Stubbe_FM_pi-xiv.qxd 8/11/06 7:05 PM Page i CHILD AND ADOLESCENT PSYCHIATRY A Practical Guide Stubbe_FM_pi-xiv.qxd 8/11/06 7:05 PM Page ii Stubbe_FM_pi-xiv.qxd 8/12/06 4:59 PM Page iii CHILD AND ADOLESCENT PSYCHIATRY A Practical Guide Dorothy Stubbe,M.D. Associate Professor of Child Psychiatry Training Director, Child and Adolescent Psychiatry Yale Child Study Center New Haven, Connecticut Stubbe_FM_pi-xiv.qxd 8/11/06 7:05 PM Page iv Acquisitions Editor/Publisher: Charles W. Mitchell Senior Managing Editor: Lisa R. Kairis Project Manager: Fran Gunning Manufacturing Manager: Ben Rivera Associate Director of Marketing:Adam Glazer Creative Director:Doug Smock Production Services: International Typesetting and Composition Printer:R.R. Donnelley, Crawfordsville ©2007 by LIPPINCOTT WILLIAMS & WILKINS,a Wolters Kluwer business 530 Walnut Street Philadelphia,PA 19106 USA LWW.com All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in the USA Library of Congress Cataloging-in-Publication Data Stubbe, Dorothy. Child & adolescent psychiatry : a practical guide / Dorothy Stubbe. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-7817-7831-2 (alk. paper) ISBN-10: 0-7817-7831-X (alk. paper) 1.Child psychiatry—Case studies. 2. Adolescent psychiatry—Case studies. I.Title. II.Title: Child and adolescent psychiatry. [DNLM: 1.Mental Disorders—diagnosis—Case Reports. 2.Adolescent. 3.Child. 4.Infant. 5.Mental Disorders—therapy—Case Reports. 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Lippincott Williams&Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10987654321 Stubbe_FM_pi-xiv.qxd 8/11/06 7:05 PM Page v Dedication This book is dedicated to the sources of my inspiration: my wonderful family (John, Grace, and Caleb), my residents and students, and the children and families who have entrusted themselves to my care. v Stubbe_FM_pi-xiv.qxd 8/11/06 7:05 PM Page vi Stubbe_FM_pi-xiv.qxd 8/11/06 7:05 PM Page vii Preface Working with troubled children and families is invigorating, rewarding, fascinating, frustrating, and confusing. Child and adolescent psychiatry is a discipline that can seem overwhelm- ing at first. There are parents, schools, protective services, pri- mary care physicians and many others providers with whom to collaborate. There are the complexities of the diagnostic inter- view with a child, which may require an enormous amount of creativity to help this child feel comfortable enough to engage, let alone communicate to you the personal information required for psychiatric understanding. It is a field that pulls at your most basic emotions—such as the wish to “adopt” your patients, over-identification with the vulnerability of the child patient, and wanting to undo the actions of “incompetent” par- ents. We are mandated reporters, which may necessitate “turn- ing in” parents to authorities. We are the professional experts called on by schools, courts, and social service agencies to make decisions that have a profound effect on the child and family, including decisions about hospitalization, custody, placement, and even incarceration. We undertake the intense work of supporting dying children and grieving parents. We are called on to answer complex developmental and behavioral questions from parents, pediatricians, other professionals, and the media. These are the tasks of learning the art and science of child and adolescent psychiatry. I vividly recall a child interview during my residency. I was called to the emergency department to evaluate a 10-year-old child who had been referred by the school because she had threatened to kill her teacher. My job, as delineated in a short memo from the school principal, was to attest to her safety, determine if the legal system or mental health system should be involved, and plan for her ongoing education if I was unable to ensure that she would be completely safe at school. So, shouldering that heavy burden, I entered the room to investigate these matters. There, sitting sullenly, was a 10- (appearing 16-) year-old African American girl who was with an emergency department “sitter” (the school had sent her alone by ambulance, and her mother was at work and couldn’t take off or she would lose her job, according to the social worker who had done an initial intake history). I introduced myself and began to launch into the history and mental status exam when, in sudden realization, I stopped short. The girl was not answering my questions. She had turned her back on me and was totally and utterly silent. Was she psychotic, vii Stubbe_FM_pi-xiv.qxd 8/11/06 7:05 PM Page viii viii Preface angry, oppositional, dissociating? I asked “are you hearing voices?” to which I received a curt reply—“No, you f—ing moron. Just get out of here!” Actually, that was a tempting proposition at that point, but I had my job to do. I sat a good long while thinking. Finally, I reached over for some play doh (which was there for monitored play) and began to squish at it and offered her some, which she finally picked up and squished as well. Finally, at my wit’s end, I said the obvious. “Well, what to do? I guess you don’t want to be here and you are stuck with a psychiatrist who is supposed to figure out if you are safe. What do you suggest we do?” She gazed at me for the first time, looking incredulous. “What do you mean, what do I suggest? You are the shrink! You can read my mind. You tell me!” I admitted that, actually, I could not read her mind (I wasn’t completely sure that she knew that) and that I did not know what to do—but I would like to hear her side of the story of what happened at school. To my utter amazement, she told me. She told of living in a scary neighborhood where only the tough survive—and she was a survivor. She told me she was not very smart (which was actually not at all true) and of the indignities foisted on her by her teacher when she did not know an answer. “I guess I just couldn’t take it anymore,” was her final statement. The girl was admitted to the children’s psychiatric inpa- tient unit, where I was rotating. I was her doctor. I learned many things from her (and from the fabulous supervision I received around her care). I learned that children are not just miniature adults even though (as in her case) they may look like it. I learned that engaging with a child uses many modal- ities. I learned that what is asked by schools and others may be impossible to do or, even more importantly, may not even be the right questions to ask. I learned that children know honesty when they see it—and they know when they are being manipulated. I learned that building rapport with both the child or adolescent and his or her caregiver (either one alone will not do) is the essence of any treatment. I learned that there are no books to address the must-know practicali- ties of child and adolescent psychiatric care. I could learn the Diagnostic and Statistical Manual (DSM). I could learn about psychopharmacology, epidemiology, and components of a workup. But I longed for a practical “how to” guide that would provide helpful advice in my work with complicated patients, situations, and dilemmas. The Practical Guide series is just that—a series of manuals that provide practical, user friendly, and engaging material Stubbe_FM_pi-xiv.qxd 8/11/06 7:05 PM Page ix Preface ix that may be used in clinical practice. I chose to write this manual on child and adolescent psychiatry because, as a for- mer trainee, as a clinician educator, and now as a training director for child and adolescent psychiatry residents, these are the gems that I have accumulated. This is the advice I now attempt to impart to residents. This manual serves as an orga- nization of the pearls of clinical practice in child and adoles- cent psychiatry—from mnemonics to recall diagnostic crite- ria to clinical vignettes to important tips for working with children and systems. This is a manual that may be used by child and adolescent psychiatry residents and many more— medical students, psychiatry residents, other mental health professionals, and even more seasoned practitioners. Working with children and families with psychiatric dis- abilities is, in my mind, the most fascinating, needed, and rewarding of all careers. I hope this manual conveys my love and dedication to children, to my profession, and to teaching. This manual does not take the place of textbooks, journals, literature reviews, intensive supervision, or clinical experi- ence. However, I do hope that this book will find its way into the pockets of and be useful to all clinicians who embark on the crucial mission of treating children who are suffering from psychiatric disorders. Stubbe_FM_pi-xiv.qxd 8/11/06 7:05 PM Page x