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Introduction
Child psychiatry is concerned with the assessment and treatment of children's emotional and behavioral problems. Over the past two decades psychiatry has increasingly turned to biological explanations for the etiology of mental disorders. (Keltner N L, 1996) These problems are very common with prevalence rates of 10-20% in several community studies. Psychological disturbance in childhood is most usefully defined as an abnormality in at least one of three areas; emotions, behavior or relationships. In childhood the distinction between disturbance and normality is often imprecise or arbitrary. Isolated symptoms are common and not pathological. Another distinctive feature of childhood psychiatric disturbance is that several factors rather than one contribute to the development of disturbance.
developments in Child Psychiatry
Historical
Child psychotherapy begins with Sigmund Freud's case of Little Hans, a 5-year-old phobic boy. In 1935 Leo Kanner published the fi rst textbook on child psychiatry in English. Major contributers to child psychiatry are Donald Winnicott, Anna Freud and Melanie Klein.
of Child psychiatry from adult psychiatry
Differences
The childs existence and emotional development depends on the family or care givers cooperation with family members. The developmental stages are very important assessment of the diagnosis Use of psychopharmacotherapy is less common in comparison to adult psychiatry Children are less able to express themselves in words The child who suffers by psychiatric problems in childhood can be an emotionally stable person in adulthood, but some of the psychic disturbances can change a whole life of the child and his family
factors
Etiological
Etiological factors are usually categorized into two groups, constitutional and environmental. The former include hereditary factors, intelligence and temperament. The three major environmental influences are the family schooling and the community. Another factor physical illness or disability, if present can have a profound effect on the child's development and on his vulnerability to disturbance.
Constitutional
Environmental
Family discord
Marital discord Children in care Children not living with both natural parents
Parental deviance
Social disadvantage
Schooling
Classification
Disruptive behaviour disorders Conduct disorder (prevalence 5.3%), Oppositional defiant disorder Hyperkinetic disorders (ADHD) (up to 5%). Tic Disorders e.g. Tourettes (up to 2%) Affective disorders Depression (2%), BPAD Anxiety disorders (3.8%), GAD, phobias, separation anxiety, panic, PTSD.
Obsessive Compulsive disorder (3%) Dissociative and somatoform disorders (rare) Psychosis e.g. drug induced, schizophrenia (v. rare in childhood, peak incidence late teens to early twenties). Developmental disorders general (2.4%) or specific learning disability, autistic spectrum disorders (0.06 to 1.5%) and other PDD Social functioning disorders e.g. elective mutism, attachment disorders Eating disorders (3%) e.g. Anorexia, Bulimia, Binge eating Sleep disorders e.g. night terrors, narcolepsy Mental and behavioural disorders due to substance misuse Other disorders such as non organic enuresis and encopresis, pica
Axis 2
Clinical syndrome
Axis3
Axis 4 Physical disorders/illness
Mental retardation
Axis 4
Axis 5 Severity of current Psychosocial stressors
Medical illness
Axis 6
Axis 5
Psychosocial disability
Conduct disorders Emotional disorders Mixed disorders of conduct and emotions Hyperkinetic disorders Disorders of social functioning
Tic disorders Pervasive developmental disorders Other behavioral and emotional disorders
Separation anxiety disorder Avoidant disorder of childhood and adolescence Over anxious disorder
Eating disorders
Axis 2
Child
Psychiatric
Assessment
Assessment is more time consuming in child psychiatry than in other branches of psychiatry or medicine. Child mental health assessment is distinctive.
It uses a developmental approach All assessments, management etc must be related to child development. E.g. what is the normal attention span at different ages? How well should a 5 year old read? Systemic thinking The Biopsychosocial approach .How the child functions and the impact of their illness on families and educational achievement, as well as individual symptoms. Synthesising information from different sources into a formulation or problem list e.g. school report, genetic tests, clinical assessment etc. Take time to develop assessment skills of both younger children and adolescents. Be familiar with normal developmental milestones (motor, verbal, and social) and developmental assessments (e.g. in community paeds)
Psychiatric Assessment
Full History from parents and child. Mental State Examination of child.
Physical examination should include neurological exam and full examination of any systems related to suspected psychiatric diagnosis e.g thyroid and cardiovascular in depression.
History Taking
Presenting complaint History of presenting complaint: o Assessment of symptoms duration, severity and effect on functioning. o Systematic enquiry about presence or absence of mood, anxiety and psychotic symptoms Past psychiatric history: Contact with services previously? Self harm? Diagnosis? Treatment? Past Medical / Surgical History Medications Family History (medical, psychiatric and developmental disorders). Genogram. Substance Misuse History (drugs and alcohol). Forensic History Developmental History o Pregnancy. Maternal illness, medications, drugs and alcohol. Birth. Developmental milestones. Social functioning in early childhood. Problems with separation from mother. Academic, social and behavioural progress at school. Activities of Daily Living. Relationships. Social circumstances of family. Premorbid personality. o What was the child like before the current problem?
Signs / Symptoms and Behaviour at the time of the interview. Appearance and Behaviour. o General appearance, facial appearance, social behaviour, retardation or agitation, quality of rapport established. Speech. o Rate and quantity. Content. Flow e.g. rapid shifts or sudden interruptions. Mood and Affect. o Low mood, anxiety, elation. How mood varies. Subjective and Objective. Thoughts and Perceptions o delusions, illusions and hallucinations, obsessional thoughts. Thoughts of harm to self or others. Cognition. o Orientation, attention and memory e.g MMSE Insight. Does the patient think they are ill? What kind of illness? Do they think they need treatment and if so, what kind.
Drug treatment
Drug Usage Comment.
Anxiolytics
Neuroleptics Schizophrenia/hyperkinetic Phenothiazines eg. chlorpromazine syndrome Butyrophenones, eg. Haloperidol Complex tics/ Tourettes syndrome
Tricyclic antidepressants
Imipramine/amitriptyline Clomipramine
Effective, but high relapse rate Most useful with persistent and sustained mood disturbance
Stimulants Methylphenidate
Hyperkinetic syndrome
Effective in the short term. Long term effects on growth. steep and appetite
Fenfluramine
Effectiveness not established. Side effects include irritability, anorexia and weight loss
Close supervision of blood levels for signs of toxicity Facilities formation and Passage of feces
Laxatives, e.g. bulkforming (methylecellulose) Stimulants (senna) softener (dioctyl) Central alpha agonist. e.g. clonidine
Extinction Punishment Application of aversive stimuli Removal of reinforcement Shaping, prompting and fading
Depressive disorder
Conduct disorders
Hyperactivity syndromes
Tics
Child
&
Adolescent
Psychiatry Care
Hospitals
Child and Adolescent Psychiatry Services :NIMHANS Banglore CAPU : Central Institute of Psychiatry, Ranchi
Research Shastri PC, Shastri JP, Shastri D. Research in child and adolescent psychiatry in India. Indian J Psychiatry [serial online] 2010 [cited 2010 Nov 24];52:219-23. Available from: http://www.indianjpsychiatry.org/text.asp?2010/52/7/219/69235
Conclusion
Child/adolescent psychiatric nursing is concerned with caring and managing mental, emotional, and behavioral disorders of childhood and adolescence.
References
1. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry. 9th ed. Hong Kong :William and Wilkinson Publishers ;1998. 2. Friedman ES, Thase ME, Wright JH. Cognitive and behavioral therapies, in Psychiatry, Third Edition. Edited by Allan Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B. First and Mario Maj. John Wiley & Sons, Ltd, 2008. 3. Hoare P. Essential child psychiatry. Churchill Livingstone.1993.