Child Psychiatric Disorders This page was last updated on January 22, 2011 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 childs 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 Axis I

ICD-10 Axis I

Clinical syndrome

Clinical syndrome

Axis 2

Axis 2
Disorders of psychological Mental retardation development Pervasive developmental disorders Specific developmental disorders Axis3

Axis3

Mental retardation

Physical disorders/illness

Axis 4

Axis 4

Medical illness

Severity of current Psychosocial stressors

Axis 5

Abnormal psychosocial

Axis 5

conditions Highest level of adaptive functioning in past year Axis 6

Psychosocial disability

Clinical syndromes of DSM-IV TR and ICD-10 DSM-IV_TR Axis I Disruptive behavior disorders

ICD-10

Attention deficit hyperactivity disorder (ADHD) Conduct disorder Oppositional defiant disorder Axis I

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

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

Gender disorders Tic disorders Elimination disorders

Functional encopresis Functional enuresis Miscellaneous disorders

Axis 2

Pervasive developmental 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: o Assessment of symptoms duration, severity and effect on functioning. o 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 o 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. o 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. o General appearance, facial appearance, social behaviour, retardation or agitation, quality of rapport established. Speech. o Rate and quantity. Content. Flow e.g. rapid shifts or sudden interruptions. Mood and Affect. o Low mood, anxiety, elation. How mood varies. Subjective and Objective. Thoughts and Perceptions o delusions, illusions and hallucinations, obsessional thoughts. Thoughts of harm to self or others. Cognition. o 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 Anxiolytics Usage Anxiety /phobic conditions

Comment. Short term adjunct to behavior treatment

Neuroleptics Phenothiazines eg.

Schizophrenia/hyperkinetic

chlorpromazine Butyrophenones, eg. Haloperidol Tricyclic antidepressants

syndrome Complex tics/ Tourettes syndrome

Extrapyramidal side effects common

Imipramine/amitriptyline Enuresis Clomipramine Major affective disorder

Effective, but high relapse rate Most useful with persistent and sustained mood disturbance Effective in the short term. Long term effects on growth. steep and appetite Effectiveness not established. Side effects include irritability, anorexia and weight loss Only short term

Stimulants Methylphenidate

Hyperkinetic syndrome

Fenfluramine

Pervasive developmental disorder

Hypnotics, eg.

Persistent. sleep disorder in preschool children

trimeprazine/promethazine Lithium Recurrent bipolar affective Close supervision of disorder blood levels for signs of toxicity Facilities formation and Passage of feces

Laxatives, e.g. bulkforming

Encopresis with constipation

(methylecellulose) Stimulants (senna) softener (dioctyl) Central alpha agonist. e.g. Unresponsive Tourette's clonidine 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 Anxiety and phobic Obsessivecompulsive Technique Desensitization, flooding, relaxation Relaxation Relapseprevention Cognitive behavioural Relaxation Positive reinforcement Extinction Time out Positive reinforcement Extinction Timeout Positive reinforcement Extinction Time out Aversive techniques Positive reinforcement Positive reinforcement Extinction and timeout

Depressive disorder

Conduct disorders

Hyperactivity syndromes

Pervasive developmental disorders

Encopresis/enuresis Mental retardation

Tics

Prompting and shaping Aversive techniques Massed practice.

Child & Adolescent Psychiatry Care Hospitals

Child and Adolescent Psychiatry Services :NIMHANS Banglore CAPU : Central Institute of Psychiatry, Ranchi

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.