some psychiatric disorders among children

1. CHILD AND ADOLESCENT
PSYCHIATRY

2. Introduction
• “Child and adolescent Mental Health is the capacity to achieve and
maintain optimum psychological functioning and well being. It is
directly related to the level reached and competency achieved in
psychological and social functioning”
• CAMHS- Child and Adolescent Mental Health Services
• The term CAMHS is used in two ways
• all services that contribute to the mental health care of children and young
people
• other applies specifically to specialist child and adolescent mental health
services, provided in Tiers 2, 3, and 4

3. • The tier concepts
• Tier 1 CAMHS is provided by professionals whose main role and training is not
in mental health, for example GPs, health visitors, paediatricians, social
workers, teachers, youth workers, and juvenile justice workers
• Tier 2 CAMHS is provided by specialist mental health professionals with
training in child development, working primarily alone, rather than in a team.
Their role may include direct contact with young people, consultation to Tier
1 and training
• Tier 3 services are provided by a multidisciplinary team who see young
people with more complex mental health problems
• Tier 4 services are very specialized services in residential, day patient, or
outpatient settings for children and adolescents with severe and/or complex
problems requiring a combination or intensity of interventions that cannot be
provided by Tier 3 CAMHS

4. Conduct disorder
• The conduct disorders are characterized by a repetitive and persistent
pattern of antisocial, aggressive, or defiant behaviors that violate age
appropriate societal norms
• Conduct disorders can be divided into conduct disorder (CD) and
oppositional defiant disorder (ODD)

5. Conduct Disorder
• Commoner in boys and in urban populations
• Clinical features - Aggression/cruelty to people and/or animals, destruction of
property, deceitfulness, theft, fire-setting, truancy and running away from home,
and severe provocative or disobedient behavior.
• ICD-10 requires 1 or more feature at a marked level for over 6mths; DSM-IV
requires 3 or more over 12mths, with 1 in last 6mths
• Aetiology
• Social disadvantage: poverty, low socio-economic class, overcrowding,
homelessness, social isolation, high community rates of deviancy, truancy,
unemployment
• Parenting: parental criminality, parental psychiatric disorder and substance
misuse, inconsistent and critical parenting style, parental conflict, teenage
pregnancy, single parenthood
• Child: low IQ, neurodevelopmental problems, brain damage, epilepsy,
difficult/under-controlled temperament, attachment problems, and poor
interpersonal relationships.

6. • Comorbidity : ADHD; learning difficulties (especially dyslexia);
substance abuse; depression; anxiety disorder; autism spectrum
disorders (ASD).
• Management
• Functional family therapy
• Multi-systemic therapy : family-based, including school and community.
Highly resource-intensive, but good outcomes
• Child interventions : social skills, problem-solving, anger management,
confidence building
• Treat comorbidity

7. Oppositional defiant disorder (ODD)
• Essence An enduring pattern of negative, hostile, and defiant
behavior, without serious violations of societal norms or the rights of
others. Behavior may occur in one situation only (e.g. home) and
tends to be most evident in interactions with familiar adults or peers
• More common in boys and in childhood rather than adolescence.
• Same management principles as for CD

8. Attention Deficit Hyperactivity Disorder
(ADHD)
• Characterized by the three core symptoms of inattention,
hyperactivity, and impulsiveness
• DSM-IV recognizes 3 subtypes: a combined subtype where all 3
features are present, an inattentive subtype (ADD), and a hyperactive-
impulsive subtype
• Symptoms should be at developmentally inappropriate levels, be
present across time and situations for at least 6 months, and starting
before age 7

9. • Aetiology : 80% of cases are genetically inherited and risk of ADHD in
siblings is 2–3 times increased. Rates are increased in low birth-weight
babies and babies born to mothers who used drugs, alcohol, or tobacco
during pregnancy, following head injury, and in some genetic and metabolic
disorders
• Comorbidity : specific learning disorders, motor co-ordination problems,
autism spectrum disorder, tic disorders, CD, ODD, substance abuse, anxiety,
depression, bipolar disorder
• Clinical features of ADHD
• Inattention Careless with detail, fails to sustain attention, appears not to
listen, fails to finish tasks, poor self-organization, loses things, forgetful,
easily distracted, and avoids tasks requiring sustained attention
• Hyperactivity Most evident in structured situations, fidgets with hands or
feet, leaves seat in class, runs/climbs about, cannot play quietly, ‘always on
the go’
• Impulsiveness Talks excessively, blurts out answers, cannot await turn,
interrupts others, intrudes on others

10. • Management
• Psycho-education
• Medication
• Behavioral interventions
• School interventions
• Treat comorbidity

11. Enuresis
• The normal variation in the age of acquisition of bladder control
makes it difficult to demarcate disorder
• Enuresis can impact on self-esteem, family and peer relationships and
restrict activities
• Aetiology : Nocturnal enuresis has a strong genetic component. Both
psychosocial and pathophysiological associations have been
demonstrated. Diurnal enuresis is more likely to be associated with
structural and functional disorders of the urinary tract;

12. • Management
• Careful assessment will inform management.
• Psychoeducation of child and parents.
• Treat organic causes, e.g. structural abnormality, infection.
• Nocturnal enuresis: there is robust evidence to support use of enuresis
alarms. ‘Night lifting’, reward systems (e.g. star charts), and medication—
desmopressin, imipramine, oxybutynin—may also be helpful.
• Diurnal enuresis: body alarms, watch alarm to remind child to use toilet,
medication, specific psychological approaches, e.g. anxiety management if
related to fear of toilet.

13. Encopresis
• Voluntary or involuntary fecal soiling in children who usually have
already been toilet trained
• Soiling more frequently than once a month after the fourth birthday
is regarded as an elimination disorder if it is not attributable to a
general medical condition
• Most soiling will cease by age 16

14. • Types
• 95% present with functional constipation with retention and overflow. Both
physical (persistent faecal loading leading to loss of sensation of rectal filling,
anal fissure) and psychological (toilet fears, fear of painful defecation) factors
may be relevant
• Never toilet trained
• Frightened to use the toilet
• Deliberately depositing faeces in inappropriate places
• Management
• Lifestyle changes, e.g. adequate fluid and dietary fibre
• Education of child and family, and assistance to view child more positively
• Medical management, e.g. laxatives
• Behavioral approaches, e.g. star charts

15. Learning Disabilities
• A term for a wide variety of learning problems.
• LD is not a problem with intelligence or motivation.
• Children with LD aren’t lazy or dumb.
• The difference only is how they receive and process information.
• LD can lead to trouble with learning new information and skills, and
putting them to use.
• The most common types of LD involve problems with reading,
writing, math, reasoning, listening, and speaking

17. • Signs and Symptoms:
• Problems pronouncing words
• Trouble finding the right word
• Difficulty rhyming
• Trouble learning the alphabet, numbers, colors, shapes, days of the week
• Difficulty following directions or learning routines
• Difficulty controlling crayons, pencils, and scissors or coloring within the lines
• Trouble with buttons, zippers, snaps, learning to tie shoes
• Management
• Learn the specifics about child’s learning disability
• Research treatments, services, and new theories
• Pursue treatment and services at home
• Nurture child’s strengths

18. Anxiety disorders
• Anxiety disorders are characterized by irrational fear or worry causing
significant distress and/or impairment in functioning and their relative
prevalence reflects this shift in content
• Anxiety disorders are among the most common psychiatric disorders in
youth
• Prevalence rates range from 5–15% with 8% requiring clinical treatment
• Separation anxiety disorder and specifi c phobia usually have onset in early
childhood
• Generalized anxiety disorder occurs across all age groups
• Obsessive–compulsive disorder, social phobia, agoraphobia, and panic
disorder tend to occur in later childhood and adolescence

19. • Aetiological factors :Genetic vulnerability; temperament that exhibits
‘behavioral inhibition’ (timidity, shyness, and emotional restraint with
unfamiliar people or situations); insecure attachment; stressful or
traumatic life events; high social adversity; over-
protective/critical/punitive parenting
• Medical conditions: hyperthyroidism; cardiomyopathy; arrhythmias;
respiratory and neurological diseases
• Substances: alcohol; caffeine; cocaine; amphetamines; cannabis;
SSRIs; LSD; ecstasy; etc.

20. • Presentation of anxiety
• Behavioral presentations include over activity, inattention, sleep disturbance,
separation difficulty, regression, school refusal, social withdrawal, aggression,
ritualistic behaviors, and somatization
• Management
• Use ABC (antecedents, behavior, consequences) approach to help child and
family understand what happens when the child feels anxious
• Stress reduction including relaxation.
• Age-appropriate CBT approaches

21. Separation Anxiety Disorder
• Characterized by increased and inappropriate anxiety around
separation from attachment figures or home, which is
developmentally abnormal and results in impaired functioning
• Causes : Genetic vulnerability; anxious, inconsistent, or overinvolved
parenting; and regression during periods of stress, illness, or
abandonment
• Symptoms : Anxiety about actual or anticipated separation from or
danger to attachment figure; sleep disturbances and nightmares;
somatization; and school refusal
• Comorbidity : Depression; anxiety disorders (panic with agoraphobia
in older children); ADHD; oppositional disorders; learning disorders;
and developmental disorders

22. Generalized Anxiety Disorder
• Characterized by developmentally inappropriate and excessive worry
and anxiety on most days about things not under one’s own control
• Severe enough to cause distress and/or dysfunction
• Affected children are often perfectionist and self-critical
• Most common anxiety disorder of adolescence, mostly seen among
adolescent female
• Symptoms : Excessive worry; restlessness, irritability, and fatigue;
poor concentration; sleep disturbances; muscle tension. In children:
somatic symptoms (headache; stomach pains or ‘irritable bowel’;
rapid heartbeat; shortness of breath); nail biting and hair pulling; and
school refusal
• Management : CBT, Psychoeducation,

23. Panic Disorder
• Recurrent, unexpected panic attacks are the hallmark of this disorder,
together with a period during which the child is concerned about
having another attack and the possible consequences of an attack,
and exhibits significant behavioral changes related to the attacks
• Latter features are referred to as anticipatory anxiety
• A panic attack is described as a discrete period of increased fear
peaking at about 10min and lasting about 30min to 1hr

24. • Symptoms : Sweating, flushing, trembling, palpitations and
tachycardia, chest pain, shortness of breath and choking, nausea and
vomiting, dizziness, paraesthesia, depersonalization and
derealization, and a fear of dying
• In young children somatic symptoms predominate rather than classic
symptoms
• The essential feature is anxiety about being in a situation in which
escape would be difficult or help unavailable should a panic attack
occur
• Comorbidity : Depression, substance abuse, and other anxiety
disorders (especially social phobia) are most common
• Management : As for generalized anxiety disorder