Foundations of Psychopathology >> Childhood Mental Disorders

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Childhood Mental Disorders
M. S. Ahluwalia

Psychopathology

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Psychopathology >> Childhood Mental Disorders >> Contents
Introduction
10
Childhood Mental
Disorders
Pervasive
Developmental
Disorders (PDD)
Autistic Disorder
Rett’s Disorder
Asperger Syndrome
Childhood Disintegrative
Disorder (CDD)
PDD- not otherwise
Specified (PDD-NOS)
Attention Deficit
Hyperactive Disorders
(ADHD)
Other Childhood
Psychopathologies
Oppositional Defiant
Disorder
Conduct Disorder
Separation Anxiety
Disorder
Tic Disorders
Childhood Depression
Mental Retardation
Most of these disorders
can be viewed as
exaggerations or
distortions of normal
behaviour.
Whether a child is
behaving like a typical
child or has a disorder is
determined by:
• Presence of
impairment, and
• Degree of stress
related to symptoms

Contents
1. Pervasive Developmental Disorders (PDDs)
2. Attention Deficit Hyperactivity Disorders (ADHD)
3. Other Childhood Psychopathologies
4. Mental Retardation (MR)
11

Psychopathology >> Childhood Mental Disorders >> Pervasive Developmental Disorders
1. Pervasive Developmental Disorders (PDDs) (1/2)
12
Pervasive – means “to be present throughout”. It is misleading because children with PDDs
generally do not have problems in all areas of functioning – there are specific problem areas,
and functioning in other areas is reasonably well.
Developmental – Although the condition begins far earlier, it is typically identified in children
around 3 years of age when they do not walk, talk or develop as well as other children of the
same age. This is a critical period in child’s development, hence the name.
PDDs refer to a group of conditions that involve delays in the
development of many basic skills such as:
• Ability to socialise with others
• Ability to communicate
• Ability to imagine (abstract thinking)
Children with PDD are confused in their thinking and generally have
problems understanding the world around them. They vary widely
in their individual abilities, intelligence, and behavior.
PDD is often described interchangeably with ‘Autistic Spectrum Disorders (ASD)’ - the
broad spectrum of developmental disorders affecting young children and adults. The range
of the disorders varies from severely impaired individuals with Autism to other individuals with
Asperger’s syndrome - who have abnormalities of social interaction but normal intelligence.

1. Pervasive Developmental Disorders (PDDs) (2/2)
13
Symptoms
Children with PDD display a wide range of symptoms, that can range in severity from mild to disabling.
Symptoms that may generally be present to some degree in a child with PDD include:
• Difficulty in Communication
• verbal communication - including problems using and understanding language
• non-verbal communication - such as gestures and facial expressions
• Difficulty in Socialisation
• social interaction, including relating to people and to his or her surroundings
• Unusual Thoughts and Behavioral Patterns
• Unusual ways of playing with toys and other objects
• Difficulty adjusting to changes in routine or familiar surroundings
• Repetitive body movements or patterns of behaviour, such as hand flapping, spinning and head
banging
• Changing response to sound (the child may be very sensitive to some noises and seem to not hear
others)
• Other Symptoms
• Temper tantrums
• Difficulty sleeping
• Aggressive behaviour
• Fearfulness or anxiety (nervousness).

Contents
1. Autistic Disorder
2. Rett’s Disorder
3. Asperger’s Syndrome
4. Childhood DisintegrativeDisorder (CDD)
5. PDD – not Otherwise Specified (PDD-NOS)
14

1.1 Autistic Disorder - Overview
15
• Autism can be found in association with other disorders such as Mental Retardation and
certain medical conditions.
• The degree of autism can range from mild to severe. Mildly affected individuals may
appear very close to normal with abnormalities of social interaction but normal intelligence
– also known as Asperger’s Syndrome. Severely afflicted individuals may have an extreme
intellectual disability and unable to function in almost any setting.
Definition
ASD is a developmental disorder characterized
by impaired development in:
• Communication
• Behavior
• Social Interaction
*details regarding symptoms on the following pages
Prevalence of Autism
It afflicts:
• 1 out of every 100 to 166 children
• 5 boys to every 1 girl
Differential Diagnosis
• Autism has been confused with childhood
schizophrenia or childhood psychosis.
• Aslo been misunderstood as schizotypal
personality disorder in adults.

1.1 Autistic Disorder – Symptoms (1/3)
16
Impairment in Communication
• Severe impairment (delay or non-existence) in receptive language
(understanding) as well as expressive language (spoken). Deficits in
comprehension include:
• Inability to understand simple directions, questions, or commands
• Absence of dramatic play – may not be able to engage in simple age-
appropriate games
• Teens and adults may continue to play games meant for younger
children
• Those who speak:
• May be unable to initiate or participate in a 2 way (reciprocal)
conversation
• Speech may lack emotion and sound flat or monotonous
• Sentences are immature ex: “want food”
• Echolalia – repeating back what the child hears without understanding
• Memorisation/recitation of songs, stories, scripts etc. is common.
Though, the autistic person may not understand any of the content.

17
Impairment in Behaviours
• Variety of repetitive, abnormal behaviors
• Tied to routine
• Everyday tasks are ritualistic
• Non-purposeful repetition of actions or
behaviors ex: teeth grinding
• Preoccupation with a limited interest or a
specific plaything – objects performing
some action such as spinning could be
extremely interesting for them. Can sit for
hours turning a light switch on and off.
• Inappropriate bonding to specific objects
such as piece of string, paper clip. Can
become hysterical in its absence.
• Tantrums or direct physical attack may
result in case there is interference with any
of the above
• Hypersensitivity or Hyposensitivity to
sensory input through vision, hearing or
touch. May lead to intolerance or use of
abnormal means to gain experience.
Example Behavioural Challenges
• Due to hypersensitivity to noise etc.:
• Loud parties and celebrations can be difficult for some of them.
• Wearing socks or tags on clothing may be perceived as painful.
• Sticky fingers, playing with modelling clay, eating birthday cake or other foods,
or walking barefoot across the grass can be unbearable.
• Due to hyposensitivity they may use abnormal means to experience visual,
auditory, or tactile (touch) input.
• They may head bang, scratch until blood is drawn, scream instead of speaking
in a normal tone, or bring everything into close visual range.
• He or she might also touch an object, image or other people thoroughly just to
experience the sensory input.
• Due to the tied routine
• Simple activities such as bathing might be accomplished only after the precise
amount of water is in the tub, at the exact temperature, the same soap is in its
assigned spot and the same towel is in the same place.
• Non-purposeful actions or behaviours
• Persistent rocking, teeth grinding, hair or finger twirling, hand flapping and
walking on tiptoe are common.
• Preoccupation - child or adult may continually play with only one type of toy.
The child may line up all the dolls or cars and the adult line up their clothes or
toiletries, for example, and repeatedly and systematically perform the same
action on each one.
• Objects that spin, open and close, or perform some other action can hold an
extreme fascination. If left alone, a person with this disorder may sit for hours
twirling a spinning toy, or stacking nesting objects.

18
Impairment in Social Interaction
• Failure to develop normal inter-personal (social) interactions in
every setting.
• Bonding between mother and infant is abnormal – they are
capable of showing affection, demonstrating bonding with
caregivers; however, the manner of demonstrating affection and
bonding can be very different from normal.
• As the child develops, abnormality persists in interactions –
affected behaviors include eye contact, facial expressions, and body
postures.
• Inability to develop normal peer and sibling relationships – child
often seems isolated
• Little or no joy in normal age-appropriate activities
• They do not seek out peers for play or other social interactions.
• In severe cases, they may not even be aware of presence of other
individuals.

1.1 Autistic Disorder - Aetiology
• Autism is a set of wide variety of symptoms and may have many causes. There is lack of universal
agreement regarding the causes.
• It is considered to be a biological disorder because:
• Autism is one of the symptoms of neurological disorders such as tuberous sclerosis, fragile X syndrome,
cerebral dysgenesis, Rett’s syndrome and inborn errors of metabolism. It seems to be the ‘final
common pathway’ of the disorders that affect brain development.
• Persons with autism tend to have number of abnormalities in brain size
• Strong two-way association between autism and seizures:
• 20-30% patients with autism develop seizures
• Patients with seizures due to other causes develop autism
• A gene on Chromosome 13 may play a role in familial autism. The passing of autism from generation to
generation in some families and its association with inherited disorders such as Fragile X synrome and
tuberous sclerosis indicate a genetic cause.
• Environment, or a combination of genetic and environmental factors (infections, toxins, nutrition etc.)
contribute to the development of autism as a majority of individuals with autism do not have a strong
family history.
19
Factors that DO NOT cause Autism
1. Vaccine based immunisation
2.Poor attachment skills on part of the mother
Landau-Kleffner Syndrome
(Acquired Epileptic Aphasia)
Some children with epilepsy develop a sudden loss of
language skills – especially receptive language or even
symptoms of autism.

Contents
20

1.2 Rett’s Disorder
• Rett’s disorder is a X- chromosome linked dominant progressive neurological disorder
• Affects only females
• One of the most common causes of mental retardation in females
21
Progression
• Normal development up to 6-18 months
• After this developmental stagnation occurs
• This is followed by rapid deterioration of high brain functions.
Within 1-2 years deterioration progresses to:
• Regression of motor and language skills - loss of speech, loss of
purposeful use of hands, stereotypic hand-wringing movements,
jerky ataxia (wobbliness) of the trunk, severe dementia, behavior
reminiscent of autism, intermittent hyperventilation,
• Microcephaly (small head) and short stature.
• Panic like attacks, screaming fits and inconsolable crying are
common. Seizures occur in about half the cases.
• Thereafter, a period of apparent stability lasts for decades.
Additional neurological abnormalities such as spastic paraparesis
(paralysis and spasticity of legs) and epileptic seizures may occur.
• Girls typically survive into adulthood - mortality rate of 1.2%/year
amongst children with Rett’s. 26% of the deaths are sudden and
associated with a heart conduction problem (abnormally prolonged
QT interval on the ECG)
Aetiology
• Mutation in the MECP2 gene on
chromosome Xq28 – could be
new or inherited (from parent
who has somatic or germline
mosaicism with the MECP2
mutation)
• Atypical Rett’s is found in patients
previously diagnosed with autism,
mild learning disability, and
mental retardation with spasticity
or tremor.

Contents
22

1.3 Asperger’s Syndrome (1/2)
• A neuro-developmental disorder, that is towards the milder, higher-functioning
end of the Autism spectrum, and effects an individual’s behaviour, use of
language and communication and pattern of social interactions.
• People with Asperger’s have:
• Normal to above-average intelligence
• Difficulties with behaviour, language and communication, and social
interactions.
• Pervasive, absorbing interests in special topics
23
Discovery and Recognition
• Named after Dr. Hans Asperger who first described the condition in 1944
giving the example of four ‘little professors.’
• The boys showed “a lack of empathy, little ability to form friendships,
one-sided conversation, intense absorption in a special interest, and
clumsy movements.”
• There is debate about whether it should be regarded as a specific entity
or a high-functioning form of Autism.
• APA included Asperger’s Syndrome as a specific entity in DSM IV, 1994.

1.3 Asperger’s Syndrome (2/2)
24
Positive Characteristics
Many experts consider Asperger’s Syndrome
to be a different, not necessarily defective,
way of thinking.
Positive characteristics of people with Asperger
syndrome have been described as beneficial in
many professions:
• Increased ability to focus on details
• Capacity to persevere in specific interests
without being swayed by others’ opinions
• Ability to work independently
• Recognition of patterns that may be missed
by others
• Intensity
• Original way of thinking.
Symptoms
Symptoms can begin as early as infancy, and include:
1. Lack of social awareness
2. Lack of interest in socialising/making friends
3. Difficulty making and sustaining friendships
4. Inability to infer the thoughts, feelings, or emotions of
others
5. Either gazing too intently or avoiding eye contact
6. Lack of changing facial expression, or use of
exaggerated facial expressions
7. Lack of use or comprehension of gestures
8. Failure to respect interpersonal boundaries
9. Unusually sensitive to noises, touch, smell, tastes, or
visual stimuli
10. Inflexibility and over-adherence to or dependence on
routines
11. Stereotypes and repetitive motor patterns such as hand
flapping or arm waving
Prevalence
• 2.5 out of every 1000 children with Autism
• 5 boys to every 1 girl

Contents
25

1.4 Childhood Disintegrative Disorder (CDD) (1/2)
26
Progression
• Normal development until ages 2-4
• Followed by severe loss of social,
communication, play and motor
skills.
• Loss of developmental milestones may
occur abruptly over few days to
weeks or gradually over an extended
period
• Occurence is later than autism, loss of
skills is more dramatic
Symptoms
Dramatic loss of previously acquired skills in two or more of
the following areas:
1. Language - a severe decline in the ability to speak and
have a conversation
2. Social skills - significant difficulty relating to and
interacting with others
3. Play - loss of interest in imaginary play and in a variety
of games and activities
4. Motor skills - dramatic decline in the ability to walk,
climb, grasp objects and other movements
5. Bowel or bladder control - frequent accidents in a child
who was previously toilet-trained
Lack of normal function or impairment also occurs in at
least two of the following three areas:
1. Social interaction
2. Communication
3. Repetitive behaviour & interest patterns
Prevalence
• Far lesser than Autism
Definition
Also known as Heller’s Syndrome, CDD is
a condition in which children develop
normally until ages 2 to 4 but then
demonstrate a severe loss of social,
communication and other skills.

1.4 Childhood Disintegrative Disorder (CDD) (2/2)
27
Aetiology
• No known cause of childhood
disintegrative disorder
• Likely a genetic basis for autism
spectrum disorders - an abnormal gene
is switched on in the early stages of
development, before birth. This gene
affects other genes that coordinate a
child’s brain development.
• Environmental exposure may
contribute to these effects, such as to a
toxin or infection.
• Autoimmune response may also play a
role in the development of childhood
disintegrative disorder. In an
autoimmune response, body’s immune
system perceives normal body
components as foreign and attacks
them.
Co-morbidity
CDD often occurs along with other conditions,
including:
• Tuberous sclerosis: A condition where non-
cancerous (benign) tumours grow in the brain.
• Lipid storage diseases: A rare group of
inherited metabolic disorders where a toxic
build up of excess fats (lipids) occurs in the
brain and nervous system.
• Sub acute sclerosis panencephalitis: A
chronic infection of the brain caused by a
form of the measles virus that results in brain
inflammation and the death of nerve cells.
It is unknown whether these conditions play a
role in triggering childhood disintegrative
disorder or share genetic/environmental risk
factors.

Contents
28

1.5 PDD not Otherwise Specified (PDD–NOS) (1/2)
• Also called atypical autism - individuals with the disorder exhibit some
but not all of the same symptoms associated with ‘classic autism’
• “not otherwise specified,” indicates that an individual’s symptoms are
non-specific. meaning that they differ from symptoms characteristic
of other pervasive developmental disorders, such as Rett’s syndrome
and childhood disintegrative disorder.
• It is a neurobiological disorder characterised by impairment in social
interaction and abnormalities in either communication, or behaviour
patterns and interests.
29
Prevalence
• 4 boys for every 1 girl
• Overall prevalence remains unclear because of the
varying clinical definitions used for diagnosis. Children
who have some symptoms of autism, not enough for a
definitive diagnosis, are often diagnosed with PDD-NOS.

1.5 PDD not Otherwise Specified (PDD–NOS) (2/2)
30
Treatment
• consists primarily of behavioural therapy
• some children may require the administration
of medications to stabilize mood or
behaviour
Progression
• Normal development for most children till
age of three after which an unusual delay
in the development of social abilities and
other symptoms associated with PDD-NOS
appear.
• The pattern in which symptoms manifest
and the behaviours displayed by affected
children vary widely.
Symptoms
• Include gaze avoidance, lack of expressive
facial responses, irregularities in speech,
repetitive and obsessive behaviours, and
delayed development of motor skills.
• The incidence of severe intellectual disability
in PDD-NOS patients is low relative to other
pervasive developmental disorders.
Aetiology
• Precise cause of PDD-NOS is not known
• Abnormalities in certain structures and in
neuronal pathways in the brain may play a
role
• Underlying genetic defects may be a
cause

Contents
31

Psychopathology >> Childhood Mental Disorders >> Attention Deficit Hyperactivity Disorder
2. Attention Deficit Hyperactivity Disorder
32
ADHD is characterised by:
• Inattention: difficulty staying focused and paying attention
• Hyperactivity: over-activity
• Impulsivity: difficulty controlling behaviour
It is normal for all children to be inattentive, hyperactive or impulsive sometimes, but for children
with ADHD, these behaviours are more severe and more frequent. Some symptoms of ADHD
are present in many kids, others are rarely present unless people have disabling ADHD.
It is one of the most common childhood disorders which can continue through adolescence and
adulthood.
Type of ADHD
Symptoms and signs of
attention deficit
Symptoms and signs of
hyperactivity-impulsiveness
1. Attention Deficit Disorder
(ADD) or ADHD without
hyperactivity
Yes No
2. ADHD hyperactive-
impulsive type
No Yes
3. Combined type/ ADHD Yes Yes

2. ADHD – Symptoms (1/3)
33
Inattention
Six or more of the following symptoms of inattention must persist for at least six months to
a degree that is maladaptive and inconsistent with the developmental level.
• Often fails to give close attention to details or makes careless mistakes in schoolwork,
work, or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or
duties in the workplace (not due to failure to understand instructions)
• Often have difficulty organising tasks and activities
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental
effort (such as schoolwork or homework)
• Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils,
books, or tools)
• Often easily distracted by extraneous stimuli
• Often forgetful in daily activities

34
Hyperactivity-Impulsiveness
• Six or more of the following symptoms must persist for at least 6 months to a degree that is
maladaptive and inconsistent with the developmental level.
• Often fidgets with hands or feet or squirms in seat
• Often leaves seat in classroom or in other situations in which remaining seated is expected
• Often runs about or climbs excessively in situations in which it is inappropriate (in
adolescents, this may be limited to subjective feelings of restlessness)
• Often has difficulty playing or engaging in leisure activities quietly
• Often “on the go” or often acts as if “driven by a motor”
• Often talks excessively
• Often blurts out answers before questions have been completed
• Often has difficulty awaiting turn
• Often interrupts or intrudes on others (e.g., butts into conversations or games)
• Some hyperactive-impulsive or inattentive symptoms that caused impairment were present
before age 7 years.
• Some impairment from the symptoms is present in two or more settings (e.g., at school and
at home)
• There must be clear evidence of clinically significant impairment in social, academic or
occupational functioning

35
Other peculiar challenges faced by ADHD children
Recent studies have shown that people with ADHD have some interesting problems beyond the
expected symptoms. These include:
Clumsiness
• Children with ADHD tend to fall down and tip over things accidentally more than normal
children. They have worse fine motor skills than other children. This is partly the reason that
people with ADHD have more accidents, have poorer handwriting, and always seem to be
spilling things.
• This poor coordination predicts a poor outcome as adults - children who have marked
coordination problems and ADHD are much more likely to have trouble with the law, reading
problems, work difficulties and substance abuse problems as adults.
Problem in Time perception
• To be coordinated and get things done, we need to have a stable internal clock.
• People with ADHD have much more difficulty figuring out how much time has really passed
either in the short term (while trying to coordinate a movement) or in the long term (trying to
decide how fast to work to get something done in a certain time frame).
• This inability to judge time can improve with medication.

2. ADHD - Aetiology
ADHD likely results from a combination of factors. The causes being researched include:
36
1. Biological Factors
• MRI scans highlight some differences in
brains:
• parts of the base of the brain
associated with attention are smaller on
the right in people with ADHD
• part of the brain that connects the left
and right front of the brain has also
been found to be smaller
• decreased activity in the front parts of
the brain in ADHD
• the brain is not as efficient in ADHD
when doing certain tasks and rather
than being able to use a small part of
the brain, a larger part must be used.
• Genes:
• ADHD often runs in families.
• Children with ADHD who carry a
particular version of a certain gene
have thinner brain tissue in the areas of
the brain associated with attention
• Brain injuries:
• Children who have suffered a brain
injury may show some behaviour similar
to those of ADHD.
2. Environmental Factors
• Studies suggest a potential link between
cigarette smoking and alcohol use during
pregnancy and ADHD in children
• In addition, preschoolers who are
exposed to high levels of lead, which can
sometimes be found in plumbing fixtures
or paint in old buildings, may have a
higher risk of developing ADHD
3. Food Habits
• Sugar: The idea that refined sugar
causes ADHD or makes symptoms worse
is popular, but more research discounts
this theory than supports it.
• Food additives: Recent British research
indicates a possible link between con-
sumption of certain food additives like
artificial colours or preservatives, and an
increase in activity

Contents
37

Psychopathology >> Childhood Mental Disorders >> Other Childhood Psychopathologies
3.1 Oppositional Defiant Disorder (ODD)
38
Diagnosis
• ODD is diagnosed when a child has a persistent or consistent pattern of disobedience
and hostility toward parents, teachers, or other adults for at least 6 months.
• The primary behavioural difficulty is the consistent pattern of refusing to follow
commands or requests by adults.
• Children with ODD:
• can be touchy, easily annoyed or angered, resentful, spiteful, or vindictive.
• repeatedly lose their temper, argue with adults, refuse to comply with requests,
rules and directions, and blame others for their mistakes. Stubbornness and
testing limits are common, even in early childhood - deliberately annoy other
people.
• The criteria for ODD are met only when:
• Problem behaviours are more frequent in the child than others of same age
and developmental level.
• Behaviours cause significant difficulties with family and friends
• Oppositional behaviours are the same both at home and in school.
• ODD is not diagnosed if the problematic behaviours occur exclusively with a mood or
psychotic disorder.
Comorbidity
When ODD is present with
ADHD, depression, Tourette’s,
anxiety disorders, or other
neuropsychiatric disorders, it
makes life with that child far
more difficult.
ODD may be a precursor of
conduct disorder.
Oppositional
Defiant
Disorder
ODD is a recurrent pattern of negativistic, defiant, disobedient, and hostile behaviour
towards authority figures (parents, teachers, or other adults.)

3.2 Conduct Disorder
39
Comorbidity
Coexisting conditions may include mood
disorders, anxiety, PTSD, substance abuse, ADHD,
learning problems, or thought disorders
Aetiology
Factors may include brain damage, child abuse, genetic
vulnerability, school failure, and traumatic life
experiences.
Importance of Treatment
• Children with these behaviours should receive a
comprehensive evaluation.
• Youngsters with conduct disorder are likely to have
ongoing problems if they and their families do not
receive early and comprehensive treatment.
• Without treatment, many of them are unable to adapt
to the demands of adulthood and continue to have
problems with relationships and holding a job.
• They often break laws or behave in an antisocial
manner.
Symptoms
Children and adolescents with this disorder have
great difficulty following rules and behaving in a
socially acceptable way, they may –
• Exhibit aggression to people and animals
• Destroy property
• Deceit and lie
• Steal
• Violate rules in serious ways
Conduct
Disorder
• It refers to a group of behavioural and emotional problems in youngsters that include
great difficulty in following rules and behaving in a socially acceptable way.
• They are often viewed by other children, adults and social agencies as “bad” or
delinquent, rather than mentally ill.

3.3 Separation Anxiety Disorder
40
Aetiology
Separation anxiety is related to
separation or impending separation
from the attachment figure (e.g.,
primary caretaker, close family
member) occurring in children
younger than 18 years and lasting for
at least 4 weeks.
Symptoms
• Clinically significant symptoms of anxiety - severe distress or
impairment of function
• unrealistic worries about the safety of loved ones,
• reluctance to fall asleep without being near the primary
attachment figure,
• excessive distress (tantrums) when separation is imminent,
• nightmares with separation-related themes and homesickness.
• In addition, physical/somatic symptoms (especially frequent in
older children and adolescents), such as dizziness, light
headedness, nausea, stomach ache, cramps, vomiting, muscle
aches, or palpitations, may be present and problematic, causing
the child and family to seek medical treatment because of
impaired ability to attend school or meet social responsibilities.
Separation
Anxiety
Disorder
Separation anxiety is a fairly common anxiety disorder that consists of excessive anxiety of
separation or impending separation from the attachment figure (e.g., primary caretaker,
close family member.) The anxiety is beyond that expected for the child’s developmental
level.

3.4 Tic Disorders
41
• They can be stopped voluntarily for brief periods.
• Most tics are mild and hardly noticeable. However, in some
cases they are frequent and severe, and can affect many
areas of a child’s life. Teachers or others may notice the tics
and wonder if the child is under stress or “nervous.”
Treatment
• Treatment for the child with a tic disorder may
include medication to help control the symptoms.
• The child and adolescent psychiatrist can also
advise the family about how to provide emotional
support and the appropriate educational
environment for the youngster.
Evaluation & Diagnosis
Through a comprehensive evaluation,
often involving pediatrician and/or
neurologic consultation, a child and
adolescent psychiatrist can determine
whether a youngster has Tourette’s
Disorder or another tic disorder.
Tic Disorder
• A tic is a problem in which a part of the body, such as face, shoulders, hands,
legs etc., moves repeatedly, quickly, suddenly and uncontrollably.
• Sounds, such as throat clearing, made involuntarily are called vocal tics.

3.4.1 Types of Tic Disorders
42
Transient Tic Disorder
• Prevalence
• Most common tic disorder
affecting up to 10% of children
during the early school years.
• Prognosis
• Transient tics go away by
themselves, though, some
may get worse with anxiety,
tiredness, and some
medications.
Chronic Tics
• Tics which do not go away and
last one year or more.
• May be related to Tourette’s
Disorder.
• Prevalence
• Affect less than 1% of children
Tourette’s Disorder
• Symptoms
• Children have both body and
vocal tics (throat clearing).
• They may also have
problems with attention, and
learning disabilities. They
may be impulsive, and/or
develop obsessions and
compulsions.
• Sometimes they may blurt
out obscene words, insult
others, or make obscene
gestures or movements.
They cannot control these
sounds and movements.
Punishment by parents and
teachers, and teasing by
classmates will not help the
child to control the tics but will
hurt the child’s self-esteem
and increase their distress.
• Some tics disappear by early
adulthood, and some continue.

3.5 Childhood Depression
43
• Childhood depression is different from the
normal mood shifts and everyday
emotions that occur as a child develops -
just because a child seems depressed or
sad does not mean they have depression.
• If symptoms become persistent, disruptive
and interfere with social activities,
interests, schoolwork and family life, it
may indicate that he or she is suffering
from the medical condition depression.
Symptoms
• The symptoms in children vary. Early medical studies focused on “masked”
depression, where a child’s depressed mood was evidenced by acting out or angry
behaviour. This occurs particularly in younger children.
• Many children display sadness or low mood similar to adults who are depressed.
• The primary symptoms of depression revolve around sadness, a feeling of
hopelessness, and mood changes and may include:
• Irritability or anger
• Continuous feelings of sadness, hopelessness
• Social withdrawal
• Increased sensitivity to rejection
• Changes in appetite (either increased or decreased)
• Changes in sleep(sleeplessness or excessive sleep)
• Vocal outbursts or crying
• Difficulty concentrating
• Fatigue and low energy
• Physical complaints, such as stomach aches and headaches, that do not respond
to treatment
• Reduced ability to function during events and activities at home or with friends, in
school, extracurricular activities, and in other hobbies or interests
• Feelings of worthlessness or guilt
• Impaired thinking or concentration
• Thoughts of death or suicide
• Not all children have all these symptoms - most will display different symptoms at
different times and in different settings.
Prognosis
• Although some children may continue to
function reasonably well, most kids with
significant depression:
• will suffer a noticeable change in social
activities, loss of interest in school and
poor academic performance, or a
change in appearance.
• may begin using drugs or alcohol,
especially if they are over the age of 12.

Contents
44

Psychopathology >> Childhood Mental Disorders >> Mental Retardation
4. Mental Retardation - Overview
45
• Intellectual functioning level is determined
by standardised tests that measure the
ability to reason in terms of mental age
(intelligence quotient or IQ). MR is defined
as IQ score below 70-75.
• Adaptive skills are the skills needed for
daily life. They include the ability to
produce and understand language
(communication); home-living skills; use of
community resources; health, safety, leisure,
self-care, and social skills; self-direction;
functional academic skills (reading, writing,
and arithmetic); and work skills.
Prognosis
• Time of onset depends on the suspected cause of the disability:
• Mental retardation begins in childhood or adolescence before the
age of 18.
• Symptoms may appear at birth or later in childhood.
• Cases of mild mental retardation may not be diagnosed before
the child enters preschool. These children typically have difficulties
with social, communication, and functional academic skills.
• Children who have a neurological disorder or illness, such as
encephalitis or meningitis may suddenly show signs of cognitive
impairment and adaptive difficulties.
• Mentally retarded children reach developmental milestones such
as walking and talking much later than the general population, if
at all.
• In most cases, it persists throughout adulthood.
• Attempt can be made to help the individual develop adaptive skills
to the degree permitted by his/her level of retardation
Mental
Retardation
Mental retardation refers to an individual’s intellectual functioning level well below average and
significant limitations in two or more adaptive skill areas.
Comorbidity
Aggression, self-injury, and mood disorders are
sometimes associated with the disability

4. Mental Retardation – Classification
46
Mild mental
retardation
IQ = 50-75
• Approx. 85% of MR cases
• Can often acquire
academic skills up to the
6th grade level
• Can become self-
sufficient and in some
cases live
independently, with
community and social
support.
Moderate mental
retardation
IQ = 35-55
• Approx. 10% of MR cases
• Can carry out work and
self-care tasks with
moderate supervision.
• Can acquire
communication skills in
childhood and are able
to live and function
successfully within a
supervised environment
such as a group home.
Severe mental
retardation
IQ = 25-40
• Approx. 3-4% of MR
cases
• May master very basic
self-care skills and
some communication
skills.
• Many severely retarded
individuals are able to
live in a group home.
Profound mental
retardation
IQ = 20-25
• Approx. 1-2% of cases
• Often caused by an
accompanying
neurological disorder.
• May develop basic self-
care and comm. skills
with support and
training.
• Need a high level of
structure and
supervision.
Depending on the level of functioning of the individual (severity) APA’s DSM classifies MR as:
Intermittent Support
• Support needed only
occasionally, perhaps
during times of stress
or crisis.
• Required for most mildly
retarded individuals.
Limited Support Extensive Support
Pervasive/Life-long/
Daily support
• Required for profoundly
retarded individuals.
American Association on Mental Retardation (AAMR) classification system focuses on the capabilities of the retarded
individual, instead of the limitations. It is also seen by some experts as mirroring the DSM classification levels. Depending on
the level of support required AAMR classifies MR as:

4. Mental Retardation – Aetiology (1/2)
47
In about 35% of cases, the cause of mental retardation cannot be found. Biological and environmental
factors that can cause mental retardation include:
Causes of
MR
1
Genetics
(Hereditary
factors)
2
Prenatal
illnesses and
infections
3
Birth defects
4
Childhood
illnesses,
infections and
injuries
5
Environmental
factors
The severity of the symptoms
and the age at which they first
appear depend on the cause.
• If retardation is caused by
chromosomal or other genetic
disorders, it is often apparent
from infancy.
• If retardation is caused by
childhood illnesses or injuries,
learning and adaptive skills
that were once easy may
suddenly become difficult or
impossible to master.

4. Mental Retardation – Aetiology (2/2)
48
1. Genetics - Hereditary factors
• About 5% of MR cases
• caused by an inherited abnormality of the genes, such as
fragile X syndrome - a defect in the chromosome that
determines sex. It is the most common inherited cause of MR.
• Single gene defects such as phenylketonuria (PKU) and
other inborn errors of metabolism may also cause MR if they
are not found and treated early.
• An accident or mutation in genetic development may also
cause retardation. Example:
• development of an extra chromosome 18 (trisomy 18)
• Down syndrome/ mongolism/ trisomy 21 is caused by an
abnormality in the development of chromosome 21. It is
the most common genetic cause of MR.
2. Prenatal illnesses and infections
• Fetal alcohol syndrome affects one in 600 children in the United States.
• Caused by excessive alcohol intake in the first 12 weeks (trimester) of
pregnancy. Even moderate alcohol use during pregnancy may cause
learning disabilities
• Drug abuse and cigarette smoking during pregnancy have also been
linked to MR.
• Maternal infections and illnesses such as glandular disorders, rubella,
toxoplasmosis, and cytomegalovirus infection
• When the mother has high blood pressure (hypertension) or blood poisoning
(toxemia), the flow of oxygen to the fetus may be reduced, causing brain
damage and MR
3. Birth defects
• Defects that cause physical deformities
of the head, brain, and central nervous
system.
• Example: Neural tube defect is a birth
defect in which the neural tube that
forms the spinal cord does not close
completely. This defect may cause
children to develop an accumulation of
cerebrospinal fluid on the brain
(hydrocephalus). Hydrocephalus can
cause learning impairment by putting
pressure on the brain.
4. Childhood illnesses, infections and injuries
• Hyperthyroidism, whooping cough, chickenpox,
measles and Hib disease (a bacterial infection)
may cause mental retardation if they are not
treated adequately.
• An infection of the membrane covering the
brain (meningitis) or an inflammation of the
brain itself (encephalitis) causes swelling that in
turn may cause brain damage and mental
retardation.
• Traumatic brain injury caused by a blow or a
violent shake to the head may also cause brain
damage and mental retardation in children.
5. Environmental factors
• Ignored or neglected infants who are
not provided the mental and physical
stimulation required for normal
development may suffer irreversible
learning impairments.
• Children who live in poverty and suffer
from malnutrition, unhealthy living
conditions, and improper or
inadequate medical care are at a
higher risk.
• Exposure to lead can also cause
mental retardation. Many children have
developed lead poisoning by eating the
flaking lead-based paint often found in
older buildings.

4. Mental Retardation - Diagnosis
49
If mental retardation is suspected, a comprehensive physical examination and
medical history should be done immediately to discover any organic cause of
symptoms.
• A complete medical, family, social, and educational history is compiled from existing
medical and school records (if applicable) and from interviews with parents.
• Conditions such as hyperthyroidism and PKU are treatable. If these conditions
are discovered early, the progression of retardation can be stopped and, in some
cases, partially reversed.
• If a neurological cause such as brain injury is suspected, the child may be referred
to a neurologist or neuropsychologist for testing.
• Children are given intelligence tests to measure their learning abilities and
intellectual functioning.
• Such tests include the Stanford-Binet Intelligence Scale, the Wechsler
Intelligence Scales, the Wechsler Preschool and Primary Scale of Intelligence,
and the Kaufmann Assessment Battery for Children.
• For infants:
• Bayley Scales of Infant Development may be used to assess motor,
language, and problem-solving skills.
• Interviews with parents or other caregivers are used to assess the child’s
daily living, muscle control, communication, and social skills. The
Woodcock-Johnson Scales of Independent Behaviour and the Vineland
Adaptive Behaviour Scale (VABS) are frequently used to test these skills.

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