case study on a child with behavioural problems

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

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There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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More than 10% of young children experience clinically significant mental health problems, with rates of impairment and persistence comparable to those seen in older children. For many of these clinical disorders, effective treatments supported by rigorous data are available. On the other hand, rigorous support for psychopharmacologic interventions is limited to 2 large randomized controlled trials. Access to psychotherapeutic interventions is limited. The pediatrician has a critical role as the leader of the medical home to promote well-being that includes emotional, behavioral, and relationship health. To be effective in this role, pediatricians promote the use of safe and effective treatments and recognize the limitations of psychopharmacologic interventions. This technical report reviews the data supporting treatments for young children with emotional, behavioral, and relationship problems and supports the policy statement of the same name.

At least 8% to 10% of children younger than 5 years experience clinically significant and impairing mental health problems, which include emotional, behavioral, and social relationship problems. 1 An additional 1.5% of children have an autism spectrum disorder, the management of which has been reviewed in a separate report from the American Academy of Pediatrics (AAP). 2 Children with emotional, behavioral, and social relationship problems (“mental health problems”), as well as their families, experience distress and can suffer substantially because of these problems. These children may demonstrate impairment across multiple domains, including social interactions, problematic parent–child relationships, physical safety, inability to participate in child care without expulsion, delayed school readiness, school problems, and physical health problems in adulthood. 3 , – 13 These clinical presentations can be distinguished from the emotional and behavioral patterns of typically developing children by their symptoms, family history, and level of impairment and, in some disorders, physiologic signs. 14 , – 17 Emotional, behavioral, and relationship disorders rarely are transient and often have lasting effects, including measurable differences in brain functioning in school-aged children and a high risk of later mental health problems. 18 , – 24 Exposure to toxic stressors, such as maltreatment or violence, and individual, family, or community stressors can increase the risk of early-onset mental health problems, although such stressors are not necessary for the development of these problems. Early exposure to adversity also has notable effects on the hypothalamic–pituitary–adrenal axis and epigenetic processes, with short-term and long-term consequences in physical and mental health, including adult cardiovascular disease and obesity. 25 In short, young children’s early emotional, behavioral, and social relationship problems can cause suffering for young children and families, weaken the developing foundation of emotional and behavioral health, and have the potential for long-term adverse consequences. 26 , 27 This technical report reviews the data supporting treatment of children with identified clinical disorders, including the efficacy, safety, and accessibility of both pharmacologic and psychotherapeutic approaches.

Although not the focus of this report, a full system of care includes primary and secondary preventive approaches, which are addressed in separate AAP reports. 28 , 29 Many family, individual, and community risk factors for adverse emotional, behavioral, and relationship health outcomes, including low-income status, exposure to toxic stressors, and parental mental health problems, can be identified early using systematic surveillance and screening. An extensive review of established prevention programs for the general population and identified children at high risk are described in the Substance Abuse and Mental Health Services Administration (SAMHSA)’s National Report of Evidence-Based Programs and Practices ( http://www.nrepp.samhsa.gov/AdvancedSearch.aspx ). Outcomes of these programs highlight the value of early intervention and the potential to improve parenting skills using universal or targeted approaches for children at risk. The programs use a variety of approaches, including home visiting, parent groups, targeted addressing of basic needs, and videos to enhance parental self-reflection skills and have demonstrated a range of outcomes related to positive emotional, behavioral, and relationship development. One model developed specifically for the pediatric primary care setting is the Video Interaction Project, in which parents are paired with a bachelor’s-level or master’s-level developmental specialist who uses video and educational techniques to support parents’ awareness of their child’s developmental needs. 30  

Acknowledging that early preventive interventions are an important component of a system of care, the body of this technical report focuses on treatment of identified clinical problems rather than children at risk because of family or community factors.

The evidence supporting family-focused therapeutic interventions for children with clinical-level concerns is robust, and these are the first-line approaches for young children with significant emotional and behavioral problems in most practice guidelines. 31 , – 35  

Generally, these interventions take an approach that focuses on enhancing emotional and behavioral regulation through specialized parenting tools and approaches. The interventions are implemented by clinicians with training in the specific treatment modality, following manuals and with fidelity to the treatment model. Primary care providers can be trained in these interventions but more often lead a medical home management approach that includes ongoing primary care management and support and concurrent comanagement with a clinician trained in implementing an evidence-based treatment (EBT).

Effective treatments exist to address early clinical concerns, including relationship disturbances, attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorders, anxiety, and posttraumatic stress disorder. Measured outcomes include improved attachment relationships, symptom reduction, diagnostic remission, enhanced functioning, and in one study, normalization of diurnal cortisol release patterns, which are known to be related to stress regulation and mood disorders. 31 , 33 , – 35 Psychotherapies, including treatments that involve cognitive, psychological, and behavioral approaches, have substantially more lasting effects than do medications. Some preschool treatments have been shown to be effective for years after the treatment ended, a finding not matched in longitudinal pharmacologic studies. 36 , – 38 It is for this reason that the recent ADHD treatment guidelines from the AAP emphasize that first-line treatment of preschoolers with well-established ADHD should be family-focused psychotherapy. 39  

This report focuses on programs that target current diagnoses or clear clinical problems (rather than risk) in infants and toddlers and includes only those with rigorous randomized controlled empirical support. Because the parent–child relationship is a central force in the early emotional and behavioral well-being of children, a number of empirically supported treatments focus on enhancing that relationship to promote child well-being. Each intervention focuses on enhancing parents’ ability to identify and respond to the infant’s cues and to meet the infant’s emotional needs. All interventions use infant–parent interactions in vivo or through video to demonstrate the infant’s cues and opportunities to meet them. Some explicitly focus on enhancing parents’ self-reflection and increasing awareness of how their own upbringing may influence their parenting approach.

Child Parent Psychotherapy and its partner Infant Parent Psychotherapy are derived from attachment theory and address the parent–child relationship through emotional support for parents, modeling protective behaviors, reflective developmental guidance, and addressing parental traumatic memories as they intrude into parent–child interactions. 40 , 41 This therapy is flexible in its delivery and can be implemented in the office, at home, or in other locations convenient for the family. On average, child–parent psychotherapy lasts approximately 32 sessions. In infants and toddlers, the empirically supported therapy enhances parent–child relationships, attachment security, child cognitive functioning, and normalization of cortisol regulation. 42 , – 44  

For infants and toddlers who have been adopted internationally, those in foster care, or those thought to be at high risk of maltreatment because of exposure to domestic violence, homelessness, or parental substance abuse, the Attachment and Biobehavioral Catch-Up caregiver training supports caregivers in developing sensitive, nurturing, nonfrightening parenting behaviors. In 10 sessions, caregivers receive parenting skills training, psychoeducation, and support in understanding the needs of infants and young children. This intervention model is associated with decreased rates of disorganized attachment, the attachment status most closely linked to psychopathology, and is associated with increased caregiver sensitivity and, notably, normalized diurnal cortisol patterns. 45 , – 47  

In the Video Feedback to Promote Positive Parenting program, mothers with low levels of sensitivity to their child’s needs review video feedback about their own parent–child interactions, with a focus on supporting sensitive discipline, reading a child’s cues, and developing empathy for a child who is frustrated or angry. In the most stressed families, this intervention is associated with decreased infant behavioral difficulties and increased parental sensitivity. 48  

Treatments focused on mother–infant dyads affected by postpartum depression show promising effects on relationships and infant regulation. 49 Data in older children suggest effective treatment of maternal depression may result in reduction of child symptoms or an increase in caregiving quality. 50 , – 52  

ADHD and disruptive behavior disorders (eg, oppositional defiant disorder and conduct disorder) are the most common group of early childhood mental health problems, and a number of parent management training models have been shown to be effective. It should be noted that the criteria for these disorders have been shown to have validity in young children, 22 , 53 although the validity is dependent on a systematic assessment process that is most easily conducted in specialty settings. All of these parent training models share similar behavioral principles, most consistently teaching parents: (1) to implement positive reinforcement to promote positive behaviors; (2) to ignore low-level provocative behaviors; and (3) to respond in a clear, consistent, and safe manner to unacceptable behaviors. The specific approaches to sharing these principles with parents vary across interventions. Table 1 presents some of the characteristics of the best-supported programs, all of which are featured on SAMHSA’s national registry of evidence-based programs and practices. 34 , 54 The New Forrest Therapy, Triple P (Positive Parenting Practices), the Incredible Years Series (IYS), Helping the Noncompliant Child, and Parent Child Interaction Therapy (PCIT) all have shown efficacy in reducing clinically significant disruptive behavior symptoms in toddlers, preschoolers, and early school-aged children. The New Forrest Therapy, Helping the Noncompliant Child, and IYS also have proven efficacy in treating ADHD. 35 , 55 , – 57  

Evidence-Based Interventions Shown To Reduce Existing Disruptive Problems in Preschoolers

n/a, not available; ECBI, Eyberg Child Behavior Inventory; SDQ, Strengths and Difficulties Questionnaire; CD, conduct disorder; ODD, oppositional defiant disorder.

In the New Forrest Therapy, sessions include parent–child activities that require sustained attention, concentration, turn-taking, working memory, and delay of gratification, all followed by positive reinforcement when the child is successful. 32 , 35 This model has been shown to decrease ADHD symptoms substantially and to decrease parents’ negative statements about their children. 35 Triple P is a multilevel intervention that includes targeted treatment of children with disruptive behaviors. 55 The 3 highest levels of care include teaching parents about the causes of disruptive behaviors and effective strategies as well as specific problem solving about the child’s individual patterns. The child is included in some sessions to create opportunities to implement the new strategies and for the therapist to model the behaviors. IYS includes a parent-focused treatment approach, in which groups of parents learn effective strategies, practice with each other, and discuss clinical vignettes presented on videos. 56 The child group treatment can occur concurrently with the parent training and focuses on emotional recognition and problem solving. This treatment initially was developed to treat oppositional defiant disorder and conduct disorder, for which a large body of evidence demonstrates its efficacy. Recent studies also have demonstrated effectiveness in treating inattention and hyperactivity. 66 An unintended yet measureable benefit is promoting language. 67 In PCIT, parents are coached in positive interactions and safe discipline with their child by the therapist, who is behind a one-way mirror and communicates to a parent via a small microphone in the parent’s ear (“bug in the ear”). This treatment is unique because parents’ achievement of specific skills determines the pace of the therapy, allowing movement from the first phase, focused on positive reinforcement, to the second phase, focused on safe, consistent consequences. PCIT has been shown to have large effects on child behavior problems and parent negative behaviors in real time. Importantly, it is also effective in reducing recidivism of maltreating parents. 68 Helping the Noncompliant Child also provides 2 portions of the treatment, with the first focused on differential attention and the second focused on compliance training. Parents move through the therapy based on observed skill acquisition, learning by demonstration, role plays, and practice at home and in the office with their child. Helping the Noncompliant Child has been shown to have similar effectiveness as NFP in treating ADHD in children 3 to 4 years old and those wtih comorbid ODD. 69  

Anxiety disorders also are common in very young children, with nearly 10% of children meeting criteria for at least 1 anxiety disorder. Cognitive behavioral therapy and child–parent psychotherapy, both of which also are listed on the SAMHSA registry of EBTs, are effective in reducing anxiety in very young children. When cognitive behavioral therapy is modified to match young children’s developmental levels, children as young as 4 years can learn the necessary skills, including relaxation strategies, naming their feelings, and learning to rate the intensity of the feelings. 31 In cognitive behavioral therapy, children are exposed to the story of their trauma in a systematic, graduated fashion, using the coping strategies and measuring feeling intensity skills that they practice simultaneously throughout the intervention. Two randomized studies have examined cognitive behavioral therapy in trauma-exposed preschoolers, and both have shown that children in the cognitive behavioral therapy treatment arm showed fewer posttraumatic stress symptoms as well as fewer symptoms of disruptive behavior disorders than did children in supportive treatment. 70 , 71 Effects are sustained for up to a year after treatment. 71 , 72 Child–parent psychotherapy is similarly effective in treating children exposed to trauma. Child–parent psychotherapy is an attachment-focused treatment that supports the parent in creating a safe, consistent relationship with the child through helping the parent understand the child’s emotional experiences and needs as well as parental reactions. 40 Child–parent psychotherapy is more effective in reducing child and parent trauma symptoms than supportive case management and community referral. 73 Importantly, child–parent psychotherapy shows treatment durability with sustained results at least 6 months after treatment.

Other more common anxiety disorders and mood disorders have received less research attention. CBT has been shown effective in addressing mixed anxiety disorders including selective mutism, generalized anxiety disorders, separation anxiety disorder, and social phobia. 62 , 63 A randomized controlled trial demonstrated that modified PCIT was effective in helping parents recognize emotions, although not better than parent education in reducing depressive symptoms. 74 Significant controversy and limited data about the validity of diagnostic criteria for bipolar disorder remain, and no rigorous studies of nonpharmacologic interventions in this age group exist. 75  

Although the studies described previously show positive effects of parent management training approaches, limitations are notable. Attrition of up to 30% is not uncommon among these approaches, suggesting that there is a significant proportion of the population for whom these treatments do not seem to be a good fit, whether because of the frequency of appointments, the content, the therapeutic relationship, stigma about mental health care, or other barriers. 60 , 76 , 77  

As highlighted in both the professional and lay press, an increasing number of publicly and privately insured preschool and even younger children are receiving prescriptions for psychotropic medications. 78 , – 81 After increasing drastically in the 1990s, claims data indicate that rates of stimulant prescriptions have plateaued in recent years, but the rates of prescriptions of atypical antipsychotic agents continue to increase. 78 , 81 , – 83 Although prescribing data are limited, it appears that pediatric providers are the primary prescribers for psychopharmacologic treatment in children younger than 5 years, as they are for older children. 84 , 85  

The evidence base related to psychopharmacologic medications in young children is limited, and clinical practice has far outpaced the evidence supporting safety or efficacy, especially for children in foster care. 33 , 81 Specifically, 2 rigorous randomized controlled trials have examined the safety and efficacy of medications in young children. Both studies found that treatment of ADHD in young children with medication, specifically methylphenidate and atomoxetine, was more effective than placebo but less effective than documented in older children. 36 , 86 , 87 Both also reported that young children had higher rates of adverse effects, especially negative emotionality and appetite and sleep problems, than did older children. 86 , 87 Less rigorously studied are the atypical antipsychotic agents, such as risperidone, olanzapine, and aripiprazole, for which prescription rates have increased substantially. 33 , 88 These agents have known metabolic risks, including obesity, hyperlipidemia, glucose intolerance, and hyperprolactinemia, as well the potential for extrapyramidal effects. 89 , 90 Long-term safety data regarding use of these medications in humans, including the effects on the brain during its most rapid development, are not available.

The balance of risks and benefits of treatment of early childhood emotional, behavioral, or relationship problems strongly favors the safety and established efficacy of the EBTs over the potential for medical risks and lower levels of evidence supporting the medication. Fewer than 50% of young children with emotional, behavioral, or relationship disturbances, even those with severity sufficient to warrant medication trials, receive any treatment, especially nonpharmacologic treatments. 11 , 78 , 91 , 92 A number of barriers limit access to nonpharmacological EBTs.

Residency training and continuing medical education has traditionally provided limited opportunities for collaboration between pediatric and child psychiatry residents and with other mental health providers, including doctoral level and master’s level clinicians, although there are calls to increase these opportunities. 93 , 94 The limited opportunities for collaboration in training and limited supervised opportunities to assess young children with mental health problems likely result in graduating residents having limited experience in early childhood mental health as they enter the primary care workforce. The AAP has worked to address this gap by developing practice transformation approaches, including educational modules and anticipatory guidance approaches that promote emotional, behavioral, and relationship wellness (see the AAP Early Brain and Child Development Web site at http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/EBCD ), and around the country, there appears to be an increase in collaborative training opportunities for pediatric residents with developmental–behavioral pediatrics faculty and fellows, triple board residents, child and adolescent psychiatry trainees, and other mental health professionals.

Many of these barriers are not specific to early childhood emotional, behavioral, and relationship health but are quite apparent in this area. Although representative epidemiologic data examining the rates of psychotherapeutic treatment of preschoolers are not available, only 1 in 5 older children with a mental health problem receives treatment, 95 and it seems likely that the rate is lower among preschool-aged children. A major challenge is the workforce shortage among child psychiatrists, child mental health professionals, and pediatric specialists trained to meet the specialized emotional, behavioral, and relationship needs of very young children and their families. 96 , – 99 Anecdotally, it seems that many therapists trained in EBTs remain close to academic centers, further exacerbating the shortage in regions without such a center. Promising statewide initiatives, such as “PCIT of the Carolinas” learning collaborative, which promote organizational readiness and capacity within agencies, clinician competence, and treatment fidelity and consultation with therapists, may begin to foster access to EBTs. Such models are promising approaches to improving access to clinicians trained to evaluate a very young child or to implement EBTs.

Even in communities with early childhood experts who are trained in EBTs, third-party payment systems traditionally have rewarded brief medication-focused visits. 28 When emotional and behavioral health services are “carved out” of health insurance, important barriers to accessing care include limitations on primary care physicians’ ability to bill for “mental health” diagnoses, limits on numbers of visits, payer restriction of mental health providers, and low payment rates. 98 , 100 , – 102 Until 2013, the Current Procedural Terminology coding system did not recognize the extended time needed for early childhood emotional and behavioral assessment and treatment (and the payment for the new code tends to be minimal), and many payers will not reimburse for services without the patient present or for phone consultation or case conferences. Lastly, the billing and coding system does not recognize relationship-focused therapy, requiring the individual participants to have an International Classification of Diseases –codable diagnosis, and only a few states accept developmentally specific diagnoses, such as the Diagnostic Criteria: 0-5, as reimbursable conditions. 103  

Finally, stigma and parental beliefs may interfere with referrals to EBTs for very young children with emotional, behavioral, and relationship problems. 104 , – 108 Parents’ interest in treatment may be influenced by perceived stigma related to the mental health problem or their own experiences with the mental health system. 109 Provider stigma about mental health and concerns about a child being “labeled” may reduce referrals as well. Some parents also may be concerned that involvement with a mental or behavioral health specialist may increase their risk of referral to child protection services.

For children with emotional, behavioral, or relationship problems, the pediatric medical home remains the hub of a child’s care, just as it is for other children with special health care needs. 110 Even without a comprehensive diagnostic assessment or knowledge of the details of each EBT, use of specific communication strategies, the “common factors” approach, has been shown to improve outcomes in older children. Specifically, implementation of the common factors approach was associated with reduced impairment from symptoms and reduced parent symptoms in a randomized controlled trial of 58 providers. 111 Subsequently, the mnemonic “HELP” was introduced by the AAP Task Force on Mental Health to prompt clinicians in key elements of the model, including offering h ope, demonstrating e mpathy, demonstrating l oyalty, using the l anguage the family uses about the concerns, and p artnering with the family to develop a clearly stated p lan, with the parents’ p ermission. 112 Because of the stigma related to mental health issues, “hope” and “loyalty” are especially powerful first steps.

Innovative and successful adaptations of EBTs have been developed for the primary care setting. 55 , 64 , 65 Triple P has been implemented successfully in primary care settings using nurse visits to provide the psychoeducation for parents and also has been studied as a self-directed intervention for parents of children with clinically significant disruptive behavior symptoms, with modest but sustained effects up to 6 months. 61 A pilot PCIT adaptation for primary care showed promising results, although larger studies are needed. 113 Most recently, a randomized controlled trial demonstrated that the Incredible Years Series can be implemented effectively in the pediatric medical home for children with mild to moderate behavior problems. In this study, parent-reported behavioral problems decreased significantly compared with the group on the wait list, as did observed negative parent–child interactions. 114  

The strategy for identifying providers of EBTs varies state to state. However, all but 3 states have an Early Childhood Comprehensive Services grant from the Human Resources and Service Administration ( http://mchb.hrsa.gov/programs/earlychildhood/comprehensivesystems/grantees/ ) and are developing systems of care for young children. EBTs tend to be concentrated around academic settings, so contacting local developmental–behavioral pediatric divisions and child and adolescent psychiatry and psychology divisions often helps, and the originator of the model often knows providers trained in the intervention (eg, www.pcit.org ). Innovative practice models, such as consultation or colocated mental health professionals, can be effective approaches to ensuring children have access to care. 115  

In areas with more trained EBT providers, opportunities for colocated care seem promising. In such models, a clinician, who is often a master’s level clinician or psychologist, works in the practice as part of the team to provide short-term mental health interventions, such as skills-training in behavioral management. In older children, such interventions are effective in decreasing ADHD and oppositional defiant disorder, although not conduct disorder or anxiety, and in increasing the likelihood of treatment completion. 116 Models of consultation that support primary care providers in the management of children who have been referred for EBT or who have no access to an EBT are under development, often through federally funded projects, such as SAMHSA’s Linking Actions to Unmet Needs in Child Health Project ( http://media.samhsa.gov/samhsaNewsletter/Volume_18_Number_3/PromotingWellness.aspx ).

Clinical emotional, behavioral, or relationship problems commonly cooccur with other developmental delays, especially speech problems. For example, in one mental health program for toddlers, 77% of children also had a developmental delay. 117 A comprehensive treatment plan includes attention to any comorbid conditions, although such combined or serial treatments have not been studied explicitly. Similarly, family mental health problems, such as maternal depression, can reduce the efficacy of parent management training approaches. In older children, effective treatment of maternal depression is effective in reducing child symptoms and fewer diagnoses. 51  

Very young children can experience significant and impairing mental health problems at rates comparable to older children. Early adversity, including abuse and neglect, increases the risk of early childhood emotional, behavioral, and relationship problems and is associated with developmental, medical, and mental health problems through the lifespan. EBTs can address early childhood mental health problems effectively, reducing symptoms and impairment and even normalizing biological markers. By contrast, the research base examining safety and efficacy of pharmacologic interventions is sparse and inadequate. Systems issues, including graduate medical education systems, access to trained providers of EBTs for very young children, and coding, billing, and payment structures all interfere with access to effective interventions. Not insignificantly, social stigma related to mental health held by parents, primary care providers, and the greater society likely work against access to care for children.

The existing data demonstrate strong empirical support for family-focused interventions for young children with emotional, behavioral, and relationship problems, especially disruptive behavior disorders and anxiety or trauma exposure. By contrast, the empirical literature examining psychopharmacologic treatment is limited and highlights risks of adverse effects. A number of workforce and other barriers may contribute to the limited access.

American Academy of Pediatrics

attention-deficit/hyperactivity disorder

evidence-based treatment

Incredible Years Series

Parent Child Interaction Therapy

Substance Abuse and Mental Health Services Administration

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

Mary Margaret Gleason, MD, FAAP

Edward Goldson, MD, FAAP

Michael W. Yogman, MD, FAAP

Dina Lieser, MD, FAAP, Chairperson

Beth DelConte, MD, FAAP

Elaine Donoghue, MD, FAAP

Marian Earls, MD, FAAP

Danette Glassy, MD, FAAP

Terri McFadden, MD, FAAP

Alan Mendelsohn, MD, FAAP

Seth Scholer, MD, FAAP

Jennifer Takagishi, MD, FAAP

Douglas Vanderbilt, MD, FAAP

Patricia Gail Williams, MD, FAAP

Lynette M. Fraga, PhD – Child Care Aware

Abbey Alkon, RN, PNP, PhD, MPH – National Association of Pediatric Nurse Practitioners

Barbara U. Hamilton, MA – Maternal and Child Health Bureau

David Willis, MD, FAAP – Maternal and Child Health Bureau

Claire Lerner, LCSW – Zero to Three

Charlotte Zia, MPH, CHES

Michael Yogman, MD, FAAP, Chairperson

Nerissa Bauer, MD, MPH, FAAP

Thresia B Gambon, MD, FAAP

Arthur Lavin, MD, FAAP

Keith M. Lemmon, MD, FAAP

Gerri Mattson, MD, FAAP

Jason Richard Rafferty, MD, MPH, EdM

Lawrence Sagin Wissow, MD, MPH, FAAP

Sharon Berry, PhD, LP – Society of Pediatric Psychology

Terry Carmichael, MSW – National Association of Social Workers

Edward Christophersen, PhD, FAAP – Society of Pediatric Psychology

Norah Johnson, PhD, RN, CPNP-BC – National Association of Pediatric Nurse Practitioners

Leonard Read Sulik, MD, FAAP – American Academy of Child and Adolescent Psychiatry

George J. Cohen, MD, FAAP

Stephanie Domain, MS

Nathan J. Blum, MD, FAAP, Chairperson

Michelle M. Macias, MD, FAAP, Immediate Past Chairperson

Nerissa S. Bauer, MD, MPH, FAAP

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• Ind Psychiatry J
• v.26(1); Jan-Jun 2017

A descriptive study of behavioral problems in schoolgoing children

Anindya kumar gupta.

Department of Psychiatry, Command Hospital (Air Force), Bengaluru, Karnataka, India

Monica Mongia

1 National Drug Dependence Treatment Centre, AIIMS, Ghaziabad, Uttar Pradesh, India

Ajoy Kumar Garg

2 Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India

Background:

Behavioral problems among schoolgoing children are of significant concern to teachers and parents. These are known to have both immediate and long-term unfavorable consequences. Despite the high prevalence, studies on psychiatric morbidity among school children are lacking in our country.

Materials and Methods:

Five hundred children aged 6–18 years were randomly selected from a government school in Kanpur, Uttar Pradesh, and assessed for cognitive, emotional, or behavioral problems using standardized tools.

About 22.7% of children showed behavioral, cognitive, or emotional problems. Additional screening and evaluation tools pointed toward a higher prevalence of externalizing symptoms among boys than girls.

Conclusion:

The study highlights the importance of regular screening of school children for preventive as well as timely remedial measures.

About 20% of children and adolescents, globally, suffer from impairments due to various mental disorders. Suicide is reportedly the third major reason for death among adolescent population.[ 1 , 2 ] The alarming rise in the number of children and adolescents in low- and middle-income countries leaves this population with inadequate attention from mental health professionals, minimal infrastructure, and limited resources for managing their mental health problems.[ 3 ]

The prevalence rates of behavioral problems across various studies conducted in different states in India vary, thus making it difficult to get a collective understanding of the extent of the problem. A study by Srinath et al ., in 2005, conducted on a community-based sample in Bengaluru, revealed the prevalence rates of behavioral problems to be around 12.5% in children up to 16 years of age.[ 4 ] Another study done on school children in Chandigarh found the rate of behavioral problems among 4–11 years’ old to be 6.3%.[ 5 ] As evident from the available literature, the overall rates of psychiatric illnesses among children and adolescent population across the various states in India and other middle- and low-income countries vary between 5% and 6%. A cursory look at the Western data on the subject indicates that these figures are still on the lower side as prevalence rates of behavioral problems among children and adolescents in Canada, Germany, and the USA have been reported to be 18.1%, 20.7%, and 21%, respectively.[ 6 ]

Further, many problems among this population do not meet the diagnostic criteria and are thus considered “subthreshold.” Nonetheless, the significant distress that children/adolescents and their families go through because of these mental health issues cannot be undermined.[ 7 ] Since research studies on psychiatric problems among children and adolescents in India are relatively few and variable in methodology, the present study was conducted with more robust screening and assessment measures to generate relevant data. This study thus improves our current understanding of the extent and type of behavioral problems among children and adolescents, in our cultural context.

MATERIALS AND METHODS

Ethical approval for the current study was obtained from the hospital ethics committee of the first author. In this descriptive study, 500 boys and girls from a government school in Kanpur in the age group of 6–18 years, without any diagnosed medical/surgical/psychiatric/other illnesses, were included after appropriate randomization. All parents/caregivers provided informed consent for participation in the current study. Brief screening was done using the parent-completed version (pediatric symptom checklist [PSC]; 4–10 years) and the youth self-report (Y-PSC; 11+ years) to assess cognitive, emotional, and behavioral problems.[ 8 ] After initial screening, wherever the score was found to be significant, children were selected for detailed evaluation. Further assessment was carried out using the following:

• Child Behavior Checklist (CBCL): The CBCL developed by Achenbach is a family of self-rated instruments that surveys a broad range of difficulties encountered in children from preschool age through adolescence. It is a multiaxial scale normed by age and gender[ 9 ]
• Wechsler Intelligence Scale for Children (WISC): The WISC is an individually administered intelligence test for children between the ages of 6 and 16 years[ 10 ]
• Childhood Autism Rating Scale (CARS): CARS is a behavior rating scale intended to help diagnose autism[ 11 ]
• Conner's Rating Scale (CRS)-Revised: CRS-revised is an instrument that uses observer ratings and self-report ratings to help assess attention-deficit/hyperactivity disorder (ADHD) and evaluate problem behaviors in children and adolescents from the age of 3 years through 18 years.[ 12 ]

Of 500 children selected, 480 children underwent detailed assessments. Two-hundred and forty children in each age group, i.e., 6–10 years and 11–18 years, were administered PSC/Y-PSC, as applicable. Mean ages of boys, girls, and their scoring pattern in PSC are shown in Table 1 .

Distribution of mean age of children and comparison of scores

About 41 (17.08%) children demonstrated positive scores in PSC and 68 (28. 33%) for Y-PSC. The CBCL was then administered to evaluate behavioral problems. Table 1 shows the distribution of mean age of children along with their mean PSC/Y-PSC scores above cutoff. The difference was not found to be statistically significant across the groups and gender.

Table 2 shows the distribution of mean CBCL scores by gender and age groups where boys had significantly higher scores than girls. However, the relation of CBCL scores (above cutoff) to gender and different age groups was not found to be significant.

Distribution of mean child behavior checklist scores by gender and age groups

The common behavioral problems in school children who scored above cutoff ( n = 52) in CBCL were found to be argumentativeness (55%), followed by lack of concentration, restless, and hyperactive behavior. Gender-wise distribution of common behavioral problems noted lack of remorse, argumentativeness, and restlessness more in boys, compared to preoccupation with cleanliness and neatness, perfectionistic ideas, and argumentativeness among girls, though the difference was not statistically significant either.

All 52 children were administered CARS and none were found to have significant scores above cutoff. An assessment of intelligence noted 7 children of 52 to be below average in intelligence, though none had intellectual disability.

On administering CRS for ADHD on 27 children in the age group of 6–10 years, 14 were found to be above cutoff, and 15 children were above cutoff scores in children in the age group of 11 years and above ( n = 25). There were no statistically significant differences between boys and girls in CRS scores. Overall, the results showed that a brief screening instrument can be useful for using in schools to obtain a cross-sectional view of common behavioral problems in children, which can then be further assessed and intervention can be provided.

A total of 109 children (22.7%) were found to have behavioral problems with initial screening by PSC/Y-PSC. This is slightly higher than another Indian study,[ 4 ] but similar to study by Muzammil et al .[ 13 ] and Malhotra andPatra.[ 14 ] Few western studies have shown higher prevalence rates.[ 15 , 16 , 17 ] The disparate estimate of prevalence and need for national data on epidemiology has been highlighted by Sharan and Sagar.[ 18 ] It emphasizes that although available Indian studies have started to address the unmet need for systematic information tracking of the prevalence and distribution of mental disorders, national data are still not available. The absence of empirical data on the magnitude, course, and treatment patterns of various mental disorders in a nationally representative sample of children and adolescents has largely restricted the efforts essential for establishing mental health policy for this population.

The mean CBCL scores of this study population were higher than most similar studies in India.[ 5 , 19 ] This can be attributed to the type of study population (school based vs. community based) and informant chosen (teachers/parents) among other factors. CBCL was being used in the present study in a population which was already screened for behavioral problems by PSC/Y-PSC, this put together with greater sensitivity of CBCL, growing concern among teachers and parents of behavioral problems or even growing magnitude of behavioral disturbances may have contributed to a higher mean score. The epidemiological issues of different vantage points have been discussed by Wolpert.[ 20 ]

The analysis of CBCL scores showed significant differences between the mean scores of boys and girls who scored above cutoff, as per age groups. This was similar to the findings by Malhotra et al .,[ 21 ] which is a clinic-based study with advantage of long-term data. The age-wise distribution of positive CBCL scores did not show any significant difference between the two groups.

The analysis for a pattern of distribution of behavioral problems in children revealed them to be more of externalizing ones. This goes along with the findings by Chaudhury et al .,[ 22 ] Shetty and Shihabuddeen,[ 23 ] and Shastri et al .[ 24 ] Girls had more internalizing behavioral problems whereas boys had more externalizing problems.

Overall difference was not significant which could be due to the small size of CBCL screened sample ( n = 52) only analyzed for these dimensions. This is similar to the findings by Deb et al .[ 25 ] No cases of autism spectrum disorder were found in this study when CARS was applied to this group of children. This is possibly due to the fact that the average age for diagnosis of children with the above disabilities is 3–4 years and these are not common in general population. This finding is similar to the study by Malhi and Singhi[ 26 ] and Vijay Sagar.[ 27 ]

Majority of children among the screened study population showed intelligence level in average range, and no cases of intellectual disability were noted though few ( n = 7) children were noted to have below average intelligence. This is similar to other school-based studies in India by Eshwar et al .[ 28 ] and Basu.[ 29 ]

Analysis of CRS when applied to these children for ADHD and related disturbances did not show a significant difference between the groups. This is similar to the study by Meyer et al .[ 30 ]

Relation of CRS scores in both genders was analyzed in respect of total number of children who scored positive in CBCL. The difference in boys and girls were not found to be significant. This is similar to the findings by Efron et al .[ 31 ] and Malhotra and Patra.[ 14 ]

All the children who showed positive scores in tests were taken up for remedial treatment or referred for further follow-up as per target symptoms.

About 22.7% of children among the total study population were found to have behavioral problems such as anxiety, hyperactivity, argumentativeness, and perfectionist ideas during initial screening which needed attention. Boys showed more externalizing behavioral problems and girls more internalizing ones. There were no children with intellectual disability or pervasive developmental disorders although ADHD was noted and addressed. This finding is close to the findings of various western studies where up to a quarter of children have various mental health issues, but higher than the available Indian studies quoted – where a different vantage point and methodology may have been responsible.

This study emphasizes the need for periodic screening of children among schools for behavioral problems which may serve as early indicators of future psychopathology. Once a detailed assessment of behavioral problems is over, life skills training modules developed by the World Health Organization for schools may help schools in reducing the number of behavioral problems and development of psychopathology among children.

This study, however, has the following limitations:

• The study is a descriptive study, trying to find out the extent of various behavioral problems in schoolgoing children. Participants may not be truthful or may not behave naturally when they know they are being observed
• Descriptive studies cannot be used to correlate variables or determine cause and effect
• Researcher bias may play a role in selection of the questionnaire and interpretation
• Findings may not be replicable in a different population
• Findings may be open to interpretation.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
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