Previous Page

Anxiety DisorderS 
Anxiety, fearfulness and worrying are regularly experienced as a normal part of development. But when they become dis attached from specific cause or when they become disabliting to the point that they negatively effect the social interaction and development, they are pathologic and should be intervent. And they may expressed as

Stranger anxiety.-- developmentally normal anxiety presents usually at the age 7- 8 months “as stranger reaction” infants begins to differentiate from there primary caregivers from strangers, they express wariness and mood changes some thing which they do not exhibit before. This must be diffenciate from stranger anxiety which is a more intense discomfort with obvious psycologic and physical discomfort. This infants later on as preschool children they develop fear of dark, animals and imaginary situations. And as they grow up as school aged children they give up imaginary fears and develop fears of bodily harm, and social anxiety will be developed during teenage years.  
Separation anxiety disorder is characterized by unrealistic and persistent worries of possible harm befalling primary care givers ,reluctance to go to school or to sleep with out being near parents ,persistent avoidance of being alone night mares involving themes of separation ,and numerous somatic symptoms and complaints of subjective distress . A large percentage of children with SAD develop feeling of panic when they are forced to separate from their parents .
Avoidance disorder is characterized by an excessive fear of contact with unfamiliar people that leads to social isolation .These children and adolescents maintain the desire for involvement with family and family peers . 
Overanxious disorder.: have unrealistic worries about future events, the appropriateness of past behaviors and concerns about competence They frequently present with somatic complaints , are markedly self conscious ,need large amounts of reassurance ,and have trouble relaxing .  
Obsessive compulsive disorder. presents with repetitive thoughts that invade consciousness or repetitive rituals or movements that do not obviously contribute to a high level of adaptation in any given situations .eg: some children at bedtime ,or preparing for school, touch certain objects verbalize certain words, or wash their hands continually
Phobias. Here the children are anxious only under specific conditions, and they try to avoid such situations that will automatically lead to anxiety  
Post-traumatic stress disorder: is characterized by recurrent and intrusive recollection and dreams of noxious events in addition to intermittently intense psycho logic and physiologic distress in situations that symbolize the original trauma . they try to avoid stimuli associated with original trauma .symptoms are re-experiencing the trauma through intrusive recollections and dreams and re enactment through play and other behaviors , psycho logic numbing by way of amnesia ,isolation, avoidance, reduced interest in activities ,and increased states of arousal as exemplified by sleep problems ,agitated emotions ,hyper vigilance ,extreme startle responses , and difficulty in concentrate

   Psychosis In Childhood 

Infantile autism
Characterized by qualitative impairment of verbal and non verbal communications ,in imaginative activities and in reciprocal social interactions.
Epidemology- 3/4 children in 10000 children, males, 30 months of age.

Clinical features.
· non or poorly developed verbal non verbal communications skills, abnormalities in speech pattern, impaired abilities to sustained a conversations,
· abnormal social play, lack of empathy, and inability to make friends.
· stereotypic body movements,
· very narrow interest. withdrawn and spends hours in solitary play
· ritualistic behavior prevails, reflecting the need to maintain a constant, predictable environment.
· tantrum like rages may accompany disruption of routine.
· eye contact is minimal or absent.
· echolalia, pronominal reversal, nonsense rhyming and other idiosyncratic language forms may predominate.
· intelligence , functionally retarded range, occasionally remarkably talented.
· lack of theory of mind- deficit in understanding what the other person may be thinking or feeling.
 
Etiology
Cause of autism is speculative, and the suggested factors are
Genetic
Abnormal neurochemical changes in catacolline pathways, increased levels of serotonine,
Brain injuries.
Constitutional vulnerabilities.
Deficit in reticular activating system.
Unfortunate interplay between psychogenic and neurodevelopment factors.
Structural creballar changes, forebrain hippochamal lesion.
 
Treatment
Behaviour therapy.
 
Prognosis
With guard, a better prognosis is associated with higher intelligence, functional speech and less bizarre of symptoms and behavior. 

Pervasive Developmental Disorder
Qualitative impairment in the development of reciprocal social interaction, verbal and non verbal communication, but not have the quantity of symptoms not required to be diagnosed as autism.
 
Late onset psychosis
Resembles psychosis of adulthood, and same diagnostic criteria applied.
 
Clinical Features.
Thought disorders, delusions and hallucinations (the latter two will differentiate psychosis from autism,)
Aggressive behavior, chaotic.
Alternating moods not apparently related to environment.
Not usually diagnosed during childhood, and the prognosis is bad.
  
Borderline personality disorder  
The majority of children with late onset psychosis suffer from this disorder, also called interactive psychosis
Characterized by
· Marked instability of mood, interpersonal relationship, and sense of self.
· Suicidal threats and gestures, often abuse themselves and others physically and very impulsive nature.
· Unpredictability is frequent
· Rage reaction and manupulativeness.
· Paranoid thinking.
· Experience great deal of difficulty with attachment and separation issues.  
. There behavior often seems to a product of their desire to be at the center of there environment, when frustrated leads to rage reaction.  
 
Disruptive Behavioral Disorder 
Numerous behaviors considered appropriate at certain developmental levels are obviously abnormal when they are present at later ages.
Lying, impulsiveness, breath holding, defiance, and temper tantrums are frequently noted around the ages of 2-4yrs when children begin to need autonomy but do not have the motor and social skills necessary for successful independence This behaviors are probably the result of frustration and anger.  

Breath holding is not unusual in the first year of life. It is frequently used by infants and toddlers in an attempt to control the caregivers or the environment. Some times it may lead to loss of consciousness and even to seizures. The parents are best advised to ignore the behavior and leave the room in response. With out sufficient reinforcement the behavior soon disappears. 

Defiance, oppositional, and temper tantrums are often used by children 18 months to 3yrs of age who feel frustrated by there conflicting desires to be in control of environment in one hand, and on, the other hand to be taken care of. The parental response to this behavior is very important. Here the parents are advised to acknowledge verbally to the child that the reasons for the frustrations are understandable but that the particular response is not acceptable. Child should be given type and space to recover. But if the child is unable to give up this behavior, but instead presents with escalation, parent should non emotionally placed the child on time out or room restriction until he or she is able to adjust more reasonably. One way to help the toddler develop a sense of autonomy and to feel more in controls to allow the child to have simple choices of activities that the parents can accept.

Care givers who responds to toddlers defiance in an angry or punitive manner runs the risk of reinforcing the defiance and teaching the child that the out of control are reasonable response to frustrations. Children are often frighten by the strength and intensity of their own angry as well as by the intensity of the angry they aroused in their parents. It is there for of prime importance that the parents provide models for the control of their anger and aggressive feeling that they whish there children to follow.  
Lying is often used by 2 to 4yrs as a method of playing with the language. By observing the reaction of parents , preschoolers learn cognitively and affectively about acceptation for honesty in communication In other sense lying is a fantasy for children who describe things as they wish them to be rather than as they are.

Also the lying can be the result of parental modeling, in which case the Childs interpretations of reality are confusing, conflicting and unclear. For instance when the parents accuse each other frequently of lying, the child may become hopelessly unsure of how the word lying is to be interpreted, moreover a loyalty conflict is added to the already distorted posses of reality testing.

Chronic lying however, often occurs in combination with several other antisocial behaviors and is a sign of underlying psychopathologic condition. Regardless of age or developmental level, when lying became a frequent way managing anxiety and conflict intervention is warranted initially by parents and if necessary by professionals.  

Stealing- Almost all children steal at one or other point of there lives. It becomes a problem when it happens more than once or twice. Some preschoolers and school aged children steal as a response to a sense of internal loss, They frequently feel neglected and are emotionally deprived. In others it can be an expression of anger or revenge for real or imagined frustration by the parents. It is important to help the child to undo the theft by returning the article, or by money or by service. 

Truancy and run away behavior are never developmentally appropriate. Some children skip school because they are afraid of peer groups or teachers or because of sense of humiliation secondary to learning difficulties, or are due to separation anxiety symptoms. Most often truancy represents disorganization in home, child abuse, neglect, personality problems. Children whom run away nowhere to go are almost always expressing a serious underlying problem. 

Fire setting. Although the interest in fire is ubiquitous in early child hood, un supervised fire setting is always in appropriate. Early school aged children tent to set fire because of both curiosity and latent hostility secondary to deprivation with in a neglected family. This young children’s sets fire with in there homes. Teenagers usually set in small groups seeking revenge from school and community authorities. This children required innervations by parents, many time save by the mental health professionals.  

Aggression is possibly the most serious disorder in this group. Several theories are put forward to explain human aggression. The drive theory proposed that the aggression is programmed within the human species. The phenomenologic proposes that every day life is sufficiently depriving and frustrating that the aggression is expected. Social learning theory suggest that aggression is learned and successively reinforced thought young childhood and adolescence. Social theorist suggest that modern crowding, the break down of shared values ,the demise of traditional family child rearing practice, are leading to increased aggression in childhood, adolescents and adult.

Factors contributing to aggression are
· sex --male.
· large children.
· more active and intrusive children.
· difficult temperaments
· large families
· marital discord and aggressive parents.

 The child of 2-5yrs may show aggression ranging from temper tantrums and screaming to hurting others and destroying furniture’s and toys. This is frequently due to a particular frustration and the inability to manage them. In toddlers aggression is usually directed towards parents. During the preschool years it is more directed to siblings and peers. Verbal aggression increase between 2 and 4yrs and retaliation and revenge after 3yrs. 

Passive aggressive behaviors are common in childhood and adolescents. They express hostility indirectly as procreations, stubbornness or resistance. Parents usually complaints that there children do not hear them and that they fail to respond to repeated request. Academic under achievement is common. Early history shows negativism in infancy and toddler hood with poor bladder and bowel training and feeding habits.

Children may unconsciously adopt passive aggressive behavior for a variety of motives. To gain independency while maintaining dependency, to counter underlying low self esteem, to maintain control and autonomy while threatened by anxiety. These children are fearful of direct expression of assertiveness, aggression and hostility. Child rearing styles of their parents are often intimidating, critical, and inconsistent, and on the other hand indulgent and permissive. Both parents and child often find it difficult to deal directly with anger. Parents should be encouraged to handle the passive aggressive behavior by setting firm limits and expectations.

Conduct disorder is a distinct clinical entity manifested by several antisocial behaviors, stealing, lying, fire setting, truancy, property destruction, cruelty to animals, repeated attempt to run away from home .  attend to a task, motoric over activity and impulsivity. This children are fidgety, have a difficult time in remaining in there seats, are easily distracted have difficulty in awaiting their turn, impulsively blurt out answers to questions, have difficulty in following instructions and sustaining attention, shift rapidly from one unaccompanied task to another ,talk excessively, intrude on others, often seen not to listen to what is being said. lost items regularly, and often engaged in physically dangerous activities with out considering possible consequences.

Etiology
Children with A.D.H.D. differ in cognitive style, levels and type of arousal, and response to rewards. There is abnormal positron emission tomografic scans with reduced glucose metabolism in premotor and superiors prefrontal cortex in adults having A.D.H.D. Genetic factors are also considered. Dispite all the studies the cause is poorly understood.

Clinical Features.
A description of problem behavior in specifies situations are elicited. A history of aggression and fears, poor relationship between the peers, academic difficulties, behavioral problems at school, and reaction to authority define the problem and provide useful information about the concurrent presence of conduct disorder, anxiety disorder, learning disabilities. History should include events of the birth and delivery, a description of the child’s temperament, examples of early separation anxiety, a description of the child’s behavior between 18 and 30 months when the child was psychologically separating from the primary care givers, and child’s activity levels between 2 to 5yrs. Some children are described as colicky. temperamentally difficult, and overactive from a very old age. with sleep and feeding abnormalities.
  The initial identification of many children with this problem commonly occurs when they enter nursery or elementary school. they are often reported to uncontrollable, refusing to sit still. They often provoke others to anger and rarely learn from their mistakes. 

Differential diagnosis. 
1. Should be evaluated for conduction disorder and learning disabilities.
2. Auditory impairment should be assessed in children presenting with concentrating difficulty.
3. Petit Mal epilepsy should be ruled out.
4. Medication
5. Over anxious children
6. Gills de la Tourette syndrome. 

Psychiatric consideration Of Central nervous system injury.

Psychotic disorders may follow infection, injury, intoxication, genetic metabolic or idiopathic illness involving CNS. Brain injury increases the risk of both intellectual and psychiatric disorders, especially when injury is severe. Social disinhibition appears to be a sequel a of injury, but no typical psychiatric syndrome is associated. The particular expression of disturbance is depend on child developmental level, temperament, past history and family relationship.

Prematurely and neonatal complications involving hypoxia have been seen as causing such conditions as hyperactivity, impulsivity, difficulties in socialization, and poor control of emotions, especially anger.

Substance abuse during pregnancy may affect both prenatal and early childhood development, especially cocaine which can cause cerebral infraction, microcephaly, developmental delays behavior and learning problems.

Children under the age of 3yrs who survive encephalitis or meningitis seem to show more lasting effect on personality and behavior. Children with hydrocephalus and motor deficit have a seven times greater chance of developing psychiatric disorder.

Management
The most significant factor in the child’s adjustment to a chronic handicapping organic condition is the capacity of parents to adjust and cope.
A frequently beneficial approach is to help the child to identify his or her ineffective reaction patterns along with more successful patterns. It involves education with an opportunity to discuss depression, isolation, and anger and those feeling of Bering different, rejected or exploited that so much effect self esteem. The parents have there own needs and will need advise, counseling and emotional support. Fair firm discipline is always useful.

  Sexual Behavior And Its Variations

Gender identity refers to the individual’s sense of self as a male or female. Gender role on other hand refers to those behaviors with in a culture commonly thought to be associated with maleness or femaleness.
Children identify them selves as male or female by about 18months of age, i.e.; gender identity. Between 18months and 30months of age they establish gender stability. The concepts that boys become male and girls become females. By 30months gender constancy, the immutability of ones gender, is firmly established and restraint to change.

Children are naturally curious about there bodies. The two year child ought to be thought the proper names for the parts of the body, including the genitals. Parents should react clammily when the there children explore and manipulate there own bodies with enjoyment, although open masturbation by older children suggest poor awareness of social reality or lack of parental censorship. Parents should inform that the masturbation is not a social activity and should be limited to the bed room when is alone . It is important that the masturbation should be considered as a normal behavior of child’s sexual life and that guilt be avoided. By puberty children should be given explanation of its normality. 

It is quiet common for the preschool children to hug and kiss each other. Especially with the ages of 10 and 12yrs boys and girls typically explore sexual issues with best friends, of same sex, as means of gathering information. This should not be viewed as prelude for homosexuality but as a development stage for the child.

Transsexulism conviction by a person biological of one gender that he or she is the member of other gender, is the most obvious example of gender identity confusion, They feel a discomfort and a sense of inappropriateness about there assigned sex, They spent years in trying to get rid of primary and secondary sexual charetertics that define them biologically. Gender roles of opposite sex are usually adopted. 

Individuals with disorder usually have difficulty in social and occupational functioning. Associate depression is a feature. Extreme feminity in boys is a predisposing factor.

Tranvestism, cross dressing may occur transiently in preschool boys who dress up in there mothers clothing, or it may occur in preschool and school boys who feel genuinely excited when dressed in women’s clothing. Cross dressing in girls is rarely an identified problems. It usually indicate that the other gender roles might also be problematic for the individual.

  Gender Identity Disorder

Persistent distress about being a particular gender while being pre occupied with cross gender roles repudiation of given anatomical structures is the hallmark of GID. It encompasses transsexualism, transvestism and effeminacy in boys.
  
Clinical features            
Age of onset before 4 years. They are often ostracized by peers and have a difficult social adjustment sometimes with subsequent depression. One half of the boys develops homosexual orientation during adolescence and adulthood. GID is associated with numerous other childhood andadolesent disorder.
 
Treatment.
Psychotherapy and pharmacotherapy is essential. The physician needs to help the parents control there own frustration and disappointment to minimize judgmental rejecting behavior, punishment, or shamming will not support the child’s attempt to struggle with what ever intra psycatric, inter personal or cultural conflict exist.  

Homosexuality 

Homosexuality, the romantic and physical attraction to someone of the same gender, has occurred through out the age in about of 5% of men and women. Historically acceptance of homosexuality wax and veined with in the societies.  
The etiology is uncertain. Many view it as a development as normal variation of sexual development, others point to problematic child parent relationship. Numerous psycho logic theories have been proposed. They include problems of sexual identification with parents, problematic relationship between either parent and the child, abuse overly erotized attachment, and underlying anxiety etc. 

Biologic causes have also been proposed. The “dual mating center” theory sating that there are hypothalamic areas that regulate male and female sexual behaviors. It is hypothesized that too little androgen production in males during a critical prenatal period causes the female center to overdevelop and conversely, excessive androgen production in females will lead to over development of male center. Other findings, of Le Vay’s, that heterosexual and homosexual men have difference in hypothalamic structure and size. Another finding is that anterior commissure is larger in homosexual men. 

There are probably multiple mechanisms leading to homosexuality in adolescence and adulthood, just as that of hertosexuality. Many complex factors leads to sexual development, and they include cultural biologic and psychological factors.

  If a child found to be engaged in homosexual behaviors parent should not immediately conclude that this means child is already homosexual. Sexual behaviors in adolescents does not predict the future sexual orientation. The firstly task of the parents or the physician when they found the child engaging in homosexual practices is to help them feel safe and less guilty. Parents should avoid suspicious, scolding guilt inducing behavior, shaming and threaten towards the child. It is important to know weather the child information and understanding about the sexual matters are appropriate for the age. 

If the same sexual behavior involves another child in the family he or she should be treated in the same manner. If an older child is the inciter seducer, he or she should be told clearly and firmly that such behaviors will not be tolerated and must is expected to behave with responsibility and control.

Previous Page