Emotional Disorders and

Problems Associated with

Physical Illness

Dr Alyson Hall
Consultant Child and Adolescent
Psychiatrist
 Emotional Disorders and Problems
Associated with Physical Illness:
Summary

1. Emotional Disorders
2. Bereavement, Separation and Loss
3. Problems Associated with Physical illness
4. Epilepsy
5. HIV
6. Elimination disorders
7. Eating disorders
8. Treatment approaches
9. Nurses Role in Prevention and Management of
Childhood Psychiatric Disorders
 1. Emotional Disorders

Disturbances of mood, persistent and not

in response to a single identified stressor
Disabling
Anxiety and fearfulness, phobias
School related anxiety, school phobia
Obsessive compulsive disorder
Depression
 Emotional Disorders - symptoms
Sleep or appetite problems, deterioration in school work, irritability or mood
swings

Anxiety
Fears – separation anxiety, social anxiety, specific phobias
Unexplained symptoms, headache, pains
Tense or fidgety
Obsessions or rituals (OCD)

Depression
Lack of pleasure, loss of interest, hopelessness,
Despair,
Sadness,
Tearfulness, lack of energy
Withdrawn

Anxious children often become depressed when they get older especially when
a parent is depressed
Emotional Disorders – risk factors
Boys= girls but adolescent girls especially at risk
No association with socio-economic status
Quiet, compliant or anxious temperament
No specific educational problems
Family factors – overprotection, harsh, inconsistent
parenting, parental anxiety or stress
Family history of mental illness, especially anxiety or
depression
Insecurity due to family conflict, bereavement, parental
illness or separation
Bullying or educational difficulties
Traumatic experiences
 School non- attendance
School refusal ( separation anxiety)
Child kept at home by parent e.g. because
of parent’s ill health, care for siblings
Fear of school ( e.g. bullying)
Truancy- conduct disorder, generally with
peers, educational difficulties or ADD
common,
 Adjustment disorders
Distress and emotional disturbance arising
in a period of adaptation to a significant life
change
Often improve without treatment but more
rapidly with treatment
Consequence of a stressful life event
 Bereavement
 Divorce
 Physical illness
 2. Bereavement, Separation and Loss
Children react to distress of those they are close to
Consider age and understanding
Consider relationship with child and circumstances of the death
Children can be worried, angry or sad but their feelings may show in
their behaviour e.g. nightmares, irritability, regression
May avoid talking to avoid upsetting adults
Child may be insecure and fear other separations
Child may have to move with loss of other relationships, friends,
school

Immediate Management
Ensure children are prepared for death before person dies
Tell them the facts as soon as possible
Should be fully involved in wake and funeral if want to
Need photographs and other reminders
Find ways to say goodbye e.g. visit grave, prayers, candles, letters
Encourage child to talk about the person over time as symptoms of
bereavement may persist
 Prolonged Response to Bereavement,
Separation and Loss

Further treatment required when symptoms persist:

Continued depression with loss of interest in activities or events

Deterioration of school performance or attendance
Poor sleep, appetite, over- eating
Unexplained physical symptoms
Persistent regression, fear of being alone
Denial that relative has died or imitating the dead person
Wanting to join the dead person
Withdrawal from friends
Consider how parent or family members are coping

May require individual therapy or group for bereaved children

3. Problems Associated with Physical
illness
How common are mental health problems with
physical illness?
Presentation of Child Psychiatric problems in
healthcare settings
Long term effects
Management

Medically unexplained symptoms

Prevalence
Aetiology
Effects
Management
 Presentation of Child Psychiatric
problems in primary healthcare settings

Children with chronic physical illness are twice as likely to

suffer from emotional or behavioral problems, especially
with epilepsy and cerebral palsy

20-30% of GP consultations involve children

2% of child and adolescent GP consultations are for
behavioral or emotional symptoms

But.. concurrent psychiatric disorders are present

- in over 20% of school children attending general
practice or paediatric clinics
- in over 30% of adolescents attending GPs
Prevalence (%) of psychiatric disorders in
children and adolescents
General Population and General Practice

40
35
30
25
20 Children
15 Adolescents
10
5
0
Gen Pop GP
 Long term effects of Problems
Associated with Physical illness

Child has fewer opportunities to learn skills affecting their

development and to develop friendships through play
School absence may contribute to learning problems
Child feels different from other children and may be
frustrated and resentful
Stigma (especially epilepsy, HIV) and risk of rejection or
bullying
Depression
Overprotection and limitation of opportunities because of
risk e.g. epilepsy, diabetes
Parents may indulge child and not set limits
Siblings can feel neglected, embarrassed, or over
responsible
 Management of Problems Associated
with Physical illness
General
The child and family should live as normal a life as possible
Help the parents to be open about the child’s difficulties with him
and siblings
Restrict the child as little as possible and encourage independence
Encourage social activities with peers
Help the parents to be firm when the child makes inappropriate
demands or misbehaves
Help siblings to understand the illness, express their feelings and
ensure their needs are not overlooked

Specific
Assess for depression and learning problems which may be
overlooked
Individual or family therapy for persistent depression or behaviour
problems
Ensure the child receives education and extra help for learning
problems which may be exacerbated by missing school
 Medically unexplained symptoms
Prevalence
10% of children have physical symptoms for which no cause has been
found
Commonest: headache, abdominal pain, tiredness, sore muscles,
vomiting, food intolerance

Aetiology
Generally associated with anxiety
Common in families where other family members have ill health, many
physical symptoms or high anxiety especially about health
Child may be under pressure, have experienced trauma or feel
stressed
Child may be sensitive to physical symptoms and pain
Child may be sensitive to others, worry a lot or be obsessive or
perfectionist
Child worries about the symptoms and effects on life especially at
school
May begin following a physical illness keeping the child away from
school or after a separation or illness in a family member
 Effects of Medically Unexplained
Symptoms

Child feels increasingly distressed

Child may miss school and underachieve
Peer relationships suffer, social isolation
Overprotection and failure to develop
appropriate maturity and independence
Parents become stressed and anxious
Family may become dominated by child’s
symptoms
Extreme cases: chronic fatigue syndrome
Management of medically unexplained
symptoms
Generally assist the child to cope with the
symptoms and re-establish a daily routine
Help family to be positive and ignore symptoms
Ensure school attendance and develop social
activities
Identify any educational problems
Encourage child to do more for himself,
independence and confidence
Additional treatment if the child continues to
suffer from anxiety or depression
Family therapy
 4. Epilepsy
Psychiatric problems are very common in children with
epilepsy
Children have problems e.g. hyperactivity, impulsivity
associated with brain pathology
Epilepsy is more common in children with developmental
delay, autism, head injury, cerebral palsy
Behaviour problems are associated with autism, head
injury, cerebral palsy and learning difficulties
Effects of stigma
Effects of overprotection, rejection or over-indulgence by
family
Some anticonvulsants improve psychiatric symptoms
 Carbamazepine for ADHD, mood stabiliser
 Sodium valproate – mood stabiliser
 Lamotrigine for persistant depression
 Prevalence of psychiatric
disorders in school children:
medical settings
40
35
30
Gen Pop
25
GP
20
Paed
15 Severe illness
10 Brain involved
5
0
% Schoolchildren
 5. HIV
Children are more likely than adults to present with
cerebral disease which can present with
developmental delay or behaviour problems
Dementia has unpredictable onset in children from 2-
3years to many years after becoming ill
When child has illness such as measles or TB they may
fear it is due to AIDS whether they are HIV positive or
not
Physically unexplained symptoms secondary to anxiety if
child is HIV positive or has relative with AIDS
Psychosis can occur with AZT combination treatments
When do you test? If have access to treatment/ what
about prevention?
When do you tell a child about mother or father being
affected or the and cause of death in relatives
Management of infection risk and sexuality in
adolescents
 6. Elimination disorders: enuresis

Bedwetting (nocturnal enuresis)

Most children become dry between 2-5 years
Children with developmental delay or family history may
have primary enuresis (never dry)
Children may wet early in the night when over tired and
sleep deeply
Children may wet when unwell or coping with change
e.g. starting school, birth of sibling
Secondary enuresis which persists may be associated
with more severe problems e.g. abuse
Child should not be blamed or punished
 Management of enuresis
Nocturnal enuresis
Avoid fluids before bed
Enough sleep
Take to toilet before wets
Be positive about dry nights
Star chart
Bell and pad- best results
Anti diuretic hormone-spray or tablets (expensive)

Day time wetting

Common when children start school
Reward for being dry, do not criticise
Reminders or rewards for using toilet
Rule out infection with MSU if persistent
 Elimination disorders: encopresis
1% children affected, boys more than girls
Most toilet trained by 4 years, occasional soiling in young
children if stressed e.g. being bullied
Failure to toilet train with developmental delay or autism
May be associated with hiding or smearing faeces in
very disturbed children
Commonest causes
 Constipation with overflow, use stool softeners, enemas,
improve diet, increase fluids
 Failure to develop toileting routine, reluctance to use toilet, pain
associated with fissures
 Severe distress following trauma or abuse
Management
 Do not punish, reward success
 Examine for and treat constipation
 If persistent refer for additional treatment, rule out abuse
 7. Presentation of eating disorders in
primary care
Anorexia Bulimia Obesity
nervosa nervosa

<1% adolescents ?>1%,older >20% increasing

1male:10 females ?? 1:10 ?1:1, variable
<85% mpmw normal weight >125% mpmw

ANOREXIA RECOVERY
POST PUBERTAL FEMALE
?OBESE
BULIMIA CHRONICITY
 Risks of Obesity

Inactivity Diabetes
Erratic inconsistent Respiratory problems
diet Poor hygiene
Inappropriate foods Orthopaedic
Secret eating problems
Food battles Complications of
surgery
Low self esteem
Cardiovascular
Bullying disease
Depression Hypertension
Social withdrawal
Overprotection
Prevention in of eating disorders in
young people
Infancy and early childhood
Fussy eaters
Managing over weight children
Adolescent growth spurt
Development of regular feeding pattern
Teenage dieters Delay introduction of solids, sugars, fats
Range of tastes, drop the bottle
Avoiding food battles
Sufficient carbohydrate
Healthy eating and exercise not diets
Treat emotional problems
Teenagers need to eat lots
Height matters more than gender
Average girl 16years- 5ft4in 57Kg >9st
5ft7in 68Kg >10st
 Which of these may be a disorder?

A 3-year-old soiling during the day

A 7-year-old soiling during the day

Frequent temper tantrums aged 2

Frequent temper tantrums aged 10

Severe anxiety at leaving mother when starting

school aged 3
Severe anxiety at leaving mother at secondary
school gate aged 11
 Psychological Treatment
Approaches
Big area
Developing area
Group and individual approaches
General to specialised
Examples
 Psychoeducation, normalising
 Behaviour Therapy
 Psychotherapy e.g. Cognitive Behaviour Therapy
 Psycho-education

Normalising “Given what you have been

through, it makes sense.”
Refining assessment “This is what other people
have experienced. Is it different for you?”
Help family understanding “Who else should see
this factsheet?”
Lots of other people have had difficulties like
this. Even David Beckham!
 Behaviour therapy

Key work from Behaviour Theorists Skinner and

Pavlov involving conditioning

Behaviour therapy – assumes that overt

behaviour can be changed by working with
antecedents and consequences (ABC)

Aims to increase desired behaviours and

reduced undesired ones
Behaviour Therapy – Implications
for parents and clinicians
Clear and fair rules for behaviour are outlined

Emphasis is placed on rewarding desired behaviour, and

looking for patterns

Unwanted behaviour is reduced by non-reinforcement

(i.e. ignoring) or by encouraging behaviour that is
incompatible with the unwanted one

Challenging/difficult behaviours may require some

monitoring forms
 Implications of Behaviour
Therapy
Importance of:

 House/ward rules
 Family consistency/staff consistency
 Modeling
 Clear/fair boundaries
 Cognitive Behavioural Therapy

It is not events in themselves that matter, but the

meaning of these events to the individual. The
‘same’ event can have different emotional
consequences depending on the interpretation

For example: If you miss the bus to school you

could feel happy, annoyed, upset. Why?
 CBT
At the heart of a CBT approach is the idea
that we can alter how we feel by noticing
and changing what we think and what we
do

Can provide a model of problem

development, as well as a way to
understanding what is happening right now
 CBT
Understanding a difficult feeling or
behaviour

Trigger

Thoughts
Behaviour Emotions

Body
 Family Therapy
A presenting problem is seen as arising from the nature
of family relationships rather than its source being
located in any one individual - SYSTEMIC APPROACH
At Butabika, the ward team often replaces ‘the family
system’.

So patients symptoms are understood in context with

family communication patterns in relationships +
community relationships.

FT looks at symptoms not only in the person, but also

through wider influences of life-cycle –births, illness, age,
bereavement. And community effects of race, tribe,
stigma.
Systemic approaches in the ward, family or community
system address how symptoms/problems get ‘stuck’
with the patient, through difficult communication
patterns between people.

These then have a negative effect on the patients’

thoughts, feelings and behaviour if not addressed.

Symptoms perform a function for the family

e.g. Keeping the parents’ marriage together by
focussing on the child.

Or sustaining enmeshed dyad relationships that

marginalise other family members
E.G – Mrs Smith thought her youngest son
Jimmy always had something wrong with
him since birth. His grandmother said he
had ‘the evil eye’ . He was often clumsy
and getting into trouble. (Cause/effect in
beliefs affects behaviour).

Mrs Smith saw his older brother - Sam as

‘sailing through life’, compared to Jimmy
who could never be good enough in his
mother’s eyes.
Wider Context –

His mother was depressed + felt

isolated from friends + family. The
father had lots of friends + family
nearby so to cope with her feelings
of loneliness it was as if she needed
to keep Jimmy close, by always
having to help him out of his
troubles. When he developed
psychotic symptoms, she felt good
about herself, because she was
needed again.
Family or Systemic Interventions
explore how particular beliefs about the problem may be
helpful to solve it or even keep a patient unwell/in sick role.

What life cycle events past or present influence the

problem/symptoms.
Developmental milestones, attachment relationship
patterns

Or traumatic memories/ experiences

How family beliefs or ‘myths’ are passed through
generations
how these evolve in renewed life cycle stages marriage,
birth to death,
Laitila says that if we don’t find ways of exploring the meaning of
people’s problems, including mental illness, as part of how they live
their lives at home and in the community, they are less likely to gain
healthy and confident lives and therefore more likely to become
mentally unwell again.

So by supporting families to support patients at Butabika, you will be

supporting them to return to be more fully part of their family and
community lives and less prone to the stigma that surrounds mental
illness, and more likely to stay well (1999:11)
 Family therapy

Focuses on the organization of and patterns in

family relationships

Generates ideas about how the family maintains

stability or copes with change
 feedback loops

 regulation and maintenance of organization

Therapist attempts to change family relationships

with a view to reducing problems and symptoms
 Family therapy: uses

Family relationship problems

 Chaotic families, scapegoating, criticism, separation
anxiety, psychosomatic problems

Used with behaviour therapy especially with

younger patients

Specific disorders:
 child behaviour problems
 anorexia nervosa
 substance misuse
 schizophrenia
 Family Therapy
Supportive, reduction of guilt, blame

For psychosomatic or very anxious families:

structural (Minuchin)
 Dealing with enmeshment, over-protectiveness rigidity,
and lack of conflict resolution
 Normalisation: avoid the sick role
 Age appropriate separation/individuation

Enmeshment Closeness Distance

Rigidity Flexibility Chaos
High EE Responsive Neglect
 Pharmacotherapy
Not used in most disorders

It is effective in some:
 ADD or Hyperkinetic disorder:
Methylphenidate

Obsessive-compulsive disorder:
SSRIs, clomipramine
 Depressive disorder:
Selective serotonin re-uptake inhibitors-SSRIs (e.g. fluoxetine)
 Psychoses :
Anti-psychotics (e.g. risperidone, olanzapine, chlorpromazine)
 Challenging behaviour in autism, mental retardation with no
obvious cause
Anti-psychotics (e.g. risperidone)
 Other therapies
Individual:
 play therapy

 psychodynamic psychotherapy

Group:
 parent management groups – Webster Stratton

 social skills groups for adolescents

 informal groups

 Psychodynamic group therapy

 6. Nurses Role in Prevention and
Management of Childhood Psychiatric
Disorders
In community services
In hospital
Needs assessment
Risk management
Physical health
Talking to the child
Observing the child’s behaviour
Assessing the child’s relationships, feelings
Consider play and education
Meeting the family
Specific treatments
 Role of nurse in community setting

Prevention:
providing advice in primary care, paediatrics, schools,
orphanages
Training parents, religious leaders, teachers
Identifying and referring parents with mental
health/drug/alcohol/learning difficulties/domestic violence

Assessment and treatment

Identifying children who require assessment
Identifying other health problems in child
Referral to clinic or hospital
Providing out patient treatment alone or with other
professionals
 Risk Assessment

Containment eg running away

Risk to self eg suicide, self harm, drug use
Risk to others eg aggression
Risk of abuse and neglect
Impairment of development
Disruption of education
Risk of placement breakdown
Risk of untreated illness
 Physical health

Assessment of height and weight (Xray for bone age)

Physical examination
Investigations
Need for treatment eg skin conditions, anaemia
Monitoring diet, fluid intake and weight
Monitoring sleep
Assist child to manage self care, hygiene
Administer any medication
Document observations and investigations in notes
Talking to the child and assessing the
child’s wishes, feelings and significant
relationships
Remain warm and non judgemental
Note what child tells you
Respond by direct questions
Reflect back and elicit feelings
Consider what child says/has said to different people
3 wishes
Observations of child’s reactions
-when parents come and leave
-to what parent says or does
-to other people
-when people are mentioned
-to issues raised
 Consider play and education
Can child play with other children?
Parallel play or cooperative play
Does child need to learn to share, take turns
Physical exercise – coordination
Child’s cognitive ability, educational level and
educational provision
Assist play and education individually or in a
group
Concentrate on literacy, numeracy and life skills,
and other learning through books and playing
games
Meeting and working with the family

Especially important in in-patient units

Essential to get to know child’s family and assess

relationships between parents and siblings

Parents attitude to child- warmth, limit setting, criticism,

visits, rejection, attitude to illness

Concerns about abuse or neglect

Child’s relationship with parents and attachment

 Specific treatments, ,
Nurses may be involved in family therapy,
behavioural programmes, individual and group
therapy
Nurses may need to administer and monitor
response to medication eg methylphenidate,
anti-psychotics, anti-convulsants, monitor
growth and report side effects
Nurses need to provide stimulation and
educational activities to promote development
In hospital or community child’s needs:
short and long term
Safety and protection
Containment: staff ratio, secure placement
To develop/maintain secure attachment (key worker for
continuity of care)
Quality of care: warmth, consistency, stimulation, limit
setting, sensitivity and continuity
Treatment : medication,individual, behavioural or family
therapy, residential therapeutic unit
Need for a home
Need for temporary admission or permanent placement
Need for contact with family, with whom?
Education: special education, day or residential, stability
 Contact details
Dr Alyson Hall
Honorary Consultant Child and Adolescent
Psychiatrist
East London Foundation NHS Trust
London, U.K

hallyandoli@doctors.org.uk