Child Psychiatrists: On the Front-lines of Neuropsychiatry

January 30, 2019
Barbara Schildkrout, MD
Volume 36, Issue 1

In medical publishing, the casebook format has become increasingly popular-and for good reason. A new casebook focuses on the overlap of neurology and psychiatry in child practice.

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In medical publishing, the casebook format has become increasingly popular-and for good reason. A memorable clinical vignette facilitates learning.1 As clinicians, we assimilate information best from case examples. We can imagine ourselves in the story, especially when the cases are drawn from real life and the authors do not edit out the confusions and uncertainties of actual psychiatric practice-the patient whose history is hard to follow; the individual with multiple diagnoses, or someone with an atypical presentation.

Pediatric Neuropsychiatry: A Case-Based Approach is a new casebook that focuses on the overlap of neurology and psychiatry in child practice.2 The co-editors, Aaron J. Hauptman and Jay A. Salpekar, two neuropsychiatry colleagues of mine, have called upon 65 contributing scholars to present a comprehensive, clinically relevant, and very readable text.

Psychiatrists are increasingly aware that the boundary between psychiatric disease and neurological disease is arbitrary.3 This book is written with the goal of presenting an integrated conceptualization of neurology/psychiatry and brain/behavior in the realm of pediatric neuropsychiatry practice.

Child and adolescent psychiatrists are on the front lines of neuropsychiatry. Everyday considerations in the practice of child and adolescent psychiatry include: brain development, genetic diseases, the influence of prenatal exposure to alcohol or drugs, nutritional influences on brain health, family dynamics, and educational opportunities that shape neurodevelopment. Many neuropsychiatric diseases that adult psychiatrists treat are first seen in children: autism spectrum disorders, ADHD, lead poisoning, fetal alcohol syndrome, sleep disorders, Tourette syndrome, epilepsy. Pediatric Neuropsychiatry: A Case-Based Approach covers all of these topics and more-pediatric traumatic brain injury, anoxic brain injury, non-epileptic seizures, childhood multiple sclerosis, autoimmune limbic encephalitis, PANS [pediatric acute-onset neuropsychiatric syndrome] and PANDAS [pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection], hypothalamic tumors.

The book contains 26 chapters that focus on case examples. The case descriptions are followed by a discussion of diagnostic impressions, a succinct summary of the relevant neuroanatomy and pathophysiology, treatment strategies, and neuropsychiatric “lessons learned.” An additional chapter discusses the pediatric neuropsychiatric exam.

Throughout the book there are unique features such as: personal reflections written by patients or family members, “Clinical Pearls,” and summaries of educational materials or available resources like rating scales for ADHD. There is a substantial section on complementary and alternative medicine strategies for patients who have epilepsy. It is clear that the authors were writing with the needs of clinicians in mind.

While there are now 33 accredited fellowships open to psychiatrists who seek post-graduate training in Behavioral Neurology & Neuropsychiatry, no such formal programs are available in pediatric neuropsychiatry.4 For child and adolescent psychiatrists who are interested in learning more about neuropsychiatric thinking, this latest casebook is an excellent resource. There is also much material here that would appeal to psychiatrists with adult patients.

I spoke with Jay and Aaron about their book. Jay Salpekar is a Child and Adolescent Psychiatrist who runs a Neuropsychiatry in Epilepsy Program at Kennedy Krieger Institute, an institution specializing in brain and spinal cord diseases and developmental disabilities in children and young adults. He is also on the full-time neurology and psychiatry faculty at Johns Hopkins University School of Medicine.

When we first came up with the idea for this book, we knew that we wanted it to be different. We wanted to include patient and family stories and also their personal reflections; we think these are as important as the scientific background for enlightening our understanding of cases.

We were so gratified by the reception we got from chapter authors, all experts in their fields. We wanted cases that would illustrate brain and behavior relationships. It didn’t have to be the most rare case or a neat and tidy case. The contributors understood the concept and were totally on-board.

Aaron Hauptman is a Child and Adolescent Psychiatrist at Boston Children’s Hospital who is also in a Behavioral Neurology and Neuropsychiatry fellowship program at Brigham and Women’s Hospital. He works with individuals with developmental and acquired CNS injuries across the lifespan. According to Aaron,

In addition to providing accurate diagnoses, one of our main goals as clinicians is to be able to offer to the children and families who are struggling with neuropsychiatric illnesses an integrated formulation of their experiences. It’s not an either/or situation. And in fact, to try to pigeonhole what’s going on as either uniquely neurological or psychiatric is both invalidating and often inaccurate. A large part of why we wrote the book was to help give other clinicians a sense of this integrated approach.

A one-to-one correlation between brain and behavior is much less certain in children because they adapt so quickly. Despite the fact that prognostication and localization are so different for pediatric patients, still attention to neuroanatomical correlates of cognition, behavior, and emotion can be tremendously valuable.

Working with these patients and families has been an unparalleled experience. I’m optimistic about shifts in the field toward increasing integration of neurology and psychiatry. We hope that our book helps more clinicians to take part in the discussion.

Disclosures:

Dr Schildkrout is Assistant Professor of Psychiatry, part time, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA. She is the author of two books: Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders and Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems.

References:

1. Benjamin S, MacGillivray L, Schildkrout B, et al. Six landmark case reports essential for neuropsychiatric literacy. J Neuropsychiatry Clin Neurosci. 2018;30:279-290.

2. Hauptman AJ, Salpekar JA. Pediatric Neuropsychiatry: A Case-Based Approach. New York: Springer; 2018.

3. Perez DL, Keshavan MS, Scharf JM, et al. Bridging the Great Divide: What Can Neurology Learn From Psychiatry? J Neuropsychiatry Clin Neurosci. 2018;30:271-278.

4. United Council for Neurologic Subspecialties. https://www.ucns.org/apps/directory/index.cfm?event=public.program.searchResults&subspecialty_ids=1&inst_state=&submit=Start+Search. Accessed November 19, 2018.

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