CHILD PSYCHIATRIC

DISORDERS

By- Rahul Dhaker

Asst. Professor, RCN

R Dhaker, Asst. Professor, RCN 1

 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.
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Cont…Introduction

• 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 ( ड टंग शन) between
disturbance and normality is often imprecise(इ साइस)
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.
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Differences of Child psychiatry from
adult psychiatry
• The child’s 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 psycho-pharmacotherapy 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
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Historical developments in Child
Psychiatry
• Child psychotherapy begins with Sigmund Freud's
case of Little Hans, a 5-year-old phobic boy.

• In 1935 Leo Kanner published the first textbook

on child psychiatry in English.

• Major contributers to child psychiatry are Donald

Winnicott, Anna Freud and Melanie Klein.
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 Etiological factors
• 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.
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• Important factors contribute to mental illness in
children are:
– Constitutional
– Environmental
– Physical damage or illness
– Family discord
– Parental deviance
– Social disadvantage
– Schooling
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Cont…Etiological factors

• Constitutional
– Genetic
– Temperamental
– Intra-uterine disease or damage
– Birth trauma
• Environmental
– Family
– School
– Community

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Cont…Etiological factors

• 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 of the father

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Cont…Etiological factors

• Social disadvantage
– Large family size'

– Overcrowding

– Father in unskilled occupation

• Schooling
– High pupil/ staff ratio

– High turnover of teachers

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 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)

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• 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.

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 History Taking
• Presenting complaint
• History of presenting complaint:
– Assessment of symptoms’ duration, severity and effect on
functioning.
– 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
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Cont…History Taking

• Developmental History
– 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.
– What was the child like before the current problem?

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Mental Health Examination
• Signs/ Symptoms and Behavior at the time of the interview.
• Appearance and Behavior-
– General appearance, facial appearance, social behavior, retardation or
agitation, quality of rapport established.
• Speech-
– Rate and quantity. Content. Flow e.g. rapid shifts or sudden interruptions.
• Mood and Affect-
– Low mood, anxiety, elation. How mood varies. Subjective and Objective.
• Thoughts and Perceptions-
– delusions, illusions and hallucinations, obsessional thoughts. Thoughts of
harm to self or others.
• Cognition (का नशन)-
– 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.

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 Attention Deficit
Hyperactivity Disorder

By- Rahul Dhaker

Asst. Professor,
RCN

R Dhaker, Asst. Professor, RCN 17

 Introduction
• Attention deficit hyperactivity disorder (ADHD)
is a behavioral disorder.

• Attention-deficit/hyperactivity disorder (ADHD) is

a brain disorder marked by an ongoing pattern of
inattention and/or hyperactivity-impulsivity that
interferes with functioning or development.

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Cont…Introduction

• Inattention(इनटे शन)
– means

– a person wanders off task,

– lacks persistence,

– has difficulty sustaining focus,

– and is disorganized; and

– these problems are not due to defiance or lack of

comprehension.
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Cont…Introduction

• Hyperactivity
– means
– a person seems to move about constantly,
– including in situations in which it is not appropriate;
– or excessively fidgets,
– taps, or talks.
– In adults, it may be extreme restlessness or wearing
others out with constant activity.
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Cont…Introduction

• Impulsivity
– means a person makes hasty actions that occur in the
moment without first thinking about them and that may
have high potential for harm; or

– a desire for immediate rewards or inability to delay

gratification.

– An impulsive person may be socially intrusive and

excessively interrupt others or make important decisions
without considering the long-term consequences.
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Signs and Symptoms

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 Inattention
• Overlook or miss details, make careless mistakes in
schoolwork, at work, or during other activities
• Have problems sustaining attention in tasks or play,
including conversations, lectures, or lengthy reading
• Not seem to listen when spoken to directly
• Not follow through on instructions and fail to finish
schoolwork, chores, or duties in the workplace or
start tasks but quickly lose focus and get easily
sidetracked
• Have problems organizing tasks and activities, such
as what to do in sequence, keeping materials and
belongings in order, having messy work and poor
time management, and failing to meet deadlines5
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 Cont…Inattention

• Avoid or dislike tasks that require sustained

mental effort, such as schoolwork or homework,
or for teens and older adults, preparing reports,
completing forms or reviewing lengthy papers
• Lose things necessary for tasks or activities, such
as school supplies, pencils, books, tools, wallets,
keys, paperwork, eyeglasses, and cell phones
• Be easily distracted by unrelated thoughts or
stimuli
• Be forgetful in daily activities, such as chores,
errands, returning calls, and keeping appointments
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 Hyperactivity-Impulsivity
• Fidget and squirm in their seats
• Leave their seats in situations when staying seated
is expected, such as in the classroom or in the
office
• Run or dash around or climb in situations where it
is inappropriate or, in teens and adults, often feel
restless
• Be unable to play or engage in hobbies quietly

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Cont…Hyperactivity-Impulsivity

• Be constantly in motion or “on the go,” or act as

if “driven by a motor”
• Talk nonstop
• Blurt out an answer before a question has been
completed, finish other people’s sentences, or
speak without waiting for a turn in conversation
• Have trouble waiting his or her turn
• Interrupt or intrude on others, for example in
conversations, games, or activities

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Treatment and Therapies

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• Treating ADHD often requires medical, educational,
behavioral and psychological intervention.
• This comprehensive approach to treatment is
sometimes called “multimodal” and, depending on
the age of the individual with ADHD, may include:
– parent training
– medication
– skills training
– counseling
– behavioral therapy
– educational supports
– education regarding ADHD
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 ADHD and the Classroom
• Some tips to share with teachers for classroom success:
– Make assignments clear – check with the student to see if they
understood what they need to do
– Give positive reinforcement and attention to positive behavior
– Make sure assignments are not long and repetitive. Shorter
assignments that provide a little challenge without being too hard
are best.
– Allow time for movement and exercise
– Communicate with parents on a regular basis
– Use a homework folder to limit the number of things the child
has to track
– Be sensitive to self-esteem issues
– Minimize distractions in the classroom
– Involve the school counselor or psychologist

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 Tips for Parents
• Create a routine. Try to follow the same schedule every day,
from wake-up time to bedtime.
• Get organized. Encourage your child to put schoolbags, clothing,
and toys in the same place every day so your child will be less
likely to lose them.
• Manage distractions. Turn off the TV, limit noise, and provide a
clean workspace when your child is doing homework. Some
children with ADHD learn well if they are moving, or listening to
background music. Watch your child and see what works.
• Limit choices. Offer choices between a few things so that your
child doesn’t get overwhelmed and overstimulated. For
example, offer choices between a few options, such as this
outfit or that one, this meal or that one, or this toy or that one.

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 Tips for Parents
• Be clear and specific when you talk with your child. Let your child know you are
listening by describing what you heard them say. Use clear, brief directions when
they need to do something.
• Help your child plan. Break down complicated tasks into simpler, shorter steps.
For long tasks, starting early and taking breaks may help limit stress.
• Use goals and praise or other rewards. Use a chart to list goals and track positive
behaviors, then let your child know they have done well by telling your child or
rewarding efforts in other ways. Be sure the goals are realistic—baby steps are
important!
• Discipline effectively. Instead of yelling or spanking, use timeouts or removal of
privileges as consequences for inappropriate behavior.
• Create positive opportunities. Children with ADHD may find certain situations
stressful. Finding out and encouraging what your child does well — whether it’s
school, sports, art, music, or play — can help create positive experiences.
• Provide a healthy lifestyle. Nutritious food, lots of physical activity, and sufficient
sleep are important; they can help keep ADHD symptoms from getting worse.

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 Introduction
• Anxiety disorder can prevent your child from making
friends, raising a hand in class, or participating in
school or social activities.
• Feelings of being ashamed, afraid, and alone are not
uncommon.
• Research has shown that if left untreated, children
with anxiety disorders are at higher risk to perform
poorly in school, miss out on important social
experiences, and engage in substance abuse.
• Anxiety disorders also often co-occur with other
disorders such as depression, eating disorders, and
attention-deficit/hyperactivity disorder (ADHD).
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• There are eleven different "types" of anxiety
disorders, and each anxiety disorder has a list of
commonly occurring symptoms clustered into 4
areas:
• Physical responses
• Thoughts
• Emotions
• Behaviors
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RCN

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• The term “anxiety disorder” refers to a group of
mental illnesses that includes
• Generalized anxiety disorder (GAD),
• Obsessive-compulsive disorder (OCD),
• Panic disorder,
• Posttraumatic stress disorder (PTSD),
• Social anxiety disorder (also called social
phobia), and
• Specific phobias.
• Each anxiety disorder has specific symptoms.

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 Etiology
• Experts don't know exactly what causes anxiety
disorders.

• Several things seem to play a role, including

genetics, brain biochemistry, an overactive fight–
flight response, stressful life circumstances, and
learned behavior.

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Cont… etiology

• Experts believe anxiety disorders are caused by a

combination of biological and environmental factors,
similar to allergies and diabetes.
• Stressful events such as starting school, moving, or the
loss of a parent or grandparent can trigger the onset of
an anxiety disorder, but stress itself does not cause an
anxiety disorder.
• Anxiety disorders tend to run in families, but not
everyone who has one passes it on to their children.
• Neither you nor your child is at fault, and an anxiety
disorder diagnosis is not a sign of weakness or poor
parenting.

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 Signs of Anxiety
• Physical Signs of Anxiety
– Blushing
– Sweating
– Trembling
– Shaky voice or difficulty speaking
– Rapid heartbeat
– Having trouble breathing
– Upset stomach or nausea
– Muscle tension

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• Emotional Signs of Anxiety
– Cries often.
– Acts extremely sensitive.
– Becomes grouchy or angry without any clear reason.
– Afraid of making even minor mistakes.
– Has extreme test anxiety.
– Has panic attacks (or is afraid of having panic attacks).
– Has phobias (about bees, dogs, etc.) and exaggerated fears (about things like
natural disasters, etc.).
– Is afraid people will find out about his learning and attention issues (more so
than other kids with the same issues).
– Worries about things that are far in the future (for example, a third grader
might worry about starting middle school).
– Is worried or afraid during drop-offs (at daycare, school, relatives’ homes,
etc.).
– Has frequent nightmares about losing a parent or loved one.
– Gets distracted from playing by his worries and fears.
– Has obsessive thoughts or compulsive behaviors (finger tapping, hand
washing, etc.).
– Is starting to have meltdowns or tantrums.

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• Behavioral Signs of Anxiety
– Asks “what if?” constantly. (“What if an earthquake
happened?”)
– Avoids participating during circle time or other class activities.
– Remains silent or preoccupied when he’s expected to work with
others.
– Refuses to go to school.
– Stays inside, alone, at lunch or recess.
– Avoids social situations with peers after school or on weekends
(extracurricular activities, birthday parties, etc.).
– Refuses to speak to peers or strangers in stores, restaurants, etc.
– Becomes emotional or angry when separating from parents or
loved ones.
– Constantly seeks approval from parents, teachers and friends.
– Says “I can’t do it!” without a real reason.

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Treatment

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• Anxiety disorders can be very difficult to cope with as
it does not only have psychological symptoms but a
mixture of both physical and psychological
manifestation.
• But like any other mental illness, anxiety disorders
also has quite a few treatment options.
• If you are looking for how to cure anxiety disorder,
then an appropriate treatment program is made for an
individual after an in-depth testing, psychometric
assessment, and discussion with a mental health
professional.
• There is two mental health professional who engage in
the treatment of any mental disorders; psychiatrists
and psychologists.
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 Psychotherapy
• Cognitive behavioral therapy:
– Among the various psychotherapies available cognitive
behavioral therapy or CBT is the most frequently used and
recommended. In CBT the whole goal is to change the
individual’s thought process.
– Here it is believed that an inner negative thought exists that
influences behavior and which needs to be changed.
• Acceptance and commitment therapy:
– Acceptance and commitment therapy or ACT is a new emerging
therapy whose aim is to accept and bring a change.
– Here the belief is that; trying to control the anxieties will only
create an additional issue.
– So instead of that here they look to accept the anxious
thoughts, become aware and mindful of them and then bring a
change.

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 Biofeedback
• Neurofeedback:
– Neurofeedback is an intervention wherein sensors are
attached to the head.
– These sensors record and process the brain activity and
display it on a screen in the form a game.
– Here the individual scores only when their brain activity
functions in a particular manner following a particular
pattern.
– Neurofeedback helps the individual focus and concentrate
which is a difficult task in anxiety especially when
individual are constantly engaged in anxious thoughts.
– Other biofeedback techniques are also used to help the
individual relax and control their thoughts.
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Transcranial magnetic stimulation
• This therapeutic intervention uses magnetic fields
to induce small electric current to specific regions
of the brain.
• This is often recommended when psychotherapy
and medications do not show expected
improvements.
• Transcranial magnetic stimulation is a safe non-
invasive intervention and is administered after
looking at the progress of the patient and their
physical condition.
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 Medications
• There are various medications prescribed for anxiety
disorders involve physical symptoms.
• These medications help in reducing the physical symptoms
and help the individual relax.
• Many antidepressants can work for anxiety disorders. They
include escitalopram (Lexapro) and fluoxetine (Prozac).
• Certain anticonvulsant medicines (typically taken
for epilepsy) and low-dose antipsychotic drugs can be added
to help make other treatments work better.
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