CHILDHOOD AND

ADOLESCENT
DISORDERS.
OBJECTIVES.

By the end of the discussion, learners should be able

to;
 Define childhood/adolescent mental disorders.
 Enumerate and describe the childhood and
adolescent mental disorders.
 Discussthe epidemiology, etiology, clinical
presentation, management and prevention of
childhood/adolescent mental disorders.
Scope of discussion.

 Definition.
 Classification
 Specific disorders.
 Childhood/adolescent psychiatry is relatively a
new field of study having gradually evolved as the
therapeutic value of the relationship with
children increased.
 Child/adolescent psychiatry employs a wide range
of treatment modalities which makes it a unique
field of speciality.
Why study child/adolescent psychiatry.

1) Its rare that children initiate a consultation with a

clinician. They are always brought in by
caretakers thus need for hyper vigilance/high
suspension index.
2) Childs stage of development is what determines
whether the behavior is normal or abnormal
thereby creating need to ascertain different
behaviors at different ages.
3) Children are generally less able to express
themselves in words, as such evidence of behavior
is based on observation by caretakers
(parents/guardians, teachers, clinicians, etc).
4) Treatment of childhood mental illness uses less of
medications but emphasizes changing the
attitudes of parents, reassuring and retraining
children, working with family and coordinating the
efforts other players who help children especially at
school.
Classification of childhood/adolescent
mental illness.

1) Mental retardation.

2) Disorders of psychological development (learning).

3) Behavioral and emotional disorders.

4) Feeding disorders of infancy and childhood.

Behavioral and emotional disorders.
They include
1. Hyperkinetic disorder (ADHD).
2. Conduct disorders.
3. Separation anxiety disorders.
4. Phobic anxiety disorder.
5. Tic disorder.
6. Sibling rivalry disorder.
7. Social anxiety disorder.
8. Non-organic enuresis.
Mental retardation (MR).

Is a significantly sub-average general intellectual

functioning resulting in or associated with
concurrent impairments in adaptive behavior and
manifested during the developmental period
(American association on mental deficiency, 1983)
MR may appear during infancy or later in early
childhood.
Approximately 3% of the general population is
estimated to be mentally retarded.
It is more common in boys than girls.
Mortality is high in severe and profound MR due to
associated physical diseases.
Etiology.
Genetic factors
I. Chromosomal abnormalities as may occur in
Down’s syndrome, Trisomy syndrome, turners
syndrome, Prader-willi syndrome, etc.
II. Metabolic disorders like phenyl ketonuria,
galactocaemia and Wilson’s disease.
III. Cranial malformations – hydrocephaly and
microcephally.
IV. Gross diseases of the brain – epilepsy, tuberculous
sclerosis, neurofibromatosis.
Prenatal factors
I. Infections – TORCHES
II. Endocrine disorders – hypothyroidism,
hypoparathyroidism, congenital/infantile DM.
III. Physical damage and disorders – injury, hypoxia,
radiation, hypertension, anemia, emphysema.
IV. Intoxication – lead and substance abuse.
V. Placental dysfunction – PET, placenta previa,
cord prolapse and nutritional growth
retardation.
Perinatal factors.
I. Birth asphyxia.
II. Prolonged and difficult labor.
III. Prematurity
IV. Kernicterus.
V. Birth trauma.
Postnatal factors.
I. Infections involving the brain.
II. Accidents.
III. Lead poisoning.
Environmental and sociocultural factors.
IV. Cultural deprivation.
V. Low socioeconomic class.
VI. Child abuse.
VII. Inadequate caretaking.
Classification of MR.

MR is graded according to Intelligence Quotient (IQ)

into
Mild (educable) 50 -70
Moderate (trainable) 35 - 50
Severe (dependent retarded) and 20 - 35
Profound (life support) <20
Clinical picture.

 Failure to achieve developmental milestones.

 Deficiencies in cognitive functions like failure to
follow commands or directions.
 Reduced ability to learn or meet academic
demands.
 Expressive or receptive language inefficiencies.
 Difficulty performing self care activities.
 Comorbidities like seizures.
 Low self esteem, depression and labile moods.
 Irritability with frustration.
 lack of curiosity.
 Acting-out behavior.
Diagnosis.

Detailed and specific history collection from parents

and caretakers.
Physical exam to reveal associated physical
illnesses.
Neurological exams
Assessment of developmental milestones.
Investigations like…… including assessment of IQ.
Treatment modalities.
 Behavioral management.
 Environmental supervision.
 Monitoring the child’s developmental needs and
problems.
 Programs that maximize speech, language,
cognitive, psychomotor, social, self-care and
occupational skills.
 Ongoing monitoring and evaluation for prognosis
like ADHD, depression, etc.
 Family therapy to help parents develop copying
skills and deal with guilt, anger, depression, etc.
 Early intervention programs for children younger
than 3yrs like schools and vocational training.
 Use of medicines may be employed in cases of
psychosis or co-morbidities.
Course work.

The mentally retarded suffer a great challenge of

social exclusion.
I. Discuss the consequences and remedies of social
exclusion of the mentally retarded.
II. Discuss the prevention, care and rehabilitation
services for the mentally retarded.
Prevention.

 Primary
 Preconception.
 During gestation.
 At delivery.
 Childhood.

 Secondary
 Tertiary.
Preconception.
 Genetic counselling.
 Immunization for maternal Rubella.
 Screening of venereal diseases
 Adequate maternal nutrition.
 Family planning and child spacing.
During gestation.
 Adequate nutrition, fetal monitoring and disease
prevention.
 Avoidance of teratogenic substances like exposure
to radiation and consumption of alcohol and
drugs.
 Analysis of fetus for possible genetic disorder
(amniocentesis, fetobiospsy and ultrasound).
At delivery.
 Delivery conducted by skilled professionals
especially high risk pregnancies.
 APGAR scoring done at 1 and 5 minutes.
 Close monitoring of the mother and child.
 Prevention of rhesus factor through screening and
gamma globulin injection.
Secondary prevention.
 Early detection and treatment of preventable
disorders like phenyl ketonuria and
hypothyroidism.
 Early screening and detection of mental
retardation.
 Psychiatric treatment for emotional and
behavioral difficulties.
Tertiary prevention.
 Rehabilitation in vocational, physical and social
skills according to the level of handicap.
 Rehabilitation is aimed at reducing disability and
maximizing functioning in a child with mental
retardation.
ENURESIS.

Is a disorder characterized by involuntary voiding of

urine by day or night which is abnormal in relation to
the individuals mental age and is not a consequence
of a medical ailment (neurological disorder, epileptic
attack or any structural abnormality of the urinary
tract).
Below 5yrs chronological age or 4yrs mental age,
enuresis is not diagnosed.

Enuresis is mostly primary but may secondary being

associated with the following factors.
1. Faulty training – too early, too late or coercive
toilet training.
2. Emotional disturbance due to harsh punishment,
dominating parents, social neglect and isolation.
3. Physical disease and anatomical defects (neural and
urinary).
Management.
1) Exclusion of physical causes by history, examination
and investigations of the nervous and renal tract.
2) Counselling to the child and caretakers.
3) Keep track of the dry/wet nights.
4) Fluid intake restriction after 6 o’clock.
5) Interruption of child’s sleep to void the bladder.
6) Bell and pad technique – classical conditioning.
7) Medication – tricyclic antidepressants. Mechanism of
action is unknown but results have demonstrated
effectiveness.
8) Parents – should not blame the child but rather
encourage.
SIBLING RIVALRY.

Is the jealousy exhibited by children (adjacent

siblings) characterized by marked competition for

the attention and affection of parents associated

with unusual pattern of negative feelings.

Always occurs with the birth of a younger sibling.

Major x-tics include
 Over hostility
 Physical trauma
 Undermining of the sibling
 Regression of the acquired skills.
 Tendency to babyish behavior.
 Temper tantrums
 Dysphoria.
 Social withdrawal
 Oppositional behavior to parents.
Management.
Typically psychological recommendations.
 Parents should divide their attention
appropriately between the two children.
 Help the elder child feel valued with limits (not
replace the new borne).
 Preparing the child mentally for the arrival of the
new sibling during pregnancy and involving him in
the care of the new borne.
SCHOOL TRAUNCY

 is a partciular form of trauncy and is a term used to describe any intentional

unauthorized absence from compulsory schooling.
 The term typically refers to absences caused by students on their own free
will, and usually does not refer to legitimate "excused" absences, such as ones
related to a medical condition.
 The exact meaning of the term itself is subject to differ from school to
school, and is usually explicitly defined in the school's handbook of policies
and procedures.
 It may also refer to students who attend school but do not go to classes.
 Truancy is commonly associated with juvenile delinquency
Causes of school trauncy

 Harsh punishments at school

 Lack of basic needs, poor parenting and low social economic status
 Long distance to school
 Peer pressure
 Bullying in school
 Social withdraw or lack of friends at school
 Poor relationships with teachers
 Boring classes
 Lack of interest in school
CAUSES CONTD

 Mental health issues and chemical/substance dependency

 Family chaos and lack of proper household routine
Effects of school trauncy

 School drop out

 Poor academic performance
 social rejection among peers
 unemployment
 Juvenile delinquency (stealing, self hatred and indulgence into drugs)
 Failure to graduate from school
 Long term effects include: poor physical and mental health, the continuance
of family poverty and a high risk of addiction and incarceration
Management

 Create a more positive school culture. One of the best ways to get in front of
chronic absenteeism is to ensure that school is a place where students are
excited to be. When students feel happy and safe, physically and emotionally,
they engage in school. This not only leads to higher attendance but higher
academic achievement as well.
 Counselling
 Family therapy
THUMB SUCKING

 Thumb sucking is a behavior found in humans, chimpanzees, captive ring-

tailed lemurs, and other primates. It usually involves placing the thumb into
the mouth and rhythmically repeating sucking contact for a prolonged
duration
 Thumb sucking or finger sucking, along with pacifier use, is perfectly
acceptable for infants. According to the American Dental Association (ADA),
this is a natural reflex for an infant that can often be seen in the womb
during development. This reflex gives your baby comfort and, as he grows, it
may help him feel secure and happy.
Intro contd

 Thumb sucking is anormal habit until the child makes 3 years of age
 By age 3-4 years, many thumb and finger sucking children have a gap between
their upper and lower teeth and their jaw development has changed, often
causing problems with speech.
 Their tongue muscles also don’t develop correctly, making speech sounds like
“s” and “th” difficult.
 If you wait until after your child’s permanent teeth come in to stop the
sucking, they can develop “buck teeth” and an appearance that is not
cosmetically pleasing.
Causes

 Boredom
 Tired and upset
 Hunger
Effects

 Thumb sucking can cause problems with the proper growth of the mouth,
alignment of the teeth, or changes in the roof of the mouth
 Speech difficulties
Management

 BEHAVIOURAL THERAPY
 Parents can use a simple behavioral approach that engages their child in the
process.
 First, create a progress chart with the help of your child. It's a good idea to
let your child help make it fun by helping to pick a color or the kinds of
stickers used to track their progress.
 Have a discussion with your child to determine how many slip-ups should
allowed each week.
 Provide a reward at the end of each week of no thumb or finger sucking.
Make a larger reward for getting to the end of a month of no thumb or finger
sucking.
Management contd

 Other methods include: placing a bitter-tasting liquid on the nail, but not
directly on the finger. This should only be done at night to discourage thumb
sucking while sleeping.
 Parents can also use mittens, gloves, or a finger-splint to be worn at night to
discourage thumb and finger sucking.
TEMPER TANTRUMS
TEMPER TANTRUMS

 A tantrum, temper tantrum, or hissy fit is an emotional outburst, usually

associated with those in emotional distress, that is typically characterized by
stubbornness, crying, screaming, violence, defiance, angry ranting, a
resistance to attempts at pacification, and, in some cases, hitting, and other
physically violent behavior.
 Physical control may be lost; the person may be unable to remain still; and
even if the "goal" of the person is met, they may not be calmed.
 A tantrum may be expressed in a tirade: a protracted, angry speech.
Intro contd

 They may range from whining and crying to screaming, kicking, hitting, and
breath holding. They're equally common in boys and girls and usually happen
between the ages of 1 to 3
 Temper tantrums are a normal part of growing up
 They develop in 3 stages:
 Stage I: This stage marks the onset of the first temper tantrum episodes. This
stage usually starts between 12-15 months. During this time, the child starts
growing feelings and emotions. It knows how to express demands. It points
fingers at objects it needs and starts crying and shouting when it is not allowed
to access those items. The child shows stubbornness and an extremely resistive
attitude when someone tries to divert his/her attention to something else. Many
children exhibit patterns like rolling on the floor, clinging to a person, being rigid
and stiff, and yelling continuously.
Intro ccontd.,

 Stage II: It is the peak period of tantrums. It occurs between the ages of 18-
36 years. The parents and the school teachers observe a noticeable increase
in the intensity of tantrums. The children tend to throw themselves on the
ground, break objects, bite other people (mainly their friends or siblings) and
frighten the elders by holding their breath. Many of these children exhibit
self-abrasive behaviour as well.
 Stage III: This stage usually starts after the age of 3. In this stage, the
children develop words and expressions properly. The tantrums usually
dissipate since the child can clearly express his/her needs. But in many cases,
children tend to retain the past habits, if they strongly believe that throwing
tantrums is the only means of getting what they want.
CAUSES OF TEMPER TANTRUMS

 Mental irritation and agitation when the people around cannot understand or are not
listening
 Confusion in the child’s mind when he/she cannot understand what the others are telling
them or want them to do
 Lack of words to fully express the feelings and demands (occurs in infants less than1-year-
old)
 Children may want to be on their own, and get upset when they cannot do what they want
 Attention seeking to test the rules
 Have something taken away from them
 Jealousy and insecurity when a child finds his/her sibling or another child of the smae age is
getting more attention
 Inability to perform activities they see people doing such as running, climbing stairs, making
electronic toys work etc
CAUSES Contd

 Irritation aroused due to the inability to solve different problems on their own
 Anger and stubbornness when people discourage the child from different activities
(such as touching objects, putting a finger or placing objects inside the mouth)
 The child may have medical illnesses (like stomach ache, ear ache) but cannot
convey what is wrong
 The child may be hungry and may not be able to express it properly
 Tiredness and sleeplessness
 Anxiety, discomfort or unexplained fear
 Troubled environment at home
 Tendency to imitate a family member or other people (say babysitter) who has
exhibits temper tantrums
Causes contd

 Inherited behavioural traits

 Overstimulation due to activity and excitement
 Hearing the word “no” repeatedly from the parents
 Disruption of normal routines such as timely feeding, bathing and sleeping
 Continuously forcing a child to do something he/she is not willing to
 The child may feel neglected and seek unnecessary attention
 Certain developmental phenomenon like “teething”
 Criticising or accusing a child repeatedly in front of outsiders
 Teasing or irritation (at times abuse) caused by some unknown person
MANAGEMENT

 Keep your child occupied with toys and similar items while you attend to
other chores.
 Make sure that the child is getting the required amount of sleep and rest
every day.
 While it is easy to give in to the temper tantrum of the child, it is neither
effective nor advisable in the longer run. In order to calm your child, you
must yourself first learn how to act and behave calmly during the tantrum
episodes.
Mgt contd.,

 Refrain from resorting to spanking or physically hitting the child when the
child is throwing a tantrum.
 In many cases, tantrums are thrown as a way to gain attention from parent/s.
Be clear and strict with the child explaining him/her why such a behavior is
undesirable.
 Try to keep your child well-fed and well-rested. Hunger and fatigue are the
two biggest triggers of temper tantrums
Prevention of temper tantrums

 Establish a routine. A consistent routine or schedule lets your child know what to expect and gives
them a sense of security.
 Be a role model. Children look up to their parents and are constantly observing their behavior. If
your child sees you handling your anger and frustration calmly, they will be more likely to mimic
your behavior when experiencing these feelings.
 Give your child choices. When appropriate, give your child several options and allow them to make
choices. This will give them the feeling that they have some control over their circumstances.
 Make sure your child is eating right and getting enough sleep. This will help prevent tantrums
caused by fatigue and irritability.
 Pick your battles. Don’t fight over trivial or unimportant things, such as which clothes your child
prefers to wear. Try to limit the number of times you say the word “no.”
 Watch your tone of voice. If you want your child to do something, make it sound like an invitation,
rather than a demand
NIGHTMARES

 Also called a bad dream, is an unpleasant dream that can cause a strong
emotional response from the mind, typically fear but also despair, anxiety
and great sadness.
 However, psychological nomenclature differentiates between nightmares and
bad dreams, specifically, people remain asleep during bad dreams whereas
nightmares awaken individuals
 The dream may contain situations of discomfort, psychological or physical
terror or panic. After a nightmare, a person will often awaken in a state of
distress and may be unable to return to sleep for a short period of time.
 Recurrent nightmares may require medical help, as they can interfere with
sleeping patterns and cause insomnia.
CAUSES

 Nightmares can have physical causes such as sleeping in an uncomfortable

position or having a fever, or psychological causes such as stress or anxiety.
 Eating before going to sleep, which triggers an increase in the body's
metabolism and brain activity, is a potential stimulus for nightmares.
 Children who experienced the death of a family member or a close friend or
know someone with a chronic illness have more frequent nightmares than
those who are only faced with stress from school or stress from social aspects
of daily life
 Post traumatic stress disorder
Management

 Story-line alteration procedures

 Face-and-conquer approaches
 Desensitization and related behavioral techniques
 Desensitization is a treatment or process that diminishes emotional
responsiveness to a negative, aversive or positive stimulus after repeated
exposure to it.
 Ensure adequate sleep
 Keep a bedtime routine light, happy and fun
 Comfort, coddle, and reassure your child
Mgt contd.,

 Imagery rehearsal therapy (IRT) Introduced by Isaac Marks in 1978- used in

posttraumatic nightmares
 Use of α adrenergic receptor antagonists in the treatment of PTSD-associated
nightmares e.g clonidine