Dr. R. A. R. Perera MBBS(Cey) M.Sc.Psych.(Col)F.R.A.C.G.P.(Aus)
Police Hospital, Colombo.
Most children show isolated psychological symptoms at one time or another and to a considerable extent, these are a normal part of growing up. However, some children suffer from psychological disorders that interfere with normal development. Accordingly, one of the first tasks when a child is referred to a psychologist is to assess whether the child has a disorder.
In this context, a psychological disorder can be defined as behavioural or emotional symptoms that are so prolonged or so severe as to cause suffering to the child or to others, social restriction or impairment of normal development. Some symptoms, such as fire-setting or deliberate self-harm, are so extreme that they need only occurs once to be regarded as abnormal. Most symptoms are only abnormal, however, if they persist and if they are seen in several situations, and should be regarded as a disorder only if they lead to impairment.
Diagnosis/assessment – 1. Age and sex appropriateness, 2. Socio-Cultural settings, 3. Duration, 4. Pervasiveness, 5. Type of symptom.
Impairment – 1. Suffering to the child, 2. Handicap to the parents, 3. Social impairment, 4. Interference with development.
Most emotional disorders of childhood are exaggerations of normal development trends. The on set is usually during the developmentally appropriate age period, For example, it is normal for infants to show a degree of anxiety over separation from people they are attached. When this anxiety becomes severe, or persists in to later childhood or adolescence, it is termed separation anxiety disorder, similarly, when stranger anxiety disorder is justified. In adolescence, specific fearfulness, though less common, usually takes the form of school refusal or adult type neurotic disorders, such as social phobia or agoraphobia.
Anxiety disorders are among the commonest psychological problems in childhood and occurring in about 3% of 10 years olds. Genetic factors are important. The parents are often anxious and communicate their anxiety by behaviors such as over-protectiveness. Some cases of anxiety, particularly specific fears, are precipitated by stress.
Management consists of the reduction of stress, behavioral therapy for specific symptoms (e.g. graded exposure to the fearful situation and general treatment such as relaxation. Medication may be helpful for severe cases, but should not be prescribed for long periods. Relapse is 70%.
Depressive disorders occur in prepuhertal children, but are uncommon (<1%). (In adolescence 4%-girls, 2%boys). The ma in clinical features are similar to those of adults. But somatic complains and anxieties are more common in small children than in adolescence. Mania is uncommon. Infants who have been severely deprived or abused sometimes show a state of withdrawal and retarded development. Children and adolescence with depressive disorders tend to have parents who are depressed, but these links are probably more a reflection of environmental (e.g. poor parenting) than genetic factors. Depression in young people is commonly precipitated by adversity.
Management – consists of reducing this adversity, and the use of individual psychological interventions (e.g. poor parenting) than genetic factors. Depression in young people is commonly precipitated by adversity.
Management – consists of reducing this adversity, and the use of individual psychological interventions (e.g. cognitive behavioral therapy, which can be administered to children over 10 years) and family therapy. Medications should be used cautiously for adolescence due to the risk of overdose. Most recover with in few months but relapse can occur.
Many children attending medical services have unexplained physical symptoms (e.g. abdominal pain and headache). They tend to come from families tht have health problems and high academic expectations. In many cases, the child is in some kind of predicament in which other avenues have been blocked; for example, the child may feel unable to achieve what the family expects academically. Pre-existing physical problems in the child or in a relative may determine the kind of disease shown.
Management – involve the psychologist and the pediatrician closely, changing the family focus from physical to psychological issues, and placing emphasis on leading as normal life as possible (e.g. returning to school).
Conduct disorders are characterized by repetitive antisocial behavior that lasts for at least for 6 months. In young children, the clinical picture is dominated by markedly opposition behavior (e.g. defiance, hostility, and disruptiveness) that is clearly outside the normal range. In older groups’ behaviors such as stealing, truancy, fighting, lying and running away is seen. In severe cases, fire setting, or cruelty to animals and other children and seen. Conduct disorders are usually associated with poor peer relationships. Conduct disorders occur more in towns than in rural areas. More in boys than girls. There is a strong link with discordant interfamilial relationships and abuse Parents are often inconsistent in applying rules and may be critical and rejecting the child. About 30% have reading difficulties and few have organic brain disease.
Management – depend on the presenting problem and the commitment of the parents. Behavioural methods are effective for young children. Medication is of little value. Older children with severe problems have to be in special schools. Children with few symptoms and good peer relationship do better. Children with early onset and poor peer relationship have 30% risk of personality disorders in adulthood. Almost all adults with antisocial personality disorder have had conduct disorder as children.
Hyperkinetic behaviours are overactive behaviors and inattention, Diagnosis depends on these two problems in more than one situation (e.g. home, clinic classroom), and long term persistence of the behavior. The diagnosis is difficult in less than 5 years due to wide normal variations. Several other abnormalities are associated with the disorder, including impulsiveness, conduct disorders and learning difficulties. Prevalence depends on diagnosis criteria’s. Brian dysfunction resulting from genetic processes or early brain damage is important in the etiology. Hyperkinesias may occasionally be the result of early social deprivation. Side effects to drug or additives are also important.
Management Counsel the parents of the biological factors. Changing the environment, for example by the moving to a house with a garden, is helpful, but difficult to achieve Behavioral programs may be helpful Stimulant medications may be helpful in severe cases. Hyperkinetic disorders are associated with an increase risk of conduct disorders in adolescence.
By 5 years of age 10% of children will still wet at night and 3% will wet during the day, Enuresis (inappropriate emptying of the bladder in the absence of organic disease) in a child over 5 years may be at night or during daytime or both. The most common cause is an inherited delay in maturation of the nervous pathways that control micturition. But there is increased level of behavioural problems in these children especially in girls. Management – children should be reassured that they are not the only ones to suffer from the problems. Parents should be advised not to punish the child. But rather to encourage the appropriate toilet habit. This process, known as shaping should be charted and a rewarding system should be arranged. (Usually a star chart). It may be necessary to treat associated psychological disorders.