Psychosocial disorders in children

These may manifest as a disturbance in:

• Emotions - eg, anxiety or depression.
• Behavior - eg, aggression.
• Physical function - eg, psychogenic disorders.
• Mental performance - eg, problems at school.

This range of disorders may be caused by a number of factors such as parenting style which is inconsistent or contradictory, family or marital problems, child abuse or neglect, overindulgence, injury or chronic illness, separation, or bereavement

The child's problems are often multi-factorial and how they are expressed may be influenced by a range of factors including developmental stage, temperament, coping and adaptive abilities of family, and the nature and duration of stress. In general, chronic stressors are more difficult to deal with than isolated stressful events.

Children do not always display their reactions to events immediately, although they may emerge later. Anticipatory guidance can be helpful to parents and children in that parents can attempt to prepare children in advance of any potentially traumatic events - eg, elective surgery or separation. Children should be allowed to express their true fears and anxieties about impending events.

In stressful situations, young children will tend to react with impaired physiological functions such as feeding and sleeping disturbances. Older children may exhibit relationship disturbances with friends and family, poor school performance, behavioral regression to an earlier developmental stage, and development of specific psychological disorders such as phobia or psychosomatic illness.

It can be difficult to assess whether the behavior of such children is normal or sufficiently problematical to require intervention. Judgment will need to take into account the frequency, range, and intensity of symptoms and the extent to which they cause impairment.

Habit disorders in children

These include a range of phenomena that may be described as tension-reducing.

All children will at some developmental stage display repetitive behaviors but whether they may be considered as disorders depends on their frequency and persistence and the effect they have on physical, emotional, and social functioning. These habit behaviors may arise originally from intentional movements which become repeated and then incorporated into the child's customary behavior. Some habits arise in imitation of adult behavior. Other habits such as hair pulling or head-banging develop as a means of providing a form of sensory input and comfort when the child is alone.

• Thumb sucking - this is quite normal in early infancy. If it continues, it may interfere with the alignment of developing teeth. It is a comfortable behavior and parents should try to ignore it while providing encouragement and reassurance about other aspects of the child's activities.
• Tics - these are repetitive movements of muscle groups that reduce tension arising from physical and emotional states, involving the head, the neck, and hands most frequently. It is difficult for the child with a tic to inhibit it for more than a short period. Parental pressure may exacerbate it while ignoring the tic can reduce it. Tics can be differentiated from dystonias and dyskinetic movements by their absence during sleep.
• Stuttering - this is not a tension-reducing habit. It arises in 5% of children as they learn to speak. About 20% of these retain the stuttering into adulthood. It is more prevalent in boys than in girls. Initially, it is better to ignore the problem since most cases will resolve spontaneously. If the dysfluent speech persists and is causing concern to refer to a speech therapist.

Anxiety disorders in children

Anxiety and fearfulness are part of normal development; however, when they persist and become generalized they can develop into socially disabling conditions and require intervention. Approximately 6-7% of children may develop anxiety disorders and, of these, 1/3 may be over-anxious while 1/3 may have some phobia. Generalized anxiety disorder, childhood-onset social phobia, separation anxiety disorder, obsessive-compulsive disorder, and phobia are demonstrated by a diffuse or specific anxiety predictably caused by certain situations.

School phobia occurs in 1-5% of children and there is a strong association with anxiety and depression. Management is by treating the underlying psychiatric condition, family therapy, parental training, and counseling with Behavioral and cognitive treatments.

Disruptive behavior

Many behaviours, which are probably undesirable but a normal occurrence at an early stage of development, can be considered pathological when they present at a later age. In young children, many behaviors such as breath-holding or temper tantrums are probably the result of anger and frustration at their inability to control their own environment. For some of these situations, it is wise for parents to avoid a punitive response and, if possible, to remove themselves from the room. It is quite likely that the child will be frightened by the intensity of their own behavior and will need comfort and reassurance. While some isolated incidents of stealing or lying are normal occurrences of early development, they may warrant intervention if they persist. Truancy, arson, antisocial behavior, and aggression should not be considered as normal developmental features.

Oppositional defiant disorder

Around one in ten children under the age of 12 years are thought to have an oppositional defiant disorder (ODD), with boys outnumbering girls by two to one. Some of the typical behaviors of a child with ODD include:

• Easily angered, annoyed or irritated
• Frequenttemper tantrums
• Argues frequently with adults, particularly the most familiar adults in their lives, such as parents
• Refuses to obey rules
• Seems to deliberately try to annoy or aggravate others
• Low self-esteem
• Low frustration threshold
• Seeks to blame others for any misfortunes or misdeeds.

Conduct disorder

Children with conduct disorder (CD) are often judged as ‘bad kids’ because of their delinquent behavior and refusal to accept rules. Around five percent of 10-year-olds are thought to have CD, with boys outnumbering girls by four to one. Around one-third of children with CD also have attention deficit hyperactivity disorder (ADHD).

Some of the typical behaviors of a child with CD may include:

• Frequent refusal to obey parents or other authority figures
• Repeated truancy
• Tendency to use drugs, including cigarettes and alcohol, at a very early age
• Lack of empathy for others
• Being aggressive to animals and other people or showing sadistic behaviors including bullying and physical or sexual abuse
• Keenness to start physical fights
• Using weapons in physical fights
• Frequent lying
• Criminal behavior such as stealing, deliberately lighting fires, breaking into houses, and vandalism
• A tendency to run away from home
• Suicidal tendencies – although these are rarer.

Attention deficit hyperactivity disorder (ADHD)

Around two to five percent of children are thought to have attention deficit hyperactivity disorder (ADHD), with boys outnumbering girls by three to one. The characteristics of ADHD can include:

• Inattention – difficulty concentrating, forgetting instructions, moving from one task to another without completing anything.
• Impulsivity – talking over the top of others, having a ‘short fuse’, being accident-prone.
• Overactivity – constant restlessness and fidgeting.

For the diagnosis to be made, the condition must be evident before the age of 7, present for >6 months, seen both at home and school, and impeding the child's functioning.^[The condition is diagnosed in 3-7% of children of school age. Methylphenidate (initiated by specialists only) is a stimulant medication that provides reduction of symptoms, at least in the short term. Behavioral modification and neuro-feedback are the non-pharmacological treatments with the largest evidence base. Various dietary interventions have been mooted, of which the addition of essential fatty acids has the widest support.

Sleeping problems

Sleep disorders can be defined as more or less sleep than is appropriate for the age of the child. By the age of 1-3 months, the longest daily sleep should be between midnight and morning. Sleeping through the night is a developmental milestone but, at the age of 1 year, 30% of children may still be waking in the night. Stable sleep patterns may not be present until the age of 5 but parental or environmental factors can encourage the development of circadian rhythm. 

Risk factors in children’s behavioral disorders

The causes of ODD, CD and ADHD are unknown but some of the risk factors include:

• Gender – boys are much more likely than girls to suffer from behavioral disorders. It is unclear if the cause is genetic or linked to socialization experiences.
• Gestation and birth – difficult pregnancies, premature birth, and low birth weight may contribute in some cases to the child’s problem behavior later in life.
• Temperament – children who are difficult to manage, temperamental, or aggressive from an early age are more likely to develop behavioral disorders later in life.
• Family life – behavioral disorders are more likely in dysfunctional families. For example, a child is at increased risk in families where domestic violence, poverty, poor parenting skills, or substance abuse are a problem.
• Learning difficulties –problems with reading and writing are often associated with behavior problems.
• Intellectual disabilities – children with intellectual disabilities are twice as likely to have behavioral disorders.
• Brain development – studies have shown that areas of the brain that control attention appear to be less active in children with ADHD.

Diagnosis of children’s behavioral disorders

Disruptive behavioral disorders are complicated and may include many different factors working in combination. For example, a child who exhibits the delinquent behaviors of CD may also have ADHD, anxiety, depression, and difficult home life.

Diagnosis methods may include:

• Diagnosis by a specialist service, which may include a pediatrician, psychologist, or child psychiatrist
• In-depth interviews with the parents, child, and teachers
• Behavior checklists or standardized questionnaires.

A diagnosis is made if the child’s behavior meets the criteria for disruptive behavior disorders in the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association.

It is important to rule out acute stressors that might be disrupting the child’s behavior. For example, a sick parent or victimized by other children might be responsible for sudden changes in a child’s typical behavior and these factors have to be considered initially.

Treatment of behavioral disorders in children

Untreated children with behavioral disorders may grow up to be dysfunctional adults. Generally, the earlier the intervention, the better the outcome is likely to be.

A large study in the United States, conducted for the National Institute of Mental Health and the Office of School Education Programs, showed that carefully designed medication management and behavioral treatment for ADHD improved all measures of behavior in school and at home.

Treatment is usually multifaceted and depends on the particular disorder and factors contributing to it, but may include:

• Parental education – for example, teaching parents how to communicate with and manage their children.
• Family therapy – the entire family is helped to improve communication and problem-solving skills.
• Cognitive-behavioral therapy – to help the child to control their thoughts and behavior.
• Social training – the child is taught important social skills, such as how to have a conversation or play cooperatively with others.
• Anger management – the child is taught how to recognize the signs of their growing frustration and given a range of coping skills designed to defuse their anger and aggressive behavior. Relaxation techniques and stress management skills are also taught.
• Support for associated problems – for example, a child with a learning difficulty will benefit from professional support.
• Encouragement – many children with behavioral disorders experience repeated failures at school and in their interactions with others. Encouraging the child to excel in their particular talents (such as sport) can help to build self-esteem.
• Medication – to help control impulsive behaviors.