managing the child with a mental disorder

8/8/2019 Managing the Child With a Mental Disorder

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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 realization

• Realization of resources a response to life

challenges – common and uncommon• Challenges generate positive and negative affects –

success involves an individualized blending with predominant positive outcome

Child

FamilySchool

Community



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 personalitydisorder.

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

adolescence

Mental retardation

Learning disorders

Motor skills disorders

Communication disorders

Pervasive development disorders

Attention deficit and disruptive behaviour disorders

Feeding and eating disorders of infancy and early childhoodTic disorders

Elimination disorders

Others

Separation anxiety disorder

Selective mutism

Reactive attachment disorder of infancy or early childhood

Stereotypic movement disorder

Disorders of infancy, childhood and adolescents NOS

Selected additional disorders that may be diagnosed in children

Delirium

Dementia

Substance related disorders

Schizophrenia

Depressive disorders

Bipolar disorders

Anxiety disorders

Panic disorders

Agoraphobia without PD

Specific phobia

Social phobia

Obsessive – compulsive disorder

Posttraumatic stress disorder

Acute distress disorder

Generalized anxiety disorder

Anxiety disorder due to a general medical condition

Somatoform disorders

Gender identity disordersEating 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 perspectiveInformation 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:

AppearanceMotor 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 frommother.

⇒ 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 withEpilepsy

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 phobiaPanic 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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managing the child with a mental disorder

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