Child PsychiatryChild PsychiatryDepartment of PsychiatryDepartment of Psychiatry

11stst Faculty of Medicine Faculty of MedicineCharles University, PragueCharles University, Prague

Head: Prof. MUDr. Jiří Raboch, DrSc.Head: Prof. MUDr. Jiří Raboch, DrSc.

Child and Adolescent PsychiatryChild and Adolescent Psychiatry

Differences of Child psychiatry from adult psychiatryDifferences of Child psychiatry from adult psychiatry:: The child’s existence and emotional development The child’s existence and emotional development

depends on the family or care giversdepends on the family or care givers - - cooperation cooperation with family memberswith family members; s; sometimes written consentometimes written consent

The developmental stages are very important The developmental stages are very important assessment of the diagnosisassessment of the diagnosis

Use of psychopharmacotherapy is less common in Use of psychopharmacotherapy is less common in comparison to adult psychiatrycomparison to adult psychiatry

Children are less able to express themselves in Children are less able to express themselves in wordswords

The child who suffers by psychiatric problems in The child who suffers by psychiatric problems in childhood can be an emotionally stable person in childhood can be an emotionally stable person in adulthood, but some of the psychic disturbances adulthood, but some of the psychic disturbances can change a whole life of the child and his familycan change a whole life of the child and his family

Disorders of Psychological Disorders of Psychological Development (F80-F89) Development (F80-F89)

F80F80 Specific developmental disorders of speech Specific developmental disorders of speech and language and language

F81F81 Specific developmental disorders of scholastic Specific developmental disorders of scholastic skills skills

F82F82 Specific developmental disorder of motor Specific developmental disorder of motor function function

F83F83 Mixed specific developmental disorders Mixed specific developmental disorders F84F84 Pervasive developmental disorders Pervasive developmental disorders F88F88 Other disorders of psychological development Other disorders of psychological development F89F89 Unspecified disorder of psychological Unspecified disorder of psychological

development development

F80 Specific Developmental F80 Specific Developmental Disorders of Speech and LanguageDisorders of Speech and Language

F80F80 Specific developmental disorders of Specific developmental disorders of speech and languagespeech and language

F80.0F80.0 Specific speech articulation disorder Specific speech articulation disorder F80.1F80.1 Expressive language disorder Expressive language disorder F80.2F80.2 Receptive language disorder Receptive language disorder F80.3F80.3 Acquired aphasia with epilepsy Acquired aphasia with epilepsy

((Landau-KleffnerLandau-Kleffner))F80.8F80.8 Other developmental disorders of Other developmental disorders of

speech and language speech and language F80.9F80.9 Developmental disorder of speech Developmental disorder of speech

and language, unspecifiedand language, unspecified

F80.0F80.0 Specific Speech Articulation Specific Speech Articulation DisorderDisorder

A specific developmental disorder in which the A specific developmental disorder in which the child's use of speech sounds is below the child's use of speech sounds is below the appropriate level for its mental age, but in which appropriate level for its mental age, but in which there is a normal level of language skills. there is a normal level of language skills.

The articulation abnormalities are not caused by a The articulation abnormalities are not caused by a neurological abnormality and nonverbal neurological abnormality and nonverbal intelligence is within normal range.intelligence is within normal range.

Developmental:Developmental:• phonological disorderphonological disorder• speech articulation disorder speech articulation disorder

DyslaliaDyslalia Functional speech articulation disorderFunctional speech articulation disorder Lalling Lalling

F80.1 Expressive Language F80.1 Expressive Language DisorderDisorder

A specific developmental disorder in which A specific developmental disorder in which the child's ability to use expressive spoken the child's ability to use expressive spoken language is markedly below the language is markedly below the appropriate level for its mental age, but in appropriate level for its mental age, but in which language comprehension is within which language comprehension is within normal limits. normal limits.

There may or may not be abnormalities in There may or may not be abnormalities in articulation. articulation.

Developmental dysphasia or aphasia, Developmental dysphasia or aphasia, expressive typeexpressive type

F80.2 Receptive Language F80.2 Receptive Language DisorderDisorder

A specific developmental disorder in which the A specific developmental disorder in which the child's understanding of language is below the child's understanding of language is below the appropriate level for its mental age, particularly appropriate level for its mental age, particularly in more subtle aspects of language in more subtle aspects of language -- grammatical grammatical structures, tone of voice. structures, tone of voice.

The social reciprocity and make- believe play is The social reciprocity and make- believe play is normal and severe hearing disturbances are not normal and severe hearing disturbances are not present.present.

Developmental: Developmental: • dysphasia or aphasia, receptive typedysphasia or aphasia, receptive type• Wernicke's aphasia Wernicke's aphasia

Word deafness Word deafness

F80.3 Acquired Aphasia with F80.3 Acquired Aphasia with Epilepsy (Landau-Kleffner)Epilepsy (Landau-Kleffner)

The child loses receptive and expressive language The child loses receptive and expressive language skills after previous period of normal language skills after previous period of normal language development. The paroxysmal abnormalities on the development. The paroxysmal abnormalities on the EEG are present and in the majority of cases EEG are present and in the majority of cases epileptic seizures occur as well. epileptic seizures occur as well.

Some children become mute in a period of few Some children become mute in a period of few months.months.

Usually the onset is between the ages of three and Usually the onset is between the ages of three and seven years, with skills being lost over days or seven years, with skills being lost over days or weeks.weeks.

An inflammatory encephalitic process has been An inflammatory encephalitic process has been suggested as a possible cause of this disorder. suggested as a possible cause of this disorder.

About two-thirds of patients are left with a more or About two-thirds of patients are left with a more or less severe receptive language deficit. less severe receptive language deficit.

TreatmentTreatment

Cooperation of neurologist and speech Cooperation of neurologist and speech therapist is very important.therapist is very important.

Psychiatric treatment is necessary if the Psychiatric treatment is necessary if the child has secondary psychic problems, for child has secondary psychic problems, for example in relationship with other children example in relationship with other children or family.or family.

Nootropic drugs, psychotherapy and Nootropic drugs, psychotherapy and special education are useful.special education are useful.

F81 Specific Developmental F81 Specific Developmental Disorders of Scholastic SkillsDisorders of Scholastic Skills

F81F81 Specific developmental disorders of Specific developmental disorders of scholastic skillsscholastic skills

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

skills skills F81.9F81.9 Developmental disorder of scholastic skills, Developmental disorder of scholastic skills,

unspecifiedunspecified

Disorders in which the normal patterns of skill Disorders in which the normal patterns of skill acquisition are disturbed from the early stages of acquisition are disturbed from the early stages of development.development.

F81.0 Specific Reading DisorderF81.0 Specific Reading Disorder

The child’s reading performance is below his level The child’s reading performance is below his level of mental age. Poor schooling, mental or visual of mental age. Poor schooling, mental or visual impairment is not the cause of the delay.impairment is not the cause of the delay.

The child has difficulties in reciting the alphabet, The child has difficulties in reciting the alphabet, there are omissions of words, distortions of the there are omissions of words, distortions of the content of the facts from material read and rate of content of the facts from material read and rate of reading is very slow.reading is very slow.

Associated emotional and behavioural disturbances Associated emotional and behavioural disturbances are common during the school age period. are common during the school age period.

• "Backward reading" "Backward reading" • Developmental dyslexiaDevelopmental dyslexia• Specific reading retardationSpecific reading retardation

F81.1 Specific Spelling DisorderF81.1 Specific Spelling Disorder

Specific and significant impairment in the Specific and significant impairment in the development of spelling skills in the absence of a development of spelling skills in the absence of a history of specific reading disorder, which is not history of specific reading disorder, which is not solely accounted for by low mental age, visual solely accounted for by low mental age, visual acuity problems, or inadequate schooling.acuity problems, or inadequate schooling.

The ability to spell orally and to write out words The ability to spell orally and to write out words correctly are both affected. correctly are both affected.

• Specific spelling retardation (without reading disorder) Specific spelling retardation (without reading disorder)

F81.2 Specific Disorder of F81.2 Specific Disorder of Arithmetical SkillsArithmetical Skills

The arithmetical performance is significantly below The arithmetical performance is significantly below the level of the general intelligence, reading and the level of the general intelligence, reading and spelling skills are within normal rage. spelling skills are within normal rage.

The deficit concerns mastery of basic The deficit concerns mastery of basic computational skills of addition, subtraction, computational skills of addition, subtraction, multiplication, and division rather than of the more multiplication, and division rather than of the more abstract mathematical skills involved in algebra, abstract mathematical skills involved in algebra, trigonometry, geometry, or calculus. trigonometry, geometry, or calculus.

Developmental: Developmental: • acalculiaacalculia• arithmetical disorderarithmetical disorder• Gerstmann's syndrome Gerstmann's syndrome

F81.3 Mixed Disorder of F81.3 Mixed Disorder of Scholastic SkillsScholastic Skills

The child can suffer from all previously The child can suffer from all previously described specific developmental disorder described specific developmental disorder of scholastic skills (both arithmetical and of scholastic skills (both arithmetical and reading or spelling skills are significantly reading or spelling skills are significantly impaired)impaired)

Disorder is not solely explicable in terms of Disorder is not solely explicable in terms of general mental retardation or of general mental retardation or of inadequate schooling inadequate schooling

F82 Specific Developmental F82 Specific Developmental Disorder of Motor FunctionDisorder of Motor Function

Serious impairment in the development of motor Serious impairment in the development of motor coordination that is not solely explicable in terms of coordination that is not solely explicable in terms of general intellectual retardation or of any specific general intellectual retardation or of any specific congenital or acquired neurological disordercongenital or acquired neurological disorder

The child is generally clumsy in fine and gross The child is generally clumsy in fine and gross movements; there are difficulties in learning to tie movements; there are difficulties in learning to tie shoe laces, to run, to throw the balls. Drawing skills shoe laces, to run, to throw the balls. Drawing skills are usually also poorare usually also poor

In most cases - marked neurodevelopmental In most cases - marked neurodevelopmental immaturitiesimmaturities

• Clumsy child syndromeClumsy child syndrome• Developmental:Developmental:

coordination disordercoordination disorder dyspraxia dyspraxia

TreatmentTreatment

The family and the school have to be properly The family and the school have to be properly informed about the child’s disorder.informed about the child’s disorder.

Special educational training is necessary, Special educational training is necessary, nootropic drugs are useful.nootropic drugs are useful.

For children with coordination difficulties special For children with coordination difficulties special physical education programs may be help to physical education programs may be help to enhance the child’s self-esteem and ability to enhance the child’s self-esteem and ability to interact with peers.interact with peers.

F84 Pervasive Developmental F84 Pervasive Developmental DisordersDisorders

F84F84 Pervasive developmental disordersPervasive developmental disorders F84.0F84.0 Childhood autism Childhood autism F84.1F84.1 Atypical autism Atypical autism F84.2F84.2 Rett's syndrome Rett's syndrome F84.3F84.3 Other childhood disintegrative disorder Other childhood disintegrative disorder F84.4F84.4 Overactive disorder associated with mental Overactive disorder associated with mental

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

Disorders characterized by qualitative abnormalities in reciprocal social interactions and in patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities.

F84.0 Childhood AutismF84.0 Childhood Autism

Described by Kanner 1943 as infantile autismsDescribed by Kanner 1943 as infantile autisms Autisms are severe impairment of developmental Autisms are severe impairment of developmental

disorder which presents before age of 3 years. The disorder which presents before age of 3 years. The abnormal functioning manifest in the area of social abnormal functioning manifest in the area of social interaction, communication and repetitive interaction, communication and repetitive behaviourbehaviour

There are typical features of clinical picture:There are typical features of clinical picture:• Inability to relateInability to relate• Disorders in development of speechDisorders in development of speech• Cognitive abnormalitiesCognitive abnormalities• Stereotyped behaviourStereotyped behaviour

F84.0 Childhood AutismF84.0 Childhood Autism The cause of childhood autism is unknown, studies The cause of childhood autism is unknown, studies

of twins suggest genetic etiologyof twins suggest genetic etiology The deficits continue through whole lifeThe deficits continue through whole life;; great great

impact on his abilities to socialize and communicate impact on his abilities to socialize and communicate with other peoplewith other people

60-80% of autistic children are unable to lead 60-80% of autistic children are unable to lead independent lifeindependent life

IQ level can be normalIQ level can be normal 30-40 cases per 100 000 children30-40 cases per 100 000 children;; more common in more common in

boys than in girlsboys than in girls

• Autistic disorderAutistic disorder Infantile:Infantile: autismautism psychosispsychosis

• Kanner's syndromeKanner's syndrome

TreatmentTreatment

Specific treatment is unknown.Specific treatment is unknown. Autistic children usually require special schooling Autistic children usually require special schooling

or residential schooling although attempts of or residential schooling although attempts of integrations are also started. integrations are also started.

Special techniques for teaching autistic children Special techniques for teaching autistic children and special psychotherapeutic approaches were and special psychotherapeutic approaches were developed.developed.

Sometimes antipsychotic drugs and Sometimes antipsychotic drugs and antidepressants are used to cope with aggressive antidepressants are used to cope with aggressive behaviour and depression.behaviour and depression.

F84.1 Atypical AutismF84.1 Atypical Autism

A type of pervasive developmental disorder that A type of pervasive developmental disorder that differs from childhood autism either in age of onset differs from childhood autism either in age of onset or in failing to fulfill all diagnostic criteriaor in failing to fulfill all diagnostic criteria

Abnormal and impaired development manifests Abnormal and impaired development manifests after age 3 years or there are impairments in after age 3 years or there are impairments in communication and stereotyped behaviour is communication and stereotyped behaviour is present, but emotional response to caregivers is present, but emotional response to caregivers is not affected.not affected.

Atypical autism is diagnosed often in profoundly Atypical autism is diagnosed often in profoundly retarded individuals.retarded individuals.

• Atypical childhood psychosisAtypical childhood psychosis• Mental retardation with autistic features Mental retardation with autistic features

F84.2 Rett's Syndrome F84.2 Rett's Syndrome (Described by Rett 1964)(Described by Rett 1964)

The syndrome was described only in girlsThe syndrome was described only in girls Normal early development is followed by partial or complete Normal early development is followed by partial or complete

loss of speech and of skills in locomotion and use of hands, loss of speech and of skills in locomotion and use of hands, together with deceleration in head growth together with deceleration in head growth

In most cases onset is between 7 and 24 months of age.In most cases onset is between 7 and 24 months of age. Loss of purposive hand movements, hand-wringing Loss of purposive hand movements, hand-wringing

stereotypies, and hyperventilationstereotypies, and hyperventilation Social interaction is poor in early childhood, but can develop Social interaction is poor in early childhood, but can develop

laterlater Motor functioning is more affected in middle childhood, Motor functioning is more affected in middle childhood,

muscles are hypotonic, kyphoscoliosis and rigid spasticity in muscles are hypotonic, kyphoscoliosis and rigid spasticity in the lower limbs occurs in majority of casesthe lower limbs occurs in majority of cases

Aggressive behaviour and self injury are rather rare, the Aggressive behaviour and self injury are rather rare, the antipsychotic drugs for the control of challenging behaviour is antipsychotic drugs for the control of challenging behaviour is not often needed. not often needed.

F84.5 Asperger's SyndromeF84.5 Asperger's Syndrome

Described by Asperger as autistic psychopathy in Described by Asperger as autistic psychopathy in 1944.1944.

Characterized by the same kind of impairment of Characterized by the same kind of impairment of social activities and stereotyped features of social activities and stereotyped features of behaviour as is described in autistic children. There behaviour as is described in autistic children. There is no delay of speech and cognitive development. is no delay of speech and cognitive development. The condition occurs predominantly in boys (8:1)The condition occurs predominantly in boys (8:1)

OOften associated with marked clumsiness.ften associated with marked clumsiness. There is a strong tendency for the abnormalities to There is a strong tendency for the abnormalities to

persist into adolescence and adult life. persist into adolescence and adult life. Psychotic episodes occasionally occur in early adult Psychotic episodes occasionally occur in early adult

life. life.

• Autistic psychopathy Autistic psychopathy • Schizoid disorder of childhood Schizoid disorder of childhood

F84.3 Other Childhood F84.3 Other Childhood Disintegrative DisorderDisintegrative Disorder

These are very rare developmental disorders with a These are very rare developmental disorders with a short period of normal development before onset. short period of normal development before onset. The child looses his acquired skills within few months.The child looses his acquired skills within few months.

General loss of interest in the environment, General loss of interest in the environment, stereotyped, repetitive motor mannerisms, and stereotyped, repetitive motor mannerisms, and autistic-like abnormalities in social interaction and autistic-like abnormalities in social interaction and communication. communication.

These children usually remain without speech and These children usually remain without speech and unable to lead independent lives.unable to lead independent lives.

• Dementia infantilisDementia infantilis• Disintegrative psychosisDisintegrative psychosis• Heller's syndromeHeller's syndrome• Symbiotic psychosisSymbiotic psychosis

Behavioural and Emotional Disorders Behavioural and Emotional Disorders with Onset Usually Occurring in with Onset Usually Occurring in

Childhood and Adolescence (F90-F98)Childhood and Adolescence (F90-F98)

F90F90 Hyperkinetic disorders Hyperkinetic disorders

F91F91 Conduct disorders Conduct disorders

F92F92 Mixed disorders of conduct and emotions Mixed disorders of conduct and emotions

F93F93 Emotional disorders with onset specific to Emotional disorders with onset specific to childhood childhood

F94F94 Disorders of social functioning with onset Disorders of social functioning with onset specific to childhood and adolescence specific to childhood and adolescence

F95F95 Tic disorders Tic disorders

F98F98 Other behavioural and emotional disorders Other behavioural and emotional disorders with onset usually occurring in childhood and with onset usually occurring in childhood and adolescenceadolescence

F90F90 Hyperkinetic Hyperkinetic DDisordersisorders

F90F90 Hyperkinetic disordersHyperkinetic disorders

F90.0F90.0 Disturbance of activity and Disturbance of activity and attention attention

F90.1F90.1 Hyperkinetic conduct disorder Hyperkinetic conduct disorder

F90.8F90.8 Other hyperkinetic disorders Other hyperkinetic disorders

F90.9F90.9 Hyperkinetic disorder, unspecified Hyperkinetic disorder, unspecified

F90 Hyperkinetic DisordersF90 Hyperkinetic Disorders

Hyperkinetic disordersHyperkinetic disorders occur mostly in first five occur mostly in first five years of life, and they are several times more years of life, and they are several times more frequent in boys than in girlsfrequent in boys than in girls

The main marks of the syndrome are:The main marks of the syndrome are:

• inattentioninattention

• impulsivityimpulsivity

• hyperactivityhyperactivity ADHDADHD: Attention-Deficit Hyperactivity Disorder : Attention-Deficit Hyperactivity Disorder

(formerly MBD: minimal brain dysfunction)(formerly MBD: minimal brain dysfunction) Prevalence is from 3% to 10% of elementary-Prevalence is from 3% to 10% of elementary-

school childrenschool children

F90 Hyperkinetic DisordersF90 Hyperkinetic Disorders EtiologyEtiology: genetic predisposition, maternal : genetic predisposition, maternal

deprivation, environmental toxins or intrauterine or deprivation, environmental toxins or intrauterine or postnatal brain damagepostnatal brain damage

About 50% of children with hyperkinetic syndrome About 50% of children with hyperkinetic syndrome have so called „soft signs” and minor abnormalities have so called „soft signs” and minor abnormalities in EEGin EEG

IQ: from subnormal to high intelligenceIQ: from subnormal to high intelligence Specific learning disabilities often coexist with Specific learning disabilities often coexist with

hyperkinetic syndromehyperkinetic syndrome TTypes of hyperactivity syndrome:ypes of hyperactivity syndrome:

• disturbance of activity and attentiondisturbance of activity and attention

• hyperkinetic conduct disorderhyperkinetic conduct disorder

TreatmentTreatment

Parents and teachers have to be advised how to Parents and teachers have to be advised how to cope with hyperactive children cope with hyperactive children

Nootropic drugsNootropic drugs and mild doses of and mild doses of antipsychoticsantipsychotics are sometimes prescribed. are sometimes prescribed.

Stimulant drugsStimulant drugs as methylphenidate sometimes as methylphenidate sometimes have the paradoxical effect, according to theory, have the paradoxical effect, according to theory, that stimulants act by reducing the excessive, that stimulants act by reducing the excessive, poorly synchronized variability in the various poorly synchronized variability in the various dimensions of arousal and reactivity seen in ADHD.dimensions of arousal and reactivity seen in ADHD.

Stimulants are the drugs of first choiceStimulants are the drugs of first choice

F91 Conduct DisordersF91 Conduct Disorders

F91F91 Conduct disordersConduct disorders F91.0F91.0 Conduct disorder confined to the family context Conduct disorder confined to the family context F91.1F91.1 Unsocialized conduct disorder Unsocialized conduct disorder F91.2F91.2 Socialized conduct disorder Socialized conduct disorder F91.3F91.3 Oppositional defiant disorder Oppositional defiant disorder F91.8F91.8 Other conduct disorders Other conduct disorders F91.9F91.9 Conduct disorder, unspecified Conduct disorder, unspecified

Conduct disorders are diagnosed when the child is Conduct disorders are diagnosed when the child is showing persistent and serious dissocial or aggressive showing persistent and serious dissocial or aggressive behaviour patterns, such as excessive fighting or behaviour patterns, such as excessive fighting or bullying, cruelty to animals or other people, bullying, cruelty to animals or other people, destructiveness to property, stealing, lying, and destructiveness to property, stealing, lying, and truancy from school and running away from home.truancy from school and running away from home.

F91.0 Conduct Disorder F91.0 Conduct Disorder Confined to the Family ContextConfined to the Family Context

The dissocial or aggressive behaviour is intent on The dissocial or aggressive behaviour is intent on family members and occurs mostly at home or family members and occurs mostly at home or immediate household. Stealing from home and immediate household. Stealing from home and destruction of beloved property of particular destruction of beloved property of particular family members is typical. Social relationships family members is typical. Social relationships outside the family are within the normal range.outside the family are within the normal range.

F91.1 Unsocialized Conduct F91.1 Unsocialized Conduct DisorderDisorder

Aggressive and dissocial behaviour is connected Aggressive and dissocial behaviour is connected with the child’s poor relationships with other with the child’s poor relationships with other children and peers groups.children and peers groups.

There is a lack of close friends, rejection by other There is a lack of close friends, rejection by other children, unpopularity in the school and hostile children, unpopularity in the school and hostile feelings toward adults.feelings toward adults.

F91.2 Socialized Conduct F91.2 Socialized Conduct DisorderDisorder

The diagnosis is applied when the child is The diagnosis is applied when the child is showing aggressive and dissocial behaviour, but showing aggressive and dissocial behaviour, but relationship with children of the same age is relationship with children of the same age is adequate.adequate.

F91.3 Oppositional Defiant F91.3 Oppositional Defiant DisorderDisorder

Children under age of 9 to 10 years, showing Children under age of 9 to 10 years, showing persistently negativistic, provocative and persistently negativistic, provocative and disruptive behaviour.disruptive behaviour.

The more aggressive conduct disorders are not The more aggressive conduct disorders are not present, general law and rights of other people present, general law and rights of other people are respected.are respected.

This type of behaviour is often directed towards a This type of behaviour is often directed towards a new member of the family - i.e. step father.new member of the family - i.e. step father.

TreatmentTreatment

Family situation should be consider and its Family situation should be consider and its relation to the child’s disorder. The family therapy relation to the child’s disorder. The family therapy is necessary to enhance emotional support and is necessary to enhance emotional support and understanding. understanding.

In the cases of dysfunctional families, abused or In the cases of dysfunctional families, abused or neglected children, an adoptive homes, foster neglected children, an adoptive homes, foster care or supervised residence is recommended.care or supervised residence is recommended.

Court intervention is required for the placement.Court intervention is required for the placement.

F92 Mixed Disorders of Conduct F92 Mixed Disorders of Conduct and Emotionsand Emotions

A group of disorders characterized by the combination A group of disorders characterized by the combination of persistently aggressive, dissocial or defiant of persistently aggressive, dissocial or defiant behaviour with overt and marked symptoms of behaviour with overt and marked symptoms of depression, anxiety or other emotional upsetsdepression, anxiety or other emotional upsets

Mood disorders in children are often expressed by a Mood disorders in children are often expressed by a challenging behaviour or somatic symptomschallenging behaviour or somatic symptoms

F92 F92 Mixed disorders of conduct and emotionsMixed disorders of conduct and emotions

F92.0 Depressive conduct disorder F92.0 Depressive conduct disorder

F92.8 Other mixed disorders of conduct and emotions F92.8 Other mixed disorders of conduct and emotions

F92.9 Mixed disorder of conduct and emotions, F92.9 Mixed disorder of conduct and emotions, unspecified unspecified

F93 F93 Emotional Disorders with Emotional Disorders with Onset Specific to ChildhoodOnset Specific to Childhood

F93F93 Emotional disorders with onset specific Emotional disorders with onset specific to childhoodto childhood

F93.0F93.0 Separation anxiety disorder of Separation anxiety disorder of childhood childhood

F93.1F93.1 Phobic anxiety disorder of childhood Phobic anxiety disorder of childhood

F93.2F93.2 Social anxiety disorder of childhood Social anxiety disorder of childhood

F93.3F93.3 Sibling rivalry disorder Sibling rivalry disorder

F93.8F93.8 Other childhood emotional disorders Other childhood emotional disorders

F93.9F93.9 Childhood emotional disorder, Childhood emotional disorder, unspecifiedunspecified

F93.0 Separation Anxiety F93.0 Separation Anxiety Disorder of ChildhoodDisorder of Childhood

The child is showing anxiety when being separated The child is showing anxiety when being separated from persons who are for him emotionally important from persons who are for him emotionally important - parents, family members. Developmental stage - parents, family members. Developmental stage should be consideredshould be considered

School refusal is often a symptom of separation School refusal is often a symptom of separation anxiety disordersanxiety disorders

Treatment:Treatment:• iin the case of school refusal the child should be returned to n the case of school refusal the child should be returned to

school immediately and strict limits should be establishedschool immediately and strict limits should be established• tthe treatment is focused on family structure and he treatment is focused on family structure and

recommendation in the ways of upbringing.recommendation in the ways of upbringing.• iin severe cases use of antidepressants is necessaryn severe cases use of antidepressants is necessary

F93.1 Phobic Anxiety Disorder F93.1 Phobic Anxiety Disorder of Childhoodof Childhood

The phobic states most commonly encountered in The phobic states most commonly encountered in children involve fear of animals, insects, dark and children involve fear of animals, insects, dark and school. Animal and insect phobias usually start at school. Animal and insect phobias usually start at the age of 5 years and almost none start in adult the age of 5 years and almost none start in adult life. Some phobias start in the late adolescence - life. Some phobias start in the late adolescence - i.e. agoraphobiai.e. agoraphobia

Treatment:Treatment:• psychotherapy and a sensible parental handling is psychotherapy and a sensible parental handling is

recommendedrecommended• the anxiety reducing techniques are useful, i.e. the anxiety reducing techniques are useful, i.e.

desensitizationdesensitization

F93.2 Social Anxiety Disorder of F93.2 Social Anxiety Disorder of ChildhoodChildhood

TThere is a wariness of strangers and social apprehension or here is a wariness of strangers and social apprehension or anxiety when encountering new, strange, or socially anxiety when encountering new, strange, or socially threatening situations. This category should be used only threatening situations. This category should be used only where such fears arise during the early years, and are both where such fears arise during the early years, and are both unusual in degree and accompanied by problems in social unusual in degree and accompanied by problems in social functioning.functioning.

A fear of social encounters is associated with avoidance A fear of social encounters is associated with avoidance behaviour, which produces problems in functioning in a peers behaviour, which produces problems in functioning in a peers group and in the school performance as well. group and in the school performance as well.

TThe social acceptance of the child can be very difficult and can he social acceptance of the child can be very difficult and can have impact on his or hers further personal development. have impact on his or hers further personal development.

TreatmentTreatment::• psychotherapypsychotherapy• aanxiolytic drugsnxiolytic drugs

F93.3 Sibling Rivalry DisorderF93.3 Sibling Rivalry Disorder

Some degree of emotional disturbance usually Some degree of emotional disturbance usually following the birth of an immediately younger following the birth of an immediately younger sibling is shown by a majority of young children.sibling is shown by a majority of young children.

Sibling rivalry disorderSibling rivalry disorder should be diagnosed only if should be diagnosed only if the degree or persistence of the disturbance is both the degree or persistence of the disturbance is both statistically unusual and associated with statistically unusual and associated with abnormalities of social interaction.abnormalities of social interaction.

The children with sibling rivalry disorder are acting The children with sibling rivalry disorder are acting with serious hatred to the new born, in severe cases with serious hatred to the new born, in severe cases they are showing physical harming behaviour and they are showing physical harming behaviour and persistent competition to gain parents attention.persistent competition to gain parents attention.

Treatment:Treatment:• psychotherapypsychotherapy dealing with family structure dealing with family structure• preventionprevention

F94 F94 Disorders of Social Disorders of Social Functioning with Onset Specific to Functioning with Onset Specific to

Childhood and AdolescenceChildhood and Adolescence

F94F94 Disorders of social functioning with onset Disorders of social functioning with onset specific to childhood and adolescencespecific to childhood and adolescence

F94.0F94.0 Elective mutism Elective mutism

F94.1F94.1 Reactive attachment disorder of childhood Reactive attachment disorder of childhood

F94.2F94.2 Disinhibited attachment disorder of childhood Disinhibited attachment disorder of childhood

F94.8F94.8 Other childhood disorders of social functioning Other childhood disorders of social functioning

F94.9F94.9 Childhood disorder of social functioning, Childhood disorder of social functioning, unspecified unspecified

This group of disorders is characterized by This group of disorders is characterized by abnormalities in social functioning which are not abnormalities in social functioning which are not associated with severe deficit and social incapacity associated with severe deficit and social incapacity found in pervasive developmental disorders.found in pervasive developmental disorders.

F94.0 Elective MutismF94.0 Elective Mutism

Characterized by a marked, emotionally Characterized by a marked, emotionally determined selectivity in speaking, such that the determined selectivity in speaking, such that the child demonstrates a language competence in child demonstrates a language competence in some situations but fails to speak in other some situations but fails to speak in other (definable) situations(definable) situations

These children show specific personality features These children show specific personality features as social anxiety and oversensitivity.as social anxiety and oversensitivity.

TreatmentTreatment::• psychotherapypsychotherapy• in severe cases anxiolytic drugsin severe cases anxiolytic drugs

F94.1 Reactive Attachment F94.1 Reactive Attachment Disorder of ChildhoodDisorder of Childhood

Characterized by abnormal social responses of the Characterized by abnormal social responses of the child to the care givers that develop before age of 5 child to the care givers that develop before age of 5 years. years.

The disorder is often an outcome of a parental The disorder is often an outcome of a parental neglect, abuse or mishandling and deprivation in neglect, abuse or mishandling and deprivation in institutional care.institutional care.

The child shows fearfulness, poor social interaction The child shows fearfulness, poor social interaction with peers, aggressive responses and self injurious with peers, aggressive responses and self injurious behaviour. behaviour.

The language development could also be delayed The language development could also be delayed and impaired physical growth can occur.and impaired physical growth can occur.

TreatmentTreatment::• avoidance of mishandling in institutional care avoidance of mishandling in institutional care • good foster homes and adoption policygood foster homes and adoption policy• social vigilance to inept parentingsocial vigilance to inept parenting

F94.2F94.2 Disinhibited Attachment Disinhibited Attachment Disorder of ChildhoodDisorder of Childhood

AAbnormal social functioningbnormal social functioning develops during first develops during first 5 years in children who have no opportunity of 5 years in children who have no opportunity of emotionally stable relationship with care givers. emotionally stable relationship with care givers. The disturbance can be recognized in children The disturbance can be recognized in children growing from infancy in institutions or growing from infancy in institutions or experiencing extremely frequent changes in care experiencing extremely frequent changes in care givers.givers.

To avoid this developmental disturbance good To avoid this developmental disturbance good adoption policy is necessary. Non - attachment adoption policy is necessary. Non - attachment institutional care should be excluded from praxis.institutional care should be excluded from praxis.

F95 F95 Tic DisordersTic Disorders A tic is an involuntary, rapid, recurrent, nonrhythmic A tic is an involuntary, rapid, recurrent, nonrhythmic

motor movement (usually involving circumscribed motor movement (usually involving circumscribed muscle groups) or vocal production that is of sudden muscle groups) or vocal production that is of sudden onset and that serves no apparent purposeonset and that serves no apparent purpose

Tics are experienced as irresistible, but can be Tics are experienced as irresistible, but can be suppressed for shorter periods of timesuppressed for shorter periods of time

Conditions of diagnosis are also a lack of Conditions of diagnosis are also a lack of neurological disorder, repetitiveness, disappearance neurological disorder, repetitiveness, disappearance during sleep, lack of rhythmicity, and lack of purposeduring sleep, lack of rhythmicity, and lack of purpose

F95 F95 Tic DisordersTic Disorders

Simple motor ticsSimple motor tics:: eye eye--blinking, neck-jerking, blinking, neck-jerking, shoulder-shruggingshoulder-shrugging,, facial grimacing facial grimacing

Simple vocal ticsSimple vocal tics:: throat clearing throat clearing,, barking, barking, sniffing, hissingsniffing, hissing

Complex motor ticsComplex motor tics:: jumping and hopping jumping and hopping Complex vocal ticsComplex vocal tics:: repetition of particular words repetition of particular words

or sentencesor sentences,, and sometimes the use of socially and sometimes the use of socially unacceptable (often obscene) words (coprolalia), unacceptable (often obscene) words (coprolalia), and the repetition of one's own sounds or words and the repetition of one's own sounds or words (palilalia)(palilalia)

Classification of Tic DisordersClassification of Tic Disorders

F95F95 Tic disorders Tic disorders

F95.0F95.0 Transient tic disorder Transient tic disorder

F95.2F95.2 Combined vocal and multiple Combined vocal and multiple motor tic disorder (de la Tourette)motor tic disorder (de la Tourette)

F95.8F95.8 Other tic disorders Other tic disorders

F95.9F95.9 Tic disorder, unspecified Tic disorder, unspecified

TreatmentTreatment Sleep therapySleep therapy HypnotherapyHypnotherapy HydrotherapyHydrotherapy NeurosurgeryNeurosurgery Shock therapyShock therapy

Antipsychotic drugsAntipsychotic drugs AntidepressantsAntidepressants Nootropic drugsNootropic drugs

Behavioural and cognitive therapyBehavioural and cognitive therapy Cooperation with the family is important.Cooperation with the family is important.

F98 Other Behavioural and Emotional F98 Other Behavioural and Emotional Disorders with Onset Usually Occurring in Disorders with Onset Usually Occurring in

Childhood and AdolescenceChildhood and Adolescence

F98F98 Other behavioural and emotional disorders with onset Other behavioural and emotional disorders with onset usually occurring in childhood and adolescenceusually occurring in childhood and adolescence

F98.0F98.0 Nonorganic enuresis Nonorganic enuresis

F98.1F98.1 Nonorganic encopresis Nonorganic encopresis

F98.2F98.2 Feeding disorder of infancy and childhood Feeding disorder of infancy and childhood

F98.3F98.3 Pica of infancy and childhood Pica of infancy and childhood

F98.4F98.4 Stereotyped movement disorders Stereotyped movement disorders

F98.5F98.5 Stuttering Stuttering ((stammeringstammering))

F98.6F98.6 Cluttering Cluttering

F98.8F98.8 Other specified behavioural and emotional disorders with Other specified behavioural and emotional disorders with onset usually occurring in onset usually occurring in

F98.9F98.9 Unspecified behavioural and emotional disorders with Unspecified behavioural and emotional disorders with onset usually occurring in childhood and adolescenceonset usually occurring in childhood and adolescence

F98.0 Nonorganic EnuresisF98.0 Nonorganic Enuresis The child is not able of voluntary bladder control The child is not able of voluntary bladder control

during the day (enuresis diurnal) or during the night during the day (enuresis diurnal) or during the night (enuresis nocturnal)(enuresis nocturnal)

The enuresis may be present from birth (enuresis The enuresis may be present from birth (enuresis primaria), or it may occur after a period of time of primaria), or it may occur after a period of time of acquired bladder control (enuresis secundaria)acquired bladder control (enuresis secundaria)

There is no neurological disorder or structural There is no neurological disorder or structural abnormality of urinary system, or lack of bladder abnormality of urinary system, or lack of bladder control is not due to epileptic attacks or cystitis or control is not due to epileptic attacks or cystitis or diabetic polyuriadiabetic polyuria

Enuresis is not diagnosed in a child less than 4 years Enuresis is not diagnosed in a child less than 4 years of mental ageof mental age

Emotional problems may arise as a secondary Emotional problems may arise as a secondary consequence of enuresisconsequence of enuresis

TreatmentTreatment

Mild restriction of fluids before bedtimeMild restriction of fluids before bedtime Waking for the toilet during the nightWaking for the toilet during the night Rewarding success and not to focus attention on Rewarding success and not to focus attention on

failurefailure AntidepressantsAntidepressants

F98.1 Nonorganic EncopresisF98.1 Nonorganic Encopresis The diagnosis involves repeated intended or The diagnosis involves repeated intended or

unintended passage of faeces in places not unintended passage of faeces in places not appropriate for that purpose.appropriate for that purpose.

The etiology:The etiology:a)a) result of inappropriate toilet trainingresult of inappropriate toilet training

b)b) the child is able of bowel control, but because of the child is able of bowel control, but because of different reasons is refusing to defecate in appropriate different reasons is refusing to defecate in appropriate placesplaces

c)c) physiological problems or emotional problemsphysiological problems or emotional problems Encopresis can be accompanied by smearing of Encopresis can be accompanied by smearing of

faeces over the body or environment or is a part of faeces over the body or environment or is a part of anal masturbation. It occurs in children with anal masturbation. It occurs in children with emotional or behavioural disturbances or mentally emotional or behavioural disturbances or mentally retarded persons.retarded persons.

TreatmentTreatment

PsychotherapyPsychotherapy• to reward successto reward success• the child is taught to establish more normal the child is taught to establish more normal

bowel habit, for example by sitting on the toilet bowel habit, for example by sitting on the toilet regularly after the mealsregularly after the meals

Anxiolytics or antidepressantsAnxiolytics or antidepressants

F98.2 Feeding Disorder of F98.2 Feeding Disorder of Infancy and ChildhoodInfancy and Childhood

Feeding disorder generally involves food refusal Feeding disorder generally involves food refusal and extreme faddiness in the presence of an and extreme faddiness in the presence of an adequate food supply, a reasonably competent adequate food supply, a reasonably competent caregiver, and the absence of organic disease. caregiver, and the absence of organic disease.

Can be associated with rumination (repeated Can be associated with rumination (repeated regurgitation without nausea)regurgitation without nausea)

Occurs often in children in institutional care or Occurs often in children in institutional care or mentally retardedmentally retarded

F98.3 Pica of Infancy and F98.3 Pica of Infancy and ChildhoodChildhood

Persistent eating of non - nutritive substances Persistent eating of non - nutritive substances (soil, wall paint)(soil, wall paint)

Common in mentally retarded children or very Common in mentally retarded children or very young children with normal intelligence levelyoung children with normal intelligence level

F98.4 Stereotyped Movement F98.4 Stereotyped Movement DisordersDisorders

Voluntary, repetitive, stereotyped, nonfunctional Voluntary, repetitive, stereotyped, nonfunctional (and often rhythmic) movements that do not form (and often rhythmic) movements that do not form part of any recognized psychiatric or neurological part of any recognized psychiatric or neurological condition.condition.

The non self-injurious movements:The non self-injurious movements:• body-rockingbody-rocking• head-rockinghead-rocking• hair-pluckinghair-plucking• hair-twistinghair-twisting• finger-flicking mannerismsfinger-flicking mannerisms• hand-flappinghand-flapping

Stereotyped self-injurious behaviourStereotyped self-injurious behaviour::• repetitive head-bangingrepetitive head-banging• face-slappingface-slapping• eye-pokingeye-poking• biting of hands, lips or other body partsbiting of hands, lips or other body parts

IIn mentally retarded children, or in some children n mentally retarded children, or in some children with visual impairment.with visual impairment.

F98.5 Stuttering (Stammering)F98.5 Stuttering (Stammering)

Frequent repetition of prolongation of Frequent repetition of prolongation of sounds or syllables or wordssounds or syllables or words

Could be transient phase in early Could be transient phase in early childhood or persistent speech failure until childhood or persistent speech failure until adult lifeadult life

F98.6 ClutteringF98.6 Cluttering

A A rapid rate of speech with breakdown in fluency, rapid rate of speech with breakdown in fluency, but no repetitions or hesitations, of a severity to but no repetitions or hesitations, of a severity to give rise to diminished speech intelligibility. give rise to diminished speech intelligibility.

Speech is erratic and dysrhythmic, with rapid Speech is erratic and dysrhythmic, with rapid jerky spurts that usually involve faulty phrasing jerky spurts that usually involve faulty phrasing patternspatterns

F98.8 F98.8 Other Specified Behavioural and Other Specified Behavioural and Emotional Disorders with Onset Usually Emotional Disorders with Onset Usually

Occurring in Childhood and AdolescenceOccurring in Childhood and Adolescence

Attention deficit disorder without Attention deficit disorder without hyperactivityhyperactivity

Excessive masturbationExcessive masturbation Nail — bitingNail — biting Nose — pickingNose — picking Thumb — suckingThumb — sucking

Psychic Disorders that Usually Occur in Psychic Disorders that Usually Occur in Adulthood but Can Have Early Onset in Adulthood but Can Have Early Onset in

Childhood or AdolescenceChildhood or Adolescence

Schizophrenic disordersSchizophrenic disorders with early onset in with early onset in childhood occur, but they are very rare and the childhood occur, but they are very rare and the prognosis is poor, because of influence on psychic prognosis is poor, because of influence on psychic development. Treatment quite often includes development. Treatment quite often includes antipsychotic drugs and residential careantipsychotic drugs and residential care

ManicManic--depressive disorderdepressive disorder is rare before puberty, is rare before puberty, but increases in incidence during adolescencebut increases in incidence during adolescence

TreatmentTreatment resembles that of adults, only resembles that of adults, only electroconvulsive therapy is not applied before electroconvulsive therapy is not applied before adolescenceadolescence

Child AbuseChild Abuse The term child abuse is used to indicate physical The term child abuse is used to indicate physical

abuse, sexual abuse, or emotional abuse and child abuse, sexual abuse, or emotional abuse and child neglect.neglect.

Child care after divorce:Child care after divorce:• some parents are not able to reach consent about child care some parents are not able to reach consent about child care

after divorce period, so child psychiatrist is asked by the after divorce period, so child psychiatrist is asked by the court to give an advice on the best solution for the childrencourt to give an advice on the best solution for the children

• after divorce disagreements are traumatic for the children after divorce disagreements are traumatic for the children and the child psychiatrist’s statements should be very and the child psychiatrist’s statements should be very carefully expressed, to protect the well being and future carefully expressed, to protect the well being and future development of the childdevelopment of the child

• the parental rights of both parents - mother and father the parental rights of both parents - mother and father should be respected and protectedshould be respected and protected

• cooperation with child psychologist and social workers is cooperation with child psychologist and social workers is necessarynecessary

Development of DrawingDevelopment of Drawing

clew 3 years old 4 years old

5 years old 6 years old

Test of maturity:

Eva is here.

Drawing of healthy child 4 year old: „Mama“

Drawing of twins 4 years old:left – mental retardation, right - healthy

Drawing of a boy 6 years old suffering from schizophrenic disorder

Drawing of a boy 16 years old suffering from catatonic schizophrenia

Drawing of a boy 10 years old suffering from conduct disorder: „Satanic court“

Drawing of a girl 10 years old suffering from dysgraphia: „Figure“

Drawing of a boy 14 years old suffering from mental anorexia

Performance therapy at a boy 9 years old in adoptive family

Performance therapy at a boy 10 years old suffering from relation disorders

Performance therapy at a boy 7 years old with confrontation to father