Managing the child with a mental disorder

Introduction
• A relatively young super-speciality – certification in the US in the late 1950’s
• Mental disorders amongst children however recognized for several centuries
• Roots of child psychiatry lie in various areas and disciplines: Juvenile justice system, the school system, psychology and psychometrics, child welfare
systems, child guidance clinics, paediatrics, adult psychiatry etc.
• Some problems the speciality addresses includes responding to questions:
• Why a child consistently misbehaves; what is the nature of an intellectual impairment; why speech development is delayed or peculiar; why
a child is odd or socially distinct from others? Etc.
• How can these children be helped?

Mental health: Capacity of individual, group and environment to interact in a manner that promotes:
a. Subjective well being
b. Optimal development and use of mental abilities (cognitive, affective and relational)
c. Achievement of individual and collective goals consistent with justice
d. Attainment and preservation of conditions of fundamental equality
• Development stage (cognitive, language, motor, moral and social) versus normality and abnormality
• Basic premises:

• Latent psycho-social resources and drive to develop

them
• Progress sequence in realization of psycho-social
resources – variation in rate and intensity of Child
realization Family
School
• Realization of resources a response to life
Community
challenges – common and uncommon
• Challenges generate positive and negative affects –
success involves an individualized blending with
predominant positive outcome
 Classification of disorders during childhood and adolescence
• DSM IV development perspective
• Four broad groups identified with distinction between disorders first diagnosed in infancy, childhood or adolescents and other disorders
 Disorders diagnosed in infancy or early childhood and not in later years such as reactive attachment disorder of childhood
 Disorders diagnosed in early childhood that continue to be present in adulthood such as mental retardation
 Disorders that are only diagnosed in childhood such as conduct disorder that often result in specific adult diagnoses – antisocial personality
disorder.
 Adult disorders that may be diagnosed in children using similar or slightly modified criteria.
• Increasing shift also to diagnosing children using adult criteria
• Modification to accommodate age/maturity related differences in experiences, manifestation and expression for anxiety, mood and
adjustment disorders as well as schizophrenia, where research findings indicate this need.
 DSM-IV disorders usually first diagnosed in infancy childhood or Selected additional disorders that may be diagnosed in children
adolescence Delirium
Mental retardation Dementia
Learning disorders Substance related disorders
Motor skills disorders Schizophrenia
Communication disorders Depressive disorders
Pervasive development disorders Bipolar disorders
Attention deficit and disruptive behaviour disorders Anxiety disorders
Feeding and eating disorders of infancy and early childhood  Panic disorders
Tic disorders  Agoraphobia without PD
Elimination disorders  Specific phobia
Others  Social phobia
 Separation anxiety disorder  Obsessive – compulsive disorder
 Selective mutism  Posttraumatic stress disorder
 Reactive attachment disorder of infancy or early childhood  Acute distress disorder
 Stereotypic movement disorder  Generalized anxiety disorder
 Disorders of infancy, childhood and adolescents NOS  Anxiety disorder due to a general medical condition
Somatoform disorders
Gender identity disorders
Eating disorders
Sleep disorders
Adjustment disorders
Other conditions that may be the focus of clinical attention such as abuse
or neglect; relational problems
Multi-axial system (5) ICD 10:
1. Clinical psychiatric disorder
2. Specific delays in development
3. Intellectual level
4. Medical conditions
5. Abnormal psycho-social situations

Multi-axial system (5) DSM IV

1. Clinical disorders and other conditions, which may be the focus of attention.
2. Personality disorders and maladaptive traits; Mental handicap.
3. General medical condition
4. Psycho-social and environmental problems
5. Global assessment of functioning (1-100 point scale).
• Measurements of psychopathology:
 Based on Western middle class norms, and
 Differing social contexts as well as inter-ethnic developmental differences need to be thought about when attempting to transfer these norms to non-
western settings.
• Symptoms of psychopathology in a child may be manifestation of difficulties within the family, either in interactions between family member(s) and the
child, between members within the family, or between the family and the wider community.
• Categories of disorder
 Serve as rough guides to aetiology, treatment and prognosis
 Individualized information on child and the family required to intervene.
• Many other psychological problems such as non-specific somatic symptoms and non-accidental injury will not present to a mental health professional
but will be seen by other services.
• It is likely for a child/adolescent to present with more than one disorder (co-morbidity).
• It is likely that some symptoms may be temporary developmental related disturbances.

Diagnostic assessment in children:

• Comprehensive history taking, careful observation and skilful eliciting of signs and symptoms apply to the assessment of children.
• Marked difference from adults due to developmental processes:
 Children are rapidly changing; each child is compared to what is the norm for children at a similar stage of development.
 What is normal at one stage may be abnormal at another
 Each aspect of child's own development; evaluated domains include:
 Gross and fine motor control
 Language
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  Social
 Emotional and
 Cognitive development.
 Assessment to achieve valuable information involves
 Interviewing using developmentally appropriate language
 Use of drawing techniques
 Use of imaginative play techniques

Beginning an assessment:
 Child usually brought by an adult:
 Involvement of parents as major role models
 Involvement of the school – teachers report
 Important to set the stage

Psychosocial history:
 Family constellation: who present, attachment to child, relationships with family members, caregivers in the absence of parents.
 Developmental history: birth, pregnancy, labour, post-natal. Developmental milestones, feeding, toilet training and sleep habits. Notable fears,
behaviours and traits.
 Medical: full history, hospitalisation, surgical procedures, and child’s response to separations from parents.
 School: academic performance and general behaviour
 Family functioning:
 Parental background: origin, health, child rearing practices, schooling and work record
 Present family life leisure and recreation
 Nature of problem solving skills: discipline practices; decision making, marital or couple relationship, religious practices and financial status.
 Parent’s description of child; feelings towards and expectations from.
 Accompanying adult often provides much of background
 If one or both parents present, information on family relationships can be assessed directly by observing interactions between parents and
between the parents and child.
 Evaluation of family dynamics and the emotional state of family members may provide insights that might explain the child’s problems – “cry
for help” to cope with a difficult situation within the family.
 Parents often are less aware of emotional symptoms' (anxiety, depression and suicidality) as well as behavioural symptoms such as substance
abuse and delinquent acts.

Interviewing the child:

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  Purpose
 Establishing a diagnosis
 Medical legal assessment
 Goal
 Provide safe and neutral space – gain trust
o Young – with parents
o Mid-childhood adolescents - alone
 Get child's perspective
Information from interview
 Presenting problem
 What and how questions, less Why questions for younger children.
o What do you think of the problem?
o How does the problem affect you (school, with friends at home)?
 School
 How performing, coping with homework, subjects and teachers liked best.
 Peers
 Special friends, best friends, what activities with peers, bullying, loneliness etc.
 Appetite
 Sleep
 Dreams
 Worries
 Depression
 Fears
 Anger
 Home environment
Learning about a child’s inner world can be achieved using more tangential questions or drawing and imaginative play techniques.

Psychological tests and assessment important:

 Systematic procedure for observing behaviour
 Comparative assessment using norms
 Intelligence testing and educational functioning
 Self-concept, depressive symptoms etc.
Use of multiple sources of information
 Different behaviours in different settings and different perspectives of adults on what is abnormal (the depressed mother, the abusive parent).
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 • School
• Social welfare agencies
• Child guidance / counselling services
• Paediatricians
• Court records
• Other family members e.g. grandparent.
• Day care providers etc.

Child mental status evaluation:

Appearance
Motor activity
Behaviour
Speech
Language
Social relatedness
Affect and mood
Cognitive functioning
Thought process and content

Epidemiology
Western studies:
Overall prevalence:
 14-20%
 Conditions leading to severely impaired functioning 7%.

Emotional and behavioural disorders:

 Most common conditions, prevalence as follows;
• 22% Pre-school children.
• 25% Urban middle childhood; ~1/2 this prevalence for children living outside big cities.
• ~20% of both young and middle adolescents.
• Lifetime risk through out childhood approx. 1 in 5 children.
Mental handicap:
• 3/1000 children IQ <50 (what is the intelligence quotient, how is it measured)
• 2.5% mild mental retardation (IQ 50-70)
Specific learning disabilities:

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 • 10% of 10 year olds in big cities, ½ outside big cities reading age below 2SD of expected reading age based on non-verbal ability.
Children with chronic physical illnesses
• 5% tend to have a psychiatric disorder;
• Has implications of health care of children, attempts to anticipate and minimize psychosocial impact of illness on child and family.

Data from developing countries:

 Minimal.
 Available suggests prevalence rates not lower than in the West.
 Ethiopia and Nigeria; 25-30% of children attended at primary care facilities had psychiatry disorder, of which only about 20% with such disorders
are identified. These rates do not reflect culture bound syndromes such as “brain fag syndrome”, or psychopathology, which does not meet criteria
for disorder.

Etiological factors
a; Child related factors:
Genetic:
Through Polygenic inheritance of intelligence and temperament
Congenital chromosal abnormalities: e.g. fragile X syndrome
Genetic factors implied in specific disorders such as infantile autism, MDD, conduct disorders, eating disorders.

Temperament:
Longitudinal studies indicate temperamental predisposing factors can be identified in children below 2 years.
⇒ Difficult children (higher likelihood of future disorder); slow adaptation to new situations with intense emotional response to separation from
mother.
⇒ Easy children (lower likelihood of future disorder): rapid adaptation, mild behavioural response to separation from mother.

Physical illness.
 Serious physical illness of any kind
 Physical illnesses affecting the brain
o Physically ill 10-11 years old children indicate
 12% with disorders
 increases to 34% if illness involves brain
 direct relationship with severity of brain disorder
 as common in brain damaged boys and girls.

Psychological factors:

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Some psychological factors such as low self-esteem, poorly developed coping mechanisms, lack of school readiness etc associated with childhood
psychopathology.

B; Environmental factors:
Family
 lack of stability, security and consistency in emotional warmth, acceptance, help and constructive discipline
 high discord within the family
 low social economic status
 large family size
 parental criminality
 maternal psychiatric disorder
 prolonged separation from parental figures
o age at which separation occurred
o reasons for separation
o previous relationship with parental figures
o method of separation and
o quality of substitute parental care is also important.
 Protective factors are therefore adequate mothering skills, affectionate ties within the family, sociability, capacity for problem solving in the child and
availability of support outside the family.

School related factors:

 Deficiencies in facilities – psychological services, special and early education programmes
 Poor teaching methods and communication affect academic outcomes and behavioural adjustment
 Poor assessment of school readiness, school failure and behavioural maladjustment – risk loss of an essential component of mental health.

Social and cultural factors

 Direct impact through family: Easy access to drugs and alcohol in poverty stricken areas – delinquency
 Urbanization – increase exposure to disease of affluence and congestion, as well as stress
o Breakdown of traditional social support structures, poor service provision in suburbs and low community cohesion – stress and crime
 In early years indirect impact through influence on patterns of family life; more direct impact as child grows older and spends more time outside the
home. Examples include:
o the influence of crowded inner city areas;
o the impact of rapid change in social norms and values on parenting practices,

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 o levels of societal violence, in particular frequent civil wars in the African setting are important societal factors, as is refugee status, poor
adherence to the Bills of Rights, gender conflicts and domestic violence etc.
o Rates of psychiatry disorder are often higher in socially disadvantaged communities.

Management
family approach is fundamental
Liaison with other agencies-school, medical, social services
Drugs
Of limited vales except with
Epilepsy
Depressive disorders
Attention deficit disorders
Occasional nocturnal enuresis
BNF as reference-age, body weight

Psycho-social - Mainstay
 Brief and problem specific-behavioral approaches most common: Encourage new behaviours through reinforcement and modelling
o Trusting relationship: acceptance and avoid criticism
o Allow expression of feeling and explore alternative ways of behaving
 Family therapy: symptoms considered an expression of malfunctioning in the family
 Group therapy: in adolescents particularly useful
 Parents support groups
 Education and occupational therapy
o Special education programs
o Occupation therapy for social interaction improvements and development of practical skills

Child-hood/ Adolescent disorders (individual reading tasks priority to disorders in bold and *)
Anxiety disorders:
*Separation Anxiety Disorder (affects both children and adolescents) – School phobia
Panic disorder with or without agoraphobia (0.6% prevalence)
Generalized anxiety disorder (4% prevalence in adolescents)
Specific and social phobia
Obssessive compulsive disorder
Post-traumatic stress disorder
Other emotional disorders - Adjustment disorders and depression in adolescents
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Attention deficit disorder and disruptive behaviour disorder
Conduct disorder
Pervasive developmental disorders (PDD)
*Infantile autism (read)
Childhood disintegrative psychoses
Rett’s disorder
Asperger’s disorder
PDD not otherwise specified.
Mental Handicap/ Retardation

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