Child psychiatric disorders and its
management
Prepared by :Dr. Basudeb Das, MD. Asst. Professor, CIP, Ranchi
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Introduction
Child psychiatry is concerned with the assessment and treatment of
children's emotional and behavioral problems. These problems are very common
with prevalence rates of 10‑20% in several community studies. Psychological
disturbance in childhood is most usefully defined as an abnormality in at least
one of three areas; emotions, behavior or relationships.
In childhood the distinction between disturbance and normality is often
imprecise or arbitrary. Isolated symptoms are common and not pathological.
Another distinctive feature of childhood psychiatric disturbance is that several
factors rather than one contribute to the development of disturbance.
Etiological factors are usually categorized into two groups, constitutional and
environmental. The former include hereditary factors, intelligence and
temperament. The three major environmental influences are the family schooling
and the community. Another factor physical illness or disability, if present can
have a profound effect on the child's development and on his vulnerability to
disturbance.
Three other considerations are of general importance in understanding
children's behavior:
-the situation‑specific nature of
behavior
-the impact of current stressful life
circumstances, and
-the role of the
family
Cause of psychiatric
disturbance
Three main factors are identified:
Constitutional
Genetic
Temperamental
Intra‑uterine disease or damage
Birth trauma
Environmental
Family
School
Community
Physical damage or
illness
Especially
neurological disease
Classification
DSM‑IV‑TR and ICD‑ 10
classification systems (modified for child psychiatry)
DSM‑IV‑TR |
ICD‑10 |
|
Axis I
-Clinical
syndrome
Axis 2
-Mental
retardation
-Pervasive
developmental disorders
-Specific developmental
disorders
Axis3
Physical disorders/illness
Axis
4
-Severity of
current
- Psychosocial
stressors
Axis
5
-Highest level of adaptive functioning in past year
|
Axis
I
Clinical
syndrome
Axis
2
Disorders of
psychological development
Axis3
Mental
retardation
Axis
4
Medical
illness
Axis
5
Abnormal psychosocial
conditions
Axis
6
Psychosocial
disability |
Clinical syndromes of
DSM‑IV TR and ICD‑10
|
DSM‑IV‑TR |
ICD‑10 |
|
Axis
I
Disruptive behavior
disorders
-
Attention
deficit hyperactivity disorder (ADHD)
-
Conduct
disorder
-
Oppositional
defiant disorder
Anxiety disorders of
childhood or adolescence
-
Separation
anxiety disorder
-
Avoidant
disorder of childhood and adolescence
-
Over anxious
disorder
Eating
disorders
-
Anorexia
nervosa
-
Bulimia
nervosa
-
Pica
-
Rumination
disorder of infancy
Gender
disorders
Tic disorders
Elimination
disorders
-
Functional
encopresis
-
Functional
enuresis
Miscellaneous disorders
Axis
2
Pervasive developmental
disorders
|
Axis
I
Conduct
disorders
Emotional
disorders
Mixed disorders of
conduct and emotions
Hyperkinetic
disorders
Disorders of social
functioning
Tic
disorders
Pervasive developmental
disorders
Other behavioral and
emotional disorders
|
Causative factors in
childhood disturbances (epidemiological research
findings)
Family
discord
- Marital discord
- Children in care
- Children not living with both natural
parents
Parental
deviance
- Psychiatric disorder in the mother
- Criminal record in the
father
Social
disadvantage
- Large family size'
- Overcrowding
- Father in unskilled
occupation
Schooling
- High pupil/ staff ratio
- High turnover of
teachers
Assessment
procedures
Assessment is more time
consuming in child psychiatry than in other branches of psychiatry or medicine.
It has three components
- The diagnostic assessment interview
- Psychological assessment
- Information about the child and
parents from other professionals
Disorders in pre‑school
children
- Behaviour problems
- Feeding and eating
difficulties
- Sleep disorder & Disorders of
attachment
- The psychiatric aspects of child
abuse
Common
problems
- Temper tantrums
- Breath holding
attacks
- Thumb‑sucking and nail
biting
-
Eating
disorders
-
Rumination disorder of
infancy
-
Repeated
regurgitation of food in the absence of any gastrointestinal abnormality with
failure to gain weight or even a loss of weight.
- Onset is
usually, between 3 months and 12 months of age.
- In
many cases, it is a reflection of the disturbed mother‑ child
relationship.
Non organic failure to
thrive (NOFTT)
This usually manifests itself in the first year of life as persistent failure to
gain weight. The child is below the third percentile for weight, with additional
evidence of developmental and cognitive delay. Extensive support and counseling
is the mainstay of treatment.
Deprivation
dwarfism
Usually presents as
idiopathic short stature. It shares many, features of NOFTT.
Pica
This is defined as the ingestion of inedible material such as dirt or rubbish.
It is a normal transitory phenomenon during the toddler period. Persistent
ingestion is found among mentally retarded, psychotic and socially deprived
children. Lead poisoning, though always mentioned. is a possible but uncommon
danger from pica.
Psychiatric aspects of
child abuse
Originally the term child abuse was restricted to the battered baby syndrome.
But it has now been extended to include physical abuse, emotional abuse, sexual
abuse and neglect.
Common features of
abused children and their
families
Vulnerability factors in
the abused child
- Product of unwanted
pregnancy
- Unwanted child in family
- Low birth weight
- Separation from mother in neonatal
period
- Mental or physical
handicap
- Habitually restless sleepless or
incessantly crying
- Physical
unattractiveness
High‑risk factors in the
parents
- Single parent
- Young as children
- Low self‑esteem
- Unrealistic expectations of child and
his‑development
- Inconsistent or punishment oriented
discipline
Adverse social
circumstances
- Low income or
unemployment
- Social isolation
- Large family
Three separate stages can be
identified in the investigation of suspected child abuse:
- The detection and disclosure
phase
- Child protection and legal
considerations
- Therapeutic and practical support for
the child and family in the immediate and long term.
Pervasive developmental
disorders
Child hood
Autism
Clinical
features
- Impaired social
relationships
- Language
abnormalities
- Restricted repertoire of
activities
Treatment
- Promotion of normal
development
- Reduction of rigidity and
stereotypies
- Alleviation of family
stress
Rett's
Syndrome
Disintegrative
disorder
Asperger's
syndrome
Schizophrenia and
related conditions
Mood
disorders
Emotional
disorders
Conduct
disorders
Three features characterize
the behavior of the conduct‑disordered child:
- The range, frequency and severity of
the disturbed behavior
- Disregard for and contravention of
normally accepted standards of behavior
- Failure to modify or desist from the
antisocial behavior despite persuasion or punishment
Classification
ICD‑10 |
DSM‑lV
TR
|
|
Conduct disorders
-
Confined to
the family context
-
Oppositional
defiant disorder
-
Unsocialized
conduct disorder
-
Socialized
conduct disorder |
Disruptive behavior
disorders
-
Attention
deficit hyperactivity disorder
-
Oppositional
disruptive disorder
-
Conduct
disorder
Solitary
Group
Undifferentiated
|
Mixed disorders of
conduct and emotions
Common
symptoms
- Aggression
- Stealing
- Lying
- Vandalism
- Arson and
fire‑setting
- Breaking into and entering
property
- Drug and solvent
abuse
Causative
factors
Family
factors
- Marital/parental
disharmony
- Parental violence
- Lack of affection and
rejection
- Ineffective and inconsistent
discipline
- Large family size
Individual
characteristics
- Genetic
- Temperamental
- Intelligence
- Physical illness
Community
influences
- Peers
- Schooling
- Neighborhood
Assessment
General physical
state
- Neurological status
- Stature
Psychiatric
state
- Mood disturbance
- Additional affective symptoms (anxiety
depression)
- Self esteem
- Intelligence level and educational
attainments
- Reading retardation
- Presence of specific disorder amenable
to treatment (e.g. enuresis)
Social
assessment
- Family attitudes
- Family communication
factors
- Family models
- School functioning
- Peer relationships and
models
- Community influences
Treatment
- Working with the family
- Counseling for the
parents
- Family therapy for the whole group
- Behavoiur modification-symptom
management, for instance aggression
- Remedial education
- Treatment of physical
problems
- Help with socioeconomic
disadvantage-support for schooling
- Removal from home including reception
into care and/or residential schooling when necessary
Disorders of
elimination
Enuresis
- Involuntary passage of urine, in the
absence of physical abnormality, after the age of 5 years in a child of normal
ability
Causative factors in
nocturnal enuresis
Individual
factors
- Genetic
- Low intelligence
- Psychiatric
disorders
- Urinary tract
infection
- Small functional bladder
capacity
Environmental
factors
- Stressful life
events
- Large family size
- Social disadvantage
Assessment and
management
History
- Family history of nocturnal
enuresis
- Previous treatment
- Sleeping
arrangements
- Concurrent
encorpesis
Examination
- Back and lower limb
reflexes
- Urine specimen to exclude renal
failure and diabetes
- Mental state of the
child
Treatment
- Minimize handicap
- Accurate history record of nocturnal
enuresis
- Enuresis alarm
- Other treatments (for instance
tricyclic antidepressants)
Encopresis
- Is the inappropriate passage of formed
faeces, usually in the underclothes in the absence of any physical pathology
after 4 years of age.
Assessment and management
Aims
- Promotion of bowel
habit
- Improvement of parent‑child
relationship
Assessment
- Exclude physical disease by history
examination and investigation (if necessary)
- Previous treatments
- Parents’ and child's attitude to
problem
Management
Dietary
- Modify diet to ensure adequate intake
of dietary fiber to increase fecal bulk
Medical
management
- Bowel washout and/or enemas may be
necessary initially
- Drugs
- Motor stimulant (senna
laxatives)
- Bulk agents
(lactulose)
- Suppositories are often useful as
well
Psychological
management
- Behavioral (star
chart)
- Individual
psychotherapy
-Enlist cooperation
-Show concern
-Develop trust
Parent counseling/ family
therapy
-Modify attitudes
-Hostile interactions
-Secondary problems
Overactive syndromes
and hyperkinetic disorder
Clinical types of
overactivity/hyperactivity
Normal
variation
- Temperamental
deviation
- Cognitive impairment
Pathological
causes
- Hyperkinetic
disorders
- Hypomania
- Anxiety state
- Conduct disorder
- Organic conditions
1. Thyrotoxicosis
2. Sydenham's
chorea
3. Lead
intoxication
4. Mental retardation.
for example phenylketonuria or rubella
5. Response to some
drugs. for instance barbiturates or benzodiazepines
Symptoms management of
ADHD/Hyperkinetic disorder
|
Motor
restless |
Counseling for parents
/teachers
Behaviour
modification
Emotional
manipulation
Stimulant
drugs
Major
tranquilizers |
|
Inattention |
Stimulant
drugs
Special
teaching
Training in attentional
skills
|
|
Disruptiveness
aggression |
Behavior
modification
Conjoint family
therapy
Individual
counseling |
|
Academic
failure Special
education placement |
Special Education
Placement
Graded and reward based
instruction
Individual
counseling |
Miscellaneous
disorders
Developmental
disorders
- Disorders of speech and
language
- Disorders of scholastic
skills
- Disorder of motor
function
- A mixed category of developmental
disorder
Tic and other habit
disorders
Sleep
disorders
Eating
disorders
Psychiatric aspects of
mental retardation in childhood
ICD-10 and DSM-IV have four
categories‑ of mental retardation:
- Mild (IQ 50‑69)
- Moderate (IQ 35‑49)
- Severe (IQ 20‑34)
- Profound (IQ less‑ than an
20)
The other important defining
criterion is that there should be evidence of social impairment and limitation
in the individuals’ daily activities and self care skills.
Psychiatric disorder in
children with mental retardation
- Approximately 40% have signs of
significant psychological disturbance
- Range of disorders is similar to
children of average ability except that the following occur much more
frequently
1. Pervasive developmental disorders
2. Pervasive hyperkinetic syndrome
3. Severe stereotyped movement disorder
4. Self‑injurious behavior and pica more common
Causes of psychiatric
disorder in children with moderate to severe mental
retardation
- Brain damage leading
to:
1. Loss of specific' functions or skills
2. Active disruption of normal brain activity
3. Increased risk of epilepsy
4. Specific learning difficulties
- Adverse temperamental
characteristics:
1. Impulsivity
2. Overactivity
3. Distractibility
Psychosocial consequences of
handicap:
- Child social isolation and low self
esteem
- Parents
overprotection/rejection
Management of mental
retardation in childhood
Key elements
are:
- Breaking the news
- Promotion of normal
development
- Treatment of medical and behavioural
problems
- Educational
provision
- Genetic counseling
- Long term care work
support
Treatment in child and
adolescent psychiatry
Drug
treatment
|
Drug |
Usage |
Comment. |
|
Anxiolytics |
Anxiety /phobic conditions |
Short term adjunct to
behavior treatment |
|
Neuroleptics |
Schizophrenia/hyperkinetic syndrome
Complex tics/
Tourette’s syndrome
|
|
|
Phenothiazines eg. chlorpromazine
Butyrophenones, eg. Haloperidol
|
|
Extrapyramidal side
effects common |
|
Tricyclic
antidepressants |
|
|
|
Imipramine/amitriptyline Clomipramine
|
Enuresis
Major affective
disorder
|
Effective, but high
relapse rate
Most useful with
persistent
and sustained mood
disturbance |
|
|
|
Stimulants |
Hyperkinetic
syndrome |
Effective in the short
term.
Long term effects on
growth.
steep and
appetite |
|
Methylphenidate |
|
Fenfluramine |
Pervasive developmental disorder
|
Effectiveness not
established. Side effects
include irritability,
anorexia
and weight
loss |
|
Hypnotics,
eg.
trimeprazine/promethazine |
Persistent. sleep disorder in preschool children |
Only short
term |
|
Lithium |
Recurrent bipolar affective disorder
|
Close supervision of
blood
levels for signs of
toxicity |
|
Laxatives, e.g. bulk-forming
(methylecellulose) Stimulants (senna) softener
(dioctyl)
|
Encopresis with constipation
|
Facilities formation
and Passage of feces
|
|
Central alpha agonist.
e.g. clonidine
|
Unresponsive Tourette's syndrome
|
Sedation and
rebound
hypertension |
Behavioral
psychotherapy
Behavioral
techniques
- Exposure techniques
- Desensitization
- Flooding
- modelling
- Response Prevention
Operant
techniques
- Reinforcement
1. Positive
2. Negative
- Extinction
- Punishment
1. Application of aversive stimuli
2. Removal of reinforce
- Shaping, prompting and
fading
Applications of Behaviour
techniques
|
Disorder |
Technique |
|
Anxiety and
phobic |
Desensitization,
flooding, relaxation |
|
Obsessive-compulsive |
Relaxation
Relapse-prevention |
|
Depressive
disorder |
Cognitive
behavioural
Relaxation |
|
Conduct
disorders |
Positive
reinforcement
Extinction |
|
Hyperactivity
syndromes |
Time
out
Positive
reinforcement
Extinction |
|
Pervasive developmental
disorders |
Time-out
Positive
reinforcement
Extinction
Time
out
Aversive
techniques |
|
Encopresis/enuresis |
Positive
reinforcement |
|
Mental
retardation |
Positive
reinforcement |
|
Extinction and
time-out |
|
Prompting and
shaping |
|
Aversive
techniques |
|
Tics |
Massed
practice. |
Reference:Hoare P. Essential child psychiatry. Churchill
Livingstone.1993
|