10-1 NERUO

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Neurological and Psychiatric Disorders in Children and Adolescents: Assessment and Treatment

Organic Syndromes

Neurological syndromes can be either acquired or developmental. Acquired syndromes follow some event, like the changes in thinking, affect, and daily function observed after an accident. Examples include a cerebral vascular event such as a stroke or a traumatic brain injury. Acquired syndromes reflect a loss of ability or decline from a previous level. For example, memory impairment in Alzheimer’s disease is a notable decline from prior memory ability. In contrast, developmental disorders are presumably present from birth and continue to affect an individual when developing. This module reviews disorders most common and relevant to childhood and adolescence.

A seizure is an event that involves excessive and abnormal electrical discharge of neurons in the brain (Lee, 2010). A seizure, in essence, is a neural electrical storm that can be measured using electroencephalography (EEG). Epilepsy refers to a disorder of recurrent seizures. Most seizures last seconds to minutes. However, status epilepticus is a medical emergency condition that describes prolonged single or repeated seizures for 30 minutes or more. Seizures are classified as focal, occurring in one part of the brain only, or generalized, such as encompassing both cerebral hemispheres (Lee, 2010). Focal seizures are called partial seizures. If consciousness is intact, it is called a simple partial seizure. If consciousness is impaired, it is called a complex partial seizure (Lee, 2010). Generalized seizures are classified by whether there is motor involvement. If there is no motor involvement, the seizure is an absence seizure. If there is motor involvement, the seizure is referred to by the type of motor behavior (myoclonic, tonic, clonic, atonic). The terms petit mal and grand mal refer specifically to absence seizures and tonic-clonic seizures, respectively. One particularly disabling childhood epilepsy is a result of Lennox-Gastaut syndrome. It typically involves many different seizure types. It peaks by age five and leads to lifelong disability (Nelson et al., 2021).

Traumatic brain injury (TBI) results from an external force acting to injure the brain, such as hitting one’s head on the floor from a fall. There are many ways to classify the severity of the injury event. Loss of consciousness (LOC) is the most common. A concussion (mild TBI) describes an LOC that may be brief or not present and normal imaging. A moderate TBI is a LOC for up to 24 hours. A severe TBI is a LOC of more than a day. Concussions compose about 80% of pediatric TBIs. Symptoms following a concussion are mostly nonspecific, such as headache, irritability, and impaired concentration (Tuerk et al., 2020). Post-concussive symptoms typically resolve in days to weeks. Symptoms following moderate to severe TBI are more individualized based on factors such as the type of injury and quality of treatment following the injury. In children, falls, accidents, play injuries, and physical abuse are common causes of TBI.

Developmental disorders are present from birth. They include the following:

• Specific learning disabilities
• Intellectual disability (formerly mental retardation)
• Genetic disorders
• Childhood dementias

Developmental disorders can have very limited and specific effects on development, such as dyslexia, or global effects with lasting complications, such as severe forms of intellectual disability. A particularly severe group of genetic disorders are leukodystrophies. These genetic diseases manifest in childhood and result from degenerative deterioration of the brain’s white matter (Ashrafi et al., 2020). Leukodystrophies comprise a wide range of motor and cognitive symptoms and generally have a poor prognosis.

Psychiatric Diagnoses and Treatment Options

Psychiatric disorders are descriptions of collections of mood-related symptoms. They affect regulation, anxiety, conduct problems, and psychosis. The disorders should be considered categorizations for creating a common language, enabling professionals to efficiently communicate when describing patients. For the most part, there are no inherent etiological assumptions for a diagnostic label. In other words, a major depressive episode can have many causes. However, the label does not assume any of them. Treatments for the disorders include biological elements (psychotropic medications, electroconvulsive therapy, or neurosurgery) and psychological elements (psychotherapy or behavioral therapies). In the United States, the recently updated Diagnostic and Statistical Manual of Mental Disorders, 5th edition, is used as the comprehensive manual of mental health diagnostic criteria.

A psychologist or psychiatrist typically completes the assessment of psychiatric disorders. Psychologists are trained in conducting psychological assessments. To prepare an assessment, a psychologist will gather the following information:

• A detailed history of family psychological symptoms
• A clinical interview focusing on current symptoms and functional impairment
• Socioemotional/personality tests

Typically, a report is generated that includes these items:

• A summary integrating the findings
• A diagnosis
• Treatment recommendations

Assessment for children also can include gathering information from collateral sources like parents and teachers and actual behavioral observations of a child in various settings. Psychodiagnostic assessments and neuropsychological assessments complement each other. Neuropsychological data provides information on which cognitive functions have been affected by a psychiatric condition and to what extent.

First-line treatments for psychiatric issues include various psychological therapies. Behavioral therapy models are common approaches to treating children with various problems. Behavior therapy focuses on reward systems, such as the token economy. In a token economy, adaptive behaviors are rewarded, and maladaptive behaviors are ignored. Cognitive therapies look at challenging maladaptive thinking patterns by weighing the evidence for specific maladaptive thoughts. Family therapy is also a common approach to treating children. Family therapy works from the basic assumption that maladaptive family systems and processes cause and maintain emotional disturbance and, thus, should be the target of treatment. Many treatment approaches also rely heavily on school involvement, often with recommendations to be included in an individualized education program (IEP). The IEP is implemented during the school day. Many other types of therapy are disorder-specific, such as treating specific phobias with systematic desensitization or childhood trauma with trauma-focused cognitive-behavioral therapy.

In contrast to psychological treatment approaches, the psychiatric approach relies heavily on a biological approach. A biological approach most often involves medication. Psychotropic medications can be classified as the following:

• Antipsychotics
• Antidepressants
• Anxiolytics
• Stimulants
• Mood stabilizers

Medications act on neurons in several ways, including the following:

• Stimulating neurotransmitter receptors (agonists and partial agonists),
• Blocking the action of neurotransmitters (antagonists), or
• Decreasing neurotransmission (inverse agonists) (Stahl, 2011).

Psychotropic medication use with children continues to be controversial for many reasons (Morris & Stone, 2011).

References

Ashrafi, M. R., Amanat, M., Garshasbi, M., Kameli, R., Nilipour, Y., Heidari, M., Rezaei, Z., & Tavasoli, A. R. (2020). An update on clinical, pathological, diagnostic, and therapeutic perspectives of childhood leukodystrophies. Expert Review of Neurotherapeutics, 20(1), 65–84. https://doi-org.ezproxy.snhu.edu/10.1080/14737175.2020.1699060.

Lee, G. P. (2010). Neuropsychology of epilepsy and epilepsy surgery. Oxford University Press, Inc.

Nelson, J. A., Demarest, S., Thomas, J., Juarez-Colunga, E., & Knupp, K. G. (2021). Evolution of infantile spasms to Lennox-Gastaut Syndrome: What is there to know? Journal of Child Neurology, 36(9), 752–759. https://doi-org.ezproxy.snhu.edu/10.1177/08830738211000514.

Stahl, S. M. (2011).Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (3rd ed.). Cambridge University Press.

Lee, G. P. (2010). Neuropsychology of epilepsy and epilepsy surgery. New York, NY: Oxford University Press, Inc.

Tuerk, C., Gagner, C., Degeilh, F., Bellerose, J., Lalonde, G., Landry-Roy, C., Seguin, M., de Beaumont, L., Gravel, J., Bernier, A., & Beauchamp, M. H. (2020). Quality of life 6 and 18 months after mild traumatic brain injury in early childhood: An exploratory study of the role of genetic, environmental, injury, and child factors. Brain Research, 1748. https://doi-org.ezproxy.snhu.edu/10.1016/j.brainres.2020.147061.