C h i l d P s y c h i a t r i c D i s o r d e r s

This page was last updated on September 19, 2013

I n t r o d u c t i o n
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.
Hi s t o r i c a l d e v e l o p me n t s i n C h i l d P s y c h i a t r y
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.
D i f f e r e n c e s o f C h i l d p s y c h i a t r y f r o m a d u l t p s y c h i a t r y
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
E t i o l o g i c a l f a c t o r s
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
C l a s s i f i c a t i o n & P r e v a l a n c e
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
C h i l d P s y c h i a t r i c A s s e s s me n t
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 Usage Comment.
Anxiolytics Anxiety /phobic conditions Short term adjunct
to behavior
treatment
Neuroleptics Schizophrenia/hyperkinetic
syndrome
Complex tics/ Tourettes
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.
C h i l d & A d o l e s c e n t P s y c h i a t r y C a r e Ho s p i t a l s