What cannot be communicated to the mother, cannot be communicated to the self – John Bowlby
Changes DSM-IV to DSM-V
- Mental retardation has been renamed to Intellectual disability (Intellectual developmental disorder)
- Needs an assessment for both cognitive capacity (IQ) and Adaptive functioning
- Severity is now determined by adaptive functioning rather than cognitive function (IQ score)
- Reorganization of the autism spectrum disorders
- Rett syndrome has been removed from the DSM (genetic mutation and molecular etiology are now known; still similar to autism and still a pervasive developmental disorder)
- Communication disorders
- Language disorder now combines an umbrella disorder, combining expressive and mixed receptive-expressive language disorder
- Speech sound disorder is renamed from “phonological disorder.”
- Childhood-onset fluency disorder, re-named from “stuttering.”
- Social (pragmatic) communication condition is a new condition for persistent difficulties in social uses of verbal and non-verbal communications. Differentiate from autism spectrum (social communication disorders are one component of ASD)
- A. Persistent difficulties in the social use of verbal and non-verbal communication as manifested by all of the following
- Deficits in using communication for social purposes, such as greeting and sharing information in a manner appropriate for the social context
- Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language
- Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and non-verbal signals to regulate interaction
- Difficulties understanding what is not explicitly stated and non-literal or ambiguous meanings of language
- B. Deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination
- C. The onset of symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities)
- D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by ASD, intellectual disability, global developmental delay, or another mental disorder.
- A. Persistent difficulties in the social use of verbal and non-verbal communication as manifested by all of the following
Overview
Mental health in childhood and adolescence is defined as the achievement of expected developmental, cognitive, social, and emotional milestones, and by secure attachments, satisfying social relationships, and the acquisition of effective social skills.
Children are not “small adults”. Their psychiatry is different, as is the rest of their physiology. Various stages of development are present from infant to adult (this continues on into the mid-20s, 23 – 25 years). Children experience a similar spectrum of psychiatric illnesses, but symptoms will be different. Family therapy plays a prominent role in therapy. Childhood psychiatric disorders should be viewed in the context of the family, social, and cultural setting since children lack certain capacities and perspectives and are vulnerable.
Categories of childhood illnesses
| Category | Description |
|---|---|
| Disorders of cognition | Intellectual disability, Learning disorder (specifiers of reading, writing, or mathematics) |
| Pervasive developmental disorders | Autism spectrum disorder (autism, asperger’s syndrome, childhood disintegrative disorder), Rett syndrome (removed from DSM-5) |
| Communication disorders | Language disorder, speech sound disorder, childhood onset fluency disorder (stuttering), social pragmatic communication disorder |
| Behavioural disorders | Attention deficit hyperactivity disorder (ADHD), oppositional-defiant disorder, conduct disorder, tourette’s syndrome |
| Other disorders | Chidhood enuresis, childhood anxietis, developmental coordination disorders, stereotypic movement disorders, tic disorders |
Physical and Social Milestones
An overview of physical and social milestones
| Age | Milestones |
|---|---|
| 0-6 months | rolls over, smiles and laughs, passes objects hand to hand, places objects in the mouth, vocalises syllables |
| 6-12 months | crawls, sits unsupported, stands with support, finger-thumb opposition, shy with strangers |
| 1-2 years | walks, runs, 3-word sentences, feeds with a spoon, parallel play |
| Early infancy | continent, draws figures, asks questions, hops, dresses, and undresses, cooperative play |
| Middle childhood | schooling, peer group activities, developing autonomy |
| Adolescence | increasing independence, autonomy, and peer group activities |
Freud’s Psychosexual Stages of Development (1856 – 1939)
Freud’s theory of psychosexual development focused on the effects of the sexual pleasure drive on the mind. He believed that at particular points along the developmental path, a body part is sensitive to sexual, erotic stimulations (erogenous zones – mouth, anus, and genitals)
Psychosexual stages
| Age (years) | Stage | Features |
|---|---|---|
| 0 – 1 | Oral | Gratification is achieved through oral means (breastfeeding) |
| 1 – 3 | Anal | Gratification is achieved by the child’s perceived ability to control their anal sphincter (defecation) |
| 3 – 6 | Phallic | Gratification is achieved (in the male child) through awareness of the phallus (penis) |
| 6 years to puberty | Latency | Sexual development is latent as intellectual/social growth becomes more prominent |
| Puberty and beyond | Genital | Sexual desires are rekindled |
Piaget’s Stages of Cognitive Development (1896 – 1980)
Piaget provided an account of cognitive development whereby the child increases their capacity to understand the world. His theory claims that children are unable to perform certain tasks until they are psychologically mature to do so.
Paget’s stages of cognitive development
| Stage | Age Range | Description |
|---|---|---|
| Sensorimotor | 0-2 years | A child’s experiences come through the senses. Driven by motor development. Coordination of senses with motor response, sensory curiosity about the world. Language used for demands and cataloging. Object permanence developed |
| Preoperational | 2-7 years | Acquisition of motor skills. Linguistic skills develop (drive). Symbolic thinking, use of proper syntax and grammar to express full concepts. Imagination and intuition are strong, but complex abstract thought is still difficult. Conservation developed. |
| Concrete operational | 7-11 years | Children begin to think logically about concrete events. Concepts attached to concrete situations. Time, space, and quantity are understood and can be applied, but not as independent concepts |
| Formal operations | 11+ | Development of abstract reasoning. Theoretical, hypothetical, and counterfactual thinking. Abstract logic and reasoning. Strategy and planning become possible. Concepts learned in one context can be applied to another |
Erickson’s Stages of Psychosocial Development (1833 – 1887)
Erikson listed 8 stages across the entire life span in which successful completion (resolution of a conflict/task) leads to a favourable result (virtue). He emphasised the importance of the ego (executive function of the mental apparatus) in personality development, instead of focusing on the basic drives as Freud did.
Erickson’s Stages of Psychosocial Development
| Stage | Task | Virtue |
|---|---|---|
| 0-2 years | trust vs mistrust | Hope |
| 1-2 years | autonomy vs doubt | Will |
| 3-6 years | initiative vs inadequacy | Purpose |
| 6-puberty | industry vs inferiority | Confidence |
| Adolescence | identity vs confusion | Fidelity |
| Early adulthood | intimacy vs isolation | Love |
| Late adulthood | generativity vs stagnation | Care |
| Old age | integrity vs despiar | Wisdom |
Bowlby and Ainsworth’s Attachment Theory
Attachment is the making of a strong, affectionate relationship with others. It is a characteristic of human beings and other species. Stable relationships are a source of enjoyment and security, while separation, loss, or threatened loss of a relationship is a source of anger, sadness, and depression. Attachment theory is the current dominant theory in child psychiatry
The Circle of Security
In the circle of security, “The Strange Situation’ paradigm by Ainsworth is used to assess attachment and early physiological difficulties. Children are observed playing for 20 minutes while caregivers and strangers enter and leave the room. The amount the child explores and engages, and the child’s reaction to the departure and return of the caregiver, are observed. Based on these, the attachment style is categorized, and management implications are decided.
In the top half of the circle, the child feels safe and secure, and there is a natural tendency to explore the world. The role of the parent is to watch over without taking over.
In the bottom half, the child is tired, frightened, or no longer interested in exploring and needs to return to safety.