Category: Child & Adolescent Mental Health

Eating Disorder Signs, Symptoms & Recommended Treatment

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An eating disorder is a psychiatric disorder in which severe disturbances in eating behaviours and related thoughts and emotions are experienced. Most often, signs and symptoms of an eating disorder are first experienced in adolescence or early adulthood, with the onset usually being a stressful life event. Eating disorder types include:

  • Anorexia Nervosa
  • Bulimia Nervosa
  • Binge Eating
  • Pica
  • Pervasive Arousal Withdrawal Syndrome (PAWS)

An Eating Disorder is NOT a Lifestyle Choice!

Anorexia Nervosa

An individual with anorexia nervosa aims to lose weight deliberately through restricted dietary choices, excessive exercise, induced vomiting, appetite suppressants, and diuretics.

Anorexia Nervosa symptoms include:

  • muscle weakness
  • irregular menstrual cycle
  • hair thinning
  • dental problems
  • impaired functioning of the immune system

Common comorbidities of anorexia nervosa include depression, OCD, social phobia, and PTSD.

Bulimia Nervosa

Bulimia Nervosa features similar psychological features in anorexia nervosa. An individual with this eating disorder experiences excessive worry about ways to control body weight, and so, aims to eat excessive amounts of food, followed by induced vomiting. These bingeing episodes usually happen several times a week.

Individuals with bulimia nervosa may have a history of anorexia nervosa, with the switch to bulimia nervosa frequently resulting from worrying of family members or friends.

NOTE: Body weight of individuals with bulimia nervosa may range from slightly underweight to obese.

Pica

Pica, which is an eating disorder that commonly affects children under the age of 6, is the persistent eating of substance which have no nutritional value such as clay, dirt, and flaking paint. Pica can feature as an individual psychopathological behaviour, or as one of the symptoms of another psychiatric disorder, such as autism.

Common causes of Pica include malnutrition and iron-deficiency anaemia.

Diagnosis requires the eating disorder to be developmentally inappropriate, and to persist for at least a month.

Pervasive Arousal Withdrawal Syndrome PAWS

Pervasive Arousal Withdrawal Syndrome (PAWS) a.k.a. Pervasive Refusal Syndrome is characterised by food and drink refusal with sudden onset following a tough health-related situation such as illness, pain or virus, or a traumatic event. PAWS is in fact commonly experienced by child refugees.

Refusal of food and drink may also be accompanied by social withdrawal, partial or complete lack of self-care, and partial or complete mobilisation refusal.

An individual with Pervasive Arousal Withdrawal Syndrome quite commonly resists any encouraging attempts of interaction or food/drink intake.

Eating Disorder Treatment

Psychopharmacology

  • Anti-depressants
  • Anti-psychotics
  • Mood stabilisers

Psychosocial Interventions

  • Individual psychotherapy
  • Group psychotherapy
  • Family psychotherapy
  • Medical care
  • Nutritional Counseling
  • Cognitive Behavioural Therapy CBT

In Malta, individuals with eating disorders can be referred to Dar Kenn Għal Saħħtek, which offers day services as well as in-patient services.

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Obsessive Compulsive Disorder OCD and Dissociative Disorder DD

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Obsessive Compulsive Disorder OCD

Obsessive Compulsive Disorder a.k.a. OCD is a common chronic long-lasting disorder in which an individual experiences uncontrollable repeated obsessions or behaviours. Children and adolescents may experience Obsessive Compulsive Disorder too, with multiple obsessions and compulsions possibly changing content over time.

Common obsessions include excessive fear of dirt, germs or sickness, excessive fear of a loved one being in danger, obsessions related to religion or sex, as well as an uncontrollable need for symmetry and exactness.

Common compulsions include ritualistic handwashing, repetitions, checking, counting, ordering, hoarding, and touching.

Tic Disorder

Tourette Syndrome (TS) is a condition related to the nervous system which causes individuals to experience tics. Tics are sudden, rapid, non-rhythmic twitches and movements (motor tics) or sounds (vocal tics) that affected individuals repeat over and over, with no control whatsoever. Children who are diagnosed with tic disorder can also exhibit associated behavioural difficulties.

Dissociative Disorder DD

Dissociative disorder is a mental disorder involving disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity. Individuals with dissociative disorders experience problems with day-to-day functioning as they tend to escape reality involuntarily. This disorder has been linked with childhood trauma.

Dissociative disorder symptoms may include amnesia, disturbances in sense of self, trance-like states, rapid mood shifts and behaviour, knowledge-memory-skills access fluctuations, hallucinations (auditory and visual), and vivid imaginary friendships (in children and adolescents). Stress tends to exacerbate these symptoms.

Treatment for dissociative disorders includes a combination of psychotherapy and medication. Although difficult to treat, early identification and intervention increases the chance of affected individuals being able to lead healthy and productive lives.

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Anxiety and Depression in Children and Adolescents

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Depression in Children

One of the top 5 most common mental health disorders in children is depression. Diagnosing depression in children is quite challenging since they may still experience periods of normal functioning despite their underlying disorder. As for diagnosing depression in adolescents, it becomes difficult to distinguish between the normal teen-related mood changes and those that come with depression. Nevertheless, early diagnosis is important since if depression in children is overlooked, it may persist through adulthood.

Signs and Symptoms of Depression in Children

  • persistent low mood
  • persistent sadness
  • lack of interest in activities they used to enjoy
  • a lingering feeling of tiredness and exhaustion
  • lethargy
  • agitation
  • sleeping too much or too little
  • eating too much or too little
  • feeling numb/emotionless
  • ongoing guilty feelings
  • poor memory
  • poor concentration
  • lack of self-esteem
  • lack of self-confidence
  • self-harming thoughts
  • suicidal thoughts

Anxiety and Depression in Children

Anxiety Disorders in Children

Separation Anxiety Disorder – child experiences fears related to an attachment figure being harmed or dying

Social Phobia a.k.a. Social Anxiety Disorder – fear of being watched and judged by others

Generalised Anxiety Disorder – worrying on different events or circumstances

Specific Phobia – fear of a particular object or stimulus

Panic Disorder – sudden panic attacks related to somatic and cognitive sensations

Emotional Unstable Personality Disorder EUPD

Emotionally Unstable Personality Disorder a.k.a. Borderline Personality Disorder is the most common type of personality disorder. EUPD causes intense fluctuating emotions that may last for a few hours to several days at a time. Emotions experienced may include impulsivity, risky behaviour, suicidal thoughts, and possibly self-harm.

A diagnosis of Emotionally Unstable Personality Disorder is usually given in adulthood as the related symptoms are associated with a lifelong personality disorder.

Substance Abuse

Substance abuse refers to the use of illegal drugs or prescription drugs or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts.

Alcohol, marijuana and opiates mimic depression symptoms, causing lack of concentration, lack of motivation, and low energy. On the other hand, Amphetamine and Cocaine mimic mania symptoms. Substance abuse tends to trigger social, physical, emotional, and occupational problems.

Individuals with Bipolar Disorder and Depression have an increased risk of substance abuse.

NOTE: Substance abuse does not rule out a mood disorder.

Self-Harm

Self-harm a.k.a. self-injury is a behavioural act in which an individual intentionally harms him/herself, usually without suicidal intention. Adolescents may seek to self-harm as a way of expressing tension, low self-esteem, physical discomfort, and pain. At times, self-harm is sought as a risk-taking act, rebellion against parents, or as an attention-seeking behaviour. However, self-harm can indicate severe psychiatric disorders such as depression, psychosis and PTSD.

Self-harming behaviour is also associated with children having developmental delays, including Autism Spectrum Disorder, and those who have experienced abuse or abandonment.

Suicide

Suicide is one of the main causes of death in children and adolescents. Severe bullying increases the risk of suicide. Additionally, being diagnosed with depression, ADHD, anxiety disorder, Attention Deficit Disorder (ADD), bipolar disorder, or schizophrenia during childhood also puts the child at a higher risk of suicide.

Reference: https://save.org/about-suicide/

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Conduct Disorder CD and Oppositional Defiant Disorder ODD

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Conduct Disorder

Conduct Disorder (CD) is the most common psychiatric disorder in the world. It is characterised by persistent anti-social behaviour where social rules are repeatedly broken and aggressive acts are repeatedly performed with the aim of upsetting others. Many children and adolescents with a Conduct Disorder diagnosis grow up into anti-social adults.

Conduct Disorder Signs & Symptoms

  • repetitive and persistent violation of societal norms, rules, laws, and basic rights of others
  • aggression, property destruction, theft, and deceitfulness
  • behavioural severity that leads to significant impairment in various areas of functioning
  • prolonged behavioural pattern lasting a year or more (thus, isolated criminal acts do not lead to a Conduct Disorder diagnosis)

Reference: https://www.icd10data.com/ICD10CM/Codes/F01-F99/F90-F98/F91-

Oppositional Defiant Disorder

Oppositional Defiant Disorder (ODD), a disruptive disorder which often accompanies ADHD, features ongoing behavioural patterns that cause significant impairment in a child’s social, academic and occupational life.

Oppositional Defiant Disorder Signs & Symptoms

  • bad temper
  • easily annoyed
  • angry or resentful
  • spiteful or vindictive
  • defying rules
  • refusing to comply with requests
  • argumentative with adults
  • deliberately seeks to annoy others
  • blaming others for own mistakes

Reference: https://icd.who.int/browse10/2019/en#/F91.3

Overview of CD, ODD & More…

Risk Factors for Conduct Disorder & Oppositional Defiant Disorder

  • anti-social parents
  • anti-social peers
  • lack of parental supervision
  • disruptive family behaviour
  • child abuse
  • child neglect
  • negative parental discipline
  • cold parental attitude
  • parental conflict
  • low family income
  • low IQ / low academic achievement
  • impulsiveness
  • attending high-crime-incidence schools
  • living in a high-crime-incidence neighbourhood

Treatment for CD & ODD

Psychosocial Interventions

  • Parental Training
  • Limit Setting Implementation
  • Cognitive Behavioural Therapy (CBT)
  • Family Therapy

Psychopharmacology

  • Stimulants – help reduce aggression
  • Anti-Depressants – SSRIs help reduce impulsive and aggressive behaviour
  • Lithium and Anti-Convulsants – help reduce aggression
  • Clonidine – help reduce impulsivity and aggression

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Attention Deficit Hyperactivity Disorder ADHD

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Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neuro-developmental disorders related to childhood. Although ADHD is most commonly diagnosed in childhood, it usually lasts well into adulthood. Children diagnosed with ADHD tend to find it hard to pay attention, are prone to controlling impulsive behaviour without any form of reflection, and are usually overactive.

Understanding ADHD – Simulation

Varying Types of Attention Deficit Hyperactivity Disorder

Predominantly Inattentive Presentation – characterised by distractibility, lack of organisational skills, lack of inability to complete tasks, and inability to follow instructions.

Predominantly Hyperactive-Impulsive Presentation – characterised by difficulty in being still, excessive fidgeting and movement, restlessness and impulsivity.

Combined Presentation – characterised by a combination of all symptoms: inattention, hyperactivity and impulsivity.

ADHD Diagnosis

For a child to be diagnosed with ADHD, the following must be evident in multiple settings eg. at home, at school, with friends, with family, even if in varying degrees:

  • at least 6 months of inattention (distractibility and organisational problems) with or without hyperactivity (lack of behavioural self-control/difficulty remaining still/excessive motor activity) and impulsivity (reacting to surrounding stimuli without thinking/reflecting on possible outcomes)
  • such behaviour needs to have a direct negative impact on the child’s functionality academically/occupationally or socially
  • deficit related to inattention, hyperactivity and impulsivity should be over the limit expected per child’s age

Reference: https://www.icd10data.com/ICD10CM/Codes/F01-F99/F90-F98/F90-

Attention Deficit Hyperactivity Disorder Risk Factors

  • Genetics
  • Premature birth / low birth weight
  • Head trauma
  • In-utero or childhood exposure to environmental toxins
  • In-utero exposure to alcohol and/or tobacco

ADHD Treatment

Psychosocial Interventions

  • Behaviour Management training for parents
  • Behavioural Interventions in the school setting
  • Organisational Skills Training

Psychopharmacology

  • Stimulants (fast effect) eg. Ritalin and Concerta
  • Non-Stimulants (slow-release yet longer effect) eg. Strattera (SNRI), and Clonidine (alpha-adrenergic agonist)

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Autism Spectrum Disorder

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Autism Spectrum Disorder (ASD) is a developmental disorder in which both communication and behaviour are affected. Signs and symptoms tend to start showing up during the first two years of life. A child with ASD exhibits issues related to social interaction, communication and play, and interest restrictions.

Autism Spectrum Disorder is considered to be a chronic disability. Through early intervention, symptoms can be improved.

Reference: https://www.nhs.uk/conditions/autism/

Understanding Autism – Simulation

Autism Spectrum Disorder Diagnosis

For an accurate Autism Spectrum Disorder diagnosis, a child’s developmental and behavioural history is required, from which certain criteria can be evident by the age of 3. These include:

  • inability to initiate and maintain social interaction
  • inability to initiate and maintain communication
  • behavioural patterns which are restrictive, repetitive and inflexible
  • unusual interests or activities which at times may seem excessive
  • impairment in functional abilities related to self, family, and society, including school/work

Note: Child may still exhibit intellectual functioning and language abilities.

Reference: https://icd.who.int/browse10/2019/en#/F84.0

Autism Spectrum Disorder Risk Factors

  • Genetic – having a sibling with ASD, or having certain chromosomal conditions such as tuberous sclerosis (genetic disorder which causes benign tumors to develop in various parts of the body) or fragile X syndrome (genetic condition which causes developmental issues such as learning disabilities and cognitive impairment).
  • Drugs – intake of certain drugs in pregnancy such as valproic acid (Epilim) and thalidomide (Thalomid)
  • Parental Age – the older the parents are when a child is born, the greater the risk for the child to develop ASD

Note: There is no scientific evidence suggesting that vaccines cause ASD.

Reference: https://www.cdc.gov/vaccinesafety/concerns/autism.html

Autism Spectrum Disorder Treatment

Psychopharmacology

ASD is linked to symptoms such as aggression, repetitive behaviour, irritability, anxiety and depression, hyperactivity, and attention deficit. Treatment for ASD may be prescribed with the aim of targeting such symptoms.

Psychosocial Interventions

Therapy can help a child with ASD to develop life skills, social skills, communicative skills, and language skills. Suggested therapy includes Behavioural Therapy, Psychological Therapy, and Educational Therapy.

Reference: https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

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