Child Psychiatric Disorders

Introduction
  • Child psychiatry is concerned with the assessment and treatment of children's emotional and behavioral problems.
  • Over the past two decades psychiatry has increasingly turned to biological explanations for the etiology of mental disorders. (Keltner N L, 1996)
  • 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.
Historical developments in Child Psychiatry
  • Child psychotherapy begins with Sigmund Freud's case of Little Hans, a 5-year-old phobic boy.
  • In 1935 Leo Kanner published the fi rst textbook on child psychiatry in English.
  • Major contributers to child psychiatry are Donald Winnicott, Anna Freud and Melanie Klein.
Differences of Child psychiatry from adult psychiatry
  • The child’s existence and emotional development depends on the family or care givers - cooperation with family members.
  • The developmental stages are very important assessment of the diagnosis
  • Use of psychopharmacotherapy is less common in comparison to adult psychiatry
  • Children are less able to express themselves in words
  • The child who suffers by psychiatric problems in childhood can be an emotionally stable person in adulthood, but some of the psychic disturbances can change a whole life of the child and his family
Etiological factors
  • 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.
Important factors contribute to mental illness in children are:
Constitutional
  • Genetic
  • Temperamental
  • Intra‑uterine disease or damage
  • Birth trauma
Environmental
  • Family
  • School
  • Community
Physical damage or illness
  • Especially neurological disease
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
Classification & Prevalance
  • Disruptive behaviour disorders – Conduct disorder (prevalence 5.3%), Oppositional defiant disorder
  • Hyperkinetic disorders (ADHD) (up to 5%).
  • Tic Disorders e.g. Tourettes’ (up to 2%)
  • Affective disorders – Depression (2%), BPAD
  • Anxiety disorders (3.8%), GAD, phobias, separation anxiety, panic, PTSD.
  • Obsessive Compulsive disorder (3%)
  • Dissociative and somatoform disorders (rare)
  • Psychosis e.g. drug induced, schizophrenia (v. rare in childhood, peak incidence late teens to early twenties).
  • Developmental disorders – general (2.4%) or specific learning disability, autistic spectrum disorders (0.06 to 1.5%) and other PDD
  • Social functioning disorders e.g. elective mutism, attachment disorders
  • Eating disorders (3%) e.g. Anorexia, Bulimia, Binge eating
  • Sleep disorders e.g. night terrors, narcolepsy
  • Mental and behavioural disorders due to substance misuse
  • Other disorders such as non organic enuresis and encopresis, pica
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
Child Psychiatric Assessment
Assessment is more time consuming in child psychiatry than in other branches of psychiatry or medicine. Child mental health assessment is distinctive.
  • It uses a developmental approach
  • All assessments, management etc must be related to child development. E.g. what is the normal attention span at different ages? How well should a 5 year old read?
  • Systemic thinking – The “Biopsychosocial” approach .How the child functions and the impact of their illness on families and educational achievement, as well as individual symptoms.
  • Synthesising information from different sources into a “formulation” or problem list e.g. school report, genetic tests, clinical assessment etc.
  • Take time to develop assessment skills of both younger children and adolescents.
  • Be familiar with normal developmental milestones (motor, verbal, and social) and developmental assessments (e.g. in community paeds)
Psychiatric Assessment
  • Full History from parents and child.
  • Mental State Examination of child.
  • Physical examination – should include neurological exam and full examination of any systems related to suspected psychiatric diagnosis e.g thyroid and cardiovascular in depression.
History Taking
  • Presenting complaint
  • History of presenting complaint:
    • Assessment of symptoms’ duration, severity and effect on functioning.
    • Systematic enquiry about presence or absence of mood, anxiety and psychotic symptoms
  • Past psychiatric history: Contact with services previously? Self harm? Diagnosis? Treatment?
  • Past Medical / Surgical History
  • Medications
  • Family History (medical, psychiatric and developmental disorders). Genogram.
  • Substance Misuse History (drugs and alcohol).
  • Forensic History
  • Developmental History
    • Pregnancy. Maternal illness, medications, drugs and alcohol. Birth. Developmental milestones. Social functioning in early childhood. Problems with separation from mother. Academic, social and behavioural progress at school. Activities of Daily Living. Relationships. Social circumstances of family.
  • Premorbid personality.
    • What was the child like before the current problem?
Mental Health Examination
  • Signs / Symptoms and Behaviour at the time of the interview.
  • Appearance and Behaviour.
    • General appearance, facial appearance, social behaviour, retardation or agitation, quality of rapport established.
  • Speech.
    • Rate and quantity. Content. Flow e.g. rapid shifts or sudden interruptions.
  • Mood and Affect.
    • Low mood, anxiety, elation. How mood varies. Subjective and Objective.
  • Thoughts and Perceptions
    • delusions, illusions and hallucinations, obsessional thoughts. Thoughts of harm to self or others.
  • Cognition.
    • Orientation, attention and memory e.g MMSE
  • Insight.  Does the patient think they are ill? What kind of illness? Do they think they need treatment and if so, what kind.
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. bulkforming
(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
  • Reinforcement
  • Extinction
  • Punishment
  • Application of aversive stimuli
  • Removal of reinforcement
  • Shaping, prompting and fading
Applications of Behaviour techniques
Disorder Technique
Anxiety and phobic Desensitization, flooding, relaxation
Obsessivecompulsive Relaxation
Relapseprevention
Depressive disorder Cognitive behavioural
Relaxation
Conduct disorders Positive reinforcement
Extinction
Hyperactivity syndromes Time out
Positive reinforcement
Extinction
Pervasive developmental disorders Timeout
Positive reinforcement
Extinction
Time out
Aversive techniques
Encopresis/enuresis Positive reinforcement
Mental retardation Positive reinforcement
Extinction and timeout
Prompting and shaping
Aversive techniques
Tics Massed practice.
Child & Adolescent Psychiatry Care Hospitals
Research
Shastri PC, Shastri JP, Shastri D. Research in child and adolescent psychiatry in India. Indian J Psychiatry [serial online] 2010 [cited 2010 Nov 24];52:219-23. Available from: http://www.indianjpsychiatry.org/text.asp?2010/52/7/219/69235
Conclusion
  • Managing child psychiatric disorders is a multi-diciplinary effort.
  • Child/adolescent psychiatric nursing is concerned with caring and managing mental, emotional, and behavioral disorders of childhood and adolescence.
References
  1. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry. 9th ed. Hong Kong :William and Wilkinson Publishers ;1998.
  2. Friedman ES, Thase ME, Wright JH. Cognitive and behavioral therapies, in Psychiatry, Third Edition. Edited by Allan Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B. First and Mario Maj. John Wiley & Sons, Ltd, 2008.
  3. Hoare P. Essential child psychiatry. Churchill Livingstone.1993.

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