Introduction

The term ‘elective mutism’ was originally coined in 1934 by the Swiss pioneer of child psychiatry, Moritz Tramer. However, it is assumed that the German physician, Kussmaul, was the first to describe three cases in 1877 under the term ‘aphasia voluntaria’. Whereas the ICD-10 stuck to the original term ‘elective mutism’, the DSM-IV has slightly changed the term to ‘selective mutism’. Both the original designation and the fact that the ICD-10 as the dominant European scheme of classification uses ‘elective mutism’ as the descriptor are the reasons why this chapter follows this term.

Children with elective mutism are rarely seen in clinical practice, although it may be assumed that there are some more in the general population who will either be referred rather late or perhaps never for assessment and intervention. Consequently, a large body of clinical knowledge rests on case reports or descriptions of small series of children with a few exceptions of studies based on more extended series of patients.

Definition and classification

According to the ICD-10, the following four criteria lead to the diagnosis of elective mutism:

• marked and consistent selectivity in speaking, i.e. failure to speak in social situations

• a normal or near-normal level of language comprehension

• a level of competence in language expression that would be sufficient for social communications, and

• demonstrable evidence that the child could and did speak normally or almost normally in some situations.

Introduction

All mental functioning, be it normal or abnormal, is mediated by the brain. Thus, no child and adolescent psychiatric disorder can be thought of as not being brain related. However, there is a separate category of disorders in which the structure of the brain itself is disordered or in which the basic neurological functions are altered so that normal mental functioning may not result. This is most obvious in those disorders that result from morphological alterations of the brain structure due to a noxious agent or event, or due to a neurobiological deficit that seriously affects the organization and development of the brain.

Classification of brain disorder in childhood and adolescence is not very satisfactory. The major classes of brain disorders as set out in the ICD-10 are derived mainly from manifestations of disorders in adulthood with insufficient consideration of developmental aspects in childhood and adolescence. Thus, in contrast to most of the remaining chapter in this volume both ICD-10 and DSM-IV are not considered as the relevant framework for classification of brain disorders in childhood and adolescence.

In this chapter the following major brain disorders with a basic neurological alteration of brain structures and functions will be described: injury, infectious disorder, cerebral palsy, epilepsy and brain tumours. In an additional section the concept of minor brain dysfunction syndromes will be discussed. This concept has been very influential in the past and has largely been ignored in the more recent academic debate in child and adolescent psychiatry.

Child and adolescent psychiatry is a rapidly expanding branch of medicine. Important research gains have been made in the past decades, and there is now a firm knowledge basis for many of the psychiatric disorders with child or adolescent onset. This knowledge has taken some time to filter through to clinical child and adolescent psychiatric services.

The aim of this book is to provide a comprehensive overview of the relevant objectives of child and adolescent psychiatry in clinical practice. The approach is decisively evidence based as far as this is possible with the current status in the field and thus avoids the consideration of various theoretical or even speculative approaches. Rather, the emphasis is on guidance for good clinical practice and help with the quality control of patient care. The various chapters have been written by experts in the respective fields. In contrast to other textbooks, the major objective is not to cover all relevant research findings exhaustively but rather to condense the scientific knowledge that is significant for clinical practice. Thus, the present deskbook deals with clinical disorders only.

The list and order of contents is guided by the ICD-10 and the various chapters also comment on the DSM-IV classification. A clear common structure for the chapters enforces the coherence of the monograph. After an introduction, definition and classification, epidemiology, the clinical picture, aetiology, treatment and outcome are specifically outlined for each disorder. Tables, figures and flowcharts, serve as additional sources of information and highlight special messages.

Introduction

Most typically, the two eating disorders anorexia nervosa (AN) and bulimia nervosa (BN) have their onset in adolescence and young adulthood. The two disorders in their typical manifestation are thus related to a period of major developmental change. The onset of anorexia nervosa, however, can be seen even before puberty and in rare cases, also at the age of 60 or older. For bulimia nervosa (BN) the typical age at onset is the period of transition from adolescence to young adulthood. It is present in a large proportion of patients in their 20s but also in their 30s and 40s. In a substantial number of cases, anorexia nervosa precedes bulimia nervosa and, in adolescence, the combination of AN with bulimic features is clinically more common than pure BN.

Thus child and adolescent psychiatrists have to deal with a large proportion of anorectic and a smaller proportion of bulimic patients, including a subgroup in which the features of the two disorders combine. Furthermore, the child and adolescent psychiatrist is confronted with a large group of subclinical cases of eating disorders. These cases are marked by a more or less pronounced pattern of dietary attempts with some of them qualifying for the diagnosis of an atypical eating disorder or eating disorder not otherwise specified (EDNOS).

A third category of eating disorders, namely binge eating disorder, is appearing more and more on the map of clinical nosology.