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Psychiatry 5th year, 4th lecture (Dr. Rebwar Ghareeb Hama)
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Psychiatry 5th year, 4th lecture (Dr. Rebwar Ghareeb Hama)


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The lecture has been given on Apr. 19th, 2011 by Dr. Rebwar Ghareeb Hama.

The lecture has been given on Apr. 19th, 2011 by Dr. Rebwar Ghareeb Hama.

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  • 1.
  • 2. CHILDHOOD DISORDERS Dr. Rebwar Ghareeb Hama Psychiatrist University of Sulaimani College of Medicine
  • 3. Classification
    • Learning Disorders
    • Motor Skills Disorders
    • Communication Disorders
    • Pervasive Developmental Disorders
    • Attention –Deficit Disorders
    • Disruptive Behavior Disorders
    • Feeding & Eating Disorders
    • Tic Disorders
    • Elimination Disorders
    • Other Disorders: like separation anxiety disorder, elective mutism ,etc…
    • Mood Disorders
    • Substance Abuse
  • 4.
    • Must be familiar with normal development and remember what is normal for one age may be a problem for another
      • Example: Tantrum Behavior
        • 2 year old ~ normal and expected behavior
        • 12 year old ~ not expected within normal development
    • Confidentiality directly related to age of child/adolescent
      • Young child ~ all information shared with caretaker
      • Adolescent ~ try to establish privacy agreement between caretaker and adolescent with understanding of what must be shared (significant danger to self and/or others, abuse)
  • 5. Motor Skills Disorders
    • This is also called developmental coordination disorders
    • Its essential characteristic is a marked impairment in the development of motor coordination
    • It is characterized by imprecise or clumsy gross motor skill
  • 6. Communication Disorders
    • This category includes disorders of speech & language
    • They include:
    • 1. Expressive language disorder :
    • the child skills in vocabulary ,the use of correct tenses ,the production of complex sentences & the recall of words are below the expected level for his or her age & intelligence
    • 2 . Mixed receptive –expressive language disorder :
    • child is impaired in both understanding and expressing language
    • 3 . Phonological disorder:
    • it is manifested by inappropriate or poor sound production
    • 4 . Stuttering or Stammering:
    • disturbance in the fluency and time patterning of speech that is inappropriate for the patient’s age
  • 7. Pervasive developmental disorders
    • These disorders are severe ,pervasive impairment in developmental areas ,such as social interaction & communication ,or stereotyped behavior ,interests and activities
    • The impairments are deviant in comparison to a person’s mental or developmental level
    • These disorders include:
    • Autistic disorder
    • Rett’s disorder
    • Childhood disintegrative disorder
    • Asperger’s disorder
  • 8. Autistic disorder
    • Sometimes called “childhood autism, early infantile autism, Kanner’s autism”
    • Prevalence is 0.02-0.05 %
    • In most cases it starts before the age of 36 months( 3 years)
    • It is more frequent in boys
    • The etiology of autistic disorder is not clear but there is more reliance on biological causes
  • 9. Clinical features
    • Impairment in social interaction: lacking social smile, fail to show the usual relatedness to their parents and other people, abnormal eye contact, …
    • Disturbance of communication &language
    • Stereotyped behavior :the activities &play are rigid ,repetitive & monotonous. Ritualistic and compulsive phenomena are common
    • Unstability of mood
    • Abnormal response to sensory stimuli( either exaggerated or decreased)
    • Other behavioral symptoms hyperkinesis or hypokinesis ,aggressive behavior ,temper tantrums, self injurious behavior
  • 10.
    • Prognosis is generally unfavorable
    • The patient needs a complicated care which include:
    • Educational therapy
    • Behavioral therapy
    • Pharmacotherapy: no specific therapy is available. It can be only symptomatic like anti-obsessive, antipsychotic and antiepileptic
  • 11.
    • In the absence of specific treatment, management has 6 main aspects:
    • Management of abnormal behavior
    • Education and social services
    • Speech and language therapy ,occupational therapy, dietary advice…
    • Treat medical conditions (e.g. epilepsy ,GIT problems)
    • Help for families
    • Pharmacotherapy :symptom management (e.g. antipsychotic for stereotypes ),SSRI for compulsive and self harming behaviors and depression, and anxiety
  • 12. Aspergers Syndrome( AS)
    • A syndrome first described by Hans Asperger’s in 1944 ,and sometimes called autistic psychopath ,is characterized by:-
    • The child develops normally until about the third year when they begin to lack warmth in relationships, and speak in monotonous stilted ways
    • Severe persistent impairment in social interactions ,repetitive behavior patterns, and restricted interests
    • IQ and language are normal or in some cases, superior
    • Motor mannerisms such as hand and finger twisting, or whole body movements
  • 13.
    • They are often clumsy and eccentric
    • They are more interested in others than autistic children
    • The disorder is more common in boys than girls
    • A family history of autism may be present
    • The cause of AS is unknown
    • It differ from autism in that there is no general delay or retardation of cognitive development or language
    • They are solitary, and embark on and spend much time in narrow interests
  • 14. Attention Deficit / Hyperactivity Disorder (ADHD )
    • This disorder is common ,appears more often in boys than in girls and causes disruption in school and at home
    • It is characterized by:
    • Features of hyperactivity: age-inappropriate hyperactivity which is mostly purposeless & intolerable causing a lot of disturbance
    • Poor attention span
    • Impulsivity
    • These symptoms should be present for at least 6 months before the diagnosis is made
    • The symptoms should be present in more than one setting ( home, school, work)
    • And should be severe enough to cause significant impairment
  • 15.
    • 3%-7% of children suffer from ADHD
    • ADHD is diagnosed approximately three times more often in boys than in girls
    • As many as half of those with ADHD also have other mental disorders
    • Over half of the children diagnosed with ADHD carry the disorder into adulthood
    • A large number of adults who were never diagnosed as a child show clear symptoms of ADHD
  • 16.
    • The symptoms of ADHD are present since the early childhood (before the age of 7 years)
    • The causes of ADHD are unknown ,but the disorder is predictably associated with a variety of other disorders that affect the brain function ,such as learning disorders
    • The suggested contributory factors to ADHD include prenatal toxic exposure, prematurity, and prenatal mechanical insult to the fetal nervous system
    • Food additives ,colorings, preservatives, and sugar have been suggested as possible causes
    • There is evidence for a genetic cause
  • 17. Symptoms of Inattention must have 6 or more
      • Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
      • Often has difficulty sustaining attention in tasks or play activities
      • Often does not seem to listen when spoken to directly
      • Often does not follow through on instructions and fails to finish school-work, chores, or duties in the workplace (not oppositional)
  • 18.
      • 5. Often has difficulty organizing tasks and activities
      • 6. Often avoids, dislikes, or is reluctant to engage in tasks that require a sustained mental effort
      • 7. Often loses things necessary for tasks or activities
      • 8. Often easily distracted by extraneous stimuli
      • 9.Often forgetful in daily activities
  • 19. Symptoms of Hyperactivity-Impulsivity Must have 6 or more
      • 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 (adolescents ~ may be subjective feelings of restlessness)
        • Often has difficulty playing or engaging in leisure activities quietly
        • Often “on the go” or often acts as if “driven by a motor”
        • Often talks excessively
  • 20.
      • Impulsivity
        • Often blurts out answers before questions have been completed
        • Often has difficulty awaiting turn
        • Often interrupts or intrudes on others
  • 21. Treatment of ADHD
    • Pharmacotherapy:
    • a. CNS stimulants: dextroamphetamine, methylphenidate, and pemoline
    • b. Antidepressants
    • Psychotherapy :
    • which include behavioral therapy , education of parents and teachers
  • 22. Disruptive behavior disorders
    • There are two types:
    • Oppositional defiant disorder:
    • described as a recurrent pattern of negativistic, defiant, disobedient, and hostile behaviors toward authority figures
    • Conduct disorder:
    • A repetitive & persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated
  • 23. Elimination Disorders
    • Enuresis :
    • The repeated voiding of urine into clothes or bed ,whether, the voiding is involuntary or intentional .The behavior must occur twice weekly for at least 3 months or must cause clinically significant distress or impairment socially or academically. The child’s age must be at least 5 years
    • Encopresis:
    • Passing feces into inappropriate places whether the passage is involuntary or intentional. The pattern must be present for at least 3 months ; the child’s age must be at least 4 years
  • 24. Separation Anxiety Disorder
    • Defined as an excessive anxiety about separation from home or from those to whom the child is attached
    • This disorder must last for at least 4 weeks
    • Must begin before age of 18 years
    • Must cause significant distress or impairment
    • Separation anxiety requires the presence of at least three symptoms related to excessive worry about separation from the major attachment figures
  • 25.
    • The worries may take the form of refusal to go to school( school phobia, school refusal), fears & distress upon separation ,repeated complaints of such physical symptoms like headaches & stomach aches when separation is anticipated and night mares related to separation issues
    • The disorder is common and onset may occur during preschool years but is most common in 7-8 years old
    • Prevalence is 3-4% of all school children
    • It occurs equally in males and females
    • Treatment : behavioral therapy
  • 26. Pediatric Psychopharmacology Summary:
    • Substantial Empirical Evidence Currently Supports
      • Stimulants for ADHD
      • SSRI’s for OCD
    • Well Designed Trials support
      • Risperidone for aggression and self-injurious behaviors in autism
      • Fluvoxamine for Childhood Anxiety Disorders
      • Fluoxetine for Moderate – Severe Major Depression
  • 27. Pediatric Psychotherapy Summary:
    • Best Evidence for;
      • CBT (cognitive behavioral therapy) for Depression, Anxiety
      • CBT/Behavioral Strategies for Conduct Problems
      • Parent Training for Conduct Problems
      • MST (multi systemic treatment) for Conduct Problems
  • 28.