Emotional Disorder in Children, Essays (university) of Medicine

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Emotional Disorders in Children

CHAPTER I

INTRODUCTION

Mental health problems in children are a common problem in children. This problem includes several types of emotional disorders which include depression, anxiety, obsessive-compulsive disorder, and trauma which is characterized by the internalization of the problem. Emotional problems in children such as anxiety, depression, and post-traumatic stress disorder tend to appear in late childhood. The disorder is often difficult for parents or caregivers to recognize because many children have different speech developments to express their emotions clearly. Many clinicians have difficulty distinguishing between normal emotional development (eg, crying, fear) and severe and prolonged emotional distress, which is called disturbance.^1 Emotional disturbances (internalization) can be grouped into several syndromes, although there is often overlap among these symptoms: depression, withdrawal, anxiety and feelings of loneliness. Some additional features of internalizing disorder are low self-esteem, suicidal behavior, poor academic performance, and social withdrawal. Grief can cause bigger problems, such as social withdrawal, suicidal behavior or thoughts, and other unexplained physical symptoms.^2

school. About 15% of children show fear, embarrassment, and withdraw from intense and persistent social situations when encountering new people or environments. Children with this pattern have a higher risk of developing separation anxiety disorder, generalized anxiety disorder and social phobia. These children exhibit physiological traits such as increased resting heart rates and higher morning cortisol levels. Separation anxiety disorder is a level of fear or anxiety that occurs due to separation from parents or caregivers that exceeds normal development. Diagnostic criteria for separation anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5), namely:3–

1. Fear or anxiety caused by separation from the individual's primary attachment, which is developmentally inappropriate and manifested by at least three of the following symptoms: a. Recurrent excessive distress in anticipation of or experiencing separation from home or attachment figures. b. Excessive and persistent feelings of anxiety about losing a major attachment figure or about possible harm to them such as illness, trauma, disaster or death. c. Excessive and persistent feelings of anxiety that you will have an unwanted experience that will result in separation from your primary attachment figure. d. Persistent reluctance or refusal to go outside, away from home, to school, work, or other places caused by fear of separation.

e. Excessive and persistent fear or aversion about being alone or without a major attachment figure in the home or other setting. f. Reluctance or refusal to sleep away from home or sleep away from major attachment figures. g. Recurring nightmares with the theme of separation. h. Physical complaints or symptoms (eg headache, stomach pain, nausea, vomiting) on separation from the primary attachment figure.

2. Persistent fear, anxiety or avoidance persisting for at least 4 weeks in children and young adults and 6 months in adults.
3. The disturbance causes significant distress or causes impairment in social, academic, occupational or other important areas of functioning.
4. The disturbance is not better explained by another mental disorder. Children with generalized anxiety disorder experience significant distress in daily activities, often the fear focuses on the child's disability in various areas, such as performance in school and social situations. Also, children with generalized anxiety disorder tend to experience fear in some situations and expect negative outcomes in the face of academic or social challenges, compared to their peers. Young children and adolescents with generalized anxiety disorder may experience autonomic symptoms such as tachycardia, shortness of breath, sweating, nausea or diarrhea when anxious compared to children who do not experience anxiety. Diagnostic criteria for generalized anxiety disorder according to the DSM-5 are:3–

create fear or anxiety, and the child will often try to avoid these social situations. This impairment has significant consequences for future achievement, such as an increased incidence of being dropped out of school, lower productivity at work as an adult, and an increase in the rate of being unpaired. The DSM-5 criteria for social phobia are:3–

1. Fear or anxiety about one or more social situations in which the individual is exposed to being coerced by others. Examples include social interactions (eg chatting or meeting new people), being observed (eg while eating or drinking), and performing actions in the presence of large crowds (eg giving speeches). Note: in children anxiety must appear in the peer environment and not only during interactions with adults.
2. The individual fears that he will show symptoms of anxiety that will be judged badly by others (eg being embarrassed or being rejected or ridiculed by others).
3. Social situations almost always cause fear and anxiety. Note: in children, fear or anxiety can be expressed by crying, tantrums, not wanting to move or not wanting to talk).
4. Social situations are avoided or faced with intense fear or anxiety.
5. The fear or anxiety is greater than the actual threat faced in the context of social situations or social culture.
6. Persistent fear, anxiety or avoidance, usually lasting 6 months or more.
7. The fear, anxiety or avoidance causes significant distress or impairment in social, occupational or other important areas of functioning.

8. The fear, anxiety or avoidance is not caused by the effects of a substance (eg drug abuse), or another medical condition.
9. The fear, anxiety or avoidance is not better explained by the symptoms of another mental disorder.
10. If a medical condition is present, the fear, anxiety or avoidance is completely unrelated and greatly exaggerated. When talking to other individuals in social interactions, children with selective mutism will not initiate conversation or reply to people who are talking to them. Lack of talk occurs in social interactions with peers or adults. Children with selective mutism will speak at home when accompanied by family members but often do not speak even when in front of their house, or when there are friends who are not too close, or distant relatives such as cousins or grandparents. Children with selective mutism often refuse to talk at school, which causes academic distraction. The criteria for selective mutism according to the DSM- are:3–
11. Persistent failure to speak in certain social situations where speaking is expected (eg school) despite speaking in other situations,
12. The disturbance causes impairment in educational or occupational achievement or social communication.
13. The duration of the disturbance has been at least 1 month (not limited to the first month of school).
14. Failure to speak is not caused by ignorance, or comfort regarding the language used in social situations.

family environment. In children, there are two common depressive disorders, namely major depressive disorder and dysthymia. The criteria for depressive disorder according to the DSM-5 are:3,

1. Five (or more) of the following symptoms that have lasted for 2 weeks and reflect a change in previous functioning; at least one of the symptoms is (a) depressed mood or (b) loss of interest or pleasure: Note: does not include symptoms caused by other medical conditions a. Depressed mood most of the day, nearly every day (note: in children symptoms may include irritable mood) b. Diminished interest or pleasure in all, or almost all, activities that last most of the day, occur almost every day. c. Significant weight loss when not on a special diet or weight gain, or decrease or increase in appetite most days (Note: in children, consider failure to thrive) d. Insomnia or hypersomnia nearly every day. e. Psychomotor agitation or retardation nearly every day. f. Fatigue or loss of energy nearly every day. g. Feelings of worthlessness or excessive guilt nearly every day. h. Reduced ability to think or concentrate, unable to make decisions, nearly every day. i. Recurrent thoughts of death (not just fear of death), recurrent suicidal ideation without a plan, or a suicide attempt or a plan to commit suicide.

2. The symptoms cause significant distress or impairment in social, occupational or other important areas of functioning.
3. The episodes are not caused by the effects of a substance or other medical condition.
4. The presence of a major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or another psychotic disorder.
5. There were no manic or hypomanic episodes. Diagnostic criteria for dysthymic disorders are:^3
6. Depressed mood that lasts most days, occurs almost every day and lasts for at least 2 years. Note: in children and adolescents, the mood may be irritable and the duration is at least 1 year.
7. By day two (or more) of the symptoms associated with depression: a. Poor appetite or overeating b. Insomnia or hypersomnia c. Low energy or tired easily d. Low self-esteem e. Difficulty concentrating or difficulty making decisions f. The feeling of having no hope
8. During a 2-year period (1 year in children and adolescents) of the disturbance, the symptoms of criteria 1 and 2 have not resolved for more than 2 months.
9. Criteria for major depressive disorder can last for 2 years.

objects. This results in children and adolescents with obsessive-compulsive disorder becoming avoidant, unable to make decisions, indecisive and slow in completing tasks. In most cases of obsessive-compulsive disorder, obsessions and compulsions are both present. The following are the diagnostic criteria for obsessive-compulsive disorder according to the DSM-5:3,

1. Presence of obsessions, compulsions or both: Obsession is defined by: a. Recurrent and persistent thoughts, urges or images that are experienced and felt are intrusive and unwanted and cause distress and anxiety. b. Individuals try to ignore or suppress these thoughts, urges or images, or neutralize them with other thoughts or with a behavior (by doing compulsions). Compulsion is defined by: a. Repetitive behavior (eg hand washing, stacking, checking) or mental behavior (eg praying, counting, repeating words) that is perceived as a response to an obsession or a rule that must be adhered to rigidly. b. The behavior is carried out with the aim of preventing or reducing anxiety or stress or preventing bad events or situations. This behavior is not really related to what they are trying to neutralize or prevent, or is clearly excessive.
2. Obsessions or compulsions that take up time (eg, spend more than 1 hour per day) or cause significant distress or impairment in social, occupational, or other important areas of functioning.

3. The obsessive-compulsive symptoms are not due to the effects of a substance (eg, drug abuse) or another medical condition.
4. The disturbance is not better explained by the symptoms of another mental disorder. E. Trauma and Stressor-Related Disorders According to the Diagnostic and Statistical Manual of Mental Disorder fifth edition (DSM-5) trauma and stressor-related disorders include reactive attachment disorder, disinhibited social engagement disorder, and post-traumatic stress disorder. Post-traumatic stress disorder in children can look different and have important implications for a child's development.^4 Reactive attachment disorder and disinhibited social engagement disorder is a clinical disorder characterized by deviant social behavior in children that reflects very negligent parenting and abuse that interferes with the development of normal attachment behavior. The second diagnosis of this disorder is thought to be caused by the loss of a caregiver figure. This disorder was first described in DSM-3, and evolved from attachment theory, which describes a child's need for protection, nurturing, comfort and interaction between parents and children to meet these needs. Diagnostic criteria for reactive attachment disorder according to the DSM- are as follows:3,
5. Pattern of inhibition, emotionally withdrawn behavior toward caregivers that occurs consistently, as indicated by the following: a. Children rarely seek solace when under pressure b. Children rarely respond to comfort when under pressure

1. Pattern of behavior in which the child actively approaches and interacts with adults who are not recognized and exhibits at least two of the following: a. Reduced or no reluctance to approach and interact with unfamiliar adults. b. Words or physical behavior that are too familiar (inconsistent with prevailing social culture and age bonds). c. Reduced or absent rechecking with caregivers after being around, even in unfamiliar surroundings. d. The desire to go out with unfamiliar adults with little or no hesitation.
2. The behavior in criterion 1 is not induced by impulses (as in attention deficit/hyperactivity disorder) but involves inhibited social behavior.
3. The child experiences an extreme pattern of observable parental neglect with at least one of: a. Persistent social neglect in the form of a social need for comfort, stimulation and affection that is not met by caregivers. b. Repeated changes in caregivers that limit opportunities to form stable attachments (eg, frequent changing of foster homes). c. Raised in an unusual environment that severely limited opportunities for forming selective attachments (eg institutions with high child-caretaker ratios).
4. Criterion 3 is suspected to be responsible for the disturbed behavior in criterion 1 (eg the disturbance in criterion 1 occurred after negligent parenting in criterion 3).
5. The child has passed the developmental age of at least 9 months.

The incidence of post-traumatic stress disorder in children and adolescents exposed to violence and trauma is quite high. In America in children and adolescents exposed to traumatic events, this disorder has a prevalence of 60% with a lifetime prevalence of 80% to 90%. Traumatic events can include sexual abuse, physical abuse, abuse, motor vehicle accidents, serious medical illnesses, or natural disasters. In children younger than 6 years, intrusive and spontaneous memories may be evident in ongoing activities, or appear as nightmares. The child may also show unexplained agitation or fear. Diagnostic criteria for post- traumatic stress disorder in children aged 6 years and under according to the DSM-5 are:3,

1. In children 6 years and younger, exposure to death or death threats, serious injury, or sexual violence in one (or more) of the following: a. Experiencing the traumatic event firsthand b. Witnessing a traumatic event happening to someone else. c. Seeing traumatic events that happened to parents or caregiver figures.
2. Presence of one (or more) intrusive symptoms associated with the traumatic event, beginning after the traumatic event occurred: a. Recurrent and unwanted intrusive memories of the traumatic event. b. Recurring nightmares with content related to the traumatic event. c. Dissociative reactions (eg flashbacks) in which the child feels or behaves as if the traumatic event were taking place. d. Intense and prolonged psychological distress when exposed to symbols or aspects that describe the traumatic event.

c. Exaggerated startle response d. Problems with concentration e. Sleep disturbances (eg difficulty getting to sleep or difficulty maintaining sleep or unsatisfactory sleep)

5. Duration of the disturbance is more than 1 month
6. The disturbance causes significant distress or interference in relationships with parents, siblings, peers or other caregivers or with behavior while at school.
7. The disturbance is not caused by the effects of a substance (eg a drug or alcohol) or another medical condition. Diagnostic criteria for post-traumatic stress disorder in children over 6 years old, adolescents and adults according to DSM-5:^3
8. Exposure to death or threatened death, serious injury or sexual violence in one (or more) of: a. Experiencing the traumatic event firsthand b. Witnessing a traumatic event happening to someone else. c. Seeing a traumatic event that happened to a family member or close friend. In the case of death or death threats to family or friends, the incident must be sadistic or accidental. d. Experiencing repeated extreme exposure to details of a traumatic incident (eg first person to find remains, or police repeatedly exposed to details of child abuse).

2. Presence of one (or more) intrusive symptoms related to the traumatic event, starting after the traumatic event occurred: a. Recurrent and unwanted intrusive memories of the traumatic event. b. Recurring nightmares with content related to the traumatic event. c. Dissociative reactions (eg flashbacks) in which the child feels or behaves as if the traumatic event were taking place. d. Intense and prolonged psychological distress when exposed to symbols or aspects that describe the traumatic event. e. Physiological reactions reminiscent of the traumatic event.
3. Persistent avoidance of stimuli related to the traumatic disorder, starting after the traumatic event occurred, can be seen from: a. Avoiding or trying to avoid memories, thoughts or feelings about or related to the traumatic event. b. Avoiding or trying to avoid external reminders (people, places, conversations, activities, objects, situations) that evoke memories, thoughts or feelings about or related to the traumatic event.
4. Negative changes in cognition and mood related to the traumatic event, starting or worsening after the traumatic event occurred, as manifested by two (or more) of: a. Inability to remember important aspects of the traumatic event (usually caused by dissociative amnesia and not caused by head injury, alcohol or drugs).