Child & Adolescent Mental Health A Practical, All in One

Guide

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For my mother, Joyce, who showed me the wonder of childhood; and
for my father, Eugene, whose dinner table stories about his patients
kept me on the edge of my seat.

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 Contents

Acknowledgments
Preface
A Note About Clinical Studies
Foreword by Harvey Karp, MD, FAAP

1: Introduction
2: Prevention
3: Attention-Deficit/Hyperactivity Disorder
4: Disruptive Behavior Disorders
5: Learning Disorders
6: Communication Disorders
7: Intellectual Disability
8: Autism Spectrum Disorders
9: Tourette’s and Tic Disorders
10: Anxiety Disorders
11: Trauma
12: Depression
13: Bipolar Disorder
14: Suicide and Self-Injurious Behavior
15: Schizophrenia and Psychosis
16: Substance Use Disorders
17: Eating Disorders
18: Sleep Disorders

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Appendix: Child and Adolescent Psychopharmacology
References
Index

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 Preface

Emerging evidence continues to point to an increase in the prevalence of mental

health problems among children, adolescents, and young adults. The surgeon
general reports that 20% of children and adolescents within the United States—
15 million youth—have a diagnosable psychiatric or developmental disorder
(U.S. Department of Health and Human Services, 1999). Whether this increase is
due to better diagnosis, an actual increase in prevalence, or both is unknown, but
half of all lifetime cases of mental illness are now recognized to begin by age 14
and three quarters by age 24 (R. C. Kessler, Berglund, et al., 2005). Despite
effective treatments, however, there are typically long delays, sometimes
decades, between when individuals first experience clinically significant
symptoms and when they first seek and receive treatment. In fact, the median
amount of time between when children first experience a psychiatric disturbance
and when they first receive treatment is nine years (R. C. Kessler, Berglund, et
al., 2005).
Diagnosable anxiety disorders affect approximately 32% of adolescents aged
13 to 18 years; disruptive behavior disorders impact 19%, mood disorders impair
over 14%, and substance use disorders affect over 11% (Fleming & Offord,
1990; Kashani, Sherman, Parker, & Reid, 1990; R. C. Kessler & Walters, 1998;
Merikangas, He, Burstein, et al., 2010; D. Shaffer et al., 1996). Other mental
illnesses, such as attention-deficit/hyperactivity disorder (ADHD, with a
prevalence of 3% to 11%), affect smaller numbers but are ubiquitous among
children, adolescents, and young adults, causing an untold amount of suffering
and lost productivity for both children and their parents (Lewinsohn, Klein, &
Seeley, 1995; Visser et al, 2014). Although federal government spending on
antidrug measures increases each year and in 2014 totaled over $25 billion, more
than 50% of high school seniors have experimented with an illicit drug, 25%
have used an illicit drug within the past 30 days, and over 20% have engaged in
binge drinking (e.g., consumed five or more alcoholic drinks in a row) within the
past 14 days (Johnston, O’Malley, Miech, Bachman, & Schulenberg, 2013).
Traumatic childhood experiences, such as being abused, witnessing abuse, or
being raised in a home with a mentally ill member, affect over 50% of children
and greatly increase the likelihood of later-onset substance abuse, mental illness,
smoking, sexually transmitted disease, and obesity, all leading causes of death

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among adults (Felitti et al., 1998). Suicide, the most feared and tragic outcome of
mental illness, has remained for many decades the third most common cause of
death among adolescents and young adults, preceded only by accidents and
homicide (R. N. Anderson & Smith, 2005; Centers for Disease Control and
Prevention, National Vital Statistics System, National Center for Health
Statistics, 2010).
In addition to simply documenting the epidemiology of mental illness and
engaging in treatment, the field of child and adolescent psychiatry is currently
making major strides in uncovering the etiology of some of the illnesses affecting
our youth. Through basic scientific research and clinical investigation, our
understanding of the neurobiological basis of mental illness has grown
immensely over the past three decades. Putative genes have been identified for
Tourette’s syndrome, ADHD, and many syndromes resulting in intellectual
disability, and advances in neuroimaging have allowed us to better understand
many of the neural networks involved in ADHD, schizophrenia, autism,
obsessive-compulsive disorder, and dyslexia (Abelson et al., 2005). As our
understanding grows, so will our ability to target treatments for these illnesses.
Concurrent with the research advances, the growth in evidence-based treatments,
including medications and psychotherapies, has already advanced our ability to
treat specific symptoms, such as psychosis, mania, tics, anxiety, hyperactivity,
and depression, allowing many individuals to lead healthy, happy, and productive
lives.
To be mentally ill in the United States is to be keenly aware of the lack of
sufficient services and practitioners. In fact, an adult in the midst of a psychotic
episode is three times more likely to end up in jail than in a hospital. It is
estimated that more than 300,000 mentally ill people are in jails and prisons and
another 500,000 are on court-ordered probation, where they generally do not
receive the care they need. Perhaps most shocking, the largest public mental
health facility in America is not a hospital, but rather the Los Angeles County
Jail, which typically houses 3,000 mentally ill inmates on any given day (Earley,
2006). As previously noted, mental illness generally begins in childhood, and
studies of youth in juvenile detention have found remarkably high rates of mental
illness. Teplin, Abram, McClelland, Dulcan, and Mericle (2002) found that
nearly two thirds of males and three quarters of females met diagnostic criteria
for one or more psychiatric disorders, and others have shown similarly high rates
(Duclos et al., 1998; McCabe, Lansing, Garland, & Hough, 2002; Wasserman,
McReynolds, Lucas, Fisher, & Santos, 2002). Further complicating the lack of
appropriate services is the lack of adequately trained practitioners.
Mental health practitioners who treat children and adolescents—including
social workers, psychologists, educational specialists, and psychiatrists—are in
short supply. The United States’ Federal Bureau of Health Professions has named
child and adolescent psychiatry as the most underserved of all medical
subspecialties. The current workforce consists of approximately 8,300 child and

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adolescents psychiatrists, whereas the need has been estimated to be over 30,000
(American Medical Association, Physician Masterfile, 2012; W. J. Kim, 2003;
Thomas & Holzer, 2006). Child and adolescent psychiatrists are not alone,
however, as the national need for child and adolescent social workers,
educational specialists, and psychologists is equally great. Even worse, the
distribution of child and adolescent psychiatric services disproportionately favors
those in urban areas with an elevated socioeconomic status (American Medical
Association, Physician Masterfile, 2012).
The disparity in service delivery is also notable. While one in three Caucasian
children receive the mental health care they need, the same is true for only one in
five African American children and only one in seven Latino children
nationwide. Many have advocated that we provide mental health care to our
children by establishing clinics in public schools. Such clinics have repeatedly
demonstrated themselves to be effective in accessing youth, yet fewer than 10%
of our 80,000 public schools provide comprehensive mental health services at
this time (U.S. Department of Health and Human Services, 1999). Equally
concerning is the fact that although we have many effective treatments, only
approximately 20% of youth with a diagnosable mental illness receive care, and
of these individuals, only 2% receive a treatment known to be effective
(Merikangas, He, Brody, et al., 2010).
In the face of service demands that overwhelm our ability to provide care for
the many children and families in need, we face a potentially crippling trifecta—
first, children represent an underserved and disenfranchised group with no voice
of their own when it comes to policy and organizational decision-making;
second, although our society has taken great strides, there remains significant
stigma attached to those with mental illness and to families with a child who is
ill; and finally, within the medical establishment itself, psychiatry (and
particularly child psychiatry) suffers an undeserved reputation as an ineffectual
and weak discipline couched within soft science. This book represents an effort
to address these concerns and is aimed at an audience of first-line treatment
providers.
Few texts currently exist that explain the core scientific knowledge and
clinical application of this knowledge for an audience of primary care
practitioners and psychotherapists. While the requirements for training child and
adolescent psychiatrists are formally circumscribed by the Accreditation Council
for Graduate Medical Education, the vast majority of child and adolescent mental
health services worldwide are provided by primary care physicians,
psychologists, and all manner of therapists, ranging from master’s-level social
workers to marriage and family therapists (Accreditation Council for Graduate
Medical Education, 2007). In the United States, nearly 85% of all prescriptions
for psychotropic medications for children, including stimulants, antipsychotics,
antidepressants, anxiolytics, and mood stabilizers, are written by primary care
practitioners, yet these individuals generally receive virtually no formal training

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in child and adolescent mental health (R. Goodwin, Gould, Blanco, & Olfson,
2001). Understandably, most primary care physicians and therapists do not feel
comfortable treating child and adolescent mental illness, but given the paucity of
trained specialists, they have little choice.
Consequently, this text has been written as a comprehensive but user-friendly
guide for those practitioners who provide the vast majority of child mental health
care but who have the least amount of training. This book describes the basics of
child and adolescent mental health and psychopathology and the treatments that
have been shown to work, including medications, psychotherapies, and
psychosocial interventions. I am hopeful that it will have great value for a variety
of health care practitioners, including pediatricians, family practitioners, nurse
practitioners, general psychiatrists, psychologists, occupational therapists, speech
and language therapists, social workers, and marriage and family therapists, who
all too often find themselves confronted with a mentally ill child whom they feel
ill equipped to help. This book also provides the core clinical knowledge
necessary for entry-level child and adolescent psychiatry residents and
psychology interns, and as such I am also hopeful that it will serve as a useful
primer for these trainees as well. In addition, this book will have utility as a
reference for schoolteachers, school counselors, and concerned parents. Finally,
there are a host of undergraduate and graduate courses in child and adolescent
psychopathology at colleges and universities nationwide for which this book
could serve as a core text. My greatest wish for this book is that it be a “call to
arms” of sorts, encouraging those who work with, care for, and treat mentally ill
children and adolescents to utilize the material within these pages to advocate
more research, expanded efforts at prevention, earlier screening, and better
treatment of our children.

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 A Note About Clinical Studies

Throughout this book, numerous treatment studies will be referenced. To

properly interpret these studies, it is important for the reader to have a grasp of
various types of methodologies employed in clinical investigations.
Randomized, double-blind, placebo-controlled trials are the gold standard or
best type of clinical intervention study, regardless of whether it is a medication,
psychotherapy, or community intervention that is being investigated. In these
studies, participants are randomly assigned to treatment groups. In one group, the
subjects receive an active treatment—for example, a medication under study. In
the other group, the subjects receive a placebo or sham treatment. Neither the
subject nor the practitioner dispensing the treatment is aware of which treatment
is being given, thus the “double-blind” component. There are numerous other
types of studies that can be performed, but none provides us with data as reliable
as the randomized, double-blind, placebo-controlled trial.
Sometimes a single randomized, controlled study does not provide adequate
information about a treatment, and the best answer to the study question can be
found by combining the results of numerous trials. Systematic reviews report the
results from many studies. A meta-analysis combines many randomized,
controlled trials and reanalyzes the data by putting it into summary form. Meta-
analyses are limited in their utility by the “worst” or most limited study among
the group, but the results from such pooled analyses often remain very useful.
When it is impossible, unethical, or too expensive to employ a blinded
approach, we sometimes engage in treatment studies in an open-label fashion,
such that both the subjects and the practitioner know which treatment is being
delivered. Open-label studies do not employ a placebo, and therefore it is
impossible to determine how many subjects improve simply because they are
taking a medication or receiving a therapy, regardless of its effect. Still, open-
label studies are often utilized for medications and treatments that are new to the
market and provide useful results for the later construction of more detailed and
sophisticated studies.
Randomized, controlled trials are expensive and take a great deal of time and
effort. Consequently, researchers often use observational studies in which groups
of people are followed or observed over time. Observational studies may take
many forms, including case-control studies, cohort studies, chart reviews, and

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case reports. In a case-control study, two groups of individuals are viewed
retrospectively to determine what caused the disorder or illness. The “cases” are
those who have a certain disorder or illness under study, whereas the “controls”
are an otherwise similar group who do not have the disorder or illness. By
contrast, cohort studies prospectively follow a group of individuals who have
experienced a similar exposure or share a common characteristic. They are
followed over time to substantiate or refute an association between a given
exposure or characteristic and a health outcome. Chart reviews and case reports
similarly describe the experiences of individuals who have received certain
treatments, but these analyses are highly subjective and open to numerous types
of bias. Thus, while observational studies are often quicker to complete and are
certainly less expensive, their results are generally not highly reliable.
Many studies will be discussed throughout this book. While our greatest
power comes from multicenter randomized, double-blind, placebo-controlled
trials, we have relatively few of these studies among children and adolescents.
Consequently, we must often draw inferences from among the remaining open-
label studies and observational data that are available to us, in addition to our
clinical experience and evidence from studies of adults.

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 Foreword

As every primary care provider knows, the impact of mental illness on children,
adolescents, and families is staggering. Diagnosable anxiety disorders affect one
third of adolescents, disruptive behavior disorders affect one fifth, mood
disorders affect one seventh, and substance dependence affects one tenth.
Roughly 5% to 10% of children struggle with ADHD, and traumatic childhood
experiences, which significantly increase the risk of substance abuse, mental
illness, smoking, sexually transmitted infections, and obesity, affect over 50% of
our children. Pediatricians are commonly the first line of defense for a child’s
mental health concerns, but they often lack sufficient training and experience in
how to handle these problems. Similarly, therapists, another line of defense, are
often not educated in the complexities and broad needs of children with
psychiatric disorders.
If I suspect a child in my care has diabetes, I run a few simple blood tests. If I
am concerned about strep throat, asthma, or an ear infection, I administer a few
other tests. But when I visit with a child who is irritable, hyperactive or
inattentive, sad, angry, shy or withdrawn, I have no blood test or other instrument
to guide me. Unfortunately, this absence of straightforward psychological metrics
is a daily problem for those of us caring for children. Study after study finds that
between 25% and 50% of pediatric office visits involve an emotional, behavioral,
or learning concern. Yet the training of pediatricians and family doctors is so
focused on the many pressing medical problems they may face in practice that
they end up receiving woefully little training in caring for the behavioral and
emotional problems of the children and families they will care for in their
communities. Equally concerning is the fact that most psychotherapists are not
trained to work specifically with children and adolescents, even though they are
often called on to do so in daily practice.
Enter Dr. Shatkin’s Child & Adolescent Mental Health: A Practical, All-in-
One Guide.
Flip through a few pages, and you will see that Dr. Shatkin, one of the
leading child and adolescent psychiatry educators in the United States, has culled
the most relevant and useful data from thousands of sources and over two
decades of clinical experience to provide the reader with an up-to-date,
accessible, and compelling understanding of not only what goes wrong for kids,

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but also how to fix it. This guide is intended for all first-line workers in the battle
against child and adolescent mental illness—pediatricians, family docs,
psychologists, social workers, school counselors, and teachers. Medical students
and residents in pediatrics and psychiatry in particular will find a wealth of
valuable information in these pages that will help them with each of their patients
every single day.
In 2013, a new version of the Diagnostic and Statistical Manual of Mental
Disorders was published by the American Psychiatric Association. This “bible”
of psychiatric diagnostics, now in its fifth edition, is extremely helpful in
identifying the symptoms that are typical in depression, ADHD, anorexia
nervosa, and so forth. However, the DSM doesn’t tell you how to take a patient
from symptoms to wellness. Dr. Shatkin’s book does.
Following two introductory chapters, Dr. Shatkin takes the reader on a tour
through the most common disorders facing children, adolescents, and families,
and what can be done about them. Evidence-based and extremely readable, Child
& Adolescent Mental Health: A Practical, All-in-One Guide delivers exactly
what it promises—a thorough, fascinating, and, most of all, essential toolkit for
those who work with children, adolescents, and their families.
For the last five years, Dr. Shatkin’s first edition of this book, Treating Child
and Adolescent Mental Illness, has helped thousands of practitioners and families
to understand what’s gone wrong and how to get kids well. And it’s no wonder—
Dr. Shatkin leads the educational efforts of the Child Study Center at the NYU
Langone Medical Center, one of the world’s leading centers of clinical care,
research, and education in the field of child and adolescent mental health. Dr.
Shatkin spends his days teaching college and medical students, psychiatry and
pediatric residents, and subspecialty fellows in child and adolescent psychiatry.
He also engages in research in medical education, sleep, and mental health
promotion and disease prevention. But most importantly, Dr. Shatkin provides
clinical help to those who need it every single day, and he is sharing his “toolkit”
with you here. Whether you read it cover to cover or use it as a case-by-case
reference, this book will change how you clinically practice for the better.
—Harvey Karp, MD, FAAP

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Child & Adolescent Mental Health

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 1

Introduction

Working with children, adolescents, and their families is an honor and a

privilege, yet those of us who help youth struggling with difficulties related to
their emotions, behavior, and cognition are few in number. The field of child
mental health remains young. The American Academy of Child and Adolescent
Psychiatry has been in existence for just over 60 years, and still the need for child
and family mental health practitioners remains staggering. Given the paucity of
child and adolescent psychiatrists and psychologists, there is an enormous
demand upon other medical professionals such as pediatricians, social workers,
general psychiatrists, and psychologists not trained directly to work with
children, along with all manner of physicians, including family practitioners and
internists, to help address the mental health needs of children and adolescents.

HISTORY

Prior to the 17th century, children were not generally considered deserving of
basic human rights. Recognizing and demarcating childhood itself as a separate
and necessary period of time to be cherished and during which time children
should be nourished, encouraged, supported, and allowed to move through innate
developmental phases appears to be a result of social changes emanating from the
Victorian age. Between the 17th and 18th centuries, it is estimated that up to 70%
of children died before reaching 5 years of age. In fact, it was not until the mid-
1800s in Western societies that all children were presumed to have the right to
some level of education and access to health care. This currently unimaginable
situation becomes somewhat understandable when we recognize that because the
child mortality rate was remarkably high until 200 years ago, families often did
not emotionally invest fully in their children until they had lived past their fifth
year, by which point many key developmental milestones had been passed.
Although mental illness was described in adults prior to the 18th century,

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