Child Psychiatry
preferred.
School refusal
In school refusal the child refuses to attend school because of specific fears about the school, the journey to it or separation anxiety. This accounts for about 1% of all school absences and is much less common than truancy in which the child conceals their absence from school and from their parents. The characteristics of children with school refusal are compared to those who habitually truant in Table 1. School refusal should be treated by returning the child to school as quickly as possible as avoidance is likely to heighten the anxiety. A grade reintroduction may be necessary, with support for both child and parents.
Child Abuse
Child abuse may take the form of neglect, emotional, physical or sexual abuse. It plays a role in precipitating psychiatric disorders in children which may continue through to adulthood. It is essential that all professionals who come into contact with children are alert to the possibility of abuse playing a role in the problems presented by a child and its family.
Table 3 Comparison of characteristics of children presenting with persistent truancy, and school refusal
School refusal
Truancy
Absence from school known to parents
Absence from school concealed from parents
Spends day at home alone or with parents
May spend day away from home with peers
Peak incidence at 11 years
Increase with age
Fear of school or separation anxiety
No emotional disorders
All social classes
Increased in lower social classes
No increase in parental marital discord
Dysfunctional family
Overprotective parenting
Harsh parenting
The incidence of abuse is difficult to measure as the majority of cases go unreported, and a definition of what constitutes abuse varies. Official figures for reported cases of abuse have risen in recent years, although this is likely to be due to greater reporting rather than a true increase in abuse. A British study found that 12% of women and 8% of men reported some form of sexual abuse before the age of 16 years.
There are many contributor factors in the abuse of children. Some children are more vulnerable than others, for example those who are unwanted, have early separation from the mother, are mentally or physically handicapped, or have temperamental characteristics that make them difficult to handle. Some parents are more likely to be abusive, particularly those who have themselves been abused as children, live in poor socioeconomic circumstances and have unrealistic styles of disciplining their children.
The most common form of sexual abuse is father-daughter incest. Sexually abused children may present with a sudden change in their social behaviour or academic performance, or with conduct disorders. Some engage in repetitive sexual play and are sexually precocious. It is important to give these children an opportunity to disclose their abuse, but great care must be taken to avoid adding to their trauma. Social services must be informed of any disclosure of sexual abuse by a child and instigating child-care proceedings. The emotional effects of childhood sexual abuse may be addressed in individual psychotherapy with the child. Adolescents and adults may also be offered group therapy which has the advantages of reducing the sense of isolation and allowing development of trust and self esteem. One-third of sexually abused children have no long-term negative effects, the rest are prone to depressive illness, low self esteem, sexual problems and have a tendency to re-victimisation in adulthood.
Disorders of Elimination
Enuresis
Enuresis is involuntary emptying of the bladder occurring after the age of 5 years in the absence of an organic cause. Bedwetting (nocturnal enuresis) is common, occurring in 10% of 5 year old, 5% of 10 year olds and 1% of 15 year olds. Daytime enuresis is less common. The enuresis is considered to be primary if there has been no preceding period of bladder control, and secondary if it follows a period of continence. It is twice as common in boys as girls, and most cases are thought to be due to delayed neurological maturation which simply corrects itself with time. There is often a positive family history of the same problem. Secondary enuresis may occur as a feature of regressive behaviour at times of stress. Management consists of excluding a physical cause, particularly a urinary tract infection, reassuring the parents and encouraging them to handle the problem calmly and gently. Instituting a simple behavioural programme such as a star chart or pad and bell can be used.
Encopresis
Encopresis is defecation in inappropriate