Child psychiatry is concerned with the assessment and treatment of children's emotional and behavioral problems. 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. 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.

Three other considerations are of general importance in understanding children's behavior:

• the situation‑specific nature of behavior
• the impact of current stressful life circumstances, and
• the role of the family

Three main factors are identified:

Constitutional

• Genetic
• Temperamental
• Intra‑uterine disease or damage
• Birth trauma

Environmental

• Family
• School
• Community

Physical damage or illness

• Especially neurological disease

DSM‑IV‑TR and ICD‑ 10 classification systems (modified for child psychiatry)

Clinical syndromes of DSM‑IV TR and ICD‑10

Causative factors in childhood disturbances (epidemiological research findings)

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

Assessment is more time consuming in child psychiatry than in other branches of psychiatry or medicine. It has three components

• The diagnostic assessment interview
• Psychological assessment
• Information about the child and parents from other professionals

• Behaviour problems
• Feeding and eating difficulties
• Sleep disorder & Disorders of attachment
• The psychiatric aspects of child abuse

• Temper tantrums
• Breath holding attacks
• Thumb‑sucking and nail biting
• Eating disorders
• Rumination disorder of infancy
• Repeated regurgitation of food in the absence of any gastrointestinal abnormality with failure to gain weight or even a loss of weight. Onset is usually, between 3 months and 12 months of age.

  In many cases, it is a reflection of the disturbed mother‑ child relationship.

Non-organic failure to thrive (NOFTT)

This usually manifests itself in the first year of life as persistent failure to gain weight. The child is below the third percentile for weight, with additional evidence of developmental and cognitive delay. Extensive support and counseling is the mainstay of treatment.

Usually presents as idiopathic short stature. It shares many, features of NOFTT.

This is defined as the ingestion of inedible material such as dirt or rubbish. It is a normal transitory phenomenon during the toddler period. Persistent ingestion is found among mentally retarded, psychotic and socially deprived children. Lead poisoning, though always mentioned. is a possible but uncommon danger from pica.

Psychiatric aspects of child abuse

Originally the term child abuse was restricted to the battered baby syndrome. But it has now been extended to include physical abuse, emotional abuse, sexual abuse and neglect.

Common features of abused children and their families

Vulnerability factors in the abused child

• Product of unwanted pregnancy
• Unwanted child in family
• Low birth weight
• Separation from mother in neonatal period
• Mental or physical handicap
• Habitually restless sleepless or incessantly crying
• Physical unattractiveness

High‑risk factors in the parents

• Single parent
• Young as children
• Low self‑esteem
• Unrealistic expectations of child and his‑development
• Inconsistent or punishment oriented discipline

Adverse social circumstances

• Low income or unemployment
• Social isolation
• Large family

Three separate stages can be identified in the investigation of suspected child abuse:

• The detection and disclosure phase
• Child protection and legal considerations
• Therapeutic and practical support for the child and family in the immediate and long term.

Childhood Autism

Clinical features

• Impaired social relationships
• Language abnormalities
• Restricted repertoire of activities

Treatment

• Promotion of normal development
• Reduction of rigidity and stereotypies
• Alleviation of family stress

Rett's Syndrome

Disintegrative disorder

Asperger's syndrome

Schizophrenia and related conditions

Mood disorders

Emotional disorders

Conduct disorders

Three features characterize the behavior of the conduct‑disordered child:

• The range, frequency and severity of the disturbed behavior
• Disregard for and contravention of normally accepted standards of behavior
• Failure to modify or desist from the antisocial behavior despite persuasion or punishment

Mixed disorders of conduct and emotions

Common symptoms

• Aggression
• Stealing
• Lying
• Vandalism
• Arson and fire‑setting
• Breaking into and entering property
• Drug and solvent abuse

Causative factors

Family factors

• Marital/parental disharmony
• Parental violence
• Lack of affection and rejection
• Ineffective and inconsistent discipline
• Large family size

Individual characteristics

• Genetic
• Temperamental
• Intelligence
• Physical illness

Community influences

• Peers
• Schooling
• Neighborhood

Assessment

General physical state

• Neurological status
• Stature

Psychiatric state

• Mood disturbance
• Additional affective symptoms (anxiety depression)
• Self esteem
• Intelligence level and educational attainments
• Reading retardation
• Presence of specific disorder amenable to treatment (e.g. enuresis)

Social assessment

• Family attitudes
• Family communication factors
• Family models
• School functioning
• Peer relationships and models
• Community influences

Treatment

• Working with the family
• Counseling for the parents
• Family therapy for the whole group
• Behavoiur modificationsymptom management, for instance aggression
• Remedial education
• Treatment of physical problems
• Help with socioeconomic disadvantagesupport for schooling
• Removal from home including reception into care and/or residential schooling when necessary

ENUERESIS

• Involuntary passage of urine, in the absence of physical abnormality, after the age of 5 years in a child of normal ability

Causative factors in nocturnal enuresis

Individual factors

• Genetic
• Low intelligence
• Psychiatric disorders
• Urinary tract infection
• Small functional bladder capacity

Environmental factors

• Stressful life events
• Large family size
• Social disadvantage

Assessment and management

History

• Family history of nocturnal enuresis
• Previous treatment
• Sleeping arrangements
• Concurrent encorpesis

Examination

• Back and lower limb reflexes
• Urine specimen to exclude renal failure and diabetes
• Mental state of the child

Treatment

• Minimize handicap
• Accurate history record of nocturnal enuresis
• Enuresis alarm
• Other treatments (for instance tricyclic antidepressants)

Is the inappropriate passage of formed faeces, usually in the underclothes in the absence of any physical pathology after 4 years of age.

Assessment and management

Aims

• Promotion of bowel habit
• provement of parent‑child relationship

Assessment

• Exclude physical disease by history examination and investigation (if necessary)
• Previous treatments
• Parents’ and child's attitude to problem

Management

• Dietary
• Modify diet to ensure adequate intake of dietary fiber to increase fecal bulk

Medical management

• Bowel washout and/or enemas may be necessary initially
• Drugs
• Motor stimulant (senna laxatives)
• Bulk agents (lactulose)
• Suppositories are often useful as well

Psychological management

• Behavioral (star chart)
• Individual psychotherapy
  • Enlist cooperation
  • Show concern
  • Develop trust
• Parent counseling/ family therapy
  • Modify attitudes
  • Hostile interactions
  • Secondary problems

Clinical types of overactivity/hyperactivity

Normal variation

• Temperamental deviation
• Cognitive impairment

Pathological causes

• Hyperkinetic disorders
• Hypomania
• Anxiety state
• Conduct disorder
• Organic conditions
  1. Thyrotoxicosis
  2. Sydenham's chorea
  3. Lead intoxication
  4. Mental retardation. for example phenylketonuria or rubella
  5. Response to some drugs. for instance barbiturates or benzodiazepines

Miscellaneous disorders

Developmental disorders

• Disorders of speech and language
• Disorders of scholastic skills
• Disorder of motor function
• A mixed category of developmental disorder

Tic and other habit disorders

Sleep disorders

Eating disorders

ICD10 and DSMIV have four categories‑ of mental retardation:

• Mild (IQ 50‑69)
• Moderate (IQ 35‑49)
• Severe (IQ 20‑34)
• Profound (IQ less‑ than an 20)

The other important defining criterion is that there should be evidence of social impairment and limitation in the individuals’ daily activities and self care skills.

Approximately 40% have signs of significant psychological disturbance. Range of disorders is similar to children of average ability except that the following occur much more frequently

1.   Pervasive developmental disorders

2.   Pervasive hyperkinetic syndrome

3.   Severe stereotyped movement disorder

4.   Self‑injurious behavior and pica more common

Brain damage leading to:

1. Loss of specific' functions or skills
2. Active disruption of normal brain activity
3. Increased risk of epilepsy
4. Specific learning difficulties

Adverse temperamental characteristics:

1. Impulsivity
2. Overactivity
3. Distractibility

• Child social isolation and low self esteem
• Parents overprotection/rejection

Key elements are:

• Breaking the news
• Promotion of normal development
• Treatment of medical and behavioural problems
• Educational provision
• Genetic counseling
• Long term care work support

Treatment in child and adolescent psychiatry

Drug treatment

Behavioral psychotherapy

Behavioral techniques

•          Exposure techniques
•          Desensitization
•          Flooding
•          modelling
•          Response Prevention

Operant techniques

         Reinforcement

1.      Positive

2.      Negative

• Extinction
• Punishmen

1. Application of aversive stimuli
2. Removal of reinforce
3. Shaping, prompting and fading

Applications of Behaviour techniques

Reference

1. :Hoare P. Essential child psychiatry. Churchill Livingstone.1993