Introduction to Child &

Adolescent Psychiatry
Recognizing mental health difficulties
Common childhood disorders
** There are some slides which has to be done by
own reading, due to time constrains
Content
• Evidence
• The specific disorder
• Child and Adolescent Psychiatry: it is a branch of
psychiatry that specializes in the study, diagnosis,
treatment, and prevention of psychopathological
disorders of children & adolescents
• Among the common are difficulties with e.g.:
• Learning and development delays
• Speech and communication with others
• Behaviors and interaction with others
• Following instructions, staying on tasks
• Mood and thinking
• Anger and aggression
• Parents and parenting
 Why should we be concerned about mental
health difficulties?
• The prevalence of child psychiatric disorder in the
developed world is 1020%, but in the developing
world, the prevalence is higher (Hackett et al, 1999)

• In many countries, the mental health problems

among children have been described as a public
health crisis (US Public Health Service, 2000).

Child & Ado Psy 4

 Why should we be concerned?
• Research shows that half of all lifetime cases of
mental illness worsened by age 14 (Kessler et al, 2005):
• learning problems
• behavioral
• depression, suicide
• bipolar disorder

Child & Ado Psy 5

Why Should We Be Concerned

• World Health Organization ~ indicated that by the year

2020, childhood neuropsychiatry disorders will rise
proportionately by over 50 percent, internationally,
to become one of the five most common causes of
morbidity, mortality, and disability among children.

Child & Ado Psy 6

WHO (2001)
• Suicide is the 3rd leading cause of death in adolescents.
Increase in number of self-harm

• 20 years ago, WHO did not consider violence to be a

central concern.
• However it has become a fast growing problem world
wide
Children as victims + as perpetrators
Major public health concern + significant cause of
morbidity and mortality

Child & Ado Psy 7

Department of Health and Human Services, 2005
• The early years of a child's life are crucial for cognitive, social
and emotional development.
• it is important to take every step necessary to ensure that children
grow up in environments where their needs are met.

• Cost to society less than optimal development are

enormous and far-reaching.
• are at an increased risk for compromised health and safety, and
learning and developmental delays.

• long term effects on the health care, and education systems.

Child & Ado MS 8

? Why should we be concerned about
mental health difficulties

Child & Ado Psy 9

• it has become a major public health burden
• it affects the child and family, and indirectly others
around them
• it is distressing and disabling
• the number of people affected is raising
• mental health services are inadequate
• stigma
• preventable and treatable, yet not detected

Child & Ado Psy 10

 Trends in child and
adolescent mental health
difficulties
read on your own
Trends: read on your own
• The prevalence of diagnosable psychiatric disorders
among children and adolescents is estimated to be
between 13% and 32% [1– 4].

• Youth who are male, younger (aged 9 –10 years),

and white are more likely to have psychiatric
disorders than those who are female, older, and
from racial/ethnic minority groups [3,5].
Trends: read on your own
• Adolescent depression is associated with numerous
poor outcomes including significant decrements in
school and work productivity and in educational
achievement (Asarnow et al, 2005)
• Depressive symptoms, externalizing behaviors, and stressful
events are associated with an increased likelihood of
attempting suicide among adolescents [7].
• Adolescents with symptoms of mania are more likely to be
sexually active, to have two or more partners in the past 90
days, and to test positive for a sexually transmitted infection
[8].
Major complication of untreated cases
read on your own

• depression
• behavioral difficulties  delinquent, defiant
• lost interest and interrupted learning
• substance abuse
• violence, criminal activities

14
Facts
Supportingon Learning
evidence: Difficulties
read on your own
 50% of all students in special education in the public
schools have learning disabilities (U.S. Dept. of Education, 1999)
 75% - 80% of special education students identified as
Learning Disabled have their basic deficits in language
and reading (National Institutes of Health, 1993)
 35% of students identified with learning disabilities
drop out of high school. This is twice the rate of their
non-disabled peers. (National Longitudinal Transition Study ; 1990;
Wagner 1991)

Childhood dis-LP 15
Supporting evidence: read on your own
• 50% of juvenile delinquents tested were found to
have undetected learning disabilities (National Center for State
Courts and the Educational Testing Service, 1977)

• Up to 60% of adolescents in treatment for substance

abuse have learning disabilities (Hazelden Foundation, Minnesota,
1992).

• 31% of adolescents with learning disabilities will be

arrested 3-5 years out of high school (National Longitudinal
Transition Study ;Wagner, 1991)

Childhood dis-LP 16
 Supporting evidence: read on your own
• Learning disabilities and substance abuse are the
most common impediments to keeping welfare
clients from becoming and remaining employed
(Office of the Inspector General on "Functional Impairments of AFDC Clients”, 1992)

Childhood dis-LP 17
 For these reasons, early
detection of mental health
problems and referral to
treatment for adolescents
are extremely important.
What can be done?
• Need to be aware when things are not right:
• from a very young age: slow in development >
walking, talking, learning, interacting with
others
• school going age: learning, interacting with
others, emotions
• anger, coping, moody
• thoughts of dying, self-harm behaviour
• substance abuse, use
General features of psychiatric disorders

A common definition:
 an abnormality + difficulties of emotions, behavior,
academics, relationships which is sufficiently severe
and persistent to cause difficulties in the child, his
social or personal functioning

 cause a distress to the child, his parents or to people

in his community.

Childhood dis-LP 20
Mental Ill Health
Manifests in a wide range difficulties
• Two terms:
1. Mental Health Problems
• broad range of emotional, behavioural and
academics difficulties & interaction
• cause of concern & distress
2. Mental Disorders
• severe and/or persistent

Child & Ado Psy 21

 Terminology:
 Intellectual disability
 Disruptive behavior  Hyperkinetic disorders
disorders: severe, persistent,  Disorders of social
socially disapproved behavior: functioning (elective
aggression: defy rules and often mutism, attachment disorders)
are disruptive in structured
environments, such as school:  Tic disorders
conduct, oppositional defiant
 Pervasive disorders
 Emotional disorders:  Miscellaneous.
subjective sense of distress,
anxiety, phobia, obsession,
conversion.

 Mixed emotional and

conducts disorders
Childhood dis-LP 22
What do we know?
Many children are struggling at home + in school
• Adults are not aware or dismissive of what they are facing
& how to manage
Depression, anxiety,
substance use/ abuse
Conduct problems, School
drop out
Early sexualized behavior,
etc., etc., etc.
Loose interest
Behavioural and or/
emotional difficulties

Developmental Needs of Children 23

Children struggling to learn

• The delay in picking up • When children cannot

the children follow with the lessons
complicates the picture

• Wasted Students
• Over flows into the
• Distress community’s
• Stress level • Wasted
• problems to the
increases • Distress, governance
Teachers’ stressed Increase in
effort • stressed morbidity

24
 Rutter, 1975.
• The constellation of family problems, worsens the difficulties
which are:
• stresses of life
• marital discord,
• family breakdown,
• parental psychiatric illness /or criminal record
• large family size  higher rates of disorder

• The presence of two or more adverse circumstances increased

the possibility factor by four.

Child & Ado MS 25

Psychiatry is just not
about medication and
medicating
Supportive, talking therapy

26
Common childhood
disorders
Common Problems
• Mental impairment
• AD/HD
• Conduct Disorder
• Learning Disabilities
• Autism/ Autistic Disorder
• Severe psychiatric disorders
• Child abuse & Neglect
• Difficulties in primary
support group (parents)

Childhood dis-LP 28
Attention Deficit Hyperactivity
Disorder (ADHD)
DEFINITION
• Persistent pattern of inattention, hyperactivity,
and impulsivity that is more frequently displayed
and more severe than is typically observed in
individuals at a comparable level of development
and interferes with functioning or development
 DIAGNOSTIC FEATURES (DSM-5)
(A) A persistent pattern of inattention and/or hyperactivity-impulsivity that
inconsistent with developmental level and interferes with functioning or
development
(B) Several inattentive or hyperactive-impulsive symptoms were present prior to age
12 years.
(C) Several inattentive or hyperactive-impulsive symptoms are present in two or
more settings (e.g., at home, school, or work; with friends or relatives; in other
activities).
(D) There is clear evidence that the symptoms interfere with, or reduce the quality
of, social, academic, or occupational functioning.
(E) The symptoms do not occur exclusively during the course of schizophrenia or
another psychotic disorder and are not better explained by another mental
disorder
INATTENTION
• Often fails to give close attention to details or makes
careless mistakes in schoolwork, at work, or during other
activities
• Often has difficulty sustaining attention in tasks or play
activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to
finish schoolwork, chores, or duties
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort
• Often loses things necessary for tasks or activities
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities
HYPERACTIVE / IMPULSIVITY

• Often fidgets with or taps hands or feet or squirms in seat.

• Often leaves seat in situations when remaining seated is
expected
• Often runs about or climbs in situations where it is
inappropriate
• Often unable to play or engage in leisure activities quietly.
• Often talks excessively.
• Often blurts out an answer before a question has been
completed
• Has difficulty waiting his or her turn
• Interrupts or intrudes on others
PREVALENCE
• ADHD occurs in most cultures in about 5% of children and about
2.5% of adults.
• Males : females in the general population, is 2:1 in children and
1.6:1 in adults.
• Females are more likely than males to present primarily with
inattentive features
Clinical Features: Presentation
 Poor attention
 Learning difficulty
 Too energetic ; restless, fidgety, cannot sit still
 Impulsiveness
 Recklessness
 Accident proneness
 Disobedience
 Temper tantrums
 Aggression
COURSE
• Difficult to distinguish from highly variable normative
behaviours before age 4 years.
• Most often identified during elementary school years, and is
relatively stable through early adolescence but some individuals
have a worsened course and remain into adulthood
• In preschool, the main manifestation is hyperactivity.
• Inattention becomes more prominent during elementary
school.
• In adulthood, along with inattention and restlessness,
impulsivity may remain problematic even when hyperactivity
has diminished.
ASSOCIATED FEATURES
• Mild delays in language, motor, or social
development
• Low frustration tolerance, irritability, or mood
lability
• Impaired academic or work performance
• Exhibit cognitive problems on tests of attention,
executive function or memory
Impact
 Life can be hard for children with ADHD.
 They're the ones who are so often in trouble at
school, can't finish a game, and have trouble
making friends.
 They may spend agonizing hours each night
struggling to keep their mind on their homework,
then forget to bring it to school.
 Family conflict can increase.
 Problems with peers and friendships

37
Impact
• Hyperactive children are less cooperative, more
negative and more active manner.
They are often dislike, rejected and have a
negative social status in schools.
Chronic rejection and multiple problems  low
self-esteem.

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Impact
 Without early identification and appropriate
treatment, AD/HD can have serious consequences
that include:
 school failure and drop out,
 depression, conduct disorder,
 failed relationships,
 underachievement in the workplace,
 substance use/abuse.
Impact
 In adolescence, these children are at increased risk
for motor vehicle accidents, tobacco use, early
pregnancy, and lower educational attainment.
Co-morbid
 Disruptive behavior: • Medical problems, such as
Conduct disorder and somatic complaints
oppositional defiant
 Tic disorders – 60%.
 Learning difficulties

41
Co-morbid: read on your own

• 70% of individuals with ADHD will have a co-

morbid learning disorder.
• 15-30% - reading and arithmetic disorders
• The incidence of combined learning and language
deficits associated with ADHD is estimated to be
12.5%

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Prognosis
• Over-activity generally lessens esp. when it is mild,
usually ceases before puberty
• Learning difficulties- less likely to improve
• Antisocial behavior- worst prognosis, and tendency
with substance use/ abuse, early sexualized behaviour

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In the adults: read on your own

• Since ADHD is known to be neurobiological in

origin, it is critical that an evaluation include a
family history.
• Children with ADHD often have parents with ADHD, who
may or may not be diagnosed with the condition.
• It is not uncommon for both parents to exhibit
behaviours consistent with this diagnosis.
(Nadeau, 2000)

44
In the adults
• ADHD persists into adulthood in up to 60% of
cases with childhood onset:
• high rates of anxiety disorders (50%),
• substance abuse (27% to 47%),
• antisocial personality disorders (12% to 27%).
(Spencer et all,1998)

45
Differential Diagnosis: read on your own
• Autism spectrum disorder
• Intellectual disability
• Depressive disorder
• Bipolar disorder
• Psychosocial issues (child abuse, divorce/separation, grief)
• Oppositional defiant disorder (ODD)
• Other neurodevelopmental disorder (language, speech
disorder)
• Anxiety disorder
• Substance / medication (anti asthmatics, anti convulsant,
steroids) induced
• Medical condition (hyperthyroidism)
Conduct Problems

47
Conduct disorders
 Conduct disorder is defined as severe, persistent and
repetitive antisocial behaviour clearly greater than
ordinary mischievousness and rebellion, and in which
the basic right of others is violated.
 constellation of symptoms, antisocial and aggressive
symptoms.

 Common among older children and adolescent.

 co-morbidity of other psychiatric disorders – ADHD,
depression, development of psychosis
48
 Conduct problems
• The persistent antisocial behavior of children and
adolescence that impairs their ability to function in the
society, academic and occupational area.

49
 Conduct problems
• Violate age appropriate rules of society

• Display lack of concern and the rights + feelings of others

• Develop pattern of repeatedly breaking rules of society and fail to

find alternative pattern of conduct

50
 Conduct problems
• arrest for crimes against people/property
• aggression to people and animals
• destruction of properties
• deceitfulness or theft
• serious violation of rules

51
Clinical Implications
 These children are of great concern:
– common presenting symptoms to any clinics
– takes a toll on the mental health and community
– poor prognosis
 Low IQ?
 aggression in boys emerge early
 in females the cases are increasing
• tend to use indirect, verbal, alienation, ostracism and
character defamation between friends

52
Clinical features:
• pre-school: aggressive behaviour, rebellious with
parents, over-activity
• later childhood: disobedience, lying, aggressive,
problems at school, truanting, stealing, vandalism,
fire-setting, disapproved sexual behaviour, alcohol
and drug abuse.

53
 Clinical signs and symptoms: read on your own
• Aggression to people and animals

• bullies, threatens or intimidates others • Destruction of Property

• often initiates physical fights
• deliberately engaged in fire
• has used a weapon that could cause
serious physical harm to others (e.g. a setting with the intention to
bat, brick, broken bottle, knife or gun)
cause damage
• is physically cruel to people or animals

• steals from a victim while confronting

• deliberately destroys other's
them (e.g. assault) property
• forces someone into sexual activity

54
Clinical signs and symptoms: read on your own
• Deceitfulness, lying, or stealing
• has broken into someone else's
• Serious violations of rules
building, house, or car • often stays out at night
• lies to obtain goods, or favors or despite parental objections
to avoid obligations
• runs away from home
• steals items without confronting
a victim (e.g. shoplifting, but • often truant from school
without breaking and entering)

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Conduct problems
 The severity of symptoms influences the stability
of the disorder.
 Mild ones may show improvement: good intelligence,
low family discord and social adjustment.
 high risk for school drop-outs, unemployment,
unhappy and not lasting relationship, with
subsequent loose contact with own children.
 Substance abuse
 Early sexualised behaviour

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Oppositional Defiant Disorder
• recurrent pattern of negativistic, defiant, disobedient and
hostile behavior towards authority figures.
often loses temper
often argues with adult
actively defies or refuses to comply with adults’ request or
rules
often deliberately annoys people
blames other for his mistakes or misbehavior
often touchy or easily annoyed by others
often angry and resentful
often spiteful or vindictive

• cause significant functional impairment in social, academic and

work related issues.
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Management
• Behavior therapy and psychotherapy are usually
necessary to help the child appropriately express and
control anger.
• Special education may be needed for youngsters with
learning disabilities.
• Parents often need assistance in devising and carrying
out special management and educational programs in
the home and at school.

58
Management
• Treatment may also include in some youngsters, such
as those with medication difficulty paying attention,
impulse problems, or those with depression.
• Treatment is rarely brief
• However, early treatment offers a child a better
chance for considerable improvement and hope for a
more successful future.

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Autistic Spectrum Disorder
(ASD)
ASD
• DSM-5: falls in the category of Neuro-
developmental disorder
• Replaces pervasive developmental disorders
including autistic disorder, childhood disintegrative
disorder, Asperger’s disorder, and pervasive
developmental disorder NOS
Autistic Spectrum Disorder
• Greek word ‘autos,’ = ‘self’

• Autistic disorder (autism) is a neurodevelopmental

disorder that leads to problems in social and
communication and is associated with restricted,
repetitive behaviors (Strathearn, 2009).
Autistic Spectrum Disorder
• The prevalence in 2013 to be 1% of the population.
(Center for Disease Control and Prevention [CDC],
2014)
• Prognosis: 10-20% with childhood autism begin to
improve at 4-6 years old.
• 10-20% cannot work,
• need to attend special school or training center,
• very dependent on their families (Volkmar and Klin, 2009)
Clinical Features
• Developmental regression
• Absence of protodeclarative pointing
• Abnormal reactions to environmental stimuli
• Abnormal social interactions
• High pain threshold
• Absence of symbolic play
• Repetitive and stereotyped behavior
• Language deficits-echolalia, pronoun reversal
Physical examination: read on your own

1. Screening
• pretend play- symbolic play
• gaze monitoring-look for mentioned object
• protodeclarative pointing
• point to mentioned unreachable object using index
finger, while looking up at the clinician’s face
2. Body movement
• clumsiness walk, abnormal motor movement
• e.g: hand flapping, bouncing, rotating
Physical examination: read on your own

3. Assessing stereotypies:
• purposeless, repetitive, patterned motions, postures,
and sounds
4. self- injury behavior
5. Screening for siblings
6. Examination for sexual abuse
 Differential Diagnosis: read on your own

• Deafness
• learning disability
• Language disorders and social (pragmatic)
communication disorder
• Attention-deficit/hyperactivity disorder
• Selective mutism
• Stereotypic movement disorder
• Schizophrenia
Autistic Disorders
DIAGNOSTIC CRITERIA (DSM-5)
INTELLECTUAL DISABILITY
(INTELLECTUAL DEVELOPMENTAL
DISORDER)
INTELLECTUAL DISABILITY
DEFINITION
• is a disorder with onset during the developmental
period that includes both intellectual and adaptive
functioning deficits in
a. conceptual (intellectual),
b. social, and practical domains (adaptive)
INTELLECTUAL DISABILITY
DEFINITION
1) Conceptual skills/ intellectual functioning: reasoning,
problem-solving, planning, abstract thinking, judgment:
academic learning, and learning from experience,
communication, language, time, money, etc.

2) Adaptive functioning: skills needed for personal

independence and social responsibility
a. Social skills (interpersonal skills, responsibility, recreation,
friendships
b. Practical skills (daily living skills, work, travel)
INTELLECTUAL DISABILITY
• confirmed by both clinical assessment and individualized,
standardized intelligence testing.
• functioning is well below normal/average, with an
intelligence quotient (IQ – intelligence testing) around 70 or
less.
• significantly impaired ability to cope with common life
demands: lack daily living skills expected of people in their
age group and culture.
• The impairment may interfere with learning,
communication, self-care, independent living, social
interaction, play, work, and safety.
Epidemiology: read on your own
• occurs in 1-10% of the population and is most
accurately diagnosed in the school years.
• sex ratio M:F=1.5 :1
AETIOLOGY: read on your own
AETIOLOGY SUBGROUPS EXAMPLES
GENETICS DOMINANT GENES Neurofibromatosis, Tuberous
sclerosis
RECESSIVE GENES Phenylketonuria, Homocystinuria,
Urea cycle abnormalities

CHROMOSOMAL ABNORMALITIES Down’s Syndrome, Kleinfelter

syndrome (XXY), Turner syndrome
(XO, Edward’s syndrome
X LINKED DISORDER Lesch-Nyhan syndrome,
Duchene’s muscular dystrophy

GENOMIC IMPRINTING Preder Willi syndrome,

Angelman’s syndrome
ANTENATAL INFECTION Rubella, HIV, CMV, syphilis

INTOXICATION Alcohol, cocaine, lead

PHYSICAL DAMAGE Injury, radiation, hypoxia

ENDOCRINE DISORDER Hypothyroidism,

hypoparathyroidism

PERINATAL Birth asphyxia, kernicterus,

intraventricular haemorrhage,
neonatal infection
POSTNATAL INJURY Accident or non accidental

INFECTION Meningoencephalitis

INTOXICATION Lead, drugs

MALNUTRITION Iodine deficiency, protein

malnutrition (marasmus,
kwarshiokor)
History taking: read on your own
• Language delay- expressive and receptive
• Fine motor delay- dressing, toileting
• Cognitive delay- logical reasoning, memory, problem
solving.
• Social delay
• Gross motor delay-infrequent, unless associated with
cerebral palsy.
• Abnormal behavior
• seizure disorders, microcephaly, macrocephaly, history
of intrauterine or postnatal growth retardation,
prematurity, and congenital anomalies
• Birth history, family history
Physical examination: read on your own
• Developmental assessment
• Head circumference, height and weight
• Hearing and vision test
• Neurological examination
• Skin: Cutaneous findings, café-au-lait macules, ash-
leaf spots, fibromas, and irregular pigmentation
patterns.
• Examination for dysmorphic features
Severity:
People of average intelligence score from about 90 to
110 on IQ tests.
Four degrees of severity of mental retardation
based on IQ score.
• mild retardation (IQ range 50-55 to about
70),
• moderate (IQ range 35-40 to 50-55),
• severe (IQ range 20-25 to 35-40), and
• profound (IQ level below 20-25).
Severity levels based on adaptive
functioning
ASSOCIATED FEATURES
• Difficulties with social judgment; assessment of
risk; self-management of behavior, emotions, or
interpersonal relationships; or motivation in school
or work environments
• Disruptive, aggressive, antisocial behaviors
• Gullibility ; a tendency for being easily led by
others. Risk for suicide, self injury
• Psychiatric disorder
ASSOCIATED FEATURES
• They often cannot be distinguished from normal
children until they attend school.
• yet they are picked, diagnosed but minimized
and misunderstood
• Low self-esteem related to the failures in life
or the message of rejection and failure
• School-going age: undiagnosed  subjected
to age-appropriate expectations  behavioural
difficulties
 Psychiatry of Mental Impairment
 Many are undiagnosed, may be subjected to
age-appropriate expectations complaints and
difficulties.

 Difficult early social interaction  overtly

rejected.

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DIFFERENTIAL DIAGNOSIS: read on your own
• Autism spectrum disorder
• Communication disorders and specific learning
disorder
• Major and mild neurocognitive disorders
• Global developmental delay
Specific Learning Disorder
Learning disorders
• in a child or adolescent are characterized by
academic underachievement in reading, written
expression, or mathematics in comparison with the
overall intellectual ability of the child (normal IQ).
• Not due to inadequate schooling, visual, hearing or
neurological deficits.
Clinical presentation
• Poor academic achievement
• Poor reading abilities
• Spelling problems, poor writing, speech delay
• Difficulty with active information  organizing or
presenting information

91
 What Is a Learning Disability?

• Learning disabilities can be divided into three broad

categories:
• Developmental speech and language disorders
• Academic skills disorders
• "Others," includes certain coordination disorders and
learning handicaps not covered by the other terms

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What Is a Learning Disability?
• Learning disability (LD) is a hidden handicap.
• LD is a disorder that affects people's ability to
either interpret what they see and hear or to link
information from different parts of the brain.
• These limitations can show up in many ways--as
specific difficulties with spoken and written
language, coordination, self-control, or attention.

93
What Is a Learning Disability?
• Such difficulties impedes learning to read or write,
or to do math.
• lifelong conditions that affect many parts of a
person's life: school or work, daily routines, family
life, and sometimes even friendships and play.
• In some overlapping with ADHD

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Child abuse
 What Is Child Abuse?
• CHILD ABUSE:

− Any child of any age, sex, race, religion, and

socioeconomic background can fall victim to child
abuse and neglect.

− Major types of child abuse are : Physical,

Emotional, & Sexual Abuse, Neglect.

96
What is healthy adult-
child relationships
Please read the other types of abuse
Healthy adult-child relationships
Adults Children
• sensitive, responsive • reciprocal interactions
• emotionally available • internalize type of
• respects children’s caregiving received
capacities respects adult authority
• taught to resist abuse
of authority
Emotional Abuse:
• also known as: verbal or mental abuse, or
psychological maltreatment
• the persistent emotional ill treatment TAKES
MANY FORMS, IN WORDS AND IN ACTIONS

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Emotional Abuse
• A pattern of behavior by parents or caregivers that
can seriously interfere with a child’s cognitive,
emotional, psychological or social development.
• Ignoring
• Rejecting
• Isolating
• Exploiting or corrupting
• Verbally assaulting
• Terrorizing
• Neglecting the child
Emotional abuse
• OR: Imposing developmentally inappropriate
expectations e.g.
− interactions beyond the child’s
developmental capability,
− overprotection,
− limitation of exploration and learning,
− preventing the child from participation
in normal social interaction
− Exploitation or corruption of a child

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• Includes using
extreme and/or
• exposing the child to
bizarre forms of
inappropriate situations
punishment, such as
or behavior: witnessing
confinement in a
acts that cause a feeling
closet or dark room
of helplessness and
or being tied to a
horror, - domestic
chair for long periods
violence or watching
of time
another sibling being
abused

102
Emotional Abuse:
• Basic food and shelter may be provided, but
withholding love and affection can have devastating
effects on a child.

• Breaks away at ONE’S feelings of self-worth and

independence.
− Conveying to a child that s/he is worthless,
unloved, inadequate, or valued only insofar
as s/he meets the needs of another person

103
• Emotional child abuse usually is invisible.

• but it involves behavior that interferes with a

child’s mental health or social development,
the effects can be extremely damaging and
may even leave deeper lifelong psychological
scars than physical abuse.

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Major Complication of
Untreated/Undetected Cases
• Depression
• Behavior Difficulties
• Substance Abuse
• Interrupted Learning
• Violence, Criminal activities
Direct traumatic effects
FEMALE MALE MODE
MODE
Negative self- Attribution of Project self
image blame blame

Victim role ROLE Abuser role –

identify with
aggressor role
Self-mutilation behavior Aggressive,
anorexic power asserting

Anxiety, Psychiatric Conduct.

phobias or disorders Substance
depression Childhood dis-LP abuse. 106
 Bullying
• Common, occurrence • age-old problem

• Many adults take the

"children will be
children" attitude
toward the problem
 not normal

107
It cannot be “normal”
• Many deaths/ suicide • Children who are afraid
related to bullying to go to school because
(Prewitt, 1988) of the bullying

• Many victims have

resorted to using
violence/ aggression to
stop the tormenting

108
Bullying
• Bullying is a form of abuse – peer abuse (Fried and
Fried, 2003)

109
Bullying
• a systematic abuse of power (Smith & Sharp, 1994)
• three crucial elements:
 repetition, harm, and unequal power.

110
• imbalance of power between two individuals, where
the stronger individual
• repeatedly
• causes harm to the weaker individual (Olweus, 1993; Olweus,
1999; Farrington 1993)

111
• Repeatedly violence, mental or physical

• conducted by an individual or a group against an

individual who is not able to defend himself or
herself (Roland, 1989, in Mellor, 1999).

• inflicted by a more powerful and stronger student

(or group of students) towards another one
perceived as weaker (Olweus, 1993, 1999; Farrington, 1993).

112
• inflicted by a more powerful and stronger
student (or group of students) towards another
one perceived as weaker (Olweus, 1993, 1999; Farrington,
1993).
 oppression (Farrington, 1993)

• an intentional behavior targeted at someone

who has not provoked it
• Olweus, 1999, 1993; Smith and Shrap 1994

113
• NOT playful fighting, or good-natured teasing
between friends
 attempting to gain power, prestige, etc

114
(i) repetition, and
(ii) imbalance of power
 is a subset of aggression

• Bullying is always aggression,  hurtful and hostile

behavior (Gendreau & Archer, 2005)
• imbalance of power between the bully and their target

Gendreau, P. L., & Archer, J. (2005). Subtypes of aggression in humans and animals. In R. E.
Tremblay, W. W.

115
Rigby (2002): evident enjoyment by the
aggressor and generally a sense of being
oppressed on the part of the victim.

116
• Bullying is always aggression, 
• the aggression is not readily observed
• not just an isolated incident (Swearer et al, 2007)

117
Bullying
• Bullying statistics show that one half of all
bullying incidents go unreported (Yerger and Gehret,
2011)

118
Bullying
• From the school shootings: school shooters
reported that they have been chronically bullied
for years (Vossekuil et al, 2002)

119
• What is the take home message?
• why should we be concerned about mental health
difficulties in children?
Scenario #3
S, a 8-year-old girl, is a quiet girl and often
fearful.
• she takes a long time to participate in school
activities and often saying she is not good
enough.
• when her mother is seen, mother is an angry
lady, she says is busy and that her daughter is
active at home, would not do any form of
school-work and she has to be beaten to get
anything from her daughter.
• mother also felt her daughter is a useless,
good for nothing child
121
Thank You