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New Advances in Child and Adolescent Psychiatry

Object permanence is probably the key concept of Piaget. A lot of times it gets very easy to confuse object constancy and object permanence. Object constancy is a key topic, or key area to know of from Mallor development, Margaret Mallor. But I guess if you have any trouble remembering the difference, just think of object permanent as permanent.

Then you run into the pre-operational phase, which is from two to seven-years of age and that looks at covering primarily the anal and phallic stages of Freudian development, or ototomy in initiative versus guilt of Ericksonian development. You look at a child again getting from the terrible two’s or after the time of object permanence, straight through to the early elementary years. Some of the common things to know of have to do with the symbolic function that’s described, which allows a lot of the development of language at that point. Egocentrism: the world revolves around that child.

So, moving along, you run into then the concrete stage of development, which is also called the operational stage - from 7-11 years-of-age - correlated with latency stage or the industry stage or Ericksonian development. That has to do with more development of logical-type thinking, reversibility, the ability to sequence and serialize and conservation.

Then you move to the formal stage of abstract development, and that’s 11-years-of-age straight through until the end of adolescence when that child, or now teenager, is able to think of their own thoughts. More hypothetical, deductive type reasoning, ability to grasp probability concepts. Go on to a higher level of work that theoretically we should all be getting exposed to in the high school and junior high stage.

To move next, we have Margaret Mollar and her stages that are considered more important, or probably the later stages, the separation and individuation phases which are the most important area to be associated with Margaret Mollar. She starts off with the normal autistic phase, at the very beginning, the first month or so, when the baby is generally thought to be half asleep, not very aware of the environment. Then moving to the normal symbiotic phase, which will be for the next couple of months, until about four or five months, where you’ll see more of a social smile -at about two or three months - and a dim awareness of the caretaker.

Scanning: stranger anxiety is an important concept to be aware of. Will tend to occur during this time, about eight months typically. Again, this is something that commonly will show up on general exams. Knowing when stranger anxiety and separation anxiety tend to occur. Stranger anxiety comes at about eight months, and then during the practicing stage, from 10-16 months, it’s right about 10 months that separation anxiety starts. So if you think of separation anxiety as the beginning of practicing, practicing more in the sense that mom is your home base but as you learn to walk you now have a new source, a new perspective, and you are starting to get around more. But at the same time you would then be meeting more people, and bumping into more people as you are walking. So that’s when stranger anxiety would logically and appropriately fit. It gets to be called "love affair with the world" at that time of emotional refueling, and so forth. Constantly coming back to mom. It gives you the energy to gradually get stronger and stronger, to be able to get away from mom more, and it’s practicing to get to the next stage.

There are some thoughts behind whether it really can be simply a matter of who’s at home in some sense because mom biologically is the person who has delivered the child, is there some kind of connection that’s different that dad can develop? Hard to say, but since children will also bond quite well with their primary caretaker, such as a nanny or someone else, in replacement if mom is not there. It doesn’t seem like the biological component.

Then of course we go to the comics where you look at the Far Side where you have the little guy carrying the head into the classroom, and we see what can happen as a child starts getting away on their own more.

Then there are other general theories that are pretty important that again tend to always come up in a lot of lectures and tend to show up in a lot of different examinations, whether they be practice exams or other places. The other theorists that you probably need to know of, or at least just generally know of the concept, if not necessarily knowing more detail, have to do with Chesson Thomas.

Developmental activities: this didn’t come out on the slide itself or on your outline, but what I have listed, put in there, had to do with some of the common things you’ll see at the ages of two, three, four and five. So if you have your list handy, and I’m sure you’ll have many of these types of lists in general neurology or psychiatry books, it’s worth knowing a few things. Gesell development is always worth being aware of in your general day-to-day practice if you are going to work with kids, as well as for examinations and some of the common visual, motor types of recognition for Gesell would have to do with just knowing the general figures, knowing how to draw a circle at the age of two-years, a cross or a plus at the age of three years.

Then you would move forward to a lot of the diagnoses of infancy, childhood and adolescence and I tried to focus more on these areas, even though of course there are a lot of diagnoses that will commonly be part of adolescence and childhood that you’ll need to be aware of, and I’m sure you are going over in a certain amount of detail. Things like mood disorders and anxiety disorders later on. We can touch on those a little bit later. In terms of the childhood components, the main things to be aware of, the main diagnoses would have to do with mental retardation, learning disorders, motor skills disorders, communication disorders, the different PDD’s, ADD and other disruptive behavior disorders, feeding and eating disorders of early childhood.

You have the Vimerend, which is more for looking at where the child generally is at socially and that’s from birth on. So sometimes it’s important to be aware at what point you can use these tests. There’s the Leiter International Performance Scale, which is commonly used to measure intelligence for many different areas, probably most well known for deaf children.

To move further ahead the childhood diagnoses, aside from what I mentioned, include tic disorders, elimination disorders such as enuresis and encopresis. And some other commonly described topics, separation anxiety disorder, selective - which used to be called elective, but now selective - mutism, reactive attachment disorder, stereotypic movement disorder and then the other not otherwise specified disorders. Some of my least favorite names from the DSM, the old NOS. But mental retardation will include several main areas. You are looking at, if you are going to do a breakdown, from mild all the way down to profound.

Then you move to learning disorders. You are looking at standardized testing, being below what would be expected for the age, the educational level, the IQ, and depending on what book you pick up you will see learning disorders are thought to be anywhere from about 10-15% in the United States of all children, although identified roughly in about 5%.

Okay, moving right along. While we are not doing this at the comedy corner or some other place, but you have reading, mathematics and learning disorder of written expression are the primary types of learning disorders. These are very big sources of difficulty, probably more likelihood of coming into a psychiatrists office, a child with attention deficit disorder along with other complications, other psychiatric disorders, learning disorders versus ADD symptoms often in children coming into the neurologists office. Often more neurologic damage, mental retardation and so forth. But nevertheless, it’s going to come up for all of us no matter how you slice it.

Communication disorders also important. You have the expressive language disorder versus a mixed receptive in expressive language disorder, and then you have chronological disorder, which is afraid of articulation disorder. Stuttering, which will be in a couple percent of children as well, and generally knowing how to treat these things you’d have to speak to a language person involved of course. Stuttering, typically you would have one of the main treatments is having a person working with the child, talking very slowly, clearly and enunciating.

Then you have the other language disorders you are looking at that aren’t part of pervasive developmental disorder or aren’t a type of PDD. You have the mixed and expressive showing results that are again below the non-verbal intellectual capacity in testing.

Pervasive developmental disorders … I don’t know, do you all know if this is going to be a topic already covered in the neurology section? I didn’t see it in too much depth when I looked at the outline. Okay, so we can go into this in a little more detail then. But you have a couple of main areas worth knowing. Obviously this could come at you from the neurologic or psychiatric side, so you never know which type of question it would fall under. But you have autistic disorder, of course. Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder.

Important things to know: autism, there are three main areas that you need to be aware of. You have the social component, or the qualitative impairment in social interaction so you just keep the key buzz words. Social, language and the repetitive or communicative … the stereotypics that are part of that. So sometimes my old mnemonic would be SLR. So you think of the language component, you have social, language and repetition. So you have the social interaction, qualitative impairments in communication and they are restricted. Repetitive and stereotype patterns that will often include multiple components of behavior, interests and activities.

To move along with autism, it obviously again can’t be due to one of the other PDD’s and you have to keep in mind as well the other language disorders, communicative disorders, to really know what you are dealing with. What else might be occurring. So you have delays or abnormal functioning, which will typically be seen prior to the age of three years in these areas that I just mentioned. And you’ll see a lot of symptoms in each of these areas that will show up from the symbolic to imaginative play.

So moving along: Rett’s disorder. Normal prenatal and perinatal development will occur but then in with psychomotor development from about zero to about five months, then you have the head circumference or the growth decelerating. It just stops continuing from about five months and after. So even though everything looks normal at birth and for the first few months, things just don’t progress from there. And a loss of a lot of the previously acquired skills will occur.

Asperger’s disorder is gradually getting more and more attention. You are primarily looking at the three main areas or characteristics of autism, except removing the language or communicative component. Where it’s actually still a problem in some ways but it’s different.

As I mentioned, the number one anxiety disorder is separation anxiety. The number one psychiatric disorder involves anxiety disorders in general. You also have to be aware of if you have something like a panic attack, it looks like, so in case you were to get an example.

Eating disorders are worth a little bit of review on as well, although it’s not a straight childhood disorder, they do come up in adolescence frequently and being aware of some of the basic differences between anorexia and bulimia, as well as a little bit about what each of them are. There’s the common characteristic that will be asked, remember, all the way back in medical school, the differences between the two and it’s always worth remembering a few of the differences; some of the cardiac problems are going to be periodically going to be for both.