Noor Ul Huda

213502263
Course: Child Psychopathology
Submitted to: Ms. Wajiha Zahra
Forman Christian College (A Chartered University)
 Introduction

This paper aims to review the nature of problems and how they may be defined as disorders. It

shall include a brief overview of predominant problems which are more prevalent among

children followed by a comprehensive differential diagnosis and assessment.

Childhood is marked by a plethora of developmental changes where marked differences

can be seen in the personality and behavior with time. It becomes an instant of concern when

behaviours and responses exhibited by children are out of proportion, inconsistent with the

context or absent altogether. Many developmental delays, prenatal risks and conditions,

significant life changes, environmental factors etc. are consistent in the profiling of emotional

and behavioural problems occurring in childhood. It is often misunderstood and misconceived

that when a problem must be characterized as a disorder. In order to understand the extent of

severity for a problem to qualify as a disorder, psychologists have come up with various

standards and criterion to effectively assess abnormality and provide treatment accordingly. Four

D’s of abnormality are the fundamental and rudimentary standards to assess abnormality. These

include deviance, dysfunction, distress and danger (Barlow, Durand, & Stewart, 2009).  If these

four are causing a hindrance in maintaining normality e.g. an child suffering from kleptomania

fulfills the criteria of breaking the rules, disruption of normal functioning where his interpersonal

relations get affected as result of his impulse of stealing, not being able to control the impulse

may cause him/her significant distress it extends towards the significant others as well. Lastly,

danger may be seen in aspects where the child puts himself or others in danger in order to act

upon his urge of stealing. Despite the belief that childhood is a stage where children do not have

extensive responsibilities and associated stresses, it is believed that children in most cultures are

likely to encounter some amount of emotional or behavioural problems during their course of
childhood and adolescence. Bedwetting is commonly associated with precursor of fear while the

transformations and evolution of personality occurring in adolescence can be related with stress,

anxiety and depression.

Prevalence of behavioural and emotional problems among school children in

Pakistan was noted following a telephonic survey. In their study of 800 cases of public schools,

an overall prevalence for behavioural problems was noted to be 15.9% while the estimates for

conducts problems constituted 26.6%. Emotional Problems were 22.9% while 5% accounted for

social and hyperactivity problems (Malik, Siddiqui, & Mahmood, 2019). Another research

reports a 9.3% prevalence of behavioural and emotional problems among young children in

Pakistan (Javed, Kundi, & Khan, 1992). Dearth of research and investigation in this regard calls

out for extensive research and surveys on national level in order to bridge the gap. Standards

being widely used to carry out diagnosis are Diagnostic and Statistical Manual of Mental

Disorders, 5th Edition: DSM-5 and International Statistical Classification of Diseases and

Related Health Problems (ICD). These provide an overview for all the disorders, their symptoms,

duration, consistency, developmental course, differential diagnosis, risk factors etc. Challenging

behaviors can be explained in terms of behaviours which share discrepancies with normal

behavioural patterns within a culture in terms of their age, severity, frequency and the risk

involved as a result such as self-injurious behavior, physical or verbal manifestation of anger,

unsuitable vocalizations, and stereotypical movements or vocalizations etc. The behaviours are

most commonly identified as soon as they act as an impetus towards the disruption of

environment, hinder child’s learning, and participation through every day activities. The extent

of support required for the condition is sometimes considered as a means to differentiate between

conditions e.g. Intellectual Disability (American Psychiatric Association, 2013). Sometimes

challenging behaviours are acquired along with development of another disorder which these

children adapt to the changes in their environment e.g. a child with a speech sound disorder

might exhibit aggression as he/she is likely to experience persistent difficulty with sound

production while communicating or alternatively a child may withdraw from expressing needs

altogether in order to avoid communication (NICE, 2015). The next section provides an

overview of disorders with an explanation of behaviors an emotional problems associated, their

assessment and treatment. Profiles for disorders, assessment procedures, treatment options have

been cited using the DSM-5 and Child Clinician’s Handbook.

Disorders

Attention Deficit Hyperactivity disorder (ADHD) 314.0X (F90.X). It is an amalgam of

behaviours which involve impulsivity, hyperactivity and inattention which are likely to disrupt a

child’s daily life activities. ADHD is increasingly prevalent in males as compared to females.

Overall prevalence ranges from 5-8 percent among children. According to DSM 5 (American

Psychiatric Association, 2013), ADHD is diagnosed when six or more symptoms related to

inattention, hyperactivity or impulsivity are established as inhibitors in carrying out daily

functional activities. These symptoms are alarming when they are inconsistent with the

developmental age and have persisted for a minimum of six months. Symptoms must be visible

before the age of 12 and must be seen in at least two contexts e.g. home, classroom etc. It is

important to rule out that the symptoms are not a presentation of any other disorder, structural

deficit or any other injury and make sure that the disruption is bringing about significant

impairments in social, functional and occupational (if applicable) life. Where genetically an

individual may be predisposed to having ADHD, a number of environmental factors may be

associated with ADHD such as low birth weight, drug/alcohol consumption by mother during
pregnancy and exposure to lead etc. ADHD is typically diagnosed after the children start going

to school and impairment is significantly affecting academic achievement. Symptoms persist in

early adolescence except for some children-hyperactivity tends to reduce. Mannuzza, Klein,

Bonagura, Malloy, Giampino, & Addalli (1991) note that few children will not meet the

diagnostic criteria as they enter teenage however, will still have ADHD.

Symptoms of ADHD can be managed with treatment however, for many individuals the

disorder is carried forward in adulthood. Individuals with ADHD are likely to experience

persistent difficulty in maintaining on task attention, they find it difficult to comprehend and

follow the instructions ultimately not being able to finish the task. As far as both hyperactivity

and impulsivity are concerned, the behaviours encountered will be characterized by recurrent

fidgeting, moving in the chair, excessive talking and interruption during a conversation. Children

with this disorder encounter significant difficulty in waiting for their turn. Diagnosis is given

when there are at least six symptoms for each category. ADHD predominantly inattentive type is

when there are at least six symptoms for inattention however, ADHD hyperactive–impulsive is

when there are six or more hyperactive and impulsive symptoms and the criteria for inattention is

not full filled. A partial remission diagnosis for ADHD is also given when the symptoms have

not persisted for the past six months but the symptoms are causing significant impairment in

academic and occupational functioning.

Most suitable are behavioural therapies for children with mild symptoms and preschool

children in order to nurture compliant behavior and manage oppositional behavior. Other than

that, primarily psycho-education, cognitive behavioural therapy, interpersonal psychotherapy,

school based-intervention, social skills acquistion training etc. are significant in management of

ADHD. Exercise is often considered and proves to be effective when excessive hyperactivity is
to be managed. Medications in severe cases include psychostimulants, methylphenidate,

dexmethylphenidate and amphetamine. Sometimes clinicians consult nutritionists and suggest

that diet is must be monitored following less sugary foods and avoid intake of artificial foods.

Meta-analysis reveals that some foods if not consumed can prove to be helpful for the child who

are too young to receive medication and emphasized upon the necessity of fatty acid rich diet

(Bolea-Alamanac, Nutt, Adamou, Asherson, Bazire & Coghill, 2014; Pelsser, Frankena,

Toorman, & Rodrigues Pereira, 2017).

Oppositional Defiant Disorder, 313.81 (F91.3). It appears when a child exhibits

irritable or angry mood. They are consistently defiant and tend to be argumentative and

vindictive towards others (APA, 2013). The symptoms are presented in more than one setting

while the child experiences a difficult in forming positive social relationships. The behaviours

exhibited in ODD inhibit the child’s ability to perform to his/her maximum potential. Prevalence

is almost 1% to 16% based on the criteria. It is more common in males during early years of

childhood. DSM notes that ODD can be diagnosed when there is a consistent pattern of

‘negativistic, hostile and defiant behavior which can be explained by four or more symptoms

which emerge for at least six months’. Symptoms are characterized by display of losing temper,

defying or refusal to comply with requests made by adults and intentionally attempting to annoy

others. Children below the age of 5 years the behaviours must occur on most days. Contrarily,

for children above the age of five, behaviours must occur at least once a week. These behaviours

must, again, be beyond expectations for age level and frequency and significant social,

occupational, academic or functional impairment must be attributed with these disorders and are

not occurring due to a psychotic disorder. ODD usually occurs in children who are 8 years old.

Conduct Disorder (CD) 312.8x (F91.x). It is manifested through persistent

pattern of maladaptive behaviors which contradict social norms that are considered adequate and

appropriate for the age and their defining feature is that pattern is most likely to infringe upon

basic rights of other people. Most common behaviours encountered in CD are aggression,

outwards violence, vandalizing property of others, deceitfulness, breaking the law. The

behaviours are seen within the context of developmental age and in the light of the extent to

which they are causing serious impairment in social, occupational and academic functioning

(APA, 2013).

DSM-5’s criteria A for diagnosing CD requires evidence for a ‘repetitive pattern of

behavior which infringes upon the basic rights of other or expected norms according to age’.

These must exist in the form of atleast three of 15 criteria (e.g. Aggression to People and

Animals, Destruction of Property, Deceitfulness or Theft, Serious Violations of Rules) in the

previous 12 month period. Clinicians must specify if the CD is childhood onset type i.e.

Individuals show at least one symptom of CD before the age of 10. Adolescent-onset type is

specific if there is not display of characteristic symptom before the age of 10. Lastly, the

unspecified onset is when the diagnosis can be established however, age for onset of disorder is

not specified. Moreover, clinicians can also specify if the profile is accompanied with limited

prosocial emotions and for that at least two of the following must be present: Lack of

remorse/guilt, Callous, Unconcerned about performance and shallow. Severity can be seen in the

categories of mild, moderate and severe. Males are at a higher risk than females and the overall

prevalence is 2% to more than 10%. Onset is likely to occur in preschool years however,

pioneering symptoms emerge during the period from middle childhood through middle

adolescence. Early onset type is likely to hold a limited prognosis. The symptoms are likely to

mature with the age e.g. Childhood lyring and shoplifting might be manifested through
behaviours of rape and theft as adolescence and adults. Associated risk factors are parental

neglect, rejection, harsh discipline, lower than average intelligence, parental criminality, peer

rejection, socializing with a delinquent peer group, exposure to violence, having a biological or

an adoptive parent or a sibling with conduct disorder. Individuals are likely to experience

inconsistent academic patterns, legal difficulties, maladjustment with work, unsatisfactory

relationships and may be susceptible to abandonment. Differential diagnosis includes

Oppositional Defiant Disorder, ADHD, Depressive and bipolar disorder, intermittent explosive

disorder and adjustment disorders.

Kleptomania- DSM-5 302.32 (F63.3). This is characterized by (Criteria A-E) consistent

repetitive failure to overcome the impulse of stealing objects which are futile or unnecessary for

person or have no monetary value. The individual experiences enhanced tension right before

stealing and achieves gratification immediately afterwards. Theft is this context is not committed

to express anger or vengeance and nor is it in a response to a delusion/hallucination. This

behavior cannot be explained by conduct disorder, manic episode or antisocial personality

disorder (above 18). The individuals do resist and try to stop themselves knowing that there act is

wrong and they do experience fear of being exposed or experience guilt. Neurotransmitter

pathways associated with addiction which likely to be associated with behavioural addictions

have similarities with kleptomania. Prevalence is about 4%-24% in shoplifters with a 3:1 female

to male ratio. In the general population is emerges at an approximation of 0.3%-0.6%. The

disorder emerges during adolescence. Despite being evicted multiple times, the disorder is likely

to remain. Risk and prognostic features involve having first degree relatives inclined towards

OCD, substance use disorder, alcohol use disorder etc. Disorder creates difficulty in maintaining

adequate legal, family, career and personal life. While establishing a differential diagnosis,
clinicians need to be mindful that it is not an ordinary theft, behavior is not a result of

malingering, manic episodes, psychotic episodes, conduct disorder and major neurocognitive

disorder.

Pyromania- 312.33 (F63.1). DSM-5 diagnostic criteria includes deliberate and

purposeful fire setting on more than one occasion. Tension or affective arousal before the act,

fascination with, interest in, curiosity about, or attraction to fire and its situational contexts),

Pleasure, gratification, or relief when setting fires, or when witnessing or participating in their

aftermath, the fire setting is not done for monetary gain, as an expression of sociopolitical

ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living

circumstances, in response to a delusion or a hallucination, or as a result of impaired judgment

(e.g., in Dementia, Mental Retardation, Substance Intoxication) and lastly, the fire setting is not

better accounted for by Conduct Disorder, a Manic Episode, or Antisocial Personality Disorder.

The necessary characteristic of this disorder is the existence of more than one episodes of

intentional fire setting and individuals experience arousal before doing it. The act is again not for

a monetary gain, to express anger or vengeance or is an outcome of a psychosis related

symptoms such as delusions or hallucinations. These individuals undergo thorough planning

before carrying out the task and they are more likely to be callous towards the consequences

resulting from their act. It is very rare with a 1.13% prevalence rate and relatively rarer in

childhood however, in childhood it is associated with CD and ADHD. It is more common in

males and poor social skills and learning deficits are considered precursors. Differential

diagnosis can be made against their intent of setting fire and other mental disorders as mentioned

in the diagnosing criteria.

 Intermittent Explosive Disorder- 312.34 (F63.81). DSM-5 criteria is given below:

A. Recurrent behavioral outburst representing a failure to control aggressive impulses as

manifested by either of the following:

1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical

aggression toward property, animals, or other individuals, occurring twice weekly, on

average, for a period of 3 months. The physical aggression does not result in damage or

destruction of property and does not result in physical injury to animals or other

individuals.

2. Three behavioral outbursts involving damage or destruction of property and/or physical

assault involving physical injury against animals or other individuals occurring within a

12-month period.

B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of

proportion to the provocation or to any precipitating psychosocial stressors.

C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-

based) and are not committed to achieve some tangible objective (e.g., money, power,

intimidation).

D. The recurrent aggressive outbursts cause either marked distress in the individual or

impairment in occupational or interpersonal functioning, or are associated with financial or legal

consequences.

E. Chronological age is at least 6 years (or equivalent developmental level).

F. The recurrent aggressive outbursts are not better explained by another mental disorder (e.g.,

major depressive disorder, bipolar disorder, disruptive mood deregulation disorder, a psychotic

disorder, antisocial personality disorder, borderline personality disorder) and are not attributable

to another medical condition (e.g., head trauma, Alzheimer’s disease) or to the physiological

effects of a substance (e.g., a drug of abuse, a medication). For children ages 6 to 18 years,

aggressive behavior that occurs as part of an adjustment disorder should not be considered for

this diagnosis.

With a prevalence of 2.7%, this disorder is prevalent among younger individuals

most. Males are more likely to have it according to some research evidence. Onset of this

disorder is more commonly seen in late childhood or adolescence. The disorder may be

characterized by episodes and frequent periods of impulsive aggressive outburst. The risk factors

are both environmental and genetic. Research shows that serotonergic abnormalities, globally in

the brain and particularly in the anterior cingulate and orbitofrontal cortex. Clinicians must rule

out that the behavior representation is not due to disruptive mood dysregulation disorder,

borderline personality disorder, Delirium, major neurocognitive disorder and personality change

due to another medical condition, substance intoxication or withdrawal, ADHD, CD, ODD or

ASD.

Disruptive Mood Dysregulation Disorder 296.99 (F34.8). DSM-5 diagnostic criteria is

given below:

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally

(e.g., physical aggression toward people or property) that are grossly out of proportion in

intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.

C. The temper outbursts occur, on average, three or more times per week.

D. The mood between temper outbursts in persistently irritable or angry most of the day, nearly

every day, and is observable by others (e.g., parents, teachers, peers).

E. Criteria A–D have been present for 12 or more months. Throughout that time, the individual

has not had a period lasting 3 or more consecutive months without all of the symptoms in

Criteria A–D.

F. Criteria A and D are present in at least two of the three settings (i.e., at home, at school, with

peers) and are severe in at least one of these.

G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.

H. By history or observation, the age of onset of Criteria A-E is before 10 years.

I. There has never been a distinct period lasting more than 1 day during which the full symptom

criteria, except duration, for a manic or hypomanic episode have been met.

Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly

positive event or its anticipation, and should not be considered as a symptom of mania or

hypomania.

J. The behaviors do not occur exclusively during an episode of major depressive disorder and are

not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic

stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]).

Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive

disorder, or bipolar disorder, though it can coexist with others, including major depressive

disorder, attention-deficit/ hyperactivity disorder, conduct disorder, and substance use disorders.
Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and

oppositional defiant disorder should only be given the diagnosis of disruptive mood

dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the

diagnosis of disruptive mood dysregulation disorder should not be assigned.

K. The symptoms are not attributable to the physiological effects of a substance or to another

medical or neurological condition.

Defining features of this disorder is ‘chronic, severe persistent irritability’. It is

more common among children with a prevalence of 2%-5% range however, males are more

susceptible as compared to females. This disorder must onset before the child is 10 years of age

and the diagnosis cannot be given to children whose developmental age < 6years. Diagnosis

should only be given to children between 7-18 years. Evidence suggests that suicidal behavior

and aggression are likely to be experienced by children who have this disorder and clinicians

must mindfully diagnose and assess children who have chronic irritability. Differential diagnosis

is made against bipolar disorders, oppositional defiant disorder, ADHD, MDD, Anxiety

disorders and ASD and Intermittent explosive disorder.

Assessment for ODD, Conduct Disorder and related disorders can be done using

Children’s Apperception Test, Child Behaviour Checklist, Teacher Report Form, Family

Environment Scale and Means-End Problem-Solving Procedure (nnly ODD and CD).

Behavioural intervention includes psych education, observation and monitoring by adults,

Reinforcement of prosocial behavior, time-out for unacceptable behavior, and involvement of

child in problem-solving communication, nondirective play, video tape modeling and synthesis

teaching (Clark, 1985). Psychotherapy involves CBT techniques such as social skills training,

problem solving, anger management, modeling and role play. Medications are neuroleptics and
antidepressants. In patient hospitalization can also be done following traditional in patient

settings. Day treatment or residential settings (Kronenberger, Meyer, & Harris, 1996).

Anxiety Disorders are characterized by intense feelings of fear causing us to take action.

These feelings are combined with a display of physiological symptoms such as palpitation,

sweating, and cognitive discrepancies like perception distortion. Common anxiety disorders

which are likely to impair an individual’s social, occupational and other significant areas of

functioning are Separation Anxiety Disorder, Specific Phobia, Social Phobia and Generalized

Anxiety Disorder.

Separation Anxiety Disorder 309.21 (F93.0). This disorder is mainly

characterized by ample fear or anxiety related with the idea of separating from home or

attachment figures. According to DSM-5, clinical features of SAD involve recurrent distress

upon the anticipation of separation from attachment figure, persistent and excessive worry about

being away from the attachment figure or losing the attachment figure, worry about experiencing

an untoward event that causes separation from a major attachment figure, persistent reluctance or

refusal to go out away from home, refusal to sleep away from home, repeated nightmares

involving the theme of separation and repeated complaints of physical symptoms- an occurrence

of any of these three symptoms beyond the duration of more than 4 weeks is considered

alarming. Clinicians also note that these symptoms cannot be diagnosed by resistance to change

seen in autism spectrum disorder, psychotic disorder, agoraphobia, generalized anxiety disorder

disorder, or illness anxiety disorder. Disturbance must cause significant impairments in social,

occupational, academic and other significant domains of functioning. Children with SAD are

likely to exhibit social withdrawal, apathy, sadness, or find it challenging to concentrate on work

or play. These may have fears of monsters, dark, criminals, accidents or may be fearful in
situations where there is a real or perceived threat to the family. Prevalence is likely to reduce in

adolescence and overall it is more frequent in females. Environmental factors such as change,

death of a loved one/pet, immigration, natural disaster and genetic factors with a 73% heritability

rate can be seen to understand the prescursors of SAD.

The Assessment of SAD can be done using Children’s Apperception Test,

Child Behavioural Checklist, Teacher’s Report Form, Family Environment Scale and revised

version of Fear Survey Schedule for Children. Treatment involves behavioural interventions like

in vivo desensitization, flooding or implosive therapy, operant conditioning, modelling.

Psychotherapy may involve techniques of CBT such as Self-monitoring, self-talk, distraction,

self-reinforcement, relaxation techniques or Brief psychodynamic psychotherapy. Family

Therapy is also significant in this situation and in severe cases medication such as

benzodiazepines, tricyclic antidepressants are suggested by psychiatrists.

Specific Phobia (300.29). This disorder’s clinical features include excessive

unmanageable fear or anxiety about a specific object/situation. In this case, the object always

acts as an impetus to the immediate fear or anxiety and is actively avoided or endured with

intense fear. Anxiety is out of proportion to the actual danger the fear or anxiety and causes

clinically significant distress or impairment. Symptoms are present for at least 6 months or more.

These symptoms are not better explained by agoraphobia, obsessive-compulsive disorder Post

dramatic stress disorder separation anxiety disorder and social anxiety disorder. If the individual

is phobic to two situations then two different diagnoses will be given for each phobia either a

situation or an object. Active avoidance of the feared situation/object is exhibited by the

individual. The individuals with specific phobia note that their physiological arousal is

increasing as their fear of being exposed to the phobic stimulus increases. It is prevalent more in
females and overall prevalence is 2 females to 1 male ratio. It begins with a traumatic event and

follows through.

Negative affectivity or neuroticism and behavioural inhibition are personality

temperamental risk factors. Parental overprotectiveness, sexual abuse, parental loss and

separation can be factors in environment leading to specific phobia. 60% individuals are likely to

attempt a suicide due to ther phobia. Individuals are not able to maintain adequate psychosocial

functioning, quality of life as compared to individuals who have other anxiety disorders. Fear of

vomiting or choking may significantly experience insufficient dietary intake.

Assessment of specific phobia includes Child Behavior Checklist, Youth Self

Report, Revised Children’s Manifest Anxiety Scale and Revised Fear Survey Schedule for

Children. Treatment in severe cases may begin from medication such as benzodiazepines,

propranolol etc. Family therapy is again significant. Managing phobia can be done through In

vivo desensitization, systematic desensitization, and modeling or CBT techniques such as self-

monitoring, self-talk, role playing (Kronenberger, Meyer, & Harris, 1996).

Social Anxiety Disorder/Social Phobia 300.23 (F40.10). It is characterized by marked

fear or anxiety about social situations in which the individual is exposed to scrutiny by others,

fear of negative evaluation. In children it is important to note that anxiety must exist when

interacting with peers and not just adults. Moreover, the social situations almost always provoke

fear, the fear is out of proportion to the actual threat posed by the social situation, the fear is

persistent for 6 months or more and cannot be explained by panic disorder, somatic symptoms,

generalized anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, body

dysmorphic disorder, selective mutism, specific phobias, MDD, ODD, Medical conditions

producing symptoms which are likely to cause embarrassment, Delusional Disorder, autism
spectrum disorder and normative shyness. Onset is usually at 13 years while 75% of individuals

encounter social phobia between the ages of 8-15 years. Behavioural Inhibition and negative

evaluation are temperamental risk factors while childhood maltreatment and adversity are

considered environmental risk factors leading to social phobia. Genetic predisposition of

temperamental traits are significantly influenced by genetic make-up.

Assessment may include Piers-Harris Self-Concept Scale, Child Behavioural

Checklist, Teacher’s Report Form, Family Environment Scale and Fear Survey Schedule for

Children (Revised). Treatment following behavioural prinicples may involve reinforcement

techniques, symbolic modeling, shaping, school based interventions (reinforcement of social

interactions in school, seating near familiar friends in school, assigning buddy system, avoiding

socially embarrassing activities) and social-skills training. CBT intervention may incorporate

self-talk, self-monitoring and lastly, play therapy and family therapy may also prove to be

significant (Kronenberger, Meyer, & Harris, 1996).

Generalized Anxiety Disorder 300.02(F41.1). Clinically, according to DSM-5, GAD

presents itself in the form of excessive anxiety and worry that is difficult to control accompanied

by one of the following symptoms: restlessness, being easily fatigued, difficulty concentrating,

irritability muscle tension, and sleep disturbance. These symptoms are likely to cause clinically

significant distress and the disturbances are not explained by substance abuse, any other medical

condition or mental disorder such as body dysmorphic disorder schizophrenia, and delusional

disorder, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, Social Anxiety

Disorder, Depressive and Psychotic Disorders. Symptoms persist for a duration of 6 months or

more. The disorder may accompany physical symptoms like muscle tension, trembling,

twitching, feeling shaky and muscle aches. Sometimes there is evidence of sweating, nausea,
diarrhea, accelerated heart rate, shortness of breath and dizziness. Stressful bowel movements

and irritability associated may support the diagnosis. Prevalence of the disorder suggests that

females are twice as likely to be with this disorder as are males. There is a 0.9% risk of GAD

among adolescents in the community of United States. Clinical expression in childhood is

primarily associated with worries about school and sporting performance and the extent of

severity of these symptoms is relatively greater for younger children. Behavioural inhibition,

neuroticism and harm avoidance are temperamental risk factors associated whereas childhood

adversities and parental overprotection are associated with this disorder. Excessive worrying

causes serious impairments in functioning of individual with optimum adequacy.

Assessment protocol may include Children’s Apperception Test (CAT), Piers-

Harris Self-Concept Scale, Child Behavioural Checklist, Revised Children’s Manifest Anxiety

Scale, Fear Survey Schedule for Children-Revised. The treatment options are relaxation

techniques, In vivo desensitization, reinforcement techniques, social skills training, Self-talk,

cognitive restructuring, self-monitoring, modification of maladaptive thoughts, family therapy,

Benzodiazepines, Tricyclic antidepressants (Kronenberger, Meyer, & Harris, 1996).

Obsessive Compulsive Disorder

OCD is characterized by presence of obsessions, compulsions or both where obsessions

are defined by recurrent and persistent thoughts, images and urges. Obsessions are not voluntary

or pleasurable, they are intrusive and unwanted resulting in significant distress. Compulsions are

rituals or repetitive behaviours carried out and they could be mental acts such as counting and

this is to an extent that carrying out these compulsions become an act of rigidity. The behaviours

or acts are primarily carried out to reduce anxiety however, young children may fail to explain

their aims of such rituals. The two are time consuming and cause significant distress in social,
academic and other areas of functioning (Criteria B). These two are not explained by

physiological effects of a substance, any other medical condition or a mental disorder. Clinicians

are to specify if the child/adolescent has a good insight, poor insight or delusional beliefs

regarding the truth of his obsessive compulsive beliefs. They also need to identify if the

individual has a current or history of tic disorder. With a prevalence rate of 1.2%, OCD has a bit

higher risk for males as compared to females. About 25% of the cases begin by the age of 14.

With a high risk of OCD for greater internalizing symptoms, higher negative emotionality and

behavioural inhibition; physical and sexual abuse in childhood or other traumatic events are

likely environmental factors recognized as risks for OCD. Additionally, orbitofrontal cortex,

anterior cingulate cortex and striatum dysfunctions are associated with OCD. Suicide attempts

are common for individuals with OCD. Clinicians must ensure that the symptoms are not due to

anxiety disorder, MDD, Other Obsessive-Compulsive and related disorders, eating disorder, tics

and stereotyped movements. Psychotic disorders, Obsessive-compulsive personality disorder and

other compulsive like behaviours.

Assessment of OCD can be done using Children’s Apperception Test, Rorschach, Child

Behaviour Checklist, Maudsley Obsessional-Compulsive Inventory, and Children’s Yale Brown

Obsessive Compulsive Scale (YBOCS). Treatment options are exposure therapies such as In

vivo desensitization, systematic desensitization, satiation, response prevention (thought stopping,

covert sensitization, aversion therapy). Other may be cognitive behavioural intervention

techniques, family therapy and medication. In case of severity clinician might resort to make

recommendations for inpatient hospitalization and refer to a psychiatrist (Kronenberger, Meyer,

& Harris, 1996).

Post-Traumatic Stress Disorder 309.81 (F43.10). The DSM-5 criteria which applies to

adolescents and children who are younger than 6 years is summarized below:

A. Children, 6 years and younger, are exposed to actual or threatened death, serious injury or

sexual violence either by directly experiencing the event, witnessing in person as it

happened to others, or by learning that a traumatic event was encountered by a parent or

caregiver.

B. Presence of one or more of intrusion symptoms in context of traumatic event: recurrent

and intrusive distressing memories of even, distressing dreams accompanying content or

affect of traumatic event, having dissociative reactions in which the child feels he/she is

reliving the event, intense or prolonged psychological distress after being exposed to

certain environmental cues which resemble the event or somehow bring back the trauma

to life and lastly marked physiological reactions as a consequence to traumatic events.

C. Persistent avoidant stimuli and/or Negative alterations in cognitions.

D. Alterations in arousal and reactivity associated with the traumatic event such as (two or

more) irritability and anger outbursts, hypervigilance, exaggerated startle response,

difficulty concentrating, sleep disturbance

E. Symptoms have persisted beyond 1 month.

F. Cause clinically significant distress and impairment in relationships with significant

others.

G. Disturbance is not attributable to physiological effects of a substance/medication.

Clinicians are required to specify whether the symptoms are accompanied with depersonalization

or derealization and if the expression is delayed until atleast 6 months.

 Criteria (A-D) which applies to children above the age of 6 years is divided into four

clusters of symptoms which includes re-experiencing the event, alterations in arousal, avoidance

and negative alterations in cognition and mood. The difference is based primarily upon

diagnostic threshold which lower for children below the age of 6. Moreover, younger children

are susceptible to developmental regression such as loss of language. Auditory pseudo-

hallucinations are also common as associated features which support the diagnosis. Children and

adolescents have lower prevalence. It can begin at any point in time after the first year of life.

Before 6 years, young children are likely to exhibit re-experiencing symptoms through play

however older children are likely to have dreams which are frightening but without the content

of traumatic event. Adolescents may have beliefs about themselves thinking they will never fit in

or be a part of society the way their peers are. Injury as a result of reckless behavior is usually

common. Lower socioeconomic status, lower education, and exposure to prior trauma, childhood

adversity, lower intelligence, and minority status, family history of psychiatric illness, emotional

problems prior to age of 6 years, and previous mental disorders are Pre-Traumatic risk factors for

PTSD. Younger age and female gender is at an increased risk. Peri-traumatic risk factors include

the severity of the trauma in terms of its magnitude and posttraumatic risk factors involve

temperamental factors like negative appraisals, inappropriate coping strategies and development

of acute stress disorder. Environmental factor include repetitive reminders of trauma, adverse life

events, financial or other relevant losses and lack of social support. Childhood abuse is likely to

be associated with a risk of suicide in this case. Differential diagnosis must be made against

adjustment disorders, other posttraumatic disorders and conditions, acute stress disorder, anxiety

and obsessive-compulsive disorder, MDD, Personality disorder, dissociative disorder, psychotic

disorder, conversion disorder and a traumatic brain injury.

 Assessment of PTSD involves Children’s Apperception Test gaining more insight into

the trauma and repressed emotions. Other assessment tools are Child Behavioural Checklist,

Children’s PTSD Inventory, Revised Children’s Manifest Anxiety Scale and Fear Survey

Schedule for Children Revised. Treatment options are systematic desensitization, family therapy

and self-talk, relaxation techniques such as progressive muscle relaxation, deep breathing,

imagery (Kronenberger, Meyer, & Harris, 1996).

Major Depressive Disorder 296.20-296.36. Symptoms are characterized by feelings of

sadness and hopelessness, loss of interest or pleasure in activities, loss or weight or weight gain,

difficulties sleeping or excessive sleepiness, noticeable restlessness or slowness, lack of energy,

troubles concentrating and indecisiveness, feeling of worthlessness, excessive guilt and suicidal

ideation. DSM-5 Criteria is presented below:

A. Five (or more) of the following symptoms have to be present during the same 2 week

period and represent a change from previous functioning; at least one of the symptoms is either

(1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are

attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective

report (eg. feels sad, empty, hopeless) or observation made by others (eg. appears

tearful). (NOTE: in children and adolescence, can be irritable mood).

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day

(as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (eg. A change of more than 5%

of body weight in a month), or decrease or increase in appetite nearly every day. (Note: in

children, consider failure to make expected weight gain).

 4. Insomnia or hypersonic nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely

subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional)

nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by

subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a

specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or

other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another

medical condition.

D. The occurrence of the major depressive episode is not better explained by schizoaffective

disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and

unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypo manic episode. Note: this exclusion does not

apply if all of the manic-like or hypo manic-like episodes are substance –induced or are

attributable to the physiological effects of another medical condition.

Risks and prognostic features involve neurotic temperamental trains, adverse

childhood experiences, stressful life events, genetic predisposition and 40% heritability.
Differential diagnosis can be manic episodes with irritable mood or mixed episodes, mood

disorder due to another medical condition, substance/medication induced depressive or bipolar

disorder, ADHD, Adjustment disorder with depressed mood, and sadness characterized as a

normal response. Children and adolescents are at an increased risk of committing suicide,

impaired school performance, interpersonal difficulties in adult later life, risk of mental disorders

and substance abuse (Cheung, Kozloff & Sacks, 2013). Depression progresses from childhood

through adolescence into adulthood if not treated. 12. Prompt intervention rehabilitates

depression and pediatric treatment for depression suggests psychotherapy and antidepressant

medications such as, selective serotonin reuptake inhibitors (SSRIs) (Mullen. 2018).

Assessment of Depression in children and adolescents can

be done and using various techniques. Personality assessment tools namely used are Rorschach,

Children’s Apperception Test (Animal or Human Version) and the sentence completion test.

Behavioural assessments include Child Behavioural Checklist, Teacher’s Report Form, Youth

Self Report or can be assessed also by using a specific scale called Children’s Depression

Inventory. Hopelessness Scale can also be used in order to gain an insight about child’s

condition. Medication usually prescribed for treating severe clinical

depression include tricyclic anti-depressants and Prozac. Psychotherapy for depression largely

follow a cognitive behavioural intervention model and this includes psycho-education of the

child where relationship between thoughts, feelings and behaviours is explained for children and

adolescents who can grasp the concept adequately. It further involves self-monitoring where

client can be taught to challenge automatic thoughts or it may involve cognitive restructuring i.e.

identifying errors of thought. Self-Reinforcement may include activity scheduling realistic goal

setting and behavioural exposure. Additionally management may include relaxation training,
social skills training, anticipatory coping, problem solving etc. Play therapy and group therapy

are often recommended and prove to be helpful. Lastly, family therapy and parent psychotherapy

is extremely necessary so they are well equipped and understand the challenges that their child

has as a result of depression (Kronenberger, Meyer, & Harris, 1996).

Conclusion

Assessment and treatment of a child is a grave responsibility on a clinician.

Clinician must take account of all aspects of a child’s background, elements of history,

perspectives of informants and must maximize benefits in order to ensure that they mindfully

assess the referral and practice staying within their competence to avoid harm, negligence and

malpractice. Clinicians are advised to highlight strengths and provide recommendations for

weaknesses. These recommendations must be practical in the light of child’s available resources

and context. Lastly, keeping individual differences in mind it is of high beneficence to follow an

eclectic approach.
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