Child Psychiatry

Prof. MUDr. Ivana Drtílková, CSc.Prof. MUDr. Ivana Drtílková, CSc.

Dept. of Psychiatry, Dept. of Psychiatry, Masaryk University , BrnoMasaryk University , Brno

Child Psychiatry

Conduct DisorderConduct Disorder

genetic and environmental genetic and environmental componentscomponents more common among boys(6-16%) more common among boys(6-16%)

than girls (2-9%)than girls (2-9%)

Child Psychiatry

Diagnosis :Diagnosis : repetitive and persistent repetitive and persistent pattern of behavior in which the rights of pattern of behavior in which the rights of others or basic social rules are violated. others or basic social rules are violated. Aggressive behavior that causes or Aggressive behavior that causes or threatensthreatens harm to other people or animals, harm to other people or animals, ( bullying or intimidating others, initiating( bullying or intimidating others, initiating physical fights..), physical fights..), Non-aggressive conduct ( property loss orNon-aggressive conduct ( property loss or damage, fire-setting ..) damage, fire-setting ..) Deceitfulness or theft Deceitfulness or theft Serious rule violations, ( running away Serious rule violations, ( running away fromfrom home overnight, often being truant from home overnight, often being truant from school.) school.)

Child Psychiatry

Treatment: Treatment: family therapy, and family therapy, and cognitive behavioral approaches which cognitive behavioral approaches which focus on building skills such as anger focus on building skills such as anger management. Pharmacological management. Pharmacological intervention alone is not sufficient..intervention alone is not sufficient..

Bed-Wetting (Primary Nocturnal Enuresis)

Bed-wetting is accidental urination Bed-wetting is accidental urination during sleep. during sleep. children over age 5 or 6 ( age at whichchildren over age 5 or 6 ( age at which continence could definitely be expected)continence could definitely be expected) Bed-wetting that develops after a child Bed-wetting that develops after a child hashas been dry for a period of time been dry for a period of time (secondary (secondary nocturnal enuresis) nocturnal enuresis)

Bed-Wetting (Primary Nocturnal Enuresis)

Cause for bed-wetting: Cause for bed-wetting:

o Delayed growth and development. Delayed growth and development. o Small bladder capacity. Small bladder capacity. o Lack of enough antidiuretic hormone Lack of enough antidiuretic hormone (ADH). (ADH). o Sound sleeping. Sound sleeping. o Psychological and social factors. Psychological and social factors.

Bed-Wetting (Primary Nocturnal Enuresis)

Medications :Medications :

o that either increase the amount of that either increase the amount of urineurine that the bladder can hold bladderthat the bladder can hold bladder capacity- (imipramine) capacity- (imipramine)

o or decrease the amount of urine or decrease the amount of urine releasedreleased by the kidneys ( desmopressin).by the kidneys ( desmopressin).

TIC DISORDERS

Tics are : abrupt, purposeless, and Tics are : abrupt, purposeless, and involuntary vocal sounds or muscular jerks. involuntary vocal sounds or muscular jerks.

They are sudden, rapid, and recurrent. They are sudden, rapid, and recurrent.

1. Transient tic disorder1. Transient tic disorder - the most - the most commoncommon

type , with symptoms lasting at least fourtype , with symptoms lasting at least four

months, but no longer than one year.months, but no longer than one year.

Onset - nearly 10 percent of school Onset - nearly 10 percent of school children-children-

more prevalent in periods of stress, more prevalent in periods of stress, fatigue, orfatigue, or

as a result of certain types of as a result of certain types of medications medications

( stimulants) ( stimulants)

TIC DISORDERS

2. Chronic tics2. Chronic tics- - lasting more than one lasting more than one year year

3. Tourette's disorder3. Tourette's disorder (TD) (TD)

Tourette's disorder is an autosomal Tourette's disorder is an autosomal dominantdominant

disorder with incomplete penetrance.disorder with incomplete penetrance.

Non-genetic cause in 10 to 15 percent ofNon-genetic cause in 10 to 15 percent of

children (complications of pregnancy, low children (complications of pregnancy, low

birthweight, head trauma, carbon birthweight, head trauma, carbon monoxide monoxide

poisoning, and encephalitis..).poisoning, and encephalitis..).

TIC DISORDERS

3. Tourette's disorder3. Tourette's disorder (TD) (TD)

Tourette's disorder (TD multiple repeated Tourette's disorder (TD multiple repeated tics tics

(abrupt, purposeless, and involuntary (abrupt, purposeless, and involuntary vocalvocal

sounds or muscular jerks.)sounds or muscular jerks.)

Begin : between the ages of 5 and 10 Begin : between the ages of 5 and 10 years ofyears of

ageage

TIC DISORDERS

Tourette a disorder - symptoms may Tourette a disorder - symptoms may include: include:

involuntary, purposeless, involuntary, purposeless, motor motor movementsmovements

(the face, neck, shoulders, trunk, or hands)(the face, neck, shoulders, trunk, or hands) head jerking head jerking squinting squinting blinking blinking shrugging shrugging grimacing grimacing nose-twitching nose-twitching

TIC DISORDERS

Tourette a disorder - symptoms may Tourette a disorder - symptoms may include:include:

any excessively repeated movements any excessively repeated movements

(i.e., foot tapping, leg jerking, (i.e., foot tapping, leg jerking, scratching) scratching) kissing kissing pinching pinching sticking out the tongue or lip-sticking out the tongue or lip-smacking smacking making obscene gestures making obscene gestures

TIC DISORDERS

Tourette a disorder is also characterized Tourette a disorder is also characterized by one or more vocal ticsby one or more vocal tics : :

grunting or moaning sounds grunting or moaning sounds barks barks tongue clicking tongue clicking sniffs sniffs hooting hooting obscenities obscenities throat clearing, snorts, or coughs throat clearing, snorts, or coughs

TIC DISORDERS

Tourette a disorderTourette a disorder is also characterized is also characterized by one or more vocal ticsby one or more vocal tics : :

squeaking noises squeaking noises hissing hissing spitting spitting whistling whistling gurgling gurgling echoing sounds or phrases repeatedlyechoing sounds or phrases repeatedly

CHILDHOOD SCHIZOPHRENIA

Definition:

Same diagnostic criteria apply to children, adolescents, and adults

Based symptoms : deficits in adaptive functioning, and duration of six months

Incidence : less than 1/10,000 births

CHILDHOOD SCHIZOPHRENIA

General Characteristics:

1. Slight male predominance 2. Less educated and professionally successful families 3. Patients have low-average to average range of intelligence 4. Patterns of behavior before a formal diagnosis: attention/conduct problems, earlier patterns of inhibition, withdrawal and sensitivity

CHILDHOOD SCHIZOPHRENIA

General Characteristics:

5. Disease is rarely observed before age 5 6. 80% of children have auditory hallucinations; 50% have delusional beliefs 7. Can be observed with additional conditions such as: conduct disorder, learning disabilities, mental retardation, and autism 8. Poor prognosis if onset before age 10 with above personality difficulties

CHILDHOOD SCHIZOPHRENIA

CHARACTERISTIC SYMPTOMS :

Positive symptoms ( productive ) :

Delusions

Hallutiations

Disorganised speech (often incoherence )

Grossly disorganized or catatonic behavior

CHILDHOOD SCHIZOPHRENIA

CHARACTERISTIC SYMPTOMS :

Negative symptoms ( nonproductive ) : affective flattening social dysfunctionProblematic in children - fantasy figures, which would not of themselves suggest psychosis.The content of hallutiations and delusions varies with age.

CHILDHOOD SCHIZOPHRENIA

TREATMENT :

Antipsychotics are the drugs of first choice in chilhood for schizofrenia

Imortance : minimizing any cognitive dulling in school children , atypical antipsychotics are preferred (risperidone, olanzapine).

DEPRESSION IN CHILDERN

Risk factors in their lives which could predispose:

• family history of mental illness or suicide, • abuse (physical, emotional or sexual),• chronic illness and the loss of a parent at an early age to death,• divorce or abandonment.

The depression could be wholly chemical, wholly due to psychological factors, or combination of the two.

DEPRESSION IN CHILDERN

Symptoms of Depression in Children

• Persistent sadness and/or irritability. • Low self-esteem or feelings or

worthlessness. A child may make such statements as, "I'm bad. I'm stupid. No one likes me."

• Loss of interest in previously enjoyed activities.

• Change in appetite (either increase or decrease).

• Change in sleep patterns (either increase or decrease).

DEPRESSION IN CHILDERN

Symptoms of Depression in Children

• Difficulty concentrating. • Anger and rage • Headaches, stomachaches or other

physical pains that seem to have no cause.

• Changes in activity level( more lethargic or more hyperactive. )

• Recurring thoughts of death or suicide.

DEPRESSION IN CHILDERN

If the child has bipolar disorder, also known

as manic depression, these symptoms could be present:• abrupt, rapid mood swings • periods of extreme hyperactivity • prolonged, explosive temper tantrums or

rages • exaggerated ideas about self or abilities Bipolar disorder is often mis-diagnosed asattention-deficit disorder with hyperactivity (ADHD), obsessive-compulsive disorder

(OCD), oppositional defiant disorder or conduct

disorder.

AUTISM IN CHILDREN First described : Leo Kanner in 1943 as a disturbance of affective contact

Prevalence: 4-5 cases per 10000The basic criteria :1) early onset (before 3-5 years of age), 2) severe abnormality of reciprocal social

relatedness,3) severe abnormality of communication

development,4) restricted, repetitive and stereotyped

patterns of behavior, interests, activities, and imagination;

5) abnormal responses to sensory stimuli.

AUTISM IN CHILDREN

SOCIAL DISTURBANCE

The human face holds little interest for the autistic infant

lack of eye contact, poor or absent attachments

general lack of social interest

COMMUNACATIVE DISTURBANCE echolalia, pronoun reversal,

inappropriate cadence and intonation, impaired semantic development

AUTISM IN CHILDREN

COGNITIVE DEVELOPMENT

Most ( approximately three-fourths ) autisticchildren scored in the mentally retarded

range A few autistic individuals exhibit truly

remarkable abilities( musical or drawing ability .

memory

BEHAVIOR FEATURES

Restricted repetitive and stereotyped patterns of

behavior, interests and activities. Interest in nonfunctional aspects of objects ( taste or feel )

AUTISM IN CHILDREN

Stereotyped movements ( hand flapping, toe walking, spinning objcts and the like).

Bizare affective responses - panicked in response to new situations.

Deficits in imaginative play.

AUTISM IN CHILDREN

ETIOLOGY AND PATHOGENESISThere may be a genetic basis to the

disorder-family members with other related

disabilitiesAutistic children exhibited : an increased frequency of physical

anomalies, persistent primitive reflexes, various neurological soft sings and increased abnormalities on EEG.TreatmentDrug treatments ( risperidone )Other therapies : behavioral treatments

(teaching autistic "appropriate" behaviors).

Attention deficit hyperactivity disorder ( ADHD)CHARACTERISTIC :1). INAPPROPRIATE OR EXCESSIVE ACTIVITY2). POOR SUSTAINED ATTENTION3). DIFFICULTIES IN INHIBITING IMPULSES IN

SOCIAL BEHAVIOR AND ON COGNITIVE TASKS.

4). DIFFICULTIES GETTING ALONG WITH OTHERS

5). SCHOOL UNDERACHIEVEMENTPREVALENCE :

8 % OCCURS BETWEEN 6 - 8 YEARS IN BOYS - 9 % IN GIRLS - 3 %

Attention deficit hyperactivity disorder ( ADHD)

Type of disorder

ADHD combined type

ADHD predominantly inattentive type

ADHD predominantly hyperactive-impulsive type

Attention deficit hyperactivity disorder ( ADHD)

Cause of ADHD

suspected contributing factors may include:

Neurophysiology - differences in brain anatomy, electrical activity and metabolism. Catecholamine function are very probably involved in the pathogenesis of hyperactivity.

Genetics - possible gene mutations may be present.

Attention deficit hyperactivity disorder ( ADHD)

Cause of ADHD

suspected contributing factors may include:

Drugs - drug use (nicotine and cocaine) by the mother during pregnancy .

Lead - chronic exposure - influence behaviour and brain chemistry.

Lack of early attachment - traumatic experiences related to the attachment

Attention deficit hyperactivity disorder ( ADHD)

Therapy of ADHD• behavioural management, psychological counselling • drugs target the brain's

neurotransmitters ( stimulants, antidepressants..)

Stimulant drugsDexamphetamine and methylphenidate

(Ritalin)work by acting on the neurotransmitters

thatrelease the chemical dopamine.

About 7O % of children with hyperactivityimprove on a stimulant regimen.

Attention deficit hyperactivity disorder ( ADHD)

Inattention criteria

• Fail to give close attention to details or make careless mistakes in school work.

• Have difficulty sustaining attention in tasks or play activities.

• Not seem to listen when spoken to directly.

• Not follow through on instructions and fail to finish school work, chores or duties in the workplace

Attention deficit hyperactivity disorder ( ADHD)

Inattention criteria

• Have difficulty organising tasks and activities.

• Avoid, dislike or be reluctant to engage in tasks that require sustained mental effort

• Lose things necessary for tasks or activities (for example: toys, school assignments, pencils, books or tools).

• Be easily distracted.

• Be forgetful in daily activities.

Attention deficit hyperactivity disorder ( ADHD)

Hyperactivity-impulsivity criteria

Hyperactivity

• Often fidgets with hands or feet or squirms in seat.

• Often leaves seat in classroom or in other situations in which remaining seated is expected.

• Often runs about or climbs excessively in situations in which it is inappropriate

Attention deficit hyperactivity disorder ( ADHD)

Hyperactivity-impulsivity criteria

Hyperactivity

• Often has difficulty playing or engaging in leisure activities quietly.

• Is often 'on the go' or often acts as if 'driven by a motor'.

• Often talks excessively

Attention deficit hyperactivity disorder ( ADHD)

Hyperactivity-impulsivity criteria

Impulsivity

• Often blurts out answers before questions have been completed.

• Often has difficulty waiting in turn.

• Often interrupts or intrudes on others (for example, 'butts into' conversations or games).

Child Psychiatry

Child and Adolescent Psychiatry, Child and Adolescent Psychiatry, edited by Melvin Lewis, Wiliams and edited by Melvin Lewis, Wiliams and Wilkins, 1996, 1260 pp.Wilkins, 1996, 1260 pp.

References :References :