The Changing Clinical Picture

The growth of child psychiatric services in Utah has been paralelled by an increased understanding of child psychiatric disorders and improved treatment approaches. For example, childhood and adolescent depression was not even acknowledged in child psychiatry textbooks until after 1960. It is commonly recognized today, and its association with the rapidly escalating problem of adolescent suicide is a source of great concern. Family disruption, school failure, social isolation and the breakdown of communication are relevant psychologic issues. Genetic and biologic factors, however, are the subject of much research and clearly play a role. Antidepressant medication is often used in connection with individual and family therapy. Occasional cases of bipolar or manic depressive illness, a familial disorder, are recognized in adolescence and respond to treatment with lithium. The antecedents of this disorder are just beginning to be recognized amidst hyperactive and cyclic mood disturbances.

Whereas the child psychiatrist plays a more prominent role in the treatment of affective disorders, the opposite is true of infantile autism, an uncommon but very serious problem. Previously thought to be a consequence of lack of emotional attachment and faulty parenting, it is now recognized as a neurologic disorder with severe problems in social relatedness and language development. A comprehensive psychoeducational approach is recommended, including behavior modification and special education. Parent training is essential. The child psychiatrist plays a supportive but vital role. To this point medication has offered only symptomatic relief. Utah has received national attention as the site of a major genetic study into inheritance patterns of autism and is one of several sites of investigation into the use of fenfluramine in accelerating learning in autistic children.

Hyperactivity in children, by contrast, is a very common disorder of concern to all physicians who work with children. Because of its prevalence, it is estimated it affects approximately 5 percent of the population. It frequently leaves deep emotional scars secondary to the many failures experienced by these children at home, school and in the community due to their inattention, impulsivity and learning difficulties. The combined use of stimulant medication and child or family therapy has been accepted for many years. More recently we have become aware that problems with attention and impulse control may persist into the adolescent and adult years even though hyperactivity is diminished. Continued treatment is often necessary. University of Utah research child psychiatrist Paul H. Wender, M.D., has been a pioneer in the study and treatment of adult hyperactivity. More recently, concern has been raised that psychostimulant medications may occasionally induce movement disorders such as tics and Tourette’s syndrome. This is under investigation currently at Primary Children's Medical Center and elsewhere.

Another area of concern to all physicians is the physi- Lcally ill child. Stress related illnesses such as tension headaches and chronic or recurrent abdominal distress respond well to identification and reduction of stress and behavioral treatment approaches such as visual imagery and deep muscle relaxation. These techniques are also useful in children with chronic illnesses such as cystic fibrosis, bronchial asthma, diabetes and cancer where stress clearly compounds their symptoms. Self-hypnosis is a helpful adjunct with pain management. Family therapy with careful attention to issues of overprotectiveness, enmeshment or lack of role definition, and difficulties with problem solving and communication may be lifesaving.

The rapid increase in serious eating disorders has also served to bring child psychiatrists into a closer working relationship with their non-psychiatrist medical colleagues. Anorexia nervosa, though heavily shaped by current sociological attitudes and psychological conflicts, requires close medical collaboration and management to maintain adequate growth and nutrition, a fact made more evident by the increased awareness of life threatening late complications affecting neurologic, cardiovascular and gastrointestinal systems. Bulimia is also a source of concern but seems to more often afflict the older or college age adolescent.

Conduct disorders, especially those accompanied by antisocial behavior, remain of great concern to child psychiatrists and the community at large. The identification of learning disorders and attention deficit problems which are sometimes a part of this syndrome may lead to specific treatment approaches; however the common association with severe family disruption and multigenerational patterns of substance abuse require involvements of the extended family in treatment. Participation by schools is essential and placement outside the home is still required at times. This remains a major challenge for the future.

Thus we see that child psychiatry in Utah is in a state of rapid growth in all parameters. Since World War II a comprehensive delivery system has evolved including both the public and private sector, both agency and individual practitioner. The understanding of child psychiatric disorders has increased greatly, leading to more specific treatment approaches. Child psychiatry is more than ever in the mainstream of medicine and the community.