What is Wrong with My Child: Ways to Help

By Emel A. Sumer MD.

One out of ten children suffer from some form of behavioral and emotional disorders. Left untreated, these issues can be life altering, leading to long-term mental health problems and even suicide. Early recognition and intervention is paramount in ensuring a healthy and happy development into adulthood. Parents usually struggle with the questions "What is wrong with my child?" and "What can I do to help?" Based on fifty years of clinical experience, the author provides practical advice and valuable information for parents, caregivers, and childcare professionals. The first section of the book contains chapters on assessment across broad spectrum of childhood development phases, including what is normal, what is not, and frequently seen psychiatric disorders and when to seek help. The second section contains frequently asked questions (FAQ) by parents and caregivers with practical answers. It is what every parent needs to know to ensure healthy emotional, behavioral, and cognitive development from infancy to adolescence.

• Language: English
• Publisher: Page Publishing, Inc.
• Release date: May 5, 2020
• ISBN: 9781645447191

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What is Wrong with My Child

Ways to Help

Emel A. Sumer, MD.

Copyright © 2020 Emel A. Sumer, MD.

All rights reserved

First Edition

PAGE PUBLISHING, INC.

Conneaut Lake, PA

First originally published by Page Publishing 2020

ISBN 978-1-64544-718-4 (pbk)

ISBN 978-1-64544-719-1 (digital)

Printed in the United States of America

Table of Contents

SECTION 1

Outline Biopsychosocial History

Family Assessment

Treatment

Ages Two to Six

Social Development

Development of Play

Therapy

SECTION 2

Epidemiology

Treatment

Case History

Case History

Epidemiology

Comorbidity

Etiology

Treatment

Psychopharmacology

Etiology

Comorbidity

Epidemiology

Etiology

Treatment

SECTION 3

Etiology

Etiology:

Case History

Etiology

Symptoms of Schizophrenia

Treatment

Assessment

Treatment

Pharmacological Therapy

Comorbidity

Epidemiology

Case Histories

Case 1

Case 2

Treatment

Case Histories

Case 1

Case 2

Case 3

Comorbidity

Etiology

Treatment

Environmental

Etiology

Treatment

Comorbidity

Prognosis

Treatment

Pharmacological treatments

Case History

Clinical Features

Psychopathology

Case History

Treatment

Epidemiology

Etiology

Treatment

SECTION 4

Epidemiology

Etiology

Treatment

Treatment

Epidemiology

Etiology

Treatment

Epidemiology

Etiology

Treatment

Treatment

SECTION 5

IN CHILDREN AND ADOLESCENTS

Terminology

CASE HISTORY

Treatment

Treatment

Pharmacotherapy

Epidemiology

Suicidal Adolescent

Evaluation of the Suicide Attempt

Warning Signs

High-Risk Parameters of Suicide

Case History

Low-Risk Case

Case History Case 1

Case 2

Treatment

Management

Treatment

Pharmacotherapy

Treatment

SECTIION 6

I am dedicating this, my life experience transcripts to my grandchildren: Nicolas, Adam and Paige Jendirsak and Holly, Tara, and Taner Sumer.

PREFACE

Child psychiatry is a comparatively new discipline. At the same time, over the last decade, there has been extraordinary progress. It has moved from psychoanalytic concepts to a biomedical field; many discoveries have been made in the research in development of diagnosis, and new clinical techniques have been increasingly gaining significance. In this book, I tried to include all updated information that would be helpful for parents.

Worldwide, 10−20% of children and adolescents experience mental health problems with age of onset being from twelve to twenty-four years. Mental health problems have been shown to contribute to low achievement in education, in risky behaviors, self-harm, suicide with depression, anxiety, and violence. This often persists into adulthood.

This book contains the most important disorders that are seen in children and adolescents, including case presentations and my experience of over fifty years as a child and adolescent psychiatrist.

This book is aimed to give information to not only parents who are raising their children but also to help childcare workers, school counselors, and mental health workers who help children and adolescents.

Each chapter communicates wisdom of child psychiatry, covering the most important topics, such as mood disorders, anxiety disorders, conduct disorders, ADHD, developmental disorders, psychotic disorders, and other topics of interest. It includes epidemiology, etiology, comorbidity, prognoses, and treatment.

The second part of the book contains questions and answers—questions most asked by parents. This is the practical part of the book that can be used as a reference by parents.

I am very grateful for what I have learned in close to fifty years in clinical and academic child and adolescent psychiatry. I am very grateful to my professor and mentor, Dr. E. James Anthony, for his teachings and supervision and for my colleagues, local and national, to the Academy of Child and Adolescent Psychiatry my residents, fellows, and most importantly, my patients and their parents.

SECTION 1

ASSESSMENT AND CHILD/ADOLESCENT DEVELOPMENT

Child and Adolescent Assessment

Child psychiatry is different from adult psychiatry just like pediatrics is different from internal medicine. Because both specialties deal with child and adolescent growth and development, an assessment has to be made with consideration of the development of the child. What is normal at age two, such as shadowing the mother or having separation anxiety, is not normal for a nine-year-old child. Or a four-year-old might have a vivid imagination claiming that he has seen a lion at the corner of the street, but if a nine-year-old child claims that he has seen a lion on the street, he is either joking or has problems with reality.

Children and adolescents usually do not come for assessment by themselves They are usually brought by their parents or caregivers. They often do not have the verbal ability to express their problems, so it’s very important to get information from the parents or caregivers. Multiple informants are very important in the evaluation. We need permission from the parents to do the interviewing and assessment. The information is gathered from the parent, school, and pediatrician. A biopsychosocial history is also taken. We need information from any previous psychiatric psychological and medical evaluations. Before the evaluation, parents have to prepare the child, such as Tommy, you’re going to see a doctor who will help us with your difficulties at school. We want to see you happy and successful. It’s okay for you to talk to the doctor who will only be speaking. There will not be any shots. It’s okay to tell him whatever is bothering you.

I personally like to meet with the parents and the child together to get the basic information. In the case of adolescents, I get permission from the adolescent to meet him or her with her parents to see the interaction between the child and the parents. The family is very important. If there are stepfamilies, I meet with them separately or conjointly. If they cooperate, I also let them know how long the assessment will be and that at the end, there will be a postdiagnostic conference with the family and the child to discuss the diagnosis and treatment planning. It can take five to six sessions to complete the assessment.

For teens, the clinician should ask if he or she wants to be seen alone first or is it okay to be seen with the parents at first. Usually the child and adolescent are seen by themselves in the assessment. If the child is younger than six years of age, it might be better to meet with the parents only at first and then together to see the patient and parent relationships. Then we would meet with the child by himself.

Adolescents are usually concerned about the confidentiality issue. They will be told that information will be shared with the parents only with his or her permission except if there is a risk of self-harm, suicide or homicide, substance abuse, high-risk sexual behavior, or running away. Those types of issues will be told to the parents. The clinician is also legally mandated to report physical or sexual abuse to the authorities to child protective agencies.

Outline Biopsychosocial History

After proper introduction, we start with the chief complaint and symptoms that brought the family in for assessment. From there, we try to learn about the child’s habits, attention span, any problems with speech and language, school performance; how the child is getting along with peers and teachers; if there are risk-taking behaviors—is the child’s mood depressed, angry, anxious, or panicky? It helps to know about the sexual behavior of the child, hobbies, sports, activities, his relationship with the family, any traumatic events in the child’s life.

We look at the past medical history—psychiatric, medical, and neurological. We want to learn about the developmental history: was the pregnancy planned? Were artificial methods used, such as tube pregnancy, delivery, and then neonatal, infancy, and early childhood development and temperaments? It helps to know some of the child’s milestones of growth. What age did he walk and talk? When did he experience separation anxiety? What kind of toddler was he? When did he start school? When did he learn his ABCs? How does he relate with other children?

Then we move on to the patient interview. The child is seen by himself. The observation of the patient is very important. We look at the following: How does he separate from the parents? What is his appearance, the child’s clothing? Does he know why he’s coming for the interview? Is he cooperating with the interviewer? Is he oppositional, relaxed, restless, or fidgety (these may be signs of anxiety or ADHD)? Does he have any tics or any serotype mannerisms, his mood—happy, sad, or angry? Does he have any obsessional thoughts or compulsive acts? What is his attention span? Is he distractible? What is his frustration tolerance? Is he impulsive? Does he show physical and verbal aggression? How is his speech and language? Is he able to communicate according to his developmental level? This also gives you an idea about his IQ intelligence. Does he have any hallucinations, delusions, or thought disorder. To asses derealization and depersonalization, I usually ask if their eyes or ears play tricks on them or if they have any unusual experiences, such as: do you feel as if you are in a dream even though you’re awake or do you ever feel that you are not yourself that you’re somebody else? To clinically estimate intelligence, we ask what he is learning at school in science, math, and history. Is he able to communicate what he has learned at school? To assess judgment and insight, we ask the question what he thinks is going on with him. Why does the child feel the way he does?

Family Assessment

Then we move onto the family assessment. Understanding the family dynamic is very important in order to understand the child or teen. Are the parents happy in their lives? Do they support each other? Do they have intimacy? How do they relate to their children? Are they consistent? Are they in agreement with the discipline of the children? Are they able to nurture, support, and educate their children and help them emancipate and gain their independence? How do they cope with crisis? What is the psychological state of the parents? For example, an anxious mother often has anxious children or a depressed mother has depressed children, which might be a contagious effect on the child and the recommendation will include psychiatric treatment for the mother as well. At the conclusion of the assessment, I meet with the child and the family together to discuss the diagnosis and treatment planning.

Treatment

Treatment planning is based on the diagnosis and target symptoms. The strengths and weaknesses of the child and the family will also be considered when making plans. The ideal plan may not work because of the limit of resources. That is why it is important to make a realistic plan. Parental motivation or ability to carry on the treatment plan influences the treatment decisions. Children from abusive homes might need to be placed at a safe home before treatment can begin. The Division of Family Services (DFS) may need to be involved in that case. Treatment planning and evaluation are an ongoing process as additional information comes to light. Treatment planning needs to be adjusted to new situations or any changes.

Child Development and Assessment

Child development is very important. The foundation of the personality develops from birth till age six. The child has to be assessed in terms of his developmental level, so what is normal and what is pathology has to be assessed according to the developmental level of the child. Child development depends on the child’s neurobiological endowment which interacts with the family, social, and cultural factors. It’s very important to look at neonatal factors such as the quality of the mother-infant relationship, exposure to risk, as well as protective factors which will affect present and future functioning. Infant and early childhood psychiatry focuses on early identification of risks and resilience mental health issues in this child and their families from birth to age six. This is a stage of rapid development. It’s during this stage that brain volume reaches 80% of adult size. By age thirty-six months, physical and emotional development is amazing.

The child’s relationship with the caregivers is predictive of his future relationships. Infants who develop secure attachment relationship with the primary caregiver during the first year of life have more positive relationships with peers and teachers and do better in school.

Infants who develop an insecure relationship are at risk for troublesome problems with stress and relationships. The infant-caregiver relationship helps the child to socialize, helps him deal with conflicts and stress. Environmental risks, such as poverty, affect the child through his development. Assessment of an infant has to be with the parent observation of the relationship. What are the parents concerned about? Although a twenty-four-month-old child’s tantrums may be normal for his age and developmental stage, the problem might be that the parent is perceiving it as an aggressive behavior and fearful of his future. One also has to look at the regulatory system—the child’s self-regulating skills, including emotional regulation as well as biological, such as sleep and eating.

At birth, an innate attachment system helps the newborn with capacities to seek maternal closeness. Social smiling begins around age two months. The infant starts his social period of development and actively seeks face-to-face interaction with his mom. At three months of age, he starts showing his temperament. The basic core of temperamental trends is now forming. Halfway through the first year, he starts differentiating his mother from himself, and this is called a period of hatching. Between eight to ten months, he starts to know his mom and is able to show separation and stranger anxiety. Also, at this age, joint attention emerges, representing the baby’s increased capacity of sharing effects, looking at objects of interest. As the baby learns to walk, the mother becomes a secure base for emotional refueling. At the end of the first year, a stable, secure or insecure avoidant, and resistant or disorganized pattern of attachment gets established. The child then has an intense focus on the environment. His attention shifts from his mother to the discovery of his environment by walking around and getting to know his surroundings. He always goes back to the mother for that emotional refueling.

A typical development could indicate an autism spectrum disorder (ASD). Some symptoms are as follows:

Difficulty in social communication and interaction

Repetitive patterns or behavior

Lack of eye contact

Lack of gestural communication, such as pushing away food or pointing at an object

In understanding the child, it is very important to understand the family genetic history. The family assessment is crucial to understanding the infant’s development. Mental illness in the mother affects the infant. The mother-child relationship affects the child relationship. In the assessment, one has to look at the size of the child: Are there any dysmorphic features, regulatory capacity, behavior with the parent versus stranger, patterns of play and vocalization? What is the parent-child relationship? Is it positive or negative? Is there mutual engagement? Is there reciprocity? Does a parent properly react to the child’s demand? Is there separation anxiety