Child Psychiatry
Child Psychiatry
Child Psychiatry
Introduction:
The psychiatric disorders that present in childhood are distinct from those in adults because they arise within complex and intimate family relationships, and are influenced by the development stage of the child. Children also present special challenges for assessment and treatment. The psychiatric disorders that present in childhood or adolescence are listed in Table 1.
Pervasive development disorders Specific development disorders Hyperkinetic disorders Conduct disorders Emotional disorders Psychiatric aspects of child abuse Disorders of elimination
Table 1 Classification of psychiatric disorders of childhood and adolescence
Normal childhood development
Some of the features of normal child development are shown in table 2. It is essential to consider the developmental stage of the stage of the child during a psychiatric assessment, as what is accepted as normal at one stage would be abnormal at another.
Early childhood experiences play an important role in determining what type of person we become in adulthood. The role of parents in this is central. The child with parents (or parent) who are loving and tolerant, yet able to set and enforce clear and reasonable limits is likely to develop a high self esteem, and secure attachment to the parents that will provide a template for secure attachments to others in later life. The theory of ‘attachment’ was first described by John Bowlby in the 1950s. It derived from his study of young children separated from their mother in hospital. Attachment behaviour begins at around 7 months and consists of clinginess and unwillingness to be separated from the main carer, usually mother. It serves strengthen the bond between mother and child and has the evolutionary function of ensuring the child is protected from predators. A securely attached child is able to use the mother as a safe base from which exploration of the outside world can begin, and will also be able to cope well with brief separations. If the attachment is insecure, because the parent fails to respond to the child’s need for attention or holding, or is inconsistent, the child will have difficulty exploring and separating. This pattern of insecure attachment may persist throughout life, affecting adult relationships.
Assessment of Children
The way in which a psychiatric history is taken and the child is examined will depend upon the age, confidence and language skills of the child. Much of the history will come from the parents, and children who are prepared to separate from their parents can then be seen alone. It is usually best to see adolescents alone and before their parents in order to establish a trusting relationship with them. The interview should take place in a relaxed and friendly atmosphere, with toys and drawing materials provided for children less than 10 years.
The history should include the following:
Presenting complaint-described by both the parent and child. It is important to lead up to asking the child about the presenting complaint gently, after gaining their confidence and talking about neutral topics. Recent behaviour or emotional difficulties-including general health, mood, sleep, appetite, elimination, relationships, antisocial behaviours, fantasy life and play, and school behaviour. Personal history-pregnancy, birth, milestones (motor, speech, feeding, toilet training, social behaviour), medical history, separations from parents, schools attended and progress in them. Family structure and function-construction of a genogram is often useful. Relationships between family members should be asked about, and the interactions during the interview observed. Temperature trails-traits such as activity level, regularity of functions (sleep, bowels, eating), adaptability to new circumstances, willingness to approach new people or situations, quality and intensity of mood, quality of relationships within and outside the family, attention and persistence can be observed from a very young age.
A mental state examination of the child should be completed, although this will often rely on watching behaviour and play. The following should be considered:
Appearance-looking for any abnormality, bruises, cuts, or grazes and appropriateness of dress. Behaviour-activity level, interactions with parents, motor function, attention and persistence with tasks. Talk-articulation, vocabulary and use of language. Mood-happy, elated, unhappy, depressed, anxious, hostile of resentful. Thoughts-content of speech