Kaplan + Sadock's Synopsis of Psychiatry, 11e

1128

Chapter 31: Child Psychiatry

lectual assessment, and a standardized measure of adaptive func- tion indicating that a child is significantly below the expected level in both areas. The severity of the intellectual disability will be determined on the basis of the level of adaptive function. A history and psychiatric interview are useful in obtaining a longitudinal picture of the child’s development and functioning. Examination of physical signs, neurological abnormalities, and in some cases, laboratory tests can be used to ascertain the cause and prognosis. History The clinician taking the history, which may elucidate pathways to intellectual disability, should pay particular attention to the mother’s pregnancy, labor, and delivery; the presence of a fam- ily history of intellectual disability; consanguinity of the par- ents; and known familial hereditary disorders. Psychiatric Interview A psychiatric interview of a child or adolescent with intellectual disability requires a high level of sensitivity in order to elicit information at the appropriate intellectual level while remain- ing respectful of the patient’s age and emotional development. The patient’s verbal abilities, including receptive and expressive language, can be initially screened by observing the communi- cation between the caretakers and patient. If the patient com- municates largely through gestures or sign language, the parents may serve as interpreters. Patients with milder forms of intel- lectual disability are often well aware of their differences from others and their failures, and may be anxious and ashamed dur- ing the interview. Approaching patients with a clear, support- ive, concrete explanation of the diagnostic process, particularly patients with sufficiently receptive language ability, may allay anxiety and fears. Providing support and praise in language appropriate to the patient’s age and understanding is beneficial. Subtle direction, structure, and reinforcement may be necessary to keep patients focused on the task or topic. In general, the psychiatric examination of an intellectu- ally disabled child or adolescent should reveal how the patient has coped with stages of development. Frustration tolerance, impulse control, and over-aggressive motor and sexual behavior are important areas of attention in the interview. It is equally important to elicit the patient’s self-image, areas of self-confi- dence, and an assessment of tenacity, persistence, curiosity, and willingness to explore the environment. In children and adolescents who have acquired language, one of several standardized instruments that include numerous domains of cognitive function are used. For children ages 6 to 16 years, the Wechsler Intelligence Test for Children is typically admin- istered, and for children ages 3 to 6 years, the Wechsler Pre- school and Primary Scale of Intelligence-Revised is commonly used. The Stanford-Binet Intelligence Scale, Fourth Edition, has the advantage that it can be administered to children even younger, starting at age 2 years. The Kaufman Assessment Bat- tery for Children can be used in children ages 2½ to 12½ years, Structured Instruments, Rating Scales and Psychological Assessment

found to be at high risk for developing both social problems and academic difficulties. Socioeconomic deprivation can also affect the adaptive function of these vulnerable infants. Early intervention may improve their cognitive, language, and percep- tual abilities. Acquired Childhood Disorders Infection.  The most serious infections affecting cerebral integrity are encephalitis and meningitis. Measles encephalitis has been virtually eliminated by the universal use of measles vaccine, and the incidence of other bacterial infections of the CNS has been markedly reduced with antibacterial agents. Most episodes of encephalitis are caused by viruses. Sometimes a clinician must retrospectively consider a probable encephalitic component in a previous obscure illness with high fever. Men- ingitis that was diagnosed late, even when followed by antibiotic treatment, can seriously affect a child’s cognitive development. Thrombotic and purulent intracranial phenomena secondary to septicemia are rarely seen today except in small infants. Head Trauma.  The best-known causes of head injury in children that produces developmental handicaps, including sei- zures, are motor vehicle accidents, but more head injuries are caused by household accidents, such as falls from tables, open windows, and on stairways. Child maltreatment is not infre- quently implicated in head traumas or intracranial trauma such as bleeding due “shaken baby” syndrome. Asphyxia.  Brain damage due to asphyxia associated with near drowning is not an uncommon cause of intellectual dis- ability. Long-term Exposures.  Long-term exposure to lead is a well-established cause of compromised intelligence and learn- ing skills. Intracranial tumors of various types and origins, sur- gery, and chemotherapy can also adversely affect brain function. Environmental and Sociocultural Factors Mild intellectual disability has been associated with significant deprivation of nutrition and nurturance. Children who have endured these conditions are at risk for a host of psychiatric disorders including mood disorders, posttraumatic stress disor- der, and attentional and anxiety disorders. Prenatal environment compromised by poor medical care and poor maternal nutrition may be contributing factors in the development of mild intellec- tual disability. Teenage pregnancies are at risk for mild intellec- tual disability in the baby due to the increased risk of obstetrical complications, prematurity, and low birth weight. Poor postnatal medical care, malnutrition, exposure to toxic substances such as lead, and potential physical trauma are additional risk factors for mild intellectual disabilities. Child neglect and inadequate caretaking may deprive an infant of both physical and emotional nurturances, leading to failure to thrive syndromes. Diagnosis The diagnosis of intellectual disability can be made after the history is obtained, using information from a standardized intel-