Paediatric Psychiatry – an overview of key conditions


Below is a very brief overview of some of the key conditions in paediatric psychiatry. You should use this piece for some quick revision and not as your primary method of learning about these conditions. Eating disorders are covered in a separate article.


Autistic Spectrum Disorder

A pervasive developmental disorder, which manifests before age 3. It is defined by the presence of abnormal functioning in three areas:

1. Social interaction:

  • Failure to notice/respond to social cues + the emotional states of others
  • Attachments are impoverished

2. Communication:

  • Expressive speech and comprehension are usually delayed or minimal
  • Concrete thinking (ideas are taken literally)
  • Absence of gestures
  • Lack of imaginative ‘make-believe’ play
  • Later: speech consists of monologues, endless questions, echolalia

3. Restricted behaviours, interests and routine:

  • Inability to adapt to new environments
  • Tendency to have a rigid routine, with resistance to change
  • Preoccupations with interests such as dates, routes or timetables

Key facts

  • Affects 1/1000 children, boy:girl = 4:1.
  • All levels of IQ can occur in association with autism, but ¾ of cases have significant learning difficulties
  • ¼ have seizures
  • No single cause, but risk factors include: obstetric complications, perinatal infection e.g. maternal rubella, and some genetic disorders (tuberous sclerosis, fragile X, Down Syndrome)
  • Asperger’s syndrome (no longer included in ICD-11 and DSM-5): an autistic spectrum disorder without cognitive impairment and fewer problems with language

Tic Disorders

Definition – Repetitive, involuntary, purposeless movements/vocal utterances

Key facts

  • Simple e.g. throat-clearing, blinking
  • Complex e.g. swearing, self-hitting
  • May be invisible to the observer, such as abdominal tensing or toe crunching
  • Transient simple tics affect 10% of children
  • Boy:girl = 3:1
  • OCD is commonly comorbid
  • Usually worsened by stress and stimulant meds, and improved by distraction
  • Tics can be voluntarily suppressed, but at the cost of internal tension, which is relieved when the tic is expressed
  • Management includes education and a “watch-and-wait” strategy

Tourette’s Syndrome

Tourette’s is the more severe expression of the spectrum of tic disorders, characterised by multiple motor tics and at least one phonic tic. It is most often associated with the exclamation of obscene words or socially inappropriate and derogatory remarks (coprolalia), but this symptom is present in only a small minority of people with Tourette’s.


Attention Deficit Hyperactivity Disorder (ADHD)

Core symptoms = inattentiveness / hyperactivity / impulsivity

Key facts

  • Affects  2-5% of school-aged children, and 1.7% of the overall UK population
  • Most cases are diagnosed in children between the ages of 6 – 12 (symptoms must be present before age 6 for diagnosis to be made).
  • Boy:girl = 3:1
  • Hyperactivity usually improves with age, but some adults continue to have symptoms of inattentiveness and impulsivity.
  • ADHD can occur in people of any intellectual ability, although it is more common in people with learning difficulties.
  • Cause is unknown – although genetics plays a role, and dopamine and noradrenalin deficiencies and frontal lobe abnormalities are implicated.

Management

1. Family: education on ADHD, and parenting advice

2. Behavioural management

3. School: support for teachers and appropriate schooling placement

4. Stimulant medication: e.g. methylphenidate, dexamphetamine.

  • These increase monoamine pathway activity
  • S/E: appetite suppression and insomnia
  • They are not addictive in ADHD

Conduct Disorder

Persistent, marked antisocial behaviours including:

  • aggression towards people or animals
  • destruction of property
  • deceitfulness or theft
  • serious violations of rules

Results in significant impairment in personal, family, social and educational functioning

Duration >12 months

CD affects 1-10% of children, becomes more common in adolescents

Boy:girl = 4:1

Risk factors: urban upbringing, deprivation, parental criminality, harsh/inconsistent parenting

Antisocial behaviour is often learned (from parents/social norms) and may be positively rewarded with attention, and thus reinforced

Overlap with ADHD and reading disorders, often child has low IQ

  • Socialised: child has a peer group often who share their antisocial behaviours
  • Unsocialised: rejected by other children, therefore the child becomes more isolated and hostile

Oppositional Defiant Disorder (ODD)

The key behavioural symptoms of ODD are negative, hostile and defiant behaviour, particularly directed towards authority figures, such as parents or teachers.

Symptoms include:

  • Loses temper
  • Actively defies or refuses to comply with adults’ requests or rules
  • Deliberately annoys people
  • Blames others for their mistakes or misbehaviour
  • Angry, resentful, spiteful or vindictive

ODD is common in children with ADHD and may be linked to parenting styles

ODD is less severe and more common than conduct disorder (see above) – children with ODD are not aggressive, do not destroy property, and do not show a pattern of theft or deceit

Management: Behavioural therapy / Parental training


Depression

Affects 1-2% of children, 8% of adolescents, increasing incidence with age.

Symptoms are similar to those seen in adults: low mood, anhedonia, altered sleep/appetite.

Children frequently present with somatic symptoms (headache, tummy-ache).

Management: antidepressants are less effective in children, so should be used with caution. Psychological therapies are preferred.


Anxiety Disorders

In addition to generalised anxiety disorder, panic disorder and phobias, children may experience the following:

Separation Anxiety

  • Affects young children. Normal for toddlers but becomes pathological in older children when it interests with social functioning (e.g. preventing children from attending school, inability to sleep without parent nearby).
  • Children become distressed when separated from attachment figure (usually mother)
  • Parental overprotection is commonly present
  • May develop following a stressful event, e.g. separation (a hospital stay), bereavement, family breakdown, change in environment (new house or school)

School Refusal

  • Child refuses to attend school due to specific fear about the school (bullying, unsympathetic teacher, fear of failure)
  • Separation anxiety may be implicated.
  • May occur in families with ‘precious’ children (difficulty conceiving, death of a sibling)
  • Anxieties of the child and parent should be addressed, and child should be reintroduced to school ASAP as further avoidance is likely to heighten the anxiety

Social Anxiety

  • An overwhelming fear of social situations.
  • This could include social interactions (e.g. having a conversation), observation by others, or performing to others.
  • The individual worries that they will be negatively evaluated by others, often resulting in avoidance of the social situation
  • The symptoms persist for several and cause significant distress and impairment of functioning.
  • More common in teens than children

Selective mutism

These children had adequate language skills in certain situations but consistently does not speak in other settings e.g. home vs. school.

Affects 4/1000 children, slightly more common in girls

Treatment: reassurance, reducing stressors, behavioural management


OCD

Definition: undesirable, intrusive and recurring thoughts (obsessions) and/or repetitive behaviors (compulsions)

  • Obsessions originate in the mind of the patient (and are not imposed by outside influences)
  • The child generally tries to resist them (but resistance may be minimal or absent in children who lack insight into the inappropriateness of the obsession/compulsion)
  • They are involuntary and often repugnant in the patient’s own mind
  • Carrying out the compulsion may create temporary relief of tension, but is not in itself pleasurable.
  • The symptoms occur repetitively causing distress and marked impairment of functioning
  • Obsessions and compulsions commonly involve cleaning, checking, contamination (dirt, pathogens), aggression, symmetry and precision, and religious and sexual themes

Key Facts

  • Prevalence of 1% to 3%
  • Takes a chronic course in > 40% of children
  • In children, boy:girl = ~ 3:2, although from adolescence onwards =  1:1

Management: Cognitive behavioural therapy + combination pharmacotherapy including SSRI


Elimination Disorders

Enuresis

  • Involuntary emptying of the bladder in children >5 in absence of an organic cause (e.g. UTI, epilepsy, diabetes).
  • Primary enuresis: bladder control never mastered
  • Secondary enuresis: follows at least a year of continence
  • Nocturnal enuresis is common: 10% of 5-year-olds, 5% of 10-year-olds, 1% of 15-year-olds
  • Boy:girl = 2:1
  • Most cases are thought to be due to delayed neurological maturation = corrects itself with time

Management:

  1. Reassurance
  2. Restrict fluids before bed
  3. Star charts celebrating each dry night = positive reinforcement
  4. ‘Pad and bell’ – underpants alarm

Encopresis

  • Voluntary or involuntary defecation in children >4
  • Often involves soiling undergarments
  • At 8 years – 2% of boys, 1% of girls
  • Subtype 1 (more common) = Constipation + overflow incontinence
    • The child avoids passing a bowel motion (onset may be related to toilet training)
    • Stool then becomes hard and painful to pass, leading to further avoidance of bowel movement
    • Overflow incontinence may then occur
  • Subtype 2 = NOT involving constipation/overflow incontinence
    • Usually occurs intermittently
    • Defecation may be in inappropriate places e.g. on the floor, despite normal bowel control
    • May be associated with oppositional defiant disorder or conduct disorder
    • May be considered an expression of anger or regression at times of stress

Gender Incongruence of Childhood

  • Previously called ‘gender dysphoria’ but this name was changed due to concerns that it pathologises gender non-conformity.
  • This diagnosis is defined by:
    • a marked incongruence between a child’s experienced/expressed gender and the assigned sex.
    • The child has a strong desire to be a different gender than the assigned sex.
    • They have a strong dislike of their sexual anatomy and anticipated secondary sex characteristics, whilst having a desire to have the anatomy and secondary sex characteristics that match the experienced gender.
    • They engage in play and activities that are typical of the experienced gender.
  • It must have persisted for about two years in pre-pubertal children.
  • It cannot be diagnosed based on just gender variant behaviour and preferences.
  • The majority of cases do not persist into adulthood (<25%) and many grow up to identify as homosexual or bisexual.
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