Psychiatry and Behavioral Health Rotation

An 8-year-old who is disruptive in class, constantly fidgeting, has difficulty concentrating, and does not complete assignments

• Inattention, hyperactivity, and/or impulsivity that is developmentally inappropriate — combined, predominantly inattentive, or predominantly hyperactive/impulsive presentations
• Highly comorbid with learning disorders, ODD, tics, and anxiety

DX: DSM-5 — ≥ 6 symptoms of inattention and/or hyperactivity-impulsivity (≥ 5 if age ≥ 17) for > 6 months

• Several symptoms present before age 12 and in ≥ 2 settings (home + school), with functional impairment
• Clinical diagnosis — rating scales (Vanderbilt) from parents and teachers support it

TX: Age 4–5: parent training in behavior management first; age ≥ 6: stimulants first-line (methylphenidate, amphetamine salts) + behavioral therapy

• Nonstimulant alternatives: atomoxetine, guanfacine ER, clonidine ER — comorbid tics, substance-use concern, or stimulant intolerance
• Monitor growth, appetite, sleep, heart rate, and blood pressure on stimulants

Social-communication deficits + restricted, repetitive behaviors present from the early developmental period

• DSM-5 folded the former subtypes (autistic disorder, Asperger, PDD-NOS) into one diagnosis, graded by support needs (levels 1–3)
• Screen all children with the M-CHAT-R at 18 and 24 months (AAP)
• Workup: audiology to exclude hearing loss; genetic testing (chromosomal microarray + fragile X) is standard of care

DX: DSM-5 — persistent deficits in all 3 social-communication domains (social-emotional reciprocity · nonverbal communication · relationships) + ≥ 2 of 4 restricted/repetitive patterns (stereotyped movements · insistence on sameness · fixated interests · sensory hyper/hyporeactivity)

• Symptoms present in the early developmental period and cause functional impairment; not better explained by intellectual disability alone

TX: Early intensive behavioral intervention (ABA-based) + speech & language and occupational therapy

• Medications treat targets, not autism: risperidone or aripiprazole — FDA-approved for irritability/aggression in ASD
• Support families early — earlier intervention = better outcomes

Deficits in BOTH intellectual functioning AND adaptive functioning, with onset during the developmental period

• Etiology pearls: Down syndrome = most common genetic cause · fragile X = most common inherited cause · fetal alcohol exposure = most common preventable cause
• Mild severity is ~85% of cases — often not identified until school age
• High rates of comorbid ADHD, autism, epilepsy, and behavioral disorders

DX: DSM-5 — deficits in intellectual functions (clinical assessment + standardized testing) AND adaptive functioning, with onset in the developmental period

• Severity (mild → profound) graded by adaptive functioning — conceptual, social, practical domains — not IQ alone
• Workup: hearing and vision first (sensory deficits masquerade as cognitive delay) → standardized IQ + adaptive assessment → chromosomal microarray + fragile X (FMR1) testing

TX: Early intervention services (before age 3) + an individualized education program (IEP)

• Speech, occupational, and behavioral therapy; family support and care coordination; genetic counseling when a cause is found
• No medication treats intellectual disability itself — treat comorbidities

Rhythmic, purposeless, PATTERNED movements (hand flapping, body rocking, head banging) that STOP WITH DISTRACTION

• vs tics: stereotypies start earlier (usually < 3 years vs ~5–7), are rhythmic and fixed in form, and lack a premonitory urge; tics are sudden, variable, urge-driven, and briefly suppressible
• Common in autism and intellectual disability; benign "primary" stereotypies also occur in typical children
• A parent video is often diagnostic — no EEG or imaging for classic distractible stereotypies

DX: DSM-5 — repetitive, seemingly driven, apparently purposeless motor behavior that interferes with activities or causes self-injury

• Onset in the early developmental period; not attributable to a substance or neurologic condition and not better explained by OCD or trichotillomania
• Specify: with or without self-injurious behavior; associated condition (e.g., intellectual disability)

TX: Behavioral intervention first-line — habit reversal and differential reinforcement + environmental modification

• Self-injury: protective measures (padding, helmets) + intensive behavioral therapy
• Medication has a limited role, reserved for severe self-injury; treat the underlying condition

Tourette disorder = BOTH multiple motor tics AND ≥ 1 vocal tic for > 1 year, onset before age 18

• Tics are sudden, rapid, nonrhythmic, preceded by a premonitory urge, briefly suppressible, wax and wane, and worsen with stress — most decline in adolescence
• Highly comorbid with ADHD and OCD — screen for both; they often impair the child more than the tics
• Coprolalia occurs in a minority and is NOT required for Tourette

DX: DSM-5 — Tourette: multiple motor AND ≥ 1 vocal tic > 1 year, onset < 18, not attributable to a substance or medical condition

• Persistent (chronic) tic disorder: motor or vocal tics (one type only) > 1 year · provisional: tics < 1 year since onset
• Clinical diagnosis — rate severity/impairment (YGTSS) to decide whether treatment is needed at all

TX: Education + watchful waiting for mild tics; CBIT (Comprehensive Behavioral Intervention for Tics) first-line for impairing tics

• Alpha-2 agonists (guanfacine, clonidine) treat both tics and comorbid ADHD; VMAT2 inhibitors or antipsychotics for debilitating tics
• Stimulants are NOT contraindicated in tic disorders — treat comorbid ADHD with monitoring

A child is referred to your office for unusual animal cruelty and bullying at school

• A repetitive pattern violating the basic rights of others or major age-appropriate norms — four categories: aggression to people/animals · destruction of property · deceitfulness or theft · serious rule violations
• Often the precursor to antisocial personality disorder (which cannot be diagnosed before age 18)
• vs ODD: ODD children are defiant but not aggressive to people/animals, destructive, or deceitful

DX: DSM-5 — ≥ 3 of 15 criteria in the past 12 months (from any of the four categories), with ≥ 1 in the past 6 months

• Specify childhood- vs adolescent-onset and "with limited prosocial emotions"; rule out substance use and abuse as drivers

TX: Multimodal psychosocial treatment integrating individual, school, and family settings

• Parent management training has the best evidence; multisystemic therapy for severe cases
• Treat comorbid ADHD, depression, and substance use — no medication treats conduct disorder itself

A child is found to backtalk and resist following instruction from parents or authorities

• Three symptom clusters: angry/irritable mood · argumentative/defiant behavior · vindictiveness
• vs conduct disorder: no aggression to people/animals, no property destruction, no theft or deceit

DX: DSM-5 — ≥ 4 symptoms for ≥ 6 months, exhibited with ≥ 1 individual who is not a sibling

• Often loses temper · easily annoyed · angry/resentful · argues with authority · defies rules · deliberately annoys · blames others · spiteful ≥ 2× in 6 months

TX: Psychosocial treatment first-line — parent management training (best evidence), CBT for anger/problem-solving, family therapy

• No medication is approved for ODD itself — treat comorbid ADHD (stimulants often improve oppositional behavior)
• Risperidone/aripiprazole reserved for severe, refractory aggression