Paediatric Disorders

Question 1

Conduct disorder

Answer 1

• Conduct disorder (CD) describes is a group of behavioural problems where a child is aggressive (verbal or physical), antisocial and defiant to a much greater degree than expected for the child’s age.
• Delinquency is a legal term and there is a link between conduct disorder and delinquent behavior, CD being a risk factor for delinquent behaviour.
• The major characteristic of the disorder is the violation of the rights of others and of social norms. This will commonly include:
  
  • fighting and physical cruelty (people & animals)
  • destructiveness (usually of property)
  • lying and stealing
  • violation of rules- truancy (including running away from home).
• Classification:
  
  • Early Onset Conduct Disorder - at least one characteristic before the age of 10
  • Adolescent Onset Conduct Disorder - where the child doesn’t show any of the characteristics before the age of 10. Most common type.
• Risk Factors:
  
  • Genetic: Parent with Antisocial Personality Disorder, Parents who had CD themselves in childhood.
  • Individual: Difficult temperament
  • Physical: Problems in processing social information or social cues as part of a learning disability or brain injury
  • Environmental: Family problems, over harsh or poor parenting, living in a deprived area.
  • Emotional: Depression, Social isolation due to lack of peer group
• Treatment - NICE recommends group-based parent-training/education programmes in the management of children with conduct disorders. Individual approaches are also used and include Cognitive Behavioural Therapy (CBT) based approaches, which help to improve a child’s problem-solving, communication, impulse control and anger management skills.

Question 2

Reactive attachment disorder (RAD) of childhood

Answer 2

• Is characterized by persistent difficulties in a child’s pattern of attachment relationships, also associated with varying degrees of emotional disturbance. Many children in the social care system meet the criteria for an attachment disorder.
• This child will be hypersensitive to changes in their environmental circumstances due to their adverse early life experiences
• Symptoms of reactive attachment disorder often emerge before age five years and are associated with grossly inadequate care by way of any form of neglect, abuse, maltreatment and abandonment.
• Symptoms include a lack of emotional responsiveness, fearfulness and hypervigilance (usually unresponsive to comfort/reassurance).
• Aggressive or defiant behaviour
• Inhibition or hesitancy in social interactions
• Disinhibition or inappropriate familiarity or closeness with strangers
• RAD may be accompanying disorder of a child who shows a failure to thrive
• Children who exhibit signs of Reactive Attachment Disorder need a comprehensive psychiatric assessment. These signs or symptoms may also be found in other psychiatric disorders.
• Treatment - involves both the child and the family. Therapists focus on understanding and strengthening the relationship between a child and his or her primary care givers. Without treatment, this condition can affect permanently a child’s social and emotional development.

Question 3

Separation anxiety disorder

Answer 3

• Child displays intense anxiety about being away from home or from their caregivers. This affects their ability to function socially and in school.
• School refusal is common and clingy behaviours and anger outbursts often occur on separation form parents. These children have a great need to stay at home or be close to their parents and may refuse to sleep alone.
• Treatment - CBT, Family therapy, Parenting strategies

Question 4

Tic disorders

Answer 4

• Tics are sudden, involuntary, non-rhythmic motor movements or vocal productions. Tics are purposeless, happen rapidly and are often repetitive in nature.
• Tics are fairly common in childhood – approx. 1% of school children; in the vast majority of cases, they are temporary conditions that resolve during neurodevelopment. In some children, however, the tics persist over time, becoming more complex and severe.
• Children usually have varying degrees of awareness of their tics and can be distressed by their tics particularly in more severe cases.
• Tics may be Simple Motor - using only a few muscles - eye blinking, nose twitching, head jerks
• Simple Vocal - simple sounds - such as a grunt or cough.
• Or Complex Motor - using many muscle groups – these tics involve slower, longer, and more complex sets of movements like facial grimacing combined with a head twist.
• Complex Vocal - full words and sentences.
• Tics usually fluctuate in intensity and if they occur only temporarily, they do not qualify for any specific tic disorder.
• Types of Tic Disorders include: Transient tic disorder (most common form), chronic vocal or chronic motor tic disorder.
• Tourette’s Syndrome (TS): A combined vocal and motor tic disorder that can often persist into adult life.
• ADHD and OCD are commonly comorbid with Tourette’s Syndrome.
• Treatment of Tic Disorders - Usually no treatment is required. In more severe cases and in Tourette’s syndrome CBT with a focus on behavioural modification can be helpful. Medication is reserved for cases where the tics are severe and have a significant impact on quality of life.