1. Child psychiatry By
Dr Sahar Abdulelah

2. The practice of child psychiatry differs from that of adult psychiatry in five important ways.
• Children seldom initiate the consultation
• The child's problems may reflect the problems of other people for example, illness in the mother.
• The child's stage of development must be considered when deciding what is abnormal. For example, repeated bed wetting may be normal in a 3-year-old child but is abnormal in a 7-year-old.
• Children are generally less able to express themselves in words.
• The emphasis of treatment is different.

4. Classification of child psychiatry
• specific and pervasive developmental disorders, with the former divided into disorders affecting motor skills, speech and language (communication), and scholastic skills (learning)
• disorders of behaviour, which are divided into conduct
(or disruptive behaviour) disorder and attention deficit (hyperkinetic) disorder
• anxiety (emotional) disorders.
• tic disorders.

5. Epidemiology
Variations with gender and age. Before puberty, disorders are more frequent overall among males than amongfemales; after puberty, disorders are more frequent among females. Particular disorders also vary in frequency according to gender and age
There are some factors associated with higher frequency of psychiatric disorders:
• breakdown of the parental relationship, parental illness, and parental criminality
• residence in urban areas with social disadvantage
• attendence at a school with a high turnover of teachers
In addition there is strong relation between physical illnesses (like brain injury) and psychiatric morbidity.

6. Aetiology Genetic factors Brain disorder
Temperament and individual factors: some studies classified children temperament into difficult & easy children. This second group was less likely than the first to develop behavioural disorders later in childhood.
Environmental factors: which include life events & family influences.
Social and cultural factors: like the effect of school.

7. Review of syndromes

8. Specific developmental disorders
-Specific reading disorder (dyslexia) Errors in reading and spelling include omissions, substitutions, or distortions of words, slow reading, long hesitations, and reversals of words or letters. There may also be poor comprehension. There may be associated emotional problems,but development in other areas is not affected. -Mathematics disorder (specific arithmetic disorder) -Communication disorders (developmental disorders (of speech and language

9. Autistic spectrum disorder
Clinical features:
Abnormal development is usually apparent before the age of 3 years. There are reports that early signs of autism can be detected in infancy-for example, absence of babbling and pointing by 12 months,
Abnormalities of social development. The child is unable to form warm emotional relationships with people (autistic aloneness). Autistic children do not respond to their parents' affectionate behaviour by smiling or cuddling. They are no more responsive to their parents than to strangers, and do not show interest in other children.
There is little difference in their behaviour towards people and inanimate objects. A characteristic sign is gaze avoidance-that is, the absence of eye-to-eye contact

10. Abnormalities of communication, speech may develop late or never appear. Occasionally, it develops normally until about the age of 2 years and then disappears in part or completely. This lack of speech is a manifestation of a severe cognitive defect. As autistic children grow up, about 50% acquire some useful speech.
Restriction of interests and behaviour. Obsessive desire for sameness is a term applied to the autistic child's stereotyped behaviour, and their distress if there is a change in the environment.

12. Epidemiology
The prevalence of autism is probably about 20 per children. It is four times as common in boys as in girls.
Aetiology
Genetic influences are of great importance. The condition is 50 times more frequent in the siblings of affected individuals than in the general population.
Brain abnormalities, structural brain studies have established that autistic children have larger brain volumes than normal children, although these apparently normalize during adolescence.
Claims of an association with MMR vaccine have not been confirmed in careful epidemiological studies.

13. Differential diagnosis
It is more usual to encounter partial syndromes than the full syndrome of childhood autism. These partial syndromes must be distinguished from the following:
• deafness, which can be excluded by appropriate tests of hearing
• communication disorder, which differs from autism in that the child usually responds normally to people and has good non-verbal communication
• learning disability, in which responses to other people are more normal than those of an autistic child. Also, an autistic child has more impairment of language relative to other skills than is found in a learning disabled child of the same age
.Other types of PDD like Asperger's & Rett syndroms

14. Prognosis
Around 10-20% of children with childhood autism begin to improve between the ages of about 4 and 6 years, and are eventually able to attend an ordinary school and obtain work. A further 10-20% can live at home, but cannot work and need to attend a special school or training centre and remain very dependent on their families and/ or support services. The remainder, at least 60%, improve little and are unable to lead an independent life; many need long-term residential care.

15. Management
In the absence of any specific treatment, management has three main apects-
-management of the abnormal behaviour (Contingency management)
- education and social services
- help for the family.
There is evidence of short-term (up to 6 months) benefit for treatment with the antipsychotic drug, risperidone, in terms of significant reductions in irritability, aggression, temper tantrums, and self injurious behaviours.

16. Attention Deficit Hyperkinetic Disorder
The cardinal features of this disorder are as follows:
• extreme and persistent restlessness
• sustained and prolonged motor activity
• difficulty in maintaining attention
• impulsiveness and difficulty in withholding responses
Epidemiology
Rates are about three times higher in boys than in girls.
The disorder is more frequent in areas of social deprivation and among children raised in institutions

18. Prognosis
Overactivity usually lessens gradually as the child grows
older, especially when it is mild and not present in every
situation. It usually ceases by puberty. However, inattention and impulsivity may persist, and about 50% of the cases diagnosed in childhood retain the full diagnosis in adolescence.

19. Treatment
Support and psychological treatment.
Medication. Stimulant drugs should be tried if there is severe restlessness and attention deficit, and where parent training and psychological approaches have not proved effective. These drugs increase dopamine and noradrenaline activity, and it is thought that these actions underlie their therapeutic effects. The most commonly prescribed medication is methylphenidate. Dexamphetamine is also used.

20. Conduct disorders
The essential feature of conduct disorder is persistent
abnormal conduct which is more serious than ordinary
childhood mischief. The behaviours include disobedience, temper tantrums, physical aggression towards siblings or adults, and destructiveness. In later childhood, conduct disorder is manifested in the home as stealing, lying, and disobedience, together with verbal or physical aggression.

21. Aetiology
Environmental factors. These are important. Conduct disorders are commonly found in children from unstable, insecure, and rejecting families living in deprived areas
Genetic factors. Conduct disorder clusters in families.
Prognosis
Almost 50% of people who had conduct disorder in adolescence showed some form of antisocial behaviour in adulthood.

22. Anxiety disorders Separation anxiety disorder
Separation anxiety disorder is a fear of separation from people to whom the child is attached which is clearly greater than normal separation anxiety of toddlers or preschool children, or persists beyond the usual preschool period, and is associated with significant problems of social functioning.

23. Sibling rivalry disorder
children who show extreme jealousy or other signs of rivalry in relation to a sibling, starting during the months following
the birth of that sibling. The signs are clearly greater than the emotional upset and rivalry which is common in such circumstances, and they are persistent and cause social problems.

24. Functional enuresis
Functional enuresis is the repeated involuntary voiding of urine occurring after an age at which continence is
usual. Most children achieve daytime and night-time continence by 3 or 4 years of age. Nocturnal enuresis is often referred to as primary if there has been no preceding period of urinary continence .It is called secondary if there has been a preceding period of urinary continence. the prevalence of nocturnal enuresis occurring once a week or more is about 10% at 5 years of age, 4% at 8 years, and 1% at 14 years.

25. There is some evidence for a genetic cause; about 70% of children with enuresis have a first-degree relative who has been enuretic.
A careful history and appropriate physical examination are required to exclude undetected physical disorder, particularly urinary infection, diabetes, or epilepsy, and to assess possible precipitating factors and the child's motivation. A question should be asked about faecal soiling.

26. Treatment
Any physical disorder should be treated. If the enuresis is functional, an explanation should be given to the child and the parents that the condition is common and the child is not to blame.
The parents should be encouraged to reward success without drawing attention to failure, and not to focus attention on the problem.
Enuresis alarms.
Medication: The synthetic antidiuretic hormone des-amino-D- argininevasopressin (desmopressin) & the tricyclic antidepressant imipramine