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 Clinical Child
Psychiatry,
Second Edition

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
© 2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94
 Clinical Child
Psychiatry,
Second Edition
Editors
William M. Klykylo and Jerald L. Kay
Wright State University School of Medicine, Dayton, Ohio, USA
Copyright © 2005 John Wiley & Sons Ltd, The Atrium, Southern Other Wiley Editorial Offices
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 DEDICATION
To our teachers, our students, our patients, and our families.
 Contents

Dedication v Chapter 11 Disruptive Behaviour Disorders 191

Preface ix Niranjan S. Karnik and Hans Steiner
List of Contributors xi
Chapter 12 Child and Adolescent Affective
Disorders and their Treatment 203
Section I The Fundamentals of Child and
Rick T. Bowers
Adolescent Psychiatric Practice 1
Chapter 13 Anxiety Disorders in Childhood
Chapter 1 The Initial Psychiatric Evaluation 3
and Adolescence 235
William M. Klykylo
Craig L. Donnelly and
Chapter 2 Psychological Assessment of Debra V. McQuade
Children 21
Chapter 14 Substance Use in Adolescents 263
Antoinette S. Cordell
Jacqueline Countryman
Chapter 3 Neurobiological Assessment 49
Chapter 15 Childhood Trauma 275
George Realmuto
Sidney Edsall, Niranjan Karnik
Chapter 4 Educational Assessment and and Hans Steiner
School Consultation 65
Dorothyann Feldis
Section III Developmental Disorders 295
Chapter 5 Psychiatric Assessment of Medically
Chapter 16 Attachment and its Disorders 297
Ill Children, Including Children
Jerald L. Kay
with HIV 75
David M. Rube and G. Oana Costea Chapter 17 The Eating Disorders 311
Randy A. Sansone and
Chapter 6 How to Plan and Tailor Treatment:
Lori A. Sansone
An Overview of Diagnosis and
Treatment Planning 91 Chapter 18 Elimination Disorders: Enuresis
Brian J. McConville and and Encopresis 327
Sergio V. Delgado Daniel J. Feeney
Chapter 7 Assessment of Infants and Chapter 19 Sexual Development and the
Toddlers 109 Treatment of Sexual Disorders
Martin J. Drell in Children and Adolescents 343
James Lock and Jennifer Couturier
Chapter 8 Play Therapy 119
Susan Mumford Chapter 20 Learning and Communications
Disorders 361
Chapter 9 Cognitive Behavioral Therapy 129
Pamela A. Gulley
Christina C. Clark
Chapter 21 The Autistic Spectrum Disorders 371
Section II Common Child and Adolescent Tom Owley, Bennett L. Leventhal
Psychiatric Disorders 151 and Edwin H. Cook, Jr.
Chapter 10 Attention Deficit Hyperactivity Chapter 22 Mental Retardation 391
Disorder 153 Bryan H. King, Matthew W. State
David M. Rube and Dorothy P. Reddy and Arthur Maerlender
viii CONTENTS

Chapter 23 Tic and Tourette’s Disorder 415 Chapter 27 Sleep Disorders 487
Barbara J. Coffey and Martin B. Scharf and
Rachel Shechter Cyvia A. Scharf
Chapter 28 Loss: Divorce, Separation,
Section IV Special Problems in Child and
and Bereavement 507
Adolescent Psychiatry 431
Jamie Snyder
Chapter 24 Psychotic Disorders 433
Chapter 29 Foster Care and Adoption 521
Michael T. Sorter
Jill D. McCarley and
Chapter 25 Neuropsychological Assessment Christina G. Weston
and the Neurologically Impaired
Chapter 30 Child Psychiatry and the Law 531
Child 447
Douglas Mossman
Scott D. Grewe and
Keith Owen Yeates
Index 553
Chapter 26 The Somatoform Disorders 471
David Ray DeMaso and
Pamela J. Beasley
 Preface To Clinical Child Psychiatry,
Second Edition

In the preface to the first edition of this work, we stated who in the United States now provide the preponder-
that the changes in child psychiatry occurring then ance of child psychiatric services, will find this volume
would have been barely imaginable 15 years earlier. useful. We also wish it to be informative to profes-
Pari passu, we could not have predicted then how much sionals outside of medicine as an overview of what
the whole world would change thereafter. Yet a world child psychiatry can – and should – do today. As
in crisis has only intensified the demands placed upon always, but in these times especially, we must work
child and adolescent psychiatry. We have ever-growing together as best we can.
demands for service to our patients, whose stressors Whatever its merits, Clinical Child Psychiatry,
and pathology become more severe and pervasive. We Second Edition, is the product of the many individu-
are fortunate that our understanding of disease and als’ efforts. We have been well served by our publisher
our armamentarium of treatments also continue to John Wiley and Sons, Ltd, and especially by our con-
increase. Regrettably, the resources allocated for those sultants Charlotte Brabants, Deborah Russell and
treatments have not always grown apace; and so we Andrea Baier. They bring to their work an enviable
must continue to do more with less and do so ever combination of knowledge, experience, patience, and
more quickly and efficiently. good humor that has encouraged and sustained us. We
The welcome growth of knowledge in our field has could not have assembled this book without the
effected changes in clinical practice and created a need support of our staff at Wright State University, most
for an update of this book. Like its predecessor, notably Edward Depp. David Rube, who served as
Clinical Child Psychiatry, Second Edition, is presented co-editor of the first edition, was able to assist us as an
neither as a comprehensive textbook covering the editorial consultant as well as the contributor of two
entire field, nor as a brief introduction. It still attempts chapters. Our contributors are the ultimate source of
to serve as a focused study of major problems, chal- this volume’s content and value, and we are in their
lenges, and practices commonly encountered in clini- debt. Finally, our families continue to support us with
cal work. It remains directed toward experienced their affection and patience.
clinicians encountering new areas of practice, as well
as to students and residents entering the field. We espe- William M. Klykylo
cially hope that pediatricians and family physicians, Jerald L. Kay
 Contributors

Pamela J. Beasley, Harvard Medical School and Craig L. Donnelly, Section of Pediatric Psychophar-
Department of Psychiatry, Children’s Hospital of macology, Dartmouth-Hitchcock Medical Center,
Boston, Hunnewell 121, 300 Longwood Ave, USA One Medical Center Drive, Lebanon, NH 03756-
0001, USA
Rick T. Bowers, 1331 Talon Ridge Court, Kettering,
OH 45440, USA Martin J. Drell, LSU Medical School, 1542 Tulane
Ave, Room A 328, New Orleans, LA 70112-2822,
Christina C. Clark, University Psychological Services USA
Association, Inc., 1020 Woodman Drive, Suite 225,
Dayton, OH, USA Sidney Edsall, Department of Psychiatry, Stanford
University, 401 Quarry Road, Palo Alto, CA 94305
Barbara J. Coffey, Child Study Center, New York Uni-
versity School of Medicine, 577 First Avenue, New Daniel J. Feeney, Pediatric Psychiatry Services,
York, NY 10016, USA Willford Hall Medical Center (WHMC), 59th
Medical Wing, 2200 Bergquist Drive, Lackland
Edwin H. Cook, Jr, University of Chicago, Depart- AFB, TX 78236, USA
ment of Psychiatry, MC 3077, 5841 South Maryland
Avenue, Chicago, IL 60637, USA Dorothyann Feldis, College of Education, 341
Teacher’s College, University of Cincinnati,
Antoinette S. Cordell, 5045 N. Main Street, Dayton, Cincinnati, OH 45221-0002, USA
OH 45415, USA
Pamela A. Gulley, Greene Country Educational
G. Oana Costea, Queen’s Children’s Psychiatric Center, Service Center, 360 E. Enon Road, Yellow Springs,
74-03 Commonwealth Blvd, Bellrose, NY 11426, OH 45387-1499, USA
USA
Scott D. Grewe, Tri-Cities Neuropsychology Clinic,
Jacqueline Countryman, 74th MDOS/SGOHC, 4881 303 Bradley Blvd., Suite 100, Richland, WA 99352-
Sugar Maple Drive, Wright Patterson AFB, OH 4497, USA
45435, USA
Jerald L. Kay, Department of Psychiatry, Wright State
Jennifer Couturier, University of Western Ontario, University School of Medicine, P.O. Box 927,
London Health Centre, 800 Commissioners Road Dayton, OH 45401-0927
East, Room E1-605, London, Ontario, Canada
Niranjan S. Karnik, Department of Psychiatry and
Sergio Delgado, Children’s Hospital Medical Center, Behavioral Sciences, Stanford University Medical
3333 Burnet Avenue, Cincinnati, OH 45229-3039, Center, 401 Quarry Road, Palo Alto, CA 94305, USA
USA
Bryan H. King, Professor of Psychiatry and Behav-
David Ray DeMaso, Harvard Medical School and ioral Sciences, University of Washington and Chil-
Department of Psychiatry, Children’s Hospital of dren’s Hospital and Regional Medical Center,
Boston, Hunnewell 121, 300 Longwood Ave, USA Seattle, WA
xii CONTRIBUTORS

William M. Klykylo, Department of Psychiatry, Dorothy Reddy, Queen’s Children’s Psychiatric

Wright State University School of Medicine, 627 S. Center, 74-03 Commonwealth Blvd, Bellrose, NY
Edwin C Moses Blvd, P.O. Box 927, Dayton, OH 11426, USA
45401-0927, USA
Lori A. Sansone, Premier Health Net, 6611 Clyo
Bennett L. Leventhal, University of Chicago, Depart- Road, Suite D, Centerville, OH 45459, USA
ment of Psychiatry, BH 440, 5841 South Maryland
Avenue, Chicago, IL 60637, USA Randy A. Sansone, Sycamore Primary Care Center,
2115 Leiter Road, Suite 300, Miamisburg, OH
James Lock, Department of Psychiatry and Behav- 45342-3659, USA
ioral Sciences, Stanford University School of Medi-
cine, 401 Quarry Road, Palo Alto, CA 94305-5719, Cyvia A. Scharf, Center for Research in Sleep Disor-
USA ders, 1275 East Kemper Road, Cincinnati, OH
45237, USA
Arthur Maerlender, Dartmouth-Hitchcock Medical
Center, One Medical Center Drive, Lebanon, NH Martin B. Scharf, Center for Research in Sleep Disor-
03757, USA ders, 1275 East Kemper Road, Cincinnati, OH
45237, USA
Jill D. McCarley, Department of Psychiatry, Wright
State University School of Medicine, 627 S. Edwin Rachel Shechter, Child Study Center, New York Uni-
C Moses Blvd, P.O. Box 927, Dayton, OH 45401- versity School of Medicine, 577 First Avenue, New
0927, USA York, NY 10016, USA

Brian J. McConville, Department of Psychiatry, Uni- Jamie Snyder, 3500 S. 91st Street, Lincoln, NE 69520-
versity of Cincinnati College of Medicine, MSB 1429, USA
7258, ML 0559, Cincinnati, OH 45267-0559, USA
Michael T. Sorter, Cincinnati Children’s Hospital
Deborah V. McQuade, Section of Child and Adoles- Medical Center, 3333 Burnet Avenue, Cincinnati,
cent Psychiatry, Dartmouth-Hitchcock Medical OH 45229, USA
Center, One Medical Center Drive, Lebanon, NH
03756, USA Matthew W. State, Department of Psychiatry, Wright
State University School of Medicine, 627 S. Edwin
Douglas Mossman, Division of Forensic Psychiatry, C Moses Blvd, P.O. Box 927, Dayton, OH 45401-
Wright State University School of Medicine, East 0927, USA
Medical Plaza, First Floor, 627 S. Edwin C. Moses
Blvd., Dayton, OH 45401-1461, USA Hans Steiner, Division of Child Psychiatry and Child
Development, Stanford University School of Medi-
Susan Mumford, Department of Psychiatry, Wright cine, 401 Quarry Road, Palo Alto, CA 94305-5719,
State University School of Medicine, 627 S. Edwin USA
C Moses Blvd, P.O. Box 927, Dayton, OH 45401-
0927, USA Christina G. Weston, Department of Psychiatry,
Wright State University, School of Medicine, PO
Tom Owley, University of Chicago, Department of Box 927, Dayton, OH 45401-0927, USA
Psychiatry, 5841 South Maryland Avenue, Chicago,
IL 60637, USA Keith Owen Yeates, Department of Psychology,
Children’s Hospital, 700 Children’s Drive, Colum-
George Realmuto, Department of Psychiatry, Univer- bus, OH 43205, USA
sity of Minnesota, F256/2B West, Riverside Avenue,
Minneapolis, MN 55454-1495, USA

David M. Rube, Queen’s Children’s Psychiatric

Center, 74-03 Commonwealth Blvd, Bellrose, NY
11426, USA
 Section I
The Fundamentals of
Child and Adolescent
Psychiatric Practice
 1
The Initial Psychiatric Evaluation
William M. Klykylo

This chapter serves as an introduction both to this text- social, and linguistic development; and identifies the
book and to the approach of patients and families in nature of the child’s relationship with his or her family,
child and adolescent psychiatric practice. Child and school, and social milieu.
adolescent psychiatrists should be broadly trained cli- Second, child and adolescent psychiatrists, like all
nicians able to address a variety of somatic, psycho- physicians, treat illnesses, bringing to bear an arma-
logic, and social needs of the patient and family. Their mentarium of somatic treatments and the more
approach should combine the caution and competence traditional skills of individual, family, and group psy-
required of a physician treating an individual patient chotherapists. Because of the breadth of training they
with a broad concern for that patient’s development receive, child and adolescent psychiatrists should have
in the context of family, school, and society. This special skill in appreciating the interaction among
textbook provides an overview of child and adoles- these therapies and their effects on one another and on
cent psychiatric practice while focusing on the more the child and family.
common areas of clinical practice. As such, it should Finally, in many cases, child and adolescent psychi-
serve the established practitioner as a rapid and acces- atrists will serve as consultants. This role is more
sible introduction to unfamiliar areas by taking into developed in our specialty than in most other areas
account the ever-expanding breadth of clinical prac- of medicine because of the constant disproportion
tice. For general readers or students in professions between the number of patients and the number of
other than medicine, this book will serve as an intro- clinicians. Inevitably, we consult and collaborate
duction both to the assessment and management of with parents, educators, and other professionals who
some commonly encountered clinical entities and to may see the child and family more frequently and
the range and standards of practice expected of a con- intensively than we do; because of the breadth of our
temporary child and adolescent psychiatrist. There are training, we should offer a special competence in coor-
currently about 6000 child psychiatrists in some sort of dinating these efforts. Concurrent with this role, we
clinical practice in the United States, whereas there are often must serve as advocates for children and their
between 7 and 12 million children with psychiatric families in today’s environment of great clinical needs
illnesses, as identified by DSM-IVTR criteria [1,2]. and comparatively limited resources.
Most of these children will not see a child and adoles-
cent psychiatrist and, in many instances, the parents,
Referral Sources
teachers, and other professionals attempting to
serve them may be unaware of the contribution that Because of the broad responsibility shared by child
child and adolescent psychiatry can make to the child’s and adolescent psychiatrists, our evaluations must
care. address not only a narrow consideration of clinical
The traditional roles of child and adolescent psy- diagnosis but also a larger set of issues that are truly
chiatrists are those of diagnostician, therapist, and biopsychosocial and require a more than casual com-
consultant. First, child and adolescent psychiatrists petence in each of these areas. We must therefore
should offer a child and family a comprehensive diag- address the specific needs and questions posed by each
nostic assessment that addresses the medical condition referral source. Children are today served by a variety
of the child; delineates the child’s emotional, cognitive, of individuals and agencies, each possessing their own

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
© 2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94
4 CLINICAL CHILD PSYCHIATRY

particular agendas and separately approaching physi- Collateral and Preliminary Information
cians and other consultants. These agendas must be
Today, most children who are seen by child and ado-
recognized and served, given today’s consumer-
lescent psychiatrists have already received a great deal
oriented society. At the same time, we have a respon-
of attention from other professionals. To fail to gather
sibility to those individuals seeking our professional
information from these people prior to a formal eval-
services to educate them with the wider range of con-
uation is a serious mistake, leading to wasted time and
cerns that may be affecting a given child’s or family’s
frustrated relationships. If at all possible, it is usually
life.
most efficient to speak directly with a referring profes-
In today’s environment, we frequently receive refer-
sional. This is especially true in the case of primary
rals from, or may be employed in contractual relation-
care physicians, who may have a long-standing rela-
ships with, various social and legal agencies such as
tionship with the child and family. Other mental health
courts and departments of human services. Each
professionals referring a child usually have conducted
of these agencies has a particular agenda, generally
their own evaluation. Children’s school records can be
mandated by legislation or its charters, to determine
a rich source of information about their cognitive and
the eligibility of children for various services or
emotional development. Examination of all these data
proceedings. The agencies frequently approach their
can enrich an evaluation; similarly, failure to do so can
duties with an intense dedication to children but
lead to embarrassing lapses.
an incomplete familiarity with the knowledge and
Clinicians may at times be tempted to assess a child
assumptions that inform our practice. Referrals may
while deliberately ignoring collateral information, pre-
also come from teachers or schools. These referrals
sumably to evolve an unbiased assessment. There may
may be a result of the child’s behavioral disruptions or
be certain unusual situations in which this tactic is indi-
eccentricities, his or her academic difficulties, or simply
cated. More often than not, however, this approach
the distinct – if at times uncertain – perception of a
ignores the reality of the lives of children, who live in
dedicated teacher that something is wrong. Referrals
asymmetrical relationships with adults and agencies,
may come to us from other physicians. In today’s
both of whom have considerable knowledge and power
atmosphere of comprehensive primary practice, these
over them. In general, this approach is a departure
physicians may have already begun the diagnosis and
from best practices.
treatment of mental illness in a child, and established
an ongoing relationship with this child and his or
her family. Such referrals require a balanced response Encounters with Referring Professionals
of both expertise and respect. Finally, many referrals
come directly from parents, who are generally Often a child and adolescent psychiatrist’s first per-
very concerned about their child’s impaired function- sonal encounter in assessing a patient is with another
ing and suffering. They may bring to the process a professional – a clinician, educator, or case worker who
mixed heritage of concern, guilt, and shame, fre- has sought the evaluation. The enormous value of
quently fearing that they will be judged as they seek their information has already been addressed. The
help. Concurrent with this are often ambivalent feel- clinician must also recognize the sensitivities of these
ings of love and frustration toward a difficult child. people: they may be grateful for the opportunity to
The task of child and adolescent psychiatrists is to rec- meet with the psychiatrist and eager in their anticipa-
ognize all these needs and address them in a fashion tion of the evaluation, perhaps even to an unrealistic
that is not only authoritative but also tactful and degree. At the same time, the act of seeking a consul-
empathetic. tation may, at least unconsciously, signify to them a
failure on their part. They may be concerned that their
relationship with the child or family will in someway
Elements of the Evaluation be disrupted or supplanted, or that they will be criti-
This section provides an overview of the elements of a cized by the psychiatrist.
comprehensive child and adolescent psychiatric evalu-
ation in the context of contemporary knowledge and
Parents
patient needs. More detailed considerations of the
process of the clinical interview are also available [3–6]. Parents bringing their child to a child and adolescent
The assessment of particular disorders as well as lab- psychiatrist come with a rich and often contradictory
oratory, psychologic, and educational assessments is mix of feelings. Frequently they reach the psychiatrist
covered in other chapters of this book. at the end of a long, complicated process of evalua-
 THE INITIAL PSYCHIATRIC EVALUATION 5

tions and treatment attempts. They are almost invari- child and adolescent psychiatrists, is the developmen-
ably concerned and anxious over their child’s condition tal history. Child and adolescent psychiatrists must be
and prospects. In a way that may be difficult for those absolutely familiar with normal developmental pat-
who are not parents to understand fully, they may have terns, milestones, and expectations. Psychiatrists often
many fears about the consequences of a psychiatric approach these phenomena informed by traditional
referral, as do referring professionals. They may feel theories of psychosexual, social, and cognitive devel-
that they will be judged or, in extreme cases, that their opment. Although these theories frequently hold great
children will be removed from their care. In a more importance for their heuristic value, the clinician must
subtle way, they may also worry that their relationship remember that they are, at best, models or theories and
with their child will be supplanted or superseded. They not immutable facts. Thus, the clinician must also be
may be concerned about the moral and philosophic aware of contemporary empirical data about normal
basis of the psychiatrist’s approach, fearing that development and its variations. The developmental
parental ethical standards and religious beliefs will in history secured by a child and adolescent psychiatrist
some way be contradicted. Sometimes, simultaneously, should in many ways be similar in depth and breadth
they may have unrealistically optimistic or hopeful fan- to that obtained by a developmental pediatrician. At
tasies of ‘absolution’ of unconscious guilt, or of quick the same time, as psychiatrists we should focus special
cures. More often than not, in my experience, parents emphasis on the social and affective consequences of
have no idea of the specifics of psychiatric assessment developmental phenomena. In other words, we should
or treatment. Their opinions have been formed by mass be concerned not only about what age a child reached
media and public prejudice. Before any specific infor- a given milestone but how the occurrence of that mile-
mation can be gathered or plans made, the above issues stone affected that child and his or her family. We must
must be addressed, in the interest of time and efficiency recognize that some developmental processes or stages
as well as of engagement. Simply put, the child and may inherently be more or less comfortable for some
adolescent psychiatrist needs to understand how the parents, and that there is a wide range of variation
parents feel about the referral and what they expect to in the degree of comfort and discomfort that devel-
gain from it. opment engenders. Finally, we must recognize the
A great deal of information should be collected from great variations in developmental patterns and expec-
parents, since they know the child best. The details of tations found among different cultures. Summaries
this data collection, including various outlines for its of typical developmental sequences are found in the
organization, are described elsewhere in this book. Appendix.
Most child and adolescent psychiatrists today use a A detailed consideration of family dynamics and
traditional medical format to organize their data, with therapeutics is beyond the scope of this textbook. We
headings such as Chief Complaint, History of Present know from the contributions of clinicians with
Illness, Past Medical History, Family History, and approaches as diverse as those of Satir [7], Whitaker
Review of Systems. More often than not, the specifi- [8], Minuchin [9], and Haley [10] that the family has an
cally medical aspects of these data are already avail- immense and profound influence on the development
able. Not infrequently, however, child and adolescent of each of its members and may be viewed as a
psychiatrists encounter families that have not received distinct entity. It is therefore invaluable, as part of
regular primary pediatric care. In these cases, it is a comprehensive psychiatric observation, to spend
incumbent on the psychiatrist as physician to take a some time in the company of the entire family.
comprehensive medical history in addition to acquir- Frequently, families referred to us have already
ing other information. In all these areas of question- been assessed in this fashion by competent family ther-
ing, psychiatrists collect data as do all other physicians, apists, and the child and adolescent psychiatrist may
usually attempting to delineate and organize the infor- not need or have the opportunity to pursue extensive
mation in a chronological fashion. What is unique family treatment. Nonetheless, the opportunity to
about a psychiatric evaluation is that physicians pursue observe firsthand how the members of a family act
not only the specific data but also their affective impli- with each other can be enriching for a clinician
cations. In other words, they seek to find out not only attempting to understand the consequences of each
what specifically happened but how it made the child family member’s behavior on the others. In addition, if
or family members feel and what consequences it had this observation is done early, it may serve as a more
on their lives. comfortable entrance to the evaluation process for a
Another area of inquiry of particular importance to shy or otherwise recalcitrant child or other uncooper-
physicians treating children, and perhaps especially to ative family member.
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