University of Oxford

Child Psychiatry

Child Psychiatry 

Introduction:

The psychiatric disorders that present in childhood are distinct from those in adults because they arise within complex and intimate family relationships, and are influenced by the development stage of the child. Children also present special challenges for assessment and treatment. The psychiatric disorders that present in childhood or adolescence are listed in Table 1.

  • Pervasive development disorders
  • Specific development disorders
  • Hyperkinetic disorders
  • Conduct disorders
  • Emotional disorders
  • Psychiatric aspects of child abuse
  • Disorders of elimination

 Table 1 Classification of psychiatric disorders of childhood and adolescence

Normal childhood development

Some of the features of normal child development are shown in table 2. It is essential to consider the developmental stage of the stage of the child during a psychiatric assessment, as what is accepted as normal at one stage would be abnormal at another.

Early childhood experiences play an important role in determining what type of person we become in adulthood. The role of parents in this is central. The child with parents (or parent) who are loving and tolerant, yet able to set and enforce clear and reasonable limits is likely to develop a high self esteem, and secure attachment to the parents that will provide a template for secure attachments to others in later life. The theory of ‘attachment’ was first described by John Bowlby in the 1950s. It derived from his study of young children separated from their mother in hospital. Attachment behaviour begins at around 7 months and consists of clinginess and unwillingness to be separated from the main carer, usually mother. It serves strengthen the bond between mother and child and has the evolutionary function of ensuring the child is protected from predators. A securely attached child is able to use the mother as a safe base from which exploration of the outside world can begin, and will also be able to cope well with brief separations. If the attachment is insecure, because the parent fails to respond to the child’s need for attention or holding, or is inconsistent, the child will have difficulty exploring and separating. This pattern of insecure attachment may persist throughout life, affecting adult relationships.

Assessment of Children

The way in which a psychiatric history is taken and the child is examined will depend upon the age, confidence and language skills of the child. Much of the history will come from the parents, and children who are prepared to separate from their parents can then be seen alone. It is usually best to see adolescents alone and before their parents in order to establish a trusting relationship with them. The interview should take place in a relaxed and friendly atmosphere, with toys and drawing materials provided for children less than 10 years.

The history should include the following:

  • Presenting complaint-described by both the parent and child. It is important to lead up to asking the child about the presenting complaint gently, after gaining their confidence and talking about neutral topics.
  • Recent behaviour or emotional difficulties-includinggeneralhealth, mood, sleep, appetite, elimination, relationships, antisocial behaviours, fantasy life and play, and school behaviour.
  • Personal history-pregnancy, birth, milestones (motor, speech, feeding, toilet training, social behaviour), medical history, separations from parents, schools attended and progress in them.
  • Family structure and function-construction of a genogram is often useful. Relationships between family members should be asked about, and the interactions during the interview observed.
  • Temperature trails-traits such as activity level, regularity of functions (sleep, bowels, eating), adaptability to new circumstances, willingness to approach new people or situations, quality and intensity of mood, quality of relationships within and outside the family, attention and persistence can be observed from a very young age.

A mental state examination of the child should be completed, although this will often rely on watching behaviour and play. The following should be considered:

  • Appearance-looking for any abnormality, bruises, cuts, or grazes and appropriateness of dress.
  • Behaviour-activity level, interactions with parents, motor function, attention and persistence with tasks.
  • Talk-articulation, vocabulary and use of language.
  • Mood-happy, elated, unhappy, depressed, anxious, hostile of resentful.
  • Thoughts-content of speech and fantasy life, for example by asking for three magic wishes.

The assessment should be completed with a physical examination and by speaking to other informants involved with the child or family, such as the family doctor, school teacher, educational psychologist, or social services. Investigations may be performed, most commonly intelligence tests and tests of academic attainment, such as standardized reading tests.

Pervasive Developmental Disorder (Autism)

Autism is severe disorder that begins early in life and is apparent by the third birthday. It is characterised by a failure to make social relationships, poor language development and resistance to change with limited and repetitive behaviours and interests. These children fail to notice or respond to other people’s emotions or social signals. They do not adapt their behaviour appropriately to new environments, and are very restricted in their play, rarely engaging in make-believe play. Typically, they will choose unusual non-soft toys and may become attached to a particular object and refuse to be separated from it. Some will have very limited language skills, and those skills that are present will generally not be used in social conversation with others. Three quarters have significant mental retardation.

Autism has a prevalence of 4 in 10,000 and is three times more common in boys than girls. It is associated with brain damage in some cases and genetic factors are thought to play an important role in the aetiology. There are no specific treatments available. The families require a great deal of support and counseling, and behaviour problems may be managed with behavioural therapy. The outcome is generally poor, with only 15% ever achieving independent functioning.

0-1 year

  • Totally dependent
  • Rapid motor development – walking by one year
  • Attachment behaviour from 7 months

1-2 years

  • Begins to talk
  • Dry by day
  • Temper tantrums
  • Separation anxiety

2-5 years

  • Complex language skills
  • Sociable
  • Development of sexual identity
  • Identification with parents
  • Beginning of conscience formation
  • Vivid fantasy life
  • See themselves as the centre of their world

5-10 years

  • Well-defined identity as a girl or boy
  • Able to separate well from mother
  • Personality attributes acquired by the end of this period persist into adulthood

Adolescence

  • Puberty – 11 to 13 years in girls and 13 to 17 years in boys
  • Establishment of personal identity
  • Establishment of autonomy from parents
  • Learning to work and develop skills to become self supporting
  • Peer group relationships are very important

Table 2 Normal childhood development

Specific Developmental Disorders

In these disorders, specific skills such as reading, spelling, arithmetical skills, and language are disturbed. The problems are present from early childhood. In order to make a diagnosis of specific developmental disorder, acquired brain trauma or disease must be excluded and the child must have had reasonable opportunities to acquire these skills at home or school. The causes of the specific developmental disorders are not known for sure but are thought to stem from abnormalities in cognitive processing. They are all much more common in boys than girls. 

Specific reading disorderis particularly common, with a prevalence of 5-10%. Typical reading problems include distortions or additions of words or parts of words, slow reading rate and loss of place in the text. Although specific reading disorder is not due to inadequate schooling, truancy is a common consequence of the academic difficulties. Conduct disorders and specific reading disorder frequency co-exist.

Hyperkinetic Disorder

In America this is known as attention deficit hyperactivity disorder (ADHD). The main features of the disorder are overactivity, restlessness, short attention span, distractibility and impulsive behaviour.  These children are often clumsy, accident prone and get into trouble with parents and teachers because they act without thinking. Other children will often avoid them and they can become socially isolated.

Symptoms are usually present from an early age, but it is most commonly diagnosed in 6 to 9 year olds in whom there is a prevalence of about 8%. It is 3 times more common in boys than girls. Many causes have been suggested, from genetic factors to allergies and poor parenting. This is one of the very few childhood psychiatric conditions that is treated with medication. Amphetamine-like stimulates are used, such as methylphenidate, which have the paradoxical effects of reducing activity levels and improving attention. This results in improvements in academic performance and development of friendships. Behavioural therapy, using a system of rewards for good behaviour, is also useful for these children.

Hyperactivity disorder tends to improve with age, with only one quarter having persisting problems in adolescence. About half of these will continue to exhibit some features of the hyperactivity into adulthood, and this often expresses itself as dissocial behaviour.     

Conduct Disorder

The main features of conduct disorders are persistent antisocial behaviours such as fighting, bullying, severe temper tantrums, damaging property, starting fires, stealing, truancy, and persistent and defiant disobedience. The child’s age must be taken into account, and normal naughtiness should not be considered a sign of conduct disorder. A third of cases have specific reading disorder, and there is considerable overlap with hyperactivity disorder. Conduct disorders are common, present in at least 4% of children with a peak in the 12 to 16 year age range, and are three times more common in boys than girls.

There are two types of conduct disorder:

  • Socialised conduct disorder. These children are able to make friends who usually also behave in an antisocial way. The bad behaviour is therefore usually most evident away from home. Relationships with adults may be good, although there are often difficulties with authority figures.
  • Unsocialised conduct disorder. These children do not have friends, either because they have been rejected by their peers or because they deliberately choose to isolate themselves. The antisocial behaviour therefore occurs alone. Some degree of emotional disorder is often also present in these children.

The causes of conduct disorders are a complex interaction between the biological make-up of the child, family influences and environmental factors as summersied Figure 1. The style of parenting is thought to be important. Conduct disorders are likely to develop if parents fail to give clear boundaries, monitor behaviour and administer ineffective or inconsistent discipline. Improving parenting skills is likely to improve behaviour even if other causative factors are present. Other treatment approaches include family therapy, behavioural therapy, remedial teaching and provision of alternative peer group activities. The outcome is better for the socialised group. Two thirds of the unsocialised group will have persisting dissocial behaviour in adulthood.

Emotional Disorders

Emotional disorders of childhood are characterised by anxiety and depression. They are present in 2-3% of children and unusually for childhood psychiatric disorders are more common in girls. They generally have a good prognosis.

Separation anxiety disorder

It is normal for toddlers and pre-school children to feel some anxiety over real or threatened separation from their parents. In separation anxiety disorder the anxiety is unusually severe or occurs in older children, and causes some problems in social functioning such as preventing the child from attending school. Symptoms include persistent worries about separation from the attachment figure (usually mother) and great distress if forced to do so. Some will refuse to go to sleep without their mother nearby and have nightmares about separation. Parental overprotection is commonly present and other causes include the child’s temperament and stressful events, particularly those involving separation such as family breakdown, bereavement or illness

Anxiety disorders of childhood

 Specific phobias about animals, the dark or strangers are normal in young children and rarely need treatment. Generalised anxiety disorder can occur and is frequency charactersied by somatic symptoms, particularly abdominal pain.

Family influences

  • martial disharmony
  • absent parent
  • parental violence, alcoholism, dissocial personality disorder
  • poor parenting

Child

  • genetic factors
  • brain damage
  • low IQ
  • temperament

  

Environmental influences

  • institution care
  • school disciplinary code
  • peer group influences
  • social deprivation

Behavioral

Figure 1 Aetiology of conduct disorder

Depressive illness

The symptoms of depressive illness are much the same in children as in adults – low mode, anhedonia, altered sleep and appetite and depressive thoughts. Fleeting suicidal thoughts are quite common, but completed suicide is rare. Moderate and severe depressive illness is uncommon is pre-pubertal children, with a steady increase in incidence over the teenage years. The causes of depression and its treatment are also similar to those in adults, although younger children seem to be less responsive to antidepressant drugs than adults, so psychological treatment approaches are preferred. 

School refusal

In school refusal the child refuses to attend school because of specific fears about the school, the journey to it or separation anxiety. This accounts for about 1% of all school absences and is much less common than truancy in which the child conceals their absence from school and from their parents. The characteristics of children with school refusal are compared to those who habitually truant in Table 1. School refusal should be treated by returning the child to school as quickly as possible as avoidance is likely to heighten the anxiety. A grade reintroduction may be necessary, with support for both child and parents.  

Child Abuse

Child abuse may take the form of neglect, emotional, physical or sexual abuse. It plays a role in precipitating psychiatric disorders in children which may continue through to adulthood. It is essential that all professionals who come into contact with children are alert to the possibility of abuse playing a role in the problems presented by a child and its family.

Table 3 Comparison of characteristics of children presenting with persistent truancy, and school refusal

School refusal

Truancy

Absence from school known to parents

Absence from school concealed from parents

Spends day at home alone or with parents

May spend day away from home with peers

Peak incidence at 11 years

Increase with age

Fear of school or separation anxiety

No emotional disorders

All social classes

Increased in lower social classes

No increase in parental marital discord

Dysfunctional family

Overprotective parenting

Harsh parenting

  

The incidence of abuse is difficult to measure as the majority of cases go unreported, and a definition of what constitutes abuse varies. Official figures for reported cases of abuse have risen in recent years, although this is likely to be due to greater reporting rather than a true increase in abuse. A British study found that 12% of women and 8% of men reported some form of sexual abuse before the age of 16 years.

There are many contributor factors in the abuse of children. Some children are more vulnerable than others, for example those who are unwanted, have early separation from the mother, are mentally or physically handicapped, or have temperamental characteristics that make them difficult to handle. Some parents are more likely to be abusive, particularly those who have themselves been abused as children, live in poor socioeconomic circumstances and have unrealistic styles of disciplining their children.

The most common form of sexual abuse is father-daughter incest. Sexually abused children may present with a sudden change in their social behaviour or academic performance, or with conduct disorders. Some engage in repetitive sexual play and are sexually precocious. It is important to give these children an opportunity to disclose their abuse, but great care must be taken to avoid adding to their trauma. Social services must be informed of any disclosure of sexual abuse by a child and instigating child-care proceedings. The emotional effects of childhood sexual abuse may be addressed in individual psychotherapy with the child. Adolescents and adults may also be offered group therapy which has the advantages of reducing the sense of isolation and allowing development of trust and self esteem. One-third of sexually abused children have no long-term negative effects, the rest are prone to depressive illness, low self esteem, sexual problems and have a tendency to re-victimisation in adulthood.

Disorders of Elimination

Enuresis

Enuresis is involuntary emptying of the bladder occurring after the age of 5 years in the absence of an organic cause. Bedwetting (nocturnal enuresis) is common, occurring in 10% of 5 year old, 5% of 10 year olds and 1% of 15 year olds. Daytime enuresis is less common. The enuresis is considered to be primary if there has been no preceding period of bladder control, and secondary if it follows a period of continence. It is twice as common in boys as girls, and most cases are thought to be due to delayed neurological maturation which simply corrects itself with time. There is often a positive family history of the same problem. Secondary enuresis may occur as a feature of regressive behaviour at times of stress. Management consists of excluding a physical cause, particularly a urinary tract infection, reassuring the parents and encouraging them to handle the problem calmly and gently. Instituting a simple behavioural programme such as a star chart or pad and bell can be used. 

  

Encopresis

Encopresis is defecation in inappropriate places despite having normal bowel control. Most children are faecally continent by the age of 3 years. At 8 years, 2% of boys and 1% of girls have encopresis. This may be due to inadequate toilet training or may have a psychological cause with the behaviour representing the child’s feelings of anger or regression at a time of stress. Constipation with overflow incontinence is the main differential diagnosis to be excluded.

Adolescence

Adolescents have difficult social and emotional issues to deal with. For example, there is frequently conflict over the degree of independence they wish to and are allowed to have from their parents. The peer group becomes very important and influential, and can provide valuable support for individuals to try new things away from the family. They can also arouse a great deal of anxiety about rejection from the group, and may promote delinquent behaviour. Development of sexual relationships is another potential source of confusion, anxiety and conflict.

The pattern of psychiatric disorders changes as children become adolescents. There is a marked increase in depressive disorder, particularly in girls, and schizophrenia becomes much more common in late adolescence. Problems with alcohol and drug abuse and eating disorders also tend to emerge at this time. Development disorders have usually resolved.

Reference:

1. Steple D. Oxford Handbook of Psychiatry, Oxford University Press, 2006

2. Smith G et al. Key topics in Psychiatry. Bios scientific publisher limited, 1996.

3. Boyle D, Davies S. Psychiatry, Mosby’s crash course 2002

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