Child Psychiatry 2

8/8/2019 Child Psychiatry 2

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CHILD

PSYCHIATRY 2


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INTRODUCTION

TICS DISORDER

ATTENTION DEFICIT HYPERACTIVITY

DISORDERCONDUCT DISORDER

ANXIETY DISORDER

ELIMINATION DISORDER


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TICS DISORDER Tic disorders are characterized by the

persistent presence of tics, which are

abrupt, repetitive involuntary movements andsounds that have been described as caricaturesof normal physical acts.

They can be suppressed but only for a short

time and only with conscious effort.


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EPIDEMIOLOGY Tic disorders have been reported in

people of all races, ethnic groups, and

socioeconomic classes.

As many as 1 in 100 people may

experience some form of tic disorder,

usually before the onset of puberty.


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CLASSIFICATION

Tic disorders are classified as follows:

Transient tic disorderconsists of

multiple motorand/orphonic tics with

duration ofat least 4 weeks, but less than 12 months.

The majority of tics seen in this disorder are motor

tics, though vocal tics may also be present.

Chronic tic disorderis either

single or multiple motor or phonic tics, but not both,which are present

for more than a year. For a diagnosis of chronic tic

disorder, symptoms must begin before a child is 18

years of age.


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Tourette's disorderis diagnosed when

both motorandphonic tics are present formore than a year. Symptoms typically begin

when children are between

5and 18 years old.

Tic Disorder NOS is diagnosed when

tics are present, but do not meet the criteria

for any specific ticdisorder.


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CAUSES The causes of tics and tic disorders are not fullyunderstood but most researchers believe that they are

multifactorial.

Abnormal neurotransmitters (dopamine, serotonin, and

cyclic) contribute to the disorders.

Recreational drugs or prescription medications.

Commonly involved are psychomotor stimulants

(methylphenidate, pemoline, amphetamines and

cocaine).

Genetic or transmitted within families.

Streptococcal infections have been associated with the

development of tics .


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SYMPTOMS The diagnostic criteria of all tic disorders specify that thesymptoms must appear before the age of 18 and that

they cannot result from ingestion of such substances as

stimulants or from general medical conditions as

Huntington's disease.

In transient tic disorder

-there may be single or multiple motor and/or vocal tics

that occur many times a day nearly every day for at least

four weeks, but

not for longer than one year.


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Chronic motor or vocal tic disorder

-is characterized by either motor tics or vocal tics, but not

both.

-The tics occur many times a day nearly every day, or

intermittently for a period of more than one year.

-During that time, the patient is never without symptoms

for more than three consecutive months.

Touretts syndrome

-experienced both multiple motor and one or more vocal

tics at some time during the illness-The tics occur many times a day, usually in bouts, nearly

every day or intermittently for a period of more than one

year. -The patient is never symptom-free for more than

three months at a time.


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DIAGNOSIS

HISTORY TAKING

-family history of tics or tic disorders

-whether the child has been diagnosed with otherchildhood developmental or psychiatric disorders

-whether he or she has recently had strep throat or

a similar infection.


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GENERAL EXAMINATION

-doctor rule out such other possible diagnoses : seizure disorders

encephalitis

Wilson's disease

schizophrenia

carbon monoxide poisoning

cocaine intoxication

brain injuries caused by trauma

cerebral palsy

side effects particularly stimulants and antiepilepticdrugs.


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TREATMENTPHARMACOLOGICAL

Typical neuroleptics (antipsychotic medications),

including haloperidol and pimozide . Atypical antipsychotics and other agents that block

dopamine receptors include risperidone and clozapine .

Selective serotonin reuptake inhibitors (SSRIs), which

include such medications as fluoxetine and sertralinecan be used to treat the obsessive-compulsive behaviors

associated with Tourette's disorder. They can also be

helpful with depression and impulse control difficulties,.


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NON-PHARMACOLOGICAL

Cognitive-behavioral approaches are the most common type of individual

psychotherapy used to treat tics and tic disorders.

Specific behavioral approaches include the following:

Massed negative practice: In this form of behavioral treatment, the child

is asked to perform the tic intentionally for specified periods of time

interspersed with rest periods.

Competing response training: This is a form of treatment of motor tics in

which the child is taught to make the opposite movement to the tic.

Self-monitoring: In awareness training, the child keeps a diary, small

notebook, or wrist counter for recording tics. It is supposed to reduce thefrequency of tic bouts by increasing the child's awareness of them.

Contingency management: This approach works best in the home and is

usually carried out by the parents. The child is praised or rewarded for

not performing the tics and for replacing them with acceptable alternativebehaviors.


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PROGNOSIS The prognosis for most tics and tic disorders is quitegood. In the majority of cases, the tics diminish in severity and

eventually disappear as the child grows older.

Factors associated with a poorer prognosis:

History of complications during the child's birth

Chronic physical illness in childhood Physical or emotional abuse in the family or a history of

family instability

Exposure to anabolic steroids or cocaine

Co-morbid psychiatric or developmental disorders


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@ ADHD (Attention Deficit Hyperactivity

Disorder)

Sever forms of overactivity ass with markedinattetion

*ICD 10 Hyperkinetic is classified more severeform of ADHD


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Antisocial behaviours:

-disobidience

-temper tantrums

-aggression

Children are socially socially disinhibited &

unpopular

Mood: -Fluctuating mood

-Low self esteem

-Depressive mood


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Cardinal features existing >6 months maladapative &inconsistent with development level

ICD 10 DSM IV

Symptoms


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Comorbidity:

- Conduct disorder- Depressive disorder

-Anxiety disorder

- Learning dissability

- Language impairment

* Hyperactivity not diagnosed in addition to

autism


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Boys : girls = 3 : 1

3 - 5% according to ICD 10Frequent in areas of social deprivation &

among children raised in institution


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Uncertain - suggestive of higher cognitive

excutive function abnormality in

nuerotransmitter in prefrontal & subcortical

Genetic

Environmental


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Neurological findings:

Suggestive of neurodevelopmental delay

Occur in quarter of children following TBI

Neuroimaging studies:

Functional abnormalities in prefrontal &cerebellum

Genetic studies:

Seen in first degree relatives

Monozygotic > Dizygotic

Biological paretns > adopted parents


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Social factors:

Poor social environment

Institutions

Other suggested causes:Zinc deficiency

Food additives


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Gradually lessens as child grows esp

puberty

Poor prognosis:

- ass learning difficulties

- antisocial behaviour (worst)

Persists into adult life antisocial disorder

& drug misuse

Prognosis


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Treatment

Non pharmacological Pharmacological


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Non PharmacologicalSupport & psychological treatment

Who needs?

- parents

- teachers

Family theraphy Behaviour theraphy

Group theraphy


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Pharmacological1) Stimulant drugs severe restlessness & attention

deficit

dopamine & noradrenaline activity

- Methylphenidate

- Dexamphetamine* Short term effect only

ADR:

- irritability- insomnia

- depression

- poor appetite

Hi h dosa e: rowth in child


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2) Noradrenaline reuptake inhibitor

AtomoxtineADR:

- nausea

- abdominal pain- loss of appetite

- sleep disturbance

- severe liver damage (rare)

*no addiction


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Conduct disorders


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Introduction

It takes time for children to learn how to behave

properly.

With help and encouragement from parents and

teachers, most of them will learn quickly.

All children will sometimes disobey adults.

Occasionally, a child will have a temper tantrum,

or an outburst of aggressive behaviour, but thisis nothing to worry about.


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Behavioural problems - the signs

Behavioural problems can occur in children of all ages very often they start

in early life. Toddlers and young children may refuse to do as they are asked by adults,

in spite of being asked many times.

They can be rude, and have tantrums. Hitting and kicking other people iscommon.

Some children have serious behavioural problems. The signs of this to look

out for are:

if the child continues to behave badly for several months or longer, isrepeatedly being disobedient, and aggressive.

if their behaviour is out of the ordinary, and seriously breaks the rulesaccepted in their family and community, this is much more than ordinarychildish mischief or adolescent rebelliousness.

**This sort of behaviour can affect a child's development, and can interferewith their ability to lead a normal life. When behaviour is this much of aproblem, it is called a conduct disorder**


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Definition

It is characterized by severe and persistent antisocial behaviour.

Largest single group of psychiatry disorder in older children andadolescent.

Children with a conduct disorder may get involved in more violentphysical fights, and may steal or lie, without any sign of guilt whenthey are found out.

They refuse to follow rules and may start to break the law.

They may start to stay out all night and truant from school during theday.

Teenagers with conduct disorder may also take risks with theirhealth and safety by taking illegal drugs.


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Clinical features Persistent abnormal conduct which is more serious thenordinary childhood mischief.

This centers around aggression and antisocial acts.

In the pre-school period, the disorder manifests asaggressive behaviour at home, often with over-activity.

The beaviours include disobedience, temper tantrums,physical aggression to siblings or adults, anddestructiveness.

In later childhood, it manifests s stealing, lying anddisobedience, together with verbal and physicalaggression.

Later it often becomes evident outside, especially atschool as vandalism, reckless behaviour or drug abuse.

Antisocial behavious among teenage girls includeemotional bullying of peers, sexual promiscuity andrunning away.


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There is no sharp dividing line between

conduct disorder and ordinary badbehaviour; instead there is a continuum on

which diagnostic criteria define a cut-off

point.

The cut-off defines the most severe that

have the worst outcome and are most in

help.


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Classification

Both ICD-10 and DSM-IV reqire the presenceof 3 symptoms from a list of 15 and a durationof at least 6 months.

In DSM-IV, conduct disorder is divided into

(a) Childhood-onset type (onset before 10 years old)(b) Adolescent-onset type (onset at 10 years of age or

later)

**DSM-IV has an additional category oppositional

defiant disorder for persistently hostile defiantprovocative and disruptive behaviour outsidenormal range but without aggressive or dyssocialbehaviour (mainly children below 10 years old).


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ICD-10 has 4 subdivision of conduct

disorder:

(a) Socialized conduct disorder

(b) Unsocialized conduct disorder(c) Conduct disorder confined to the family

context

(d) Oppositional defiant disorder


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Aetiology

Environmental factor- unstable, insecure, and rejectingfamilies living in deprived areas. Frequent amongchildren from broken homes in which family relationships

are poor. It is also related to wider social environment ofthe neighbourhood and school.

Genetic factor- persistent cases originating in childhoodhave a stronger genetic causes than those starting inadolescence. Alcoholism and antisocial personalitydisorder in father re reported to be strongly associated.There is evident that the variant of the monoamine-oxidase A gene predispose to conduct disorder but onlywhen combined with adverse facto in the childsenvironment.


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Organic factor- children with brain damage and epilepsyare more prone to conduct disorder, as they are topsychiatric disorders.

Other associations

difficult temperament

Child abuse Inadequate parenting

Traumatic life experiences

learning or reading difficulties (these make it difficultfor them to understand and take part in lessons. It is then

easy for them to get bored, feel stupid and misbehave) Depressed

have been bullied or abused

`hyperactive' (this causes difficulties with self-control,paying attention and following rules)


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Treatment

Parental training programmes

It uses behavioural principles. Parents are taught howthe childs antisocial behaviour maybe reinforcedunintentionally by their attention to it and how it may beprovoked by interactions with members of the family.

They are also taught how to reinforce normal behaviourby praise or rewards and how to set limits on abnormalbehaviour (removing childs privileges such as an hourless time to play a game)


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Anger management

Young people who are habitually aggressivehave been shown to misperceive hostileintentions in other people who are not in facthostile. They also tend to under estimate thelevel of their own aggressive behaviour, andchoose inappropriate behaviour rather thanmore appropriate verbal responces.

This management seek to correct these ideas byteaching how to inhibit sudden inappropriateresponses to angry feelings.


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Other methods

Remedial teaching should be arranged if there areassociated reading difficulties (special educationalprogramme). Group therapy is seldom helpful. Treatmentof co-morbid condition is also helpful.

Residential care

Residential placement may be necessary in a fosterhome, group home and special school.

Drug

Lithium, methylphenidate, carbamazepine


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Prognosis

Among males, the symptoms and behaviours in

adult life usually resemble those in childhood,

with antisocial personality traits, aggression,alcohol and drug misuse, and criminality.

Among females, the picture in adult life

corresponds less closely to that in earlier years,with a range of emotional and personality

problems.


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Two thirds of children grow up as normaladults

One third develop antisocial personality

Poor predictors- onset before age10,learning difficulties

Good predictors-Caring relationship with

one adult, absence of truancy, stable perrelationships


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Factors predisposing poor outcome:

In the young person:

Early onset

Many symptoms and behaviours

Severe symptoms and behaviours

Pervasiveness

Associated hyperactivity

In the family:

Parental psychiatry disorder Parental criminality

High hostility/ discord focused on the child


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Separation Anxiety

Disorder


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Definition

Development of inappropriate and

excessive anxiety emerging or related to

separation from the major attachmentfigure


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Epidemiology

4%in children and young adolescents

Boys=girls

Onset most common: 7-8years old


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Etiology

1. Biopsychosocial Factors

There is neurophysiological correlation of

behavioral inhibition(extreme shyness)

Children with this constellation are

shown to have higher resting heart rate

and acceleration of heart rate with tasksrequiring cognitive concentration


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Additional physiological correlation of

behavioral inhibition :

Elevated salivary cortisol level

Elevated urine catecholamine levels

Greater pupillary dilatation during cognitive

tasks


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Mothers with anxiety disorders who

show insecure attachment to their children

tend to have children with higher rates ofanxiety disorder.

External life stressors-death of relative,

child illness, moving to new neighborhood


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2.Learning Factors

Phobic anxiety may be communicated

from parents to children by direct

modelling

If parents are fearful, the child would

develop a phobic adaptations to new

situations Overprotection,exaggeration-teach

children to be anxious


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3.Genetic Factors

Parents who have panic disorder with

agoraphobia tend to have increased risk of

having a child with anxiety disorder


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Diagnosis and Clinical Features

According to DSM IV, disorder must characterised 3(or more) A:

1. Recurrent excessive distress when separation from home ormajor attachment figures occurs or is anticipated

2. Persistent and excessive worry about losing or about possible

harm befalling, major attachment figures3. Persistent and excessive worry that untoward event that will lead

to separation from a major attachment figure( getting lost or beingkidnapped )

4. Persistent reluctance or refusal to go to school or elsewherebecause of fear of separation

5. Persistently and excessive fearful or reluctant to be alone orwithout major attachment at home or without significant adults inother settings

6. Persistent reluctance or refusal to go to sleep without being neara major attachment figure or to sleep away from home


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7. Repeated nightmares involving the theme of separation

8. Repeated complaints of physical symptoms( such as headaches,stomachaches, nausea, or vomiting) when separation from amajor attachment figures occurs or is anticipated

B. The duration of disturbance must be at least 4 weeksC. The onset is before age of 18 years

D. The disturbance causes clinically significant distress or impairmentin social, academic or other important areas of functioning

The disturbance does not occur during exclusively during the course ofPervasive Development disorder, Schizophrenia, other Psychotic

Disorder and in adolescents and adults, is not better accountedfor by Panic Disorder with Agoraphobia

Specify if-Early Onset:before age of 6 years


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Pathology and Laboratory

Examination Pathology and Laboratory Examination-

none to help in diagnosis of SAD


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Differential Diagnosis

Generalized anxiety disorder

Schizophrenia

Depressive disorders

Pervasive development disorders

Major depressive disorders

Panic disorder with agoraphobia


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Course and prognosis

Young children who can attend schoolgenerally can attend school have better

Early age onset and later age at diagnosisare factors the predict slow recovery

Significant overlap of separation anxietydisorder and depressive disorders

Children with anxiety disorder are at riskfor an adult anxiety disorder but link notestablished clearly yet


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Treatment

Multimodal treatment plan including:

1. Cognitive-behavioral therapy

2. Family education

3. Family psychosocial intervention

4. Pharmacological


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Specific cognitive strategies and relaxation

exercise control anxiety

Family intervention is critical in managingSAD especially children who refuse to

attend school


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Pharmacological

SSRI- fluoxetine, fluvoxamine

Tricyclics not recommended-cardiac adr

Beta blockers-propanolol used no data to supportefficacy

Diphenhydramine(Benadryl) short term to control sleepdisturbance

Benzodiazepine-alprazolam can control SAD symptoms

Clonazepam control symptoms panic and other anxietysymptoms


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Elimination

disorders

(Enuresis and Encopresis)


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Occurs in children who have problems going to

the bathroom for both defecation and urination.

Particularly in children older than 5 years.

There may be a problem if this behavior occurs

repeatedly for longer than 3 months.


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Functional enuresis


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Functional enuresis Normally, most children achieve daytime

and night-time continence by age 3 or 4.

Therefore the definition of functional

enuresis is :

The repeated involuntary voiding of

urine occurring after an age at which

incontinence is usual in the absence ofany identified physical disorder.


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Enuresis

It may be:

1. Nocturnal (bed-wetting)

2. Diurnal (daytime wetting)

3. Both


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Nocturnal enuresis is often referred to as:

Primary- if there has been no preceding

period of urinary incontinence

Secondary- if there has been a preceding

period of urinary incontinence


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Epidemiology

Prevalence: varies

Nocturnal enuresis occurs more

frequently in boys

Diurnal enuresis:

-Has a lower prevalence

-More common in girls than boysMore than half of daytime wetter also wet

their beds at night.


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Aetiology Delay in maturation of the nervous system- may be

alone or in combination with environmental stressors.

Genetic cause- 70% of children with enuresis have a firstdegree relative who has been enuretic.

Concordance rates are twice as high in monozygotic asin dizygotic twins.

Proportion of enuretic children with psychiatric disorderis greater than that of other children.

Large families living in overcrowded conditions.

Stressful events- associated with onset of secondaryenuresis.


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AssessmentA careful history

Appropriate physical examination

-Rule out urinary infections, diabetes,

epilepsy.

Psychiatric disorders should be sought

Assess any distressing circumstances

affecting the child.

Attitudes of parents and siblings to the bed-

wetting are evaluated.


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Treatment Functional enuresis- give an explanation to the child and

parents that:

1. the condition is common

2. child is not to be blamed

3. punishment and disapproval is are inappropriate andunlikely to be effective

4. encourage to rewards success without drawing attentionto failure and not to focus attention on the problem

Many younger enuretic children improve spontaneously

soon after an explanation like this except those above 6years of age.

Next, advice about restricting fluid before bedtime, liftingthe child during night and use of star charts to rewardsuccess.


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Enuresis alarms: Modern alarms consist of a detector pad

attached to the night clothes.

An alarm buzzer carried in a pocket or on the

wrist. When the child begin to pass urine the detector

is activated and alarm sounds.

Child turns off the alarm, gets up to complete the

emptying of bladder. Requires 6-8 weeks of treatment.

Seldom succeeds with children under 6 years oldand those who are uncooperative.


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Medication

Synthetic antidiuretic hormone

desamino- D- arginine vasopressin

- treatment of nocturnal enuresis in children

over5 years of age.

- Tablet or nasal spray.

Patients relapse when treatment is stopped.ADR: rhinitis, nasal pain- therefore only use

as a temporary relief.


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Many younger enuretic children improvespontaneously soon after an explanationlike this except those above 6 years ofage.

Next, advice about restricting fluid beforebedtime, lifting the child during night anduse of star charts to reward success.

Imipramine- immediate improvement butrelapses when stopped.


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Encopresis


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Encopresis Repeated passing of feces into places other than the

toilet (may or may not be done on purpose).

They may have other symptoms which include:-

- Loss of appetite

- Abdominal pain

- Loose, watery stools (bowel movements)

- Scratching or rubbing the anal area due to irritation from

watery stools- Decreased interest in physical activity

- Withdrawal from friends and family

- Secretive behavior associated with bowel movements


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Causes C

ommonest cause is chronic (long-term) constipationwith resulting overflow incontinence (retentive

encopresis).


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Factors contributing to constipation are:

- A diet low in fiber

- Lack of exercise- Fear or reluctance to use unfamiliar bathrooms, such as

public restrooms

- Not taking the time to use the bathroom

- Changes in bathroom routines

Other possible causes: physical problem related to the

intestine's ability to move stool, develop fear orfrustration related to toilet training, stressful events in

the child's life or the child simply refuses to use the

toilet.


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Diagnosis and Epidemiology

According to DSM IV there is encopresis with constipationand overflow incontinence and encopresis without

constipation and overflow incontinence.

There are 4 diagnostic criteria: repeated passage of fecesinto inappropriate places whether accidently or on purpose,

once a month for at least 3 months, at least 4 years old (or

the developmental equivalent) and behavior is not caused

solely by substance use or by a general medical condition. It is estimated that 1.5% to 10% of children have

encopresis.

Approximately 80% of affected children are boys.


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Treatment

Begins by clearing any feces that has become impacted in

the colon.

Try to keep the child's bowel movements soft and easy

to pass. In more severe cases, may recommend to use stool

softeners or laxatives to help reduce constipation.

Psychotherapy (a type of counseling) may be used to

help the child cope with the shame, guilt, or loss of self-esteem associated with the disorder.


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Other problems associated with

Encopresis

At risk for emotional and social problems.

Develop self-esteem problems, become depressed, dopoorly in school, and refuse to socialize with other

children, including not wanting to go to parties or to

attend events requiring them to stay overnight.

If the child does not develop good bowel habits, he or

she may suffer from chronic constipation.


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Prognosis and Prevention Tends to get better as the child gets older, although the

problem can come and go for years.

May still have an occasional accident until he or she

regains muscle tone and control over his or her bowel

movements. May not be possible to prevent encopresis, getting

treatment as soon as symptoms appear may help reduce

the frustration and distress as well as the complications

related to it.

Being positive and patient with a child will help prevent

any fear or negative feelings about using the toilet.


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