Intoduction and normal development

Child Mental Illness

• A significant proportion of adult mental illness originates before the age of 18 years.
• Three underlying dimensions of child mental illness affect perception of problems:
  • Child's impairment of wellbeing: experiencing significant periods of time with learning and social problems, often with early onset.
  • Child's development: delays in physical and emotional development can impact capacity.
  • Social and cultural context: verbal and non-verbal communication with others affects perception.

Differences Between Child and Adult Psychiatry

• Child psychiatry practice differs from adult psychiatry.
• Assessment of children differs from that of adults.

Key Issues in Children's Mental Health Services

• Complexity of comparing children to a generic 'normal adult' standard.
• Importance of considering internal and external factors affecting the child's behavior.
• Trust issues: who is trusted to communicate with the child?
• Impact of child's development on mental problem outcomes (e.g., mental illness at pre-pubertal stage affecting adolescence).
• Need to consider stress and coping mechanisms in addition to standard examination topics.

Child Development and Response to Stress

• Children respond to trouble and distress in different ways, depending on age.
• Examples: a 7-year-old child may behave like a 5-year-old in a stressful situation.
• Parents' responses to the child's behavior also vary with age.
• Children express distress in various ways, and evidence is often obtained through demonstrations of difficulties.

Normal Development in Child Psychiatry

• Child psychiatry practice requires knowledge of normal childhood development
• Normal development is influenced by genetics, environment, and social factors
• Development should be compared to the normal range for the child's age group

Developmental Milestones

Year Two

• Children begin to seek independence and may throw tantrums
• Tantrums decrease in frequency as children get older
• Children start to learn to point and understand simple sentences

Preschool Years

• A period of rapid language development and social interaction
• Children learn new skills during this period

The First Year of Life

• A time of rapid motor, sensory, and social development
• Smile at faces: 3 weeks
• Selective smiling: 6 months
• Fear of strangers: 8 months
• Anxiety when separated from mother: shortly after 8 months
• Forming a close and secure relationship with caregiver: by the end of the first year
• Established pattern of sleeping and feeding, and weaning onto solid foods: by the end of the first year
• Ability to point at objects and understand simple causal relationships: by the end of the first year
• Making sounds, saying 'mama', 'dada', and one or two other words: by the end of the first year

Child Development in Year Two

• Children typically begin to walk by 18 months old
• They start to learn self-control and regulate their behavior
• Temper tantrums are common, especially when their exploratory desires are frustrated
• These tantrums are short-lived and decrease as the child learns to accept boundaries
• Children develop gestural communication, pointing at things to share their interest with others
• By the end of the second year, children can combine two to three words to form simple sentences

Preschool Years (2-5 Years)

• Intellectual abilities increase, with significant advancements in language complexity
• Social development occurs as children learn to navigate family dynamics
• Children begin to identify with parents and internalize their moral standards
• Social skills rapidly develop through interactions with siblings, peers, and adults
• Temper tantrums continue, but decrease in frequency and intensity before school age
• Attention span and concentration increase steadily
• Children are naturally curious, asking many questions about their environment
• Fantasy life is vivid and rich, allowing children to temporarily escape reality and fulfill desires
• Transitional objects like teddy bears or blankets provide comfort and reassurance
• Children begin to explore their own identity, recognizing differences between males and females
• Sexual play and exploration are common during this stage
• Defense mechanisms develop to cope with anxiety from intolerable emotions
• Common mental health issues in this age group include difficulties with feeding, sleeping, separation anxiety, and minor aggression
• Persistent issues should be referred to mental health services

Developmental Psychopathology

• The stage of development determines whether behavior is normal or pathological, e.g., bedwetting is normal at 3 years but abnormal at 7 years.
• Life events affect children differently at various stages of development, e.g., infants under 6 months can adapt to new caregivers, while children aged 6 months to 3 years show distress when separated from familiar caregivers.
• Psychopathology can change as the child grows older, e.g., anxiety disorders in childhood tend to improve, depressive disorders often recur, and conduct disorders can lead to aggression and substance abuse.

Common Problems in Later Childhood and Early Adolescence

• Common problems in this age group (12-16 years) include fluctuating mood, anxiety, relationship difficulties, disobedience, truancy, substance experimentation, fighting, and stealing.
• Schizophrenia and bipolar disorder may onset during this period, but are uncommon.

The Influence of Genes

• Susceptibility genes have been identified for autism, ADHD, and specific reading disorder.
• However, identified genes explain only a small amount of variance for most disorders, suggesting multiple genes of small effect.
• Environmental factors also play a key role, as neurodevelopmental disorders display remarkable syndromal overlap despite genetic differences (heterogeneity).

The Influence of the Environment

• Environmental factors can predispose to, precipitate, or maintain disorders.
• They can also protect against the effects of other causative agents, e.g., a caring relationship can reduce the risk of depression in adulthood following poor parental care in childhood.
• Genetic and environmental factors interact, affecting the likelihood of exposures or their expression.

The Dividing Line between Normal and Abnormal

• Common childhood disorders exist on a continuum with normal behavior, but are studied using a categorical system.
• A cut-off point is arbitrary, and children who fall just below the threshold can still have problems and need help.
• Even mild depressive symptomatology can be associated with poor academic performance.

Continuities and Discontinuities

• Some childhood symptoms and behavior problems are associated with problems in adulthood, increasing the likelihood of adverse outcomes, e.g., substance misuse and suicidality.
• Overactivity and difficulties in behavioral management in childhood can have long-term consequences.

Classification of Psychiatric Disorders in Children and Adolescents

• Seven categories of psychiatric disorders in children and adolescents: adjustment reactions, autism spectrum disorders (ASD), specific developmental disorders, conduct disorders, attention-deficit hyperactivity disorders, emotional disorders, and symptomatic disorders.

DSM-5 and ICD-10 Classifications

• Both classification systems are complex.
• DSM-5: disorders of childhood are integrated into other sections, no longer in a separate 'infancy, childhood and adolescence' section.
• DSM-5: chapters organized chronologically, with infancy and childhood diagnoses listed first.

Epidemiology of Psychiatric Disorders in Children and Adolescents

• Behavioural and emotional disorders are common in childhood.
• Rates of emotional and behavioural disorders vary according to diagnostic criteria and methods used.
• Similar rates of emotional and behavioural disorders in developed and low- to middle-income countries.

Classification of Main Childhood Psychiatric Disorders

• DSM-5 and ICD-10 are two classification systems used to categorize childhood psychiatric disorders.
• Neurodevelopmental disorders, autism spectrum disorders, attention-deficit hyperactivity disorders, intellectual disability, and communication disorders are classified under DSM-5.
• ICD-10 categorizes these disorders into F8 Disorders of Psychological Development, F9 Behavioural and Emotional Disorders with Onset Usually Occurring in Childhood and Adolescence, and other related categories.

Prevalence of Child Psychiatric Disorders

• A landmark study on the Isle of Wight in 1970 found a prevalence of approximately 7% for psychiatric disorders among 10-11 year olds.
• Boys had higher rates of psychiatric disorders compared to girls.
• Subsequent studies have confirmed these findings, with a prevalence of nearly 10% among 5-15 year olds, and 20% among 14-year olds.
• Conduct disorder and emotional disorders are the most common conditions, with a prevalence of 5% and 4% respectively.

Epidemiology

• A systematic review and meta-analysis reported a pooled prevalence of mental disorders worldwide of 13% among children and adolescents.
• Anxiety disorder had a prevalence of 7%, depressive disorder 3%, ADHD 3%, and any disruptive disorder 6%.
• In adolescence, the prevalence of anxiety disorders was 31%, behavior disorders 19%, mood disorders 14%, and substance use disorders 11%.
• The overall prevalence of disorders with severe impairment and/or distress was 22%.

Variations with Gender and Age

• Before puberty, disorders are more frequent among males than females.
• After puberty, disorders are more frequent among females.
• Particular disorders vary in frequency according to gender and age.
• Rates of psychiatric problems differ between urban and rural areas, with higher rates in urban areas.

Comorbidity

• Studies using DSM criteria find high rates of comorbidity between childhood disorders.
• For example, in the National Comorbidity study, 40% of children had comorbid disorders.

Disorders by Gender

• Autism spectrum disorders, specific developmental disorders, ADHD, oppositional and conduct disorders, juvenile delinquency, nocturnal enuresis, and tic disorders are more frequent in males.
• Depression, anxiety disorders, eating disorders, and deliberate self-harm are more frequent in females.
• Depression before puberty and selective mutism are equally frequent in both genders.

Disorders by Age

• Depressive disorders, mania, psychosis, agoraphobia, eating disorders, substance abuse, deliberate self-harm, and juvenile delinquency usually begin after puberty.

Outcomes of Child and Adolescent Mental Illness

• Most mild symptoms and behavioral or developmental problems are short-lived.
• Severe conditions often persist for years, with 75% of children with conduct disorder and 50% of those with emotional disorders still affected 4 years later.
• Anxiety disorders, depression, and ADHD can persist into adulthood.
• A family history of emotional disorders and the presence of comorbid difficulties are associated with a risk of recurrence.