Principles of Pediatric Neuropsychiatry through Complex Clinical Cases

By Ayol Samuels, David Myland Kaufman and Audrey Walker

Principles of Pediatric Neuropsychiatry through Complex Clinical Cases provides basic diagnosis and treatment tactics, along with the tools that clinicians need to perform both a psychiatric and neurological “consultation, including differential diagnoses and questions to ask. Readers are then offered the neuropsychiatric details of the particular illness that has afflicted sample patients, along with treatment guidelines offered to said patient and their parents. Cases presented include the following topics: Absence Seizures, ESES, Myotonic Dystrophy, Adrenal Leukodystrophy, ADHD with Comorbidities, Wilson’s Disease, ASD, Schizophrenia, Astrocytoma with Hypoactive Delirium, Systemic Lupus Erythematous, Traumatic Brain Injury, OCD, Tourette’s, Klein Levin Syndrome, and more.

• Presents the most complex cases in Pediatric Neuropsychiatry
• Provides the combined perspectives of the pediatric neurologist and psychiatrist at every stage of the patient evaluation
• Highlights the difficulties in conveying the complexity of the diagnosis to patients and families and provides strategies for clinicians
• Provides concise reviews of demographic factors, clinical presentation, and diagnostic and treatment considerations for central pediatric neuropsychiatric conditions
• Includes take-home generalizable principles for differentiating psychiatric syndrome from a neurological disease etiology

• Language: English
• Publisher: Academic Press
• Release date: Mar 27, 2024
• ISBN: 9780128189382

Ayol Samuels

Ayol Samuels works in the Department of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine, USA

Book preview

Chapter 1

Introduction

Ayol Samuels, Audrey M. Walker and David Myland Kaufman

The discovery of functional neuroimaging, video electroencephalograms, and advanced genetics has spurred a renewed interest in clinical neuropsychiatry among psychiatrists and neurologists. Classic dichotomous thinking—that mind and brain are separate—has given way to nuanced concepts. Still, in clinical practice, psychiatrists and neurologists mostly treat different maladies. The psychiatrist treats disorders of affect, thought, and behavior that stem from a complex array of biological, psychological, and environmental etiologies; the neurologist treats sensorimotor and cognitive symptoms, many of which stem from disorders that have identifiable biological determinants and respond to specific treatments. Nevertheless, patients’ symptoms are not guided by artificial historical lines. Many neurological disorders can present with abnormal affect, behavior, and thoughts. Correct and early diagnosis of these patients is challenging but crucial for providing appropriate treatment.

Determining whether symptoms represent a primary psychiatric disorder or a neurologic disorder (or both) does not lend itself to simple algorithms. In this book, we follow the model of a neuropsychiatry clinical case conference to teach guiding principles so the clinician can make decisions at the intersection of neurology and psychiatry. The reader will follow a pediatric neurologist and child psychiatrist as they jointly meet the patient and discuss their thoughts and next steps at every point along the clinical encounter with the binocular vision of modern-day neurology and psychiatry. In our book, as in pediatric neuropsychiatry generally, the cases are complex and sometimes there is no satisfying resolution, begging an approach of yes-and rather than either-or.

We invite the reader to come and meet our patients and struggle with us. We close each case discussion with a dialog between clinician and patient/parent, highlighting the complex reactions that families have when one of their member’s behavior and personality has suddenly changed and demonstrating optimum ways of conveying the complexity of what is happening to the child or adolescent in your office. Finally, each chapter closes with a brief clinical overview of the final working diagnosis and/or related conditions.

In much of the medical world, primary care doctors—family physicians, pediatricians, and emergency doctors—are the ones initially seeing children and adolescents presenting with various psychiatric symptoms and determining the initial diagnosis, treatment, and disposition. Sometimes psychologists and social workers are the first to see them and must decide whether to refer them for a medical work-up. Thus this book speaks to all these front-line health-care providers, in addition to child psychiatrists and neurologists. They can use this book as a reference when seeing a patient in the office and as an accessible way to learn about pediatric neuropsychiatry. Finally, because standard examinations have shown a preference for these topics, trainees can use this book in preparing for examinations.

This book is sprinkled with various side bars that relate to the topic at hand. We have broken them up by themes:

: Public policy/advocacy

: History

: Ethical/legal considerations

: Treatment pearls

: Understanding diagnostic tests

: Patient experience

Guiding principles in pediatric neuropsychiatry

By far, most children and adolescents who present to a physician or therapist with mood or behavioral symptoms will have a primary psychiatric condition. It is for this reason that many national guidelines, for example, recommend against routine structural neuroimaging even for patients presenting with a first-episode psychosis. On the other hand, according to the DSM-5, most of our psychiatric diagnoses are considered diagnoses of exclusion, requiring the clinician to first exclude other possible medical causes. Thus we need guiding principles to tell us when to raise our antennae to the possibility of an underlying neurological condition. In other words, what characteristics are atypical for a primary psychiatric disorder and suggest an underlying neurologic etiology? These principles can act as indications that patients require monitoring, further diagnostic inquiry, or no further work-up.

We have woven the following guiding principles throughout this book. Each case highlights two or three.

Demographics

Different primary psychiatric conditions have age ranges during which they most commonly present. If a child or adolescent presents for the first time with a symptom that is unusual for his age, this is a clue that should raise suspicion of secondary causes, typically a neurologic or general medical illness. For example, because schizophrenia very rarely presents prior to age 13, when a 10-year-old presents with true auditory hallucinations, neurological etiologies should appear on the radar.

The neurological conditions that can lead to psychiatric symptoms also are governed by demographic considerations. For example, we should consider a diagnosis of an autoimmune condition such as neuropsychiatric systemic lupus erythematous more likely in a 15-year-old girl than in a 7-year-old boy.

Typicality of the symptoms

Understanding the nature of a symptom can sometimes help in determining whether that symptom is typical or not of a primary psychiatric condition, much as drilling down to the nature of chest pain can help point us toward cardiac or noncardiac causes. Thus hallucinations that are auditory, complex, and demeaning in nature are typical for a primary psychotic disorder, whereas visual hallucinations of shapes are not and may indicate instead etiologies such as migraine or seizure.

DSM-5 categories tell us that typically psychiatric illnesses present with one or more cardinal (category A) symptoms plus several associated ones. Astute physicians have often said, one symptom does not make a diagnosis and without a cardinal symptom, neither do several. Thus, a child who will not get out of bed and will not eat should not automatically get a diagnosis of depression. Instead, we need to ask, Does this child demonstrate the cardinal symptoms of depression—depressed mood (irritable mood can suffice for children)—or generalized and subjective anhedonia? and, are there any additional depressive symptoms, such as excessive guilt, suicidal ideation, or hopelessness? When patients present with isolated symptoms, especially when nonspecific-poor appetite, insomnia, fatigue, disorganized behavior, poor concentration, apathy, irritability-alternative possibilities should be