Disorders of Childhood

Abstract

Childhood is a time of great vulnerability to psychiatric illness. According to the World Health Organization, around 20 % of the world’s children and adolescents have mental disorders or problems. This chapter introduces three cases that will highlight some of the most common disorders and treatments.

“The foundation for good mental health is laid in the early years of childhood and adolescence.” Mental Health Promotion in Young People—an Investment for the Future: World Health Organization, 2010.

Appendices

Appendix A: Tables with Possible Answers to the Vignettes

Vignette 18.1: Sam

Table 18.1.1

Facts	Hypotheses	Information needed	Learning issues
Referral was initiated by the school	Attention deficit hyperactivity disorder (ADHD)	Collateral information including history from teacher, direct observation of the child in the classroom, input from the child’s pediatrician	Elements of a comprehensive child psychiatry evaluation and how it differs from an adult evaluation
Poor school performance, hyperactivity, and behavior problems at school	Autism spectrum disorder	A more detailed history including (1) In what environment(s) do these behaviors occur in?, (2) Are there other symptoms that might narrow the differential including sleep disturbances, change in appetite, loss of interests in activities, moodiness, tearfulness, anxiety, etc.?, (3) Are these new or old behaviors?, (4) What is the child’s level of function in different areas (e.g., home, school, and with friends), (5) social/environmental details, and (6) family history	Differential diagnosis of childhood attentional and learning problems
Mother seems irritated that an evaluation has been requested	Intellectual disability (ID)	An individualized education program ( IEP ) evaluation to assess IQ and academic functioning	Recognition of important aspects of the child mental status exam including the parent–child relationship
	Specific learning disorder
	Mood or anxiety disorder
	Environmental causes (e.g., being bullied at school)
	Oppositional defiant disorder (ODD)

Table 18.1.2

Facts	Hypotheses	Information needed	Learning issues
High IQ, no impairment in academic performance	ADHD, autism spectrum disorder, and intellectual disability are less likely	More thorough social history	Synthesis of data to develop working hypothesis
Deficits in working memory and attention scales as demonstrated by the WISC	Still on the differential are: Mood disorder Anxiety disorder Environmental cause		Prevalence and treatment of ADHD
Child is highly distractible			Recognition of posttraumatic stress disorder as a potential cause of acute attentional problems
Hypervigilant to loud noises
Symptoms have started within the last year; previous school functioning was normal

1. WISC Weschler intelligence scale for children, ADHD attention deficit hyperactivity disorder

Table 18.1.3

Facts	Hypotheses	Information needed	Learning issues
Pediatrician’s impression of the mother is overall favorable	Child abuse	Is there physical evidence of child abuse? For example, multiple bruises in different stages of healing, fractures not consistent with normal injury	The importance of considering abuse and trauma as potential causes of changes in child mental status
The patient’s mother has become more withdrawn since a new boyfriend has moved into her home	Witness to domestic violence		Appreciation of the role of the health provider as a mandated reporter of child abuse
Pediatrician believes he smelled alcohol on the boyfriend’s breath during an in-office visit

Vignette 18.2: Teddy

Table 18.2.1

Facts	Hypotheses	Information needed	Learning issues
Previously bowel trained	Spinal cord injury	Physical examination	Differential diagnosis of encopresis to include possible physiological and psychological causes
History of intermittent constipation requiring medical intervention	Hirschsprung disease	Plain film of the abdomen
Encopresis does not occur at night	Anal stenosis	Anorectal manometry sometimes useful
	Imperforate anus with fistula	History of trauma suggesting spinal cord injury
	Psychogenic origin	Detailed social history

Table 18.2.2

Facts	Hypotheses	Information needed	Learning issues
Physical examination is unremarkable	Retentive encopresis less likely	Family patterns of interaction around issues of control	Common physical manifestations of psychological conflicts in childhood
Onset of problems coincided with the divorce of Teddy’s parents	Psychological etiology more likely

Vignette 18.3: Michael

Table 18.3.1

Facts	Hypotheses	Information needed	Learning issues
Language delay	Language delay	Birth history	Diagnostic assessment procedures for developmental delay
No pointing or gestures	Intellectual disability	Developmental history
	Autism spectrum disorder	Infant temperament
		Social development and parent–child interaction
		Language milestones
		Medical assessment
		Physical exam
		Laboratory tests
		Psychological testing

Table 18.3.2

Facts	Hypotheses	Information needed	Learning issues
Labs normal	Autism spectrum disorder	Detailed information about child’s strengths and weaknesses to help inform treatment plan	Diagnostic criteria for autism spectrum disorder
Normal facial features	Possible intellectual disability
Genetics normal
2 years language delayed
Fine/gross motor delays
No social reciprocity
No communicative intent
No nonverbal gestures
Poor social interaction
Perseverative motor behaviors
Limited interests
Inflexible
No fantasy play

Appendix B: Answers to Review Questions

• 1. d

• 2. e

• 3. a

• 4. c