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Abstract
Childhood psychiatric services in the end of 1600’s were in the form of houses which collected poor and mentally ill children, they were called the almshouses. In the beginning of the 19th century the child guidance clinics were born, they provided services which are similar to those provided by child psychiatric outpatient clinics now, these clinics continued through the mid-century.
The first inpatient psychiatric units for children set up in the USA at the end of the World War I. As the gap increased between outpatient clinic services and inpatient management, Day-hospital unit for children were developed by Connel in 1961 for partial hospitalization.
WHO has estimated that by the year 2020 neuropsychiatric disorders will become one of the five most common causes of morbidity, mortality and disability among children. This is so distressing. However, appropriate identification and treatment of childhood mental disorders can reduce symptoms, improve adaptive functioning and serve as a buffer to prevent further long-term impairment.
Childhood psychiatric services have shifted dramatically from inpatient and residential treatment to individualized programs that fit the child and his family.
Now there is a continuum of care that ranges from outpatient clinic services to inpatient care, giving grades of intensity and restrictiveness. This continuum is expanded to include non-traditional services, of which the mobile crisis teams to examine and intervene with children at risk of psychiatric insult during a crisis, acute stabilization in psychiatric hospitals, which allow the child to stay for few days and then return to community services for continuation of the treatment, inpatient and residential treatment for children which are the most intensive and restrictive services, day hospitals which allow partial hospitalization for the child to help him integrate into his society, outreach services for those who are unable to access mainstream mental health services, and in-home services in which the clinical team works within the family and trying to treat the child as well as providing support to the family, wraparound services which is a highly individualized treatment plan which covers every area in the child’s every day life, and respite services which help the primary care giver to take some rest from his demanding child.
The continuum of care provided more flexible and understanding view of child psychiatric services for those children and their families.
Other services provided to children are assessment or evaluation, consultation to at risk children or to those referred by a GP or a pediatrician, child psychiatric liaison for agencies and institutions, and school-based psychiatric services which is considered one of the most accessible services, additionally, screening for those high risk of a developmental delay, and case-management for a comprehensive and individualized plan of management.
Measuring quality of service can be evaluated by assessing structure, processes, and outcomes of care, outcomes of care may be measured by: symptom severity (the changes of symptoms on a rating scale); levels of functioning; social and psychological wellbeing (independent of symptoms); quality of life; child or parent satisfaction or impressions of improvement; the prevention of the emergence of co-morbid disorders or conditions.
Prevalence of a psychiatric disorder is strongly related to its service use. Two psychiatric disorders were discussed for their prevalence and management; those two disorders are autism spectrum disorders (ASD) and attention deficit hyperactive disorder (ADHD).
Prevalence of ASD has been increasing since first discovered by Dr. Leo Kanner from 4 per 10000 to 60 per 10000 in current estimates, with affection of boys more than girls with a ratio of 4:1, it is a disease of all socio-economic levels. Cognitive function in these children may be affected in some of them,old studies suggested that most of these children have mental retardation, but the most recent studies revealed that the majority of children with ASD do not have mental retardation. It has many co-morbid psychiatric disorders, as anxiety, depression, hyperactivity, tics & compulsive behaviour may be associated with ASD in variable degrees.
Prevalence of ADHD is 3-5% of children as estimated by the American Psychiatric Association, it is the most frequently seen disorder in child psychiatry, the symptoms may persist into adulthood in about 60% of patients, it affects boys more than girls with a ratio of 2:1 o 4:1 , girls are mainly of the inattentive type, prevalence is higher in educated families, psychiatric co-morbidities associated with ADHD are conduct disorder, oppositional defiant disorder, anxiety, depression, and substance used disorders.
When autism was discovered, the psychoanalytic school was dominating, it was thought that the cause of this disorder is the cold relationship with the mother, and she was then called the Refrigerator Mother , this concept was against the treatment, and the child was isolated in special institutes to separate him from his mother (the main problem), as this child’s main problem is in communication and social interaction, this was to deteriorate him more. Now as different schools and views exist, the treatment plans of ASD differed. The intervention approaches for ASD are the psychodynamic, the biological, & the educational behavioral interventions.
Examples of psychodynamic therapies are holding therapy, and pheraplay which provide intense stimulation to overcome autistic children’s sensory deficits.
Biological treatments are mainly pharmacotherapy, the most commonly used medications for ASD are Anti-psychotics (typical and atypical), serotonin reuptake inhibitors, Anti-epileptics, also tricyclic anti-depressants can be used. Other biological treatments used are secretin, vitamin B6 and Magnesium, dietary modification, anti-yeast therapy. Those kinds of treatment were not proved to be effective.
Educational/behavioural treatments are based on the idea that most behaviour is learned through interaction between an individual and the environment.
The behavioural interventions are Applied Behavioural Analysis in which the child learns socially significant behaviour such as academics, toileting, and self-help. Another intervention is the Intensive Behavioural Intervention –the most famous is the Lovaas program which uses the ABA in an intensive way. Other kinds of behavioural interventions are developmental social-pragmatic model which focuses on social interaction and communication skills, and floor time which gives the child the lead in playing with the adult, visual cued strategies, social stories, and facilitated communications can be used.
Sensory motor integration therapy is provided to autistic children as they appear to have difficulties modulating their response to sensory input.
Other therapies are auditory integration training, and music therapy.
Treatments of ADHD are divided into pharmacotherapy for treatment of the core symptoms of ADHD: inattention, hyperactivity, and impulsivity. Medications used are psychostimulants, methylphenidate is their most frequently used, others are dextroamphitamine and pemoline; and non-stimulant medications; clonidine, antidepressants as TCAs and buprobion, and atomoxetine which is an effective non-stimulant medication.
Non-pharmacological therapy of ADHD include psychosocial interventions like CBT, behavioural modification, parent education, parent management training, school-based psychosocial interventions(e.g. placement on class).
Other non-pharmacological therapies are dietary intervention and complementary & alternative interventions as herbal medications, social and community interventions as provision of support by friends and family is important.
The best treatment for ADHD is the multimodal therapy which integrates pharmacotherapy with other environmental, educational, psychotherapeutic, and school-based approaches.
In Egypt the child psychiatric services available are produced by University hospitals, Ministry of Health and Population, and The General Secretariat of Mental Health. Services range from outpatient clinic services –medication monitoring, psychotherapy sessions to inpatient admission, though no specialized inpatient unit for children has been developed yet. The first Day Unit for children has been developed in Abbassya Mental Hospital. School-based services are not organized. However, there are specialized schools for mentally handicapped children.