PHYSICAL EXAMINATION
Usually, a physical examination has already been completed by the child’s pediatrician. If not, the clinician should refer the family to the primary physician. In some circumstances, however, it is important that the child psychiatrist complete the physical examination. Table 12–5 lists those aspects of the physical examination to which the clinician should pay particular attention.
Table 12–5 Physical Examination Items Deserving Special Attention
Growth parameters: height, weight, and head circumference plotted on standard curves Minor physical anomalies (associated with developmental problems such as hyperactivity): Abnormally small or large head “Electric” hair (fine, dry hair standing upright from the scalp) Epicanthic folds (skin folds in the upper internal eyelid) Hypertelorism (eyes deep-set and widely separated) Low-set, malformed, asymmetrical ears with adherent earlobes High palate Furrowed tongue In-curved little finger Long third toe Syndactyly Gap between first and second toes Other head, face, or body dysplasias that might indicate a congenital disorder (e.g., signs of fetal alcohol syndrome) |
Table 12–6 lists symptoms that could be referable to the central nervous system and indicate the need for a neurologic examination. The psychiatrist can perform a brief, routine neurologic screen during the interview by observing the child’s speech, gait, posture, balance, gross and fine motor tone, power and coordination, facial symmetry, and ocular movements and by checking for tics, tremors, clonus, or choreiform movements of the fingers and hands. Table 12–7 lists extensions to the routine screen that can be implemented by baring the child’s feet and forearms.
Table 12–6 Symptoms that Indicate the Need for Neurologic Examination
Headache Visual impairment Deafness Tinnitus Poor balance Episodic disruption of consciousness Memory defects Intermittent confusion Anesthesia Paresthesia Motor weakness Impaired coordination Abnormal movements Recent loss of sphincter control |
Table 12–7 Extension of the Neurologic Examination
| Domain | Functions or Abnormalities |
|---|---|
Cranial nerves | Movement of eyes, face, and tongue Pupillary reflexes Visual fields Hearing |
Motor power and tone | Shoulder Elbow Wrist Hand Knee Ankle |
Reflexes | Biceps Triceps Supinator Patellar Ankle Plantar |
Fundi | Papilledema Arteriovenous abnormalities Abnormal pigmentation |
Note: Leave the examination of the reflexes and fundi to the end.
Some child psychiatrists avoid physical examination. The clinician may worry that an upsetting physical examination will impede a positive relationship or tilt the spontaneous development of the child’s transference. There may be some point to these considerations, but the potential benefits of a nonintrusive physical examination outweigh its disadvantages.
Soft or nonfocal signs are phenomena thought to have no clear locus or origin, to be developmentally normal up to a certain age, and to reflect uneven neurologic maturation in older children. Table 12–8 lists commonly identified neurologic soft signs. Can these signs be consensually identified and elicited in a standard manner? Do they have significant test–retest and inter-rater reliability? Do they occur frequently enough in an at-risk population to make them worth eliciting? Are they singly or in clusters associated with disorders such as learning disability, attention-deficit/hyperactivity disorder, or schizophrenia? Do they predict which hyperkinetic children will respond to stimulant medication? For none of these questions is there a clear answer.
Table 12–8 Neurologic Soft Signs
Choreiform or athetoid movements, especially of the out-stretched fingers and hands Dysdiadochokinesia (difficulty performing rapid alternating movements) Dysgraphesthesia (difficulty interpreting a figure traced on the palm of the hand) General clumsiness Synkinesis (the tendency for other parts of the body to move in unison when one part is moving) |
TowbinKE: Physical examination and medical investigation. In: ThaparA, PineDS, LeckmanJF,et al. (eds). Rutter’s Child and Adolescent Psychiatry, 6th edn. Oxford: Blackwell, 2015.
SPECIAL INVESTIGATIONS
The routine use of special investigations for all referred adolescents is not justified. Before ordering a consultation, test, or special investigation, the clinician should consider whether it is a screen inquiry that has a reasonable chance of yielding important information in the clinical population in question (e.g., routine drug or pregnancy testing for hospitalized adolescents) or, in the case of a discretionary probe, whether the particular inquiry could conceivably rule out (or help to rule in) a diagnostic hypothesis. Table 12–9 lists the types of consultations and special investigations often used in child and adolescent psychiatry.
Table 12–9 Common Consultations and Special Investigations
Consultations Pediatric consultation Neurologic consultation Other specialist consultations (e.g., speech pathology) Special investigations Laboratory testing (e.g., blood, urinalysis, electrolytes, liver function, thyroid function, urine drug screening, and genetic screening) Acoustic and ophthalmologic examination Electroencephalography Neuroimaging Psychological testing |
CLINICAL SITUATIONS LIKELY TO REQUIRE SPECIAL INVESTIGATIONS
The clinician must rule out physical disease by the judicious ordering of specific consultations, tests, or investigations in suspicious clinical situations. Table 12–10 lists the clinical situations in which organic causes must be ruled out.
Table 12–10 Clinical Situations Likely to Require Special Investigation
Acute or subacute disintegration of development and behavior, with loss of previously attained developmental milestones, deterioration in school performance, and the emergence of erratic aggressive behavior, clinging dependency, or confusion Acute psychotic episode Anorexia or weight loss Attention-deficit, hyperactivity, and impulsivity, especially if of recent or sudden origin Delay in speech and language development, loss of previously acquired speech and language, or the recent emergence of deviant speech or language Depression, especially if associated with slowed thinking, deterioration of concentration, vagueness, and fatigue Episodic or progressive lapses or deterioration of awareness with dreaminess; obtundation; defect in the sensorium; and perhaps, subjective depersonalization, derealization, and hallucinosis Episodic violence out of proportion to the apparent precipitant, often with memory gaps or amnesia for the episode General or specific learning problems (e.g., in reading, writing, or calculation) Localized or generalized abnormal movements that may be associated with vocal abnormalities Pervasive developmental impairment (especially if associated with an uneven profile of abilities) Sleep disturbance or excessive drowsiness Somatoform symptoms of recent onset that mimic a physical disorder but are not consistent with the typical pattern of physical disorder |
Acute or Sub-acute Disintegration of Behavior and Development
After a period of normal or relatively normal development, the child may fail to make developmental progress and lose recently acquired skills such as sphincter control, coordination, dexterity, attention and concentration, memory, language, capacity for problem solving, school performance, emotional control, and social competence. In some cases, the child may demonstrate abnormal motor patterns, hallucinations, delusions, and disorganization of thinking. Table 12–11 lists organic causes that must be excluded.
Table 12–11 Excluding Organic Causes of Disintegration of Behavior and Development
| Possible Organic Cause | Special Investigations |
|---|---|
| General systemic disease | |
Thyroid disorder | Thyroid function tests |
Adrenal insufficiency | Adrenal function tests |
Porphyria | Examination for urinary porphyrins |
Disseminated lupus erythematosus (LE) | Examination for LE cells |
Wilson disease | Serum ceruloplasmin |
| Toxic factors | |
Delirium due to systemic infection, electrolyte abnormality, or physiologic toxins | Electroencephalography; specific biochemical, bacteriologic, or virologic tests |
Drugs (e.g., intoxication with sympathomimetic drugs, anticholinergic drugs, hallucinogens, or anticonvulsants; withdrawal from sedatives) | Urine drug screen, blood toxicology |
| Central nervous system disease | |
Seizure disorder | Electroencephalography with nasopharyngeal electrodes, telemetry |
Space-occupying lesion | Skull X-ray, CT scan, MRI |
Herpes encephalitis | Electroencephalography, examination of cerebrospinal fluid, immunologic testing |
Metabolic or subacute viral encephalitis | Electroencephalography, examination of cerebrospinal fluid, immunologic testing |
Degenerative diseases | Urine amino acids, electroencephalography, MRI, Biopsy |
Demyelinating disease | MRI |
Leukemic infiltration of central nervous system | Examination of blood and cerebrospinal fluid |
Acute Psychotic Episode
The child or adolescent may become mentally disorganized, socially inappropriate, affectively incongruent, or emotionally labile and report audiovisual hallucinations, illusions, ideas of reference, and delusions of persecution or grandeur. Sometimes the patient becomes mute, immobile, posturing, apparently self-absorbed, and assuming odd postures of the arms, head, and trunk. The following disorders must be excluded: substance-induced psychotic disorder (using urine and blood toxicology) and psychotic disorder due to general medical condition (which requires pediatric consultation and tests specific to hypothesized medical conditions such as hyperthyroidism, hypersteroidism, neurologic disorder).
Anorexia or Weight Loss
The child or adolescent may lose weight markedly as a result of voluntary restriction of food intake. The following conditions should be ruled out: chronic systemic infection (especially tuberculosis); systemic malignancy (especially pancreatic, mediastinal, retroperitoneal, pulmonary, lymphatic, or leukemic malignancy); hypothalamic or pituitary tumor (using skull X-rays, computed tomography [CT] scan, tomogram of sella turcica, or magnetic resonance imaging [MRI]); diabetes mellitus (using urinalysis and glucose tolerance testing); hyperthyroidism (using thyroid function tests); and drug addiction (using toxicology screens).
Headache
The chief causes of headache in childhood are migraine and tension headaches. Migraine is episodic and can be associated with vertigo, unexplained vomiting and abdominal pain, and, rarely, with hemiplegia, temporary episodic impairment of receptive or expressive language, and confusion. Tension headaches are commonly of daily occurrence and difficult to localize. Headaches due to raised intracranial pressure tend to be worse upon wakening or to wake the child, and tend to be associated with vomiting, papilledema, cranial nerve dysfunction, sluggish papillary reflexes, and visual impairment. Seizure-related headache can be ictal or postictal. Specialist consultation is required if the clinician suspects an organic cause of headache.
Attention-Deficit, Hyperactivity, and Impulsivity
Before or after starting school, the child may demonstrate poor concentration, distractibility, and a tendency to impulsiveness, with or without hyperactivity and learning problems. Table 12–12 lists organic causes that must be excluded.
Table 12–12 Excluding Organic Causes of Attention-Deficit, Hyperactivity, and Impulsivity
| Possible Organic Cause | Special Investigations |
|---|---|
Hyperthyroidism | Thyroid function tests (if there is other evidence of hyperdynamic cardiovascular function and sympathetic overactivity) |
Plumbism | Urine lead levels, examination of blood for stippled cells, X-rays of long bones |
Seizure disorder | Electroencephalography with nasopharyngeal leads |
Sleep apnea | Otorhinolaryngologic examination, sleep electroencephalography and observation |
Sydenham chorea | Blood antistreptolysin-O antibody titer |
Delay in Speech and Language Development
The child may manifest a relative delay in comprehending speech or in expressing and correctly enunciating words, phrases, and sentences. Table 12–13 lists organic causes that must be excluded.
Table 12–13 Excluding Organic Causes of Speech and Language Development Delay
| Possible Organic Cause | Special Investigations |
|---|---|
Deafness | Acoustic testing |
Palatal abnormality | Physical examination |
Cerebral palsy | Neurologic examination |
Mental retardation | Physical examination, psychological testing |
Seizure disorder | Electroencephalography |
Aphasia | Consult with speech pathology, neuropsychological testing |
Developmental articulatory dyspraxia | Consult with speech pathology and pediatric neurology |
Pervasive developmental disorder | See Table 30–4 |
Depression
The child or adolescent may become underactive or overactive; insomniac or hypersomniac; impaired in thought tempo, concentration, and energy; readily provoked to tantrum or weeping; socially withdrawn; or preoccupied with thoughts of low self-esteem, guilt, and loss. The differential diagnosis includes virtually any physical disorder that could sap energy, impair thinking, and disrupt the capacity to cope.
The following general systemic diseases should be excluded: malignancy, chronic infectious disease, viral infection (e.g., influenza, infectious hepatitis, infectious mononucleosis), hypothyroidism, hypoadrenalism, chronic anemia, and subnutrition (e.g., anorexia nervosa). Chronic intoxication with anticonvulsants or sedatives must be excluded (using urine drug screens and blood levels), as must degenerative central nervous disease (using central nervous system examination, specific tests for the systemic diseases being excluded, CT scan, or MRI).
It is often difficult to determine to what degree a child’s depression is part of a pathophysiologic process or to what degree it represents a secondary psychological reaction to loss of function, hospitalization, restriction of freedom, lack of stimulation, or loneliness.
Episodic or Progressive Lapses or Deterioration of Awareness
The patient, usually an adolescent, may experience recurrent episodes during which he or she has a sense of being abruptly altered, different, or unreal and of observing the self as a spectator. The adolescent may perceive that the world is unreal and different or that conversations and scenes have been experienced previously in precisely the same manner. The following organic causes must be excluded: seizure disorder (using electroencephalography), cardiac arrhythmia (using electrocardiology), narcolepsy (using electroencephalography), migraine, and hallucinogenic drug use (using urine drug screen).
Episodic Violence
The child or adolescent may periodically lose control, assault others, or destroy property. Violent behavior may be unheralded, but it usually arises from an emotional context of tension with or without alcohol or drug intake and is disproportionate to the apparent provocation. The individual may or may not have a conduct disorder. The following disorders must be excluded: temporal lobe seizures (using electroencephalography with nasopharyngeal leads), herpes encephalitis (using electroencephalography, immunologic study, and examination of cerebrospinal fluid for viral culture and immunology), drug effects (e.g., alcohol, phencyclidine, hallucinogens, amphetamine; using urine drug screen), and idiosyncratic reaction to alcohol (using patient’s history).
General or Specific Learning Problems
The child or adolescent may manifest a general or specific difficulty in learning, particularly in reading, writing, written expression, calculation, or spatial skills. Table 12–14 lists organic causes that must be excluded.
Table 12–14 Excluding Organic Causes of Learning Problems
| Possible Organic Cause | Special Investigations |
|---|---|
Visual defect | Test visual acuity and visual fields; ophthalmoscopy |
Deafness | Acoustic testing |
Cerebral palsy | Neurologic examination |
Mental retardation | Physical examination, psychological testing |
Seizure disorder | Electroencephalography |
Dementia due to intracranial space—occupying lesion or cerebral degeneration | Neurologic examination: skull x-rays, CT scan, MRI |
Inability to pay attention in class because of debilitating illness, fatigue, hunger, pain, or drug use | None |
Localized or Generalized Abnormal Movements
The child or adolescent may manifest repetitive movements that may or may not be partly or wholly under control. The following disorders must be excluded: attention-deficit/hyperactivity disorder, tic disorder, Sydenham chorea (using antistreptolysin-O titer), Huntington’s disease, Wilson’s disease, paroxysmal choreoathetosis, dystonia musculorum deformans, cerebellar tumor or degeneration, and drug effects (e.g., caffeinism, extrapyramidal side effects of neuroleptic medication).
Pervasive Developmental Impairment
During infancy or afterward, the child may manifest a severe arrest or retardation of language, intellect, and social development. Additional features may include unexplained episodes of panic or rage, marked resistance to environmental change, hyperactivity, repetitive motor phenomena, and deviant speech and language. The onset may be in early infancy (before 30 months) or afterward (up to about 7 years). Sometimes the child regresses from a state of relatively normal development to a state of developmental impairment. More often, the child’s abnormal development becomes evident gradually. Several organic causes must be excluded (Table 12–15).
Table 12–15 Excluding Organic Causes of Pervasive Developmental Impairment
| Possible Organic Cause | Special Investigations |
|---|---|
Hearing impairment | Acoustic testing |
Aphasia | Speech pathology consultation, language testing |
Seizure disorder | Electroencephalography |
Chromosomal anomaly | Chromosome analysis (especially if the child looks dysplastic) |
Metabolic disorder | Tests for amino acids in the urine (especially phenylketonuria) |
Intracranial lesion | Skull X-ray, CT scan, MRI (only if an intracranial space-occupying lesion or demyelinating disease is suspected) |
Herpes encephalitis | Virologic studies of the cerebrospinal fluid, immunologic testing (if there has been an acute or subacute regression), electroencephalography |
Sleep Disturbance or Excessive Drowsiness
The child may present with hypersomnia, insomnia, nightmares, night terrors, restless sleep, or sleepwalking. Table 12–16 lists organic causes that must be excluded.
Table 12–16 Excluding Organic Causes of Sleep Disturbance or Excessive Drowsiness
| Possible Organic Cause | Special Investigations |
|---|---|
Seizure disorder | Electroencephalography (including polysomnography) |
Delirium (e.g., in acute febrile illness or toxic states) | Electroencephalography |
Narcolepsy | Electroencephalography |
Intoxication with or withdrawal from sedative, opiate, anticonvulsant, neuroleptic, or antidepressant drugs | Urinary drug screen |
Hypoglycemia | Blood sugar (e.g., insulinoma) |
Sleep apnea | Polysomnography, otorhinolaryngologic examination |
Any debilitating disease, especially disease associated with chronic hypoxia (e.g., congenital heart disease, pulmonary insufficiency, anemia) | None |
SOMATOFORM OR “FUNCTIONAL” SYMPTOMS
The child or adolescent may develop a set of symptoms that mimic physical disorder. Common functional (previously conversion) symptoms are loss of consciousness, loss of phonation, motor impairment, abnormal movements, seizures, special sensory defect, anesthesia, pain, loss of balance, bizarre gait, or gastrointestinal complaints such as vomiting and abdominal pain. Functional Neurological Symptom Disorder (previously conversion disorder) can mimic many physical conditions. The inquiry plan should both exclude the hypothetical physical disorder and establish positive criteria for conversion (i.e., emotional trauma coinciding with onset; pattern of symptoms representing the patient’s naive idea of pathology; contact with a model for the disease; pattern of symptoms fulfilling a communicative purpose; secondary gain for the patient in the form of nurturance, security, or avoidance of difficulty; and a pattern of symptoms and signs inconsistent with physical disease). Table 12–17 lists the physical disorders especially likely to be mistaken for a Functional Neurological Symptom Disorder.
Table 12–17 Excluding Disorders Likely to be Mistaken for Functional Neurological Symptom Disorder
| Possible Organic Cause | Special Investigations |
|---|---|
General Systemic Disease | |
Disseminated lupus erythematosus (LE) | Examination for LE cells |
Hypocalcemia | Blood calcium |
Hypoglycemia | Blood sugar (e.g., insulinoma) |
Porphyria | Urinary porphyrins |
Central Nervous System Disease | |
Multiple sclerosis | Neurologic examination, MRI |
Movement disorders (chorea, dystonia musculorum deformans, Tourette’s syndrome, Wilson’s disease) | None |
Spinal cord tumor | Neurologic examination, radiography, MRI |
Intracranial space–occupying lesion (especially in brain stem, cerebellum, frontal lobe, or parietotemporal cortex) | Neurologic examination, skull radiography, CT scan, MRI |
Seizure disorder | Electroencephalography |
Migraine | None |
Dystonic reactions produced by neuroleptic drugs | None |
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