Common Psychological Problems of Children 27/01/10 -Sudipta Roy Clinical Psychologist

Introduction Worldwide, the prevalence of clinically significant psychiatric disorders in children is at least 7%. This rate rises in socially disadvantaged and densely populated urban areas. It also increases by 3%–4% after puberty.

Introduction…… Childhood psychopathology presents as: 1. disturbed or antisocial behaviour(externalising disorders) —prevalence 3%–5% 2. troubled emotions and feelings(internalising disorders) — prevalence 2%–5%

Introduction…. 3. a mixture of psychological problems and physical illness (somatoform disorders) — prevalence 1%–3% 4. more rarely as childhood psychosis or pervasive developmental (autism spectrum) disorders — prevalence about 0.1%.

Some Essential features Linked to the developmental expectations Transient Environment Dependent More often identified in Boys than girls May have a continuity into Adulthood problems Responsive to psychological treatments Early Screening and identification can work at preventive level

Our Focus 1.Attention Deficit Hyperactive Disorder (ADHD) 2. Autism 3. Sleep terrors and Sleep walking 4. Enuresis 5. Nail Biting

Pattern Diagnostic Features Prevalence Concomitant Problems Causes Assessments Treatment Illustrative case

ATTENTION DEFICIT HYPERACTIVE DISORDER Six or more for atleast six months of the following- maladaptive and inconsistent with developmental level: (Inattention) 1. Fails to give close attention to details 2.Difficulty in sustaining attention or play activities 3.Does not seem to listen when spoken directly to

ADHD Avoids/ dislike doing things that need sustained mental effort Does not follow through instructions, leaves work incomplete Has difficulty organizing tasks and activities Loses important things Easily distracted Forgetful in daily activities

ADHD Or Six for atleast six months of the following: Hyperactivity- Impulsivity) Hyperactivity Cluster 1. fidgets with hands, feet, squirms 2.Leaves seat and/or classroom even when demanded 3. Runs or climbs excessively and inappropriately

ADHD Has difficulty in working, playing quietly Is on the “go” Often talks excessively IMPULSIVITY cluster Blurts out answers when questions are not yet complete Has difficulty waiting for turns Interrupts or intrudes on others

ADHD other criteria Must present itself before 7 years of age Impairment across two or more settings Affects other areas of functioning Types Attention Deficit predominantly inattentive type Attention Deficit predominantly hyperactive- impulsive type Combined type

Prevalence Variable rates 2-20% of school going children Conservative reports claim 3-7% Co-occurrence with: learning disorders, sociopathy, anxiety and depressive disorders, disruptive behavior disorders, conversion disorders.

Causes Genetics Biological Contributors to ADHD Environmental Factors Psychological Factors

Causes Genetics Heredity or a positive family history appears to be the most common identifiable cause of ADHD The frequency of disorders in the sibling is much greater than in the general population

Biological Contributors to ADHD ADHD is a biologically determined spectrum disorder presenting a myriad of variables and distinctions Brain scans of children with ADHD demonstrates decreased metabolic activity in areas of the brain which is thought to be responsible for the regulation of attention and inhibition

Cont… The variability in symptoms in individuals with ADHD can be explained in part by anomalies in different parts of the brain circuitry Children with ADHD show decreased metabolic activity in cortical areas of the brain that are thought to be responsible for the regulation of inhibition and attention

Nerve Cells In children with ADHD these neuron- synaptic bridges are blocked or incomplete which prevents learning from becoming automatic

Neurotransmitters The two primary neurotransmitters’ systems most directly involved in ADHD are the dopamine and norepinephrine system which are known to influence a variety of behaviors, including attention, inhibition, motor activity, motivation Relative deficiencies in these neurotransmitters help explain the signs and symptoms seen in those with ADHD

Environmental Factors Environmental factors alone do not cause ADHD Early environmental insults like maternal smoking, obstetric complications Alcohol consumption Significant prematurity of birth Smallness for gestational age These factors may increase the or play a contributing role in the probability of developing ADHD

Psychological Factors Various psychological factors related to ADHD are: Prolonged emotional deprivation Stressful psychic events Disruption of family equilibrium Child’s temperament Demands of society to adhere to a routinized way of behaving and performing

Cont… Other anxiety-inducing factors also contribute to the initiation or perpetuation of ADHD

Treatment Behavior Modification Medication

Behavior Modification Routine Environment Restructuring Self Monitoring Positive Reinforcements Appropriate social skills Parental Training

ENURESIS Enuresis is an elimination disorder Also known as: Bed wetting Nocturnal bedwetting

Cont… DSM IV- TR defines Enuresis as- Involuntary or intentional Repeated urination into bed or clothes Occurring twice per week for at least 3 consecutive months in a child of at least 5 years of age Not due to either a drug side effect or a medical condition. Causes severe distress to the client or leads to impairment in social academic, important areas of functioning.

Classification Their time of occurrence Whether achieved dryness for a while or not

Types of enuresis Secondary: child or adult begins wetting again after having stayed dry. Nocturnal enuresis: Only at night during sleep Diurnal: Occurs in the day time either in sleep or in waking state Nocturnal and Diurnal: Occurs both in day and night

Prevalence  Variable according to age 7-10% in children below 10 yrs. By age 10 yrs. Prevalence reduces to less than 3% Three times more prevalent in boys than girls

Concurrent Problems Encopresis: Inappropriate passing of stools ADHD Social and emotional immaturity

Investigate and Rule Out Diabetes Spina bifida Seizures Hormonal factors: not enough anti diuretic hormone UTI Small urinary tract, bladder Abnormality in the urethral valve

Causes Genetic Stress Neurological-developmental delay Poor habit development

Treatment There are two types of treatments Behavior therapy Medicines

Behavior Therapy Behavior therapy helps the child not to wet the bed. Behavioral treatment include the following points Limit fluids before bedtime Have your child go to the bathroom at the beginning of the bed time routine and then again right before going to sleep An alarm system that rings when the bed gets wet and teaches the child to respond to bladder sensations at night

Cont… A reward system for dry nights Asking your child to change the bed sheets when he or she wets Bladder training: having your child practice holding his urine for longer and longer times during the day, in effort to stretch the bladder so it can hold more urine

Indications of Medication Doctor may prescribe the medicine if you’re the child is 7 years of age or older Medicines are not cure for bed wetting One kind of medicine helps the bladder hold more urine The other kind helps the kidneys make less urine Note these medicines may have side effects such as dry mouth and flushing of the cheeks

Sleep Terrors (Night terrors) and sleep walking  Introduction  These disorders are sleep disorders known under the group of parasomnias  The common feature: activities associated with waking state are done in sleep

Sleep Terrors (Night terrors) and sleep walking  Diagnostic Features- Occur mostly in deep sleep (stage 4) In the 1 st 3 rd of the night b/w to 2.00 a.m. Screams, frightened, confused, thrash around violently, not aware of the surroundings Talking, comforting trying to awaken them usually does not work

ST… Sweating, breathing unevenly, fast heart rates dilated pupils Attacks last for minutes Child has no memory for that event

Occurrence Mostly in boys 5-7 yrs old May also happen in girls 3- 7 years old Occasional terrors estimated to take place in about 0-40% of the age group Persists in %

Sleep walking or Somnambulism Introduction Abnormal sleep behavior Blank stare, unresponsive to communication More elaborate version of sleep talking or simple arousal e.g. sitting up without actually walking

Sleep walking or Somnambulism, Diagnostic features Recurrent episodes The arousal occurs during Slow Wave Sleep, stages 3 and 4 NREM The subject typically leaves the bed and is active in a confused and disoriented state, often moving slowly and clumsily possibly with injury to themselves

Sleep walking or Somnambulism The sleep walking may be preceded by a scream or occurrence of a Sleep Terror If terror is associated, movements maybe much more rapid, with episodes of rushing into walls, through windows or out into street There is reduced responsiveness, but the subject may yell, talk, scream

An unbelievable story of the sleepwalking nurse who draws masterpieces in a trance

Sleep walking or Somnambulism The response may include complex behavior like escape or defense against perceived threat Acts such as starting a car and driving in sleep can also be performed On awakening temporary disorientation Is associated with significant distress

Causes largely unknown but associated with… Fever Some medications Lack of sleep Irregular sleep times Emotional tensions Stress, conflicts Can run in families Not emptying bladder before sleep Sleeping in a new environment Sleeping in a noisy environment

Treatment only if persistent, disrupts sleep, has other symptoms and risk of injury Usually temporary Handled by comfort, reassurances Minor suggestions Stress reduction If prolonged: may need 1. Psychological evaluation 2. Psychotherapy/counseling 3. Medication