Child Psychiatry

Samah Khan #1001221Moaz Allababidi #11000961

Group C

Introduction ICD-10 Classification Child Assessment Pervasive Developmental Disorders Learning Disorders Disruptive Behavior Disorders Psychotic Disorders Mood Disorders Anxiety Disorders

Index

Definition (WHO): “Child and adolescent

Mental Health is the capacity to achieve and maintain optimum psychological functioning and well being. It is directly related to the level reached and competency achieved in psychological and social functioning”

Introduction

F80 - F89: Disorders of Psychological

Development

F80  Specific developmental disorders of speech and language F80.0 Specific speech articulation disorder F80.1 Expressive language disorder F80.2 Receptive language disorder F80.3 Acquired aphasia with epilepsy [Landau-Kleffner syndrome] F80.8 Other developmental disorders of speech and language F80.9 Developmental disorder of speech and language, unspecified

F81  Specific developmental disorders of scholastic skills F81.0 Specific reading disorder F81.1 Specific spelling disorder F81.2 Specific disorder of arithmetical skills F81.3 Mixed disorder of scholastic skills F81.8 Other developmental disorders of scholastic skills F81.9 Developmental disorder of scholastic skills, unspecified

ICD-10 classification

F82  Specific developmental disorder of motor function

F83  Mixed specific developmental disorders

F84 Pervasive developmental disorders F84.0 Childhood Autism F84.1 Atypical Autism F84.2 Rett’s syndrome F84.3 Other childhood disintegrative disorder F84.4 Overactive disorder associated with mental

retardation and stereotyped movement F84.5 Asperger’s syndrome F84.8 Other pervasive developmental disorders F84.9 Pervasive developmental disorder, unspecified

ICD-10 classification

F90 - F98: Behavioural and emotional

disorders with onset usually occurring in childhood and adolescence

F90 Hyperkinetic disorders (ADHD) F91 Conduct disorders F92 Mixed disorders of conduct and emotions F93 Emotional disorders with onset specific to

childhood F94 Disorders of social functioning with onset in

childhood and adolescence F95 Tic disorders

ICD-10 classification

Just like any other psychiatric history with focus on:

Detailed school history Developmental history Family interview Collateral from the child’s school (‘ABC’)

1. Academic performance2. Behaviour in school3. Classmate relationship

Child Assessment

1. Developmental disorders

Autistic spectrum disorders including: Asperger's disorder Rett’s syndrome Learning disorders

2. Disorders of attention and behavior Attention deficit hyperactivity disorder (ADHD) Oppositional defiant disorder Conduct disorder

3. Psychotic disorders Childhood onset schizophrenia

4. Mood disorders Depression Bipolar disorder

5. Anxiety disorders Panic disorder Phobias Obsessive Compulsive Disorder

6. Eating disorders Anorexia nervosa Bulimia nervosa

Broad Classification of Disorders

Pervasive developmental disorders: Impairment across multiple domains

(impairment is global): Psychological Impairment Social Impairment Academic Impairment

They are referred to as developmental disorders because they reveal themselves in early childhood (generally before 3 years of age), often as delays in normal development.

It significantly affects verbal, nonverbal, or logical communication and

social interaction skills .

Other characteristics often associated include the following : Engagement in Repetitive activities and Stereotyped movements Resistance to Environmental change or Change in daily routines Unusual responses to sensory experiences

1 - (Pervasive) Developmental disorders

Marked impairment in the use of nonverbal behaviours for social interaction: Avoid eye contact Inappropriate use of facial expression: may smile or laugh at inappropriate

times, or cry at something silly or funny Unable to “read” other people’s nonverbal gestures and body language Invade personal space Resist physical affection Not showing, bringing, or pointing out things they like Prefer solitary activity and not actively participate in simple social play Lack of awareness of other children, even siblings and does not understand

the needs of others or someone’s distress

Failure to develop peer relationships appropriate to developmental level: Does not seek other children to play with In younger child, shows little or no interest in developing friendships In an older child, may wish to develop friendship but have lack of

understanding for social conventions of friendship.

Characteristics of Autism(Social Interaction)

Impaired ability to sustain conversation Making irrelevant comments Stereotyped, repetitive or idiosyncratic* use of

language: May be “echolailic”** aka "movie talk” Verbal rituals such as saying “I’m fine” whenever

they meet someone whether or not they are asked. Imagination play may be absent or very impaired,

usually do not engage in simple imitation games May display inappropriate use of toys

Characteristics of Autism(Communication)

*Idiosyncratic language refers to language with private meanings or meaning that only makes sense to certain people– it may be used repeatedly but be inappropriate to conversation. It can be something heard on tv, or could be made-up words.**Echolalia (aka echologia) is the automatic repetition of vocalizations made by another person (by the same person is called palilalia)

Abnormalities in pitch, intonation, rate, rhythm or stress

May speak too loudly or too softly; May not know when to use loud or soft voice (intonation) Speech may be monotonous May contain question-like rises at the end of sentences

Immature grammatical structures: Inappropriate use of pronouns: I, you, she, he, it, his,

her, they, my, mine etc. May use incorrect verb tense, such as “he doed good, he

goed to the park, me be gooder”

Disturbance in language comprehension May be unable to understand simple questions,

directions or jokes.

Characteristics of Autism(Language)

Specific interests: child may display limited interests and know everything

there is to know about that particular interest and conversation will only revolve

around that area of interest

Unusual preoccupations: e.g. Road signs, toilet brushes, vacuum

cleaners, labels from cans etc.

Repetitive use of objects & compulsions/rituals: may fixate

on spinning or moving items; arranging things in a certain order etc

Unusual sensory interests: may touch, feel, smell, taste all items in

their environment, e.g. licking puzzle pieces or putting them in their mouth or

smelling blocks etc. Often they are hypersensitive to sound or touch

Repetitive motor mannerisms and self-stimulation: hand/finger flicking, flapping or complex whole body movements

Self injury: e.g. biting, smacking, pinching, poking

Special skills: unusual talents in one or more areas

Characteristics of Autism(Activities & Interests)

Previously known as “high functioning” type of autism –

higher performing children and less likely to be intellectually disabled

Communication handicap is less severe Abnormal speech intonation Appropriate language comprehension

Social interactions impaired Impaired reading of social cues Clumsy Difficulty with transition Preoccupation with matters of private interest

Asperger’s Syndrome

No specific treatment Usually require special schooling or residential

schooling but also with attempts to integrate them with regular students

Special techniques for teaching autistic children and special psychotherapeutic approaches

Antipsychotic drugs and antidepressants are used to cope with aggressive behaviour and depression

Treatment

Previously cerebroatrophic hyperammonaemia Postnatal progressive neurodevelopmental

disorder almost exclusively in girls Clinical features & characteristics:

Small hands and feet Microcephaly Repetitive stereotyped hand movements eg. hands

wringing or repeatedly putting hands in mouth Usually no verbal skills and 50% don’t walk Prone to GI disorders, esp. constipation Seizures – 80% Scoliosis FTT

Rett’s Syndrome

Common indicators of learning disorders that parents should watch for in their child include the following:

Difficulty understanding and following instructions Trouble remembering what someone just told him or her Fails to master reading, spelling, writing, and/or math skills, and

thus fails Difficulty distinguishing right from left; difficulty identifying

words or a tendency to reverse letters, words, or numbers; (for example, confusing 25 with 52, "b" with "d," or "on" with "no").

Lacks coordination in walking, sports, or small activities such as holding a pencil or tying a shoelace.

Easily loses or misplaces homework, schoolbooks, or other items.

Difficulty understanding the concept of time; is confused by "yesterday, today, tomorrow."

Learning Disorders

Symptoms

READING

• Slow, hesitant word by word reading

• Reading without punctuation

• Mirror reading, word guessing

• Omission substitution, addition of words

• Understanding, recall and drawing inference

WRITING

• Avoiding or slow writing

• Awkward pencil holding

• Poor handwriting, spelling, size inconsistency, mixing small and capital letters

• Transposition, mirror writing, add or omit letters in words

MATHEMATICS

• Longer time • Mistakes in sums

involving 0 • Difficulty in

keeping tenth, hundredth or thousand place

• Carry over or borrowing problem

• Difficulty in word problems

Management

SN PROFESSIONALS MANAGEMENT

1 Clinical Psychologists • Psychoeducation• Provide psychotherapy for the emotional

problems, anxiety, behavioural problems, poor self esteem

• Address the neuropsychological problems

2 Psychiatrists • Provide psychotherapy • Medications if required for the

comorbidities

3 Special educators • Major role in providing training and special education as per need of the child

ADD

Attention Deficit Disorder (Hyperactive type) - ADHD

Attention Deficit Disorder (Withdrawn type)

Oppositional Defiant Disorder

Conduct Disorder

2 - Disruptive Behaviour Disorders

Characterized by:

Developmentally inappropriate inattention Impulsivity Over-activity

Restless, overactive, distractible, reckless, disruptive behaviour, accident-prone

Up to 11% of school age children

Possible etiology: Subtle Dysfunction in the Frontal Lobe (which is responsible for

planning, attention, regulation of motor activity brain under-active in these children) Reduced metabolic activity Hypoperfusion

Not enough dopamine

Attention Deficit Hyperactivity Disorder

(ADHD)

Medication: Stimulants

Ritalin (methylphenidate) Dexedrine (dextroamphetamine) Adderall (D,L dextroaamphetamine)

Extended release Ritalin LA; Metadate CD, Concerta and decrease dosing to once daily

Adderall XR Vyvanse is also extended release Side effects

Anorexia, Weight loss, Lowers the seizure threshold, Abnormal movements, Labile mood, Insomnia, Hyper-focused, Agitation

Medications for ADHD – stimulants

Tricyclic Antidepressants

Imipramine, Desipramine, Clomipramine Concern about cardiac conduction

Clonidine (Catapress) Developed as an antihypertensive Reduce norepinephrine activity in the brain

Side effects Most common: dyspepsia, nausea, vomiting, fatigue, appetite

decreased, dizziness, and mood swings Less common: insomnia, sedation, depression, tremor, itching,

dry eyes, Adverse events: Increased heart rate and blood pressure; ventolin

inhalers can increase Drug interactions: Paxil and Prozac

Medications for ADHD – nonstimulants

Characterized by:

Enduring pattern of disobedience Argumentative Explosive (Impulsive) Frequently in conflict with adults Tendency to blame others

Comorbid Diagnosis with ADHD, anxiety and mood disorders

Oppositional Defiant Disorder

Characterized by:

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social rules are violated (“antisocial behaviors”)

Higher than expected rates of associated ADHD, depression and learning disorders

Considered a precursor to Antisocial Personality Disorder (must intervene and change child’s behavior to avoid this), which is not diagnosed till age of 18.

Conduct Disorder

Onset before age 18 (early onset) Onset before age 13 (very early onset) Typically presents after age 7 Presentation:

Earliest: delays in language and motor development Auditory (most common positive symptom) and visual

hallucinations Prodormal phase preceding psychotic symptoms: deterioration in

academics, social withdrawal, disorganized or unusual behavior, decreased ability to perform daily activities, deterioration in self-care, bizarre hygiene & eating behaviors, change in affect, lack of impulse control, hostility & aggression and lethargy

Delusions in >50%, but less complex than adults Diagnostic criteria similar to that of adults and based on

observed behavior by caretakers or self reports if child is old enough

3 - Psychotic disordersChildhood onset Schizophrenia

4 - Mood Disorders Depression

Frequent vague, non-specific physical complaints eg. Headaches, muscle aches, stomach-aches or fatigue

Frequent school absences or poor performance in school Talk/efforts to run away from home Outbursts of shouting, crying, unexplained irritability, complaining Being bored Lack of interest in playing with friends Alcohol or substance abuse (adolescents) Social isolation, poor communication Fear of death Extreme sensitivity to rejection or failure Increased irritability, anger or hostility Reckless behaviour Difficulty with relationships

5 of the following symptoms, must include first

2, occurring almost everyday for 2 weeks Depressed mood Anhedonia Appetite loss or increase Sleep disturbance – too much or too little Fatigue Feelings of worthlessness or guilt Difficulty concentrating or deciding Recurrent thoughts of death

Diagnostic Criteria for Major Depressive Disorder

Antidepressant medication Cognitive-Behavioral Therapy (CBT) Family Therapy Other therapies (interpersonal therapy, group

therapy, supportive psychotherapy)

Treatment

Characteristics of bipolar disorder in children:

Tend to move rapidly from cycle to cycle, even in one day, with few “well” periods

May experience both mania and depression together Moody and behavioral traits such as temperamental, rigid,

opposition, extreme irritability, episodic rage/tantrums Extreme separation anxiety as a baby Less sleep, very high energy, extremely talkative Teenagers – may believe they have superhero powers, highly

distractible, high risk-taking behavior including substance abuse and sexual indiscretions

Treatment: atypical antipsychotics (Risperdal, Zyprexa, Seroquel) and mood stabilizers (lithium or anticonvulsants like sodium valproic acid, Carbamazepine, Oxcarbazepine, Lamotrigine)

Bipolar Disorder

PA is an “acute anxiety episode in which the child or adolescent

experiences a set of emotional, cognitive and somatic symptoms in the absence of real danger that are similar to those triggered by objectively life-threatening situations”

Emotional symptoms: sense of unreality or being detached from oneself, feelings of choking, intense fearfulness

Somatic symptoms: palpitations, sweating, dizziness, trembling or shaking 

Cognitive symptoms: fear of losing control or going crazy, fear of dying

Peak intensity: within few minutes ie 5-10mins and subsides 15-30 minutes later 

Treatment: CBT, counseling psychotherapy; medical: antidepressants (SSRIs) and benzodiazepines

5 - Anxiety Disorders Panic disorder

Phobias

Age Normal Fear

Birth - 6 Months Loud noises, loss of physical support, rapid position changes, rapidly approaching other

objects

7 - 12 Months Strangers, looming objects, unexpected objects or unfamiliar people

1 – 5 Years Strangers, storms, animals, dark, separation from parents, objects, machines loud noises,

the toilet

6 – 12 Years Supernatural, bodily injury, disease, burglars, failure, criticism, punishment

12 – 18Years Performance in school, peer scrutiny, appearance, performance

Developmentally normal fears:

Intense, irrational fears of certain things or situations 3 main types of phobias:

Specific Phobia: Intense fear of a particular object that’s harmless.

Social Phobia: The fear of embarrassment in front of people.

Agoraphobia: characterized as being in places or circumstances that prove to be difficult or humiliating to escape

Specific phobias are grouped under four main types: Animal (e.g. dogs, spiders), Natural environment (e.g. heights, water), Blood-injection-injury Situational (e.g. airplanes, elevators).

Phobic reaction twofold: 1. intense irrational fear and 2. avoidance

Phobias

Symptoms:

Avoidance or distress over the object of fear results in significant disruption of routine, school functioning, family or social relationships

Crying, tantrums, trembling, freezing or clinging Tachycardia, dizziness, sweaty palms, shortness of breath,

looking flushed Feeling of choking Chest pain/discomfort Upset stomach Numbness

Treatment: CBT (relaxation training, imagery techniques, token reinforcements by parents etc), exposure therapy

Phobias

Obsessions as defined by: (DSM IV) Recurrent and persistent thoughts, impulses, or images

which are intrusive and cause marked anxiety or distress Thoughts, images, or impulses are not simply excessive

worries about real problems The person attempts to suppress the thoughts, images, or

impulses, with some other thought or actionThe person recognizes that his obsessions are a product of

his/her own mind (insight)Compulsions as defined by: (DSM IV) Repetitive behaviors that the person is driven to perform in

response to an obsession The behaviors of mental acts are aimed at reducing or

preventing distress or some dreaded event

Obsessive Compulsive Disorder

Symptoms at home:

Repeated actions to prevent a feared consequence

Consuming obsessions and compulsions Distress if ritual is interrupted Difficulty explaining unusual behavior Attempts to hide obsessions or compulsions Resistance to stopping the obsessions of

compulsions Concern that they are “crazy” because of their

thoughts

Obsessive Compulsive Disorder

Symptoms at school: (parents usually seek help when academic

performance affected): Difficulty concentrating – problem finishing or initiating school

work Social Isolation Low self-esteem Co-morbid conditions eg. ADHD, learning disorders/cognitive

problems Daydreaming – the child may be obsessing Constant need for reassurance Rereading and re-writing, repetitively erasing Repetitive behaviors – touching, checking, tracing letters Fear of doing wrong Avoid touching certain “unclean” things Withdrawal from activities or friends

Obsessive Compulsive Disorder

Treatment:

Family-based CBT Younger children need parental guidance Need to educate them that it’s not their fault

(reduce self-blame) Exposure therapy (therapist and parents) Constant praise for good behavior and

achievements Interaction with school and working with them –

flexibility and supportive environment

Obsessive Compulsive Disorder

Epidemiological research shows that anywhere from 3-

18% of children have a psychiatric disorder that causes significant functional impairment

Treatment will usually involve one or more of the following: behavior therapy, cognitive behavior therapy, problem-solving therapies, psychodynamic therapy, parent-training programs, family therapy and/or the use of medications.

Children are more resilient than adults and so early intervention at this critical period is possible with the potential for making a lifelong difference to those being seen.

Conclusion