Psychosocial+and+Psychotrophic+Interventions+in+Children+and+Adolescents

=**Psychosocial and Psychotrophic Interventions in Children and Adolescents**=


 * 1. Estimate the prevalence of mental illness in children and the percent of those that receive treatment.**

There is a prevalence of 12-16% of children with mental illness (7.5-9.5 million children), less than 20% of which have some sort of intervention, of which only a fraction of those received care from child/adolescent psychiatrists.


 * 2. Summarize the theoretical basis for treatment of mental illness. Include biologic, psychoanalytic, family, developmental, behavioral, and psychosocial theories.**

__Biologic__ Biologic theories emphasizes that psychiatric illness may be due to the expression of an abnormal genotype, injury or defects in nervous system maturation, or physical trauma (traumatic birth).

__Psychoanalytic__ Psychoanalytic theories suggests that pathological processes evolve from past experiences that affected the patient adversely. Freud's functional theory proposes that neurosis occure when sexual desires is repressed and converted to physical symptoms/defenses. His structural theory proposed that there exists an possible imbalance between the superego, ego, and id resulting in neurosis. (see Theories of Human Behavior)

__Family__ Family theory postulates that psychiatric problems can arise from problems with family functioning. The systems theory suggests that family function out of equilibrium can cause problems. Communication theory suggests that lack of or ineffective communication between family members can cause problems. Structural theory focuses on relationships between family members such as enmeshment (i.e., everybody lives together in close affinity and can predict each other's behaviors) or alliances (e.g., one parent teams up with child against other parent).

__Developmental__ Developmental theories suggest that pathology can be studied from a developmental frame of reference. For example, attachment theory (Mahler) suggests that genetic and environmental factors can affect a child's development from attachment to caregiver towards personal independence and early problems with attachment (anxious/resistant, anxious/avoidant vs. secure attachment) can lead to future problems.

__Behavioral__ Behavioral learning theory postulates that abnormal behavior is the result from failure to learn or learning inappropriate things as a result of bad conditioning. Classical and operant conditioning can help to break bad conditioned behaviors and modify existing behaviors.

__Psychosocial__ Psychosocial theory emphasizes environmental and life experiences in playing a role in psychiatric problems. Under the Eriksonian psychosocial development model, problems arise from failure to pass different crises that manifest in each of the 8 stages of life.


 * 3. Compare the different types of psychotherapy used in children and adolescents; indicate the factors that most of these therapies have in common.**

Common factors in psychotherapy are a development of a rapport or alliance and providing support with the patient, and neutral/initial, middle, and terminal stages in therapy.

__Play Therapy__ Play therapy uses the playroom, toys, games, drawings, etc. to allow kids to ventilate trauma and interact with the therapist in a more natural manor.

__Supportive Therapy__ Supportive therapy focuses on the management and resolution of current difficulties and life decisions using the patient's strengths and available resources. The therapist focuses on positives and supports a patient resolve their own issues (used in higher functioning patients).

__Filial Therapy__ Filial therapy focuses on the treatment of more than one family member in the same therapeutic session, emphasizing factors such as relationships and communication patterns between family members (e.g., parent with child) rather than on the symptoms of individuals.

__Psychodynamic Psychotherapy__ Psychodynamic psychotherapy focuses on self-understanding, removal or replacement of poor defense mechanisms, and constructive liberation of psychic energy. It may involve a high level of introspection and reflection from the patient to dive into their past and muster enough resilience to deal with their problems.

__Psychoanalysis__ Psychoanalysis uses 3-5 sessions/week of free association and interpretation between psychotherapist and patient to produce a transference neurosis by which the origin of the neurosis is discovered and reinterpreted.

__Cognitive Therapy__ Cognitive therapy is based on the concept that the way the patient thinks affects how the patient feels emotionally. Cognitive therapy deals with correcting cognitive distortions and developing effective coping mechanisms.

__Remedial, Educational, Patterning Psychotherapy__ Remedial, educational, patterning psychotherapy involves getting the patient to admit something is wrong and then doing tasks (e.g., writing down what is wrong) to reinforce it with the goal being to prevent relapse of psychiatric problem.

__Behavioral Therapy__ Behavioral therapy uses operant conditioning and positive reinforcement to bring about behavioral changes.

__Family Therapy__ Family therapies use structural and communication family systems theories to try to rebalance and improve family function and communication. Therapy is typically multigenerational.

__Group Therapy__ In preschool and early school ages, social skill groups can help treat shyness, anxiety, and aggressive behaviors while parent-child groups can help treat with developmental delays. Latency age groups utilize interviews, verbalization of fantasies, group play, work, and open ended discussions in therapy. Early adolescence groups may use same gender groups engaging in play, activity, psychodrama (acting out) under the directive role of the therapies. Late adolescence may be more verbal and exploratory with the therapist taking on a more passive role. Topic and task oriented groups are typically used to treat substance abuse, traumatized children, supportive/educational therapy of children of divorced parents, and confrontational therapy with delinquent adolescents. Parent groups may be supportive or informative and can focus on self-help or parent effectiveness training.


 * 4. Describe the indications for psychotherapy.**

Indications for successful psychotherapy include motivation, environmental stability, sufficient cognitive capacity, definable target or goal, and involvement of parents in psychotherapy for children.


 * 5. Contrast child and adolescent therapy from adult therapy.**

Therapy for children and adolescents are different from adult therapy in several ways.


 * **Motivation** || Typically, the motivation for therapy in kids is forced and non-voluntary. ||
 * **Therapeutic Alliance** || Therapeutic alliance may be difficult to develop, especially in teenagers who don’t trust health professionals. ||
 * **Perception of Cause** || Kids may perceive their cause of their illness as external rather than internal and see no reason to change. ||
 * **Transference** || Kids also tend to engage in transference readily and intensely, transferring their feelings of anger to the therapist. ||
 * **Psychological/Intellectual Capacity** || Kids have limited introspection and self-observance capacity; their self-centeredness means they cannot analyze themselves well. ||
 * **Developmental Fluidity** || Kids experience strong regression and maturation forces dynamically so it is important to aim for gradual progression. ||
 * **Confidentiality** || Child’s rights versus Parent’s right ||
 * **Power of Environment** || kids are still dependent and have not yet gained full autonomy. ||


 * 6. Describe the unique characteristics of adolescent interviews and adolescent treatment.**

__Interviews__ Adolescent interviews may include the involvement of parents and in troubled youths may include distrust of establishment as well as control/power/narcissistic characteristics. Adolescent interviews may be action oriented in children with limited raw or primitive verbal communication and in higher functioning children may include straightforwardness regarding issues such as drug use, suicide, and sexuality.

__Treatment__ Adolescent treatment may involve intense transference and countertransference that can be taxing on the therapist. Group therapy is often useful. Family therapy may be adjunctive but, nonetheless, important. Special attention should be given to substance abuse and teen suicide. Institutionalization may be necessary if there is emergence of psychosis, severe developmental deficits, or personality deficits. However, over a certain age, there may be issues regarding minor’s right to refuse hospitalization over parental wishes that may ultimately elicit the state’s decision.


 * 7. Explain the use of milieu therapy, including the type of environment, and disorders appropriately treated with this therapy.**

Milieu therapy refers to residential, partial hospitalization or hospital treatment where the patient’s environment can be manipulated for his or her benefit and rehabilitation. The environment should be nurturing, protective, and structured with a therapeutic atmosphere with rules, schedules, and recreation. Staff often includes psychiatrist, nurses, and child case workers, etc. working as a team with consistency and communication. Group living with peers and child care workers can allow reenactment of family conflicts to provide corrective emotional experiences. Treatment can be multimodality: individual, family, group, behavioral, activity, medical, educational, etc. Duration of therapy can be long or short term, depending of the duration of the crisis intervention.


 * 8. Discuss the general principles of underlying psychotropic use in children and adolescents.**

General principles underlying psychotropic use in children and adolescents that should be considered are as follows:

Drugs should be used to treat a diagnosed disorder not individule symptoms. The effects of drugs on growth, development, and physiological consequences should be carefully considered given their lack of study in children. The role and expectation of the drug should be clear. Issues of compliance and communication should be carefully explained to the patient and parents. Duration of drug use, drug holidays, and periodic tampering should be used to reevaluate psychotropic medication.


 * 9. List the kinds of baseline assessments recommended before psychotropic treatment is begun.**

A physical examination should be preformed as baseline assessment before psychotropic treatment is begun, including laboratory tests such as complete blood count, urine analysis, liver function test, blood urea nitrogen, creatinine, thyroid function test, lead level, EKG, and EEG. Behavioral assessment rating scales should also be performed to screen for depression, psychosis, and to give a baseline for treatment.


 * 10. Provide examples of commonly used pediatric psychotropic drugs and their appropriate use. List biological therapies that are of questionable validity.**

__Stimulants__
 * **Drug** || **Indication** || **Age** || **Notes** ||
 * Methylpenidate (Ritalin) || ADHD || 6 years+ ||  ||
 * Amphetamine (Dexedrine, Adderal) || ADHD || 3 years+ || Concerns about cardiovascular effects ||

__Antipsychotics__
 * **Drug** || **Indication** || **Age** || **Notes** ||
 * Haloperidol (Haldol) || Tourette’s disorder (severe explosive behaviors unresponsive to other treatments) || 3 years+ ||  ||
 * Chlorpromazine (Thorazine) || Severe explosive behaviors || 6 months+ ||  ||
 * Risperidol (Risperdal) || Autism spectrum || Unknown Age ||  ||

__Tricyclic Antidepressants__
 * **Drug** || **Indication** || **Age** || **Notes** ||
 * Imipramine (Tofranil) || Enuresis, Depressure || 6 years+ ||  ||
 * Clomipramine (Anafranil) || OCD || 10 years+ ||  ||

__SSRI Antidepressants__
 * **Drug** || **Indication** || **Age** || **Notes** ||
 * Fluoxetine (Prozac) || Depression, OCD || Unknown age || Some correlation with suicide (2x) ||
 * Sertraline (Zoloft) || Depression, OCD || Unknown age || Some correlation with suicide (2x) ||
 * Fluvoxamine (Luvox) || OCD || Unknown age || Some correlation with suicide (2x) ||

__Mood Stabilizers__
 * **Drug** || **Indication** || **Age** || **Notes** ||
 * Litium || Bipolar, aggression || Unknown age ||  ||
 * Carbamazepine (Tegretol) || Bipolar, aggression || Unknown age ||  ||

__Antinuretic__
 * **Drug** || **Indication** || **Age** || **Notes** ||
 * Desmopressom (DDAVP) || Bedwetting || Unknown age ||  ||

__Other Biological Therapies of Questionable Validity__ Electroconvulsive therapy (ECT) Psychosurgery Diets (for allergy) Megavitamins