Child Psychiatry(2)

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 longterm 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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