Child Psychiatry(2)

Department of psychology
The first affiliated hospital of ZZU
Huirong guo
Contents
 Conduct disorder( 品行障碍 )
 Juvenile delinquency （青少年犯罪）
 Hyperkinetic syndrome （多动综合症）
 Disorders of development (Childhood autism ) （发育
障碍－儿童孤独症）
 Child abuse （儿童虐待）
Conduct disorder
 Conduct disorder ( 品行障碍 )
 Conduct disorder is characterized by sever and
persistent antisocial behavior
 It is the most common type of psychiatric disorder
among older children and adolescents
 Conduct disorder ( 品行障碍 )
Prognosis
 Mild disorders often improve, but more severe
disorders usually run a prolonged course in childhood
and some persist into adult life. There are no good
indications of outcome for individual children,
although in general the behavior is more likely to
persist when it is severe and when the quality of
personal relationship is poor
 Clinical features
 The essential feature is persistent abnormal conduct, more
serious than ordinary childish mischief and rebelliousness.
The dividing line between conduct disorder and normal is
necessarily arbitrary
 In the pre-school period the disorder usually manifests as
aggressive behavior to other children, rebellion against the
parents, and often over-activity
Clinical features
 In later childhood the disorder is seen at home where
may be disobedience, lying, and verbal or physical
aggression, at school, where may be work and behavior
problems and truanting, and more generally as stealing,
vandalism, and fire setting.
 Some children present with sexual behavior that incurs
the disapproval of adults. In younger children,
masturbation and sexual curiosity may be frequent and
obtrusive. Adolescent girls may be promiscuous. Older
children and adolescents may abuse drugs or alcohol
 Etiology
 Environmental factors are important. Conduct disorders
of all kinds are more frequent among children from
unstable, insecure, and rejecting families living in deprived
areas. Antisocial behavior is frequent amongst children
from broken homes and amongst those who have been in
residential care in early childhood
 Conduct disorders are also related to adverse factors in the
wider social environment of the neighborhood and school,
such as over-crowding and high crime rates
 Etiology
 As well as these environmental causes, constitutional
factors may predispose to conduct disorder. From
adoption studies it seems that genetic factors are not of
great general importance although they may play a part
in the etiology of aggressive behavior. Conduct disorder
is associated with speech and reading difficulties
 Treatment
 For mild conduct disorders, which often recover with time, it is
usually sufficient to advise parents on maintaining a consistent
approach and setting clear limits to the child’s behavior. For more
severe disorders any stressful circumstances are reduced if possible
 A behavioral approach is sometimes used in an attempt to limit the
problems by rewarding desirable behavior and chaotic
relationships. If the child has reading or other educational
difficulties, remedial teaching should be arranged
 There is no effective medication
 Treatment
 These measures may reduce the immediate difficulties, but there is
no convincing evidence that treatment affects the long-term
outlook. When adverse social and family factors improve for any
reason, the abnormal behavior may improve as well
 Occasionally, a conduct disorder is so severe that the child needs
placement in a foster home, residential home, or special school.
This arrangement should be made only for compelling reasons, and
only after assessment by a child psychiatrist and discussion with all
those involved. Although institutional care may contain the
immediate problems, there is no evidence that it improves the long-
term prognosis
Juvenile delinquency
Juvenile delinquency
（青少年犯罪）
 Delinquency is breaking the law; it is a legal category and
not a psychiatric diagnosis
 It is considered here because some juvenile delinquents have
conduct disorders. Delinquency is most common about the
age 15-16 years
 It is much more common in boys than girls. When asked
about their own conduct, most adolescent boys admit having
broken the law at some time
 A fifth of adolescent boys are convicted of an offence, usually
a trivial one; of those convicted, only a few continue to
offend in adult life
 Causes
 The causes of juvenile delinquency overlap with the social causes
of conduct disorder. Delinquency is related to low social class,
poverty, poor housing, and poor education. Rates of delinquency
are greater in areas of social deprivation and in schools in
disadvantaged areas
 They are higher in children from broken homes, families with
discord, and very large families. Amongst boys with criminal
fathers about half are convicted for one offence, as against a
fifth of those fathers are not criminals
 The reasons may include poor parenting and shared attitudes to
the law.
 Management
 Since delinquent behavior is usually a passing phase, it is
generally appropriate that non-serious first offences
receive minimal intervention except for clear indications of
disapproval
 For serious or recurrent offences, the main emphasis is on
improving the family environment, helping the offender to
develop better skills for solving problems, improving
educational and vocational accomplishments, and, if
possible, reducing harmful peer group influences
Hyperkinetic syndrome
Hyperkinetic syndrome
（多动综合症）
 About a third of child are described as over-active by their
parents, and up to a fifth of schoolchildren are described in this
way by their teachers. These reports encompass behavior varying
from normal high spirits to severe and persistent disorder
 The boundary between normal over-activity and persistent
disorder is drawn in an arbitrary way, and there are disputes as
to whether the criterion for disorder should be set high or low
(thereby excluding all normal over-activity) or low (thereby
making sure that no abnormal behavior is missed)
 Clinical picture
 In the United States the cut-off used is lower than in the
United Kingdom and many other countries, and the
same given to the disorder also differs. The ICD uses the
term hyperkinetic disorder, while the DSM uses the term
attention deficit-hyperactivity disorder, a name chosen
to denote an important symptom associated with the
over-activity
 Clinical picture
 The over-activity usually becomes evident when the child
stars to walk, though sometimes it is obvious before then.
Then child constantly moves, interferes with objects, and
does not sustain attention, children with the fully
developed syndrome are impulsive, reckless, and prone to
accidents. Mood fluctuates, but depressive mood is
common
 There are learning difficulties at school and minor forms
of antisocial behavior are common, particularly
disobedience, temper tantrums, and aggression. This
behavior exhausts the parents
 Etiology
 Studies of twins suggest genetic factors. An innate
tendency to over-activity may be increased by social
factors, with the condition being more frequent among
young children living in poor social conditions. However,
social factors are unlikely to be the sole cause of
hyperkinetic disorder
 Lead intoxication and food additives have been suggested
as causes, but current evidence suggests that if diet has an
effect, it is only a small subgroup of cases
 Prognosis
 As the child grows older the over-activity generally lessens,
particularly when it is mild and not invariably present.
Usually it ceases by puberty. Associated learning difficulties
are less likely to improve, and antisocial behavior has the
worst prognosis
 When the over-activity is severe, accompanied by major
learning difficulties, or associated with low intelligence, it
may persist into adult life
 Treatment
 For unknown reasons, stimulant drugs such as
methylphenidate sometimes have the paradoxical effect of
reducing the over-activity
 Such treatment is generally reserved for severe cases, and
a special opinion should be obtained. Surprisingly, there is
no convincing evidence that hyperactive children treated in
this way become addicted to the stimulant drug, but they
may experience side effects of irritability, depression, and
poor appetite, and there may be slowing of growth
 Treatment
 Although there is short6-term improvement in about
two-third of cases, the long-term benefits are
uncertain. Whether or not drugs are used, parents
and teachers need support for their efforts to cope
with the over-activity. Remedial teaching may be
needed as well
Childhood autism
Childhood autism （儿童孤独症
）
 Autism is the least rare of group of pervasive
developmental disorders. Autism is a severe disorder of
behavior starting in early childhood after a brief period of
normal development. It is rare, occurring in adult 30-40
per 1,000,000 children, and is four times more common in
boys than in girls
 Clinical picture
 Inability to relate: autistic children do not respond to their
parents’ affectionate behavior by smiling or cuddling. Indeed,
they are no more responsive to their parents than to strangers,
and often there is no clear difference between behavior to people
and to inanimate objects. A characteristic sign is gaze avoidance,
which is the avoidance of eye contact
 Speech and language disorder is another important feature.
Speech may develop normally and then decline, or develop late,
or never develop. This lack of speech, together with specific
linguistic deficits, is a manifestation of a more general cognitive
defect, which also affects non-verbal communication
 Clinical picture
 Resistance to change: autistic children show distress when there
is a change in their environment. For example, they may
repeatedly prefer the same food, insist on wearing the same
clothes, or engage in the same repetitive games
 Odd behavior and mannerisms are common
 Other features: autistic children may be emotionally labile,
suddenly showing anger of fear without apparent reason: they
may be overactive and distractible, they may sleep badly, or
they may be wet or soil themselves. About a quarter of autistic
children develop seizures, usually about the time of adolescence
 Etiology
 The cause of childhood autism is unknown, though studies
of twins suggest a genetic etiology
 It is likely that the basic abnormality is cognitive, affecting
particularly symbolic thinking and language, and that the
behavior abnormalities are in some way secondary to this
cognitive abnormality
 Abnormal parenting has not been shown to be cause—an
important point for families to understand
 Prognosis
 As autistic children grow up, about half acquire some useful
speech, although usually they still have serious impairments.
Those who improve may continue to show emotional coldness
and odd behavior
 As mentioned already, a substantial minority develops epilepsy
in adolescence. Between 10 and 20 per cent of children with
childhood autism are eventually able to attend an ordinary
school and later obtain work
 A further 10-20 per cent can at home but cannot work and need
to attend a special or training center. The rest (60-80 per cent)
are unable to lead an independent life
 Differential diagnosis
 This can be difficult and requires the advice of a specialist.
Childhood autism has to be distinguished from a number
of other disorders including deafness, which can be
excluded by appropriate tests of hearing, developmental
language disorder, in which the child usually responds
normally to people, and mental retardation, in which there
is general intellectual retardation and a more normal
response to other people
 Also, compared with a mentally handicapped child of the
same age, the autistic child has more impairment of
language relative to other skills
 Treatment
 The advice is a specialist should be obtained. There is
no specific treatment. Management has three aspects:
 1 the management of abnormal behavior
 2 the provision of educational and social resources
 3 support for the family
 Treatment
 Abnormal behavior is managed by behavioral methods.
These begin by identifying any factors that appear to be
reinforcing the behavior (for example parents attending
more to the child when behavior is most abnormal). The
parents are then shown that, usually by a clinical
psychologist, how to modify these factors in the home.
Such methods lead to a degree of short-term improvement
in some cases but have not been shown to produce lasting
benefit
 Treatment
 Most autistic children require special schooling, and some need
residential schooling. Day care in the school holidays is helpful
to some families. The aim of schooling is to help the child to
achieve his remaining potential for development
 The family of an autistic child needs help. Although he can do
little to treat the child, the doctor can encourage the family in
their efforts to establish as normal a life as possible for the child.
Many parents find it helpful to join a voluntary organization in
which they can meet other parents of autistic children and
discuss common problems
Childhood abuse
 physical abuse （躯体虐待）
 sexual abuse （性虐待）
 emotional abuse （情感虐待）
 Physical abuse
 Physical abuse refers to deliberate infliction of injury on a
child, usually by one of the parents. Surveys indicate an
annual rate of about one child per thousand receiving
injuries of such severity that there is evidence of bone
fracture or bleeding around the brain. Less severe injury is
probably much more frequent, but does not always come
to professional attention
 Physical abuse
 Clinical features
 The problem may become apparent when the parents
bring a child to the doctor with an injury say to have been
caused accidentally. Alternatively relatives, neighbors, or
other people may become concerned and report the
problem to the police, social workers, or voluntary
agencies
 Clinical features
 The most common form of injury are bruising, abrasions, bits,
burns, torn lips, fractures, subdural hemorrhage, retinal
hemorrhage, and fearful response to adults, suspicion of physical
abuse should be aroused by the following:
 the nature of the injuries
 a previous history of suspicious injury
 unconvincing explanations of the way in which the injury was
sustained
 delay in seeking help
 incongruous reactions to injury by the parents
 other evidence that the child is distressed such as social
withdrawal, low self-esteem, and aggressive behavior
 Etiology
Social factors
 Child abuse is more frequent in neighborhoods where family violence
is common, schools, housing, and employment are unsatisfactory, and
there is little feeling of community

 Parental factors
 Compared with other parents, those who abuse their children tend to
be very young, of abnormal personality, socially isolated, in an
unhappy or broken marriage, and with a criminal record. A minority
has a psychiatric disorder, usually either affective disorder or
schizophrenia. Many parents give a history of having themselves
suffered abuse or deprivation in childhood
 Etiology
Risk factors in the child
 These include premature birth, separation from the
parents in early life, a period of special care in the
neonatal period, congenital malformations, chronic
illness, and a difficult temperament. A common factor
is that all these cause can impede the normal bonding
between parent and child
 Management
 Doctors and others involved in the care of children
should be alert to the possibility of child abuse. They
need to be particularly aware of the greater danger to
children who have the risk factors described above, are
in the care of parents with the predisposing
characteristics listed above, and live in a disadvantaged
neighborhood
 Management
A doctor who suspects abuse should refer the child to hospital
with a full account of the reasons for suspicion. Usually the
child will be admitted for assessment, which includes
photographs of injuries and radiographs of the skeleton
 Radiological examination may show evidence of previous
injury; occasionally, it may reveal evidence of a bone disorder
such as osteogenesis imperfecta suggesting that fractures were
caused accidentally and not through abuse
 Management
 CT should be performed if subdural hemorrhage is suspected.
All findings should be documented fully since evidence may
be needed in subsequent legal proceedings
 When it has been decided that non-accidental injury is
probable, an experienced senior doctor and social worker
should talk to the parents. Other children in the family should
been seen and examined to ensure their safety. The procedure
varied with the administrative arrangements in different
countries
 Management
 In the United Kingdom the social services play an
important role. The general practitioner should be
involved in any immediate and long-term plans for the
child and the rest the family
 Sometimes the children can return home if support and
close supervision are provided for the parents. When abuse
has been severe or prolonged. However, the child may need
to move to foster care while treatment is given to the
parents. Sometimes permanent separation is necessary
 Management
 These very difficulty decisions are usually made by a
pediatrician or child psychiatrist and social worker, both
experienced in such problems
 Since children returning to their parents may suffer
further serious injury or even death, it is vitally important
that a very careful assessment be made before a physically
abused child is returned to the parents, and that there be
close supervision of the child after return
 Prognosis
 Children who have been subject to physical abuse are at
high risk of subsequent emotional and behavioral disorder,
delayed development, and learning difficulties. When in
adult, former victims of abuse may have difficulties in
rearing their own children
 Sexual abuse
 The term sexual abuse refers to the involvement of children in
sexual activities to which they cannot give legally informed
consent or which violate generally accepted cultural rules and
which they may not fully comprehend. The term covers various
forms of sexual contact (sometimes involving violence) as well as
activities such as posing for pornographic photographs or films
 The abuser is usually known to the child and is often a member
of the family. The prevalence of sexual abuse is difficult to
determine; more cases have been reported to doctors in recent
years
 Clinical features
 The children are more often female and the offenders usually
male. Sexual abuse may be reported directly by the child or
by a relative. Children are more likely to report abuse when
the offender is a stranger than when he is a family member.
Sexual abuse is sometimes discovered during the
investigation of other conditions, for example symptoms in
the around genital or anal area, behavioral or emotional
disturbance, inappropriate sexual behavior, or pregnancy
 In adolescent girls, running away from home or unexplained
suicidal attempts should raise the suspicion of sexual abuse.
When abuse occurs within the family, marital and other
family problems are common
 Clinical features
 The immediate consequences of sexual abuse include
anxiety, fear, depression, anger, inappropriate sexual
behavior, and unwanted pregnancy. Long-term effects
include low self-esteem, mood disorder, self-harm,
difficulties in relationships, and sexual mal-adjustment
 Assessment
 It is important to be alert to the possibility of sexual abuse
and to give serious attention to any complaint by a child of
being abused in this way. It is also important not to make the
diagnosis without adequate evidence from a thorough social
investigation of the family, and from physical and
psychological examination of the child
 Assessment
 It is essential that information from children is obtained
carefully. The child should be encouraged sympathetically to
describe what has happen; drawing or toys may help younger
children to give a description, but great care should be taken
not to suggest answers to the child
 When the circumstances make it appropriate, a physical
examination is carried out including inspection of the
genitalia and the anal region. If intercourse may have taken
place in the past 72 hours, specimens should be collected from
the genital area and any other relevant regions
 Management
 The initial management and the measure to protect the
child are similar to those for physical abuse. In families
where sexual abuse has occurred, the members may deny
the seriousness of the abuse and of other family problems,
and may have deviant sexual attitudes and behavior
 The sexual development of the abused child is often
abnormal and requires help. Decisions about treatment
and removal from home are taken only after the most
careful consideration of all the implications
 Emotional abuse
 The term emotional abuse usually refers to persistent
emotional neglect or rejection sufficient to impair a child’s
physical or psychological development
 Emotional abuse often accompanies other forms of child
abuse but may occur alone. Usually the parents require
help for their own emotional problems, so that they can
relate more appropriately to the child. The child need
counseling or, in severe cases, separation from the parents
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