child psychiatry

Child psychiatry د.وليد عزيز العميدي
Child psychiatry is a medical discipline that deals with children and adolescents with emotional ,
behavioral and developmental disorders .
The practice of child psychiatry differs from that of adult psychiatry in 5 important ways:
1-Children seldom initiate consultation , instead they are brought by a parent , or another
adult.
2-The child`s problems may reflect the problems of other people , e.g. illness in the
mother .
3-The child`s stage of development must be considered when deciding what is abnormal
.some behavior are normal at an early age but abnormal at later one . e.g. repeated bed
wetting may be normal in a 3 y. old child but is abnormal in a child aged 7 y.
4-Children are generally less able to express themselves in words , for this reason ,
evidence of disturbance often comes from observations of behavior made by parents ,
teachers and others .
5-The emphasis of treatment is different , medication is used less in the treatment of
children than in the treatment of adults , and usually started by a specialist rather than the
family doctor . instead , there is more emphasis on working with parents and the whole
family , reassuring and retraining children , and coordinating the efforts of others who
can help children , especially at school.
In child psychiatry it is important to adopt a developmental approach for 3 reasons:
1-The stage of development determines whether behavior is normal or pathological.
2-The effects of life events differ as the child develops , e.g. infants under 6 months can
move to a new carer with little disturbance , but children aged
6 months to 1 year of age show great distress when separated from the original carer ,
because the attachment relationship has been formed . after the age of 3 y. , attachment
bonds are still strong but the child`s ability to understand and to use language can reduce
the effect of a change of caretaker.
3-Psychopathology may change as the child grows older , anxiety disorders in childhood
tends to improve as the child develops , depressive disorders often recur and continue
into adult life .
Common presentations:
-Emotional disorders : these include anxiety , fearfulness , depression and somatization , school
refusal may be part of an emotional disorder , particularly phobic avoidance.
-conduct disorders : lying , stealing and fighting.
-developmental disorders: include:
1-Failure of normal development : encopresis , enuresis , language delay and clumsiness.
2-Hyperkinetic syndrome.
3-Pervasive developmental disorders.
Epidemiology of child psychiatric disorders:
The epidemiological surveys carried out by Rutter and his colleagues of the entire population of
9 – 11 y. old on the Isle of Wight followed up at age 14 – 15 y. , were a landmark for child
psychiatry. The findings from this and other studies have led to the following conclusions:
? The prevalence in rural communities of child psychiatric disorder among 10 -11 y. old is
6.8% . this rate is almost doubled in urban areas . conduct disorder is the most common
disorder (60%) , followed by emotional disorder (40%).
? Conduct disorders and inattentive and overactive behaviors are more common in boys ,
emotional disorders are equally prevalent between the sexes in childhood , but show a
female preponderance in adolescence.
? Childhood conduct disorder is strongly associated with family discord and SRR.
? Brain injury is arisk factor for child psychiatric disorder . children with active epilepsy
have a much higher rate of psychiatric disorder .
? Depressive disorders increase after puberty.
Aetiology of child psychiatric disorders:
- Constitutional factors:
1-Genetic factors: polygenic influences are thought to be important in traits of
intelligence , temperament , personality and specific disorders : autism , ADHD ,
depression and reading disabilities .
2-Chromosomal factors : Down`s syndrome (triosomy 21).
- Physical factors :
1-Intra-uterine infections/toxins: rubella, toxoplasmosis , alcohol and drugs.
2-Premature birth : behavioral and developmental abnormalities are more often
associated with very low birth weight in boys than in girls .
3-Brain injury: children with chronic physical disease have twice the rate of psychiatric
disorders , and three times the rate if associated with physical handicap.
- Temperamental factors : difficult children , at risk of developing psychiatric disorder , are
characterized by irregularity of biological functions , negative and withdrawal responses ,
non-adaptability and intense mood expression which is frequently negative.
- Family factors : chronic family discord and violence are strongly associated with the
development of conduct disorder . Maternal depression is a risk factor for psychiatric
disorder . Large family size is associated with specific reading retardation and conduct
disorder.
- Environmental and social factors :
1-Life events: such as losses , illnesses , death of parent or relative , birth of sibling …..
have been shown to be a risk factor for the development of psychiatric disorder.
2-School : poorly organized schools have an adverse effect .
3-Urban environment : the rate of psychiatric disorders is almost doubled in urban areas.
Protective factors:
- Child factors: positive temperament , social competence , academic achievement and high self
–esteem.
-Family factors: supportive parents , family closeness .
-Community and social factors: positive and supportive friendships , continuing further
education .
Psychiatric assessment of children and their families :
The aims of assessment are to obtain a clear account of the presenting problem , to find out how
this problem is related to the child`s past development and present life in its psychological and
social context , and to plan treatment of the child and family.
The psychiatric assessment of children differs in several ways from that of adults :
- A more flexible approach .
- Interview family members .
- Information from schools.
Introductory stage: the whole family is seen together and information gathered . a clear
behavioral account of the problem is obtained.
This is followed by either :
Individual interviews : these are often essential as the parents may not be fully aware of the
child`s emotional difficulties . For younger children , observation of play and drawings are
informative .
With
Parental interviews : in addition to the information obtained directly from the parents , it is useful
to observe how the child separates from the parents , and quality of parent`s relationship .
Or
Whole family interview : family interactions , including communication become focus of
interest.
Further investigations : in cases of eating disorders and neuropsychiatric disorders , physical
examination is necessary with particular reference to CNS .
Measurement of weight , height , and head circumference is important , psychological testing
may be helpful , i.e. IQ using ( WISC) .
Further information is often required from child`s school , social workers , paediatricians …
Classification:
Classification of child psychiatric disorders in the UK is based upon a multi-axial diagnostic
system:
Axis I : psychiatric diagnosis.
Axis II : specific developmental delays .
Axis III : intelligence level .
Axis IV : medical conditions.
Axis V : psychosocial circumstances .
DSM-IV : Disorders first diagnosed in infancy , childhood , or adolescence :
- Learning disorders.
- Motor skills disorders.
- Communication disorders .
- Pervasive developmental disorders.
- Attention deficit and disruptive disorder.
- Tic disorders.
- Feeding and eating disorders.
- Elimination disorder.
- Other disorder of infancy and childhood.
ICD-10 :
F8 disorders of psychological development :
- Specific developmental disorders of scholastic skills.
- =========================== of motor function.
- =========================== of speech and language.
- Pervasive developmental disorders.
F9 behavioral and emotional disorders with onset usually occuring in childhood and adolescence
:
- Hyperkinetic disorders.
- Conduct disorders.
- Mixed disorders of conduct and emotions.
- Emotional disorders with onset specific to childhood and adolescence.
- Tic disorders .
- Disorders of social functioning with onset specific to childhood and adolescence.
- Other behavioral and emotional disorders with onset usually in childhood and adolescence (
includes elimination disorders and feeding disorders).
Some common problems of preschool children:
- Temper tantrums : occasional temper tantrums are normal in toddlers , and only persistent or
very severe tantrums are abnormal . the immediate cause is often unwitting reinforcement by
excessive attention and inconsistent discipline on the part of the parents.
Temper tantrums usually respond to kind and but firm and consistent setting of limits. The
parents should be helped with any problems of their own and advised how to respond to the
tantrums.
- Pica : is the eating of items generally regarded as inedible , e.g. soil , paint and paper .
Cases should be investigated carefully because some are due to brain damage or autism or
mental retardation . some are associated with emotional distress which should be reduced if
possible . otherwise , treatment consist of common –sense precautions to keep the child away
from the abnormal items of diet . pica usually diminished as the child grows older.
Reactive attachment disorder of the infancy and early childhood :
Attachment disorders are more extreme variations from the norm , they are pervasive
affecting all relationships and they cause distress .
They starts before the age of 5 y. and are associated with grossly abnormal care-giving , there
are 2 subtypes:
? Disinhibited : these children seek comfort but do so indiscriminately , seeking it as much
from strangers as from caregivers.
Such behavior has been described most clearly in children raised in institutions , or
experiencing repeated changes in foster care.
In DSM-IV , the diagnosis requires that the disturbance of relationship appears to be a
direct result of abnormal caregiving . ICD-10 does not use this criterion but requires
that the behavior is present in several situations .
? Inhibited : the children show a combination of behavioral inhibition , vigilance and
fearfulness , which is sometime called frozen watchfulness .
This behavior is seen among children who have been abused.
? Learning disorders : are problems that make educational achievement difficult .
- Reading disorder(dyslexia) : characterized by an impaired ability to recognize words ,
slow and inaccurate reading and poor comprehension .
Usually identified at age of 7y. , 4 % of school aged children , male predominance 4:1 .
- Disorders of written expression: often coexists with dyslexia and manifests as
difficulties with spelling , syntax , grammar and composition , 2-8% of school aged
children , m.:f.=3:1
-mathematics disorder : difficulty with various compnents of mathematics such as
learning number names , remembering the signs of addition and subtarction , learning
multiplication tables.
Occurs in about 1% of school aged children , more commonly in females , associated
with visuo-spatial deficits and attributed to right parietal dysfunction.
? Communication disorders : language disorders include expressive and mixed receptiveexpressive
language disorder , whereas speech disorders include phonological disorder
and stuttering .
Stuttering : is a condition in which the normal flow of speech is disrupted by involuntary
speech motor events .
Stuttering can include a variety of specific disruption of fluency , including sound of
syllable repetitions , sound prolongations .
Male predomenance 3:1 , 1% of general population , typical age of onset 2 to 7y. With
the peak at age of 5 y. .
50-80% recover spontaneously
Preschoolers and school aged children who stutter exhibits an increase incidence of social
anxiety , school refusal and other anxiety symptoms .
Aetiology : genetic , incomplete cerebral dominance , hyperdopaminergic state .
Management : speech therapy .