Psychiatric disorders in children

Psychiatric disorders in children...........

1. Childhood psychiatric disorders Presented by Dr. Pinky Majumdar Dr. Ashik Kamal Alvee MD Residents (phase A) Department of Paediatrics Dhaka medical college hospital

2. Introduction Psychiatric disorders are behavioral or mental pattern that causes significant distress or impairment if personal functioning. Such features may be persistent, relapsing ,remitting or occur as a single episode. The causes of mental disorder are often unclear but alarming. But healthy living is impossible without sound mental health. Nowadays it is not uncommon in pediatric age group.

3. Epidemiology Worldwide 10-20% of children and adolescents experience mental disorders. In Bangladesh no reliable current data is available regarding childhood psychiatric illness. Some studies are available which shows the prevalence of mental health disorders varying 13.4 – 22.9%. Psychiatric problems are more prevalent in urban areas than rural areas.

4. Prevalence studies in Bangladesh Author Sample size/residence Age Diagnostic tool Prevalence rate Khan et al. 2013 8000/rural & urban 2-9 TQP/RNDA/MCHAT/DSM4 29.5% Khan et al. 2009 4003/rural data 2-9 TQP-BCL 14.6% Rabbani et al. 2009 3564/urban/rural/semi urban 5-17 DSM 4 29.5% Mullik & goodman et al. 922/urban/rural/semi urban 5-10 SDQ/DAWBA/DSM 4 15.5%

5. Psychiatric disorders are increasing alarmingly in Bangladesh day by day . Some causes are assumed for this situation Complicated urban life. Addiction to electronic devices like mobile, video game. Increased stress in school Busy and working parents. Decreased playground. Nuclear family. Decreased social values and bonding.

6. Classification of psychiatric disorder Eating disorder Anorexia nervosa, Bulimia nervosa Pica, Rumination Somatic disorder Conversion disorder Factitious disorder Somatic symptom Motor disorder Tics Stereotype disorders Elimination disorder Enuresis, encopresis Anxiety disorder Separation anxiety disorder Generalised anxiety disorder OCD Panic disorder PTSD Mood disorder Major depressive disorder Bipolar disorder Conduct disorder Autism spectral disorder Childhood psychosis

7. Breath holding attack Movement disorders Sibling rivalry Conduct disorder. Elimination disorders (Enuresis, encopresis) Tantrums Eating disorders (e.g. Pica, Rumination) Anxiety disorders (e.g. School Phobia, OCD etc) ADHD Autism spectral disorders Somatoform disorders Psychosis (e.g. schizophrenia) Common psychiatric disorders in Bangladesh

8. Sibling Rivalry It is one type of maladjustment of children among siblings. The Child’s emotional need of affection and security may appear to be threatened with the birth of another child. The older children feel deprived and this may initiate hostility in his behavior. Management Parents have to give their time and attention to both the baby. Conscious efforts should be made to involve the older child in care of younger one.

9. Breath holding spells Following trauma or stress, children cries briefly and holds breath in expiration. Types: two types 1) Pallied and 2) cyanotic Pallied spell : it occurs due to excessive vagal tone leading to cerebral hypoperfusion, convulsion , limpness. Cyanotic spells : 3 times more common than Pallied spells. Patient develops cyanosis and hypoxemia during spells No specific treatment is necessary or effective. Parents should be reassured.

10. Temper tantrums It is an expression of anger and frustration. In this condition child is lying or throwing himself down, kicking, screaming, throwing things or hitting. This is very common in one to four year age group. At home these behavior can be annoying for parents but in public they serve as an embracement. This condition can be managed. Parents are advised to use distraction, not to use negative terms but child’s demand leading to tantrum should not be granted.

11. Somatic symptom and related disorder Soma means body Somatoform disorders involves patterns in which individuals complaints of bodily symptoms that suggest the presence of medical problems But for which no organic basis can be found that satisfactorily explains the symptoms. Such individuals are typically preoccupied with their state of health and with various presumed disorders or diseases of bodily organs.

12. Clinical clues on history of conversion disorder Predominantly in pubertal and post pubertal age Higher incidence in girls. Half of the patients complaints concomitant chronic pain. Having mental disorder previously. History of previous medically unexplained symptoms Sudden onset of symptoms at maximum intensity Paroxysmal symptoms in presence of family members or friends Out of proportion of severity of neurological symptoms

13. Clinical symptoms Motor symptoms Weakness, paralysis, seizures, apnea and abnormal movements, tremor Sensory deficits Anesthesia, blindness, deafness, peripheral nerve sensory loss, hallucinations Visceral symptoms Vomiting , Diarrhea, urinary retention, pseudocyesis, globus hystericus

14. Contd.. Non epileptic seizures. Characterized by More gradual onset Truncal muscles involvement more Lateral rolling of head and body Movements increased if restraint applied Closed eyelids-manually opening the eyes produce more forceful closure Rapid post ictal re-orientation

15. Treatment Psychotherapy Cognitive behavior therapy Psychopharmacology V - Validate E - Educate E - Empathize R - Rehabilitate

16. Anxiety disorder Anxiety disorders are characterized by pathological anxiety in which Anxiety becomes disabling, interferes with social interaction, achievements of goals or hampers quality of life. Can lead to low self esteem, social withdrawal and academic underachievement. Types Separation anxiety disorder. Generalized anxiety disorder. Post traumatic stress disorder. Obsessive compulsive disorder. Panic disorder.

17. Separation anxiety disorder Most commonly experienced one is School refusal. School refusal Characteristics Peaks at 3 years age and in early teen-age. Frightened to leave home. Headache, tachycardia before leaving to school. Difficulty in returning to school from holidays. Forced to attend school met with tears . Child stays in or near home.

18. Management of school refusal Management of school refusal often requires parent’s management training and family therapy. Working with school personnel is always needed. Anxiety often requires special attention from teachers, counselors and school nurses physiologist and psychiatrist. Some needs drug therapy. SSRI is group of choice.

19. Some other forms of Separation anxiety disorder Childhood onset social phobia Excessive anxiety in social setting leading to social isolation Selective mutism Children are extremely talkative at home but become silent outside

20. Generalised anxiety disorder Occurs in children who often experiences unrealistic worries about different events or activities for at least 6 months with at least 1 somatic complaint. When history and physical findings are suggestive pediatricians should rule out hyperthyroidism, hypoglycemia, pheochromocytoma. Post traumatic stress disorder It is typically precipitated by an extreme stressor. PTSD is an anxiety disorder resulting from a long term and short term effects of trauma and cause behavioral and psychotic sequels in toddlers, children and adolescent. It may be acute (<3 months) or chronic (>3months)

21. Obsessive compulsive disorders One of the most common psychiatric disorders with life time prevalence of 1-3% worldwide with 80% having onset in childhood. It is characterized by specific repetitive thoughts that invade consciousness (obsessions) or repetitive rituals or movements that are driven by anxiety (compulsions) Most common obsessions are concerned with bodily wastes and secretions. Most common compulsions are hand washing, continuous checking of locks or touching of same objects.

22. Management of anxiety disorder Mainly done by cognitive behavioral therapy Sometimes combination with drug therapy is needed. In most cases selective serotonin reuptake inhibitors (SSIRs) are used. In severe cases beta blockers are used.

23. Attention Deficit Hyperactivity Disorder (ADHD) This is a neuro-developmental disorder. But it is discussed with psychiatric disorders because it has psychiatric components also. Approximately 6.4 million children in the world is suffering from this disorder. Pathogenesis 5-10% reduction in prefrontal cortex and basal ganglia volume. Prefrontal cortex and basal ganglia are rich in dopamine receptors Dopaminergic medication in ADHD patient and fluorodopa positron emission tomography scan support dopamine hypothesis.

24. Symptoms According to DSM 5 symptoms of inattention are Has trouble holding attention on tasks Does not seem to listen Does not follow instructions Has trouble organizing tasks and activities. Reluctant to do tasks that require mental effort over a long period of time. Easily distracted. Forgetful in daily activities.

25. Contd.. symptoms of hyperactivity are   Fidgets with or taps hands or feet, or squirms in seat. Unable to play quietly. Is often “on the go” Talks excessively. Blurts out an answer before a question has been completed. Has trouble waiting his/her turn. Interrupts or intrudes on others

26. ADHD key points Must have symptoms for at least 6 months. Symptoms must be present prior to age 7. Evidence of significant functional impairment. Symptoms are extreme of normal behavior.

27. Treatment Behavioral therapy Aims at identifying behaviors that impairs a child’s life and ultimately improving behavior. Pharmacological Treatment Stimulants : Amphetamine, Dextroamphetamine Serotonin and nor epinephrine reuptake inhibitor : Atomoxetine α- agonist : Clonidine Tricyclic anti Depressant : Imipramine, Clomipramine SSRI MAOI

28. Autism spectral disorders Autism spectrum disorder (ASD) commonly referred to as autism, is a complex developmental brain disorder caused by a combination of genetic and environmental influences, Characterized in varying degrees, by communication difficulties, social and behavioral challenges and repetitive behaviors, considered to be a life span disorder. Auto – Childs are locked within themselves Spectrum – wide range of symptoms and severity.

29. Epidemiology Over 10 million patients worldwide. 1 in 58 children have ASD. 4 to 5 times more common among boys than girls. Rates of ASD related to differences in diagnostic criteria, practices, inclusions of sub threshold cases, age, location of the study. Bangladesh – 0.075% of all rural children. 3% prevalence in urban area.

30. Etiology/risk factors Mostly unknown Genetic Risk factors include Prenatal rubella, CMV infection of mother GDM Advanced paternal or maternal age Use of psychiatric drug of mother during pregnancy

31. 2 core symptoms interaction Defects in social interaction and communication Restricted and repetitive Pattern of behavior Early signs of Autism Before 12 months After 12 months No words (16 months) No joyful expressions No sharing of sounds or facial expressions No meaningful two-word phrases (24 months) No babbling Lack of social interaction No gestures such as waving or pointing Prevalence of behavioral issues Warning ! What are the symptoms?

32. Fails to respond to name Resists cuddling and holding Unaware of others feelings Seems to prefer playing alone, living in his/her own life Starts talking later than of 2 years of age Loses previously acquired ability to say words or sentences Does not make eye contact upon request May use a singsong voice or robot like speech Cant initiate a conversation or keep on going May repeat words or phrases Performs repetitive movements Develops specific routines or rituals Disturbed at slightest change in routine Moves constantly Fascinated by parts of an object, such as spinning wheels Sensitive to light, sound, and touch and yet oblivious to pain Defects in social interaction and communication Restricted and repetitive Pattern of behavior Clinical characteristics

33. Psycho-education and behavioral interventions Teach-treatment and education of autistic and related handicapped children Applied behavioral analysis communication Alternative communication Social skill techniques Parental involvement Psychopharmacology Antidepressants, SSRIs, Beta blockers, mood stabilizers etc. Others Sensory and auditory integration, megavitamin therapy, gluten and casein free diet etc Referral to an expert on autism and related problems . Management of ASD

34. Disruptive ,impulse control, conduct disorder These are an interrelated set of syndromes characterized by a core deficit of self regulation in anger, aggression and specific behavioral problems. Oppositional defiant disorder : Characterized by persistent pattern of outbursts, arguing, disobedience generally against authority figure. Intermittent explosive disorder : Characterized by recurrent verbal or physical aggression that is grossly inappropriate to provocation. Some age specific behavioral disorders Stealing, Lying, Aggression Cutting and other self injury behavior etc.

35. Childhood psychosis Childhood schizophrenia This is not very much common in pediatric age group, but in adolescent period. Characterised by active (positive) symptoms like hallucination, delusion, disorganized speech, disorganized behavior and some negative symptoms like social withdrawal, loss of motivation and cognitive impairment Symptoms last at least for 6 months. Treatment Antipsychotic drugs. Cognitive behavior therapy.

36. Eating disorders Eating disorders are any psychological disorders characterized by abnormal or disturbed eating habits. Types Pica Rumination disorder Anorexia nervosa Bulimia nervosa

37. Rumination disorder Rumination disorder is the repeated regurgitation of food, where the regurgitated food may be rechewed, reswallowed or spit out, for a period of at least 1 month following a period of normal functioning. Age of appearance : 1 st year of life (Between 3 and 12 months). Features Weight loss Malnutrition (Can lead to growth delay and negative effect on development)

38. Behavioral treatment : Aims at reinforcing correct eating behavior. Aversive conditioning techniques (withdrawal of positive attention): Considered when a child’s health is at risk. In severe dehydration and malnutrition : An intensive integrated medical-behavioral treatment is needed. Treatment

39. Pica DSM-5 criteria , for diagnosing Pica are: Persistent eating of non-nutritive substances (e.g., paper, soap, charcoal, clay, wool, ashes, paint, earth) for at least 1 month. Eating is inappropriate to the developmental level of the individual. This behavior is not part of the culture or social practice. If occurring in the presence of other mental disorders it is severe enough to warrant independent clinical attention. EPIDEMIOLOGY Most common in childhood (After 2 years of age). More common in those with intellectual disability and autism spectrum disorders.

40. Etiology Nutritional deficiencies (e.g., iron, zinc, and calcium). Child abuse and neglect. Poor supervision from family. Mental disorder (e.g. autism spectrum disorders). Cultural and familial factors. Treatment Proper supervision and play opportunities : To stimulate child psychology. Parental counselling: In case of parental negligence. Management of any other concurrent mental disorder. Specific treatment: Management of the sequelae related to an ingested item (e.g. lead poisoning, parasitic Infestation).

41. Anorexia nervosa It involves overestimation of body size and shape. It has 2 subtypes Restrictive subtype: Excessive dieting and compulsive exercising Binge-purge subtype: Patients might intermittently overeat and then attempt to rid themselves of calories by vomiting or taking laxatives, still with a strong drive for thinness.

42. Bulimia nervosa Episodes of eating large amounts of food in a brief period , followed by compensatory vomiting, laxative use, and exercise or fasting to rid the body of the effects of overeating in an effort to avoid obesity Fig: cycle of bulimia nervosa

43. Treatment Prescribing proper nutrition Should work to increase weight 0.5-1 lb /week up to 90% of average weight for age, sex and height (for anorexia nervosa patients). Stabilizing intake (for bulimia nervosa patients). Behavior therapies Cognitive behavior therapy, dialectical behavior therapy, group therapy. Drug therapy Given specially in cases of depression(e.g. SSRIs)

44. Mood disorders Definition Mood disorders are sets of psychiatric symptoms characterized by a core deficit in emotional self-regulation. Epidemiology Approximately 1% children in prepubertal phase and 3% children in pubertal phase. Types Depressive disorders. Bipolar disorders.

45. Major depressive disorder Here, a period of at least 2 weeks in which there is a depressed mood and loss of interest in all activities for most of the day. Persistent depressive disorder Characterized by depressed mood for more days ( at least 1 year ). Symptoms are less severe than major depressive disorder. Disruptive mood dysregulation disorder A severe, persistent irritability evident for at least 1 year , characterized by frequent temper outbursts and a persistently irritable mood that is present for most of the day. Depressive disorders

46. CLINICAL COURSE Time of onset : May appear at any age, commonly in puberty. Median duration : 5-8 months . The course is quite variable. Depressed children appear to be more likely to develop non-depressive psychiatric disorders in adulthood.( Bipolar disorder in 20% ) Recurrence : 50%-70% after 5 years. Negative prognostic factors More severe symptoms. Longer time to remission. History of maltreatment. Co-morbid psychiatric disorders.

47. Comorbidity Present in 40-90% cases Anxiety disorder, ADHD, Eating disorder, Substance use disorders. Etiology/ Risk factors Twins Positive family history Physical/sexual abuse. Chronic illness. School difficulties (bullying, academic failure). Family disharmony. Parental psychopathology. Domestic violence.

48. Treatment Guided self-help This include provision of educational materials (e.g., pamphlets, books, workbooks, internet sites) that provide information to the youth about dealing with stressful situations . Supportive psychotherapy Focuses on teaching thoughts (e.g., positive self-talk) and behaviors (e.g., pleasurable activities, problem-solving, effective communication) Moderate/ severe depression Cognitive behavior therapy/antidepressant drugs or both Fig: flow chart of treatment in depressive disorder

49. Bipolar disorders More common in teenagers It includes manic and depressive episodes. Features of manic episodes are Euphoria. Excessively cheerfulness Inflated self-esteem Feeling of having full energy despite little sleep. Speech can be rapid, pressured, and loud. There are also features of depression.

50. Treatment Medication It is the primary treatment Atypical antipsychotics are first choice (risperidone, quetiapine) Mood stabilizers (lithium carbonate) are also used. Antidepressant medication Psychotherapy : An adjunctive treatment for the bipolar disorders. Risk of suicide 15 times more than a healthy child.

51. Motor disorders Motor disorders are interrelated sets of psychiatric symptoms characterized by abnormal motor movements and associated phenomena. Motors disorders include Tic disorders. Stereotypic (same type) movement. Developmental coordination disorders.

52. Tic disorders A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization. Types Tourette’s disorder : Both motor and vocal tics have been present at some time during the illness, although not necessarily concurrently. (Persists >1 year) Persistent tic disorders : Motor or vocal tics have been present during the illness, but not both. (Persists >1 year) Provisional tic disorders: Single or multiple motor and/or vocal tics. The tics have been present for less than 1 year.

53. Movements in tic disorder Simple motor tics (e.g., eye blinking, neck jerking, shoulder shrugging) Complex motor tics (e.g., tapping the foot, imitating someone else’s movement) Simple vocal tics (e.g., throat clearing, sniffing, coughing) Complex vocal tics (e.g., partial words ,words out of context) Tics are worsened by anxiety, excitement, or exhaustion.

54. Clinical course Onset : Typically between ages 4 - 6 years Peak severity : Between ages 10 - 12 years. Attenuation of tic severity : By age 18-20 years. Differential diagnoses Repetitive movements Dystonia Chorea Compulsions Myoclonus Akathisia Stereotypies Various neurological diseases Wilson’s disease Huntington’s syndrome Various frontal/subcortical lesions

55. Epidemiology Risk factors Frontal/ sub frontal lesions. Male sex. In 1 st degree relatives. Twins ( 80% in monozygotic and 20% in dizygotic). As many as 1 in 100 people experience some form of tic disorder, usually before the onset of puberty

56. Treatment Options are Psychoeducation: Open discussion about patient’s typical exacerbating and alleviating factors, course of the disease and treatment options (including no treatment). Behavioral therapy : When tics are distressing or functionally impairing. Medications: Should be considered when the tics are causing severe impairment in the quality of life (Haloperidol, Pimozide Risperidone etc ).

57. Stereotypic Movement Disorder A psychiatric disorder characterized by repetitive, seemingly driven, and apparently purposeless motor behavior (stereotypic) that interferes with social, academic, or other activities that may result in self-injury. Examples Hand shaking or waving, body rocking, head banging, self-biting, and hitting one’s own body etc. Typically begin within the first 3 years of life These movements resolve over time.

58. Enuresis Involuntary passage of urine beyond the age when bladder control should have been achieved. Age of onset : usually between 3-8 years. Types Nocturnal only Daytime only Nocturnal and daytime enuresis Psychiatric conditions connected to enuresis Stress, ADHD.

59. Key points about enuresis in psychiatric illness Repeated voiding of urine into bed or clothes (involuntary or intentional) Behavior is manifested by a frequency of twice a week for at least 3 consecutive months. Age is at least 5 years. The behavior is not due to the direct physiological effect of a substance (such as a diuretic) or a general medical condition ( e.g , diabetes, spina bifida,seizure disorder etc ).

60. Treatment Reward the child for dry night. UTI, Diabetes mellitus, diabetes insipidus, any other medical condition should be ruled out. Fluid restriction and night lifting to toilet causes temporary improvement, eventually relapses. Bladder training (practicing to hold urine for longer period of time) Conditioning with a alarm when there is bed wetting. It generally works within weeks. Drug therapy : tricyclic anti depressant (imipramine)

61. Encopresis Involuntary passage of feces beyond the age when bowel control should have been achieved. Causes of encopresis Encopresis is commonly caused by constipation, by psychological disorders (e.g. anxiety, fear, anger) or neurological disorders.

62. Key points about encopresis in psychiatric illness Age must be at least 4 years. A repeated passage of feces into inappropriate places, e.g., clothing or floor. (Intentional or involuntary) At least 1 event month for at least 3 consecutive months. The behavior is not attributable to the effects of a substance, e.g., laxative, or another medical condition, with the exception of a mechanism involving constipation.

63. Treatment A combination of laxative and sitting on toilet for timed intervals daily. If no constipation then laxative use not needed. Supportive psychotherapy and relaxation techniques useful in anxiety.

64. Approach at detecting psychiatric disorder Psychosocial interviewing in a routine pediatric visit is the primary approach towards assessing a psychiatric disorder. Domains which are included in the interview are named HEADSS (home, education, activities, drugs, sexuality, suicide/depression). Interview of both children and parents are taken. During interview we have to look for signs of psychiatric disorders which gives clinicians the tools needed to recognize early symptoms.

65. Mental health action signs • Feeling very sad or withdrawn for more than 2 weeks . • Seriously trying to harm or kill thyrself, or making plans to do so. • Sudden overwhelming fear, sometimes with a racing heart or fast breathing. • Involvement in many fights or wanting to badly hurt others. • Severe out-of-control behavior that can hurt thyself or others. • Not eating, throwing up or using laxatives to lose weight. • Intense worries or fears that get in the way of daily activities. • Extreme difficulty in concentrating or staying still. • Severe mood swings that cause problems in relationships. • Drastic changes in behavior or personality.

66. Fig : Psychological assessment tools

67. Medical conditions having association with various psychiatric diseases Rumination : Pyloric stenosis, Gastroparesis etc. Pica : Iron, Zinc, Calcium deficiency etc. Tics : Wilson’s disease, Huntington's disease, Frontal-subcortical circuit defect etc. Anxiety : Hyperthyroidism, Hypoglycemia, pheochromocytoma etc. Depression : chronic diseases, hypothyroidism etc.

68. Investigations Investigations Significance CBC with PBF Diagnosis of chronic diseases, malignancy (depression) Iron deficiency anemia (Pica) S. Iron profile Iron deficiency (Pica) S. calcium Calcium deficiency (Pica) S. T3, T4, TSH Hypothyroidism (can mimic depression) Hyperthyroidism (can mimic anxiety) Random blood sugar Hypoglycemia (can mimic anxiety) SGPT, S. bilirubin, PT Increased (Wilson’s disease) S. Ceruloplasmin level Decreased (Wilson’s disease)

69. Investigations Significance 24 hour urinary copper Increased (Wilson’s disease) Urine VMA, catecholamines Increased (pheochromocytoma) MRI of brain To see if any structural defect EEG (electroencephalogram) Helpful in diagnosis Barium meal X-ray, USG of Whole abdomen Helpful in diagnosis of Pyloric stenosis, gastroparesis Liver biopsy Diagnosis of Wilson’s disease

70. Psychopharmacology Target symptoms Drugs Agitation Atypical/typical antipsychotic Anxiolytic Aggression Stimulant Atypical antipsychotic Anxiety Antidepressant Anxiolytic Depression Antidepressant Hyperactivity, inattention, impulsivity Stimulant Alpha-agonist Mania Atypical antipsychotic Psychosis Atypical antipsychotic Target Symptom Approach to Psychopharmacologic Management

71. Anti psychotics Atypical antipsychotics Aripiprazole Olanzapine Quetapine Risperidone Typical antipsychotics Haloperidol Antidepressants Selective serotonin reuptake inhibitors Citalopam , Escitalopam , Fluoxetine Sertraline Tricyclic antidepressant Clomipramine Atypical antidepressant Bupropione Anxiolytics Lorazepam,Clonazepam,Buspirone

72. Stimulants Methylphenidate Amphetamine Dextroamphetamine Dexmethylphenidate Alpha agonists Clonidine Guanfacine Mood stabilizers Lithium carbonate divalproex Contd..

73. Psychotherapy The use of psychotherapy involves a series of interconnected steps including performing an assessment, deciding upon treatment and monitoring plan, obtaining consent, and implementing treatment. Types Behavior therapy. Cognitive behavior therapy. Family therapy. Supportive psychotherapy.

74. Behavior therapy The treatment begins with a behavioral assessment with interview, observation, diary or rating scale components, along with a functional analysis immediately preceding external events, and real-world consequences of the behavior. A treatment plan is then developed to modify the maladaptive functions of the behavior, using tools such as positive and negative reinforcement , punishment, response cost, systematic desensitization etc.

75. Cognitive behavior therapy Cognitive behavioral therapy (CBT) is a type of psychotherapeutic treatment that helps patients understand the thoughts and feelings that influence behaviors. Cognitive behavior therapy is focused on helping patients deal with specific problem. Here the therapist has major role. During the course of treatment, patient learn how to IDENTIFY and CHANGE destructive or disturbing thought by themselves.

76. Conclusion Mental health is an important component of healthy living and early diagnosis and management of child psychiatric disorders can ensure the child a healthy life and a sound adulthood. 10 th October is observed as world mental health day worldwide every year.