The psychiatric disorders that present in childhood are distinct from those in adults because they arise within complex and intimate family relationships, and are influenced by the development stage of the child. Children also present special challenges for assessment and treatment. Pervasive development disorders
Specific development disorders
Hyperkinetic disorders
Conduct disorders
Emotional disorders
Psychiatric aspects of child abuse
Disorders of elimination
Table 1 Classification of psychiatric disorders of childhood and adolescence
Normal childhood development
It derived from his study of young children separated from their mother in hospital. It serves strengthen the bond between mother and child and has the evolutionary function of ensuring the child is protected from predators. If the attachment is insecure, because the parent fails to respond to the child’s need for attention or holding, or is inconsistent, the child will have difficulty exploring and separating. Assessment of Children
The way in which a psychiatric history is taken and the child is examined will depend upon the age, confidence and language skills of the child. Presenting complaint-described by both the parent and child. Recent behaviour or emotional difficulties-including general health, mood, sleep, appetite, elimination, relationships, antisocial behaviours, fantasy life and play, and school behaviour.
Personal history-pregnancy, birth, milestones (motor, speech, feeding, toilet training, social behaviour), medical history, separations from parents, schools attended and progress in them.
A mental state examination of the child should be completed, although this will often rely on watching behaviour and play. Behaviour-activity level, interactions with parents, motor function, attention and persistence with tasks.
Pervasive Developmental Disorder (Autism)
Attachment behaviour from 7 months
Separation anxiety
Complex language skills
Development of sexual identity
Identification with parents
Adolescence
Establishment of autonomy from parents
Peer group relationships are very important
Table 2 Normal childhood development
Specific Developmental Disorders
Conduct disorders and specific reading disorder frequency co-exist.
Hyperkinetic Disorder
Behavioural therapy, using a system of rewards for good behaviour, is also useful for these children.
Conduct Disorder
The child’s age must be taken into account, and normal naughtiness should not be considered a sign of conduct disorder. A third of cases have specific reading disorder, and there is considerable overlap with hyperactivity disorder. Conduct disorders are common, present in at least 4% of children with a peak in the 12 to 16 year age range, and are three times more common in boys than girls.
There are two types of conduct disorder:
Socialised conduct disorder. Unsocialised conduct disorder. The antisocial behaviour therefore occurs alone. Some degree of emotional disorder is often also present in these children.
The causes of conduct disorders are a complex interaction between the biological make-up of the child, family influences and environmental factors as summersied Figure 1. Conduct disorders are likely to develop if parents fail to give clear boundaries, monitor behaviour and administer ineffective or inconsistent discipline. Improving parenting skills is likely to improve behaviour even if other causative factors are present. Emotional Disorders
Emotional disorders of childhood are characterised by anxiety and depression. They are present in 2-3% of children and unusually for childhood psychiatric disorders are more common in girls. Separation anxiety disorder
It is normal for toddlers and pre-school children to feel some anxiety over real or threatened separation from their parents. In separation anxiety disorder the anxiety is unusually severe or occurs in older children, and causes some problems in social functioning such as preventing the child from attending school. Anxiety disorders of childhood
Family influences
absent parent
parental violence, alcoholism, dissocial personality disorder
poor parenting
Child
genetic factors
brain damage
school disciplinary code
peer group influences
social deprivation
Figure 1 Aetiology of conduct disorder
Depressive illness
School refusal
In school refusal the child refuses to attend school because of specific fears about the school, the journey to it or separation anxiety. A grade reintroduction may be necessary, with support for both child and parents.
Child Abuse
Child abuse may take the form of neglect, emotional, physical or sexual abuse. It plays a role in precipitating psychiatric disorders in children which may continue through to adulthood. It is essential that all professionals who come into contact with children are alert to the possibility of abuse playing a role in the problems presented by a child and its family.
Table 3 Comparison of characteristics of children presenting with persistent truancy, and school refusal
School refusal
Truancy
Absence from school known to parents
Absence from school concealed from parents
Increase with age
Fear of school or separation anxiety
No emotional disorders
Increased in lower social classes
Dysfunctional family
Overprotective parenting
Harsh parenting
There are many contributor factors in the abuse of children. Some parents are more likely to be abusive, particularly those who have themselves been abused as children, live in poor socioeconomic circumstances and have unrealistic styles of disciplining their children.
Sexually abused children may present with a sudden change in their social behaviour or academic performance, or with conduct disorders. Social services must be informed of any disclosure of sexual abuse by a child and instigating child-care proceedings. The emotional effects of childhood sexual abuse may be addressed in individual psychotherapy with the child. Disorders of Elimination
Enuresis
Encopresis
Most children are faecally continent by the age of 3 years. Adolescence
The pattern of psychiatric disorders changes as children become adolescents. Problems with alcohol and drug abuse and eating disorders also tend to emerge at this time. Development disorders have usually resolved.
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