I n t r o d u c t i o n 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. Hi s t o r i c a l d e v e l o p me n t s i n C h i l d P s y c h i a t r y 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. D i f f e r e n c e s o f C h i l d p s y c h i a t r y f r o m a d u l t p s y c h i a t r y 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 E t i o l o g i c a l f a c t o r s 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. Important factors contribute to mental illness in children are: Constitutional Genetic Temperamental Intra-uterine disease or damage Birth trauma Environmental Family School Community Physical damage or illness Especially neurological disease Family discord Marital discord Children in care Children not living with both natural parents Parental deviance Psychiatric disorder in the mother Criminal record in the father Social disadvantage Large family size' Overcrowding Father in unskilled occupation Schooling High pupil/ staff ratio High turnover of teachers C l a s s i f i c a t i o n & P r e v a l a n c e 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 DSM-IV-TR and ICD- 10 classification systems (modified for child psychiatry) DSM-IV-TR ICD-10 Axis I Clinical syndrome Axis 2 Mental retardation Pervasive developmental disorders Specific developmental disorders Axis3 Physical disorders/illness Axis 4 Severity of current Psychosocial stressors Axis 5 Highest level of adaptive functioning in past year Axis I Clinical syndrome Axis 2 Disorders of psychological development Axis3 Mental retardation Axis 4 Medical illness Axis 5 Abnormal psychosocial conditions Axis 6 Psychosocial disability
Clinical syndromes of DSM-IV TR and ICD-10 DSM-IV_TR ICD-10 Axis I Disruptive behavior disorders Attention deficit hyperactivity disorder (ADHD) Conduct disorder Oppositional defiant disorder Anxiety disorders of childhood or adolescence Separation anxiety disorder Avoidant disorder of childhood and adolescence Over anxious disorder Eating disorders Anorexia nervosa Bulimia nervosa Pica Rumination disorder of infancy Gender disorders Tic disorders Elimination disorders Functional encopresis Functional enuresis Miscellaneous disorders Axis 2 Pervasive developmental disorders Axis I 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 C h i l d P s y c h i a t r i c A s s e s s me n t 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? Mental Health Examination 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. Treatment in child and adolescent psychiatry Drug treatment Drug Usage Comment. Anxiolytics Anxiety /phobic conditions Short term adjunct to behavior treatment Neuroleptics Schizophrenia/hyperkinetic syndrome Complex tics/ Tourettes syndrome
Phenothiazines eg. chlorpromazine Butyrophenones, eg. Haloperidol Extrapyramidal side effects common Tricyclic antidepressants Imipramine/amitriptyline Clomipramine Enuresis Major affective disorder Effective, but high relapse rate Most useful with persistent and sustained mood disturbance Stimulants Hyperkinetic syndrome Effective in the short term. Long term effects on growth. steep and appetite Methylphenidate Fenfluramine Pervasive developmental disorder Effectiveness not established. Side effects include irritability, anorexia and weight loss Hypnotics, eg. trimeprazine/promethazine Persistent. sleep disorder in preschool children Only short term Lithium Recurrent bipolar affective disorder Close supervision of blood levels for signs of toxicity Laxatives, e.g. bulkforming (methylecellulose) Stimulants (senna) softener (dioctyl) Encopresis with constipation
Facilities formation and Passage of feces Central alpha agonist. e.g. clonidine Unresponsive Tourette's syndrome Sedation and rebound hypertension Behavioral psychotherapy Behavioral techniques Exposure techniques Desensitization Flooding Modelling Response Prevention Reinforcement Extinction Punishment Application of aversive stimuli Removal of reinforcement Shaping, prompting and fading Applications of Behaviour techniques
Disorder Technique Anxiety and phobic Desensitization, flooding, relaxation Obsessivecompulsive Relaxation Relapseprevention Depressive disorder Cognitive behavioural Relaxation Conduct disorders Positive reinforcement Extinction Hyperactivity syndromes Time out Positive reinforcement Extinction Pervasive developmental disorders Timeout Positive reinforcement Extinction Time out Aversive techniques Encopresis/enuresis Positive reinforcement Mental retardation Positive reinforcement Extinction and timeout Prompting and shaping Aversive techniques Tics Massed practice. C h i l d & A d o l e s c e n t P s y c h i a t r y C a r e Ho s p i t a l s