For instance, a fear of attending school becomes stronger if the child is al- lowed to repeatedly skip school. SSRIs, including sertraline and fluoxetine, have been shown in multiple studies to be ef- fective in treating different forms of childhood anxiety disor- ders and are most effective when used in combination with psychotherapy (Mohatt et al. 2014).

OCD and PTSD are anxiety-related diagnoses that are now listed in their own sections of DSM-5: “Obsessive-Compulsive and Related Disorders” (which includes hoarding disorder and trichotillomania) and “Trauma- and Stressor-Related Disorders” (which includes acute stress and adjustment dis- orders). OCD responds very well to the same first-line thera- pies as used for other anxiety disorders: CBT and SSRIs. PTSD has been found to respond well to exposure-based therapies such as trauma-focused CBT, but its response to medications in children is not so well established.

Recurrent and Excessive Physical Complaints

Primary care practitioners know that recurrent headaches, chest pain, nausea, and fatigue are the presenting concern in about 10% of all office visits by adolescents, and recurrent ab- dominal pain alone is the presenting concern for about 5% of all pediatric office visits (Silber 2011). Although these somatic complaints may have many etiologies, the most common eti- ologies are psychiatric. Knowing this, whenever we hear a psychosomatic complaint, we consider whether anxiety disor-

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ders, depressive disorders, or adjustment disorders are the cause. Treatments for anxiety and depression are both effec- tive and straightforward. The treatments for somatic disorders (somatic symptom disorder, factitious disorder, conversion disorder) are more challenging, so we consider them after rul- ing out anxiety and depressive disorders (Table 3–7).

We do not, however, favor considering somatic disorders only after excluding all possible causes for somatic complaints. Contemporary medicine overvalues biological explanations for somatic symptoms and usually leaves other explanations, including psychiatric etiologies, as diagnoses of exclusion. The unfortunate effects of a medical-before-psychiatric ap- proach are that

• Mental illness may go unrecognized. • Patients and parents may react poorly to hearing an “it is

all in your head” explanation after multiple investigations and appointments.

• Families may try to prove that symptoms are “real” and insist on inappropriate tests or procedures.

• Acceptance of psychiatric care or forms of appropriate functional assistance may be decreased.

To counteract these pitfalls, we recommend describing psy- chiatric etiologies to families when presenting your initial so- matic symptom differential diagnosis and then openly discussing them throughout. You can do this by describing what you think are the most likely psychobiological pathways for somatic symptoms. For instance, you can explain how stress affects the autonomic nervous system, which can lower gastric pH and alter intestinal motility (for nausea and abdominal pain) or can alter blood vessel smooth muscle tone (for headaches). By offering a biological account for physical symptoms of a mental illness, you will help patients and their caregivers more readily accept psychiatric interventions such as CBT and relaxation therapy because you have taught them that psychiatric inter- vention can modify autonomic nervous system functioning.

Children with somatic symptom disorders usually lack awareness that stress or anxiety is linked to their physical ex- periences or may lack an ability to adequately use words to describe their emotional states (referred to as alexithymia). The classic childhood pattern is that somatic symptoms increase before stressful experiences, such as attending school, visit- ing someone else’s home, or performing publicly, whereas

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TABLE 3–7. Recurrent and excessive physical complaints

Diagnostic category Suggested screening questions

First consider

Abuse or maltreatment

“Has anything or anyone made you feel uncomfortable or unsafe?”

(for caregiver) “Has anything happened to your child that really shouldn’t have happened?”

Adjustment disorder

“Was there something stressful in the past 3 months that happened right before these symptoms appeared?”

Anxiety disorders

(for caregiver) “Does your child have a lot of worries that cause distress?”

Depressive disorders

(for caregiver) “Has your child’s mood been unusually down or low for more than a couple of weeks?”

Other diagnostic possibilities

Conversion disorder

For practitioner: consider when you identify a loss of motor or sensory function that is inconsistent with recognized disorders.

Factitious disorder imposed on self

(for caregiver—asked away from the child) “Do you suspect your child may be intentionally exaggerating symptoms?”

Factitious disorder imposed on another

For practitioner: consider when parent has pattern of reporting symptoms in her child inconsistent with recognized disorders.

Panic attacks “Do you experience sudden surges of fear that make your body feel shaky or your heart race?”

Somatic symptom disorder

(for caregiver) “Does your child have recurrent physical symptoms that disrupt his or her daily life? Does your child have an excessive focus on his or her physical symptoms?”

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the somatic symptoms decrease if stressful situations are avoided. Specifically experienced symptoms may change over time, in that a child with recurrent abdominal pain early in life may develop recurrent headaches and fatigue as a teenager.

In the case of a conversion disorder with prominent un- usual motor problems (such as paralysis of only one shoul- der) or sensory problems (such as a loss of all feeling in the legs with normal reflexes), we similarly find it important to help the child exit her presentation without accusing her of having biologically “false” symptoms. For instance, you can explain to a patient that your examination identified no ma- jor medical difficulties but that in your experience other young people with similar symptoms experienced a fairly rapid resolution. A face-saving explanation such as “I believe that in a short time your nerves will simply reset themselves, like how the seasons change” may be particularly helpful. Success- fully responding to conversion symptoms relies as much on the art of medicine as on the science of medicine.

A young person also may intentionally falsify symptoms to malinger when there is a clear secondary gain or as part of a factitious disorder. Detecting a case of factitious disorder imposed on another requires a practitioner to mentally shift his or her thinking to consider this possibility because it is difficult to accept that a caregiver might misrepresent, simu- late, or cause signs of illness in her children. Suspected cases of factitious disorder are best managed by all of a patient’s practitioners communicating directly with one another about their concerns, consulting local experts in this topic, and then arriving at a unified rather than divided approach to helping the child.

Sleep Problems

Sleep problems are very common, present in 5%–20% of chil- dren (Meltzer et al. 2010). Most childhood insomnia can be traced to poor sleep habits and inadequate enforcement of bedtime habits by caregivers. The contemporary incorpora- tion of electronics into every aspect of daily life means that it is no longer sufficient for practitioners to simply recommend no television in the bedroom of a child with insomnia. Cell phones have effectively become sleep prevention devices

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through the applications, text messaging, and games they bring into the bedroom. Restricting all computer access and video game use after a certain time in the evening can yield a dramatic improvement in the amount of sleep that children (and their caregivers!) get.

Another key sleep hygiene problem is a loss of the behav- ioral association that being in bed equals sleep time. Behav- ioral routines around going to bed help signal to the brain when it is time to disconnect. Doing homework in bed, eat- ing in bed, playing in bed, and communicating with friends from bed break that behavioral association. For those with insomnia, the act of lying awake in bed for a long time, star- ing at the clock, and waiting for sleep can become another sleep-interfering behavior. If sleep does not come quickly, the behavioral association of bed equals sleep is improved by getting out of the bed for a nonelectronic “quiet and boring” activity such as sitting in a chair to read and returning to bed only when feeling sleepy. A list of sleep hygiene practices ap- pears in Chapter 14, “Psychosocial Interventions.”

Sleep is also impaired by distracting thoughts, worries, or symptoms of many different DSM-5 conditions (Table 3–8). Addressing problems such as maltreatment, PTSD, anxiety, and mood disorders can significantly improve sleep. In some cases, insomnia worsens or perpetuates a mood disorder to such a degree that using a medication for the restoration of adequate sleep can be a way to help resolve that mood disor- der more quickly.

Reasonable bedtimes may be a sticking point worth ad- dressing. Caregivers cannot expect adolescents to fall asleep at 8:00 P.M. every night, even though that may be a reasonable expectation for younger children. For children with long-term sleep phase advancement problems, such as rarely falling asleep before 3:00 A.M., changing bedtimes too quickly does not work because it takes weeks to retrain the circadian rhythm and behavioral associations with sleep.

Obstructive sleep apnea also can have negative psychiatric effects; thus, when apnea is found in a (typically obese) child through polysomnography, a sleep apnea treatment also may improve other psychiatric symptoms. When the tonsils are large, a simple tonsillectomy or adenoidectomy may be help- ful. Any more extensive surgical intervention on the palate or pharynx of a growing child should be viewed with much greater skepticism because of higher rates of complications.

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Continuous positive airway pressure (CPAP) systems can be effective and safe for sleep apnea treatment, but it is typically quite difficult to get a child to actually use a CPAP machine ev- ery night—far more often, these systems are purchased but not used. Notably, with severe sleep apnea, potent sedatives such as benzodiazepines at night would not be recommended.

Parents and patients often ask for a prescribed medica- tion to help with sleep. The challenges of this strategy include limitations in effectiveness, creating psychological associa- tions that one cannot sleep without a pill, physiological de-

TABLE 3–8. Sleep problems

Diagnostic category Suggested screening questions

First consider

Abuse “Has anything or anyone made you feel uncomfortable or unsafe?”

(for caregiver) “Has anything happened to your child that really shouldn’t have happened?”

Bullying “Have other kids been teasing you or making you feel afraid?”

Poor sleep habits

“What is your routine before going to bed? What do you do when you cannot sleep?”

Common diagnostic possibilities

Generalized anxiety disorder

“Do you feel tense, restless, or worried most of the time? Do these worries keep you awake?”

Insomnia disorder

“Have you had difficulty with sleep 3 or more nights a week for at least the past 3 months?”

Major depressive disorder

“Have you felt really down, depressed, or uninterested in things you used to enjoy for more than 2 weeks?”

Posttraumatic stress disorder

“Do you avoid reminders of traumatic events in your past? Do you startle easily or get frequent nightmares?”

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pendence or tolerance, and exposure to unwanted adverse effects. After sleep hygiene measures fail, for moderate to se- vere insomnia we consider a medication. The core principle should be to favor nonaddictive, safe, and low–side effect sedative options with children. The secondary principle is that if a child has insomnia plus another psychiatric disorder, selecting a medication that can address both conditions at once is preferred to using multiple medications.

Antihistamines are a reasonable first-line option because of their safety profile. Melatonin, up to 5 mg nightly, is considered generally safe, but at least theoretical concerns exist for the neg- ative effects it may have on other hormone systems. More po- tent sedative options include the -agonists (clonidine, guanfacine), which, when administered nightly, could help with sleep in addition to other conditions such as ADHD. Anxiety that continues to cause insomnia despite the use of SSRIs and CBT may benefit from hydroxyzine as a nonaddictive option or an off-label trial of a sedating antidepressant such as mirtazap- ine. In severe cases, a low dose of a benzodiazepine or an off- label benzodiazepine analogue (zolpidem, zaleplon) might be necessary to achieve results. For children requiring an antipsy- chotic to treat their psychiatric disorder, a sedating option such as quetiapine or risperidone taken at bedtime may improve the comorbid insomnia. Use of an antipsychotic solely as a sleep aid is inappropriate and unsafe (McVoy and Findling 2013).

Self-Harm and Suicidality

Suicidality and self-harm behaviors are very common among adolescents, more common than most of us realize (Table 3–9). In research surveys, 14%–24% of adolescents self-reported that they have committed an act of self-harm, and about 6%–7% stated that they have made a suicide at- tempt in the previous year (Lewis and Heath 2015). Thank- fully, completed suicides are far more rare than the number of suicide attempts. You are more likely to get full and honest answers about suicidality and substance abuse when inter- viewing a young person away from his or her caregivers, so ask for privacy before you ask about self-harm.

Asking young people if they feel suicidal can be awkward until you become accustomed to asking about it. Despite the awkward feelings, these questions cannot be avoided. Be-

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TABLE 3–9. Self-harm and suicidality

Diagnostic category Suggested screening questions

First consider

Risk acuitya “Have you ever thought about hurting yourself or taking your own life? Have you ever done something to hurt yourself or tried to kill yourself? Do you have any plans now for how you would kill yourself?”

Current triggersa

“Do you have any recent relationship problems or big disappointments?”

Current supportsa

“Do you have anyone in your life who helps support you?”

Access to lethal meansa

“Can you easily get a gun or enough pills that you think could kill you?”

Common diagnostic possibilities

Bipolar disorder

“Has there ever been a period of a week or more when you were the opposite of depressed, with super high energy and little need for sleep?”

Persistent depressive disorder (dysthymia)

“Have you felt persistently sad or gloomy for more than a year?”

Major depressive disorder

“Have you felt really down, depressed, or uninterested in things you used to enjoy for more than 2 weeks?”

Substance use disordera

“Have you been using drugs or alcohol?”

aThese questions should be asked when the patient is alone.

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cause suicide is one of the three leading causes of death among the young, asking a young person about feelings of suicide is just as important as screening an adult for chest pain or shortness of breath.

If you fear that asking about suicide creates risks, allow us to put your mind at ease. Asking about suicidal thoughts, plans, and past actions not only gathers essential diagnostic information but also shows your concern. For a self-harming or suicidal young person, having an adult in her life who communicates that she cares about her is therapeutic.

When asking about suicidality, we suggest starting with broad questions, then getting specific. Asking “Have you ever. . .” risk questions before “How about now.. .” questions just flows better conversationally. If you uncover self-harming or suicidal behaviors, continuing to ask questions about pre- vious suicidal behaviors (the strongest predictor of future be- havior), current self-harm plans, and current stressors is key to being able to understand the immediacy of any risks. If you learn that the adolescent tried to avoid premature discovery of a suicide attempt, such as hiding emptied pill bottles, this would be very concerning. Easy, impulsive access to lethal means, such as a loaded firearm, is another major risk factor.

Recurrent self-harm behaviors, such as cutting, are often cited by young people themselves as a coping mechanism that they perform in part to reduce their risk of suicide. How- ever, recurrent self-harm increases the risk for future suicidal behaviors.

The strongest predictors of a future suicide completion are a history of suicide attempts, an active mood disorder, current substance abuse, and a family history of suicidal behavior. For adolescents in particular, suicide attempts are often triggered after an acute loss or disappointment, such as breakup with a boyfriend or girlfriend or an acute family conflict. Nearly 90% of adolescent suicide deaths occur from firearms or suffoca- tion, which includes hanging, so suicidal plans involving these strategies are the most concerning (Eaton et al. 2008). Suicide attempts by overdose are much more common but are also much less likely to be lethal.

After learning both the general and the specific details of the situation, we suggest keeping in mind a prudent layper- son standard for when to consider an acute hospitalization. Child mental health specialists are not really much better than anyone else would be in assessing risks once all the de- tails of the situation are known. The difference is that child

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mental health specialists excel at eliciting the details of a sit- uation. The key is to keep asking for more information to flesh out the whole situation rather than stopping your inqui- ries at “they said they feel suicidal.” You should consider hospitalization for any young person who appears to have a significant safety risk after you elicit the details of the situa- tion. Psychiatric hospitalization keeps a patient physically safe for at least a short time while initiating further steps in her care.

Young people with recurrent self-harm behavior or sig- nificant suicidal thoughts should be referred for psychother- apy because this is clearly the most effective treatment available. If a family declines to use counseling with a mental health professional, you can also encourage the use of as many other social supports and supervision arrangements as possible.

Medications do not have a significant role in reducing suicide or self-harm risks on a short-term basis. However, if a child has major depressive disorder or an anxiety disorder, then long-term suicide risks can be reduced through success- ful treatment with SSRIs. See Chapter 15, “Psychotherapeutic Interventions,” for more information about SSRI use and sui- cidality. For a severe depression, the greatest treatment re- sponses occur when SSRIs are combined with psychotherapy. Frequent monitoring and making the environment safe (i.e., restricting access to dangerous medications and firearms) are advised for all suicidal young people.

Substance Abuse

The key to making any diagnosis is thinking of the possibil- ity, which can be a challenge when it comes to adolescent substance abuse (Table 3–10). When we see fresh-faced, youthful adolescents in our offices, we can find it hard to si- multaneously view them as possible substance abusers. The available statistics dictate that we do so. In the United States alone, national surveys show that past-month adolescent al- cohol use rates in the United States are about 9% of 14 – to 15- year-olds and 23% of 16- to 17-year-olds, and for marijuana, about 7% of 12- to 17-year-olds report past-month use. Co- caine, hallucinogens, and inhalants are also abused by ado- lescents but at rates of less than 1% (Substance Abuse and Mental Health Services Administration 2014).

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Recognition starts with remembering to ask about sub- stance use and ideally doing so without a parent in the room. We prefer to ask parents to leave the room for this aspect of the encounter and openly reemphasize applicable confidentiality rules during the separation process. Generally, everyone will understand the concept of maintaining confidentiality unless

TABLE 3–10. Substance abuse

Diagnostic category Suggested screening questions

First consider

Safetya “Have you ever been in a car driven by someone who was drunk or high? Have you injured yourself while you were drunk or high? Have you blacked out or done things you regret while drunk or high?”

Common diagnostic possibilities

Substance use disordera

“Have people asked you to cut down on drinking or using drugs? Do you ever drink or use drugs when you are alone? Do you get strong cravings or end up using more than you wanted to?”

Substance withdrawal

“Do you get more moody or anxious while your alcohol or drugs are wearing off?”

Substance tolerance

“Has the same amount of drug or alcohol been losing its effect over time?”

Substance/ medication- induced mental disorder

“Did you develop more mood or anxiety problems after you started using?”

“Self- medication” role of substances

“Are there any problems that you wanted the alcohol or drugs to resolve?”

aThese questions should be asked when the patient is alone.

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Common Clinical Concerns 51

a major safety risk exists, such as having blackouts or driving while intoxicated. This same one-on-one time can be used to discuss other sensitive topics such as self-harm and suicidality.

A widely recommended screening tool for adolescents is the CRAFFT (Figure 3–1), which the American Academy of Pediatrics recommends using during adolescent health maintenance appointments (Yuma-Guerrero et al. 2012). If two or more question answers are positive, there is a high chance of a substance use disorder being present (Knight et al. 2002).

Urine drug testing may help to evaluate the cause of an acute intoxication or may be used for tracking care within a specialized substance abuse treatment program. However, we do not otherwise recommend urine drug testing as a part of routine care because it can unnecessarily diminish the ther- apeutic alliance.

In the past, the emphasis was on needing to determine whether a patient’s substance use represented abuse or de- pendence. Because this differentiation was often unclear and carried both stigma and legal ramifications, these separate dependence and abuse diagnoses were merged into a single substance use disorder diagnosis in DSM-5. The hallmarks of a substance use disorder include loss of control over one’s use, social impairments, use in risky situations or despite negative consequences, and physiological changes of toler- ance or withdrawal. In other words, not all adolescents who use substances have a disorder.

You should be alert to symptoms caused by substance abuse that look like another psychiatric illness. Sedative drugs (hyp- notics, anxiolytics, and alcohol) can cause depression during in- toxication but anxiety during withdrawal. Stimulating drugs (amphetamines, cocaine) can cause psychosis and anxiety dur- ing intoxication but depression during withdrawal. Both drug classes cause sexual and sleep disturbances. Psychotic symp- toms may occur from anticholinergics, cardiovascular drugs, steroids, stimulants, and depressants. Marijuana can cause de- pressed mood and anxiety, even though adolescents claim that it treats their depression or anxiety. In an adolescent vulnerable to psychosis, marijuana can trigger persisting psychotic symp- toms (van Nierop and Janssens 2013).

When substance-created psychiatric symptoms are possi- ble, we motivate the adolescent to do a self-test of not using for a specific period of time (e.g., at least 2 weeks) to see what happens. Most substance-induced mental disorders will im-

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FIGURE 3–1. The CRAFFT Screening Interview. Source. © John R. Knight, MD, Boston Children’s Hospital, 2015. All rights reserved. Reproduced with permission. For more information, contact ceasar@childrens.harvard.edu.

Begin: “I’m going to ask you a few questions that I ask all my patients. Please be honest. I will keep your answers confidential.”

Part A

During the PAST 12 MONTHS, did you: No Yes 1. Drink any alcohol (more than a few sips)?

(Do not count a few sips of alcohol taken during family or religious events)

2. Smoke any marijuana or hashish?

3. Use anything else to get high? (“anything else” includes illegal drugs, synthetic marijuana, over-the-counter and prescription drugs, or things that people sniff or “huff”)

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53 FIGURE 3–1. The CRAFFT Screening Interview. (continued)

For clinic use only: Did the patient answer “yes” to any questions in Part A? No Yes

Ask CAR question only, then stop Ask all 6 CRAFFT questions

Part B

1. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

3. Do you ever use alcohol or drugs while you are by yourself, or ALONE? 4. Do you ever FORGET things you did while using alcohol or drugs? 5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?

6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?

*Two or more YES answers on the CRAFFT suggest a serious problem and need for further assessment.

Yes No

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54 DSM-5 Pocket Guide for Child and Adolescent Mental Health

prove after a few weeks of abstinence. For adolescents who say “I can stop whenever I want to,” we would follow this statement by empowering them to do just that for the reasons that make the most sense to them. This does two things: 1) it determines whether their symptoms really are substance in- duced, and 2) if they cannot go more than 2 weeks without using, then it highlights their lack control over their use.

Care of a substance use disorder is based on educating adolescents about the negative outcomes from use, helping them learn their triggers and motivating reasons to use, building motivation for change, and shaping family involve- ment in resolving the problem. Motivational interviewing, CBT, family therapy, supervised peer groups, mindfulness training, identifying triggers (to avoid future cue-based use), changing peer groups, and arranging for rewards for evi- dence of sobriety are all specific outpatient care options.

Disturbed Eating

Eating disorders such as anorexia and bulimia can present a di- agnostic challenge in that young people who have become sig- nificantly ill with an eating disorder generally try to hide their symptoms, even when asked directly by a trusted person (Ta- ble 3–11). With low-weight anorexia nervosa particular, with- holding information or even lying to practitioners often happens in the service of maintaining disordered eating. Ther- apists sometimes refer to these lies as the eating disorder, rather than the patient herself, doing the talking. Because of this inconsistency, collateral informants (i.e., parents and other caregivers) are typically very helpful for understanding the ex- tent of symptoms and behaviors. An investigative approach helps. When you learn that a young person who denies self-in- duced vomiting goes to the bathroom immediately after most of her meals, you should explore the possibility of disturbed eating and body image. Remember that young people with eating disorders often show rigid thinking and perfectionism.

Postpartum Maternal Mental Health

Maternal peripartum depression is common, even more so in developing countries (about 1 in 5) than in developed coun- tries (about 1 in 10) (Paschetta et al. 2014). The risk that the

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Common Clinical Concerns 55

mother of a newborn will experience depression increases with stressors such as poverty, lack of partner support, un- wanted pregnancy, and domestic violence. When a woman has depressive symptoms during her pregnancy, the chances that she will develop postpartum depression increase, so we counsel increased vigilance for these parents.

Postdelivery obstetric care for mothers and the first year of health maintenance care for children ideally include some

TABLE 3–11. Disturbed eating

Diagnostic category Suggested screening questions

First consider

Medically induced weight loss

“Have you had recurring diarrhea?” (inflammatory bowel disease) Have you been losing weight despite wanting to maintain?” (endocrine disorder/ malignancy)

Self-harma “Have you been thinking about hurting yourself? Have you ever hurt yourself or attempted suicide?”

Common diagnostic possibilities

Anorexia nervosa

“Do you worry about losing control when you eat? Do you prefer to eat alone?” (on growth curve: an unexpected loss of weight or failure to gain appropriately)

Bulimia nervosa

“Have you had recurring times when you overeat and then feel the need to compensate afterward? Do you use laxatives or vomit after meals?”

Major depressive disorder

“Have you felt really down, depressed, or uninterested in things you used to enjoy for more than 2 weeks?”

Substance use disordera

“Have you been using drugs or alcohol?”

aThese questions should be asked when the patient is alone.

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56 DSM-5 Pocket Guide for Child and Adolescent Mental Health

form of screening for maternal depressive and anxiety prob- lems (Table 3–12). You can accomplish this by conversation- ally asking the mother about her psychological well-being (which helps to communicate its importance) and can sup- plement this approach with a brief rating scale screen (such as the Patient Health Questionnaire 9-item or Generalized Anxiety Disorder 7-item scale) in routine office care. Fatigue and poor sleep, which are often associated with parenthood itself, need to be recognized as potential signs of an episode of major depressive disorder.

Good parental mental health is important for children. When parents struggle, there can be negative effects on the child’s physical state (poor health, poor weight gain), cogni- tive status (delayed acquisition of milestones, impaired at- tention), social development (ODD, conduct problems), behavior (more crying, irritability, and temperament chal- lenges), and emotional development (depression, anxiety) (Satyanarayana et al. 2011). In rare instances, a parental men- tal health condition can become so severe, such as developing psychosis, that a parent will actually harm her child.

Treating parental mental health problems during a child’s early development phase has been found to have positive ef- fects on child mental health. When a parent or other caregiver with mental illness receives care, this also greatly increases the chance that the child will develop an easygoing tempera- ment, which will pay dividends in the household for years (Hanington et al. 2010).

Treating a parent or caregiver begins with addressing life stressors ranging from mild (keeping up with laundry or cleaning) to severe (loss of employment, poor relationship with partner). Rallying a parent’s personal care system to support her and take her distress seriously may be sufficient to produce positive change. Psychotherapy is indicated for any situations in which major depression, GAD, or another significant disorder has set in.

The decision to use psychiatric medications postpartum is similar to what one would choose at any other time for mental health treatment. The degree of psychiatric medica- tion transmission through breast milk is typically too low to generate any effects on a breast-feeding child, with the nota- ble exception of lithium (Davanzo et al. 2011). Moderate to severe depression generally responds most quickly to a com- bination of SSRIs and psychotherapy, so this should be the usual approach (Lanza di Scalea and Wisner 2009).

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Common Clinical Concerns 57

Medication choices during pregnancy itself have to be weighed a bit more carefully against the potential effects a specific medication may have on a developing fetus. The tra- ditional advice was to avoid lithium because of the risk of Eb- stein’s anomaly, but recent research (Pearlstein 2013) identifies those congenital defects of the tricuspid valve as more rare than previously believed. Lithium may be pre- scribed, with caution and counseling, during pregnancy. We do, however, advise against the use of valproate, a known te- ratogen whose maternal use is associated with neurodevel- opmental disorders in children. The rare, but well-reported, risk of low birth weight or pulmonary hypertension of the newborn from SSRI use during pregnancy means that SSRIs should be reserved for more severe cases of depression and anxiety (Pearlstein 2013).

Any time a parent develops psychosis or suicidality, a hospital admission level of care should be considered.

TABLE 3–12. Postpartum maternal mental health

Diagnostic category Suggested screening questions

First consider

Suicidality “Have you been having thoughts about hurting yourself?”

Psychosis “Have you been hearing voices or feeling worried that your mind is playing tricks on you?”

Child safety “Have you felt worried that you might intentionally hurt your child?”

Common diagnostic possibilities

Anxiety disorder

“Do you feel tense or worried most of the time? Do worries affect your sleep?”

Major depressive disorder

“Have you felt really down, depressed, or uninterested in things you used to enjoy for more than 2 weeks?”

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Chapter 4

The 15-Minute Pediatric Diagnostic Interview

Even the most seasoned and skilled practitioner would like to have at least 30 minutes to perform a diagnostic men- tal health interview. Determining the character traits, cogni- tive ability, and emotional health of another person, especially a child or an adolescent, is difficult. So why even discuss a 15-minute diagnostic interview?

Short diagnostic mental health interviews are not ideal, but the reality is that they are performed with young people every day. Primary care and emergency department practi- tioners are routinely expected to perform very quick inter- views. Pediatric primary care practitioners can be expected to evaluate as many as 30 different children per day, which leaves only about 15 minutes to spend with each patient. Emergency department practitioners are pressured to rap- idly assess mental health concerns, particularly during eve- ning hours when emergency environments are most stressed.

The time available for performing a mental health evalu- ation is further constrained when a patient or family is fo- cused on physical health concerns instead. By the time your assessment identifies a psychiatric issue—the anxiety that precedes vague abdominal pain or the dsyphoria that is ex- perienced as a headache—you may have only a few minutes remaining in an appointment to conduct a full mental health diagnostic assessment. Patients also may have the “Oh, by the way.. .” moments, when major mental health questions are broached seemingly as a practitioner places his hand on the door to leave the examination room.

Practitioners frequently find their available time re- stricted in one way or another, so it helps to think about how to best use even a small amount of time to advance the care of children and adolescents with mental distress.

The following five steps are one way to efficiently per- form a focused mental health diagnostic assessment with a

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60 DSM-5 Pocket Guide for Child and Adolescent Mental Health

child or an adolescent. Even under time constraints, you can build a therapeutic alliance and develop an initial treatment plan by following these five steps.

1. Prescreen mental health concerns with a validated tool. 2. Identify the leading concerns. 3. Identify and address safety issues. 4. Diagnose a probable or unspecified disorder. 5. Recommend a next step.

Step 1: Prescreen Mental Health Concerns With a Validated Tool

We recommend the use of pre-interview assessment tools as a standard part of the workup for well-child visits but espe- cially when the chief complaint is a mental or behavioral health problem. Preassessment screening tools engage a pa- tient and his caregivers in the treatment, normalize conversa- tions about mental distress, and assist you in identifying the chief complaint. Several brief screening instruments for a wide variety of mental health concerns are available. One ex- ample is the DSM-5 (American Psychiatric Association 2013) Level 1 Cross-Cutting Symptom Measure, which lists se- lected symptoms of major DSM-5 disorders in a brief format. Versions exist for caregivers of children and adolescents be- tween ages 6 and 17 and for patients between ages 11 and 17. These measures are free and can be reproduced for clinical use and are referenced further in Chapter 10, “Selected DSM- 5 Assessment Measures.” We also recommend considering use of the Pediatric Symptom Checklist or the Strengths and Difficulties Questionnaire, two other brief but broad-based assessment measures that have the additional benefit of score validation for children in primary care medical settings.

Whatever screening tool you select for your practice set- ting, you should familiarize yourself with its scoring system. Most screening tools are designed to have high sensitivity, meaning that they aim to identify anyone who may have a par- ticular diagnosis, but lower specificity, meaning that they will identify some persons for additional concern who ultimately will not have the diagnosis for which you are screening. Posi- tive results in certain categories may suggest follow-up mea- sures to use, such as a high inattention score on the DSM-5

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The 15-Minute Pediatric Diagnostic Interview 61

Level 1 assessment being followed up with the DSM-5 Level 2 Inattention rating scale. Using follow-up measures can in- crease the efficiency of a clinic and, if patients are followed up over time, can be a good introduction to using validated scales to measure treatment response, relapse, and recovery. At the very least, the results of screening measures also can be used as conversation starters: “I see that you indicated a few concerns in the questionnaire; can you tell me more about that?”

Although the use of brief, broad screening measures is likely best for a fast-paced care facility, if time and the practice plan allow, a more detailed symptom checklist should be con- sidered instead. Tools such as the Behavior Assessment Sys- tem for Children (Reynolds and Kamphaus 1998) and the Child Behavior Checklist (Achenbach 1991, 1992) take signif- icantly more time for caregivers to complete and for office staff to score and interpret, but once completed, they result in reliable, broad-based pictures of a young person’s difficulties.

If you fail to recognize the presence of a mental health concern in advance, you can still choose to pause the evalua- tion process when such concerns arise and ask for the symp- tom screening information to be completed before continuing. For instance, you may say, “Given the concerns you just raised, could you take a few moments to complete this informa- tion, and I’ll be back to discuss this more with you?” Taking this approach could allow you to proceed with seeing your next scheduled patient during that time and even have the assess- ment tool scored by an assistant while staying on schedule.

When you have identified a specific mental health concern, a condition- or symptom-focused rating scale could be used instead to provide better diagnostic information. Examples of focused DSM-5 scales include the Level 2 Cross-Cutting Symptom Measures for parents or children to characterize symptom categories such as anger, anxiety, depression, inat- tention, irritability, mania, sleep disturbance, somatic symp- toms, and substance use; these scales are discussed in Chapter 10 in brief but are also available online (www.psychiatry.org/ practice/dsm/dsm5/online-assessment-measures#Level2). Other symptom-focused scales have been validated and normed with diagnostic score cutoffs in children and are dis- cussed in Chapter 11, “Rating Scales and Alternative Diag- nostic Systems.” Positive results on these instruments more strongly suggest that a particular diagnosis is present, but the use of a diagnostic instrument ultimately relies on the pru- dent judgment of a practitioner.

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62 DSM-5 Pocket Guide for Child and Adolescent Mental Health

Even the best rating scales and symptom checklists are in- herently imperfect, so it is important to understand their lim- itations. Questions may be misunderstood, may miss key symptoms, may be influenced by a young person’s or care- giver’s tendency to overreport or underreport symptoms, or may be intentionally answered untruthfully. This is why all surveys and questionnaires must be followed up with a per- sonalized diagnostic interview to yield a more complete and reliable picture. For instance, if we see an adolescent who de- nied having depression symptoms on his rating scale yet ap- pears withdrawn, speaks in a low monotone, and describes feeling hopeless, then depression must be considered, re- gardless of the scores on a symptom checklist.

Step 2: Identify the Leading Concerns

Once a pertinent rating scale has been completed and scored, the next step in a brief interview is to identify the young person’s and caregiver’s leading concern for further investigation. Identifying the leading concern can be as sim- ple as asking specifically, “What are you most concerned about today?”

An unlimited list of concerns or complaints is too chal- lenging to manage within a brief investigation, even if the concerns ultimately relate to the same diagnosis, as is often the case with depression. For instance, a family may describe sleep problems, poor academic performance, self-harm be- havior, irritability, and conflict with a sibling as separate con- cerns. If you identify one of these areas, such as self-harm, as the chief concern for that day, with the understanding that re- maining concerns such as sibling conflict may need to be ad- dressed at another appointment, then a 15-minute interview can be more fruitful.

Your own careful judgment is the key. For example, if a patient and his caregivers are most concerned about sleep disturbances but your screening tools or examination alert you to a safety issue, you must explain to the family that sleep disturbances are important, but the patient’s safety is the leading concern at present.

Having the patient and his caregivers each identify a leading concern builds your therapeutic alliance and in- creases investment in your assessment and treatment. When

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The 15-Minute Pediatric Diagnostic Interview 63

a patient and his caregivers believe that you truly understand the leading concern, they are more likely to engage in treat- ment and follow the next steps you recommend.

Step 3: Identify and Address Safety Issues

Any mental health evaluation, no matter how brief, includes an assessment of safety. If you identify safety concerns, then the near-term care plan needs to account for how to reduce or eliminate that risk.

• If you suspect that self-harm or suicidal behaviors may oc- cur, as when evaluating for depression, ask: “Do you ever think about hurting yourself? Have you ever deliberately hurt yourself?”

• If it is possible that abuse or neglect may be related to the reported symptoms, ask: “Has anything made you feel un- comfortable or unsafe? Has anyone ever tried to hurt you?”

• If it is possible that the child poses a risk to another per- son, ask: “Have you ever hurt someone else on purpose? Do you have any plans to do that now?”

Step 4: Diagnose a Probable or Unspecified Disorder

By inquiring about the circumstances and details surround- ing a patient’s (and his caregiver’s) chief concern and review- ing the results of assessment tools, a practitioner can usually arrive at a probable diagnosis in 15 minutes. Confirmation of all but the most obvious diagnoses will take more assessment time or a future appointment to clarify. For instance, you might determine in just 15 minutes that a child has significant developmental impairments, leading to a diagnosis of un- specified neurodevelopmental disorder. Then, during his next appointment you would make more detailed inquiries to refine the diagnosis further, changing that diagnosis to something more specific such as a language disorder or an autism spectrum disorder.

In Chapter 3, “Common Clinical Concerns,” we outline the more likely diagnoses to consider and some specific

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64 DSM-5 Pocket Guide for Child and Adolescent Mental Health

screening questions you can use when confronted with com- mon pediatric concerns.

Rapid assessments proceed more fruitfully with aware- ness of the key aspects of common clinical conditions. This is no different from the rest of medicine, in which shorthand un- derstandings of disorders are used to guide clinical suspicion. When an adult reports chest pain radiating down his left arm, we suspect a heart attack. When a febrile infant pulls at his ears and acts grumpy, we suspect an ear infection. In a similar way, we can learn to recognize basic patterns of mental health. When a child experiences several weeks of a persistently low mood and loses interest in the activities and friends he usually enjoys, we suspect major depressive disorder. To help inform your clinical suspicion, Table 4–1 contains a list of common psychiatric conditions and shorthand descriptions. Addi- tional information is available in later chapters.

Remember that these are descriptions of behaviors and symptoms. In isolation, these behaviors are not a diagnosis. In the DSM-5 diagnostic system, for any constellation of be- haviors and symptoms to qualify as a psychiatric diagnosis, they must meet two conditions:

1. They cause a significant functional impairment. 2. They are not better explained by another etiology.

The second rule is very important. A child can be inatten- tive for any number of reasons without having attention- deficit/hyperactivity disorder, and an adolescent can be sad for many reasons without experiencing a major depressive episode. If these kinds of behaviors and symptoms do not sig- nificantly impair function or can be better explained by an- other etiology, a formal mental health diagnosis should not be made. You can (and should) plan to follow up with the child or adolescent to see how these symptoms develop over time.

Under DSM-IV (American Psychiatric Association 1994), a disorder that did not meet full diagnostic criteria but still met the two conditions described earlier could be labeled as a not otherwise specified (NOS) condition. DSM-IV’s NOS diag- nosis allowed a clinician to initiate treatment for a patient whose presentation was not consistent with a more specific diagnosis. The heterogeneity of this category discouraged re- search, frustrated epidemiology, and diminished the clinical utility of diagnoses (Fairburn and Bohn 2005). These diagnos-

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TABLE 4–1. Shorthand descriptions of common DSM-5 diagnoses in children

Attention-deficit/ hyperactivity disorder

Developmentally inappropriate and persistent difficulty with inattention and/or hyperactivity with symptoms present in multiple settings

Anorexia nervosa Restrictive eating and food avoidance, often with an accompanying desire to avoid obesity, which persists despite negative consequences

Autism spectrum disorder

A developmentally inappropriate and persistent pattern of predominant impairments in social relatedness and restricted interests and behaviors

Bipolar disorder Discrete episode of elevated mood for multiple days with rapid thoughts, decreased need for sleep, persisting high energy, and unusual risk taking

Bulimia nervosa More than 3 months of recurring episodes of binge eating followed by an intense desire to compensate afterward (e.g., by purging or using laxatives)

Conduct disorder Repetitive significant violations of social rules and the rights of others over the course of a year

Encopresis Inappropriate stool leakage with psychological adaptations, usually facilitated by chronic constipation

Generalized anxiety disorder

More than 6 months of persisting but diffuse, changing worries for more days than not that cause symptoms such as tension, fatigue, irritability, and poor concentration

Major depressive disorder

More than 2 weeks of low (or irritable) mood coupled with new neurovegetative symptoms (e.g., loss of concentration, low energy, altered sleep or appetite)

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66 DSM-5 Pocket Guide for Child and Adolescent Mental Health

tic labels were frequently used in children and adolescents. For example, in a recent national survey of outpatient visits to physicians in the United States, 35% of all visits to physi- cians for mental health problems resulted in an NOS diagno- sis for children and adolescents, and the number of NOS visits grew proportionally over the decade analyzed by the researchers (Safer et al. 2015). NOS diagnoses tend, over time, to be neither reliable nor valid, so they are a poor foundation for an ongoing treatment plan.

In an effort to reverse this trend, DSM-5 removed the NOS option in favor of other specified and unspecified disor- ders. The unspecified and other specified criteria found in each chapter of DSM-5 provide more details than the compa-

Obsessive- compulsive disorder

Time-consuming internal repetition of unwanted thoughts and/or a persistent focus on repeating specific types of behaviors or mental acts (e.g., cleaning, counting)

Oppositional defiant disorder

Developmentally inappropriate opposition to and defiance of adult rules and requests for more than 6 months

Panic attack Sudden worry or fear accompanied by body symptoms such as a racing heart rate and physiological arousal (panic disorder considered if recurring attacks are feared and are affecting function)

Phobia (social or specific)

Excessive fear of an object or a situation that causes a dysfunctional degree of avoidance and distress for >6 months

Posttraumatic stress disorder

A traumatic experience has led to avoidance of trauma reminders, hypervigilance to future threats, and unwanted reexperiencing (including nightmares) for >1 month

Source. American Psychiatric Association 2013.

TABLE 4–1. Shorthand descriptions of common DSM-5 diagnoses in children (continued)

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The 15-Minute Pediatric Diagnostic Interview 67

rable NOS sections in DSM-IV. In general, practitioners are advised to consider an unspecified diagnosis when a young person experiences symptoms characteristic of a mental dis- order that cause clinically significant distress but do not meet the full criteria for a named diagnosis. If a practitioner wishes to communicate the specific reason that symptoms in a child or an adolescent do not meet criteria, the practitioner is en- couraged to use the other specified diagnosis. In a 15-minute diagnostic interview, practitioners may be more likely to ar- rive at unspecified diagnostic labels rather than full diagno- ses, but this should be a reminder of the need for additional diagnostic clarification later. Children and adolescents de- serve the most accurate diagnosis possible.

Step 5: Recommend a Next Step

Treat versus refer decisions end up being based on patient factors, such as diagnosis and severity, along with the fit be- tween a patient’s treatment needs and your abilities and availabilities as a practitioner and the type of services avail- able in your local community.

Therapist Referral

For nearly every moderate or severe mental health problem, referring a child or an adolescent to a skilled mental health therapist is essential. Explaining why you think seeing a ther- apist will be helpful may increase motivation for patients and caregivers to follow through on your referral. If caregivers have reservations about working with a mental health prac- titioner, it helps to address those concerns during the referral and to normalize the referral by saying something like “Just as I would refer you to a specialist to examine your eyes if I thought you needed glasses, I recommend that you see a mental health spe- cialist for the concerns we have identified together.”

Family- and Self-Help-Delivered Interventions

For low-severity problems, it may be appropriate to provide coaching on behavior or life management changes a patient and his caregivers can make at home. Providing guidance on how to improve sleep hygiene, to manage a problem behav- ior, or to support a young person through a life adjustment is

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68 DSM-5 Pocket Guide for Child and Adolescent Mental Health

an everyday occurrence for most primary care practitioners, and we provide some guidance in Chapter 14, “Psychosocial Interventions.” Handout instructions, books, videos, or Web sites so that the family can obtain additional guidance after the appointment also may be of assistance.

Educational Assessment

For children struggling in school for whom a learning dis- ability is a consideration, we advocate for educational test- ing. The route for doing this may hinge on motivating the parent to make a written request for a learning disability as- sessment at the child’s school, which is required in some set- tings, including the United States.

Early Intervention Services Referral

For very young children with developmental concerns, refer the child to a local early intervention program. In the United States, this involves the federally sponsored Zero to Three pro- gram (http://zerotothree.org) or a school district–sponsored program for children ages 4–5 years.

Safety Plan For a significant suicide, homicide, or other behavior-related safety risk, an immediate safety plan or hospitalization should be explored with the local mental health crisis system. For milder risks such as depression without active suicidal thoughts or plans, appropriate parental supervision and monitoring would be enough to detect any worsening risks.

Medications It is usually inappropriate to recommend a new long-term psychotropic medication after only a 15-minute assessment. The exception might be a short-term trial of an over-the- counter medication with low medical side-effect risks, such as melatonin to help with insomnia. However, after a second appointment or any evaluation of a longer duration when the diagnosis becomes more certain, a prescription may be ap- propriate. Whenever you suspect more severe health disor- ders, such as bipolar disorder or schizophrenia, you should refer a patient and his caregivers immediately to a specialty mental health practitioner.

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The 15-Minute Pediatric Diagnostic Interview 69

Follow-Up Appointment

If you identify a mental health problem, a follow-up appoint- ment should be recommended. This can serve several pur- poses:

• Provide enough time to better complete the diagnostic process

• Communicate your ongoing therapeutic connection and support around the problem

• Track the response to any initial intervention so that the treatment plan can be adjusted

• Identify any problems with the referral plan, creating an opportunity for resolution

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Chapter 5

The 30-Minute Pediatric Diagnostic Interview

Every interview with a young person with mental dis- tress will be unique. Sometimes you will need to calm a screaming child or warm up a reluctant adolescent before you can ask any diagnostic questions. In moments like those, it sometimes feels like you are wasting time. You have other people to see and other tasks to attend to. However, good in- terviewers learn to receive these moments as part of the inter- view itself. They watch and listen to the child or adolescent for clues about whether the distress is internal or external and what events bring her into and out of engagement with a practitioner.

Every young person is also unique, so we begin an initial encounter by getting to know the child or adolescent we are seeing. We use different strategies depending on the child’s age and developmental status, the location in which we are meet- ing, our familiarity with the patient, the patient’s sense of hu- mor, and many other variables. Before introducing ourselves to a patient, we like to know how long she has been waiting and with whom. A child who has sat calmly for 15 minutes in a waiting room will likely have different needs from the same child who has been waiting hours to see you in the emergency department. When we meet a patient, we prefer to open the conversation with a topic in which the child or adolescent is already engaged. If a young child brings a stuffed animal to an appointment or wears a colorful shirt, we ask about it. If an adolescent brings a book or is listening to music, we ask her to describe the book or song. The point is not to make an aesthetic judgment about the stuffed animals, clothes, books, and music with which a young person presents but to under- stand how she thinks.

Asking about something that the patient is consciously (or unconsciously) presenting to you also builds the thera- peutic alliance. Imagine if you walked into a medical encoun-

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72 DSM-5 Pocket Guide for Child and Adolescent Mental Health

ter and your physician began asking you about her interests but waved off any attempts to discuss your own. You, like most of us, would feel ignored and would likely be reluctant to engage in treatment with the physician. Now imagine if you visited another physician and she knew your name, said it correctly, and then asked how you came by your name. You would likely be more engaged with this second physician and her treatment. You can (and should) extend the same en- gaging courtesy to the children and adolescents you meet as patients.

We favor beginning every interview by introducing your- self, asking the young person her name, assessing her expec- tations for the encounter, clarifying any misperceptions, and giving a sense of how long the encounter will last. Caregiv- ers, rather than young people themselves, set up most evalu- ations, so verbally acknowledging this right away (“So, your mom wanted you to see me.. . .”) shows a young person that you can see things through her eyes.

When the encounter is limited to 30 minutes, we believe that you can successfully develop a therapeutic alliance and perform a diagnostic interview. Before we explain how, we need to offer a few caveats.

• Any psychiatric examination that obtains all the informa- tion from a single source is incomplete. This is especially true when interviewing a child or an adolescent. You should disclose to the person you are interviewing that you will be speaking to some of her adult caregivers about her health and what you will be discussing. See Chapter 3, “Common Clinical Concerns,” and Chapter 10, “Selected DSM-5 Assessment Measures,” for tools to use in inter- viewing adult caregivers.

• A successful psychiatric examination ultimately provides access to the internal world of a person. The thoughts, im- pulses, and desires of a young person can be engaged in many ways. In what follows, we offer an interview that is best suited for a young person who can tolerate direct questions. When interviewing a child or an adolescent who cannot do so because of age, impairment, or disinter- est, we recommend focusing on the most essential portion of the examination and spending the remainder of your time developing a therapeutic alliance.

• A skilled psychiatric examination always includes an ac- count of the relationships that constitute a person’s exis-

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The 30-Minute Pediatric Diagnostic Interview 73

tence. This is especially true with children and adolescents, whose dependence on other people is more apparent than it is for the average adult. During every interview with a young person, we always ask questions such as “Who do you live with?” “How do you spend your days?” “Who cares for you?” and “Who can you trust?” These kinds of questions naturally lead into other critical questions about the care- givers in a young person’s life.

With these caveats in mind, we offer the following as a guideline for a diagnostic interview that uses DSM-5 (Amer- ican Psychiatric Association 2013) criteria. The interview does not include prompts for DSM-5 categories that are un- common in childhood and adolescence—namely, the neuro- cognitive, gambling, paraphilia, personality, and sexual dysfunction disorders. (We do, however, provide guidance for assessing personality traits in Chapter 10.) We have taught a version of this interview to students, residents, fel- lows, and faculty. Until you develop the habits of an experi- enced practitioner, it helps to practice a structured interview. This helps in becoming comfortable asking about intimate concerns, remembering to screen all patients for the major categories of mental illness, and developing good interview habits.

Of course, a structured interview has a downside. We have sometimes witnessed practitioners read one question after another, without stopping for the usual pauses that sig- nify human speech or even looking at the patient. In The Pocket Guide to the DSM-5™ Diagnostic Exam (Nussbaum 2013), we called these kinds of interviewers psychiatric ro- bots who ask things like “I hear you are suicidal, but can you spell world backward?”—questions that show more fidelity to an outlined interview than attention to the specific person be- fore you. These kinds of interviewers speak so stiffly and stay so determinedly on script that when witnessing them, you wonder which of their joints need to be oiled first. Trust us, we both have performed the psychiatric robot interview our- selves at some point during our careers. We wrote this guide in part so that you can learn from our mistakes.

What we found (and still find) challenging is providing the right amount of structure for the interview. An excitable person will need to be calmed, a sad person must be encour- aged, and sometimes the same person will need both in the same interview. Fortunately, you always have the best possi-

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74 DSM-5 Pocket Guide for Child and Adolescent Mental Health

ble guide: the person before you. Follow her lead. Observe her body language. If she appears disinterested, it is time to alter your approach.

As you use this diagnostic interview, strike a balance be- tween becoming a psychiatric robot and practicing a formal version until it becomes a habit. The 30-minute diagnostic in- terview will seem forced at first, but gradually it provides the infrastructure for a conversational interview.

No matter how distracted or upset the patient, good in- terviewers always give a person a few minutes to speak her own mind. Then, they summarize and clarify the patient’s concerns and organize the examination as necessary, modu- lating the structure and language of the interview to fit the needs of the patient. They ask clear and succinct questions. If the patient is vague, they seek precision. If she remains vague, they explore why. They do not ask permission to change the subject but use transition statements, such as “I think I understand this, but how about that?” Developing a sup- ply of stock questions is helpful, which is why we advise us- ing this structured interview until it becomes a habit. Then you can use these questions to develop a conversational style for an interview in which a patient tells her story, you form an alliance with her, you gain insight into her thought pro- cess, and you gather the clinical data needed to make an ac- curate diagnosis. When you do so, you reduce the patient’s alienation by making the strange more familiar.

Outline of the 30-Minute Pediatric Diagnostic Interview

The interview outline in this section includes headings that indicate the time allotted for each portion of the interview (boldface type), instructions to the interviewer (roman type), and questions for the interviewer to ask (italic type).

Minute 1

Introduce yourself to the patient. Ask how she would like to be addressed. Set expectations for how long you will meet and what you will accomplish. Describe applicable limits of confidentiality with an adolescent, such as “What we talk about will remain confidential except if there is a risk for your

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The 30-Minute Pediatric Diagnostic Interview 75

safety—then we would talk together with your parent about how to best keep you safe.” Then ask, “Why are you here today?”

Minutes 2–4

Listen

A patient’s uninterrupted speech indicates much of her men- tal status, guides your history taking, and builds the alliance. As she speaks, listen to the content and form of her state- ments. What is she saying or not saying? How is she saying it? How do her statements match her appearance? Although you may be tempted to interrupt or begin asking questions, with experience, you will find that allowing the person to talk initially without interruptions gives you more informa- tion about her than the answers to your questions will. When you do speak next, try to have your question be both respon- sive and open ended, along the lines of “You said ____; can you tell me more about that?” Depending on the nature of the ill- ness, some people will be unable to fill this time; their inabil- ity to do so also provides valuable information about their mental status and distress. When the person does not speak spontaneously, you may have to use prompts and proceed to the history of the current illness.

Minutes 5–12

History of Current Illness

Your questions should follow the DSM-5 criteria, as de- scribed in Chapter 6, “DSM-5 Pediatric Diagnostic Inter- view.” Additionally, you should focus on what has changed recently—the “why now?” of the presentation. As you do, seek understanding of precipitating events: When did the pa- tient’s current distress begin? When was the last time she felt emotionally well? Can she identify any precipitating, perpet- uating, or extenuating events? How have her thoughts and behaviors affected her psychosocial functioning? How does the patient view her current level of functioning, and how is it different from what it was days, weeks, or months ago?

Psychiatric History

“When did you first notice symptoms? When did you first seek treatment? Did you ever experience a full recovery? Have you ever

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76 DSM-5 Pocket Guide for Child and Adolescent Mental Health

been hospitalized? How many times? What was the reason for those hospitalizations, and how long were you hospitalized? Do you re- ceive outpatient mental health treatment? Do you take medications for a mental illness? Which medicines have helped the most? Did you have any adverse effects from any medications? What was the reason for stopping prior medications? How long were you taking each medication, and how often did you take it? Do you know the name, strength, and number of doses per day of medicines you are currently taking?”

Safety

Students and trainees may feel uncomfortable asking these questions and may worry that they will upset patients or even give them ideas about ways to hurt themselves or oth- ers. These fears are largely unfounded, and with practice you will find that these questions become much easier to ask. It is important to remember that one of the biggest predictors of future behavior is past behavior, so asking about prior epi- sodes of violence to self and others is required for an overall risk assessment. “Do you frequently think about hurting your- self? Have you ever hurt yourself, such as cutting or hitting? Have you ever attempted to kill yourself? How many attempts have you made? What did you do? What medical or psychiatric treatment did you receive after these attempts? Do you often become so upset that you make threats to hurt other people, animals, or property? Have you ever hurt people or animals, destroyed property, tricked other people, or stolen things?”

Minutes 13–17

Review of Systems

The psychiatric review of systems is an overview of common psychiatric symptoms that you may not have elicited in the history of the current illness. If a person answers affirma- tively to these questions, you should explore further with the DSM-5 criteria, as modeled in Chapter 6.

Mood. “Have you been feeling sad, blue, down, depressed, or ir- ritable? If so, does feeling this way make it hard to do things, to con- centrate, or to sleep? Are you angry most of the time? Has there been a time when for many days straight your mood was super happy, you were more self-confident, and you had much more en- ergy than usual? If so, can you describe what happened?” (See

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The 30-Minute Pediatric Diagnostic Interview 77

“Depressive Disorders” or “Bipolar and Related Disorders” in Chapter 6.)

Psychosis. “Have you seen visions or other things that other people did not see? Have you heard noises, sounds, or voices that other people did not hear? Do you ever feel like people are following you or trying to hurt you in some way? Have you ever felt that you had special powers or found special messages from the radio or TV seemingly meant just for you?” (See “Schizophrenia Spectrum and Other Psychotic Disorders” in Chapter 6.)

Anxiety. “Would you say that you worry a lot or more than other kids your age? Do people say that you worry too much or are too shy? Do you feel afraid when you’re alone or away from your family? Do you get scared about going to school? Is it hard for you to control or stop your worrying? Are there specific things, places, or situations that make you feel very anxious or fearful? Have you ever felt sud- denly frightened, nervous, or anxious for no reason at all? If so, can you tell me about that?” (See “Anxiety Disorders” in Chapter 6.)

Obsessions and compulsions. “Do you ever get unwanted thoughts or pictures stuck in your mind and repeating that you can- not get rid of? Is there anything you feel you have to check, clean, or organize over and over again in order to feel OK?” (See “Obsessive- Compulsive and Related Disorders” in Chapter 6.)

Trauma. “What is the worst thing that has ever happened to you? Has someone ever touched you in a way you did not want? Have you ever felt that your life was in danger or thought that you were going to be seriously injured? Do you have unhappy memories that make it hard to sleep or to feel OK now?” (See “Trauma- and Stressor-Related Disorders” in Chapter 6.)

Dissociation. “Do people say that you daydream a lot or look spaced out? Do you lose track of time and feel unsure of what you did during that time? Do you ever feel as if you are standing outside your body or watching yourself?” (See “Dissociative Disorders” in Chapter 6.)

Eating and feeding. “Do you avoid particular foods so much that it affects your health or weight? Do you worry about losing control over how much you eat?” (See “Feeding and Eating Dis- orders” in Chapter 6.)

Elimination. “Have you had any problem with passing urine or feces onto your clothing or bed?” (See “Elimination Disorders” in Chapter 6.)

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78 DSM-5 Pocket Guide for Child and Adolescent Mental Health

Somatic concerns. “Do you worry about your health more than other kids do? Do you often miss school because you do not feel well? Do you get sick with aches and pains more often than most young people do?” (See “Somatic Symptom and Related Disor- ders” in Chapter 6.)

Sleeping. “Do you struggle to fall asleep, or do you wake up a lot at night? Do you often feel sleepy during the day? Has anyone said that you stop breathing or gasp for air while sleeping?” (See “Sleep-Wake Disorders” in Chapter 6.)

Substances and other addictions. “In the past year, have you drunk alcohol, smoked marijuana, or used anything else to get high? Have you ever ridden in a car with someone who was high or drinking alcohol? Do you ever use alcohol or drugs when you are alone? Do you ever use alcohol or drugs to relax?” (Knight et al. 2002). (See “Substance-Related and Addictive Disorders” in Chapter 6.)

Minutes 18–23

Past Medical History “Do you have any chronic medical problems? Have these illnesses affected you emotionally? Have you ever undergone surgery? Have you ever experienced a seizure or hit your head so hard that you lost consciousness? Do you take any medications for medical illness? Do you take any supplements, vitamins, or over-the-counter or herbal medicines regularly?”

Allergies. “Are you allergic to any medications? Can you de- scribe your allergy?”

Family history. “Have any of your relatives ever had mental or behavioral health problems, such as attention-deficit/hyperactivity disorder, anxiety, depression, bipolar disorder, psychosis, problems from drinking or drugs, suicide attempts, nervous breakdowns, or psychiatric hospitalizations?”

Developmental history. “Do you know if your mother had any difficulties during her pregnancy or delivery? What were you like as a young child? Did you ever receive developmental, speech, or special education services?” (See Chapter 12, “Developmental Milestones,” for early developmental milestones.) Look at the child’s current height and weight on a growth curve.

Social history. “Did you have any behavior or learning prob- lems during your early childhood? When you started school, did

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The 30-Minute Pediatric Diagnostic Interview 79

you have trouble relating socially to your classmates or difficulty keeping up academically? How far have you made it in school? Who lived in your home during your early childhood? Who lives there now? Was a religious faith part of your upbringing? Currently? Have you ever held a job outside of the home? Have you ever been suspended? Expelled? Arrested? Jailed? What do you like to do? How do you spend your time online? What do you like about your- self? What do your friends like about you? Do you have any friends you can confide in? Are you sexually active? Are you really uncom- fortable with your assigned gender?”

Minutes 24–28

Mental Status Examination

By this point of the interview, you should have already ob- served or obtained most of the pertinent mental status exam- ination data. See Chapter 9, “The Mental Status Examination: A Psychiatric Glossary,” for a more detailed version of the mental status examination, which includes the following components:

• Appearance • Behavior • Speech • Emotion • Thought process • Thought content • Cognition and intellectual resources • Insight and judgment: “What problems do you have? Are you

sick in any way? What are your future plans?”

Mini-Mental State Examination

The Mini-Mental State Examination (MMSE) is a commonly used basic cognition ability assessment in adult and geriatric psychiatric care that has standardized questions and yields a numerical score. We find that the MMSE is less pertinent to administer to young persons than to older adults. When it is used, the MMSE is more challenging to interpret for the younger developmental ages. However, if a major mental ill- ness (e.g., schizophrenia) or encephalopathy is suspected, a MMSE may add diagnostic value. When the MMSE is used, the lead-in could be along the lines of “Have you had any prob-

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80 DSM-5 Pocket Guide for Child and Adolescent Mental Health

lems with your concentration or your memory? Can you help me understand the extent to which you might be having those types of difficulties?” The MMSE then includes the following items: name, date and time, place, immediate recall, attention (counting backward from 100 by 7s, spelling world back- ward), delayed recall, general information (president, gover- nor, five large cities), abstractions, proverbs, naming, repetition, three-stage command, reading, copying, and writ- ing (Folstein et al. 1975).

Minutes 29–30

Ask any follow-up questions. Thank the patient for her time and, if appropriate, begin discussing diagnosis and treat- ment.

Consider asking the following: “Have the questions I asked addressed your major concerns? Is there anything important I missed or anything that I really should know about to better under- stand what you are going through?”

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