The Canadian Journal of Psychiatry

This essay discusses the position of child psychiatry as a subspecialty in Canada today. Proceeding from a review of a paper written by Dr. Quentin Rae-Grant in 1970 “Adult and Child Psychiatry — One or Two Nations?” the author, using the concept of a nation as a metaphor, explores the evolution of child psychiatry as a subspecialty in Canada. The history of child psychiatry in Canada is reviewed briefly; from its early beginnings to an increased understanding of its uniqueness as a subspecialty, finally through to the formation of the Canadian Academy of Child Psychiatry in 1980. The essay stresses the mutuality of our dependence on the Canadian Psychiatric Association. The author emphasizes our mutual dependence on the greater organizational body of psychiatrists, and encourages a greater participation of child psychiatrists within the Canadian Psychiatric Association. The author also emphasizes the need to have a closer relationship with the Canadian Paediatric Society. In addition, the author discusses in some detail the more complex and controversial relationship between child psychiatry and the Royal College of Physicians and Surgeons of Canada. Finally the author emphasizes the importance of a close working relationship with the American Academy of Child and Adolescent Psychiatry. All of these relationships are emphasized in terms of mutual dependence.

This paper examines the relevance recent findings in Infant Psychiatry may have for the understanding of adult psychopathology. For example, evidence of both continuity and discontinuity within development is cited as one way in which the continuity of specific psychiatric conditions from childhood to adulthood can be understood. Another example are the aims of Developmental Psychopathologists who examine the mechanisms which underlie developmental transformations and who try to differentiate variations seen in normal individuals from disorders.

The paper ends by citing the advantages Infancy as a developmental period has in providing reference points for the understanding of cohesion within development. These are:

1. The rapid rate of change seen in children during this age period. This allows the observation of many developmental transformation and reorganizations.

2. The degree to which infants document how much we can shape our own environment.

3. The pervasive importance interpersonal relationships have for any human activity.

4. The need to understand development and hence change within the context of the environment.

5. The persuasive evidence which suggests that psychological disorders are generally based on real rather than imagined adverse events.

Parental welfare status was found to be a marker for identifying a group of children with an increased prevalence of psychiatric disorder and poor school performance. The marker was particularly strong for psychiatric disorder in young boys and for poor school performance in young girls. For instance, the prevalence rates of psychiatric disorder, in the 6 to 11 age group, for welfare and non-welfare boys, were 40.0% and 13.9%, respectively; and for poor school performance in welfare and non-welfare girls, 27.8% and 6.1%, respectively.

The relationship between different measures of psychosocial disadvantage and these child deficits was examined. Multivariate analyses revealed, for example, that parental welfare status made an independent contribution to the prediction of psychiatric disorder and was a more powerful predictor of poor school performance in girls compared to boys. The implications of these and other results are discussed.

This paper reports on the characteristics of two dimensions (behavior control and communication) of the McMaster Model of Family Functioning (MMFF) as assessed through the MMFF semi-structured interview in families of the normal nonclinical population of Quebec City (N= 118). Interrater reliability as well as scores distribution are reported. Particular attention is given to the absence of association found between family functioning and socioeconomic status. Exploratory data about the relationship between parental conflict and family functioning are also discussed in terms of future inquiries in child psychiatric epidemiology.

In child psychiatry one may frequently and reasonably suspect the existence of a neurophysiological abnormality of some kind even though this abnormality is not detectable with readily available technology: in children presenting developmental or acquired aphasia, in some specific learning disabilities, in severe developmental disorders or perhaps in a subgroup of those labeled Attention Deficit Disorder.

1. The importance for us as child psychiatrists to keep in mind the possible role of neurophysiological factors is put into perspective.

2. What Evoked Potentials are is briefly described as well as the basic principles of the technique used in recording them.

3. A review of the literature reveals how the Brainstem Auditory Evoked Responses (BAER) have helped in understanding unknown facets of known diseases (Diabetes, Hyperthyroidism, Bell Palsy, etc….) from this, it is argued that this is reasonable to expect the same usefulness for diagnosis in child psychiatry.

4. An opinion is offered as to how and when a child psychiatrist should make use of this investigation.

Sexual abuse allegations directed at one parent can arise in the context of custody and access disputes. The role of the clinician, when such allegations occur, is to provide an assessment of the total situation, taking the allegations into account. To assess the probability that sexual abuse has occurred involves a thorough assessment of the accuser, the accused, the accusation, the child, and different family subsystems. Particular attention should be paid to interviewing the young child with detailed focus on the interviewing process, how the interviews are reported and what conclusions may be drawn from them. Following a thorough assessment, the clinician may reach one of three conclusions: that the sexual abuse has probably occurred, has probably not occurred, or is unsure. A strong caution is given against becoming entangled in an endless process of trying to find out whether the allegations are true or false. Whatever conclusions are reached are but one factor in the recommendation regarding custody and/or access. Ultimately the recommendation will be made according to the best interests of the child, taking into account the child's relationships and attachments, as well as the sexual abuse allegations.

There have been, in the last decade, approximately 500 surrogate births in the United States and the demand is increasing. The average cost is $25,000 and as there is no regulatory legislation in place, each arrangement is covered by a private legal contract. There is little reliable data regarding any member of the “incubating family”, or on the adopting couple. This paper is an attempt to point out the potential hazards, based on a theoretical and clinical appreciation of child and adult biopsychosocial processes. The authors advocate careful longitudinal study of all children and adults involved in this complex reproductive alternative.

Recent awareness of the pervasiveness of sexual abuse of children has resulted in a move to implement prevention programs. In conducting these programs the question of effectiveness is frequently asked.

In an attempt to answer some of this concern, a questionnaire was developed and tested to determine children's base level of knowledge. The video format prevention program, “Feeling Yes, Feeling No”, available from the National Film Board (Canada) was tested as a method of increasing awareness. A school with a cross section of town and rural children, with differing socioeconomic backgrounds, participated in the study.

The study consisted of a pretest of knowledge, a structured video interactive classroom prevention program, and a post-test measure of change. One hundred and thirty-seven students in grades 4, 5, and 6 participated. The program took 4 weeks to complete.

When asked about their feelings with regard to the program, 97% of the children stated that they enjoyed it. The results indicated that while most children have a basic level of self-protective knowledge and assertiveness, they can, in a classroom setting, learn significant and additional facts about avoiding sexual assault. Eight of twenty-nine knowledge questions elicited a large change in response, suggesting increased awareness of self-protection. The most significant changes occurred with girls, the same group apparently most at risk.

A deviance based model of deafness is compared with one based on ethnicity. The function of inadequate communication in deaf member families is explored. Techniques of intervention are examined with a focus on three strategic interventions namely: 1) circular interviewing; 2) positive connotation; and, 3) use of rituals. Case histories are provided.

Thirty-seven offspring from 21 families with a manic-depressive parent were studied 3 to 7 years following initial evaluation. The study examined both pedigree information and psychosocial variables including parental, marital and overall adjustment, measures of chronicity and severity of parental illness and family assessment measures in rleationship to offspring functioning.

Nine of the 37 offspring (24%) received a positive DSM-III diagnosis, which is a similar percentage of positive diagnosis of children as we found previously. The diagnoses clustered in the affective illness spectrum. When the presence of affective traits was considered, there was evidence for continuity of psychopathology in most cases. Associations between offspring psychopathology and both non-specific and specific parental risk factors are discussed.

Children with overanxious and/or avoidant disorder (DSM-III) were treated with alprazolam (Xanax, Upjohn) to determine its safety, clinical and cognitive effects. Ten male and two female patients (age range 8.8 to 16.5 years; mean 11.5)participated in an open clinical trial consisting of a baseline placebo period (1 week), alprazolam therapy (4 weeks), a drug-tapering period (1 week), and a post-drug placebo period (1 week). There was a drug-free follow-up approximately 4 weeks after termination of the study. Dosages were individually adjusted and the daily maximum ranged from 0.50 mg to 1.5 mg. Evaluations included clinical assessments, parent, teacher and self ratings, and cognitive tests. Clinical global improvement with alprazolam therapy was marked in 1 patient, moderate in 6, minimal in 4, and none in 1. Clinician ratings indicated significant improvements of anxiety, depression, and psychomotor excitation. Parent questionnaires indicated significant improvements of anxiety and hyperactivity while teacher questionnaires showed significant improvement of an anxious-passive factor. Significant improvements in the paired associate learning tasks, maze task and the block design tasks were maintained after drug withdrawal suggesting a practice effect. Adverse effects were infrequent, mild and transient. There were no clinically significant changes of laboratory values, blood pressure, pulse or respiration during the 4 weeks of alprazolam administration. Body weight increased significantly (mean increase was 0.87 kg). Double-blind trials with alprazolam are recommended in child psychiatry disorders.

The author presents the complexities of directing a DTC (Day Treatment Center) in a rural setting. These complexities are explored from the pespective of system's theory. The various systems contained within the DTC are in dynamic equilibrium with each other as well as with various community groups. Changes in any one system have significant impact on the groups the system impinges on. As an example, the DTC had not functioned well for a period of time prior to the author's arrival. During that period the staff communicated poorly among themselves, resulting in conflicts between the teaching and non-teaching staff. When these conflicts were resolved the well-established incompatibilities and stresses within the system of the non-teaching staff surfaced.

In the process of this conflict resolution the DTC was reorganized. New groups were established to access children at primary and secondary levels of medical prevention. Rapport with other systems in the community improved. Consequently, with better communication between groups of staff and with the community, the treatment of the children could be more effective.

Residential treatment for disturbed, particularly delinquent, adolescents has been described several decades ago by the founders and leaders of institutions. Theoretical considerations in treatment were prominent. The importance of structured milieu and the control of aggression came to acquire recognition. This study describes a structured centre, known to be effective in treating disturbed delinquents, using data gathered over twelve years of clinical work, observation and research. Factors considered essential in defining this institution are isolated and made compatible with the factors indicated by Rutter in his review of the residential treatment of delinquents. These factors are being used in a further study which compares the effectiveness of different types of facilities for a range of diagnostic categories.

A 12 year old boy was diagnosed as having overanxious disorder of childhood and school phobia. He was later found to be suffering from the effects of a cerebral tumor. Surgical removal of the tumor led to alleviation of the anxiety. The authors utilize this case to illustrate some aspects of differential diagnosis in child psychiatry. In particular, they point out the necessity of comprehensive physical examination in child psychiatry inpatient units. The danger of attributing physical symptoms to functional illness purely in the absence of positive physical findings is noted. The importance of utilizing a biopsychosocial diagnostic model in child psychiatry is stressed.

In this paper we focus on the evaluation, assessment, diagnostic conclusions, and individual psychotherapy of a four year old twin who presented with the symptom of encopresis. Of great relevance to this boy is the literature concerning his vulnerability as a twin to develop symptomatology as he starts dealing with separation and individuation issues. Especially relevant are the multiple impacts of attitudes, perceptions and family rearing issues on the psychological development of this twin, and also on the development of this specific symptom choice — encopresis. Incorporating literature with case material, the meaning of the symptom of encopresis to this twin is discussed. The hypothesis defended is that the symptom enabled the twin to attract attention from his somewhat favoured brother, and to promote the process of separation and individuation from his parents and from his twin. It promoted his sense of himself as a separate and unique person in his own right. The child developed a sense of himself despite parental interference. With individual psychotherapy and family therapy, the need for the symptom was neglected.

A case is presented that shows the usefulness of integrating systems theory and attachment theory in the formulation and treatment of a clinical problem. The 5 year old son of East Indian immigrants presented with persistent psychogenic vomiting associated with pathological family attachments. It was evident that the precarious family equilibrium was stabilized by the child's psychogenic vomiting. The therapeutic team suggested to the family that their problems might be more satisfactorily resolved if the mother and child maintained their link by two-way radio. Three weeks later the vomiting had ceased, the child no longer felt that he needed the radio and both parents had established new patterns of relating to their child, whose attendance and peer socialization at school showed marked improvement. To some extent the rapid resolution of the problems was facilitated by the cultural strengths of the family.

This paper describes the psychiatric and clinical manifestations of the epilepsy-aphasia syndrome which occurs in children. In 1957, Landau and Kleffner reported the development of receptive and expressive aphasia at 5 to 6 years of age, in six children with normal language development at that time. Since this first report, further accounts of acquired language disabilities associated with EEG abnormalities have appeared. However, the clinical syndrome remains ill defined and its pathophysiology is poorly understood.

There are no reported cases of this syndrome presenting initially to psychiatry. This paper reports a child who presented to psychiatry with severe aggression associated with the clinical syndrome of epilepsy-aphasia. The discussion examines the relationships between the aggressive behavior and the EEG findings and aphasia.

This case report describes the psychosexual development of a child with true hermaphroditism who was assigned to the male sex at birth, but reassigned to the female sex at age two months. Given this child's excessive exposure to male sex hormone in utero, relative to physically normal females, one would predict a biological predisposition to behave in a masculine manner. This has occurred since two years of age. In addition, this child has had periodic episodes of gender disturbance, dysphoria, and ambivalence. In contrast, a physically normal fraternal twin sister has been conventionally feminine. A number of psychosocial factors appeared to have exacerbated the biologic predisposition to behave in a masculine manner, and thus may have been responsible for “pushing” this child into varying degrees of gender identity conflict. These included a closer father-daughter than mother-daughter relationship, parental tolerance of cross-gender behavior, and a mother who has been psychologically disturbed since the birth of her children. The heuristic value of this case will be discussed in relation to contemporary models of psychosexual development which emphasize the interaction of biological and psychosocial factors.

In assessing the credibility of young children's (ages 2–7) allegations of sexual abuse clinicians need to know how dynamics of sexual abuse affect disclosure, what situations are most commonly associated with fictitious allegations and how the child's developmental stage affects disclosures. Understanding these issues allows for clear decision making. A clear decision making process flows naturally from an understanding of these issues.

This paper will consider three types of interview that are held with sexually abused children. After discussing common problems in technique, it will suggest a methodology designed to help determine a child's credibility and assist in forming and demonstrating a reliable expert opinion for court purposes. Next, it will describe three types of data crucial in investigating allegations of sexual abuse, and will suggest clinical criteria useful in distinguishing true from false allegations. Finally, it will examine the validity of these criteria, comparing them to those of other workers in the field.

In the past decade much has been learned about the clinical features, diagnosis and understanding of people with anorexia nervosa and bulimia nervosa. In order to provide the next level of improvement in our care for these patients, our understanding of certain problems must be addressed by empirical research. Areas which require further study include the definition of high risk groups, the refinement of diagnoses, understanding factors which result in chronicity, determining the complications of chronicity and comparative evaluations of different treatments. These five areas are outlined in this article. Populations at risk for anorexia nervosa and bulimia nervosa may be those who must be thin and achieve according to career choice, those with a particular family and personal psychiatric history; obesity and chronic medical illnesses may be further risks. Improved diagnostic understanding has occurred by the differentiation of bulimic from restricting subtypes of anorexia nervosa. Further work must determine the relationship between the bulimic subtype of anorexia nervosa and bulimia in normal weight women and to further clarify the relationship between eating disorders and affective disorders. A number of factors may result in a chronic illness. These have been described on a variety of levels. The consequences of starvation in altering an individual's thinking, feeling and behaviour do play a role. It is not clear what factors at a neurochemical level contribute to this. Elevated endogenous opiates decreased noradrenergic function and decreased serotonin may be important.

Information about the chronic complications is required for clinicians to understand the broad range of difficulties that may develop over time so that clinicians may use this information in planning treatment strategies. Two examples, those of osteoporosis and the pregnant woman with an eating disorder, highlight this problem. Finally, treatment is briefly reviewed in terms of options available and the idea of developing a stepped-care approach to treatment.