Medical student lecture:introduction to child psychiatry

Regina Bussing, MD, MSHSAssociate Professor and Chief

Division of Child and Adolescent Psychiatry

LECTURE FOCUSLECTURE FOCUS

1. Child Development

2. Evaluation Strategies

3. Treatment Modalities

4. Childhood Disorders

MAJOR DEVELOPMENTAL STAGES

Prenatal/Birth Infancy (Birth –18 months) Trust - form

attachment/bond Toddler (1.5 - 3 years) Autonomy -

walk/talk/tolerate separation Early childhood (3-5 years) Initiative - build

vocabulary, build superego Middle childhood (6-12 years) Industry - build

peer-relations and competencies Adolescence (12-adult) Identity

MILESTONES: Developmental Markers*

MILESTONES: Developmental Markers*

• Sitting 6 months• Walking 1 year• Talking 1 year• Toilet Training 2 years +• Rides Tricycle 3 years• Dresses Self 5 years• Draws a person (main parts) 5 years• Rides Bicycle 6 years * Normal variation is present; Denver II-R

REASONS TO LEARN ABOUT NORMAL DEVELOPMENT

REASONS TO LEARN ABOUT NORMAL DEVELOPMENT

• To identify and be supportive of age-appropriate emotional expressions (e.g. expressions of autonomy; stranger anxiety) - these are healthy.

• To better identify what is really abnormal so treatment is focused on psychopathology - e.g., adolescent suicide attempts, drug use.

• To better understand adult psychopathology.

• To better understand common patterns of regression (a return to earlier developmental behaviors) that may occur with illness or stress.

CONCEPT OF REGRESSIONCONCEPT OF REGRESSION

STRESS ----> Return to earlier developmental stage

EXAMPLES:

• A 7yr old child with previous normal development now hospitalized with leukemia begins bedwetting, thumb sucking, and using “baby talk”.

• A 42 year old previously healthy male becomes totally dependent on his wife for ADLs following a mild heart attack.

EVALUATION STRATEGIESEVALUATION STRATEGIES

Patient Interview

Testing (IQ, Education, Projective, Personality, Neuropsych, labs, EEG, MRI)

Observation

Collateral Information (Parents, School)

SHIFTING FOCUS OF ASSESSMENT

• Infants and toddlers: History; observation

– gross and fine motor functions

– language and communication

– social behavior

– bonding

• Usual Concerns:

– delayed development (e.g., MR),

– abnormal development (e.g., PDD)

– poor bonding (e.g., neglect, abuse)

Shifting Focus of Assessment • Preschoolers: Observation, personal

interview, parent interview– observe milestones– assess what child talks and thinks about (e.g.

through play)– Parent-child relation

• Possible concerns: as before, plus – speech-language delays, – hyperactivity, – aggressive/defiant behaviors, – excessive anxiety, – toilet training

SHIFTING FOCUS OF ASSESSMENT

Shifting Focus of Assessment

• School-age child: Observation, interviews, reports from school

– how does child function in family?

– how does child function in school? (behavior and academics)

– what kind of peer relations?

– formal psychological and academic testing

• Common concerns: – learning problems

– externalizing conditions

– separation anxiety

SHIFTING FOCUS OF ASSESSMENT

IMPROVING THE ODDS FOR SUCCESSFUL

DEVELOPMENTAL OUTCOMES

PROTECTIVE FACTORS

•Good parent-child relationship

•Easy, outgoing temperament

•Positive peer influence

•Successful school experiences

•Caring adult role models

•Participation in pro-social groups

• Access to needed services, e.g. healthcare, mental health, crisis intervention

TREATMENT MODALITIES**(Usually 2 or more modalities are used simultaneously)

TREATMENT MODALITIES**(Usually 2 or more modalities are used simultaneously)

• Individual Therapies (play, behavioral, cognitive, supportive, dynamic)

• Family Therapy & Parent Training

• Group Therapy - especially important for adolescents

• Examples of Pharmacotherapy:

ADHD Stimulants (e.g., Ritalin)

MDD & Anxiety SSRIs (e.g., Prozac, Zoloft)

Bipolar Disorders Valproate, Lithium

Enuresis DDAVP, TCAs (IMI)

Psychosis Antipsychotics

CHILD ABUSE1-800-96ABUSE CHILD ABUSE

1-800-96ABUSE "Abuse" means any willful act or threatened act that results in any

physical, mental, or sexual injury or harm that causes or is likely to cause the child's physical, mental, or emotional health to be significantly impaired. Abuse of a child includes acts or omissions. Corporal discipline of a child by a parent or legal custodian for disciplinary purposes does not in itself constitute abuse when it does not result in harm to the child. [Subsection 39.01 (2), F.S.]

The Florida Abuse Hotline will accept a report when:

1. There is reasonable cause to suspect that a child (less than 18 years old)

2. who can be located in Florida, or is temporarily out of the state but expected to return in the immediate future,

3. has been harmed or is believed to be threatened with harm 4. from a person responsible for the care of the child.

Know state reporting laws and procedures (http://www5.myflorida.com/cf_web/myflorida2/healthhuman/childabuse/)

DISORDERS OF CHILDHOOD AND ADOLESCENCE

DISORDERS OF CHILDHOOD AND ADOLESCENCE

• Basically all adult Axis I disorders can occur in children and adolescents (Depression, Bipolar, Schizophrenia, Anxiety, etc.).

• Personality Disorders (Axis II) are usually not diagnosed (and ASPD can’t be), although personality traits are often identified.

• Specific disorders with childhood onset are listed separately in DSM-IV (ADHD, Conduct Disorder, Learning Disorders, MR, etc). These may persist into adulthood.

• Comorbidity is common.• Epidemiology: 1 in 5 children involved

MENTAL RETARDATION Diagnostic Criteria

MENTAL RETARDATION Diagnostic Criteria

• IQ 70 or less on an individually administered IQ test• Onset before age 18 years• Concurrent deficits or impairments in adaptive

functioning in at least two of these areas:communication, self care, home living, social and interpersonal skills, use

of community resources, self direction, functional academic skills, work, leisure, health, or safety.

• Epidemiology: 1-3% in US• Causes:

– Unknown (50% of mild MR)– Known (75% of severe MR) – Hereditary (Down’s, fragile X;

PKU);Toxins; Birth Trauma; Infection.

MILD MR: IQ 50/55 to 70 (~ 85%)

• School: may acquire skills up to 6th grade level.

• Social and Communication Skills: develop spontaneously.

• May first be detected in school.

• May acquire vocational skills and be self-supportive.

•Social and Communication Skills: develop, but impaired.

•Early detection (i.e., before entering school).

•School: unlikely to progress past 2nd grade level.

•May work under close supervision (sheltered workshop).

•Social and Communication Skills: develop, but impaired.

•Early detection (i.e., before entering school).

•School: unlikely to progress past 2nd grade level.

•May work under close supervision (sheltered workshop).

MODERATE MR: IQ 35/40 to 50/55 (~ 10%)

SEVERE MR: IQ 20/25 to 35/40 (~ 3%)

• School: May learn to sight-read (survival words)• Social/Communication Skills: little or no

communicative speech. Often display poor motor development.

• May acquire elementary hygiene skills and perform simple tasks; unable to benefit from vocational training

•Social and Communication Skills: rarely have communicative speech efforts; minimal sensorimotor abilities.

•Require constant aid and supervision; nursing care.

•Social and Communication Skills: rarely have communicative speech efforts; minimal sensorimotor abilities.

•Require constant aid and supervision; nursing care.

PROFOUND MR: IQ Below 20/25 (~ 1-2%)

TREATMENT CONSIDERATIONS

Family is coping with loss of “ideal” child - Grief and loss issues.

Appropriate placement essential:- School setting, day care, group homes,

sheltered workshop and respite care.

Specific problems may be responsive to medications- Seizures; depression; hyperactivity;

aggression.

May experience “independent” psychiatric disorders, including schizophrenia, bipolar disorder, etc.

Pervasive Developmental Disorder

Developmental disorders with severe and pervasive impairment in essential developmental areas

• Reciprocal social skills• Language development• Range of behavioral repertoire DSM-IV includes the following under PDD:

1. Autism2. Rett’s Disorder3. Childhood Integrative Disorder4. Asperger’s Disorder5. PDD, not otherwise specified

Autism

Autism

• Prevalence estimates: variable and increasing

• Boys are effected 3 to 5 times more than girls

• 50 to 70% have some degree of MR

• Associated with Congenital Rubella, PKU, Tuberous Sclerosis and Fragile X Syndrome

• 20 to 25% have grand-mal seizures and about 50% have non-specific EEG abnormalities

• MRI, EEG, Karyotyping indicated in almost all cases

• Prevalence estimates: variable and increasing

• Boys are effected 3 to 5 times more than girls

• 50 to 70% have some degree of MR

• Associated with Congenital Rubella, PKU, Tuberous Sclerosis and Fragile X Syndrome

• 20 to 25% have grand-mal seizures and about 50% have non-specific EEG abnormalities

• MRI, EEG, Karyotyping indicated in almost all cases

INTERVENTIONS IN AUTISM:

Presently no curative treatment available; symptomatic interventions focus.

Mainstay: Early intervention; speech and language services; structured behavioral and educational programs; OT, PT.

Medications: To control seizures, hyperactivity, severe aggression, SIB, repetitive behaviors or mood disorders.

CARD PROGRAM: http://card.ufl.edu

Retts Disorder

• Normal growth for the first few months of life

• Deceleration of head growth between 5-48 months

• Truncal incoordination

• Lack of purposeful hand movements; flapping

• Disorder of females

• Similar criteria as PDD

• Over 80 percent of patients diagnosed with Rett's have a specific mutation in the MeCP2 gene on the X chromosome. This mutation is not inherited, but occurs after conception.

http://dukemednews.duke.edu/news/article.php?id=5085

“I Have the Courage “I cannot speak,

but you understand me. I cannot walk, so you push me. I cannot sing, but I love music. I cannot crawl, so you carry me.

I cannot tell jokes, but I love to laugh. I cannot wash myself, so you bathe

me. I cannot play with Barbies,

but I can push a switch. I cannot wave bye-bye, so you do that for me. I cannot dress myself,

so you make me pretty. I cannot read, so you tell me stories.

I cannot touch, but I can feel. I cannot go up the stairs,

so you put me on the lift. I cannot tell you how much I love you,

so look into my eyes and you will see.

I cannot tell what the future will hold, but I have the courage to go on

Childhood Disintegrative Disorder

• Normal Development for at least two years of life.• Clinically significant loss of previously acquired

skills prior to age 10 years in two or more of the following areas:

– Language– Social Skills Or adoptive behavior– Bowel or bladder control– Play– Motor skills

• Abnormal functioning in at least two areas:– Social interaction; communication; patterns of

behaviors/interests

Asperger’s Disorder

• “High functioning autism”

• Impaired use of non-verbal communication (gaze, posture, gestures regulating social interaction)

• Lack of interactive play, impaired peer relations

• Stereotypic, repetitive mannerisms

• No delays in language and cognitive development

PDD NOSDiagnosis assigned when there is a severe and pervasive impairment in the development of reciprocal social interaction, or communication skills, or when stereotyped behaviors and activities are present but the criteria are not met for a specific pervasive developmental disorder.

Diagnosis assigned when there is a severe and pervasive impairment in the development of reciprocal social interaction, or communication skills, or when stereotyped behaviors and activities are present but the criteria are not met for a specific pervasive developmental disorder.

LEARNING, MOTOR SKILLS, & COMMUNICATION DISORDERSLEARNING, MOTOR SKILLS, & COMMUNICATION DISORDERS

• Measured achievement in a specific (academic, motor, speech) area is substantially below that expected based on the age/IQ of the individual. This differs from MR where the deficits are global in nature.

• Types:– Reading Disorder

– Mathematics Disorder

– Disorder of Written Expression

– Developmental Coordination Disorder

– Expressive Language Disorder

– Mixed Receptive-Expressive Language Disorder

– Phonological Disorder

– Stuttering

ELIMINATION DISORDERSELIMINATION DISORDERS

• Encopresis (incontinence of feces)– Repeated passage of feces into inappropriate places

– Age at least 4 years

– Frequency at least 1x per month x 3 months

– Not due to laxatives or medical problem

– Specify: with or without overflow incontinence and constipation

• Enuresis (incontinence of urine)– Repeated voiding into bed or clothes

– Age at least 5 years

– Frequency 2x per week x 3 months

– Not due to medical problem

– Specify: nocturnal, diurnal, or both

– More common in males

ADHD

• Persistent pattern of inattention and/or hyperactivity more frequent and severe than is typical of children at a similar level of development.

• Onset before age 7

• Impairment in at least two settings:social, academic, or work

• Duration at least six months

• Inattention, Hyperactivity, Impulsivity

EpidemiologyEpidemiologyIncidence: 2 to 20% of grade-school children

Boys > Girls; Ratio 3-5:1

Family members (siblings and parents) of affected children are at higher risk

Incidence: 2 to 20% of grade-school children

Boys > Girls; Ratio 3-5:1

Family members (siblings and parents) of affected children are at higher risk

EtiologyEtiologySpecific etiology unknown; contributory factors

• Genetics• Pre and perinatal complications• Neurological • Environmental toxins

Specific etiology unknown; contributory factors

• Genetics• Pre and perinatal complications• Neurological • Environmental toxins

ADHD ContinuedADHD Continued

Treatment

1. Predominantly Inattentive type

2. Predominantly Hyperactive type

3. Combined type

1. Predominantly Inattentive type

2. Predominantly Hyperactive type

3. Combined type

ADHD ContinuedADHD Continued

Types

Pharmacotherapy

Stimulants: Methylphenidate, Dextroamphetamine, (Pemoline)

Non-Stimulants: Atomoxetine (Strattera); Clonidine and Guanfacine; Bupropion; TCAs; (atypical antipsychotics for treatment unresponsive cases)

Psychotherapy

Behavioral modifications; environmental structuring; parental Education and training; social skills training

Pharmacotherapy

Stimulants: Methylphenidate, Dextroamphetamine, (Pemoline)

Non-Stimulants: Atomoxetine (Strattera); Clonidine and Guanfacine; Bupropion; TCAs; (atypical antipsychotics for treatment unresponsive cases)

Psychotherapy

Behavioral modifications; environmental structuring; parental Education and training; social skills training

Tic Disorders

• Tourette’s Syndrome

• Chronic Motor Tic Disorder

• Chronic Vocal Tic Disorder

• Transient Tic Disorder

• Tic Disorder NOS

Tics are sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations

DSM-IV Diagnoses:

Tics are sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations

DSM-IV Diagnoses:

Oppositional Defiant Disorder

• Recurrent pattern of negativistic, defiant, disobedient & hostile behavior towards authority figures

• Duration > 6 Months

• Impairment in social, academic and work settings

• Symptoms not part of the mood or thought disorder

• Treatment: Parent training (PCIT)

Individual psychotherapy

Family Therapy

Conduct Disorder

• Aggression to people and animals

• Destruction of property

• Deceitfulness or theft

• Serious violation of rules

• Treatment: Multimodality treatment programsEnvironmental structuringFamily TherapyGroup TherapyInd. Therapy – problem solving skillsMedications as adjuncts

ANXIETY DISORDERSANXIETY DISORDERS

• Common in childhood: 15%

• Comorbidity is common

• All adult anxiety disorders may be seen in children.

• PTSD - may be a result of abuse

• Separation Anxiety Disorder– Developmentally inappropriate and excessive anxiety about

separation from caretakers or home, of at least 4 weeks duration with onset before 18 years

– Can lead to school refusal (school phobia)

– Associated with physical complaints, fear of sleeping alone, worries about parent’s safety

Mood Disorders

• Childhood Depression– irritability

– sleep cycle disturbance

– oppositional behavior

– social isolation

– crying spells

• Dysthymia– symptoms at least 1 year

Adolescents and Suicide

• In 1998, 4,153 young people, ages 15-24, committed suicide in the United States an average of 11.3 per day.1

• Suicide is the third leading cause of death in this age group following unintentional injury and homicide2

• Suicide accounts for 13.5% of all deaths in this age-group1

1 Murphy, SL, 1998 2 The Surgeon General’s Call to Action to Prevent Suicide, 1999

Suicide-Related Fatalitiesby Cause

393 320

34

1211

41 47 490

200400600800

100012001400

Suicide Prevention

• Don’t dismiss suicidal ideation, severe depression, runaway, significant substance abuse, etc. as just “normal” for age.

• Educate families to control access to potentially lethal methods of self-harm (Guns; OTC).

• Provide crisis hotline information.GAINESVILLE

24 hours / 7 days

(352) 264-6789