Definition and classification

The ICD-10 classification of ‘Behavioural and emotional disorders with onset usually occurring in childhood and adolescence’ (F90–98) is shown in Table 16.1. In general, if the criteria for one of the other ‘adult’ disorders (such as depression) are met, then such a diagnosis should be made rather than a ‘childhood-onset’ diagnosis. Recognition of different dimensions of childhood functioning has led the WHO to develop a multiaxial framework for the diagnosis of child psychiatric disorder (Table 16.2). DSM-IV-TR disorders usually first diagnosed in infancy, childhood or adolescence are outlined in Table 16.3.

Table 16.1 ICD-10 classification: F90–F98 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence

Table 16.2 ICD-10 Multiaxial framework

Table 16.3 DSM-IV-TR disorders usually first diagnosed in infancy, childhood or adolescence

Rutter has pointed out that the majority of child psychiatric disorder is a quantitative deviance from the norm, with suffering and/or handicap. In other words, most children show some of the ‘symptoms’ of child psychiatric disorder at some point in their development (generally at a roughly similar time). These are usually of a certain intensity and duration and resolve with appropriate environment and management (e.g. tantrums are common in two to three-year-olds but might be considered a disorder in a nine-year-old). It is important to emphasize that a deviance on its own is not sufficient to constitute a disorder: consequent suffering and/or handicap is also required (although not necessarily to the child). The example given by Rutter is of a child who has a high level of intelligence: the child is quantitatively deviant from the norm, but would not suffer unless this was out of step with social expectations, or if the child was not provided with appropriate educational opportunities.

As with all generalizations there are exceptions, both to this view of child psychiatric disorder (such as the pervasive developmental disorders, which are qualitatively different) and to the converse description of adult psychiatric disorder as a qualitative deviance (e.g. depressive disorder without psychosis may be regarded as a more severe or prolonged form of normal misery).

There is a high level of comorbidity seen in children and adolescents. This perhaps reflects the above and also the essentially descriptive nature of most diagnoses.

In child and adolescent psychiatry it is essential to have a clear knowledge of the normal development of all aspects of behavioural and psychological functioning. Detailed accounts of childhood development may be found in paediatric texts and developmental psychology books. Table 16.4 shows an outline of various developmental milestones, and includes references to various different theories of psychological development. It must be noted that these theories are ways of conceptualizing development, each designed to explain and predict, with implications for management and treatment. They are not the literal truth and are by no means mutually exclusive. Only brief outlines of the theories can be given here.

Table 16.4 Childhood development and developmental stages

Some aspects of Freud’s psychoanalytic theory are described in Chapter 4. Erikson saw development as a series of stages or psychosocial crises that must be overcome to make proper relationships at each stage in life. The stages relate to a widening and narrowing social world (see Chapter 2).

Piaget produced a theory of cognitive development based on careful observation of a relatively small number of children. Others have subsequently refined and modified Piaget’s theory, on the basis of psychological experimentation and further observation. The sensorimotor stage (zero to two years, approximately) is a process of distinguishing the self and others through sensory inputs and motor manipulation of objects. The preoperational stage (approximately two to seven years) is a period of development of appreciation of symbols for outside objects, but the rules connecting them are primitive and developing. The child’s view of the world is very self-centred (egocentric). At the concrete operational stage (approximately seven to 12 years), categorization and development of hierarchy of concepts (e.g. volume over height) occurs. At the formal operational stage (age 12 onwards) there is even more development of the internal world, with the ability to see another’s viewpoint being developed further and hypothesizing by manipulation of internal concepts occurring.

Epidemiology

Clinical features

The first general point to note is that it is relatively unusual for the child or adolescent to be the one initiating psychiatric contact. This is more usually a parent or other carer, school, social services or the court. Arising from this, and confirmed by population studies as above, is the observation that there are often considerable discontinuities in a child’s presentation in different circumstances (in particular school and home, but also with different people). This of course has considerable implications for assessment (see later).

Although there are exceptions, in general collections of symptoms or disorder classifications are not closely correlated with particular aetiologies. In other words, different children will produce different disturbances in the same predicament, and some may show no disturbance at all.

Aetiology

In child and adolescent psychiatry multifactorial aetiology is the rule. This is not simply in the sense of many factors contributing to a given predicament, but in the interaction of such factors at all levels of a child’s or adolescent’s functioning, either adding to or subtracting from the risk (Figure 16.1). Such interactions may be circular rather than simply linear. There is also a variation in effect, according to the development level of the child, the family’s stage in the life cycle and the particular resilience and vulnerability factors operating in an individual situation. Aetiological factors according to biopsychosocial level are summarized in Figure 16.2.

Figure 16.1 • Interactive multifactorial aetiology.

A,B,C etc. are aetiological factors.

Figure 16.2 • Aetiological factors for child psychiatric disorders.

Level of individual self-esteem is an issue that can influence the persistence or otherwise of behavioural disturbance. A child with low self-esteem will take longer to respond to positive reinforcement of wanted behaviour, and may feel more comfortable with failure and a reputation as rather bad, to the extent of sabotaging success. (This latter point is often difficult for parents to understand, and may be seen as ‘ungrateful’.) Low self-esteem develops where there is repeated criticism or failure without balancing praise and/or success.

‘Attachment’ is an important concept in psychiatry as it encompasses both early social relationships and subsequent patterns of interaction with others. It must be emphasized that attachment is a relationship variable, not a personal characteristic. Quality of attachment to one carer does not predict type of attachment to another. The cardinal features of attachment are shown in Figure 16.3. The quality of attachments has been explored, most notably by Ainsworth, who devised an experimental procedure (the strange situation procedure) in which a child goes through a series of short separations and reunions with both carer and a stranger in an unfamiliar room. Responses were classified to produce three ‘types’ of attachment (Table 16.5).

Figure 16.3 • The cardinal features of attachment.

It is important to note that attachment occurs in dyadic relationship and is only one aspect of that relationship.

Table 16.5 Attachment: Ainsworth’s strange situation procedure (showing child’s behaviour seen in different situations)

Other researchers have questioned the utility and predictive validity of this descriptive schema, but follow-up studies have shown that those infants designated as ‘securely’ attached later show greater social competence and better peer relationships. Conversely, children reared in institutional environments who have had a lack of consistency of carers, and where emotional links may not have been encouraged, showed increased levels of emotional and behavioural disorder throughout childhood and into adulthood – in particular showing disturbed relationships. Parenting ability of adults who as children were designated as ‘insecurely attached’ was mitigated where there was a supportive spouse. In clinical practice, assortative mating (where people choose partners with similar backgrounds) may lessen the likelihood of this situation occurring. Similarly, clinical observation of families in whom there is inconsistency and neglect of parenting shows clinginess, overfriendliness and inappropriate attention-seeking in the children. Adoption studies confirm the strong influence of environment in determining levels of difficult behaviour in children.

Brief separations of children from their carers in families with healthy relationships and functioning show little persisting disturbance in the children. However, where family relationships are dysfunctional (see below) child psychiatric disorder can arise subsequently. If the change is to another family where parenting is more appropriate to the child’s need, then the child is likely to do well, despite the separation. Response to separation for hospital admission is complicated by the anxieties associated by a family with such an admission (and hence the reasons for admission). Generally, though, single short admissions have little lasting effect, whereas repeated admission does increase the risk for psychiatric disorder (although again this is confounded with the reason for such multiple admission).

Research confirms an increase in emotional and conduct disorders after divorce (particularly in boys), which usually resolves within two years, especially if discord between the parents has subsided and the quality of relationship of the child with individual parents is adequate. The structure of families is much less important than the quality of the relationships between parents and children.

All behaviour arises in the context of relationships. Taking a family perspective raises interactional issues that may be aetiologically important in a given case. Minuchin and others have described particular features of families with a child with a ‘psychosomatic’ complaint (enmeshment, rigidity, inappropriate parent–child alliances). Most papers have been descriptive of the therapeutic approaches of a particular ‘school of family therapy’, although there is considerable overlap between these. A linear view of causality is generally not helpful in considering families and the wider system: a circular model is preferable. Changes in one part of the system will require other parts to adjust to take account of this, or alternatively act in such a way to maintain the status quo. An example would be where a particular child is taking all its parent’s attention by naughty behaviour: this relieves the pressure on the siblings, who may act to ‘wind up’ the identified child if their naughtiness then appears to be reduced. There are many similar features of family systems that may trigger, maintain or predetermine a presenting complex of symptoms. Table 16.6 summarizes the areas that must be considered, though research is difficult and scanty in determining the relative importance of these different variables.

Table 16.6 Elements of family functioning

Children in local authority care are at increased risk of suffering a psychiatric disorder. This factor is confounded with the reasons for the child being looked after.

Some characteristics of schools, regardless of catchment area, influence the level of child psychiatric disorder (Table 16.7). Epidemiological studies have further emphasized that there is a discontinuity between a child’s presentation in school and at home. Children spend a large part of their formative years in school. Poor relationships between home and school can be significant in maintaining an undesirable symptom complex.

Table 16.7 Features of a school associated with a lower level of child psychiatric disorder (independent of catchment population)

Culture may determine whether a behaviour is seen as handicapping, and also has some bearing on parenting style (e.g. the amount of physical chastisement that is socially permissible varies considerably). Cross-cultural studies have shown variations in level of conduct disorder and in sleep disorder, but these studies have also included some socioeconomic confounding factors.

Management

Assessment

As will be apparent from the above, a full assessment is a complex procedure, starting from the moment of consideration of the referral. The initiator of the referral is rarely the child and may often not even be the family (or alternatively may be one parent, but not the other). Other agencies that impinge on children include: education; other parts of the health service (e.g. paediatric medicine); social services; the courts; solicitors; the probation service; and so on. Determining whose idea it was to refer a child to a psychiatry service is an important first step, and will influence the approach taken.

Studies of referred populations of children show that child psychiatric disorder is not necessarily a prerequisite for a referral: the child’s symptomatology may reflect disorder elsewhere in their environment, with the child reacting normally to this. Paradoxically, nor is child psychiatric disorder a sufficient reason for referral: most children with such disorders are not seen by psychiatrists or psychiatric services. The question ‘Why now?’ or perhaps ‘What led to you being referred to us?’ usually reveals some additional stimulus, such as school complaints on a background of conduct problems, police involvement or, in the case of divorce, disputes between parents over finances. More simply, a parent may feel at the end of their tether (although additional pressures often contribute to this too).

The next question is, ‘who to invite to the assessment?’ Some idea of the child’s family context is essential, so the family is usually requested to attend. Some child psychiatric teams request prior knowledge of family compositions so as to avoid misunderstanding or extra alienation by making assumptions. It may also be important to see other, non-related, members of the household or members of other agencies working with a family.

At the first assessment appointment a considerable amount of information is required to obtain a sufficiently wide view of the presenting problem (Table 16.8). Studies suggest that an active probing style produces more detailed information than does a ‘free-form’ dialogue, but it is important to start with open questioning before proceeding to more specific queries.

Table 16.8 Information to be amassed in a child psychiatric 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 < div class='tao-gold-member'> Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Cultural psychiatry Psychiatry of the elderly Eating disorders Psychiatry of sexuality Mood disorders, suicide and parasuicide History taking and clinical examination Stay updated, free articles. Join our Telegram channel Join Tags: Textbook of Psychiatry Jul 12, 2016 | Posted by admin in PSYCHIATRY | Comments Off on Child and adolescent psychiatry Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access