Behaviour-based disorders

Attention Deficit/Hyperactivity Disorder

Although most children can, at times, be restless and inattentive, for children with Attention Deficit/Hyperactivity Disorder (ADHD), these issues may be severe, persistent and impairing. Youth diagnosed with ADHD display behaviours that cause difficulty in multiple areas, including at home, in school or with friends. ADHD is more common in boys than girls.

Signs and Symptoms

Inattention
• Has difficulty paying attention, listening and attending to detail
• Has poor organization and study skills
• May be forgetful and distracted
Impulsiveness
• Blurts out answers, often interrupts or intrudes
• Is impatient in school and play situations (which gets in the way of social relationships)
Hyperactivity
• Seems to be in constant motion, fidgets or squirms
• Runs or climbs often
• Talks excessively

Conduct Disorder

Children with a conduct disorder do not respect authority, have little regard for the basic rights of others and break major societal rules. Conduct Disorder behaviour can occur in a variety of settings and can cause difficulties at home, in school and within the community. The cause of Conduct Disorder is believed to be a combination of genetic vulnerability and environmental factors, including the home situation. Treatment plans may include behavioural therapy and pharmacotherapy (drug treatments).

Signs and Symptoms

Aggression to people and animals
• Bullies, threatens or intimidates others
• Initiates physical fights or is physically cruel to people or animals
• Uses weapons (e.g., bats, bricks, knives and guns) that could cause serious physical harm to others
• Steals from a victim while confronting them (assault)
• Forces others into sexual activity
Destruction of property
• Deliberately sets fires with the intention of causing damage
• Deliberately destroys the property of others
Deceitfulness, lying or stealing
• Breaks into buildings, houses or cars
• Lies to obtain goods or favours, or to avoid obligations
• Steals items without confronting a victim (e.g., shoplifting without breaking and entering)
Serious violations of rules
• Stays out at night despite parental objections
• Runs away from home
• Is often truant from school

Co-occurring disorders
Many individuals with a Conduct Disorder may have a coexisting issue, such as: depression, anxiety, post-traumatic stress, substance abuse, attention deficit/hyperactivity, learning problems or thought disorders.

Elimination Disorders

Encopresis (soiling)
Encopresis involves soiling with no physical reason in children who are old enough to be physically capable of bowel control. Children with Encopresis pass feces in inappropriate places, such as in their underwear or on the floor. Some children, in the process of toilet training, may have difficulty in mastering bowel control. By the age of four, however, if accidents occur at least once a month for three months and are not due to a physical abnormality or a general medical condition, a child is considered to have Encopresis. There are two basic categories of Encopresis: primary (children who have never attained bowel control) and secondary (children who begin to soil again after attaining control).

Signs and Symptoms

Encopresis is generally involuntary, but can occasionally be intentional. In involuntary Encopresis:
• Stools are withheld, often due to constipation and pain during bowel movements. (Stools then become harder and more painful to pass. In severe cases, a large amount of dry stool can become impacted in the rectum and watery feces leak out, soiling the child's underwear. Retained feces may result in large masses of stool that can dilate the colon, causing an abnormal enlargement of the colon.)

Subtypes
• With constipation and overflow incontinence, there is evidence of constipation on physical examination or by history. Feces are generally poorly formed and leakage is continuous, occurring both during the day and during sleep. Only small amounts of feces are passed during toileting, and incontinence is resolved after treatment of constipation.
• Without constipation and overflow incontinence, there is no evidence of constipation on physical examination or by history. Feces are likely to be of normal form and consistency, and soiling is intermittent. Feces may be deposited in a prominent location (when this occurs, it is usually associated with the presence of Oppositional Defiant Disorder or Conduct Disorder and may be the consequence of anal masturbation).

Enuresis (bedwetting)
Enuresis involves urination in clothing or in bed beyond the age when children are expected to be toilet trained, and in the absence of medical problems. By the age of five at the latest, most children have achieved bladder control during both day and night. When children continue to have trouble with urination, they have Enuresis, often referred to as bedwetting. There are two basic types of Enuresis:
• Primary (the more common of the two types involving children who have never been trained and have not achieved a six-month period of dryness at night); and
• Secondary (children who have been dry for up to a year and then start wetting again, usually between the ages of five and eight). Secondary Enuresis may include transient (temporary) Enuresis, brought on by trauma or stress, such as a divorce in the family, and may last anywhere from a couple of weeks to several months.

Signs and Symptoms

Involuntary urination — during the day or night:
• Younger children (ages five and six) may be indifferent to this condition, and are more bothered by the feeling of a wet bed and annoyed parents.
• Older children may be more affected by the social impact of this condition and the interference in their lives (during sleepovers, camp, etc.); secondary problems of avoidance behaviours or low self-esteem may occur.

Subtypes

Nocturnal
• Most common subtype
• Passage of urine only during nighttime sleep
• Urination during the rapid eye movement (REM) stage of sleep; may include a dream that involves the act of urinating
Diurnal only:
• Passage of urine during waking hours
• More common in females than in males and uncommon after age nine
• Most commonly occurs in the early afternoon on school days
• May occur due to a reluctance to use the toilet because of social anxiety or a preoccupation with an activity
Nocturnal and diurnal
• A combination of the two subtypes described above

Obsessive Compulsive Disorder

Obsessive Compulsive Disorder (OCD) is a type of anxiety disorder characterized by obsessions and/or compulsions that children feel unable to control and that are severe enough to interfere with the activities of daily life. Obsessions are repeated unwanted thoughts, while compulsions are repeated and purposeless behaviours that are performed to relieve the anxiety caused by the obsessive thoughts. Unlike adults, children do not always have the necessary skills or life experience to recognize that the obsessions or compulsions are excessive or unreasonable. When obsessive thoughts become so frequent or intense or rituals become so extensive that they interfere with daily life, a diagnosis of OCD is considered.

Signs and Symptoms*

• Indications of frequent washing, such as raw, chapped hands; high rate of soap and towel use; increase in laundry; unwarranted showering or bathing; and excessive tooth brushing
• Sudden drop in test grades
• Constant doing and redoing of homework in an attempt to be perfect
• Persistent fear of illness
• Long time spent preparing for bed or getting ready for school
• Continual fear that something terrible will happen to self or family
• Collecting things others might discard
• Fear of dirt or germs
• Need for order: things must always be in a certain place
• Thoughts of nonsense words or images
• Religious obsessions
• Preoccupation with body wastes
• Sexual or aggressive thoughts
• Touching rituals
• Ordering and arranging articles
• Repetition of rituals, such as putting clothes on and off or moving in a special way
• Hoarding and collecting things
• Counting rituals
• Checking drawers and locks


*Symptoms can come and go, and often there is no logical relationship between the obsession or compulsion and the fears the child is experiencing.

Oppositional Defiant Disorder

Oppositional Defiant Disorder (ODD), a manifestation of Conduct Disorder, is characterized by a recurrent pattern of defiant, disobedient and hostile behaviour towards authority figures that seriously interferes with day-to-day functioning and persists for at least six months. All children are oppositional from time to time, and oppositional behaviour is often a normal part of development for two to three year olds and early adolescents. However, a diagnosis of ODD is considered when the behaviour is so frequent and consistent that it stands out when compared with other children of the same age and developmental level and when it affects social, family and academic life. These symptoms are usually seen in multiple settings, but may be more noticeable at home or at school.

Signs and Symptoms

• Frequent temper tantrums
• Excessive arguing with adults
• Active defiance and refusal to comply with adult requests and rules
• Deliberate attempts to annoy or upset people
• Blaming others for mistakes or misbehaviour
• Touchiness or being easily annoyed by others
• Frequent anger and resentment
• Mean and hateful talking when upset
• Desire to seek revenge

Psychosomatic Illness (Somatoform Disorder)

Sometimes a child or adolescent continually complains of a discomfort or a pain for which a physician cannot find a cause. The pain or the discomfort, however, is very real to them. Physical complaints with no apparent medical basis may be a reflection of stress, such as nervousness in a social situation, a demanding school setting or separation from parents. Stress, as it affects the body and the mind, has an effect on some illnesses and can influence how children or adolescents perceive the symptoms of the illness, how they deal with the illness and the rate of recovery.

Somatoform Disorders is the term used to describe a group of disorders characterized by physical symptoms that cannot be fully explained by a neurological or generalized medical (or “organic”) condition. It is rare for children to be diagnosed with a Somatoform Disorder, as the criteria for these disorders were established for adults and certain symptoms are not yet experienced by children.

Signs and Symptoms*

• Headaches
• Abdominal distress
• Symptoms that mimic neurological disorders, such as double vision, poor balance and coordination, and paralysis and seizures
• Imagined physical deformities or defects
• Back pain
• Fatigue
• Sore muscles
• Academic problems or refusal to go to school
• Social withdrawal
• Anxiety
• Behavioural problems

* With the hormonal changes of puberty, many of these symptoms, including anxiety and worry, fatigue, loss of appetite, and aches and pains, are more commonly felt by girls.

Specific Phobias

Specific Phobias, a form of anxiety, is an intense fear of a specific object or situation that’s generally considered harmless by most people. Most youth outgrow common childhood fears such as fear of the dark, fear of monsters or fear of being left alone. For some children and teens, however, fears can become severe. If a fear is excessive, it may be a phobia. Symptoms of Specific Phobias may develop as young as age five, especially phobias related to the natural environment, such as spiders, darkness, loud noises, animals or bodily injury. Older children often develop fears of needles, natural events (such as fires or earthquakes), heights, escalators or enclosed spaces. While teens and adults with phobias realize that these fears are irrational, younger children may not be able to recognize that their fears are excessive or unreasonable. Phobias are different from usual fears: they are irrational, don’t decrease with reassurance and interfere with a child’s life.

Signs and Symptoms

• A persistent, irrational fear of a specific object, activity or situation
• Avoidance of the feared object or situation
• Extreme anxiety and panicky feelings when faced with the feared object or situation, including sweating, rapid heartbeat, looking flushed, trembling and shortness of breath
• Impaired ability to function because of the fear
• Younger children may cry, throw tantrums, cling, freeze or want to be picked up

Substance-related Disorders

Adolescence is a time for adventure and experimentation. Many teenagers try alcohol or drugs at least once, and most do not develop a problem. But, not all children and adolescents escape the dangers as easily. Instead, they are at risk for developing serious substance-use disorders. It is important to know that using a substance once or twice is not a substance disorder. To qualify as a substance disorder, the effects of alcohol or drug use must have a serious, negative impact on the user’s life.

There is ample evidence that shows substance abuse disrupts the normal process of adolescent development. A variety of negative outcomes, including serious drug use later in life, school failure and poor judgment, are associated with Substance Disorders. Substance abuse is the strongest predictor of car accidents, homicides, suicide, HIV exposure and other medical and mental health conditions. Teenagers who abuse substances often have other untreated disorders — including depression, ADHD or anxiety — that increase their vulnerability. What can be done to prevent these problems? Early drug education, open communication, positive role models and early recognition are a good start.

Signs and Symptoms

Physical
• Fatigue
• Repeated health complaints
• Red and glazed eyes
• Persistent cough
Emotional
• Personality change
• Sudden mood changes
• Irritability
• Irresponsible behaviour
• Low self-esteem
• Poor judgment
• Depression
• Lack of interest in things that used to provide pleasure
Family
• Starting arguments
• Breaking rules
• Missing curfews
• Withdrawing (spending time behind closed doors)
School
• Decreased interest
• Negative attitude
• Drop in grades
• Frequent absences
• Discipline problems
Social problems
• Having new friends who are not interested in normal home and school activities and who have problems with the law

*These symptoms may be signs of other problems as well.

Tic Disorders

Tourette's Disorder
Tourette's Disorder (TD) causes involuntary motor and vocal tics that can vary and become stronger and weaker with time. (A motor tic is a rapid, repeated twitch that produces a quick, sudden movement. A vocal tic is a sound made involuntarily.) Tics may involve different parts of the body (face, neck, shoulders, trunk or hands). Vocal tics may include meaningless sounds and noises. TD is thought to be due to genetic factors and faulty brain chemistry. Treatment includes genetic counseling, psycho-education and pharmacotherapy.

Signs and Symptoms

• Involuntary motor and one or more vocal tics, which occur at some time during the illness but not necessarily together
• Variation in types of tics, which are sometimes stronger or weaker and change over time in frequency and complexity
• Motor tics, including excessive blinking, shrugging, grimacing and nose-twitching, which are the most common simple motor tics
• Vocal tics, including grunting, tongue-clicking, hooting and throat-clearing
• Some complex motor tics, which may appear purposeful, such as kissing, pinching, sticking out the tongue, touching, gyrating or making obscene gestures (also known as copropraxia)

Transient Tic Disorder
Transient Tic Disorder, a more common tic disorder, generally appears during the early school years. This disorder affects from five to 24 percent of all children. It differs from Tourette's Disorder in that the tics occur daily for at least two weeks but for no longer than one year. However, the child may have a series of transient tics over the course of years. Tics can be voluntarily suppressed for brief periods, and most are mild and hardly noticeable. In some cases, tics are frequent and severe and may affect many aspects of a child's life.

Chronic Motor/Vocal Tic Disorder
Chronic Motor/Vocal Tic Disorder is another category of tic disorder that appears before age 21. It usually perists unchanged throughout a period of more than one year and involves either motor or vocal tics, but not both.

Trichotillomania

Trichotillomania (TTM) is a disorder that causes individuals to pull out the hair from their scalp, eyelashes, eyebrows or other parts of the body, resulting in noticeable bald patches. TTM is currently defined as an impulse-control disorder, but there are still questions about how it should be classified. It may seem, at times, to resemble a habit, an addiction, a tic disorder or an Obsessive Compulsive Disorder (OCD). Many people with TTM also have symptoms of OCD, such as compulsive counting, checking or washing, so TTM is considered by some to be a subtype or variant of OCD.

Signs and Symptoms

• Recurrent pulling out of hair resulting in noticeable hair loss
• Increasing sense of tension immediately before pulling out the hair or when resisting the behaviour
• Pleasure, gratification or relief when pulling out the hair
• Significant distress or impairment in social, occupational or other important areas of functioning
• Other associated behaviours may include nail biting, thumb sucking, head banging, picking at skin and compulsive scratching

Schizophrenia

Schizophrenia is characterized by the distorted thinking associated with delusions and hallucinations. It may have a gradual onset, with symptoms of withdrawal and disordered language (difficulty with verbal or written expression), or it can have a sudden onset in adolescence. Evidence suggests that schizophrenia is due to an inherited biochemical abnormality in the brain. Schizophrenia is one of the most baffling, troubling and potentially dangerous of the mental disorders because it seems so unbelievable. When a person has schizophrenia (psychosis), his or her brain does not process information in the usual way, making it impossible to control thinking or behaviour. In the most severe stage, a person with schizophrenia has difficulty telling the difference between fantasy and reality, and has thoughts of hurting him or herself or someone else. Treatment includes medication, such as neuroleptics, to alleviate the painful and intrusive thoughts, and structured programs and education for the youngster and family to improve daily functioning.

Signs and Symptoms

• Positive symptoms — this includes delusions, which are ideas that may seem real but are not based in reality. For example, someone may think she is being singled out by the government to join an elite military force or is convinced the answers to a television game show are secretly being sent to her through the cable wires. Hallucinations, another positive symptom, occur when a person sees, hears or feels things that are not there. Hallucinations can seem so real to people with schizophrenia that they act in bizarre ways and do things that look strange to those around them.
• Negative symptoms — refers to the absence of normal function. For example, teenagers may become distant, withdrawn, uninvolved with life, want to be alone and have no energy for people or activities.
• Disorganized speech — evident in people with schizophrenia who often talk in a rapid but disjointed way. They either do not make sense or change topics so frequently that they are difficult to understand.
• Disorganized or catatonic behaviour — includes becoming suddenly violent or walking around confused, or sitting and staring as if immobilized; this may reflect a person's disordered thinking.

Depression Disorders

Depression

Depression in children and teenagers is different from the feelings of sadness and other everyday emotions that most children experience. Depressed children are sorrowful beyond the range of normal sadness. Depressed children do not necessarily have the same signs and symptoms as adults. If a child or teenager’s symptoms become persistent, disruptive and interfere with social activities, interests, schoolwork and family life, he or she may be depressed. Depression is most likely due to an inherited predisposition to a chemical imbalance in the brain. Effective treatments include medication and cognitive behaviour therapy.

Signs and Symptoms

• Frequent crying bouts, sadness and tearfulness
• Stress at school
• Distress about things that happened with friends
• Social withdrawal
• Difficulty pleasing
• Periods of swinging from great sadness to sudden anger
• Depression or irritability
• Difficulty concentrating
• Feelings of worthlessness
• Sleep problems (sleeping more or less than normal) or changes in appetite (eating more or less than normal)
• Restlessness or slowing down
• Decreased interest or pleasure in activities
• Extreme sensitivity to failure, low self-esteem and feelings of guilt
• Poor concentration
• Frequent absences and declining academic performance
• Boredom and low energy
• Thoughts of death

There are two basic types of depression: major depression, which lasts at least two weeks; and milder but chronic dysthymia.

Dysthymia

Dysthymia is a disorder similar to clinical depression. Although it is less severe, dysthymia tends to be chronic and longer lasting. Major depression lasts at least two weeks, but chronic dysthymic disorder lasts a year or longer, and seems to characterize the child's temperament or personality. A "down mood" is a pervasive part of the child’s life. Dysthymia involves long-term, chronic symptoms that are not disabling, but keep the child from functioning well or from feeling good.

Signs and Symptoms

• Low self-esteem
• Feelings of hopelessness
• Persistent feelings of sadness
• Feelings of inadequacy
• Excessive guilt
• Thoughts about wanting to die, suicidal thoughts or attempts
• Loss of interest in usual activities
• Difficulty with relationships
• Sleep disturbances (e.g., insomnia, hypersomnia)
• Changes in appetite or weight
• Decreased energy
• Difficulty concentrating and decreased ability to make decisions
• Hypersensitivity to failure or rejection
• Irritability, hostility or aggression
• Frequent physical complaints (e.g., headache, stomach ache, fatigue)
• Running away or threats of running away from home

Bipolar Disorder

Bipolar Disorder, also known as manic depression, is characterized by intense, persistent mood swings between the poles of depression and mania. These moods are greatly intensified or clearly different from the youngster's usual personality and are far out of proportion to events in the environment in intensity and/or duration. The youngster experiences the typical signs of both depression (helplessness, hopelessness and worthlessness) and mania (grandiosity and exuberance) over a period of anywhere from several days to several months. Bipolar Disorder can cause serious disruption to one's life. The disorder may be genetic and caused by a chemical imbalance in the brain. Medication is successful in moderating the symptoms.

Signs and Symptoms

Depression
• Feeling worthless and hopeless
• Being passive and lethargic
• Having difficulty sleeping or eating
• Not caring about physical state
• Feeling agitated
• Mania — easily and unpredictably switching to being manic at least once, as evidenced by:
• Elevated mood
• Feelings of grandiosity
• Seemingly unlimited energy despite a lack of sleep
• Risky behaviour
• Lack of awareness of usual human limits
• Possible delusions and hallucinations
• Signs of being out of touch with reality
• Belief that he or she is better than anyone else
• Feelings of invincibility
• Flight of ideas
• Rapid sequencing of thoughts that, at first, may seem illogical, but are actually related to one another
• Periods of “normal” behaviour and moods interspersed with periods of manic behaviour or depression (mixed presentations are most common in pre-pubertal children. Teenagers show distinct manic and depressive episodes. Less common are youngsters who cycle rapidly, four times a year, or day to day, alternating between depression and mania.)

Neurological Disorders

Autism Disorders Spectrum

Autistic Disorder and Asperger's Disorder are the two most common forms of the Autism Disorders Spectrum (ASD). Children with these disorders have difficulty accomplishing developmental tasks entailing social language, communication and socialization. The diagnosis of Autistic Disorder is generally made between birth and 30 months of age, whereas the diagnosis of Asperger's Disorder is generally made later in a child's life. Although the disorder is present from birth, some youngsters may not be diagnosed until they enter school or some may have been given another diagnosis because they are developing normally in some areas of life. These disorders appear to have a genetic cause. Treatment can include a combination of medications and specialized training to develop and improve acquisition of necessary skills.

Autistic Disorder

Signs and Symptoms

Language
• Are delayed in spoken language
• Make no attempt to use non-verbal communication
• Do not initiate conversations
• Use stereotyped and repetitive or idiosyncratic language
• Parrot or repeat phrases
• Show a lack spontaneous imaginative play
Social interaction
• Do not use non-verbal methods such as eye gaze, facial expressions, body postures or gestures to interact
• Do not develop age-appropriate peer relationships
• Do not seek to share enjoyment or experiences with others; lack social or emotional reciprocity
• Are preoccupied with stereotyped and restricted patterns of behaviour
• Have an inflexible adherence to specific non-functional routines or rituals
• Have stereotyped mannerisms such as hand or finger flapping
• Are preoccupied with parts of objects

Asperger's Disorder

Although people with Asperger's Disorder are of average or high intelligence, with no significant language problems, they have difficulties with social interaction.

Signs and Symptoms

• Difficulty using and interpreting non-verbal behaviours, such as facial expressions and body language, as well as verbal conventions, such as conversational turn-taking (all of which help us understand the nuances of social interaction)
• Usually have some pattern of restricted, repetitive and stereotyped behaviours, interests and activities

Eating and Body Disorders

Anorexia

People with anorexia are obsessed with food, weight and body shape. They struggle to maintain a weight that is far below normal for their age and height.

Signs and Symptoms

Physical symptoms include:
• Extreme weight loss
• Thin appearance
• Abnormal blood counts and low blood pressure
• Fatigue, dizziness or fainting
• Brittle nails
• Hair that thins or falls out
• Soft, downy hair that covers the body
• Absence of menstruation
• Constipation
• Dry skin
• Intolerance of cold
• Irregular heart rhythms
• Dehydration
• Osteoporosis
Emotional/behavioural symptoms include:
• Refusing to eat or skipping meals
• Denying being hungry
• Exercising excessively
• Having a flat mood
• Having difficulty concentrating
• Being preoccupied with food
• Eating only a few foods, usually those low in fat and calories
• Having rigid meal or eating habits
• Weighing foods
• Cooking for others but refusing to eat
• Repeatedly weighing of themselves
• Frequently checking in the mirror
• Wearing baggy or layered clothing
• Complaining about being fat

Binge-eating Disorder

Binge-eating disorder, sometimes called compulsive overeating, is a serious disorder in which a person frequently eats unusually large amounts of food, often in secret. People with binge-eating disorder may be deeply embarrassed about gorging and decide to stop, but they feel such a compulsion that they cannot resist the urge to eat. A binge usually lasts about two hours — though some experts say binges can last an entire day — and involves eating a larger amount of food than most people would eat under similar situations (e.g., eating 10,000 to 20,000 calories worth of food during a binge, while someone following a normal diet may eat 1,500 to 3,000 calories in a day). After a binge, a person may try to diet or eat normal meals. But restricting eating may simply lead to more binge eating, creating a vicious cycle. Treatment can help binge eaters win back control and overcome secret shame.

Signs and Symptoms

• Eating large amounts of food
• Eating even when full
• Eating rapidly during binge episodes
• Feeling that eating behaviour is out of control
• Frequent dieting without weight loss
• Frequently eating alone
• Hoarding food
• Hiding empty food containers
• Feeling depressed, disgusted or upset about eating

Body Dysmorphic Disorder

While many people spend a lot of time and effort on appearance, individuals with Body Dysmorphic Disorder (BDD) are beset by a more extreme version of normal appearance concerns. BDD is characterized by a time-consuming and potentially disabling preoccupation with imagined or slight defects in one's appearance or excessive concern about a slight physical anomaly. To meet the criteria for this diagnosis, the preoccupation must cause significant distress or impair school, personal or social functioning. Although virtually any body part can become the source of preoccupation, BDD most commonly involves the eyes, ears, nose, skin, chin, jaw or other facial features.

Although the cause of BDD is unknown, most likely there are multiple sources including biological, psychological and sociocultural factors. Both medication and cognitive/behavioural therapy have been helpful in moderating the symptoms.

Signs and Symptoms 

• Feeling ashamed of a "defect"
• Inventing elaborate means to hide the deformity from the world
• Camouflaging behaviours include excessive hair combing and hair removal, and ritualized application of makeup
• Avoiding situations that might expose the perceived defect

Bulimia

Bulimia is a type of eating disorder in which the person is preoccupied with weight and body shape, and often judges him/herself harshly for perceived shortcomings. People with bulimia engage in episodes of overeating (at home or they may visit fast-food restaurants, secretly eating in the car). Then they try to rid themselves of the extra calories with self-induced vomiting or excessive exercise. Binges often occur in private. Because most people with bulimia are of normal weight or even slightly overweight, it may not be readily apparent that something is wrong. Bulimia is a serious, potentially life-threatening eating disorder. Because it is not just about food but about self-image, it can be difficult to overcome. The aim of treatment is to help individuals develop a more realistic view of themselves, feel better about themselves, adopt healthier eating patterns and reverse serious complications.

Signs and Symptoms

Physical symptoms may include:
• Abnormal bowel functioning
• Damaged teeth and gums
• Swollen salivary glands in the cheeks
• Sores in the throat and mouth
• Bloating
• Dehydration
• Fatigue
• Dry skin
• Irregular heartbeat
• Sores, scars or calluses on the knuckles or hands
• Menstrual irregularities or loss of menstruation (amenorrhea)
• Emotional and behavioural symptoms may include:
• Constant dieting
• Feeling that eating behaviour can not be controlled
• Eating until the point of discomfort or pain
• Eating much more food during a binge episode than during a normal meal or snack
• Exercising for hours on end
• Misusing laxatives, diuretics or enemas
• Being preoccupied with body shape and weight
• Having a distorted, excessively negative body image
• Going to the bathroom after eating or during meals
• Hoarding food
• Being secretive about eating, hiding food or not eating around other people

Compulsive Skin Picking

Compulsive Skin Picking (CSP), also known as dermatillomania, is an impulse disorder characterized by repetitive picking at one’s own skin to the point of causing damage. CSP has obsessive-compulsive features that are quite similar to Obsessive Compulsive Disorder, Body Dysmorphic Disorder and Trichotillomania. It is sometimes found in individuals with these disorders, as well as in patients with certain medical conditions. CSP has negative effects on a person's life: individuals with CSP take measures to hide their disorder by not leaving home, avoiding social contact, wearing long sleeves and pants in summer, and using heavy make-up for coverage. The disorder is more typically found among females than males.

Signs and Symptoms

• Recurrent skin picking of face, lips, scalp, hands or arms
• Feeling an increase in tension immediately before picking
• Feeling pleasure, gratification, decrease in tension or relief when skin picking
• Having sensations such as itching, tingling, burning or an uncontrollable urge to pick one’s skin
• Picking at normal skin variations such as freckles and moles, pre-existing scabs, sores or acne blemishes, or imagined skin defects that nobody else can observe
• Using fingernails, as well as teeth, tweezers, pins or other mechanical devices to pick at something (as a result, CSP may cause bleeding, bruises, infections or permanent disfigurement of the skin)

Stress and Anxiety Disorders

Anxiety Disorders

Anxiety is a natural human emotion; everyone feels anxious or worried at times. Many young children are frightened by the dark, have a variety of bedtime rituals and can get anxious at times of separation from a parent. However, a youngster who experiences anxiety more strongly and more readily than others and worries excessively to a degree that interferes with his or her life may have an Anxiety Disorder. Anxiety in children and teenagers can arise because of separation, fears, something catastrophic happening, being judged, worrying about things before they happen, worrying about getting a perfect score on a test, or being in school or in social situations. Anxiety is a complex emotion, and its signs and symptoms may be manifested in different ways.

Separation Anxiety Disorder

Children with separation anxiety disorder (SAD) have intense anxiety about being away from home or caregivers, which affects their ability to function socially and in school. These children may cling to parents, refuse to go to school or be afraid to sleep alone.

Generalized Anxiety Disorder

Children with generalized anxiety disorder (GAD) have recurring fears and worries that they find difficult to control. They worry about almost everything — school, sports, being on time, even natural disasters. They may be restless, irritable, tense or easily tired, and they may have trouble concentrating or sleeping. Children with GAD are usually eager to please others and may be perfectionists, dissatisfied with their own less-than-perfect performance.

Social Phobia

Young people with this disorder are extremely shy and have a constant fear of social or performance situations such as speaking in class or eating in public. They respond to these feelings by avoiding the feared situation. This fear is often accompanied by physical symptoms such as sweating, blushing, heart palpitations, shortness of breath or muscle tenseness. Young people with Social Phobia are often overly sensitive to criticism, have trouble being assertive and suffer from low self-esteem. Social phobia can be limited to specific situations, so the teenager may fear dating and recreational events, but be confident in academic and work situations.

Post-Traumatic Stress Disorder

Children who experience a physical or emotional trauma such as witnessing a shooting or disaster, surviving physical or sexual abuse, or being in a car accident may develop Post-Traumatic Stress Disorder (PTSD). A child may develop PTSD after being directly exposed to or witnessing an extreme traumatic situation involving threatened death or serious injury, or after hearing about such an event involving a family member. Victims of repeated abuse or children who live in violent environments or war zones may experience PTSD. Treatment includes community and family support, and psychotherapy.

Signs and Symptoms

Re-experiencing
• Replaying the event in his or her mind
• Recurrent memories of the event or repetitive play about the event
• Nightmares
• Arousal
• Disorganized and agitated behaviour
• Irritability or anger
• Nervousness about everyone and everything, as when people get too close
• Jumpy when hearing loud noises
• Avoidance
• Avoidance of thoughts, feelings or places that remind the child of what happened
• Numbing (lack of emotions)
• Other behaviours
• Regression to earlier behaviour, such as clinging, bedwetting and thumb sucking
• Difficulty sleeping or concentrating
• Detachment from others or social withdrawal
• Excessive use of alcohol or other substances to self-medicate

Acute Stress Disorder

This disorder refers to the immediate reaction of intense fear, helplessness or horror of a person exposed to a traumatic event, during which the person experienced, witnessed or was confronted with a situation involving actual or threatened death or serious injury (e.g, sexual assault or mugging).

Agoraphobia

Agoraphobia involves intense fear and avoidance of any place or situation where escape might be difficult or help unavailable if the individual should develop sudden panic-like symptoms. Examples include being in a car or being in crowds.

Panic Disorder (with or without Agoraphobia)

Panic Disorder (PD) is characterized by recurrent, unexpected panic attacks. As a result, people with this disorder feel intense fear when in certain situations or places. Some individuals with PD avoid places where they think panic attacks might occur, or worry about being trapped in places where help might be unavailable if an attack occurred (this is part of Agoraphobia). Young people who have PD with Agoraphobia most often avoid places with large numbers of unfamiliar people, such as school auditoriums, large parties and restaurants.

While severe anxiety may trigger a panic attack, people with PD will often have symptoms of panic without any apparent trigger. PD often begins during adolescence, although it may start during childhood, and sometimes runs in families. Unlike the occasional, mild worries that children often experience, PD may dramatically affect a child's life by interrupting his or her normal activities when an episode occurs or when the child becomes preoccupied with worry about possible future panic attacks.

Signs and Symptoms

• Trouble breathing
• Dizziness or lightheadedness
• Racing or pounding heartbeat
• Tingling and numbing sensations
• Hot or cold flushes
• Terror when in certain situations or places
• Intense fearfulness (a sense that something terrible is happening)
• Shortness of breath or a feeling of being smothered
• Trembling or shaking
• Sense of unreality
• Fear of dying, losing control or losing his or her mind

Specific Phobia

This refers to an intense, unreasonable fear of a specific object or situation. Some common phobias are animals, flying or lightning.

Mutism

Selective mutism refers to selective silence in a child who speaks freely in very familiar situations. Children who demonstrate this condition appear comfortable and talkative with close family members. However, whenever people other than the closest family members are present, the child is quiet and shy. Some children avoid eye contact and do not communicate in any form with others. They refrain from the use of gestures or changes in facial expression.

Children who are selectively mute show wide variations in their social actions. Some children enjoy contact with others and will play easily, but remain silent. Some have a close friend who often speaks for them by interpreting gestures. Others find all aspects of social situations uncomfortable and do not participate at all. Whatever form selective mutism takes, it can persist. There are children in the second, third and fourth grades who have never spoken in school. There are students in high school who have not uttered any or no more than a few words in a school setting. This condition can have dramatically negative effects on social functioning.

Signs and Symptoms

• A persistent failure to speak in specific social situations in which speaking is expected (e.g., at school) despite speaking in other situations
• Lack of speech that interferes with educational or occupational success
• Silence of at least one month's duration after the beginning of the school year
• Failure to speak not due to lack of knowledge of language used in the situation
• Lack of speech is not solely accounted for by a Communication Disorder, Psychotic Disorder or a Pervasive Developmental Disorder

School Refusal Behaviour

School Refusal Behaviour refers to children who are entirely absent or truant from school or who leave during the day. It can be associated with Social Anxiety Disorder, Separation Anxiety Disorder, Social Phobia and Conduct Disorder.

Reactive Attachment Disorder

Attachment refers to the intimate bond formed between an infant or very young child and the primary caregiver. This bond, or attachment, is considered vital to the child's emotional development and ability to establish other healthy social relationships. When infants and children under the age of five show disturbed and developmentally inappropriate social relatedness and do not initiate or respond to most social interactions, a diagnosis of Reactive Attachment Disorder is considered. This disorder develops primarily from the child living in a grossly deprived environment. There may be repeated changes of caregivers or caregivers who persistently disregard the child's physical needs or emotional needs for comfort, stimulation and affection. The physical and emotional milestones of children with Reactive Attachment Disorder deviate from expected developmental norms.

Signs and Symptoms

• Appear significantly malnourished
• Show a pattern of inhibited, hyper-vigilant or ambivalent reactions (e.g., frozen watchfulness, resistance to comfort and a mixture of approach and avoidance)
• Feel dull, listless or apathetic with a lack of spontaneous activity and reciprocity with the caregiver
• Appear sad, joyless or miserable
• Show minimal curiosity about their surroundings and little exploratory behaviour (older infants)
• Show delayed responsiveness to a stimulus that might elicit fright or withdrawal in other children
• Shrink from contact; others may exhibit indiscriminate attachments
There are two major subtypes of Reactive Attachment Disorder:
• Inhibited — the child's predominant disturbance is the persistent failure to initiate and to respond to most social interactions in a developmentally appropriate way
• Disinhibited — the child's predominant disturbance is indiscriminate sociability or a lack of selectivity in the choice of attachment figures

Learning Disorders

Learning disorders

A child with a learning disorder shows difficulty in acquiring age-appropriate competence in reading, mathematics, written expression or social skills. Learning disorders are thought to be due to variations in brain structure and function. Treatment includes the design of individualized learning strategies and modifications in school requirements.

Signs and Symptoms

• Achievement in reading, mathematics or written expression is substantially below what is expected in relation to the child’s age, schooling and level of intelligence.

Major types of learning disorders are Reading Disorder; Mathematics Disorder; Disorder of Written Expression; and Non-verbal Learning Disorder.

Reading Disorder

A child with a Reading Disorder reads significantly below the expected level. His oral reading is characterized by distortions, substitutions or omissions; both oral and silent reading is slow and shows comprehension errors. Symptoms such as inability to distinguish among common letters or to associate common phonemes with letter symbols may be apparent as early as kindergarten.

Mathematics Disorder

A child with a Mathematics Disorder may have problems in a number of different skills, such as understanding mathematical terms, operations or concepts, recognizing and reading mathematical signs, copying numbers correctly, adding and carrying numbers, observing signs, following sequences of mathematical steps, counting objects, and learning multiplication tables.

Disorder of Written Expression

A child with a Disorder of Written Expression has a combination of difficulties in the ability to compose written text, evidenced by grammatical or punctuation errors, poor paragraph organization, multiple spelling errors, and exceptionally poor handwriting.

Non-verbal Learning Disorder

A child with a Non-verbal Learning Disorder has marked problems with acquiring social skills and usually has both social and academic problems. He or she may fail to interpret the emotional responses of other people and can be insensitive to the wishes and desires of others. Children who have difficulties acquiring social skills should also be evaluated for a pervasive developmental disorder.