ELFT Training Packages

for Primary Care

‘Common Childhood Mental

Health Problems’
Dr Justin Wakefield
Consultant Child & Adolescent Psychiatrist
East London NHS Foundation Trust
12.02.2015
 Definition of a “problem”
• Impairing abnormalities of behaviour, emotions and relationships

• ABNORMAL in relation to
– child’s age and gender
– developmental stage
– culture
– persistence
– extent of disturbance
– severity and frequency

• IMPAIRMENT
– causes suffering to child/distress to family
– social restriction
– impedes the child’s development
– effects on others
Which of these may be a problem?
• A 3-year-old soiling during the day
A 7-year-old soiling during the day

• Frequent temper tantrums aged 2 Frequent

temper tantrums aged 10

• Severe anxiety at leaving mother at nursery gate

aged 3
Severe anxiety at leaving mother at secondary
school gate aged 11
 Importance of Child and
Adolescent Mental Health

• ½ of mental illness in adults has started

before the age of 15
 Aetiology
• Child
– boys
– low intelligence
– difficult temperament
– physical illness
– developmental delay
– genetic factors
• Family
– traumatic stress
– parenting issues
– marital disharmony
– maternal ill-health
– parental psychiatric disturbance/substance misuse issues
– abuse
• Environment
– peer relationship problems
– social deprivation
– school factors
– stresses resulting from accidents
 Aetiology
• Consider whether child, family,
environmental factors are:

– PREDISPOSING
– PRECIPITATING
– PERPETUATING

• WHAT IS PROTECTIVE AND AIDING

RESILIENCE?
 Common Childhood Mental
Health Problems
• Pre-school behavior problems
• Conduct disorders
• Emotional disorders
• Adjustment disorders
• Disorders of activity and attention
• Failures of normal development
• Attachment disorders and abuse
• Adult-type disorders
 Epidemiology
Overall rates of problems
- pre-school behaviour problems 22%
- signif behav or emotional problems aged 10 15%
- signif psychological problems in adolescence 20%

Prevalence of some psychiatric disorders

- Conduct disorder 5%
- Hyperkinetic disorder 1%
- Anorexia nervosa 0.1-0.2% of adolescent girls
- Autism 0.66%
 1. Pre-school behaviour problems
• Feeding and eating
• sleeping
• temper tantrums
• oppositional behaviour
 2. Conduct disorder
• Disorder of behaviour characterised by
repetitive and persistent pattern of
dissocial, aggressive or defiant conduct.
• Not just delinquency
• Problem behaviours vary with
development
• New NICE guidelines
 Conduct disorder - under 5s
• aggression - physical and verbal
• destructiveness
• poor attention and concentration
• frequent, severe tantrums
 Conduct disorder - 5-12 years
• lying
• stealing
• defiance
• disruption in school
• cruelty to animals
• fire setting
• solvent abuse
Conduct disorder - adolescence
• truancy
• delinquency
• violence
• sex offences
• drug/alcohol/substance abuse
 Conduct disorder – risk factors
• boys >> girls
• inner cities > rural areas
• socio-economic disadvantage
• family conflict and poor communication in
the family
• “difficult” temperament
• Specific reading disability
 3. Emotional disorders
• Disturbances of mood, persistent and not
in response to a single identified stressor.
• Disabling

• Anxiety and fearfulness

• Depression
Emotional disorders - symptoms
• Fears - separation anxiety; social anxiety;
specific phobias
• Lack of pleasure; loss of interest;
hopelessness; despair; sadness;
tearfulness; lack of energy
• Physical symptoms - abdominal pain,
headaches
• Fall off in school performance
 Emotional disorders – risk factors
• boys = girls
• no association with socio-economic status
• family factors - overprotection; parental
anxiety
• quiet, compliant temperament
• no specific educational problems
 School non-attendance
• Truancy
• School refusal (separation anxiety)
• Child kept at home by parent
• Fear of school (eg bullying)
 4. Adjustment disorders
• Distress and emotional disturbance arising
in a period of adaptation to a significant life
change or to the consequence of a
stressful life event
• bereavement
• divorce
• physical illness
 5. Attention Deficit /
Hyperactivity Disorder (ADHD)
• overactivity
• inattention
• impulsivity

• early onset
• pervasive and persistent
• boys >>> girls
 6. Failures of normal
development : specific

• speech and language ( receptive and

expressive)
• reading (dyslexia)
• spelling
• arithmetical skills
• motor function (dyspraxia)
• enuresis / encopresis
 6. Failures of normal
development : pervasive

• Autistic spectrum disorders

- impaired quality of reciprocal social interaction
- impaired communication
- restricted, repetitive interests

• Asperger’s Syndrome
 7. Attachment disorders
• Marked distress and social impairment as
a result of an extremely abnormal pattern
of attachment, typically repeated changes
of care-giver in early childhood
• Reactive attachment disorder
• Disinhibited attachment disorder
 Abuse
• physical (non-accidental injury)
• emotional
• sexual
• neglect
• Munchaussen Syndrome by Proxy??/
Factitious Induced Illness (FII)
 8. Adult type disorders
• psychoses - schizophrenia; bipolar
disorder
• depression
• post traumatic stress disorder
• obsessive compulsive disorder
• eating disorders
• deliberate self harm
 Assessment
Main areas to cover in assessment.

i) Description and history of main problems

ii) Child’s peri-natal, developmental, medical, educational
and social history
iii) Family history including any psychological health
problems and information regarding parents own
experience of being parented
iv) Mental state of the child
v) Family communication and relationships
An assessment also offers the opportunity to engage
therapeutically with a family.
 Formulation
Following an assessment it is important to
formulate the case.
A formulation is a compact summary
of relevant aspects of :
i) presenting features
ii) aetiological factors
iii) diagnosis
iv) management plan
v) prognosis.
 Diagnosis
• There are two major diagnostic systems:
– ICD- 10 Classification of Mental and
Behavioural Disorders
– DSM-5 Diagnostic and Statistical Manual of
Mental Disorders
• Both systems multi-axial. In ICD 10:
– Axis I Clinical Syndrome
– Axis II Disorders of Psychological Development
– Axis III Mental Retardation
– Axis IV Medical Illness
– Axis V Abnormalities of psychosocial environment
– Axis VI Level of disability
Treatment approaches in child psychiatry
• Parental counselling
• Psycho-education
• Behaviour therapy
• Cognitive-behavioural therapy
• Family therapy
• Pharmacotherapy
• Individual psychotherapy
• Group therapy
• Liaison with other agencies
– (education, social services, Paediatrics)
• Usually out-patient
– Also day hospital or in-patient
 Prognosis
• This depends on
– nature and severity of the disorder
– family and environmental context
– treatment offered
• Symptoms tend to be stubborn
without treatment
• Treatment effectiveness include
– Behavioural work for behavioural problems
– Methylphenidate in hyperkinetic disorder
– Family work in anorexia nervosa