The disorders outlined in this chapter are ones that usually appear during childhood or adolescence.
CHILDHOOD DEVELOPMENT
Normal childhood development is summarized in Table 11.1.
| Age | Milestones | Freudian stage | Piagetian stage | Ericksonian stage |
|---|---|---|---|---|
| 0–6 months | Vocalizes up to double-syllable sounds, rolls over, objects – palmar grasp, hand to hand and to mouth, smiles and laughs | Oral | Sensorimotor | Trust vs mistrust |
| 6 months to 1 year | Crawls, stands with support, sits unsupported, pincer grasp present, stranger shyness | Oral | Sensorimotor | Trust vs mistrust |
| 1–2 years | Walks, runs, builds up to 2–3 word sentences, feeds self with spoon, parallel play, beginning to attain continence | Anal | Sensorimotor | Autonomy vs shame and doubt |
| 3–5 years | Attains continence, cooperative play, draws a man, much questioning, speech increases in fluency, learns to skip and hop and to dress and undress | Phallic | Preoperational | Initiative vs guilt |
| 6 years to puberty (middle childhood) | Increasing involvement with peer group, schooling, increased autonomy | Latency | Concrete operational | Industry vs inferiority |
| Adolescence | Moves towards independence, relates mostly to peer group | Genital | Formal operational | Identity vs confusion |
CHILD PSYCHIATRIC INTERVIEW
The assessment of a child requires the gathering of information from all relevant sources such as the child’s family, teachers, doctor, social workers, paediatricians and the police (in the case of conduct problems, for example). More than one assessment interview may be required, and the family is usually asked to attend. (However, in the case of suspected child abuse the child should be interviewed without the presence of the suspected abuser.) Table 11.2 summarizes the information to be gathered at such an interview.
| Source and nature of referral • Who made referral? • Who initiated referral? • Family attitudes to referral |
| Description of presenting complaints • Onset, frequency, intensity, duration, location (home, school, etc.) • Antecedents and consequences • Ameliorating and exacerbating factors • Specific examples • Parental and family beliefs about causation • Past attempts to solve problem |
| Description of child’s current general functioning • School • behaviour and emotions • academic performance • peer and staff relationships • Peer relationships generally • Family relationships |
| Personal/developmental history • Pregnancy, labour, delivery • Early developmental milestones • Separations/disruptions • Physical illnesses and their meaning for parents • Reactions to school • Puberty • Temperamental style |
| Family history • Personal and social histories of both parents especially • history of mental illness • their experience of being parented • History of family development • how parents came together • history of pregnancies • separations and effects on children • Who lives at home currently • Strengths/weaknesses of all at home • Current social stresses and supports |
| Information from observation of family interaction: • structure, organisation, communication, sensitivity |
| Information from observation of child at interview: • motor, sensory, speech, language, social relating skills |
| Mental state, concerns, and spontaneous account if age appropriate |
| Results of physical examination |
| Plan for future investigation and management |
PREVALENCE OF PSYCHIATRIC DISORDER
A study by Rutter and colleagues of 10- and 11-year-olds in the Isle of Wight in 1970 found that the 1-year prevalence of psychiatric disorder was 6.8%, with the rate in boys being twice that in girls. Of the 6.8%, 3% had conduct disorder and 2% emotional disorder. The prevalence increased with reduced IQ, and there was a strong association with physical handicap and particularly with brain injury. A similar survey in an inner London borough, in which there was a high prevalence of overcrowding, found that the 1-year prevalence of psychiatric disorder was 13%, double that in the Isle of Wight.
HYPERKINETIC DISORDER OR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
The cluster of age-inappropriate behavioural abnormalities of the triad
constitutes the core of the ICD-10 diagnostic group of disorders known as hyperkinetic disorder, and known in DSM-IV-TR as attention-deficit/hyperactivity disorder (often abbreviated to ADHD). The first two abnormalities are particularly important for the ICD-10 diagnosis. The clinical features in the next subsection are mainly based on the ICD-10 criteria, while those of DSM-IV-TR follow after it. Although ADHD is considered in this chapter on children and adolescents, it should be borne in mind that it can also occur in adults.
• Inattention
• Hyperactivity
• Impulsivity
Clinical features
There is impaired attention and overactivity, and both occur in more than one situation, e.g. at home, in school, at a clinic. Impaired attention leads to frequent changes from one activity to another and to unfinished activities. Overactivity manifests as excessive restlessness, e.g. running and jumping around, noisiness and excessive talkativeness.
Associated features include disinhibition in social relationships, recklessness and the impulsive defying of rules.
For an ICD-10 diagnosis these behaviour problems should start before the age of 6 years and be of long duration.
DSM-IV-TR criteria for attention-deficit/hyperactivity disorder
A. Either (1) or (2):
(1) At least six of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
b) Often has difficulty sustaining attention in tasks or play activities
c) Often does not seem to listen when spoken to directly
d) Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not because of difficulty understanding instructions)
e) Often has difficulty organizing tasks and activities
f) Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork or homework)
g) Often loses things necessary for tasks and activities
h) Is often easily distracted by extraneous stimuli
i) Is often forgetful in daily activities.
(2) At least six of the following symptoms of hyperactivity (a–f) impulsivity (g–i) have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
a) Often fidgets with hands or feet or squirms in seat
b) Often leaves seat in classroom or in other situations in which remaining seated is expected
c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents and adults may be limited to subjective feelings of restlessness)
d) Often has difficulty playing or engaging in leisure activities quietly
e) Is often ‘on the go’, or often acts as if ‘driven by a motor’
f) Often talks excessively
g) Often blurts out answers before questions have been completed
h) Often has difficulty awaiting turn
B. Some hyperactive–impulsive or inattentive symptoms that caused impairment were present before the age of 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
D. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning.
E. The symptoms do not occur exclusively during a pervasive developmental disorder (e.g. autism, Rett’s disorder, Asperger’s disorder), schizophrenia or other psychotic disorder, and are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder or a personality disorder).
Epidemiology
Prevalence
In the UK hyperkinetic disorders have been found to have a prevalence of up to 20–30 per 1000 children. The prevalence of attention-deficit/hyperactivity disorder in the US is around 30–50 per 1000 in school-age children. This much higher prevalence in America may be partly the result of differences in diagnosis or terminology.
Social class
Hyperkinetic disorders are commoner in those living in poor social conditions.
Sex ratio
This disorder is much more common in males. Male : female ratio ranges from 4 : 1 to 9 : 1.
Aetiology
Genetic (studies of adopted children), biochemical and social factors have been suggested.
Management
• Remedial teaching
• Behaviour modification – appropriate methods can be taught to parents and teachers to prevent reinforcement of problem behaviour.
• Drug treatment – under specialist supervision central nervous system stimulant drugs (e.g. methylphenidate and dexamfetamine) can be used. Such use must be selective because of the side effects, such as irritability, depressed mood, insomnia, reduced appetite and retarded growth. The newer non-stimulant drug atomoxetine may also be prescribed for ADHD and must be initiated by a specialist physician who has experience in managing this disorder.
Prognosis
The symptoms often cease by puberty, although in severe cases they may continue into adult life.
CONDUCT DISORDER
Clinical features
The characteristic features are a repetitive and persistent pattern of dissocial, aggressive or defiant conduct, which at its most extreme amounts to major violations of age-appropriate social expectations and is therefore more severe than ordinary childish mischief or adolescent rebelliousness (ICD-10). An isolated dissocial or criminal act is not sufficient to make this diagnosis, for which an enduring pattern of dissocial behaviour is required.
DSM-IV-TR criteria for conduct disorder
A. A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:
Aggression to people and animals
(1) Often bullies, threatens, or intimidates others
(2) Often initiates physical fights
(3) Has used a weapon that can cause serious physical harm to others
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