INTRODUCTION

Mental health is an important part of overall health for children as well as adults. For many
adults who have mental disorders, symptoms were present—but often not recognized or
addressed—in childhood and adolescence. For a young person with symptoms of a mental
disorder, the earlier treatment is started, the more effective it can be. Early treatment can help
prevent more severe, lasting problems as a child grows up.

CHILDHOOD PSYCHIATRIC DISORDERS

 Psychiatric disorders among children are described as serious changes in the way children
typically learn, behave, or handle their emotions, which cause distress and problems
getting through the day
 They are ‘disorders of psychological development’ and ‘behavioural and emotional
disorders with onset usually occurring in childhood and adolescence

CLASSIFICATION
1. Mental retardation
2. Specific developmental disorders
3. Pervasive developmental disorders
4. Disruptive behavioral disorders
a) Oppositional defiant disorder
b) Attention deficit hyperactivity disorder (ADHD)
c) Conduct disorders
5. Anxiety disorders.

I. MENTAL RETARDATION

Definition:

Mental retardation is defined as significantly sub-average general intellectual functioning,

associated with significant deficit or impairment in adaptive functioning, which manifests
during the developmental period (before 18 years of age).

Classification of Mental Retardation by IQ:

A. Mild Mental Retardation

 This is the commonest type of mental retardation, accounting for 85-90% of
all cases.
 Have IQ between 50-70
 In the preschool period (before 5 years of age) often develop like other normal
children, with very little deficit.
 Later often progress up to the 6th class (grade) in school and can achieve
vocational and social self-sufficiency with a little support.

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  Supervised care may be needed only under stressful conditions or in the
presence of an associated disease.
 This group has been referred to as ‘educable’ in a previous educational
classification of mental retardation
B. Moderate Mental Retardation
 Have an IQ between 35 and 50
 This group was earlier called as ‘trainable’, although many of these persons
can also be educated
 Despite a poor social awareness, these children can learn to speak
 Often, they drop out of school after the 2nd class (grade)
 They can be trained to support themselves by performing semiskilled or
unskilled work under supervision.
 A mild stress may destabilise them from their adaptation; thus they work best
in supervised occupational settings.
C. Severe Mental Retardation
 Have an IQ between 20-35
 Recognised early in life with poor motor development (significantly delayed
developmental milestones) and absent or markedly delayed speech and other
communication skills.
 They can perform simple tasks under close supervision.
 In the earlier educational classification, they were called as ‘dependent’
D. Profound Mental Retardation
 Associated physical disorders often contribute to mental retardation in this
subtype.
 The achievement of developmental mile stones is markedly delayed.
 They often need nursing care or ‘life support’ under a carefully planned and
structured environment (such as group homes or residential placements).

Mental Retardation Level IQ Range

Mild 50-70
Moderate 35-50
Severe 20-35
Profound <20

(*As intelligence tests employed to measure IQ generally have an error of measurement of

about 5 points, each figure means ± 5 points, e.g. IQ of 50 means an IQ of 50 ± 5, depending
on the adaptive behaviour).

Causes of Mental Retardation:

1. Genetic

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 i. Chromosomal abnormalities (such as Down’s syndrome, Fragile-X syndrome,
Turner’s syndrome, Klinefelter’s syndrome)
ii. Inborn errors of metabolism, involving aminoacids (phenylketonuria, homo-
cystinuria, Hartnup’s disease), lipids (Tay-Sachs disease, Gaucher’s disease,
Niemann-Pick disease),carbohydrates (galactosaemia, glycogen storage
diseases), purines (Lesch-Nyhan syndrome),and mucopolysaccharides
(Hurler’s disease, Hunter’s disease, Sanfillipo’s disease)
iii. Single-gene disorders (such as tuberous sclerosis, neurofibromatosis,
dystrophia myotonica)
iv. Cranial anomalies (such as microcephaly)

2. Perinatal causes
i. Infections (such as rubella, syphilis, toxoplasmosis, cytomegalo-inclusion
body disease)
ii. Prematurity
iii. Birth trauma
iv. Hypoxia
v. Intrauterine growth retardation (IUGR)
vi. Kernicterus
vii. Placental abnormalities
viii. Drugs during first trimester.

3. Acquired physical disorders in childhood

i. Infections, especially encephalopathies
ii. Cretinism
iii. Trauma
iv. Lead poisoning
v. Cerebral palsy.

4. Sociocultural causes
i. Deprivation of sociocultural stimulation.

5. Psychiatric disorders
i. Pervasive developmental disorders (such as Infantile autism)
ii. Childhood onset schizophrenia.

Management

The management of mental retardation can be discussed under prevention at primary,

secondary and tertiary levels.

I. Primary Prevention

This consists of:

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 1. Improvement in socioeconomic condition of society at large, aiming at elimination of
under-stimulation, malnutrition, prematurity and perinatal factors.
2. Education of lay public, aiming at removal of the misconceptions about individuals
with mental retardation.
3. Medical measures for good perinatal medical care to prevent infections, trauma,
excessive use of medications, malnutrition, obstetric complications, and diseases of
pregnancy.
4. Universal immunisation of children with BCG, polio, DPT, and MMR.
5. Facilitating research activities to study the causes of mental retardation and their
treatment.
6. Genetic counselling in at-risk parents, e.g. in phenylketonuria, Down’s syndrome.

II. Secondary Prevention

1. Early detection and treatment of preventable disorders, e.g. phenylketonuria (low

phenylalanine diet), maple syrup urine disease (low branched amino-acid diet) and
hypothyroidism (thyroxine).
2. Early detection of handicaps in sensory, motor or behavioural areas with early
remedial measures and treatment.
3. Early treatment of correctable dis orders, e.g. infections (antibiotics), skull
configuration anomalies (surgical correction).
4. Early recognition of presence of mental retardation. A delay in diagnosis may cause
unfortunate delay in rehabilitation.
5. As far as possible, individuals with mental retardation should be integrated with
normal individuals in society, and any kind of segregation or discrimination should be
actively avoided. They should be provided with facilities to enable them to reach their
own full potential. However, there is a role of special schools for those with more
severe mental retardation.

III. Tertiary Prevention

1. Adequate treatment of psychological and behavioural problems.

2. Behaviour modification, using the principles of positive and negative reinforcement.
3. Rehabilitation in vocational, physical, and social areas, commensurate with the level
of handicap.
4. Parental counselling is extremely important to lessen the levels of stress, teaching
them to adapt to the situation, enlisting them (especially parents) as co-therapists, and
encouraging formation of parents’ or carers’ organisation (s) and self-help groups.
5. Institutionalisation or residential care may be needed for individuals with profound
mental retardation.
6. Legislation:
a) In 1995, the ‘Persons with Disability Act’ came in to being in India. This act
envisages mandatory support for prevention, early detection, education,
employment, and other facilities for the welfare of persons with disabilities in

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 general, and mental retardation in particular. This Act provides for affirmative
action and non-discrimination of persons with disabilities.
b) In 1999, the ‘National Trust Act’ came in to force. This Act proposes to
involve the parents of mentally challenged persons and voluntary
organisations in setting up and running a variety of services and facilities with
govern mental funding.

II. SPECIFIC DEVELOPMENTAL DISORDERS

The deficit in functioning may be in scholastic skills, speech and language, and motor skills.
These may include

» Reading (develop mental reading disorder)

» Language (develop mental language disorder)
» Arithmetic or mathematics (developmental arithmetic or mathematics disorder)
» Articulation (developmental articulation disorder or phonological disorder)
» Coordination (developmental coordination dis order)

1. Specific Reading Disorder

 Also called as developmental reading disorder or dyslexia
 Child presents with a serious delay in learning to read which is evident from the
early years
 Problems may include omissions, distortions, or substitutions of words, long
hesitations, reversal of words, or simply slow reading
 Writing and spelling are also impaired

2. Specific Arithmetic Disorder

 Also called as developmental arithmetic disorder or developmental mathematic
disorder or dyscalculia
 Child presents with arithmetic abilities well below the level expected for the
mental age
 Problems may include
 Failure to understand simple mathematical concepts
 Failure to recognise mathematical signs or numerical symbols
 Difficulty in carrying out mathematical manipulations
 Difficulty in learning mathematical tables

3. Specific Developmental Disorder of Speech and Language

 Also called as developmental language disorder, developmental communication
disorder, or dysphasia.
 There are three main types:
i. Phonological disorder
 Also called as dyslalia

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  Characterised by below par accuracy in the use of speech sounds
despite normal language skills.
 The problems include severe articulation errors that make it
difficult for others to understand the speech.
 Speech sounds or phonemes are omitted, distorted or substituted
(e.g. wabbit for rabbit, ca for car, bu for blue).

ii. Expressive language disorder

 Characterised by a below par ability of using expressive speech.
 Problems include
 Restricted vocabulary
 Difficulty in selecting appropriate words
 Immature grammatical usage
 Cluttering of speech may also be present

iii. Receptive language disorder

 Often presents as a receptive-expressive language disorder and
both receptive and expressive impairments are present together.
 Characterised by a below par understanding of language.
 Problems include failure to respond to simple instructions
 Important to rule out deafness and pervasive developmental
disorder.

4. Specific Developmental Disorder of Motor Function

 Also called as motor skills disorder, developmental coordination disorder, clumsy
child syndrome or motor dyspraxia.
 Characterised by poor coordination in daily activities of life, e.g. in dressing,
walking, feeding, and playing.
 There is an inability to perform fine or gross motor tasks.

Management

 The treatment of specific developmental disorders is based on learning theory

principles and is behavioural in approach.
 It involves use of special remedial teaching, focusing on the under lying deficit (for
example, perceptual motor training in motor skills disorder).
 The treatment of common co-morbid emotional problems is often necessary.
 Parental education and counselling are important components of good management.

III. PERVASIVE DEVELOPMENTAL DISORDERS (PDD)

PDD includes childhood autism, atypical autism, Rett's Syndrome and Asperger's syndrome,

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A. Childhood autism
 Developmental disability that can cause significant social, communication and
behavioral challenges
 Characteristics includes:
1) Behavioral characteristics
 Stereotyped behaviours such as head-banging, body-spinning, hand-flicking,
lining-up objects, rocking, clapping, twirling, etc.
 Ritualistic and compulsive behaviour.
 Resistance to even the slightest change in the environment.
 Attachment may develop to inanimate objects.
 Hyperkinesis is commonly associated

2) Communication and language

 Lack of verbal or facial response to sounds or voices; might be thought as
deaf initially.
 In infancy, absences of communicative sounds like babbling.
 Absent or delayed speech (about half of autistic children never develop
useful speech).
 Abnormal speech patterns and content.
 Presence of echolalia, perseveration, poor articulation and pronominal
reversal (I-You) is common.
 Rote memory (memory for material without much reference to the meaning,
emotions, or to the context to which it is associated) is usually good.
 Abstract thinking is impaired

3) Activities
 Marked impairment in reciprocal social and interpersonal interaction
 Absent social smile.
 Lack of eye-to-eye-contact.
 Lack of awareness of others’ existence or feelings; treats people as furniture.
 Lack of attachment to parents and absence of separation anxiety.
 No or abnormal social play; prefers solitary games.
 Marked impairment in making friends.
 Lack of imitative behaviour.
 Absence of fear in presence of danger

4) Other features
 Moderate to profound mental retardation
 Particularly enjoy music
 Epilepsy is common in children with an IQ of less than 50
 Over-responsive or under-responsive to sensory stimuli
 May have a heightened pain threshold or an altered response to pain

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  Idiot Savant Syndrome: Inspite of a pervasive or abnormal development
of functions, certain functions may remain normal, e.g. calculating
ability, prodigious remote memory, musical abilities, etc.
 Kanner's "Autistic triad"- Kanner said autistic aloofness, speech and
language disorder and obsessive desire for sameness constitute a triad
characteristic of infantile autism

B. Atypical autism
 A pervasive developmental disorder that differs from autism in terms of either age of
onset or failure to fulfil diagnostic criteria i.e. disturbance in reciprocal social
interactions, communication and restrictive stereotyped behavior.
 Atypical autism is seen in profoundly retarded individuals

C. Rett’s syndrome
 A condition of unknown cause, reported only in girls.
 It is characterized by apparently normal or near-normal early development which is
followed by partial or complete loss of acquired hand skills and of speech, together
with deceleration in head growth
 Onset is between 7 and 24 months of age.

D. Asperger’s syndrome
 The condition is characterized by severe and sustained abnormalities of social
behavior similar to those of childhood autism with stereotyped and repetitive
activities and motor mannerisms such as hand and finger-twisting or whole body
movements.
 It differs from autism in that there is no general delay or retardation of cognitive
development or language.

Treatment

The treatment consists of three modes of intervention which are often used together.

1. Behaviour Therapy
i. Development of a regular routine with as few changes as possible.
ii. Structured class room training, aiming at learning new material and maintenance
of acquired learning.
iii. Positive reinforcements to teach self-care skills.
iv. Speech therapy and/or sign language teaching.
v. Behavioural techniques to encourage interpersonal interactions.

2. Psychotherapy
 Parental counselling and supportive psychotherapy can be very useful in allaying
parental anxiety and guilt, and helping their active involvement in therapy.

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  Overstimulation of child should be avoided during treatment.

3. Pharmacotherapy

Drug treatment can be used for treatment of autism as well as for treatment of co-morbid
epilepsy.

i. Haloperidol decreases dopamine levels in brain. It is believed to decrease hyper

activity and behavioural symptoms.
ii. Risperidone, an atypical antipsychotic, is helpful in some patients and is licensed in
some countries for treatment of autism in children aged 5 and above.

 Both haloperidol and risperidone can cause extrapyramidal side-effects (EPSE),

though usually more with haloperidol. The starting dose for Risperidone is usually
0.25-0.5 mg (based on body weight), with a dose range of 0.02-0.06 mg/kg/day.

iii. Anticonvulsant medication is used for the treatment of generalised or other seizures, if
present.

IV. DISRUPTIVE BEHAVIORAL DISORDERS

Disruptive behavioral disorder includes children who display a broad range of behaviors that
bring them into conflict with their environment and display age-inappropriate actions and
attitudes that violate family expectations, societal norms, and personal property rights of
others.

Types:

a) Oppositional defiant disorder

b) Attention deficit hyperactivity disorder
c) Conduct disorders

1. Oppositional Defiant Disorder

Definition:
ODD is a behavioral disorder characterized by an ongoing pattern of defiant, disobedient
and hostile behaviour beginning in childhood or adolescence.
Symptoms:
 Loses temper
 Argues with adult
 Actively defiant
 Deliberately annoying
 Easily annoyed
 Blames others
 Often angry

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  Spiteful and vindictive

2. Attention Deficit Hyperactivity Disorder (ADHD)

Definition:
Attention Deficit Hyperactivity Disorder or ADHD is a persistent pattern of inattention,
impulsivity and hyperactivity more frequent and severe than is typical of children at a
similar level of development.

Characters:
The characteristic clinical features are:
A. Poor attention span with distractibility
a. Fails to finish the things started
b. Shifts from one uncompleted activity to another
c. Doesn’t seem to listen
d. Easily distracted by external stimuli
e. Often loses things.
B. Hyperactivity
a. Fidgety
b. Difficulty in sitting still at one place for long
c. Moving about here and there
d. Talks excessively
e. Interference in other people’s activities.
C. Impulsivity
a. Acts before thinking, on the spur of the moment.
b. Difficulty in waiting for turn at work or play.

Management:

1) Pharmacotherapy
 CNS stimulants: Dextroamphetamine, methylphenidate,
 Tricyclic antidepressants
 Antipsychotics
 Barbiturates are contraindicated in ADD as they increase hyperactivity.
2) Psychological therapies
 Behavior modification techniques
 Cognitive behavior therapy
 Social skills training


3. Conduct Disorders
Definition:
Conduct disorder is characterized by a persistent and significant pattern of conduct, in
which the basic rights of others are violated or rules of society are not followed.

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 Characteristics:
The characteristic clinical features include:
a. Frequent lying.
b. Stealing or robbery.
c. Running away from home and school (Truancy)
d. Physical violence such as rape, fire-setting, assault or breaking-in, use of
weapons.
e. Cruelty towards other people and animals.

Management of disruptive behavioral disorders:

Treatment of disruptive behavior disorders is usually multifaceted. It may include:

1) Parental education: Parents should be taught how to communicate with and manage
their children.
2) Functional Family Therapy: The entire family is helped to improve communication
and problem solving skills.
3) Cognitive Behavior Therapy: Cognitive behavior therapy helps the child to control
their thoughts and behavior.
4) Social training: The child is taught important social skills like having a conversation
or playing cooperatively with others.
5) Anger management: The child is taught how to recognize the signs of growing
frustration and taught coping skills designed to manage anger and aggression.
Relaxation techniques and stress management skills are taught to them.
6) Encouragement: Many children with behavior disorders experience repeated failures
at school and in their interaction with others. Encouraging the child to excel in their
particular talent like sports can help to build self -esteem.
7) Medications: For ADHD, stimulant medications like dextroamphetamine (10-40
mg/day), methyl phenidate (10-60 mg/day) and magnesium pemoline (37.5-115
mg/day) are the treatment of choice. They act on the reticular activating system,
causing stimulation of inhibitory influences on cerebral cortex, thus decreasing
hyperactivity and/or distractibility.
In case of conduct disorder, drug treatment may be needed in presence of epilepsy
(anticonvulsants), hyperactivity (stimulant medication), impulse control disorder,
episodic aggressive behavior (lithium, carbamazepine) and psychotic symptoms
(antipsychotics).

V. ANXIETY DISORDERS

Anxiety is defined as a state of apprehension or unease arising out of anticipation of danger.It

is a normal phenomenon, but it becomes pathological when it causes significant subjective
distress or impairment in functioning of the individual

Types of anxiety disorder in children:

 Separation anxiety disorder

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  Phobic anxiety disorder
 Social anxiety disorder

1. Separation anxiety disorder

» Presence of excessive anxiety concerning separation from those individuals to
whom the child is attached is called separation anxiety
» Features of separation anxiety are:
 Unrealistic worries about possible harm befalling major attachment figures
or fear that they will leave and not return.
 Persistent reluctance or refusal to go to sleep without being near or next to
a major attachment figure.
 Persistent inappropriate fear of being alone
 Repeated nightmares
 Repeated occurrence of physical symptoms e.g. nausea, stomach-ache,
headache, etc., on
2. Phobic anxiety disorder
» A disabling and irrational fear of some object, situation or activity is called phobia
» It leads to avoidance of the feared object or situation and causes extreme feeling
of terror, dread , anxiety and may restrict one’s life
» Minor phobic symptoms are common in childhood and usually concern animals,
insects, darkness, school and death.
3. Social anxiety disorder
» Social anxiety is the difficulty of children, could be as young as 4 years, upon
interacting with others, which makes them shy and obedient in classes, reluctant to
join any class groups and most frequently avoiding any social gatherings or
situations
» Encourage children to join social groups and interact with other children,
otherwise the situation gets worse by the passing of years.
» Don’t force the child to do something in front of others.
» This would make them even more uncomfortable, they need time and a gentle
encouragement is always the right way.

Management:

a. Individual counseling
 This is often useful to give the child an opportunity to understand the basis for
anxiety and also to teach the child some strategies for anxiety management.
b. Parental counseling
 Parental counseling is needed when there is evidence that they are overanxious
or over-protective about the child.
 They should be persuaded to allow the child more autonomy.
c. Family therapy
 It is often needed when the child's disorder appears to be related to the family
system.

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  Treatment is designed to promote healthy functioning of the family system.
d. Pharmacological management
 Anxiolytic drugs such as diazepam may be needed occasionally when anxiety
is extremely severe, but they should be used for short periods only.

NURSING ROLE AND MANAGEMENT IN CHILD PSYCHIATRY

» Establishing a therapeutic relationship with the patient.
» Providing an opportunity for the patient to release tension as problem are discussed.
» Assisting the patient in gaining insight about the problem.
» Providing opportunity to practice new skills.
» Reinforcing appropriate behavior as it occurs.
» Providing consistent emotional support.
» Assessing the child and understand his strengths and abilities.
» Monitor the child’s developmental levels and initiate supportive interventions such as
speech, language or occupational skills as needed.
» Provide a safe therapeutic environment.
» Teach the child adaptive skills such as eating, dressing, grooming and toileting.
» Deliver psycho education and medication management, participate in therapies
» Teaching the patient and family regarding nutrition, exercise, hygiene and the
relationship between physical and emotional health.
» Teach stress management and daily living skills

CONCLUSION
Childhood is the most beautiful of all life’s seasons. Children with psychiatric disorders are
not outcast. They need affection, attention and understanding. Treatment and management of
the disorders at an early age and early identification is vital for the result of a fruitful life
despite the disorders.

REFERENCE
1. A Padmaja, “Textbook of Child Health Nursing”, 1st edition, 2016, Jaypee Publications
2. Ahuja Niraj, ‘A short textbook of Psychiatry’, 7th edition, 2011, Jaypee publishers
3. Datta Parul, ‘Paediatric Nursing’,2018, 4th Edition, Jaypee brothers’ medical publishers
4. Hockenberry, “Wong’s nursing care of infants and children”, 2003, 7th edition, Elsevier.
5. Padmaja A, “Textbook of child health nursing”, 2016, Jaypee, New Delhi.
6. Sharma Rimple, “Essentials of paediatric Nursing”, 2021, 3rd edition, Jaypee, New Delhi.
7. Sreevani R, ‘A Guide to mental health and psychiatric nursing’, 2 nd edition, Jaypee
publishers.
8. www.who.int
9. www.nimh.nih.gov

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