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Common Behavioral and Psychological Disorders Affecting Children
Specific Learning Objectives (ILOs)
By the end of this lecture, the student will be able to:
Enumerate the common behavioral or psychological disorders affecting the child.
Diagnose the child with behavioral or psychological disorders.
Manage the common behavioral or psychological disorders affecting the child.
Contents
Attention-deficit hyperactivity disorder (ADHD)
Autism spectrum disorders (ASD)
Disruptive behavioral disorders
Eating disorders
Enuresis
Encopresis
Sleep disorders
Case Study 1: ADHD Diagnosis
Patient Description
A 6-year-old male child whose mother states that:
"His teacher is concerned about his ability to focus at school."
"He is having difficulty mastering kindergarten material."
Possible Diagnosis
Attention-Deficit Hyperactivity Disorder (ADHD)
Definition of ADHD
ADHD is characterized by:
A persistent pattern of excessive inattention and/or hyperactivity/impulsivity.
This pattern interferes with functioning, resulting in significant social and academic impairments.
It is more common in males.
Typically presents between ages 3 and 13.
Often shows a familial pattern.
Diagnostic Criteria for ADHD
To diagnose ADHD, one must observe:
Six or more symptoms from each of the categories listed below:
Inattention
Hyperactivity/Impulsivity
Symptoms must be present for six or more months.
Symptoms must occur in at least two settings (i.e., home, school, work).
Some symptoms must be present before the age of seven.
Core Symptoms of ADHD (According to DSM-5)
Inattention symptoms include:
a) Careless mistakes
b) Cannot sustain attention in tasks or play
c) Does not listen when spoken to directly
d) Fails to complete tasks
e) Disorganized
f) Avoids and dislikes tasks that require sustained mental effort
g) Loses things necessary for tasks or activities
h) Distractible
i) Forgetful
Hyperactivity/Impulsivity symptoms include:
a) Fidgets, squirms in seat
b) Leaves seat when expected to remain seated
c) Runs and climbs excessively
d) Cannot play quietly
e) “On the go,” driven by a motor
f) Talks excessively
g) Blurts out answers before questions are completed
h) Difficulty awaiting a turn
i) Interrupts/intrudes on others
Types of ADHD
a) Inattentive
b) Hyperactive/impulsive
c) Mixed
Gender Differences in Symptoms
Girls tend to exhibit inattentive symptoms, while boys display impulsive/hyperactive symptoms.
Differential Diagnosis of ADHD
Conditions that could be mistaken for ADHD include:
Learning disorders
Hearing and visual defects
Thyroid disorders
Atopic conditions
Congenital problems (e.g., fetal alcohol syndrome, Fragile X syndrome)
Lead poisoning
History of head injury
Traumatic life events (e.g., abuse)
Treatment of ADHD
Non-pharmacological Treatments:
Psychoeducation
Behavioral management (e.g., parent training, classroom management, social skills training)
Note: Sugar and food additives are not considered etiologic factors.
Pharmacological Treatments:
1st line: Stimulants (e.g., methylphenidate, amphetamines)
2nd line: Atomoxetine
3rd line/adjunct: Non-stimulants (e.g., guanfacine, clonidine, bupropion)
For comorbid symptoms: Antidepressants and antipsychotics can be considered.
Case Study 2: Autism Spectrum Disorders Diagnosis
Patient Description
A mother reports:
Her 2-year-old child has delayed speech and cannot say any words thus far.
The child shows low interest in contacting the surroundings.
Possible Diagnosis
Autism Spectrum Disorders (ASD)
Definition of ASD
Autism Spectrum Disorders are characterized by:
Abnormal or impaired social interaction and communication.
Restricted activities and interests, evident before the age of 3 years.
More common in males.
May be associated with tuberous sclerosis and Fragile X syndrome.
Symptom severity and IQ can vary widely.
Characteristic Features of Autism
Patients may:
Fail to develop normal social behaviors (e.g., social smile, eye contact).
Lack interest in relationships or sharing of interests and emotions.
Exhibit difficulties adjusting behavior to different social contexts.
Have delayed or absent development of spoken language and lack of facial expressions/nonverbal communication.
Show stereotyped repetitive speech and behavior (e.g., hand flapping) and restricted interests (e.g., preoccupation with objects).
Exhibit hyper-/hypo-reactivity to sensory input.
Symptoms must cause clinically significant impairment in social, occupational, or other important areas of functioning.
Treatment for Autism
Team-Based Treatment:
Involves collaboration among school professionals, psychologists, occupational therapists, physiotherapists, speech-language pathologists, pediatricians, and psychiatrists.
Psychosocial Treatments:
Family education and support.
School programming.
Behavioral therapy.
Social skills training.
Pharmacotherapy:
While medications do not treat ASD directly, they can manage associated symptoms:
Atypical antipsychotics (for irritability, aggression, agitation, self-mutilation, tics).
SSRIs (for anxiety and depression).
Stimulants (for attention and hyperactivity related to ADHD).
Other Possible Psychiatric Disorders in Children
Disruptive Behavioral Disorders:
Includes conduct disorder and oppositional defiant disorder. Both are more common in males and those with a history of abuse.
Conduct Disorder
Defined as a repetitive, persistent pattern of violating the basic rights of others or societal norms for one year or more.
Behaviors may be:
Aggressive (e.g., rape, robbery, animal cruelty).
Nonaggressive (e.g., stealing, lying, deliberately annoying others).
There is a potential progression to antisocial personality disorder in adulthood.
Oppositional Defiant Disorder (ODD)
Defined by a pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures for six or more months.
This can lead to conduct disorder if untreated.
Treatment includes individual and family therapy.
Eating Disorders:
Pica:
Definition: Repeated or chronic ingestion of non-food items (e.g., clay, paper, paint, dirt) after age 2, requiring investigation.
Predisposing factors: Intellectual disability, lack of parental nurturing, family disorganization, poor supervision, neglect, and conditions associated with autism and low socioeconomic status. Often linked with iron deficiency, increasing risks for lead poisoning and parasitic infections.
Case Study 3: Enuresis Diagnosis
Patient Description
A 7-year-old boy has never achieved complete nighttime dryness since potty training at age 3 years. He recalls experiencing a dry night intermittently, but with no predictability.
Provisional Diagnosis
Enuresis
Definition of Enuresis
Defined as the involuntary passage of urine during sleep in children aged 5 years or older, in the absence of congenital or acquired urinary tract defects.
Types of Enuresis
Primary Enuresis:
Most common type, defined as bedwetting in a child who has never achieved night bladder control. Factors may include hyposecretion of ADH, diminished arousability during sleep, and abnormal bladder function.
Key History Questions to include:
Periods of dryness, family stress, family history of enuresis (60-70% have a relative with past enuresis), bowel control, peer interactions, emotional changes, symptoms of urinary infection.
Physical Examination:
Generally unrevealing; however, it is essential to look for anatomical or neurological defects.
Examination of the genitalia for abnormalities and assessment of gait and anal reflexes.
Laboratory Studies:
Urine dipstick and microscopic analysis to detect infection, diabetes, etc.
Ultrasound and CT imaging may be required to identify structural issues.
Treatment for Enuresis
Initial treatment should focus on behavioral strategies due to the high rate of spontaneous resolution:
Reassurance (approx. 20% resolve spontaneously each year).
Behavior modification: Limiting fluids and avoiding caffeine before bedtime, ensuring accessibility to toilets, use of dry charts, and reward systems.
Conditioning techniques such as alarms that awaken the child upon urination.
Medications: For children age 7 and above, treatments can include desmopressin or imipramine as second-line therapy.
Secondary Enuresis:
Refers to bedwetting in a child who previously had established nighttime bladder control for at least 6 months. Often indicates underlying psychological or medical conditions such as sleep disorders, constipation, urinary tract infections, diabetes, etc.
Encopresis Diagnosis
Clinical Features:
Encopresis involves fecal incontinence, characterized by repeated passage of stool in inappropriate places (e.g., clothing, floor) in a child over 4 years of age, occurring at least once a month for three months.
Causes can include chronic constipation, Hirschsprung disease, hypothyroidism, spinal cord lesions, anorectal malformations, or bowel obstruction.
Types of Encopresis
Retentive Encopresis (most common type):
Defined as a child that holds in bowel movements, leading to constipation and fecal impaction, which causes overflow incontinence.
Emotional factors can also contribute such as disturbed parent-child relationships and stressful toilet training experiences.
Management involves:
Clearing impacted fecal material using methods like mineral oil or laxatives, but avoiding long-term laxative dependency.
Behavioral management and support from the family, alongside psychotherapy as necessary.
Sleep Disorders
Overview
Sleep problems significantly affect various aspects of physical, mental, and social well-being. They can stem from medical problems causing nighttime distress or mental disorders (e.g., bipolar disorder).
Common Sleep Disorders Affecting Children
Insomnia:
Characterized by difficulties in falling or staying asleep, leading to daytime sleepiness and mood changes.
Obstructive Sleep Apnea Syndrome (OSAS):
Occurs in approximately 3% to 12% of preschool-age children and is often linked to enlarged adenoids or tonsils.
May not cause significant blood oxygen drops in children due to different response mechanisms compared to adults.
Night Terrors:
Occur during deep non-REM sleep and are characterized by sudden partial arousal, often leaving the child confused and distressed.
Commonly seen between the ages of 2 to 6 years.
Nightmares:
Frightening dreams occurring during REM sleep that wake children up feeling scared or upset, often occurring in stressful times.
Narcolepsy:
Characterized by recurrent, irresistible bouts of sleep in inappropriate situations, treatable but can affect safety and school performance.