Paediatric Psychiatry – an overview of key conditions
Table of Contents
Below is a very brief overview of some of the key conditions in paediatricpsychiatry. 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
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
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
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.
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.
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
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.
In addition to generalised anxiety disorder, panic disorder and phobias, children may experience the following:
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)
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
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
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
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.