Child Psychiatry
rewards for good behaviour, is also useful for these children.
Hyperactivity disorder tends to improve with age, with only one quarter having persisting problems in adolescence. About half of these will continue to exhibit some features of the hyperactivity into adulthood, and this often expresses itself as dissocial behaviour.
Conduct Disorder
The main features of conduct disorders are persistent antisocial behaviours such as fighting, bullying, severe temper tantrums, damaging property, starting fires, stealing, truancy, and persistent and defiant disobedience. The child’s age must be taken into account, and normal naughtiness should not be considered a sign of conduct disorder. A third of cases have specific reading disorder, and there is considerable overlap with hyperactivity disorder. Conduct disorders are common, present in at least 4% of children with a peak in the 12 to 16 year age range, and are three times more common in boys than girls.
There are two types of conduct disorder:
Socialised conduct disorder. These children are able to make friends who usually also behave in an antisocial way. The bad behaviour is therefore usually most evident away from home. Relationships with adults may be good, although there are often difficulties with authority figures. Unsocialised conduct disorder. These children do not have friends, either because they have been rejected by their peers or because they deliberately choose to isolate themselves. The antisocial behaviour therefore occurs alone. Some degree of emotional disorder is often also present in these children.
The causes of conduct disorders are a complex interaction between the biological make-up of the child, family influences and environmental factors as summersied Figure 1. The style of parenting is thought to be important. Conduct disorders are likely to develop if parents fail to give clear boundaries, monitor behaviour and administer ineffective or inconsistent discipline. Improving parenting skills is likely to improve behaviour even if other causative factors are present. Other treatment approaches include family therapy, behavioural therapy, remedial teaching and provision of alternative peer group activities. The outcome is better for the socialised group. Two thirds of the unsocialised group will have persisting dissocial behaviour in adulthood.
Emotional Disorders
Emotional disorders of childhood are characterised by anxiety and depression. They are present in 2-3% of children and unusually for childhood psychiatric disorders are more common in girls. They generally have a good prognosis.
Separation anxiety disorder
It is normal for toddlers and pre-school children to feel some anxiety over real or threatened separation from their parents. In separation anxiety disorder the anxiety is unusually severe or occurs in older children, and causes some problems in social functioning such as preventing the child from attending school. Symptoms include persistent worries about separation from the attachment figure (usually mother) and great distress if forced to do so. Some will refuse to go to sleep without their mother nearby and have nightmares about separation. Parental overprotection is commonly present and other causes include the child’s temperament and stressful events, particularly those involving separation such as family breakdown, bereavement or illness
Anxiety disorders of childhood
Specific phobias about animals, the dark or strangers are normal in young children and rarely need treatment. Generalised anxiety disorder can occur and is frequency charactersied by somatic symptoms, particularly abdominal pain.
Family influences
martial disharmony absent parent parental violence, alcoholism, dissocial personality disorder poor parenting
Child
genetic factors brain damage low IQ temperament
Environmental influences
institution care school disciplinary code peer group influences social deprivation
Behavioral
Figure 1 Aetiology of conduct disorder
Depressive illness
The symptoms of depressive illness are much the same in children as in adults – low mode, anhedonia, altered sleep and appetite and depressive thoughts. Fleeting suicidal thoughts are quite common, but completed suicide is rare. Moderate and severe depressive illness is uncommon is pre-pubertal children, with a steady increase in incidence over the teenage years. The causes of depression and its treatment are also similar to those in adults, although younger children seem to be less responsive to antidepressant drugs than adults, so psychological treatment approaches are