4.4 Major psychiatric disorders
The major psychiatric disorders are characterized by relatively specific symptomatology and functional impairment in the family, social and educational domains. The primary care physician’s role in the management of these disorders is early recognition, baseline risk assessment, diagnostic clarification if warranted, collaboration in shared care, and ensuring maintenance of the patient’s general health. A contemporary conceptualization is that individuals are on developmental trajectories and, although variability in functioning and achievement over time is typical, nevertheless the individual shows steady improvement in ability and mastery of their environment across childhood and adolescence. Disorders can be developmental continuities: a child, although progressing, is doing so on an impaired trajectory compared with their peers – the child more rapidly develops symptoms and impairment. Examples of developmental dis- continuities include the onset of major depression disorder or obsessive compulsive disorder.
The following symptoms should alert the primary physician to the possibility of a serious psychiatric disorder:
In this chapter we describe some of the major psychiatric disorders that may occur at various ages in childhood and adolescence.
The role of the primary care physician
• Recognize as early as possible the signs of a major psychiatric disorder.
• Exclude as quickly as possible non-psychiatric causes of the symptoms.
• Refer as soon as possible to mental health consultant.
• Explain the nature of the problem and the reason for referral to the patient and family.
• Collaborate with the psychiatrist in the shared extended care of the patient.
• Support the patient and family in adhering to the treatment plan.
Infancy and early childhood
Reactive attachment disorders
Both infant and parent contribute to attachment. However, attachment is best conceptualized as the quality of the relationship between the two. Attachment disorders do not include disorders with a biological (proven or presumed) substrate. Hence impaired emotional reciprocity seen in autism is not a feature of a reactive attachment disorder. Occasionally, the distinction between pervasive development disorders and attachment disorders can be difficult. Typically, the infant fails to initiate or to respond appropriately to social interaction, exhibiting social withdrawal, inhibition, avoidance or, conversely, a superficial, undiscriminating sociability.
Attachment disorders develop as a result of parent depression, psychosis, personality disorder or severe psychosocial stress; the parent has failed to attend to the infant’s basic needs for affection, contact comfort and stimulation, or there have been so many changes of caregiver that the infant has not been able to develop a stable attachment. Attachment disorder should be distinguished from pervasive developmental disorder, intellectual retardation and developmental language disorder.
Non-organic failure to thrive is arrested physical and psychosocial development secondary to severe attachment disorder, and should be differentiated from physical causes of failure to thrive. It is usually encountered in children from 18 months to 7 years of age. Typically, during hospital admission the child develops greater language and/or social ability as well as gaining weight, only to stall after returning home. The prognosis for intellectual and social development is poor unless adequate surrogate care is provided or the primary caregiver’s parental capacity can be addressed.
Reactive attachment disorder
• Caused by defect in infant’s capacity to elicit parental care and/or by failure of the parent to provide adequate or consistent care
• Reflected in the infant’s failure to initiate or respond to social contact
• Can lead to stunting of physical or intellectual growth
• Must be differentiated from organic failure to thrive
• Treatment involves the provision of adequate surrogate parental care while the mother–child unit is treated
Pervasive developmental disorders
This group of conditions is characterized by a developmental continuity in delayed intellectual, communicative and social development, together with stereotyped behaviour and circumscribed interests.
Autistic disorder occurs in about 1 in 1000 children, with a male to female ratio of 3 : 1. The features of autistic disorder are shown in Box 4.4.1. The incidence of all autistic spectrum disorders may be as high as 3–6 per 1000 children. A major cause of varying prevalence is inconsistency in diagnostic approaches. In approximately 50% of autistic children, a physical cause can be diagnosed (e.g. congenital rubella, fragile X syndrome, neurofibromatosis, phenylketonuria, tuberous sclerosis). There are numerous causal theories for pervasive developmental disorders of unknown aetiology, such as deficits of interneuron communication, possibly dendritic spine morphological change, more so in males. However, definitive statements about causation are not currently possible.
Box 4.4.1 Clinical features of autistic disorder
• Marked impairment of eye-to-eye gaze and communicative gestures
• Failure to develop peer relationships
• Lack of socio-emotional reciprocity
• Impaired capacity for joint attention
• Incapacity for make-believe play
• Delay of language development
• Unusual use of language (e.g. for self-enchantment rather than communication)
• Stereotyped, restricted interests and rituals
The child suspected of autistic disorder should be assessed as follows:
• Assessment of hearing and vision
• Psychological testing for cognitive level and pattern of intellectual abilities
• Speech and language assessment
• Genetic and metabolic testing to exclude known genetic and biological causes
Autistic disorder should be differentiated from:
• Developmental language disorder
• Sensory impairment (e.g. deafness)
• Selective mutism (see below)
• Severe psychosocial deprivation
• Mild forms of pervasive developmental disorder (see below).
Although many parents become concerned that their child is abnormal by the age of 6–12 months, autistic disorder is often not diagnosed until much later in childhood. This is regrettable because the earlier the diagnosis, the sooner effective treatment can be provided. In a minority of cases, the child is described as developing normally at first, only to regress into an autistic state when 2 or 3 years old.
John, aged 4 years, was referred because his preschool teacher was concerned about his poor language and lack of interest in other children. His mother said John had always been ‘different’. He did not seek or give affection. He did not play with toys like other children but preferred to line them up or watch them falling, one by one, off a table. If anyone interrupted this game, he would scream. He was fascinated by light switches and electric fans, and liked to parrot television commercials. John avoided looking at people by averting his gaze to one side. He did not respond to the doctor’s questions. At one point, he suddenly became upset and began to run around the office on tiptoes, flicking his fingertips. He was referred to a developmental paediatrician for a full diagnostic work-up for suspected autistic disorder.
The best predictors of outcome are IQ and the presence of functional speech at 5 years of age. Epilepsy occurs in approximately 20%, usually in adolescence. Treatment may be specific if a known disorder is diagnosed (e.g. fragile X syndrome). In all cases, diagnosis is multidisciplinary and involves a comprehensive behavioural analysis that establishes targets for behavioural interventions. Often behaviour is slowly shaped towards the desired outcome. Specific augmentation and communication strategies are effective, especially if commenced early in life. Pharmacotherapy has a limited role, and is of use mainly in children who exhibit severe hyperactivity, aggressiveness or self-harm.
Parents are not usually concerned about children with Asperger’s disorder until the child is 2–4 years old. By middle childhood, the child exhibits the following characteristics:
• impairment of non-verbal communication (e.g. impaired eye contact, lack of facial expression and gesture, and monotonous vocal intonation but intact language development otherwise)
• average or above average intelligence
• lack of interest in peer relationships
• lack of social reciprocity, shared enjoyment and humour
• circumscribed interests (e.g. fixated on earthquakes) and inflexible routines
It is unclear whether Asperger’s disorder is a variant of, or different from, autistic disorder, and whether it is distinct from non-verbal language disability, semantic pragmatic processing disorder or related to later schizoid personality disorder. Because of uncertainty about the boundaries of this condition, its prevalence is unclear. A useful approximation is an Asperger’s to autism ratio of 5 : 1. Like autism, this condition is more common in males. By adolescence, many children with this condition become frustrated by their lack of friends and the teasing or social rejection to which they are prone. Treatment involves social–cognitive language programming in the educational mainstream. As adults, people with Asperger’s disorder are more effective in jobs that make few social demands.
Middle childhood
Disruptive behaviour disorder
Oppositional defiant disorder and attention-deficit/ hyperactivity disorder (ADHD) are described in Chapters 4.2 and 4.3 respectively. Conduct disorder refers to a group of children characterized by some or all of the features listed in Box 4.4.2.
Box 4.4.2 Features of conduct disorder
• Persistently aggressive behaviour (bullying, intimidation, frequent fighting, cruelty, coercive sexual behaviour, use of a weapon)
• Destructiveness (fire-setting, vandalism)
• Deceitfulness (breaking and entering, stealing, lying, trickery)
• Rule violation (truancy, staying out late at night, running away from home, refusal to accept rules at home or school)
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