Melvin Lewis

Risk Factors for Presenting Problems in Child Psychiatric Emergencies

OBJECTIVE To determine demographic and school-related risk factors for psychiatric emergencies presented by children in a hospital emergency room serving the majority of an urban community. METHOD 1,436 consecutive psychiatric emergency room visits for children younger than 16 years of age seen over a 10-year period were broadly classified by presenting problem as exhibiting either suicidal ideation, suicide attempt, oppositional-defiance, or aggression. The strength of association of these classes of presentation with demographic risk factors (age, sex, and minority status) and with the school day (weekday or weekend) and school season (school year or vacation) of presentation were modeled using logistic regression. The capacity of these presenting problems and risk factors to predict whether the child was hospitalized was also assessed. RESULTS Risk factors additively associated with suicidality included increasing age, being female, and presenting on weekdays and during the school year. Similar risk factors discriminated suicide attempters from suicidal ideators, and racial minority membership contributed additional risk for presenting with a suicide attempt. Risk factors associated with aggressive and oppositional presentation included younger age and male sex. Aggressive children presented relatively more often on weekends, and oppositional children presented more during school vacations. Independent risk factors for hospitalization included a suicidal or aggressive presentation, increasing age, and presentation during the school year. Hospitalization of children at the time of their initial visit protected against suicidality in subsequent presentations of the subset of children who had repeated emergency room visits. CONCLUSIONS These findings are consistent with previously reported risk factors for suicidal behaviors and externalizing disorders. The distinctive profiles of risk discerned for the different groups of emergency room psychiatric subjects also suggest some degree of specificity for the risk factors associated with each class of presenting problem. They also suggest the importance of home and school environments as being variably either risk or protective factors for these presenting problems. The findings also suggest a role for hospitalization in the prevention of future suicidality.

Conversion Reactions in Childhood and Adolescence

Thirty cases of conversion disorder were reviewed retrospectively and compared to a matched group of cases which received a diagnosis of adjustment reaction. In comparison to the adjustment disorder cases, children with conversion disorders were more likely to be referred by physicians, more likely to complain of neurological symptoms, more likely to have been hospitalized, and to have experienced sexually stressful events. A model of illness similar to that of the child was more often observed in family members of conversion cases. Children with conversion disorder were more likely to have exhibited academic difficulty and to have terminated therapy prematurely. Directions for future research and the utility and importance of positive criteria for making this diagnosis are discussed.

Biopsychosocial issues and risk factors in the family when the child has a chronic illness.

Between 10 and 20 million American children and adolescents have some type of chronic health condition or impairment. There has been a recent interest in the psychological aspects--emotional and behavioral--of chronic illness in children and adolescents. Major new areas of science, such as behavioral medicine, have emerged to address the research and clinical demands of this field. Several studies already have demonstrated the increased risk for psychiatric problems in children with chronic health conditions to be three to four times greater than their healthy peers. The proposed perspective shifts from a traditional sole reliance on medical diagnosis to a focus more on the dimensions of adjustment, socioeconomic status, visibility of condition, social support, and family functioning.

Memory and Psychoanalysis: A New Look at Infantile Amnesia and Transference

OBJECTIVE This article reexamines the psychoanalytic concepts of infantile amnesia and transference in the light of certain findings derived from neurobiological research, information-processing theory, child development research, cognitive-developmental theory, and, more speculatively, evolutionary theory concerning memory. METHOD Relevant developments from recent research in the neurosciences, and psychopathological phenomena in two psychiatric disorders--posttraumatic stress disorder and child abuse--in which memory changes are of critical importance, are first reviewed briefly. Four alternative hypotheses for infantile amnesia and three for transference are then derived from this review. RESULTS The hypotheses discussed provide plausible alternative explanations for at least part of the phenomena classically subsumed in the psychoanalytic concepts of infantile amnesia and transference. CONCLUSIONS Neurobiological, information-processing, developmental shifts, cognitive-developmental, and evolutionary findings and theories provide alternative hypotheses for infantile amnesia and transference that suggest a need for revisions and redefinitions for these two psychoanalytic concepts.

Language, cognitive development, and personality. A synthesis.

Abstract Prerequisites for language development include genetic factors, an intact central nervous system, adequate psychological care, specific linguistic stimulation, and cognitive-developmental structures. Deficits in any of these areas may lead to impairment in language development, which sometimes are etiologically specific. A dismaturation between non-linguistic representation and symbolic language development may also occur. “Affective conservation” in particular may be delayed, leading to anxiety. Misunderstanding may result from a failure to recognize the differential rates of development of specific cognitive functions, including affective conservation and language. Certain peculiarities in language usage and specific speech patterns reflect neurotic conflicts. Maturation of language development, associated with maturation of cognitive development, enables the child to deal with anxiety more effectively than previously when the childs ability to comprehend and conceptualize experiences was still limited. Attention to cognitive functions, particularly symbolic language development, may enhance treatment.

Psycotherapy in the residential treatment of the borderline child

The concept of borderline diagnosis is defined and the goals of residential treatment are delineated. The specific aims and techniques of psychotherapy are then outlined. Concomitant work with parents is utilized. The importance of working through during termination is noted.

Treatment recommendation, implementation, and follow-up in child abuse

Seventy cases of child abuse identified at an urban general medical hospital were studied to find variables which predict treatment recommendations and follow-up care. Response to only the most vivid cases often overlooks the need to assess other abuse. Continued clinical research and improved follow-up documentation are recommended.

Comments on Some Ethical, Legal, and Clinical Issues Affecting Consent in Treatment, Organ Transplants, and Research in Children

Abstract Essential elements of key terms used in the determination of the ethics and legality of decisions for treatment and research in children are described. Important ethical, legal, and clinical premises are stated. Applications of these terms and premises in the mechanisms used to decide specific issues in treatment, organ transplant, and research in children are discussed.

Child care in the residential treatment of the borderline child

The concept of borderline diagnosis is defined and indications for residential treatment are delineated. Specific techniques for child care in group living are described. Channels of communication within the residential treatment home are clarified.

Transitory or Pseudo-Organicity and Borderline Personality in a 7-Year-Old Child

In some children, signs suggestive of organicity consistent with the minimal brain dysfunction syndrome may mask a borderline condition. If the treatment in these cases is based solely on the so-called “organicity,” which the child may or may not have, the child is in danger of acquiring, so to speak, an added iatrogenic vulnerability. By virtue of the label Minimal Brain Dysfunction, and the treatment that ensues, significant personality difficulties may be either missed or inadequately treated. Minimal brain dysfunction is defined here operationally in terms of a cluster of deviant behavior items (Eisenberg, 1957; Pincus and Glaser, 1966; Wender, 1972). These may include short attention span, distractibility, hyperkinesis, impulsiveness, labile emotions, poor motor coordination, deficits in the perception of space, form, movement and time, disordered or delayed language or symbol development, diminished ability to experience pleasure, and a diminished responsiveness to both positive and negative reinforcement. A particular behavior item may be present in varying degree at any given time and place, and is in no way pathognomonic. Multiple, heterogenous etiological factors, including biogenetic, congenital, traumatic, infective, and psychosocial elements, may underlie each item. Such children often appear to be stimulus-hungry and have strong object-seeking tendencies. Unfortunately, they are also often misunderstood, and are rejected by their parents, their peers, and their teachers, which reinforces their already low self-esteem. The natural history of the syndrome, not surprisingly, is as varied as its forms; some have a good prognosis, while others develop