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Psychological difficulties in children

by Dr. R. A. R. Perera

Most children show isolated psychological symptoms at one time or another and, to a considerable extent, these are a normal part of growing up.

However, some children suffer from psychiatric disorders that interfere with normal development. Accordingly, one of the first tasks when a child is referred to the clinic is to assess whether the child has a disorder.

In this context, a psychiatric disorder can be defined as behavioral or emotional symptoms that are so prolonged or so severe as to cause suffering to the child or to others, social restriction or impairment of normal development.

Some symptoms, such as fire-setting or deliberate self-harm, are so extreme that they need only occurs once to be regarded as abnormal.

Most symptoms are only abnormal, however, if they persist and if they are seen in several situations, and should be regarded as a disorder only if they lead to impairment.

Diagnosis / Assessment

1. Age and sex appropriateness

2. Socio - cultural settings

3. Duration/Pervasiveness

4. Type of symptom/impairment a. Suffering to the child, b. Headicap to the parents, c. Social impairment, d. Interference with development.

Emotional disorders

Most emotional disorders of childhood are exaggerations of normal development trends. The onset is usually during the developmentally appropriate age period. For example, it is normal for infants to show a degree of anxiety over separation from people they are attached.

When this anxiety becomes severe, or persists in to later childhood or adolescence, it is termed separation anxiety disorder. Similarly, when stranger anxiety persists beyond the preschool years, the diagnosis of social anxiety disorder is justified. In adolescence, specific fearfulness, though less common, usually takes the form of school refusal or adult type neurotic disorders, such as social phobia or agoraphobia.

Anxiety disorders are among the commonest psychiatric problems in childhood and occurring in about 3% of 10 year olds. Genetic factors are important. The parents are often anxious and communicate their anxiety by behaviours such as over-protectiveness. Some cases of anxiety, particularly specific fears, are precipitated by stress.

Management: consists of the reduction of stress, behavioral therapy for specific symptoms (e.g. graded exposure to the fearful situation) and general treatment such as relaxation. Anxiolytics may be helpful for severe cases, but should not be prescribed for long periods.

Affective disorders

Depressive disorders occur in prepubertal children, but are uncommon (1%). (In adolescence 4% - girls, 2% - boys). The main clinical features are similar to adults. But somatic complains and anxieties are more common in prepubertals than in adolescence. Mania is uncommon.

Infants who have been severely deprived or abused sometimes show a state of withdrawal and retarded development (anaclitic depression). Children and adolescence with depressive disorders tend to have parents who are depressed, but these links are probably more a reflection of environmental (e.g. poor parenting) than genetic factors. Depression in young people is commonly precipitated by adversity.

Management: consists of reducing this adversity, and the use of individual psychological interventions (e.g. cognitive behavioral therapy, which can be administered to children over 10 years) and family therapy. Antidepressants should be used cautiously for adolescence due to the risk of overdose. Most recover within few months but relapse can occur.

Many children attending medical services have unexplained physical symptoms (e.g. abdominal pain and headache) these children tend to come from families that have health problems and high academic expectations.

In many cases, the child is in some kind of predicament in which other avenues have been blocked; for example, the child may feel unable to achieve what the family expects academically. Pre-existing physical problems in the child or in a relative may determine the kind of symptomalgy shown.

Management: Involve the psychiatrist/psychologist and the paediatrician closely, changing the family focus from physical to psychological issues, and placing emphasis on leading as normal life as possible (e.g. returning to school).

Conduct disorders

Conduct disorders are characterised by repetitive antisocial behaviour that lasts for at least for 6 months. In young children, the clinical picture is dominated by markedly opposition behaviour (e.g. defiance, hostility, and disruptiveness) that is clearly outside the normal range. In older groups' behaviours such as stealing, truancy, fighting, lying and running away is seen.

In severe cases, fire setting, or cruelty to animals and other children are seen. Conduct disorders are usually associated with poor peer relationships. Conduct disorders occur more in towns (10% than in rural areas. More in boys than girls.

There is a strong link with discordant interfamilial relationships and abused parents are often inconsistent in applying rules and may be critical and rejecting the child. About 30% have reading difficulties and few have organic brain disease.

Management: Depend on the presenting problem and the commitment of the parents. Behaviourial methods are effective for young children. Medication is of little value. Older children with severe problems have to be in special schools. Children with few symptoms and good peer relationship do better. Children with early onset and poor peer relationship have 30% risk of personality disorders in adulthood.

Almost all adults with anti-social personality disorder have had conduct disorder as children.

Hyperkinetic disorders

Hyperkinetic behaviours are overactive behaviours and inattention. Diagnosis depends on these two problems in more than one situation (e.g. home, clinic, classroom), and long-term persistence of the behaviour.

The diagnosis is difficult in less than 5 years due wide normal variations. Several other abnormalities are associated with the disorder, including impulsiveness, conduct disorders and learning difficulties. Prevalence depends on diagnosis criterias.

Brain dysfunction resulting from genetic processes or early brain damage is important in the etiology. Hyperkinesis may occasionally be the result of early social deprivation.

Side effects to drugs or additives are also important. Management: Counsel the parents of the biological factors. Changing the environment, for example by moving to a house with a garden, is helpful, but difficult to achieve. Behaviourial programs may be helpful. Stimulant medications (methyl phendiate) may be helpful in severe cases. Hyperkinetic disorders are associated with an increase risk of conduct disorders in adolescence.

By 5 years of age 10% of children will still wet at night and 3% will wet during the day. Enuresis (inappropriate emptying of the bladder in the absence of organic disease) in a child over 5 years may be nocturnal diurnal or both.

The most common cause is an inherited delay in maturation of the nervous pathways that control micturition. But there is increased level of behaviourial problems in these children especially in girls.

Management: Children should be reassured that they are not the only ones to suffer from the problem. Parents should be advised not to punish the child. But rather to encourage the appropriate toilet habit. This process, known as shaping should be charted and rewarded on 'dry' days. It may be necessary to treat associated psychiatric disorders.

Glaucoma

Early diagnosis and treatment could prevent further deterioration:

Glaucoma occurs when the nerve at the back of the eye becomes damaged. This can cause a person's sight to deteriorate and can lead to blindness.

What is glaucoma? Glaucoma is the name given to a group of conditions that affect the eye.

There are four different types of glaucoma - acute, chronic, developmental and secondary. In each case, the optic nerve behind the eye is damaged. This nerve carries information from the eye to the brain enabling us to see. This damage can be caused by a weak nerve or more usually by the build-up of fluid in the eye. This occurs when fluid in the eye cannot drain properly.

Acute glaucoma can occur suddenly and can be painful. If left untreated, it can lead to blindness.

Chronic glaucoma is the most common form of the condition. The drainage channels from the eye become blocked over time and vision gradually becomes impaired. Developmental glaucoma mostly affects babies and young children. It is rare but potentially serious and is caused by malformation of the eye.

Secondary glaucoma occurs when another problem in the eye causes fluid to build-up and eyesight to deteriorate.

How common is it?

By the age of 40, about one person in every 100 has some form of glaucoma. However, the incidence rises steadily as people get older. By the age of 70, about one person in every 10 has some form of glaucoma.

People who are of African origin are more likely to develop the condition. People who are highly short-sighted, those with diabetes and those with a family history are also at increased risk.

In the UK people over the age of 40 and with a family history of glaucoma are entitled to free eye tests on the NHS every two years.

What are the symptoms?

Acute glaucoma can be painful. The sudden increase in pressure can make the eye red.

Eyesight can deteriorate and may even blackout. There may be nausea and vomiting. Chronic glaucoma is less easily spotted. There is no pain and the deterioration in eyesight may be subtle.

Some people go for an eye test after noticing their sight is less good in one eye than the other. The fact that this type of glaucoma can creep up on people is one reason why doctors advise regular eye tests.

How is it treated?

Glaucoma is treated by reducing pressure on the eyes.

Eye drops are a common first approach. However, if they fail to unblock the drainage channels then an operation may be needed.

These can take the form of laser surgery or a trabeculectomy - an operation to improve drainage of the eyes.

Can it be cured?

In many cases, the damage that has been caused by the glaucoma cannot be reversed. However, early diagnosis and treatment can prevent further deterioration

BBC.com

Football is 'good for men's mental health'

by Helen Neill

Playing in a football team can help men feel more confident and enthusiastic about their lives, according to researchers.

A new study, carried out by the University of Nottingham, suggests the sport can improve the mental health of men who are suffering from problems such as depression.

They evaluated more than 100 men playing for league teams in the north west of England.

Bonding experience

Lead researcher Alan Pringle said that one of the benefits of playing football regularly is the friendships men have with their team-mates.

He told Newsbeat that depression can make people become lethargic and withdrawn and that "people who wouldn't normally go out, will play football".

He said it acts as "therapy in disguise", and that many men talk about the confidence they get from working with their own team, and facing the opposition.

Nine out of 10 felt that their mental health had improved significantly since they joined a team, and more than 70% said that they were now more optimistic about the future.

Doctors are already encouraged to "prescribe" exercise to people who are suffering from mild depression.

Mind spokesperson Alison Kerry said: "If you're feeling low, outdoor exercise is a fantastic way of boosting your mental wellbeing.

"Men often find it harder to talk about their problems than women and football presents an opportunity for greater social interaction in an informal and fun way."