Psychological problems in children

Dr Sanchoo Balachandran MD(Hom)
Calicut.  Kerala

Psychosocial Problems
Causes
Physical or emotional stress
Birth defects
Physical injury
Inconsistent and contradictory child rearing practices.
Marital conflict.
Child abuse and neglect, overindulges.
Chronic illness.

Psychosocial disorders may manifest as

• Disturbance in feeling {depression and anxiety} 
• Bodily function {psychosomatic disorders) 
• In behavior (conduct disturbance, passive aggressive behavior} 
• In performance {learning}   
• Specific agents doesn’t produce specific disorders 

Variables depend on
(1) Temperament of the child
(2) Developmental level of the child – Infants and toddlers presented with impairment of physiological functions, for example, feeding, sleep e.t.c. Whereas school aged children may present with disturbance in the interpersonal relationship or impairment of school performance or development of psychosomatic disorder and specific psychological syndromes. Eg. Phobias. Or regressing to a childish behavior
(3) Past experience.
(4) Coping and adaptive abilities of the family.
Children may react immediately to traumatic events or may keep their feelings dormant until maladaptive reactions become apparent during later periods of vulnerability.

DECISION making-whether the behavior is NORMAL OR ABNORMAL?
Some symptomatic development may be a normal part of growth. E.g. Temper tantrum is a normal negativism of toddlers; on the other hand temper tantrum on slight provocation in a six-year-old child may indicate psychosocial disturbance.

Criteria for decision making-
(1) Age.
(2) Frequency
(3) Intensity
(4) Number of symptoms
(5) Degree of functional impairment.

Management
(1) Anticipatory guidance during periods of stress may considerably help children and their families for a positive outcome. E.g. Surgery, divorce e.t.c.
(2) Children should allow expressing their feelings or encouraging doing so, rather than being told to be a good girl or a brave boy.

Psychosomatic Illness 
Psychological conflict that significantly alters somatic function is the hallmark of the psychosomatic disorder. There are three categories of psychosomatic disorders.
1) Psycophysiological disorders factors that affect the physical condition occurs when psychological reactions effect the development of a physical condition with demonstrable organic pathologic aspects (diabetes mellitus, rheumatoid arthritis, or asthma) Psycho physiological disorders has a more insidious onset than somatoforms orders. Chronic anxiety produces functional abnormalities with in the autonomic system that leads to structural changes in organ system.
2)Somatoform disorder presents with dysfunction’s that are not under conscious control and for which there is no demonstrable organic cause. (Dystrophic disorder, conversion disorder, hypochondrias is, somatisation disorder and somatoform pain disorder)

Conversion disorder
Usually presents in adolescents or adult hood
Usually starts suddenly can often be traced to a precipitating factor. and abruptly after a period of short duration.
Voluntary musculature and organs of special sense are the usual target sites for the hysterical expressions of psychological conflict. they may expressed in many forms including hysterical blindness, paralysis gait disturbances diplopic etc. Physical examination often fails to reveal objective abnormalities. histories often reveal a close relationship with a person who exhibited a similar of an actual illness.
Affected children and their families tend to be rather dramatic and hypochondria cal.

Hypochondriasis
Preoccupation with a fear of having serious illness and somatisation disorder, use of multiple somatic disturbance as a means of assuaging inner tension are also somatoform disorders.
As with conversion disorders this disorder provides alternative means for the discharge of physiological and emotional tension.
3) Factitious disorder presents with somatic and psychological complaints that are consciously controlled and self-induced for the purpose of secondary gain. (Manchausen by proxy syndrome)

Manchausen by proxy syndrome
Is a disorder characterized by parents inducing physical symptoms in their children, consider as a form of child abuse, sometimes ending in death,

Warning Observations Include
1) Persistent or recurrent illness that cannot be explained.
2) Investigation result at variance with the general health of the child.
3) Experienced doctors comments that they have never seen such cases.
4) Symptoms that do not occur when the parent is away.
5) Particularly attentive parent who refuses to leave the child alone even for a short period of time.
6) A parent who is not that worried about his or her child.
7) Clinical syndromes that poorly respond to treatment.
Signs and symptoms vary ,they include fractures, unusual injuries poisonings, persistent apnea, etc.

Factors influencing the development of psychosomatic disorders
1) Temperament
2) Environmental stress.
3) Family issues
4) Individual psychodynamics.

Guiding principles for the management of  children with psychosomatic illness.
Symptoms of affected children are not with in their conscious control, and their problems are real
It is essential for a psychiatric assessment to be arranged early in the management of these disorders: otherwise after elaborate and expensive tests have being done, the child and family often being convinced that the patient has a very serious illness for which a real cause existed that cannot be found.
Role of the emotions and the genesis of this disorders must be accepted by the parents before truly effective intervention can be affected.
Psychotherapy for the child and counseling for the family are indicated .
Child and family should be helped live as normally as possible to avoid crippling psycho logic invalidism. Stress should be placed for early return to school after acute illness, participation in recreational activities, and normal peer interactions.
Physician should be alert for indications of psychosomatic illness in parents with which children may unconsciously identify, successful treatment of parental illness may be necessary to ensure a favorable outcome in the child.

Vegetative Disorder 
Rumination disorder
The hall mark of this disorder is a weight loss a failure to gain at the expected level because of repeated regurgitation of food without nausea or associated gastrointestinal illness. .This rare disorder occurs more commonly in males usually between the age 3and 14 mo of age. It is potentially fatal. D/D includes congenital anomalies of GIT, and disorders of pyloric valve.

Pica
This eating disorder involves repeated or chronic ingestion of non-nutrient substance. The age of onset is 1 to 2yrs of age but may be earlier. Pica usually remits in childhood but can continue into adolescence adulthood. Mental retardation and lack of parental nurturing(psychological and nutritional) are predisposing factors. Although tasting and mouthing of objects is normal in infants and toddlers, pica after the second year of life needs investigation. It is often a symptom of family disorganization, poor supervision, affect ional neglect. It is more prevalent in lower socioeconomic classes. Differential diagnosis include autism, schizophrenia and certain physical disorders such as Kleine Levin syndrome.

Enuresis

• The involuntary discharge of urine after the age at which balder control should have being established is one of the common problem encountered.
• Bed wetting may be divided into
• Primary (persistent) type. in which the child has never been dry at night.-75%
• Secondary (regressive) type. in which the child who has been continent for at least one year begins wet the bed again.-50% in late school aged children.
• Persistent nocturnal enuresis is often the result of inadequate toilet training and it has been shown to occur throughout the sleep cycle. Chronic psychological stress occurring during the toddler period ,overcrowding, immigration, socioeconomic disadvantages, and psychopathologic condition are the other causes of bedwetting.
• The regressive type of bed wetting is precipitated by stressful environmental events, such as move to a new home ,marital conflict, birth of a sibling or death in family. Such bed wetting is intermittent and transitory, prognosis is better.
• Marked increase in UTI is found-urine analysis is indicated.

Management

• It is important to enlist the cooperation of the child to deal with the problem. Rewarding the child for being dry at night is a useful step.
• Older children should be expected to launder their own soiled bed clothes and pajamas.
• Children should be given no liquids after dinner time.
• Child should void before retiring.
• Waking the child repeatedly is useful only in few children and may further aggravate anger in the child or parent.
• Punishment or humiliation of the child by parents or others should be strongly discouraged.
• The use of conditioning devices is usually not necessary and should be reserved for persistent and refractory cases in which the child’s self- esteem has being seriously eroded. Consent of the child should be obtained.

Encopresis
This term refers to the passage of feaces into inappropriate places at any age after bowel control should have established. Predominantly a male disorder effect 1%of school aged children, other factor is low socioeconomic backgrounds. Encopresis indicates a more serious disturbers than enuresis and is often associated with anger.

Clinical manifestations
Chronic soiling may persist from infancy (primary), or may appear as a regressive phenomenon. It is often associated with chronic constipation. fecal impaction and overflow incontence and may progress to psycogenic mega colon. It usually represents unconscious anger and defiance in child, and parents may respond with retaliatory and punitive measures. School performance and attendance may be affected as the child becomes target of scorn and derision from schoolmates because of the offensive odor.

Management

• Measures similar to enuresis may be helpful.
• Psychotherapeutic intervention with the child and family.
• Use of mineral oil and high fiber diet.
• Sitting on the toilet for 10 to 15 minutes after each meal is often necessary.
• Rewards for compliance should be offered.
• Power and autonomy struggles should be avoided, and records of child’s elimination should be noted.
• Enemas may be needed, however chronic use should be avoided.

Sleep disorders
This are common in childhood and may be temporary, intermittent , or chronic in nature.   They related to other areas of child life like, peer groups, school performance may also expressed as sleep disturbance
Depression.
Narcolepsy.
Is a disorder causing frequent day time naps and cataplexy, sleep paralysis, and hypnologic hallucination.

Night mares.
7-15% of children suffers, more in girls, before the age of 10, charetersticed by anxiety dreams occur during rapid eye movement sleep. child awakens become lucid rapidly, and usually remembers the content of the dream.

Night terrors
2%-5%, more common in boys, especially in preschool children, chareterstied by arousal from stage for sleep, is confused and disoriented, shows signs of intense automatic activities( labored breathing, tachypnoea, tachycardia, sweating, dilated pupils) and appears to frightened. A period of somnambulism may occur. After a minute child will become oriented, and will not be able to recall the contented of the dream. And are usually self-limited.

Causes
specific developmental conflict or traumatic events.
febrile illness as a predisposing factor.
Sleep walking
10 -= 15%, school aged children
occurs in 3 or 4th stage of sleep, usually associated with nocturnal enurism, and family history of somnambulism, usually related to psychopathologic conditions and temporal lobe epilepsy should be ruled out.

Habit disorders

• Habit disorders includes tension discharging phenomena, such as—
• Head banging, body rocking.– occurring when a child is put to bed or is alone, this movements seems to provide a kind of sensory solace for the child whose is feeling otherwise uncared for or un stimulated by human touch or interaction. This movements represents a kind of internal stroking such patterns are often seen in the mentally retarded or in children sufferening from maternal or emotional deprivation.
• Nail biting, hair pulling( trichotillomania ), thumb sucking,– normal in early infancy, like other rhythmic patterns it can be seen as a way of securing extra self- nurturance.
• Teeth grinding (bruxism),–seems to result from tension originating in unexpressed anger or resentment, it may create problems in dental occlusion. helping the child to find ways to express resentment may relive the problem. bed time can be made more enjoyable and relaxed by reading or talking with the child, permitting experience and review of some of the fears or angers experienced during the day. Praise and emotional support are useful at these times

Hitting or biting parts of once own body, body manipulations,
Repetitive vocalization
Breath holding, swolling air(aerophagia)
Tics, which involve the involuntary movements of various muscle groups of the body are also included.–discharges of tension originating in emotional and physical state that have no apparent useful function. The parts of the body most frequently are the muscles of the face neck shoulders, trunks, and hands. There may be lips smacking and grimacing, tongue trusting eye blinking throat clearing and so on.
Tics usually accompany other psycatric syndromes, or follow encephalitis.
Gilles de la trourette syndrome — unknown etiology, multiple tics, compulsive barking, and grunting or shouting obscene words – boys 3 to 4 times more : prior to 7yrs :

Stuttering dysfluent speech :Primary stuttering usually begins as a atypical development during the learning of speech it starts gradually initially with the repetition of consonants ,often followed by a repetition of words and phrases . most cases resolves spontaneously and seems to remit more readily in girls.

All children at various developmental points show repetitive patterns of movement that can discussed as habits. Weather they are considered as disorders depends on the degree to which interfere with child’s physical, emotional, or social functioning. some hobbit patterns may be learned by imitation of adults. Many being as a purposeful movements that, for some reason becomes repetitive, with the habit losing its original significance and becomining a means of discharging tension.

Anxiety DisorderS
Anxiety, fearfulness and worrying are regularly experienced as a normal part of development. But when they become dis attached from specific cause or when they become disabliting to the point that they negatively affect the social interaction and development, they are pathologic and should be intervent. And they may expressed as

Stranger anxiety.— developmentally normal anxiety presents usually at the age 7- 8 months “as stranger reaction” infants begins to differentiate from their primary caregivers from strangers, they express wariness and mood changes something which they do not exhibit before. This must be diffenciate from stranger anxiety which is a more intense discomfort with obvious psycologic and physical discomfort. This infants later on as preschool children they develop fear of dark, animals and imaginary situations. And as they grow up as school aged children they give up imaginary fears and develop fears of bodily harm, and social anxiety will be developed during teenage years.

Separation anxiety disorder is characterized by unrealistic and persistent worries of possible harm befalling primary care givers ,reluctance to go to school or to sleep without being near parents ,persistent avoidance of being alone night mares involving themes of separation ,and numerous somatic symptoms and complaints of subjective distress . A large percentage of children with SAD develop feeling of panic when they are forced to separate from their parents .

Avoidance disorder is characterized by an excessive fear of contact with unfamiliar people that leads to social isolation .These children and adolescents maintain the desire for involvement with family and family peers

Overanxious disorder.: have unrealistic worries about future events, the appropriateness of past behaviors and concerns about competence They frequently present with somatic complaints , are markedly self-conscious ,need large amounts of reassurance ,and have trouble relaxing .

Obsessive compulsive disorder. presents with repetitive thoughts that invade consciousness or repetitive rituals or movements that do not obviously contribute to a high level of adaptation in any given situations .eg: some children at bedtime ,or preparing for school, touch certain objects verbalize certain words, or wash their hands continually

Phobias. Here the children are anxious only under specific conditions, and they try to avoid such situations that will automatically lead to anxiety

Post-traumatic stress disorder: is characterized by recurrent and intrusive recollection and dreams of noxious events in addition to intermittently intense psycho logic and physiologic distress in situations that symbolize the original trauma . they try to avoid stimuli associated with original trauma .symptoms are re-experiencing the trauma through intrusive recollections and dreams and re enhancement through play and other behaviors , psycho logic numbing by way of amnesia ,isolation, avoidance, reduced interest in activities ,and increased states of arousal as exemplified by sleep problems ,agitated emotions ,hyper vigilance ,extreme startle responses , and difficulty in concentrate

Psychosis in Childhood
Infantile autism
Characterized by qualitative impairment of verbal and non verbal communications ,in imaginative activities and in reciprocal social interactions.

Epidemology- 3/4 children in 10000 children, males, 30 months of age.

Clinical features.

• Non or poorly developed verbal nonverbal communications skills, abnormalities in speech pattern, Impaired abilities to sustained a conversations,
• Abnormal social play, lack of empathy, and inability to make friends.
• Stereotypic body movements,
• Very narrow interest. withdrawn and spends hours in solitary play
• Ritualistic behavior prevails, reflecting the need to maintain a constant, predictable environment.
• Tantrum like rages may accompany disruption of routine.
• Eye contact is minimal or absent.
• Echolalia, pronominal reversal, nonsense rhyming and other idiosyncratic language forms may predominate.
• Intelligence , functionally retarded range, occasionally remarkably talented.
• Lack of theory of mind- deficit in understanding what the other person may be thinking or feeling.

Etiology

• Cause of autism is speculative, and the suggested factors are
• Genetic
• Abnormal neurochemical changes in catacolline pathways, increased levels of serotonine,
• Brain injuries.
• Constitutional vulnerabilities.
• Deficit in reticular activating system.
• Unfortunate interplay between psychogenic and neurodevelopment factors.
• Structural creballar changes, forebrain hippochamal lesion.

Treatment : Behaviour therapy.

Prognosis  :With guard, a better prognosis is associated with higher intelligence, functional speech and less bizarre of symptoms and behavior.

Pervasive Developmental Disorder :Qualitative impairment in the development of reciprocal social interaction, verbal and non verbal communication, but not have the quantity of symptoms not required to be diagnosed as autism.

Late onset psychosis : Resembles psychosis of adulthood, and same diagnostic criteria applied.

Clinical Features.

• Thought disorders, delusions and hallucinations (the latter two will differentiate psychosis from autism,) 
• Aggressive behavior, chaotic. 
• Alternating moods not apparently related to environment. 
• Not usually diagnosed during childhood, and the prognosis is bad.    

Borderline personality disorder
The majority of children with late onset psychosis suffer from this disorder, also called interactive psychosis

Characterized by

• Marked instability of mood, interpersonal relationship, and sense of self.
• Suicidal threats and gestures, often abuse themselves and others physically and very impulsive nature.
• Unpredictability is frequent
• Rage reaction and manupulativeness.
• Paranoid thinking.
• Experience great deal of difficulty with attachment and separation issues.
• Their behavior often seems to a product of their desire to be at the center of their environment, when frustrated leads to rage reaction.

Disruptive Behavioral Disorder
Numerous behaviors considered appropriate at certain developmental levels are obviously abnormal when they are present at later ages.
Lying, impulsiveness, breath holding, defiance, and temper tantrums are frequently noted around the ages of 2-4yrs when children begin to need autonomy but do not have the motor and social skills necessary for successful independence This behaviors are probably the result of frustration and anger.

Breath holding is not unusual in the first year of life. It is frequently used by infants and toddlers in an attempt to control the caregivers or the environment. Sometimes it may lead to loss of consciousness and even to seizures. The parents are best advised to ignore the behavior and leave the room in response. Without sufficient reinforcement the behavior soon disappears.

Defiance, oppositional, and temper tantrums are often used by children 18 months to 3yrs of age who feel frustrated by their conflicting desires to be in control of environment in one hand, and on, the other hand to be taken care of. The parental response to this behavior is very important. Here the parents are advised to acknowledge verbally to the child that the reasons for the frustrations are understandable but that the particular response is not acceptable. Child should be given type and space to recover. But if the child is unable to give up this behavior, but instead presents with escalation, parent should non emotionally placed the child on time out or room restriction until he or she is able to adjust more reasonably. One way to help the toddler develop a sense of autonomy and to feel more in controls to allow the child to have simple choices of activities that the parents can accept.

Care givers who responds to toddlers defiance in an angry or punitive manner runs the risk of reinforcing the defiance and teaching the child that the out of control are reasonable response to frustrations. Children are often frighten by the strength and intensity of their own angry as well as by the intensity of the angry they aroused in their parents. It is there for of prime importance that the parents provide models for the control of their anger and aggressive feeling that they wish their children to follow.

Lying is often used by 2 to 4yrs as a method of playing with the language. By observing the reaction of parents , preschoolers learn cognitively and affectively about acceptation for honesty in communication In other sense lying is a fantasy for children who describe things as they wish them to be rather than as they are.

Also the lying can be the result of parental modeling, in which case the Childs interpretations of reality are confusing, conflicting and unclear. For instance when the parents accuse each other frequently of lying, the child may become hopelessly unsure of how the word lying is to be interpreted, moreover a loyalty conflict is added to the already distorted possess of reality testing.

Chronic lying however, often occurs in combination with several other antisocial behaviors and is a sign of underlying psychopathologic condition. Regardless of age or developmental level, when lying became a frequent way managing anxiety and conflict intervention is warranted initially by parents and if necessary by professionals.

Stealing- Almost all children steal at one or other point of their lives. It becomes a problem when it happens more than once or twice. Some preschoolers and school aged children steal as a response to a sense of internal loss, They frequently feel neglected and are emotionally deprived. In others it can be an expression of anger or revenge for real or imagined frustration by the parents. It is important to help the child to undo the theft by returning the article, or by money or by service.

Truancy and run away behavior are never developmentally appropriate. Some children skip school because they are afraid of peer groups or teachers or because of sense of humiliation secondary to learning difficulties, or are due to separation anxiety symptoms. Most often truancy represents disorganization in home, child abuse, neglect, personality problems. Children whom run away nowhere to go are almost always expressing a serious underlying problem.

Fire setting. Although the interest in fire is ubiquitous in early child hood, un supervised fire setting is always in appropriate. Early school aged children tent to set fire because of both curiosity and latent hostility secondary to deprivation with in a neglected family. This young children’s sets fire with in their homes. Teenagers usually set in small groups seeking revenge from school and community authorities. This children required innervations by parents, many time save by the mental health professionals.

Aggression is possibly the most serious disorder in this group. Several theories are put forward to explain human aggression. The drive theory proposed that the aggression is programmed within the human species. The phenomenologic proposes that everyday life is sufficiently depriving and frustrating that the aggression is expected. Social learning theory suggest that aggression is learned and successively reinforced thought young childhood and adolescence. Social theorist suggest that modern crowding, the breakdown of shared values ,the demise of traditional family child rearing practice, are leading to increased aggression in childhood, adolescents and adult.

Factors contributing to aggression are

•  sex –male.
•  large children.
•  more active and intrusive children.
•  difficult temperaments
•  large families
•  marital discord and aggressive parents.

The child of 2-5yrs may show aggression ranging from temper tantrums and screaming to hurting others and destroying furniture’s and toys. This is frequently due to a particular frustration and the inability to manage them. In toddlers aggression is usually directed towards parents. During the preschool years it is more directed to siblings and peers. Verbal aggression increase between 2 and 4yrs and retaliation and revenge after 3yrs.

Passive aggressive behaviors are common in childhood and adolescents. They express hostility indirectly as procreations, stubbornness or resistance. Parents usually complaints that there children do not hear them and that they fail to respond to repeated request. Academic under achievement is common. Early history shows negativism in infancy and toddler hood with poor bladder and bowel training and feeding habits.

Children may unconsciously adopt passive aggressive behavior for a variety of motives. To gain independency while maintaining dependency, to counter underlying low self-esteem, to maintain control and autonomy while threatened by anxiety. These children are fearful of direct expression of assertiveness, aggression and hostility. Child rearing styles of their parents are often intimidating, critical, and inconsistent, and on the other hand indulgent and permissive. Both parents and child often find it difficult to deal directly with anger. Parents should be encouraged to handle the passive aggressive behavior by setting firm limits and expectations.

Conduct disorder is a distinct clinical entity manifested by several antisocial behaviors, stealing, lying, fire setting, truancy, property destruction, cruelty to animals, repeated attempt to run away from home .  attend to a task, motoric over activity and impulsivity. This children are fidgety, have a difficult time in remaining in their seats, are easily distracted have difficulty in awaiting their turn, impulsively blurt out answers to questions, have difficulty in following instructions and sustaining attention, shift rapidly from one unaccompanied task to another ,talk excessively, intrude on others, often seen not to listen to what is being said. lost items regularly, and often engaged in physically dangerous activities without considering possible consequences.

Etiology
Children with A.D.H.D. differ in cognitive style, levels and type of arousal, and response to rewards. There is abnormal positron emission tomografic scans with reduced glucose metabolism in premotor and superiors prefrontal cortex in adults having A.D.H.D. Genetic factors are also considered. Dispite all the studies the cause is poorly understood.

Clinical Features.
A description of problem behavior in specifies situations are elicited. A history of aggression and fears, poor relationship between the peers, academic difficulties, behavioral problems at school, and reaction to authority define the problem and provide useful information about the concurrent presence of conduct disorder, anxiety disorder, learning disabilities. History should include events of the birth and delivery, a description of the child’s temperament, examples of early separation anxiety, a description of the child’s behavior between 18 and 30 months when the child was psychologically separating from the primary care givers, and child’s activity levels between 2 to 5yrs. Some children are described as colicky. temperamentally difficult, and overactive from a very old age. with sleep and feeding abnormalities.

The initial identification of many children with this problem commonly occurs when they enter nursery or elementary school. they are often reported to uncontrollable, refusing to sit still. They often provoke others to anger and rarely learn from their mistakes.

Differential diagnosis.
1. Should be evaluated for conduction disorder and learning disabilities.
2. Auditory impairment should be assessed in children presenting with concentrating difficulty.
3. Petit Mal epilepsy should be ruled out.
4. Medication
5. Over anxious children
6. Gills de la Tourette syndrome.

Psychiatric consideration Of Central nervous system injury.
Psychotic disorders may follow infection, injury, intoxication, genetic metabolic or idiopathic illness involving CNS. Brain injury increases the risk of both intellectual and psychiatric disorders, especially when injury is severe. Social disinhibition appears to be a sequel a of injury, but no typical psychiatric syndrome is associated. The particular expression of disturbance is depend on child developmental level, temperament, past history and family relationship.

Prematurely and neonatal complications involving hypoxia have been seen as causing such conditions as hyperactivity, impulsivity, difficulties in socialization, and poor control of emotions, especially anger.

Substance abuse during pregnancy may affect both prenatal and early childhood development, especially cocaine which can cause cerebral infraction, microcephaly, developmental delays behavior and learning problems.

Children under the age of 3yrs who survive encephalitis or meningitis seem to show more lasting effect on personality and behavior. Children with hydrocephalus and motor deficit have a seven times greater chance of developing psychiatric disorder.

Management
The most significant factor in the child’s adjustment to a chronic handicapping organic condition is the capacity of parents to adjust and cope.
A frequently beneficial approach is to help the child to identify his or her ineffective reaction patterns along with more successful patterns. It involves education with an opportunity to discuss depression, isolation, and anger and those feeling of Bering different, rejected or exploited that so much effect self-esteem. The parents have their own needs and will need advice, counseling and emotional support. Fair firm discipline is always useful.

Sexual Behavior and Its Variations
Gender identity refers to the individual’s sense of self as a male or female. Gender role on other hand refers to those behaviors with in a culture commonly thought to be associated with maleness or femaleness.

Children identify themselves as male or female by about 18months of age, i.e.; gender identity. Between 18months and 30months of age they establish gender stability. The concepts that boys become male and girls become females. By 30months gender constancy, the immutability of ones gender, is firmly established and restraint to change.

Children are naturally curious about their bodies. The two year child ought to be thought the proper names for the parts of the body, including the genitals. Parents should react clammily when the their children explore and manipulate their own bodies with enjoyment, although open masturbation by older children suggest poor awareness of social reality or lack of parental censorship. Parents should inform that the masturbation is not a social activity and should be limited to the bed room when is alone . It is important that the masturbation should be considered as a normal behavior of child’s sexual life and that guilt be avoided. By puberty children should be given explanation of its normality.

It is quiet common for the preschool children to hug and kiss each other. Especially with the ages of 10 and 12yrs boys and girls typically explore sexual issues with best friends, of same sex, as means of gathering information. This should not be viewed as prelude for homosexuality but as a development stage for the child.

Transsexulism conviction by a person biological of one gender that he or she is the member of other gender, is the most obvious example of gender identity confusion, They feel a discomfort and a sense of inappropriateness about their assigned sex, They spent years in trying to get rid of primary and secondary sexual charetertics that define them biologically. Gender roles of opposite sex are usually adopted.

Individuals with disorder usually have difficulty in social and occupational functioning. Associate depression is a feature. Extreme feminity in boys is a predisposing factor.

Tranvestism, cross dressing may occur transiently in preschool boys who dress up in their mothers clothing, or it may occur in preschool and school boys who feel genuinely excited when dressed in women’s clothing. Cross dressing in girls is rarely an identified problems. It usually indicate that the other gender roles might also be problematic for the individual.

Gender Identity Disorder

Persistent distress about being a particular gender while being pre occupied with cross gender roles repudiation of given anatomical structures is the hallmark of GID. It encompasses transsexualism, transvestism and effeminacy in boys.

Clinical features
Age of onset before 4 years. They are often ostracized by peers and have a difficult social adjustment sometimes with subsequent depression. One half of the boys develops homosexual orientation during adolescence and adulthood. GID is associated with numerous other childhood andadolesent disorder.

Treatment.
Psychotherapy and pharmacotherapy is essential. The physician needs to help the parents control their own frustration and disappointment to minimize judgmental rejecting behavior, punishment, or shamming will not support the child’s attempt to struggle with whatever intra psycatric, inter personal or cultural conflict exist.

Homosexuality
Homosexuality, the romantic and physical attraction to someone of the same gender, has occurred through out the age in about of 5% of men and women. Historically acceptance of homosexuality wax and veined with in the societies.

The etiology is uncertain. Many view it as a development as normal variation of sexual development, others point to problematic child parent relationship. Numerous psycho logic theories have been proposed. They include problems of sexual identification with parents, problematic relationship between either parent and the child, abuse overly erotized attachment, and underlying anxiety etc.

Biologic causes have also been proposed. The “dual mating center” theory sating that there are hypothalamic areas that regulate male and female sexual behaviors. It is hypothesized that too little androgen production in males during a critical prenatal period causes the female center to overdevelop and conversely, excessive androgen production in females will lead to over development of male center. Other findings, of Le Vay’s, that heterosexual and homosexual men have difference in hypothalamic structure and size. Another finding is that anterior commissure is larger in homosexual men.

There are probably multiple mechanisms leading to homosexuality in adolescence and adulthood, just as that of hertosexuality. Many complex factors leads to sexual development, and they include cultural biologic and psychological factors.

If a child found to be engaged in homosexual behaviors parent should not immediately conclude that this means child is already homosexual. Sexual behaviors in adolescents does not predict the future sexual orientation. The firstly task of the parents or the physician when they found the child engaging in homosexual practices is to help them feel safe and less guilty. Parents should avoid suspicious, scolding guilt inducing behavior, shaming and threaten towards the child. It is important to know whether the child information and understanding about the sexual matters are appropriate for the age.

If the same sexual behavior involves another child in the family he or she should be treated in the same manner. If an older child is the inciter seducer, he or she should be told clearly and firmly that such behaviors will not be tolerated and must is expected to behave with responsibility and control.