Tag Archives: psychology

Emotional abuse and neglect

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With many thanks to Dr Harriet Clompus, paediatric SpR with an interest in community paediatrics for summarising this core-info topic so neatly and usefully.

Emotional Neglect and Abuse

Core-info, a Cardiff university based research group, examines all areas of child abuse by systematically reviewing worldwide  literature and producing recommendations based on best evidence.  This is a useful resource for paediatricians, general practitioners, health visitors, nurses, social workers, educators.  Find all their reviews at www.core-info.cardiff.ac.uk.

Core-info have produced a leaflet in cooperation with National Society of Prevention of Cruelty against Children (NSCPCC) following a review in 2011 of the available literature on emotional neglect and abuse in children less than 6 years old.  The leaflet is available at NSCPCC resources at www.nspcc.org.uk/inform.  You can also subscribe to CASPAR a news service that signposts you to latest policy, practice and research in child protection.

Definitions of emotional neglect and emotional abuse vary, but all include persistent, harmful interaction with the child by the primary care-giver.

The Core-info/NSPCC leaflet reports one in 10 children in the UK experience severe neglect in childhood.  It uses the WHO definitions for emotional neglect and abuse. (World report on violence and health  (2002) page 60.  Edited by Krug et al)

‘Emotional neglect is the failure of a parent to provide for the emotional development of the child.’

Examples of emotional neglect include:-

–  Ignoring the child’s need to interact

–  Failing to express positive feelings to the child, showing no emotion in interactions with the child

– Denying the child opportunities for interacting and communicating with peers and adults.

‘Emotional abuse includes failure of a care-giver to provide an adequate and supportive environment and includes acts that have an adverse effect on the emotional health and development of a child.  Such acts include restricting a child’s movements, denigration, ridicule, threats and intimidation, discrimination, rejection and other non-physical forms of hostile treatment.’

Examples of emotional abuse include:-

–  Persistently telling a child they are worthless or unloved

–  Bullying a child or frequently making them frightened

– Persistently ridiculing, making fun of or criticising a child.

The core-info/NSCPCC leaflet categorises behaviour/interactions to be concerned about in three different age groups (it only gives data up to 6 years and on mother (not father or other caregiver) interaction, reflecting data collection in studies reviewed).  Attachment to mother is disordered and emotionally neglected children show typical pattern of initially passive and withdrawn and then hostile and disruptive behaviour and developmental delay especially in speech and language.

1) Infant (<12 months old)

  • Mother-child interaction:  mother insensitive and unresponsive to child’s needs.  Rarely speaks to child, describes them as irritating/demanding.  Failing to engage emotionally with child during feeds.  Child unconcerned when mother leaves and when mother returns, child avoids her or does not go to her for comfort.
  • Behaviour:  Quiet and passive child.  May demonstrate developmental delay within first year, particularly in speech and language (particularly if mother has had depression).

2) Toddlers (1-3 years old)

  • Mother-child interaction: More obvious that mother is unresponsive or does not respond appropriately to child (called ‘lacking attunement’).  Mother is often critical of child and ignores signals for help.  Child is angry and avoidant of their mother.
  • Emotionally neglected/abused children grow less passive and more aggressive and hostile, particularly with other children.  They show more memory deficits than other children, including physically abused children.

3) Children (3 -6 years)

  • Mother-child interaction: Mother offers little or no praise, rarely speaks to the child and shows less positive contact.  Mother is unlikely to reach out to the child to relieve distress and the child is unlikely to go to the mother for comfort.  Neglectful mothers are more likely to resort to physical punishment than other mothers.
  • Emotionally neglected children show more speech and language delay than physically abused children.  Girls show more language delay than boys.  Their behaviour is often disruptive (rated more disruptive by parents and teachers than physically abused children or controls). They show little creativity in their play, have difficulty interpreting others emotions and have poor interactions with other children.  They tend to be less likely to help others or expect help themselves.

 

Implications for practice:

–  All practitioners (gps, paediatricians, nursery nurses and teachers, health visitors etc)  need to consider emotional neglect and abuse when assessing a child’s welfare.  The longer a child is left in an emotionally neglectful or emotionally abusive environment, the greater the damage.  However intensive work with families to increase parental sensitivity to their child’s needs, can lead to improvements in child’s emotional development.

– Important attachment disorders are recognisable in young infants and merit referral to professionals trained in infant mental health (Waltham forest has a Parent Infant Mental Health Service (PIMHS) which accepts referrals related to disordered attachment in children under 3 years.  PIMHS works with the mother and child to foster healthier attachment (the earlier in a child’s life this is done, the better the outcome).   Any health care professional can refer a family to PIMHS.  See paediatric pearls from May 2012 for more information:- www.paediatricpearls.co.uk/…/the-parent-infant-mental-health-service-pimhs

– In older children (>3 years) it can be difficult to know when and where to refer.  Emotional neglect and abuse is by definition a persistent behaviour pattern, so cannot be diagnosed on the basis of one short consultation.  Concerns about parent-child interaction witnessed in a short consultation in A+E or GP surgery may trigger a health-visitor review to gather information, prior to a possible referral to social services.  Information should be sought from all those involved in the child’s care including nursery/school teachers.   If concerns around behaviour witnessed in A+E or GP surgery are severe, an immediate referral to social services may be appropriate.

– Professionals should be able to recognise speech and language delay and refer appropriately.  See paediatric pearls from April 2012 www.paediatricpearls.co.uk/…/stages-of-normal-speech-development/.  Many of the features found in emotionally neglected and abused children may also be observed in those with Autistic Spectrum Disorder (ASD) or Attention Deficit and Hyperactivity Disorder (ADHD).  If a child is showing language delay and behavioural disruption they should be referred for a formal child development assessment (either in speech and communication clinic (SACC)  or child development clinic (CDC) – refer to Wood Street Child Development team in WF)

–  Consider risk factors – Core-info’s systematic review did not encompass ‘risk factors’ for emotional neglect and abuse.   However  it states that ‘many of these children live in homes where certain risk factors are present.  Namely – domestic abuse, maternal substance misuse, parental unemployment or mental health issues, an absence of a helpful supportive social network, lack of intimate emotional support and poverty’.

June 2013 ready to go!

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Lots of things to talk about this month.  Reminder of what Koplik spots look like, good e-learning on human trafficking, a link to the new primary care guidelines page, night terrors v. nightmares, some good allergy websites and Jess Spedding again on scaphoid injuries.  Do leave comments below.

Parasomnias

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Parasomnias – with thanks to Dr Sophia Datsopoulos

A group of sleep disorders that are paroxysmal, predictable in timing in the sleep cycle and characterized by retrograde amnesia. Polysomnography (type of sleep study in which various parameters are measured in order to rule in or out various sleep disorders), if performed, is abnormal. Diagnosis is based on a thorough history; extensive work-up seldom necessary.

Focus on: ‘Pavor Nocturnus’ or Night Terrors

Children aged three to eight years, M>F. Often family history of night terrors or sleepwalking. Occur approximately 90 minutes into sleep,
during non-REM sleep.

Presentation: Child suddenly sits bolt upright, screams, and is inconsolable for up to 15 minutes, before relaxing and falling back to sleep
with no memory of the event the next morning. Tachycardia, tachypnoea and other signs of autonomic arousal are apparent.

Management:

– Reassure families that they have a benign course and are self-limiting

– Advise them not to attempt to wake the child during an episode and that comforting during the episode may delay its recovery

– Explore and alleviate any stress in the child’s environment. Encourage a relaxing bedtime routine

– If frequent and occurring at a specific times every night, behavioural interventions such as scheduled awakenings (see http://www.epic.edu.au/sites/default/files/Sleep/PDFed/Night%20terrors.pdf) may be beneficial

– More severe forms may benefit from treatment with benzodiazepines (e.g., clonazepam) under direction of specialist services.

Main differential: nightmares – these can occur at any age, during the lighter stage of sleep when dreaming, and so tend to be later in the night.  Seizures due to temporal lobe epilepsy can appear similar to night terrors but the seizures are usually brief (30 seconds to a few minutes) and are more common in older children and adults.

 

Comparison: Night Terrors and Nightmares

Factor Sleep Terrors Nightmares
Age 3 – 8 years Any age
Gender M>F Either
Occurrence in sleep cycle NREM REM
Arousable? No Yes
Memory for event No Yes
Exacerbated by stress Yes Yes

REM = rapid eye movement; NREM = non-rapid eye movement.

 

Next month: Focus on: Somnambulism (sleep waking) and Somniloquy (sleep talking)

 

February 2013 uploaded!

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A timely reminder of an albeit old guideline on otitis media this month, continuation of our minor injuries series and introduction to a new series on sleep disorders.  Also a link to a new Whipps “1st afebrile fit” guideline and a bit of background on hypospadias.

Hypospadias

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With thanks to Dr Nikolina Kyprianou for this article and to Mr Devesh Misra, consultant paediatric urologist at the Royal London Hospital, for checking it.

Hypospadias is a congenital abnormality where the male urethral opening is displaced ventrally.  It may be displaced anywhere within the glans, the shaft of the penis, the scrotum, or the perineum.  It results from failure of the urethral folds to close during fetal development and it is often associated with abnormal penile curvature (chordee) due to disrupted development of the penile shaft.  Males with severe uncorrected forms of hypospadias may have difficulties in controlling their urinary stream which may require urination in a sitting position.  They can also have erectile dysfunction and infertility (due to impaired semen delivery).

Severity

The location of the urethral meatus classifies the hypospadias and its severity.

Figure 1. Different types of hypospadias

3 classes of severity:

  • 1st degree: urethral opening within the glans/subcoronal (50% of cases)
  • 2nd degree: urethral opening on the penile shaft (20% of cases)
  • 3rd degree: urethral opening within the scrotum or perineum (30% of cases)

Pathogenesis

Hypospadias results due to disruption of the androgenic stimulation that is required for the normal male external genitalia to develop.  Environmental factors have been found to be associated with hypospadias suggesting a multifactorial aetiology.  These include:

  • Advanced maternal age
  • Pre-existing maternal diabetes mellitus
  • Gestational age before 37 weeks
  • History of paternal hypospadias
  • Exposure to smoking and pesticides
  • IVF

Incidence

Hypospadias is one of the most common congenital abnormalities with an incidence from 0.3 to 0.7% in live male births.  It is more common in the Caucasian population and in those of Jewish and Italian descent.

Diagnosis

The diagnosis is usually made during the newborn examination.  Physical findings include:

  • The appearance of two urethral openings: the first  one will be in the normal position at the end of the glans, which will be  a blind ending urethral pit.  The second is the abnormally located true urethral meatus.
  • Abnormal foreskin due to its incomplete closure around the glans leading to the appearance of a dorsal hooded prepuce.
  • Abnormal penile curvature (chordee).

In 6% of cases the foreskin is normal and the urethral abnormality only becomes evident during/after circumcision when the glans of the penis is visualised.

Evaluation

Isolated hypospadias: this is only rarely associated with upper genitourinary tract abnormalities and therefore there is no need to
routinely perform imaging studies of the tract.

Cryptorchidism and hypospadias: these patients have an increased risk of disorders of sex development. Cryptorchidism is present in 10% of
patients with hypospadias and is higher in patients with proximal hypospadias (eg. scrotal or perineal urethral meatus).  Proximal hypospadias on its own is also associated with disorders of sex development.  These patients should be referred to a specialist so that they can have the following investigations:

  • Pelvic USS to evaluate internal genitalia.
  • Karyotype analysis.
  • Serum electrolytes as a screen for salt-wasting forms of congenital adrenal hyperplasia.

Hypospadias with other organ system anomalies eg. Congenital cardiac disease, imperforate anus, limb malformations, or cleft lip.  These patients require renal and bladder USS because they are at risk of upper tract abnormalities.  They should be referred to a specialist who will also perform genetic testing.

Management

Parents should be advised not to circumcise their baby in order to preserve the foreskin and optimise later surgical choices.  These patients need to be referred to the local paediatric urologist who will determine the severity of the hypospadias and the need and timing for surgical correction.

The goal of surgery is to create a straight penis by repairing any curvature (orthoplasty), to create a urethra with its meatus at the tip of the penis (urethroplasty), to reform the glans into a more natural conical configuration (glansplasty), to achieve cosmetically acceptable penile skin coverage, and to create a normal-appearing scrotum.   Surgery is usually performed within the first year of life because early correction is associated with improved wound
healing, reduced rate of complications and improved emotional and psychological result.  The repair is usually planned as a single-stage procedure, but in infants with severe hypospadias a two-stage repair may be necessary.

Prognosis

With the use of modern instruments, sutures and antibiotics and by performing the procedure at a younger age, the repair of hypospadias has been successful.

For a useful leaflet for parents please follow link and download the PDF document: http://www.patient.co.uk/health/Hypospadias.htm

References:

Baskin LS, Erol A, Li YW, Cunha GR. Anatomical studies of hypospadias. J Urol 1998; 160:1108.

Baskin LS, Ebbers MB. Hypospadias: anatomy, etiology, and technique. J Pediatr Surg 2006; 41:463.

Carlson WH, Kisely SR, MacLellan DL. Maternal and fetal risk factors associated with severity of hypospadias: a comparison of mild and severe cases. J Pediatr Urol 2009; 5:283.

Brouwers MM, Feitz WF, Roelofs LA, et al.  Risk factors for hypospadias. Eur J Pediatr 2007; 166:671.

www.patient.co.uk

 

September 2012 newsletter!

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Take a look at September 2012’s edition of Paediatric Pearls!  Safeguarding issues surrounding head and spinal injuries, simple motor tics, chronic fatigue syndrome, the new CATS website and some pointers to gems you might have missed from the last 3 years.  Do leave comments.

Feeding disorders

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Fussy eating is one of the most common things that parents present with to both primary and secondary care.  My colleague, Ann Duthie, has kindly allowed me to paraphrase a recent talk she gave to the department on this subject.  I hope you find the structure as sensible, helpful and reassuring as we did.

FEEDING DISORDERS IN CHILDREN encompass the behaviour of those who have difficulty consuming adequate nutrition by mouth (impaired feeding), those who eat too much and those who eat the wrong thing (pica).  We have not covered here eating disorders such as anorexia or bulimia.

Common presentations include:

  • Dysphagia
  • Food refusal
  • Self feeding inadequacy
  • Excessive meal duration
  • Choking, gagging, vomiting
  • Inappropriate mealtime behaviours
  • Food selectivity by type and texture

 

Normal feeding development is as follows:

  • Up to 6 mths – breast/bottle fed milk
  • 6-12 mths – solids introduced and increased in variety & volume.  Milk intake begins to decrease.
  • At 1 yr – teeth; family diet; ½ pt milk/day; change in attitude to food; active and wt gain slows
  • 15 mths – hold spoon, messy feeding, use feeding cup

The child moves from a state of total dependency on parents for food to one in which he/she can exert control & independence to determine what is
eaten, when and how.  Some parents struggle to adapt to this:

  • Messy
  • Feeding cues can be missed
  • Parental fear that insufficient food will be taken, child will lose weight
  • Parents own food preferences
  • Rejection of a food and assumption that child will never like it
  • Time pressures

The health professional must look for an organic cause of food refusal:

Organ system GI disorder Mechanism
Mouth Carious teeth
Structural with oral
dysphagia		 Pain
Reluctance to swallow
Pharynx Tonsils
Aspiration		 Pain, obstruction
Choke, gag
Oesophagus Reflux oesophagitis
Cows milk allergy		 Pain, burning
Stomach Motility disorder Reduced appetite,
discomfort
Colon Constipation Pain, discomfort, reduced
appetite

Children with neurodevelopmental problems or autism may have additional factors affecting their feeding behaviours.

There are 5 key elements to the assessment:

  • How is the problem manifested?
  • Is the child suffering from any disease?
  • Have child’s growth & development been affected?
  • What is the emotional climate like during mealtimes?
  • Are there any great stress factors in the family?

 

Red flags to look out for include:

  • Swallowing difficulty with cough, choke or gag
  • Vomiting/abdominal pain/arching/grimacing/eye watering
  • Recurrent chest infections
  • Stridor on feeding
  • Snoring with sleep apnoeas
  • Constipation

The history is, as always in medicine, of paramount importance and needs to be fairly detailed:

  • Birth History
  • Previous illness (inc. h/o vomiting, respiratory symptoms) & hospitalisations
  • Developmental progress
  • Chronology of feeding problem
    – Diet since birth
  • – Changes of milk formulae
    – Introduction of solids
  • Current diet (typical day)
  • What happens at meal times?
  • Family & Social history

Height and weight must be measured and plotted on an age appropriate growth chart and corrected for prematurity if less than 2 years of age.  Refer children with red flags or significant faltering growth to secondary services.

  • Management of the well child in primary care:
  • Reduce milk intake if necessary (maximum of 500mls total in 24 hours)
  • Encourage family foods
  • Meal time management (see NHS Lothian’s dietetic advice)
  • Aim: Improve infants comfort at meal times, relieve parental fears and improve parent-infant relationship

 

The multidisciplinary approach:

  • Health Visitor – can assess child within home situation
  • Dietician
  • – Nutritional assessment and feeding advice
  • – Calorie enrichment
  • – Calorie supplementation
  • – Enteral feeds (very occasionally)
  • Speech & Language therapist
  • – Direct assessment of feeding & advice in home situation
  • – Parent-child interaction
  • – Is swallow safe?
  • – Toddler feeding groups (eg. Waltham Forest’s “Ooey Gooey” group at Wood Street)

Summary points:

  • Feeding disorders in children are common
  • Occur in healthy children but assessment should be made for organic causes
  • – GI tract problems
  • – Developmental delay
  • – Autistic spectrum disorder
  • Watch out for obligate milk drinkers
  • Meal time management is crucial
  • Involve Health Visitor

 

Further resources:

Weaning your premature baby.  Free download from Leicestershire Dietetic Service 2011

Help! My child won’t eat and My child still won’t eat.  British Dietetic Association.  Available to buy in packs from http://www.ndr-uk.org/

My Child Won’t Eat by C Gonzalez                    – these are both books and the links are to www.amazon.co.uk

New Toddler Taming by C Green

The Perinatal Parent Infant Mental Health Service (PPIMHS)

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The PPIMHS teams are made up of perinatal psychiatrists, community mental health practitioners and psychotherapists/psychologists and they accept referrals from Health Visitors, GPs, midwives, Children’s Centres workers or other health professionals and self-referrals.  Click here for their referral form.  They may signpost elsewhere after the initial consultation if appropriate or they will offer the parent/carer and infant/child 9-12 sessions to work on the parent-infant relationship and/or psychiatric support as required.

Groups particularly at risk of having problems with bonding include families with ex-premature babies who have spent a significant amount of time on the Special Care Baby Unit, those where the baby has feeding issues or is difficult to soothe, those where breastfeeding failed to establish and those where there was a traumatic birth or difficult conception and/or pregnancy.  Many of the parents on their case load have a personal history of disturbed attachments and are keen not to let history repeat itself.  A recent audit showed that 41% of their mothers had some sort of mental health diagnosis which means that 59% did not.  Click here for an information leaflet about their service that you might like to give to your patients.

Mums with postnatal depression or post-partum psychosis should be referred directly to PPIMHS.  Parents struggling with a crying baby or fussy toddler but with no bonding issues should be referred to their health visitor.  The PPIMHS team is a tier 3 (specialised) service concentrating primarily on the parent-infant relationship and perinatal mental health.

Symptoms in the baby that might suggest a bonding problem:

extreme clingy behaviours, fussy, difficult to soothe, abnormal self-soothing behaviours (eg. head-banging, hair-pulling, scratching), excessive sleep problems, extreme feeding problems, lack of verbal and non-verbal communication, stiff or floppy posture, extreme fearfulness or watchfulness, lack of interest in the world, no comfort sought from parents, avoids eye contact with parents, smiles very little.

Symptoms in the parent:

high anxiety and panic about the baby, excessive A and E or GP presentations, feeling frightened of harming the baby, lack of separation between parent and baby, baby never put down, excessive sterilising of bottles and toys, detached feelings about the baby, no pride in their development, anger about baby as if baby intends to upset the parent, feelings of failure as a parent, inability to cope.

There is some evidence around this issue and around maternal stress during pregnancy and the effect of high maternal cortisol levels on the foetus’ developing brain.  I have asked the Waltham Forest PPIMHS psychologists to write a bit about that and correct anything I have written about their service!

November’s Paediatric Pearls available now!

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This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month!  NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below).  Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.

Educational psychologists in Waltham forest

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Our local educational psychologists are running drop in sessions on the 3rd Wednesday of every month at their base in Leyton, E10.  The current flyer which includes contact details is here and sessions will be on-going in 2012 even if not listed here.  They tell me that they would be happy to run EP drop in sessions or parent workshops/training/support groups  at local GP surgeries and jointly with GPs or other medical colleagues  – GPs are welcome to contact them to discuss.  Their Urdu speaking colleague runs sessions in a local Mosque as well.