Karen A. Frankel

Diagnoses and Presenting Symptoms in an Infant Psychiatry Clinic: Comparison of Two Diagnostic Systems

OBJECTIVE To present data from a general infant psychiatry clinic, including range and frequency of presenting symptoms, relationship between symptoms and diagnoses, and comparison of two diagnostic systems, DSM-IV and Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-3). METHOD A retrospective chart review was conducted for 177 children, ages birth to 58 months, who were seen between 1982 and 1997. Presenting symptoms were identified. Subjects were given diagnoses using both DSM-IV and DC: 0-3. Presenting symptom variables were reduced using subjective and empirical determinants. Stepwise regression analyses were used to determine whether presenting symptoms and demographic variables predicted diagnoses. RESULTS Descriptive statistics on the distribution of current presenting symptoms and assigned diagnosis were compared with previous studies. The study demonstrated interrater reliability for diagnoses using both diagnostic systems, evidence of diagnostic validity via the regression analyses, and good concordance where DSM-IV and DC: 0-3 overlap. DSM-IV disruptive behavior disorders may be better conceptualized in DC: 0-3 as regulatory disorders, leading to alternative conceptualization of the disorder and a different course of treatment. CONCLUSIONS This study clarifies a developmental progression of presenting symptoms and diagnoses and suggests the need for continued diagnostic re-evaluation in early childhood. Greater attention to relationship factors and consideration of trauma factors is encouraged.

Elevated Picture Completion Scores: A Possible Indicator of Hypervigilance in Maltreated Preschoolers.

OBJECTIVE The Picture Completion subtest of the Wechsler Preschool and Primary Scales of Intelligence-Revised (WPPSI-R) measures visual alertness and the ability to differentiate essential from nonessential details. In children who are hypervigilant as a result of maltreatment, these skills may be over-functioning. It was hypothesized that the Picture Completion subtest scores of these children would be significantly elevated in comparison to their other nonverbal scores and their overall intellectual functioning. METHOD Fourteen children from a therapeutic day treatment preschool program for maltreated children were administered the WPPSI-R. Standardized discrepancy scores between Picture Completion scores and Performance mean scores (PC-Performance Discrepancy) and the mean of all subscale scores (PC-Overall IQ Discrepancy) were formed and then analyzed. RESULTS The abused preschoolers scored significantly lower than the population mean on four of the five WPPSI-R Performance subscales. Only on Picture Completion did they score significantly higher. Average PC-Performance Discrepancy and PC-Overall IQ Discrepancy scores were greater than one, indicating that the mean difference of childrens Picture Completion score from either their Performance mean score or all of their mean scores was more than one standard deviation. CONCLUSION Elevated Picture Completion score may serve as a marker for hypervigilance and/or PTSD in children with histories of maltreatment.

The Haven Mother's House Modified Therapeutic Community: Meeting the gap in infant mental health services for pregnant and parenting mothers with drug addiction†

The specialized needs of pregnant and parenting women in the treatment of drug addiction must not be underestimated. The impact of substance abuse on developmental outcomes for young infants and children supports the notion that attention to the parent-child relationship is a critical aspect of addiction treatment for this population. As such, the standard of care appears to be shifting from separating mothers and young children while the mother completes addiction treatment to women residing with their children while in treatment and receiving concurrent addiction treatment and parenting education. While parenting education is important, it may not provide the needed relationship intervention to address the myriad of issues often present for female recovering addicts and their children. This article describes the evolution and workings of a program for integrating infant mental health practice into a long-term residential treatment community for pregnant and parenting women with addiction. The principles and structure of the modified therapeutic community are described, as are the ways in which infant mental health practice have been effectively integrated and incorporated into the addiction treatment philosophy. A case example is provided, and clinical implications are discussed.

Trajectories of Cognitive Development Among American Indian Young Children

Children who begin kindergarten with stronger skills learn faster than do those who enter with lower skills. Minority children tend to enter kindergarten already at a disadvantage, and the gap widens across time. However, little is known about cognitive development among American Indian young children. In this study, 110 American Indian infants from one Northern Plains reservation community were assessed four times between ages 6 months and 36 months, with the Mullen Scales of Early Learning. At 6 months of age, scores were near the national norms; a drop occurred between 6 months and 15 months. Scores then tended to level off below the norms through 36 months. In each domain, we observed a crucial decline over the 1st year of life and relatively little change in the 2nd and 3rd years of life, highlighting the importance of developing culturally syntonic interventions to facilitate cognitive development during the 1st year of life.

Approaches to the Management of Young Children’s Externalizing Behavior Problems in the Primary Care Setting

Purpose of reviewThe current review summarizes the management of early-childhood externalizing behavior problems (ages 2–5) within the primary care setting. The review highlights factors pediatricians should consider when addressing externalizing behavior problems and summarizes general principles, opportunities for prevention and health promotion, parent-training interventions, integrated models, and therapies to consider when referring families to a specialty mental health provider.Recent findingsPediatricians have an important role in addressing early-childhood externalizing behavior problems in the primary care setting, and practices can take a range of meaningful steps to address these issues both universally and for children with higher levels of impairment. In particular, integrated approaches offer the opportunity to increase access to behavioral health services while also providing the chance to build medical providers’ skills in managing early-childhood externalizing behavior problems in the primary care setting.SummaryPediatricians have a range of options to consider and can use the literature regarding evidence-based programs to guide their decisions on the best interventions to implement in their settings. Further dissemination work is needed to better understand which programs are most effective when implemented in community settings.

Update on Screening, Referring, and Treating the Behavioral, Social, and Mental Health Problems of Very Young Children

Opinion statementVery young children can experience a wide range of mental health disorders including posttraumatic stress disorder, anxiety disorders, depression, and parent-child relationship disorders, among others. These disorders cause young children true psychological suffering and family stress and often do not resolve without treatment. Pediatricians have a pivotal role in routinely screening all young children for mental health concerns and referring to specialized early childhood mental health providers when concerns are present. A “watchful waiting” approach is strongly discouraged. There are a number of highly effective evidence-based practices that exist to treat most mental health problems in young children. We strongly espouse dyadic mental health services that focus clinical interventions on the parent-child relationship, which is seen as the vehicle of change at these developmental stages. The conservative use of psychiatric medications should be reserved for preschoolers ages 3 and over, should occur only after a course of psychotherapy has been unsuccessful in ameliorating severe symptoms, and should be managed under the supervision of a child and adolescent psychiatrist.