The mind

Published on 21/03/2015 by admin

Filed under Pediatrics

Last modified 22/04/2025

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15 The mind

History

Taking a behaviour history gives a doctor insight into functional as well as neuropsychiatric disorders. The information largely needs to be gathered from the parents, but this gives only one perspective. The family has already made a judgement about the behaviour – that is why they have come to the clinic. It is important to seek the opinions of others who know the child well, e.g. siblings, grandparents, teachers and other professionals; the mother may see the child’s behaviour as irritating, while the friend sees it as good fun, the teacher sees it as enthusiastic and the grandparent sees it as lacking discipline. Do opinions tally? Is the concerning behaviour limited to one setting?

Ask the parents what they have done to try and resolve the problems; what has worked, and what has not. Talk to the child. Even very young children should be engaged. They may tell you things that others might not know. Bear in mind that you are unlikely to discover all that is important at the first meeting. Consider children as ‘barometers’ of the social context in which they live. Talking to siblings is invaluable and frequently sheds light on family dynamics. The family’s focus on one child’s behaviour may signal unacknowledged problems in other family members, including marital problems, or indeed the child may be made a scapegoat for these problems.

Transient behaviour problems occur in most children, and most resolve. Some children get stuck. Try to establish what it is about the child and their family that prevents them moving on.

Tantrums

What are tantrums?

Toddlers like being ‘in charge’ (as can be seen in Case 15.1). This desire is often thwarted by their abilities and the limits set by their parents. For example, 2-year-olds may want to eat their meal with their parents’ cutlery although they do not have the fine motor skills to do so, or their parents may prevent them from adding tomato sauce to their ice cream, for example.

This lack of control causes frustration, and tantrums may follow. This is normal behaviour between the ages of 1 and 4 years.

Tantrums are usually dramatic. Crying, screaming, dropping to the floor and thrashing of limbs are common. Some children are able to induce vomiting. Occasionally these episodes may be mistaken for seizures. The key distinction is a history of provocation and the complex pattern of behaviours seen in tantrums.

Tantrums may be seen in children who receive inconsistent messages from different parents, and may in a sense mimic their parents’ behaviour. Note that children, despite appearances, never really want to ‘win the war’ – to do so would be very frightening as it would affirm their own power and destructiveness.

Specific strategies

Hyperactivity

What is attention deficit hyperactivity disorder?

The girl’s condition in Case 15.2 is an example of attention deficit hyperactivity disorder (ADHD) which is a triad of inattention, impulsivity and hyperactivity, with impairment of social or educational functioning as a consequence. In order to make the diagnosis, these difficulties should be seen before the age of 7 years and usually much younger. The patterns of behaviour need to be chronic (of at least 6 months’ duration), pervasive – i.e. they affect the child in two or more situations, such as at home, at school, or with grandparents and friends – and cause functional impairment.

In children, levels of activity and attention vary. This is related to age (lower in younger children), gender (worse in boys), environment and intelligence. These factors need careful consideration before labelling behaviour as ADHD. For example, in preschool children it is difficult to be certain that any pattern of behaviour represents ADHD. Many children who appear to be significantly hyperactive or inattentive at 3 or 4 years of age settle dramatically after starting school. Parental tolerance also varies. Factors such as the availability of additional welfare benefits or support may influence parental expectations. Do the parents show ADHD symptoms? Is there a dispute with the school over responsibility for conduct problems?

Management

Autistic spectrum disorders

In recent years the diagnosis of autistic spectrum disorders has become more common. Parental anxiety about autism has been further raised by controversial reports allegedly linking the measles, mumps and rubella (MMR) vaccine with autism and inflammatory bowel disease. Despite the overwhelming evidence of MMR’s safety, vaccination rates have fallen.

Case 15.3 describes a boy with autism and demonstrates some of the key features of the autistic spectrum.

Key features of autistic spectrum disorders

The key features begin before 3 years. They are impaired social functioning, impaired communication, repetitive behaviours and stereotyped movements. Diagnosis before 18 months may be difficult, but, in retrospect, parents may well recall very early concerns. Boys are more commonly affected.

Intervention

Intervention begins with early diagnosis. Interagency agreement about diagnosis and joint planning of intervention is essential (see also Chapter 3, p. 20). Key individuals include speech and language therapists, educational and clinical psychologists, specialist nurses and ideally an identified key worker to help the family negotiate the bureaucratic maze. Special schooling may be necessary. Transition to adult services is often fraught, as support is much less readily available.

Depression

What is depression?

The resilience of children to cope with stress, including bereavement (as in Case 15.4), is dependent on the child’s previous experiences coupled with the number and severity of other problems they have to face. A seemingly minor event may be more significant for a child than the parents realize (e.g. the death of a pet, loss of a friend) and normal sadness gives way to depression. There may be a family history of depression. Symptoms include diurnal variation in mood, being worse in the morning, irritability, low energy, poor self-esteem and thoughts of suicide. Interviewing the child may well elicit symptoms otherwise unknown to the parents. Poor appetite, sleep problems and other psychiatric conditions may be present.

School refusal

Difficult transitions in childhood can precipitate the onset of behaviour which presents to the doctor as ‘illness’ (as in Case 15.5). Perhaps it is better to view the child as stuck in a ‘predicament’ that brings him to professional attention.

Boys and girls in equal measure may try to avoid going to school, sometimes by playing truant, sometimes through symptoms of illness (‘somatization’). School refusal usually boils down to anxiety about change, separation from parents and family conflict, or fear as a result of bullying and, perhaps, for the health or safety of a parent. The parents are often ambivalent about school, which may contribute to the child’s sense of insecurity and anxiety. The child may be grieving or depressed. Bullying, or fear of a particular lesson, may play a part, but changing the school regime or even changing school often fails to solve the problem.

The term ‘school phobia’ has been used, despite the fact that the child is not usually phobic about school. Nevertheless, getting the child back into school as quickly as possible is often the best way to overcome the problem, demonstrating to the child and family that school is not as bad as anticipated. Good liaison with the local education welfare service is essential. The child and parents need reassurance that it is medically safe to go to school. Addressing underlying separation anxiety or family problems, or an entrenched pattern of non-attendance, may require the skills of a child psychiatrist. Return to school is the norm, but more anxiety or phobic problems may emerge in later life.

Chronic fatigue syndrome/myalgic encephalomyelitis

Management

Substance abuse

Children and adolescents are exposed to a variety of legal and illegal substances and the health effects vary. Rarely, acute intoxications of drugs or alcohol lead to hospital admission. Usually these behaviours do not precipitate immediate health problems, but can be the start of dependency or addiction that persists into adult life. The commonest substances used are tobacco and alcohol. Other than marijuana, illicit drug use under 16 years is relatively uncommon. As Case 15.7 illustrates the issues around these behaviours are complex both for families and society.

Eating disorders

Anorexia nervosa

Anorexia nervosa usually presents with insidious weight loss, often with excessive exercise and always with deception around food intake (as in Case 15.8). The child may like cooking and food, but denies having an appetite. Anorexia nervosa is much commoner in girls (the male to female ratio is 1:10), with as many as 1% of adolescent girls being affected. The characteristics are inappropriately low body weight (<15% under expected weight-for-height), intense fear of fatness, even when weight loss is achieved, and disordered body image, usually with accompanying physical sequelae such as amenorrhoea.

Self-esteem is low, but the child usually denies emotional difficulties. The widening social life and sexual challenges of adolescence may well present the child with overwhelming anxiety, and a need to regain a sense of control over her life and her body. Denial of food stands symbolically for mastery over emotional turmoil.

Examination should include repeated weight measurements (at least weekly) in underwear and on the same scales. Where possible, female staff should weigh and measure. Lanugo hair may be seen. Blood pressure and the body mass index should be recorded.

Management involves stabilization of weight and exploration of the control issues beyond the food obsession. Confident handling reduces anxiety in both child and parents. Beware of the parents who are excessively enmeshed in the child’s problems and who subtly undermine and frustrate the therapeutic regime.

The management of anorexia should be supervised by a child psychiatrist. Early referral and treatment is important. Partnership between paediatric services, child psychiatry/psychology and primary care is needed.

Cognitive therapy can be useful in challenging the child’s mistaken negative thoughts about herself. Inpatient care should be avoided unless essential. It may be needed to stabilize weight. Wherever treated, advise on realistic weight for age, and target rates of gain (not to be exceeded or under-achieved) should be set for gradual improvement over a period of weeks. It is vital to address the child’s underlying feelings. Low mood is common but usually resolves with weight gain.