Matzová Z.,Giblová Z., Trebatická J.

The autistic spectrum is bound together by thepresence of qualitatively similar characteristics definedby the classic triad of impairments.

Include: Autism (including highly functional autism)

Atypical autism (Differs from autism in terms of either age of onset or of failure to fulfill all three sets of diagnostic criteria.)

Asperger´s syndrome

Autism spectrum disorders

Definition (ICD-10)

The presence of abnormal or impaired developmentthat is manifest before the age of 3 years.

Abnormal funcioning is in each of the mentionedthree areas „triad of impairment“. 1.Social deficits

2.Communication deficits

3. Restricted/repetive interests and behaviours

Autism

1. Social deficits

Difficulties with reciprocal social interaction and relationship-forming

Manifests as: An infant does not enjoy being held

A lack of interaction such as pointing, imitating, offering comfort, sharing enjoyment

Verbal signs of social difficulty (e.g.will rarely speak regarding to concern for others)

Unusual eye contact and facial expressions

Failure to understand the other´s situation or feelings

Autism

2. Communication deficits

Deficits in communication are recognized by asocialquality, rather than reduced quantity

The normal flow of reciprocal conversation is oftenabsent

There is an anusual social quality abd pitch / rhythm / intonation of speech

Echolalia (repeating the words or phrases of others) and pronominal reversal (e.g. referring to themselvesas „she“ or „he“)

Autism

3.Restricted/repetitive interests and behaviours

Stimming - Self-stimulatory behaviour, the repetition of physical movements, sounds, words, or moving objects.

Stimming behaviours can consist of tactile, visual, auditory, olfactory and vestibular stimming. (e.g. hand flapping, clapping, rocking, excessive or hard blinking, pacing, head banging, repeating noises or words, snapping fingers; and spinning objects

Motor stereotypies – lining things up, f lipping things, step counting, unusual responses to sensory input, rocking

Some of these may be common in young children – clinicians must look at the number and intensity of behaviors

Rituals, rigidity, sameness (Sheldon Cooper diet routine , Rain Man’s pancake Tuesday, etc.)

Prevalent in about 25% of ASD population

Develop later than motor type, stable throughout life

Circumscribed interests – highly fixated or unusual interests

A particular movie, cartoon character, topic, the phone book, shoe size, washing mashines, collectin of objects

In later childhood restricted interests are more sophicticated (particular types of stones, car hubs, insect)

Self-injurious behavior – hand f lapping, hitting, is often a form of response to anxiety

Present in other disorders but more common in ASD than general population

Autism

Associated features

(Various other difficulties that are commonly associatedwith autism)

Sensory defensiveness - extreme response to innocentsensory stimuli (e.g.sound made by domesticappliences or certain textures against skin)

Problematic sleeping

Manipulation with food (sometimes prefering limitedtype of food, color or consistency of food)

Autism

Develomental warning signs in preschool children:

Delay or absence of spoken language

Looks through people, not aware of others

Not responsive to other people´s facial expressions/feelings

Lack of pretend, little or no imagination

Does not show typical interest in play with peers

Unable to share pleasure

Impairnment on non-werbal comunication

Lack of initiating of activity or social play

Unusual or repetitive hand and finger mannerisms

Unusual reactions or lack of reaction to sensory stimuli

Autism

Epidemiology

The incidence in population is currently estimated at 0.3-0.6%

Occurrs more among boys than girls (4: 1)

Etiology The causes are multifactorial.

The real etiology remains unknown, research is focused on:Genetic factors

Prenatal factors (infections or other

complications)

Postnatal factors (infections, etc.)

Neuropsychological dysfunctions

Deregulation of the immune system

Abnormalities of neurotransmitters

Structural abnormalities in areas of the brain

related to the "mirror neural

system"

Epilepsy

Mental retardation

Anxiety

Depression

ADHD

Behavioural disorders

Sleep disordes

Tic disorders

Comorbidity

1 in 10 cases of ASD currently have identifiable medical cause. Hence assessment should usually include: General physical examination for stigmata

Neurological examination + EEG.

Karyotyping.

Detection of hearing.

Diagnostics

Diagnostics Assigned only by a psychiatrist

Based also, but not only on observation !

Assessment should combine more diagnostic methods

Gold Standards are Autism Diagnostic Interview – Revised (ADI-R) and Autism Diagnostic Observation Scale (ADOS)

Management:

is combination of non-pharmacological management and symptom modification, treatment of co-morbid or co-existing difficulties

Non-farmacologial management

Communication Interventions

Social skills interventions

Behavioural interventions

Pharmacological interventions

- increased likehood of unpredictable effects and adverse effects.

Antipsychotics (management of aggresions, tantrums, self injury)

Stimulants (when co-existing ADHD)

Atomoxetine (when co-existing ADHD)

Antidepressants (to improve repetitive behaviours)

Melatonin (in USA for sleeping. wake cycle problems)

Autism

Treatment - summary Pharmacological interventions have a limited role

The key is early intervention!

Applied Behavior Analysis Gold standard, based on behaviorism

Uses positive reinforcement to decrease maladaptive and unwanted behaviors, increase adaptive behaviors

Uses negative reinforcement/negative punishment when necessary (rarely)

Treatment can begin when children are as young as 3

Focus is on compliance

Intensive (20-40 hours/week), one-on-one format

Targets a wide range of skills

Includes parents (and important others when possible – siblings, teachers, etc.)

Fe in History

Source: https://www.appliedbehavioranalysisprograms.com/historys-30-most-inspiring-people-on-the-autism-spectrum/

Hans Christian Andersen – Children’s Author

Susan Boyle – Singer

Tim Burton – Movie Director

Lewis Carroll – Author of “Alice in Wonderland”

Charles Darwin – Naturalist, Geologist, and Biologist

Emily Dickinson – Poet

Albert Einstein – Scientist & Mathematician

Bobby Fischer – Chess Grandmaster

Bill Gates – Co-founder of the Microsoft Corporation

Temple Grandin – Animal Scientist - movie

Thomas Jefferson – Early American Politician

Steve Jobs – Former CEO of Apple

Stanley Kubrick – Film Director

Michelangelo – Sculptor, Painter, Architect, Poet

Wolfgang Amadeus Mozart – Classical Composer

Sir Isaac Newton – Mathematician, Astronomer, & Physicist

Satoshi Tajiri – Creator of Nintendo’s Pokémon

Nikola Tesla – Inventor

Andy Warhol – Artist

Ludwig Wittgenstein – Philosopher

Schizophrenia Schizophrenia is severe brain disorder, in which

children interpret reality abnormaly.

Schizophrenia is expressed in cognitive, emotional and behavioral changes (problems).

EOS-Early onset schizophrenia – onset before age 18 years.

VEOS-Very early onset schizophrenia – onset beforeage 13 years.

Epidemiology Onset prior to age 13 is very rare.

Prevalence of VEOS is 0.9 in 10 000

Prevalence of EOS is 17.6 in 10 000

Schizophrenia peaks in the age 18-35 years.

Male onset is in average in 5 years younger than in females. Therefore EOS and VEOS are predominantly found in males.

Diagnostic criteria ICD 10Diagnostic critera in ICD-10 and DSM-IV for schizophrenia are the same as adult critera.

1. At least 1 of the following:

• Thought echo, insertion, withdrowal or broadcasting

• Delusions of control,influence or passivity; clearly reffered to body or limb movements or specific thoughts, actions or sensations and delusional preception.

• Hallucinatory voices giving a running commentary on the patient´s behaviour or discussing him/her betweenthemselves, or other types of hallucinatory voices coming from some part of the body.

• Persistent delusions of other kinds that are culturally inapropriate or implausabile (e.g. religious, politicalidentity, superhuman powers..)

2. Or at least 2 of the following:

• Persistent hallucinations in any modality, when accompanied by fleeting or half-formed delusions without clear affectivecontent,persistent over-valued ideas, or occuring everyday for weeks or months.

• Breaks of interpolations in the train of thoughts, resulting in incoherence or irrelevant speech or neologism.

• Catatonic behaviour such as excitement, posturing or waxy flexibility, negativism, mustism and stupor.

• Negative symptom such as marked apathy, paucity of speech, and blunting or incongruity of emotionalresponses.

• A significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as lossof interest, aimlessness, idelness, a self-absorbed attitude, a social withdrowal.

3. Duration of at least 1 month.

Types of schizophrenia according ICD 10• Dellusions and HallucinationsParanoid Sch.

• Disorganized speech, behaviour, flat or inappropriate affectHebephrenic sch.

• Meeting general criteria , no specific sy predominantesCatatonic sch.

• Some residual sy, but depressive pict.predominantes

Post-schizophrenicdepression

• Previous positive sy.,now prominwnt negative sy.Residual sch.

• Gradually arises without an acute episodeSimple sch.

Early nonspecific symptoms (pre-morbid functioning) The earliest indications often includes descrete or

greater developmental problems/delays:

Motor delays

Speech delays

Cognitive deficits (academic difficulties)

Problems in social interactions (social withdrawal, isolation, disruptive behaviour)

Symptoms might look like ASD (hand flapping, rocking, speech delay, problematic social interactions)

Prodromal phase Period of pre-psychotic state, where there is a

deviation form child´s previous experience and behaviour.

Most important symptom: decline from cognitive funcions and from social functioning.

There can be also present eccentric interests, bizarre ideas and behavior.

Clinical features in VEOS Gradual onset

Isolation

Trouble sleeping

Strange behavior

Strange thoughts or fears

Irritability or depressed mood

Avoidance of friends and family

Lack of motivation

Change in school performace

Delusions (might be many forms) but in VOES are typicaly not veryfrequent

Hallucinations (complains on the noise in the head)

Visual hallucinations are more frequent compared with adults

Clinical features in EOS Disorganization (thinking, speach and behavior)

Positive sy. (delusions, hallucinations )

Negative symptoms (Affective blunting, Avolition, Alogia, Social withdrawal)

We can also observe: Agressive or bizarre behavior

Lack of eye contact

Decreased care for hygene

Isolation from friends and family

Problems with concentration, with memory, with school performance

Problems with sleeping

Problems with eating

Schizophrenia Etiology and risk factors:

Genetics

Pre- and perinatal factors

Neuropathology

Neurotransmitters pathologies

Psychological and social factors

Differential diagnostics Early Onset BD

Schizoaffective Disorder

Substance Induced Psychosis

PTSD

Major Depressive Disorder

OCD

ASD

Factitive Disorder

Dissociative Disorders

Personality Disorders

Schizophrenia In examination should focus also on:

History of substance misuse

Risk to self and others

Family functioning

Sustained attention and memory deficits The cognitive level of child will influence his/her ability to express and

understand the psychotic symptoms

Physical assessment should focus to exclude potentional medical causes of psychotic symptoms.

Further investigations based on history and examination: MRI,Karyotype/cytogenetics, EEG, blood and urine analysis, ECG.

Schizophrenia Potential organic causes for psychosis:

acute intoxication

delirium

CNS lesions

tumours

infections

metabolic disorders

seizure disorders

Schizophrenia Treatment:

Terapeutical recommentadions are still primarily based on adult literature.

Mediacation use tends to be off licence.

Current recomendations suggest using atypical antipsychotics. Medication should be continued at least 6-12 months after improvements in symptoms.

Children and adolecsents are more sensitive to adverse effects of medication (compared to adults). They must be monitorized. (EPS, hyperprolactinemia, weight gain, tachycardia, seizures, sedation, hypotension, hepatotoxicity, hypersalivation.)

Schizophrenia Treatment:

Depot preparations are not recommended for VEOS, but might be used in adolescents with poor mediacal compliance.

ECT is used and effective in some cases of schizophrenia in children and adolecents.

Psychological treatments include psychoeducation, family intervetions, parental support group, individual therapy, social skills training, problem solving and communication skills.

Course of illness VEOS and EOS has usually insidious course

The 1.st episode is typically responsive to the treatment

Relapse rates during first 5 years of the illness are 81,9%

Risk factors for relapse:

Poor insight

Negative attitude toward medication

Substance abuse

Cognitive impairment

Negative symptoms

Poor social support

Poor parental support

Affective disorders (mood disorders) according ICD 10 F30 Manic episode:

(Hypomania, Mania with/without psychotic sy.)

F31 Bipolar affective disorder

(Current episode)

F32 Depressive episode

(Mild, moderate, severe with/without psychotic sy.)

F33 Recurrent depressive disorder

(Current episode)

F34 Persistent mood [affective] disorders

(Cyclothymia, Dysthymia)

Mood disorder according DSM IV. Major Depressive Disorder

Dysthymic Disorder

Depressive Disorder NOS

Bipolar Disorder

Bipolar I. (manic episode lastin 7 days)

Bipolar II. (major depression and hypomanic episode lasting at least4 days)

Bipolar NOS.

Mood Disorder NOS

Mood Disorder due to General Medical Condition

Substance Induced Mood Disorder

Depression and Dysthymia Depression is an episodic recurring disorder

characterized by persistent (at least 2 weeks) and pervasive sadness or unhappiness, loss of enjoyment of everyday activities, irritability and associated symptoms such as negative thinking, lack of energy, difficulties of concentrating, and appetite and sleep distrubances.

Patient with dysthymia has chronically depressed mood for at least one year, but not severe enough to quantify for a diagnosis of depression. Symptom-free interval last less then 2 months.

Depression children Negative self image (I am bad, I can´t do anything, people do not like me, I

am stupid..)

Somatic complains (headaches, stomachaches)

Social withdrowal (moving away from others, they do not want to engage)

Behavioral problems, anger outbursts (low tolerance for frustration, loosingemotinal control)

Isolation

Rejection sensititvity with outbursts or crying (on regular coments the kidfeels rejected)

Thoughts of deaths or dying (thinking that others would be better offwithout them)

These must be changes from the baselines!!

Depression in adolescents Irrtability, depressed mood, hoplessness

Social withdrowal (stops doing previous activities, sports in clubs, socialacitivities) Isolation

Lost of interest and pleasures, anhedonia, boredom

Sadness demonstrated through black clothes, morbid themes in poetry and music, hiding face behind hair

Sleep distrubance (more in the adolescents- hypersomnia, if there is less of sleep, it can be BPD)

Lack of motivation, decreased concentration, skipping school, low grades

Rebellious behaviour, drugs, pomiscuit sexual activity

Loss of appetite or binge eating

Agitation or psychomotor retardation

Suicidal ideation, attempts

Differencies according to age

Epidemiology Depression:

1-2% prepubertal children

5% adolescents

Female/male ratio:

Prepubertal children 1:1

In adolescence 2:1 (more females)

Etiology of MDBiological factors, psychological factors

Family history of MD or BD

Parental substance use

Female gender

Puberty

Chronic medical illness

Previous history of depression

Comorbid psychiatric disorder (ADHD, anxiety, specific learning disorder)

Highly emotional temperamental style

Negative cognitive style

Low self esteem

Trauma

Bereavement and loss

Etiology of MD Family factors

Abuse, neglect, agression toward child

Negative parenting style (rejection, lack of care)

Parental mental disorder

Conflict child-parent relationship

Agression between parents

Social factors

Bullying

Deliquency

Poor or unsafe socioeconomic state (homelessness, refugees, etnical minority)

Suicidal riskSuicidal behaviors and risk need to be carefully evaluated in every depressed young person!

Factors with highest suicidal risk:

Previous suicidal attemt

Suicidality in family history

Loneliness, isolation, rejection

Humiliation, aggitation

Substance abuse

Selfinjury in personal history

Legal problems

Current loss

Access to means (e.g.weapons, medicaments..)

Treatment Psychotherapy and Pharmacotherapy:

Management is according severity of the symptoms.

Always include psychotherapy!

In mild depression we might start with psychotherapyonly first.

In pharmacotherapy prefer monotherapy (fluoxetine or other SSRI).

Improvment occurs within 2-6 weeks in 60-70%

Duration of the treatment is at least 3 monts, stoppingwith medication should be progressive.

Treatment Indications for hospitalization:

Severe depresion

Higher risk for suicidality

Psychotic sy in depresion

Patient isolated

Non-functional family (family incapable of collaboration)

Treatment Electroconvulsive therapy (ECT)

Good evidence of effectiveness in severe cases

Transcranial Magnetic Stimulation (TMS)

Light Therapy (in seasonal mood disorder)

Complementary and Alternative Medicine (CAM)

St. John’s Wort

Omega 3 Fatty Acids

S-Adenosyl Methionine (SAMe)

Exercise

BAD - Epidemiology Prevalence rate of approximately 2% in pediatric

populations

BP I. 0,4-1,6%

BP II. 0,5%

0,5% onset 5-9 yrs >male

7,5% onset 10-14 yrs >male

20-30% before 20 yrs M=F

1/2 to 2/3 of adults with bipolar disorder experienced onset prior to age 18 years.

Manic episode Distinct period of abnormally and persistently elevated,

expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy,

Lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary)

A hypomanic episode is essentially a manic episode lasting most of the day, nearly every day, for at least 4 but less than 7 consecutive days and that produces a noticeable change in functioning but not marked impairment

Symptoms in mania Distractible

Increased activity/psychomotor agitation

Grandiosity/super-hero mentality

Flight of ideas or racing thoughts

Activities that are dangerous or hypersexual

Sleep decreased

Tolkative or pressured speech

Clinical presentation of BAD Adolescents

Mania – psychotic sy. (dissconect with reality), labile mood, mixedmanic/depressive sy.

More chronic and refractory to treatment than adult onset

Ususally continues in adulthood as BPD.

Children (juvenile mania- subtype)

Changes in mood, energy level and behavior are very labile and erratic

Mixed features are more common (very uncomon to see pure manicchildren in this age)

High rates of disruptive behaviors (symptoms overlap with ADHD)

Offten diagnosed with ADHD first, it might be comorbidity

They do not necessery continue to have a symptoms to adulthood.

BAD Genetics

The greater genetic load the earlier age of onset

1 parent with affective disorder = 25% risk for the child

2 parents = 75% risk for the child

Predicting factors of mania in depressed youth

Depressive episode- rapid onset, psychomotorretardation, psychosis

Family history of affective disorders

History of mania or hypomania after threatment of depresion with antidepressants

Comorbidity of BAD ADHD 90% of patients with pre-adolescent onset

BPD, 50% of patients with onset in adolescence

CD and ODD

Differential diagnostics of BAD Somatic conditions

Thyroid disorder

Seizure disorder (Temporal lobe)

Multiple sclerosis

Infections

Toxic and drug related causes

Other psychiatric disorders:

ADHD

PTSD

Anxiety D.

CD

ASD

Attachment dis.

Addictions

Ajustment dissorder

Management of BAD Lithium

Anticonvulsants

Antipsychotics

Aripiprazole: manic or mixed states, patients aged 10–17 years

Asenapine: bipolar mania, patients aged 10–17 years

Lithium: mania, patients aged 12–17 years

Olanzapine: manic or mixed states, patients aged 13–17 years

Quetiapine: manic states, patients aged 10–17 years

Risperidone: manic or mixed states, patients aged 10–17 years

CAN sy• Physical abuse (active/passive form)

• Sexual abuse (active/passive form)

• Psychological abuse (active/passive form)

• Neglect (physical and emotional)

• Münchhausen syndrome by proxy

CAN sy Child abuse and neglect must be meticulously

documented

Any potential pieces of evidence coming into the physician’s hands should be safely secured so as to preserve the chain of evidence for judicial purposes

Physical abuse Intentionally causing an injuring to a child, using physical

force against a child

Blunt trauma (bruises, fractures, oral injuries), burning, shaking - shaken baby syndrome , or others

Sexual abuse Inappropriate sexual behavior with a child

Touching or kissing a child’s genitals, making a child touch an adult’s genitals, forcing a child to undress, performing sexual acts in front of a child, sexual jokes, showing pornography, commercial exploitation of children.

Psychological abuse Attitudes, behaviors, or failure to act that interferes

with a child’s mental health or social development.

Yelling, screaming, frightening, bullying. Humiliating, name-calling, negative comparisons. Lack of affection. Habitual blaming. Extreme forms of punishment. Exposure to violence.

Rejecting children

Blaming them

Constantly scolding them, especially for problems beyond their control

Neglect (physical and emotional) Failing to provide for a child’s basic needs. Includes food, water, a

place to live, love, and attention.

Neglect is the most common type of maltreatment and has the most serious long-term consequences.

Emotional neglect and early childhood deprivation are the potentially most severe risk factors for impaired emotional or intellectual development and are also found as cofactors in most cases of other types of child maltreatment. They are characterized by lack of recognition of the child’s developmental needs and by the lack of a normal parent–child interaction.

Münchhausen syndrome by proxy ,,Psychiatric disorder where a child is taken to the doctor with

disease symptomps, that have been fabricated or deliberately induced by a person caring for the child ( usually mother).’’

The child absolves many diagnostic and therapeutic interventions repeatedly.

The person caring for the child denies knowledge of the true causes of the child’s disease manifestations.

The medically inexplicable symptoms and signs resolve when the child is separated from the responsible individual.

Parent/ caregiver could be not just passively seeking medical care for the child, but also active inducer (injuries, substances)

Signs that children may be receiving mistreatment, are abused or neglected Learning problems that cannot be explained

No adult supervision

Withdrawal from others

No desire to go home after school or other activities

Fearfulness, as though waiting for something bad to happen

Changes in school performance or behavior

Untreated medical conditions

Burns, marks, bruises, welts, scars.

Apathy, depression, hostility, difficulty concentrating.

Inappropriate interest or knowledge of sexual acts, seductiveness.

Dirty, unbathed, hungry children .

Signs that adults may be mistreating children Sees the child as bad or worthless.

Makes frequent demands that the child cannot achieve.

Asks teachers to use physical discipline if the child misbehaves.

Denies child’s problems in school or at home.

Sees the child as a burden.

Rarely looks at the child.

Over-protective and demands secrecy.

Intervention If there is suspicion of child abuse or neglect, very

important is to act as soon as possible.

REPORTING - conversation with parents or family, notification of the Child Protection Office or police, cooperation with psychologists, psychiatrists, social workers or other specialists.

Necessary to know of the locally available child protection resources and personnel.

Always properly done documentation !