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.
Triad of impairments
- Failure to notice/respond to social cues + the emotional states of others
- Attachments are impoverished
- Expressive speech and comprehension are usually delayed or minimal
- Concrete thinking (ideas are taken literally)
- Absence of gestures
- Later: speech consists of monologues, endless questions, echolalia
Restricted behaviours and routine:
- Inability to adapt to new environments
- No imaginative ‘make-believe’ play
- Affects 1/1000 children, boy:girl = 4:1.
- ¾ 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 (tuberose sclerosis, fragile X, Downs)
- Asperger’s syndrome: an autistic spectrum disorder with normal IQ and language
Definition – Repetitive, involuntary, purposeless movements/vocal utterances
- 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 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
- 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.
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
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
Behaviours may include: bullying, stealing, fighting, fire-setting, truancy, cruelty to people and animals:
- Socialised: child has a peer group often who share their antisocial behaviours
- Unsocialised: rejected by other children à child becomes more isolated and hostile
Oppositional defiant disorder
The key behavioural symptoms of ODD are negative, hostile and defiant behaviour, particularly directed towards authority figures, such as parents or teachers.
- 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 – these children are not aggressive, do not destroy property, and do not show a pattern of theft or deceit
Management: Behavioural therapy / Parental training
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.
Separation anxiety disorders
Children become distressed when separated from attachment figure (usually mother).
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).
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).
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.
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
- Restrict fluids before bed
- Star charts celebrating each dry night = positive reinforcement
- ‘Pad and bell’ – underpants alarm
Defecation in inappropriate places despite normal bowel control, after age 4.
At 8 years – 2% of boys, 1% of girls
May be caused by inadequate toilet training, or may be an expression of anger or regression at times of stress
Exclude constipation with overflow incontinence
These children can speak, but won’t in certain situations e.g. school
Affects 4/1000 children, slightly more common in girls
Treatment: reassurance, reducing stressors, behavioural management