Common Problems with Possible Serious Outcomes of Childhood and Adolescence
The Role of The Child Psychiatrist in Routine Pediatric Health Screening-Unaddressed Medical Need!
Routine Well Child Mental Health Visits: An Essential Part of Comprehensive HealthCare for Children
The Role of the Child Psychiatrist in Screening for Biologically Based Mental Health Problems in Childhood
From the series” I want you to know what I know.”
Mental Health Problems that Shouldn’t be Missed and their Treatments
There are certain emotional, cognitive, behavioral, and physical symptoms that occur in childhood, that may represent biologically based mental health problems. These problems can get more serious and progress to minor and major mental health disorders. These mental health disorders often have serious consequences and complications, leading to excessive emotional, mental and physical distress, impairment , disability, drug and alcohol addiction, and premature death from accidents, especially auto accidents and suicide.
These serious consequences and complications caused by these biologically based mental health problems can be prevented by early detection, evaluation, and adequate treatment. This is not being adequately done.
Primary care practitioners do routine and periodic, well child visits for mostly physical reasons, and will refer to a specialist if there are concerns whether they think there is a diagnosis or not, in part they are doing it for preventive reasons. The same can be done for mental health problems in a preventive way after an appropriate and more comprehensive screen than usually done. Routine and periodic “Well Child Mental Health Visits,” , done by a specialist, can in part accomplish this goal. The Child Psychiatrist involved in the evaluation and treatment of biologically based mental health disorders on a daily basis is in a unique position because of training and experience, to do “Well Child Mental Health Visits,” in a clinically effective way, in the most cost and time effective manner.
The “Well Child Mental Health Visit”, would be done after a primary care practitioner, or any health care provider, after doing their screen has concerns and wants further evaluation by a specialist. It also could be a direct referral from a concerned parent. The emphasis here need to be directed toward prevention as part of the total healthcare by early detection and if necessary appropriate treatment.
Awareness of availability of such a mental health visits with a child psychiatrist, and the purpose of such visits with referral and education from appropriate sources would go far in reducing the stigma of visits with a psychiatric professional, which still is a problem in our enlightened age. This stigma is still a major obstacle to getting mental health evaluation and treatment especially by a psychiatrist.
Another major obstacle to “Well Child Mental Health Visits,” is lack of insurance coverage for such visits. At present only if the problems already qualify for a disorder, and thus coded diagnostically is their reimbursement. This lack of insurance for these services cause the most problems in the working middle class who have heath care insurance. The poor with no or public health care insurance often are getting the equivalent of these mental health care visits, as are the wealthy, or better off financially who are willing to pay out of pocket for this service.
A third and perhaps even greater obstacle is the lack of information about these symptoms, and the mental health problems and disorders, that result and their complications. Health care providers, other professionals, parents, and others who are interested in the general health care and mental health care of children are either unaware of the magnitude of these problems or the serious complications that can occur without early evaluation and treatment.
There are many mental health issues and many treatments. The emphasis here is on those problems emotional, cognitive, behavioral, and physical, that have a strong biological basis, and shouldn’t be missed.
In these biological based problems non biological psychosocial treatments may have their place and may be appropriate if not the initial and exclusive treatment. However if the symptoms are severe, and of long duration, medication management is not only necessary but essential. Medications are not only necessary and essential for symptom relief, with a return to normal functioning, but also to prevent relapses, re occurrences, and to prevent complications.
What are some of these emotional, cognitive, behavioral, and physical symptoms and problems that shouldn’t be missed? What follows is for the purpose of examples to make the point. Even for the sake of example it is only an introduction and the briefest summary.
The mental health disorders, representing these problems, are often missed because they may be mild in their initial presentation, not thought of, or may be disguised by other issues, and most commonly by physical signs and symptoms.
Many times the childhood problems discussed below, just may be transient issues due to biological, developmental, environmental or other causes and should be treated as such. The emphasis here will be on those that may have a biologically based mental health basis, and may be the first warning signs or the beginnings of a mental health disorder, especially if there is a family history of mental health or drug and alcohol problems. The actual diagnosis is made only after a complete psychiatric examination, including personal, family history, and ruling out other non psychiatric causes. Many times only a medication trial can help clarify the diagnosis. This is often best done by an experienced Child and Adolescent Psychiatrist.
Any one item in this list may represent a simple adjustment issue or the first sign or the beginings of a mental health disorder, listed above. It is more likely that these problems will occur in clusters and combined with the child or teens personal developmental history, together with environmental stressors, and a biological genetic basis as seen in family history of mental health disorders, or traits, or inferred by a combination of factors, will point to a possible mental health diagnosis. Often only a Child Psychiatrist familiar with biological based disorders and their treatment can has the experience and training to come to some tentative conclusion , a provisional diagnosis, that may have to be have to be confirmed by further evaluation visits and perhaps a medication treatment trial.
Possible diagnoses, these problems may represent, and this is not an all inclusive list, and more than one may apply, include the following: Attention Deficit Hyperactivity , Autistic Spectrum , Attachment, Bipolar, Panic, Generalized Anxiety, Schizophrenia, Obsessive Compulsive, Learning Disorders, Separation Anxiety, Unipolar Depressive, Substance Abuse Disorders.
A partial list of problems to be aware of and to screen:
1. Infantile Colic: This challenging problem of the infant that is fussy, excitable, sleepless, hard to feed, soothe and can’t be easily calmed down. This goes on for month after month causing great distress for all involved.
2. Abnormal or Changes in Relatedness at any age: Lack or insufficient eye contact, non verbal communication, poor emotional give and take, robotic like in speech and emotional responses, doesn’t seem to get emotional nuances, especially jokes, sympathy, empathy, too withdrawn, prefers things over people or animals
3. Abnormal or Change in Language, Speech, or Communication: Too little too much, not logical, too much fantasy, too much logic, emotions and thoughts don’t connect, goes off on tangents.
4. Temper Tantrums: These are not normal tantrums, but those that are severe, excessive, to the point of rage, almost seizure like, where the child, nor anyone else can calm the child down. If an adult tried to duplicate these they just couldn’t physically do it.
5. Separation Anxiety: Here the duration and intensity of the separation reaction is excessive, and the child cannot be easily calmed down. The child becomes so fearful at separation that they get themselves physically ill with throwing up, diarrhea, headaches, sleeping and eating disturbance.
6. Fantasy and Play: Excessive amount with abnormal, too exclusive themes, especially if odd, strange, illogical, bizarre for developmental age, or involved with death destruction, sexuality.
7. Headaches : Headaches of such intensity and duration that the child cannot do daily activities especially fun things, often force to go the bed, to get relief of the headaches, with other symptoms like stomach upset, often accompanied by unusual mood changes and fears. Childhood headaches are often not taken of treated seriously.
8. Problems with Concentration, Activity Level, and Impulsivity: Beyond what is accepted for the developmental age, or if it is episodic, that is comes and goes, in its presentation.
9. Mood Changes: If too high, too low, too much , too little, rapidly changing, unexplained by and excessive to circumstance and environment.
10. Antisocial and High Risk Behaviors: If these are accompanied by lack of guilt, remorse, shame, not learning from experience, such as lying, stealing, breaking rules, hurting people, animals and property.
11. Sleep Difficulties: Trouble falling asleep, staying asleep, waking up in the middle of the night, fragmented sleep, waking up too early and not being able to get back to sleep, too little sleep, too much sleep, bed wetting, nightmares, night terrors, sleep walking and talking, waking up in the middle of the night to eat, all of these alone or together may be significant.
12. Appetite and Weight Changes: Significant changes in any direction, should be treated seriously, especially excessive weight gain associated with carbohydrate craving that does not correlate with any known stressor.
13. Fears and Worries: Beyond what is developmentally appropriate, leading to distress, and impairment at home, school, socially with anxiety or panic like attack, rituals, habit problems, and avoidance.
14. Psychosomatic Symptoms: Physical disorders like Asthma and Skin problems that just don’t get better, long lasting stomach, and intestinal problems, constipation, diarrhea, tremors, abnormal movements, and sounds that are unexplained.
15. School Problems: Any decline in grades and other school performance changes, dropping out of activities, especially school absences, school avoidance, and school refusal.
16. Personality Changes: Not normal self, too friendly, too out going, isolative, shy, fearful.
17. Excessive Concerns about Death, Dying, Suicide: Common in adolescents, but never should be taken lightly or dismissed, and unusual in younger children.
18. Tobacco, Drug and Alcohol Use: This should be taken seriously at any ages especially if starting at an early age, and should not seen as just experimentation.
There is much to gain and loose here, in the proper application of a “Well Child Mental Health Visit”, it should be available to all children and teens. The same concepts can of course be applied to the adult person with similar problems. In terms of prevention much more can be accomplished with the younger individuals.
A word about diagnosis, disorders, and labels in general, and how they relate to severity of mental health problems.
Diagnostic labels in themselves don’t give justice to the severity of the disorder in terms of personal distress a person may be feeling, or how much they are suffering, and how much impairment that the label or the disorder may cause for the person in themselves, at home, at work, school, socially or during leisure time. This is especially true in the child or younger adolescent.
For example child or teen with a Bipolar Disorder, which is normally seen as a Major Mental Health Disorder and Diagnosis, may function reasonably well at school and socially, because his major symptoms are around his sadness, and mood instability which they can control for the most part, and the thinking processes are relatively sparred. At home and when alone the sadness and mood problems may plague the person with feelings of hopelessness, feeling better off dead, near suicide, in emotional anguish, terrorized by their shifting but controlled moods, and this person is in great distress, is in much emotional pain, and suffering in a quiet manner.
Does this person have a minor or major problem? One had to decide base on symptom severity, which may translate to personal distress, or it may not, and the level of functioning or impairment, rather then on the diagnostic label and what connotations it may carry.
The Diagnostic and Statistical Manual of the American Psychiatric Association, has a GAF, Global Assessment of Functioning Scale, that addresses these issues for children and adults, and adds some attempt at an objective measure. The GAF or the Child’s version of the GAF, the CGAF, can be used for both evaluating the severity, rather than just an arbitrary label, such as a diagnostic label, and also be used for efficacy of treatment response.