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Chapter 31: Child Psychiatry
found to be at high risk for developing both social problems
and academic difficulties. Socioeconomic deprivation can also
affect the adaptive function of these vulnerable infants. Early
intervention may improve their cognitive, language, and percep-
tual abilities.
Acquired Childhood Disorders
Infection.
The most serious infections affecting cerebral
integrity are encephalitis and meningitis. Measles encephalitis
has been virtually eliminated by the universal use of measles
vaccine, and the incidence of other bacterial infections of the
CNS has been markedly reduced with antibacterial agents. Most
episodes of encephalitis are caused by viruses. Sometimes a
clinician must retrospectively consider a probable encephalitic
component in a previous obscure illness with high fever. Men-
ingitis that was diagnosed late, even when followed by antibiotic
treatment, can seriously affect a child’s cognitive development.
Thrombotic and purulent intracranial phenomena secondary to
septicemia are rarely seen today except in small infants.
Head Trauma.
The best-known causes of head injury in
children that produces developmental handicaps, including sei-
zures, are motor vehicle accidents, but more head injuries are
caused by household accidents, such as falls from tables, open
windows, and on stairways. Child maltreatment is not infre-
quently implicated in head traumas or intracranial trauma such
as bleeding due “shaken baby” syndrome.
Asphyxia.
Brain damage due to asphyxia associated with
near drowning is not an uncommon cause of intellectual dis-
ability.
Long-term Exposures.
Long-term exposure to lead is a
well-established cause of compromised intelligence and learn-
ing skills. Intracranial tumors of various types and origins, sur-
gery, and chemotherapy can also adversely affect brain function.
Environmental and Sociocultural Factors
Mild intellectual disability has been associated with significant
deprivation of nutrition and nurturance. Children who have
endured these conditions are at risk for a host of psychiatric
disorders including mood disorders, posttraumatic stress disor-
der, and attentional and anxiety disorders. Prenatal environment
compromised by poor medical care and poor maternal nutrition
may be contributing factors in the development of mild intellec-
tual disability. Teenage pregnancies are at risk for mild intellec-
tual disability in the baby due to the increased risk of obstetrical
complications, prematurity, and low birth weight. Poor postnatal
medical care, malnutrition, exposure to toxic substances such as
lead, and potential physical trauma are additional risk factors
for mild intellectual disabilities. Child neglect and inadequate
caretaking may deprive an infant of both physical and emotional
nurturances, leading to failure to thrive syndromes.
Diagnosis
The diagnosis of intellectual disability can be made after the
history is obtained, using information from a standardized intel-
lectual assessment, and a standardized measure of adaptive func-
tion indicating that a child is significantly below the expected
level in both areas. The severity of the intellectual disability will
be determined on the basis of the level of adaptive function.
A history and psychiatric interview are useful in obtaining a
longitudinal picture of the child’s development and functioning.
Examination of physical signs, neurological abnormalities, and
in some cases, laboratory tests can be used to ascertain the cause
and prognosis.
History
The clinician taking the history, which may elucidate pathways
to intellectual disability, should pay particular attention to the
mother’s pregnancy, labor, and delivery; the presence of a fam-
ily history of intellectual disability; consanguinity of the par-
ents; and known familial hereditary disorders.
Psychiatric Interview
A psychiatric interview of a child or adolescent with intellectual
disability requires a high level of sensitivity in order to elicit
information at the appropriate intellectual level while remain-
ing respectful of the patient’s age and emotional development.
The patient’s verbal abilities, including receptive and expressive
language, can be initially screened by observing the communi-
cation between the caretakers and patient. If the patient com-
municates largely through gestures or sign language, the parents
may serve as interpreters. Patients with milder forms of intel-
lectual disability are often well aware of their differences from
others and their failures, and may be anxious and ashamed dur-
ing the interview. Approaching patients with a clear, support-
ive, concrete explanation of the diagnostic process, particularly
patients with sufficiently receptive language ability, may allay
anxiety and fears. Providing support and praise in language
appropriate to the patient’s age and understanding is beneficial.
Subtle direction, structure, and reinforcement may be necessary
to keep patients focused on the task or topic.
In general, the psychiatric examination of an intellectu-
ally disabled child or adolescent should reveal how the patient
has coped with stages of development. Frustration tolerance,
impulse control, and over-aggressive motor and sexual behavior
are important areas of attention in the interview. It is equally
important to elicit the patient’s self-image, areas of self-confi-
dence, and an assessment of tenacity, persistence, curiosity, and
willingness to explore the environment.
Structured Instruments, Rating Scales and
Psychological Assessment
In children and adolescents who have acquired language, one of
several standardized instruments that include numerous domains
of cognitive function are used. For children ages 6 to 16 years,
the Wechsler Intelligence Test for Children is typically admin-
istered, and for children ages 3 to 6 years, the Wechsler Pre-
school and Primary Scale of Intelligence-Revised is commonly
used. The Stanford-Binet Intelligence Scale, Fourth Edition,
has the advantage that it can be administered to children even
younger, starting at age 2 years. The Kaufman Assessment Bat-
tery for Children can be used in children ages 2½ to 12½ years,
