Psychosocial Problems 
Causes
Physical or emotional stress
· Birth defects
· Physical injury
· Inconsistent and contradictory child rearing practices.
· Marital conflict.
· Child abuse and neglect, overindulges.
· Chronic illness.

Psychosocial disorders may manifest as
Disturbance in feeling {depression and anxiety}
Bodily function {psychosomatic disorders)
In behavior (conduct disturbance, passive aggressive behavior}
In performance {learning}  
Specific agents doesn’t produce specific disorders 

Variables depend on
(1) Temperament of the child
(2) Developmental level of the child - Infants and toddlers presented with impairment of physiological functions, for example, feeding, sleep e.t.c. Where as school aged children may present with disturbance in the interpersonal relationship or impairment of school performance or development of psychosomatic disorder and specific psychological syndromes. Eg. Phobias. Or regressing to a childish behavior
(3) Past experience.
(4) Coping and adaptive abilities of the family.
Children may react immediately to traumatic events or may keep their feelings dormant until maladaptive reactions become apparent during later periods of vulnerability.
DECISION making-whether the behavior is NORMAL OR ABNORMAL? 
Some symptomatic development may be a normal part of growth. E.g. Temper tantrum is a normal negativism of toddlers; on the other hand temper tantrum on slight provocation in a six-year-old child may indicate psychosocial disturbance.  

Criteria for decision making-
(1) Age.
(2) Frequency
(3) Intensity
(4) Number of symptoms
(5) Degree of functional impairment.
 
Management
(1) Anticipatory guidance during periods of stress may considerably help children and their families for a positive outcome. E.g. Surgery, divorce e.t.c.
(2) Children should allow expressing their feelings or encouraging doing so, rather than being told to be a good girl or a brave boy. 

Psychosomatic Illness 
Psychological conflict that significantly alters somatic function is the hallmark of the psychosomatic disorder. There are three categories of psychosomatic disorders. 
1)Psycophysiological disorders factors that effect the physical condition occurs when psychological reactions effect the development of a physical condition with demonstrable organic pathologic aspects (diabetes mellitus, rheumatoid arthritis, or asthma) Psycho physiological disorders has a more insidious onset than somatoforms orders. Chronic anxiety produces functional abnormalities with in the autonomic system that leads to structural changes in organ system. 
2)Somatoform disorder presents with dysfunction’s that are not under conscious control and for which there is no demonstrable organic cause. (Dystrophic disorder, conversion disorder, hypochondrias is, somatisation disorder and somatoform pain disorder) 

Conversion disorder 
Usually presents in adolescents or adult hood
Usually starts suddenly can often be traced to a precipitating factor. and abruptly after a period of short duration.
Voluntary musculature and organs of special sense are the usual target sites for the hysterical expressions of psychological conflict. they may expressed in many forms including hysterical blindness, paralysis gait disturbances diplopic etc. Physical examination often fails to reveal objective abnormalities. histories often reveal a close relationship with a person who exhibited a similar of an actual illness.
Affected children and there families tend to be rather dramatic and hypochondria cal.

Hypochondriasis 
Preoccupation with a fear of having serious illness and somatisation disorder, use of multiple somatic disturbance as a means of assuaging inner tension are also somatoform disorders.
As with conversion disorders this disorder provides alternative means for the discharge of physiological and emotional tension. 
3) Factitious disorder presents with somatic and psychological complaints that are consciously controlled and self induced for the purpose of secondary gain. (Manchausen by proxy syndrome)
 
Manchausen by proxy syndrome
Is a disorder characterized by parents inducing physical symptoms in their children, consider as a form of child abuse, some times ending in death,
 
Warning Observations Include
1) Persistent or recurrent illness that cannot be explained.
2) Investigation result at variance with the general health of the child.
3) Experienced doctors comments that they have never seen such cases.
4) Symptoms that do not occur when the parent is away.
5) Particularly attentive parent who refuses to leave the child alone even for a short period of time.
6) A parent who is not that worried about his or her child.
7) Clinical syndromes that poorly respond to treatment. 
  Signs and symptoms vary ,they include fractures, unusual injuries poisonings, persistent apnea, etc.

Factors influencing the development of psychosomatic disorders
1) Temperament
2) Environmental stress.
3) Family issues
4) Individual psychodynamics.
 
Guiding principles for the management of  children with psychosomatic illness. 

Symptoms of affected children are not with in their conscious control, and their problems are real
It is essential for a psychiatric assessment to be arranged early in the management of these disorders: otherwise after elaborate and expensive tests have being done, the child and family often being convinced that the patient has a very serious illness for which a real cause existed that cannot be fount.
Role of the emotions and the genesis of this disorders must be accepted by the parents before truly effective intervention can be affected.
Psychotherapy for the child and counseling for the family are indicated .
Child and family should be helped live as normally as possible to avoid crippling psycho logic invalidism. Stress should be placed for early return to school after acute illness, participation in recreational activities, and normal peer interactions.
Physician should be alert for indications of psychosomatic illness in parents with which children may unconsciously identify, successful treatment of parental illness may be necessary to ensure a favorable outcome in the child.
 
Vegetative Disorder 
Rumination disorder 
The hall mark of this disorder is a weight loss a failure to gain at the expected level because of repeated regurgitation of food without nausea or associated gastrointestinal illness. .This rare disorder occurs more commonly in males usually between the age 3and 14 mo of age. It is potentially fatal. D/D includes congenital anomalies of GIT, and disorders of pyloric valve. 
Pica
This eating disorder involves repeated or chronic ingestion of non-nutrient substance. The age of onset is 1 to 2yrs of age but may be earlier. Pica usually remits in childhood but can continue into adolescence adulthood. Mental retardation and lack of parental nurturing(psychological and nutritional) are predisposing factors. Although tasting and mouthing of objects is normal in infants and toddlers, pica after the second year of life needs investigation. It is often a symptom of family disorganization, poor supervision, affect ional neglect. It is more prevalent in lower socioeconomic classes. Differential diagnosis include autism, schizophrenia and certain physical disorders such as Kleine Levin syndrome.
Enuresis
The involuntary discharge of urine after the age at which balder control should have being established is one of the common problem encountered.
Bed wetting may be divided into
Primary (persistent) type. in which the child has never been dry at night.-75%
Secondary (regressive) type. in which the child who has been continent for at least one year begins wet the bed again.-50% in late school aged children.
Persistent nocturnal enuresis is often the result of inadequate toilet training and it has been shown to occur through out the sleep cycle. Chronic psychological stress occurring during the toddler period ,overcrowding, immigration, socioeconomic disadvantages, and psychopathologic condition are the other causes of bedwetting. 
The regressive type of bed wetting is precipitated by stressful environmental events, such as move to a new home ,marital conflict, birth of a sibling or death in family. Such bed wetting is intermittent and transitory, prognosis is better. 
Marked increase in UTI is found-urine analysis is indicated.

Management 
It is important to enlist the cooperation of the child to deal with the problem. Rewarding the child for being dry at night is a useful step.
Older children should be expected to launder their own soiled bed clothes and pajamas.
Children should be given no liquids after dinner time.
Child should void before retiring.
Waking the child repeatedly is useful only in few children and may further aggravate anger in the child or parent.
Punishment or humiliation of the child by parents or others should be strongly discouraged.
The use of conditioning devices is usually not necessary and should be reserved for persistent and refractory cases in which the child's self- esteem has being seriously eroded. Consent of the child should be obtained.

Encopresis
This term refers to the passage of feaces into inappropriate places at any age after bowel control should have established. Predominantly a male disorder effect 1%of school aged children, other factor is low socioeconomic backgrounds. Encopresis indicates a more serious disturbers than enuresis and is often associated with anger.

Clinical manifestations
Chronic soiling may persist from infancy (primary), or may appear as a regressive phenomenon. It is often associated with chronic constipation. fecal impaction and overflow incontence and may progress to psycogenic mega colon. It usually represents unconscious anger and defiance in child, and parents may respond with retaliatory and punitive measures. School performance and attendance may be affected as the child becomes target of scorn and derision from schoolmates because of the offensive odor.
Management  
Measures similar to enuresis may be helpful.
Psychotherapeutic intervention with the child and family.
Use of mineral oil and high fiber diet.
Sitting on the toilet for 10 to 15 minutes after each meal is often necessary.
Rewards for compliance should be offered.
Power and autonomy struggles should be avoided, and records of child's elimination should be noted.
Enemas may be needed, however chronic use should be avoided.

Sleep disorders 
This are common in childhood and may be temporary, intermittent , or chronic in nature.   They related to other areas of child life like, peer groups, school performance may also expressed as sleep disturbance
Depression. 
Narcolepsy.
Is a disorder causing frequent day time naps and cataplexy, sleep paralysis, and hypnologic hallucination.
Night mares.
7-15% of children suffers, more in girls, before the age of 10, charetersticed by anxiety dreams occur during rapid eye movement sleep. child awakens become lucid rapidly, and usually remembers the content of the dream. 
Night terrors
2%-5%, more common in boys, especially in preschool children, chareterstied by arousal from stage for sleep, is confused and disoriented, shows signs of intense automatic activities( labored breathing, tachypnoea, tachycardia, sweating, dilated pupils) and appears to frightened. A period of somnambulism may occur. After a minute child will become oriented, and will not be able to recall the contented of the dream. And are usually self-limited.
Causes
specific developmental conflict or traumatic events.
febrile illness as a predisposing factor. 
Sleep walking
10 -= 15%, school aged children
occurs in 3 or 4th stage of sleep, usually associated with nocturnal enurism, and family history of somnambulism, usually related to psychopathologic conditions and temporal lobe epilepsy should be ruled out.
  
Habit disorders
 
Habit disorders includes tension discharging phenomena, such as— 
Head banging, body rocking.-- occurring when a child is put to bed or is alone, this movements seems to provide a kind of sensory solace for the child whose is feeling otherwise uncared for or un stimulated by human touch or interaction. This movements represents a kind of internal stroking such patterns are often seen in the mentally retarded or in children sufferening from maternal or emotional deprivation. 
Nail biting, hair pulling( trichotillomania ), thumb sucking,-- normal in early infancy, like other rhythmic patterns it can be seen as a way of securing extra self- nurturance.
Teeth grinding (bruxism),--seems to result from tension originating in unexpressed anger or resentment, it may create problems in dental occlusion. helping the child to find ways to express resentment may relive the problem. bed time can be made more enjoyable and relaxed by reading or talking with the child, permitting experience and review of some of the fears or angers experienced during the day. Praise and emotional support are useful at these times
Hitting or biting parts of once own body, body manipulations,
Repetitive vocalization 
Breath holding, swolling air(aerophagia)
Tics, which involve the involuntary movements of various muscle groups of the body are also included.--discharges of tension originating in emotional and physical state that have no apparent useful function. The parts of the body most frequently are the muscles of the face neck shoulders, trunks, and hands. There may be lips smacking and grimacing, tongue trusting eye blinking throat clearing and so on.
Tics usually accompany other psycatric syndromes, or follow encephalitis.
Gilles de la trourette syndrome -- unknown etiology, multiple tics, compulsive barking, and grunting or shouting obscene words - boys 3 to 4 times more : prior to 7yrs :

Stuttering dysfluent speech :Primary stuttering usually begins as a atypical development during the learning of speech it starts gradually initially with the repetition of consonants ,often followed by a repetition of words and phrases . most cases resolves spontaneously and seems to remit more readily in girls
All children at various developmental points show repetitive patterns of movement that can discussed as habits. Weather they are considered as disorders depends on the degree to which interfere with child’s physical, emotional, or social functioning. some hobbit patterns may be learned by imitation of adults. Many being as a purposeful movements that, for some reason becomes repetitive, with the habit losing its original significance and becomining a means of discharging tension. 

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