Child Psychiatry

Branch of medicine concerned with the study and treatment of mental, emotional,
and behavioral disorders of childhood. Child psychiatry has been recognized as a division
of the field of psychiatry and neurology since the mid 1920s.

Mental Health Information for Children

Many children and adolescents have mental health problems that interfere with their
normal development and daily life activities. Some mental health problems are mild,
while others are more severe. Some mental health problems last for only short periods of
time, while others, potentially, last a lifetime.

Anxiety disorders are the most common mental health problems that occur in children
and adolescents. Three percent to 5 percent of school-aged children are diagnosed with
attention-deficit/hyperactivity disorder (ADHD).

Eating disorders, including anorexia nervosa and bulimia nervosa, are common among
adolescent and young women in the US.

The National Institute of Mental Health (NIMH) states that research studies have reported
that up to 3 percent of children and up to 8 percent of adolescents in the US suffer from
depression.

It is important to know that help is available. Most children and adolescents who
experience mental health problems can return to normal daily activities, if they receive
appropriate treatment

I- Mental Retardation

Definition: MR is a term for a pattern of persistently slow learning of basic motor

and language skills ("milestones") during childhood, and a significantly below-normal
global intellectual capacity as an adult. One common criterion for diagnosis of mental
retardation is a tested intelligence quotient (IQ) of 70 or below and deficits in adaptive
functioning.

People with mental retardation may be described as having developmental disabilities,

global developmental delay, or learning difficulties.

Signs and Symptoms

There are many signs. For example, children with developmental disabilities may
learn to sit up, to crawl, or to walk later than other children, or they may learn to talk
later. Both adults and children with intellectual disabilities may also:

• Have trouble speaking.

 • Find it hard to remember things.
• Have trouble understanding social rules.
• Have trouble discerning cause and effect.
• Have trouble solving problems.
• Have trouble thinking logically.
• Persistence of infantile behavior.

In early childhood mild disability (IQ 60–70) may not be obvious, and may not be
diagnosed until children begin school. Even when poor academic performance is
recognized, it may take expert assessment to distinguish mild mental disability from
learning disability or behavior problems. As they become adults, many people can live
independently and may be considered by others in their community as "slow" rather than
retarded.

Moderate disability (IQ 50–60) is nearly always obvious within the first years of life.
These people will encounter difficulty in school, at home, and in the community. In many
cases they will need to join special, usually separate, classes in school, but they can still
progress to become functioning members of society. As adults they may live with their
parents, in a supportive group home, or even semi-independently with significant
supportive services to help them, for example, manage their finances.

Among people with intellectual disabilities, only about one in eight will score below
50 on IQ tests. A person with a more severe disability will need more intensive support
and supervision his or her entire life.

The limitations of cognitive function will cause a child to learn and develop more
slowly than a typical child. Children may take longer to learn to speak, walk, and take
care of their personal needs such as dressing or eating. Learning will take them longer,
require more repetition, and there may be some things they cannot learn. The extent of
the limits of learning is a function of the severity of the disability.

Nevertheless, virtually every child is able to learn, develop, and grow to some extent.

Diagnosis

According to the latest edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV), there are three criteria before a person is considered to have a
developmental disability: an IQ below 70, significant limitations in two or more areas of
adaptive behavior (i.e., ability to function at age level in an ordinary environment), and
evidence that the limitations became apparent in childhood.

1. IQ below 70

IQ tests were created as an attempt to measure a person's abilities in several areas,

including language, numeracy and problem-solving. The average score is 100. People
with a score below 75 will often, but not always, have difficulties with daily living skills.
 Since factors other than mental ability (depression, anxiety, lack of adequate effort,
cultural differences, etc.) can yield low IQ scores, it is important for the evaluator to rule
them out prior to concluding that measured IQ is "significantly below average".

The following ranges, based on the Wechsler Adult Intelligence Scale (WAIS), are
in standard use today:

Class IQ

Profound mental retardation Below 20

Severe mental retardation 20–34

Moderate mental retardation 35–49

Mild mental retardation 50–69

Borderline mental retardation 70–79

2. Significant limitations in two or more areas of adaptive behavior

Adaptive behavior, or adaptive functioning, refers to the skills needed to live

independently (or at the minimally acceptable level for age).

To assess adaptive behavior, professionals compare the functional abilities of a child

to those of other children of similar age. To measure adaptive behavior, professionals use
structured interviews, with which they systematically elicit information about the person's
functioning in the community from someone who knows them well. There are many
adaptive behavior scales, and accurate assessment of the quality of someone's adaptive
behavior requires clinical judgment as well. Certain skills are important to adaptive
behavior, such as:

• Daily living skills, such as getting dressed, using the bathroom, and feeding
oneself.
• Communication skills, such as understanding what is said and being able to
answer.
• Social skills with peers, family members, spouses, adults, and others.
3. Evidence that the limitations became apparent in childhood

This third condition is used to distinguish it from similar conditions such as Alzheimer's
disease or is due to traumatic injuries that damaged the brain.

Causes

Down syndrome, fetal alcohol syndrome and Fragile X syndrome are the three most
common inborn causes. However, doctors have found many other causes. The most
common are:

• Genetic conditions. Sometimes disability is caused by abnormal genes inherited

from parents, errors when genes combine, or other reasons.
• Problems during pregnancy. Mental disability can result when the fetus does not
develop inside the mother properly. For example, there may be a problem with the
way the fetus's cells divide as it grows. A woman who drinks alcohol (see fetal
alcohol syndrome) or gets an infection like rubella during pregnancy may also
have a baby with mental disability.
• Problems at birth. If a baby has problems during labor and birth, such as not
getting enough oxygen, he or she may have developmental disability due to brain
damage.
• Health problems. Diseases like whooping cough, measles, or meningitis can cause
mental disability. It can also be caused by not getting enough medical care, or by
being exposed to poisons like lead or mercury.
• Iodine deficiency, affecting approximately 2 billion people worldwide, is the
leading preventable cause of mental disability in areas of the developing world
where iodine deficiency is endemic.
• Malnutrition is a common cause of reduced intelligence in parts of the world
affected by famine, such as Ethiopia.
• The use of forceps during birth can lead to mental retardation in an otherwise
normal child. They can fracture the skull and cause brain damage.
• Institutionalization at a young age can cause mental retardation in normal
children.
• Sensory deprivation in the form of severe environmental restrictions (such as
being locked in a basement or under a staircase), prolonged isolation, or severe
atypical parent-child interactions.

Treatment and assistance

By most definitions mental retardation is more accurately considered a disability

rather than a disease. MR can be distinguished in many ways from mental illness, such as
schizophrenia or depression. Currently, there is no "cure" for an established disability,
though with appropriate support and teaching, most individuals can learn to do many
things.

Although there is no specific medication for "mental retardation", many people

with developmental disabilities have further medical complications and may take several
medications. Beyond that there are specific programs that people with developmental
disabilities can take part in wherein they learn basic life skills. These "goals" may take a
much longer amount of time for them to accomplish, but the ultimate goal is
independence. This may be anything from independence in tooth brushing to an
independent residence. People with developmental disabilities learn throughout their lives
and can obtain many new skills even late in life with the help of their families, caregivers,
clinicians and the people who coordinate the efforts of all of these people.

II- Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder (ADHD) is a condition that becomes

apparent in some children in the preschool and early school years. It is hard for these
children to control their behavior and/or pay attention. It is estimated that between 3 and
5 percent of children have ADHD, or approximately 2 million children in the United
States. This means that in a classroom of 25 to 30 children, it is likely that at least one
will have ADHD.

Signs and Symptoms

The principal characteristics of ADHD are inattention, hyperactivity, and

impulsivity. These symptoms appear early in a child’s life. Because many normal
children may have these symptoms, but at a low level, or the symptoms may be caused by
another disorder, it is important that the child receive a thorough examination and
appropriate diagnosis by a well-qualified professional.

According to the most recent version of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR), there are three patterns of behavior that indicate ADHD.

People with ADHD may show several signs of being consistently inattentive.
They may have a pattern of being hyperactive and impulsive far more than others of their
age. Or they may show all three types of behavior. This means that there are three
subtypes of ADHD recognized by professionals. These are the predominantly
hyperactive-impulsive type (that does not show significant inattention); the
predominantly inattentive type (that does not show significant hyperactive-impulsive
behavior) sometimes called ADD—an outdated term for this entire disorder; and the
combined type (that displays both inattentive and hyperactive-impulsive symptoms).

Hyperactivity-Impulsivity

Hyperactive children always seem to be “on the go” or constantly in motion. They dash
around touching or playing with whatever is in sight, or talk incessantly. Sitting still at
dinner or during a school lesson or story can be a difficult task. They squirm and fidget in
their seats or roam around the room. Or they may wiggle their feet, touch everything, or
noisily tap their pencil. Hyperactive teenagers or adults may feel internally restless. They
often report needing to stay busy and may try to do several things at once.

Impulsive children seem unable to control their immediate reactions or think before they
act. They will often reveal out inappropriate comments, display their emotions without
restraint, and act without regard for the later consequences of their conduct. They may
grab a toy from another child or hit when they’re upset.

Some signs of hyperactivity-impulsivity are:

• Feeling restless, often fidgeting with hands or feet, or squirming while seated
• Running, climbing, or leaving a seat in situations where sitting or quiet
behavior is expected
• Blurting out answers before hearing the whole question
• Having difficulty waiting in line or taking turns.

Inattention

Children who are inattentive have a hard time keeping their minds on any one
thing and may get bored with a task after only a few minutes. If they are doing something
they really enjoy, they have no trouble paying attention. But focusing purposefully,
conscious attention to organizing and completing a task or learning something new is
difficult.

Homework is particularly hard for these children. They will forget to write down an
assignment, or leave it at school. They will forget to bring a book home, or bring the
wrong one. The homework, if finally finished, is full of errors and erasures. Homework is
often accompanied by frustration for both parent and child.

The DSM-IV-TR gives these signs of inattention:

• Often becoming easily distracted by irrelevant sights and sounds

• Often failing to pay attention to details and making careless mistakes
• Rarely following instructions carefully and completely losing or forgetting
things like toys, or pencils, books, and tools needed for a task
• Often skipping from one uncompleted activity to another.

Children diagnosed with the Predominantly Inattentive Type of ADHD are seldom
impulsive or hyperactive, yet they have significant problems paying attention. They
appear to be daydreaming, “spacey,” easily confused, slow moving, and lethargic. They
may have difficulty processing information as quickly and accurately as other children.
When the teacher gives oral or even written instructions, this child has a hard time
understanding what he or she is supposed to do and makes frequent mistakes.
 These children don’t show significant problems with impulsivity and overactivity in
the classroom, on the school ground, or at home. They may get along better with other
children than the more impulsive and hyperactive types of ADHD, and they may not have
the same sorts of social problems so common with the combined type of ADHD. So often
their problems with inattention are overlooked. But they need help just as much as
children with other types of ADHD, who cause more obvious problems in the classroom.

Treatment of ADHD

For children with ADHD, no single treatment is the answer for every child. A child
may sometimes have undesirable side effects to a medication that would make that
particular treatment unacceptable. And if a child with ADHD also has anxiety or
depression, a treatment combining medication and behavioral therapy might be best.
Each child’s needs and personal history must be carefully considered.

• The medications that seem to be the most effective are a class of drugs known as
stimulants.

• Medications for ADHD help many children focus and be more successful at
school, home, and play. Avoiding negative experiences now may actually help
prevent addictions and other emotional problems later.

• About 80 percent of children who need medication for ADHD still need it as
teenagers. Over 50 percent need medication as adults.

III- Eating Disorders: Anorexia and Bulimia

Teenagers are not always known for having 3 full nutritional meals a day,
especially with their busy schedules. Parents are often working, trying to keep up with
their own and their children’s busy schedules. When the family becomes so busy and
scheduled, it can be difficult to note when a family member is not eating sufficiently to
nourish their bodies. Usually changes in eating patterns occur over a period to time and
are often noted only when they become severe and out of control. The following
information is offered to assist families in evaluating possible eating problems before
they become serious or out of control.

Warning Signs for Anorexia

1. Loss of weight Note serious loss of weight would be a loss that is less than 85%
of what a person’ weight should be for their age and height. Pediatricians are
aware of these growth guidelines.
2. Intense fear of gaining weight
3. A misperception of the size and shape of their body. They will express they feel
fat where most others believe the person looks fine and or may even be
significantly underweight.
4. Loss of menstrual periods.
 5. Food restriction through dieting, fasting, counting calories excessively, refusing
all fats, refusing all meats with no other protein substitution.
6. Excessive exercising- often obsessed with the need to exercise excessively.
7. Misuse of laxatives, diuretics and enemas.
8. May be obsessed with food, collecting recipes or hoarding food while continuing
to personally restrict their own food.
9. An occasional period of binge eating or self-induced vomiting.

Warning Signs for Bulimia

1. Binge eating where an excessive amount of food is consumed in a short period of

time, usually less than 2 hours.
2. Feeling ashamed for their eating problems so begin to secretly eat.
3. Self-induced vomiting after a binge episode of eating. One’s fingers, toothbrushes
or other items that induce the gag reflex are often used.
4. Fasting or excessive exercising
5. A feeling of being out of control to stop the eating episode.
6. Misuse of diuretics, laxatives and enemas.
7. Self evaluation is heavily based on their body shape and weight.

Treatment

These warning signs are only clues to guide a person towards help. Once a person
receives treatment the focus is on balancing food intake to a nutritionally supportive level
and reconnecting with feelings. Often when one feels overwhelmed, they tend to push
away what they feel, try to forget and keep moving forward trying to do your best. When
this pattern of struggling on continues and one is not able to address what is important, a
person can disconnect, devalue what is important to them almost to a point of insisting
nothing is wrong. When this occurs, there is often not a conscious awareness but more a
feeling--- and that feeling is one of fearing loss of control.

Successful treatment for one with an eating problem needs to balance proper nutrition
with proper emotional care of oneself.

IV- Depression

Definition: Depression is a serious health problem that affects people of all ages,
including children and adolescents. It is the persistent experience of a sad or irritable
mood and the loss of interest or pleasure in nearly all activities. These feelings are
accompanied by a range of additional symptoms affecting appetite and sleep, activity
level and concentration, and feelings of self-worth.

Depression is a form of mental illness that affects the whole body — it impacts the
way one feels, thinks and acts. If left untreated, depression can lead to school failure,
alcohol or other drug use, and even suicide.
 The prevalence in childhood is estimated to be 2 % and increase up to 6 % in
adolescent and adulthood.

Causes

As in adults, depression in children can be caused by any combination of factors that

relate to physical health, life events, family history, environment, genetic vulnerability,
and biochemical disturbance.

Signs and Symptoms of Depression in Children Include:

• Irritability or anger
• Continuous feelings of sadness, hopelessness
• Social withdrawal
• Increased sensitivity to rejection
• Changes in appetite -- either increased or decreased
• Changes in sleep -- sleeplessness or excessive sleep
• Vocal outbursts or crying
• Difficulty concentrating
• Fatigue and low energy
• Physical complaints (such as stomachaches, headaches) that do not respond to
treatment
• Reduced ability to function during events and activities at home or with
friends, in school, extracurricular activities, and in other hobbies or interests
• Feelings of worthlessness or guilt
• Impaired thinking or concentration
• Thoughts of death or suicide

Not all children have all of these symptoms. In fact, most will display different
symptoms at different times and in different settings. Although some children may
continue to function reasonably well in structured environments, most kids with
significant depression will suffer a noticeable change in social activities, loss of interest
in school and poor academic performance, or a change in appearance. Children may also
begin using drugs or alcohol, especially if they are over the age of 12.

Treatment Options

Treatment options for children with depression are similar to those for adults,
including psychotherapy (counseling) and medicine. The role that family and the child's
environment play in the treatment process is different from that of adults.

Children with bipolar disorder are usually treated with psychotherapy and a
combination of medicines, usually an antidepressant and a mood stabilizer. Use of an
antidepressant alone can trigger bouts of mania.