11. CHILD AND ADOLESCENT PSYCHIATRY.pptx

CHILD AND ADOLESCENT PSYCHIATRY
• MENTAL RETARDATION IQ<70
• IQ=mental age divide by chronological age multiply by 100
• It is a heterogenous disorder consisting of
-below average intellectual functioning
-impairment in ability of individual to adapt to the daily demands of
social environment
INTELLIGENCE-the ability to learn from experience,to solve problems
,to adapt to the daily demands of the social environment and form
abstract concept
Jumatatu, 1 Mei 2023 1

CLASSIFICATION OF MR
• Mild MR(IQ 55-70) 85%
• Moderate MR(IQ 40-55) 10%
• Severe MR(IQ 25-40) 3-4%
• Profound MR(IQ<25) 1-2%

EPIDEMIOLOGY
• Prevalence of MR between 1-3% depending on criteria used
• Male/female ratio 1.5-1
• More common in lower social economic group

ETIOLOGY
• Over 40% of cases have no known etiology
• 30%chromosomal causes
COMMON CHROMOSALS CAUSES OF MR
-Down sydrome (trisomy21),Alzheimers’dementia after age of 40yrs and
depression are commonly present in DS
-Flagile X sydrome;(defect in the long arm of X-chromosome)up to 80% of pt
have ADHD
-Prader –willi sydrome(chromosome 15 deletion) obesity and hyperphagia
are common pro blems
-Williams sydrome;chromosome 7 deletion;supravalvular aortic stenosis and
hypertension

ETIOLOGY CONT-
• BIOLOGICAL FACTORS
Prenatal factors-maternal illness eg
diabetes,infections(rubella,syphilis,HIV),drugs ,malnutritions
Perinatal factors-blood gp incompatibility,brain
trauma,prematurity
Infancy/childhood factors-CNS infection,lead intoxication,severe
malnutrition,hypothyroidism
Social –cultural factors-lack of psychosocial stimulation, child
abuse and neglect

DIFFERENTIAL DIAGNOSIS
• Deafness
• Learning disorder
• Communication disorder
• Borderline interllectual functioning
• Pervasive developmental disorder

CLINICAL PRESENTATION
• Have low intelligence compared to peer of same age and
culture
• They tend to be aggresive
• Have self injuries behaviouh
• Steretype-repetitive fixed pattern of physical action or speech
• Echopraxia-emitation of movements
• Pica-feeding on non nutritional materials
• Rumination-repeated regurgitation of food

TREATMENT
• Interventions directed at improving adaptive functions are applied
at home in school and vocational settings
• Co –morbid psychiatric disorder eg depression,bipolar disorder
,anxiety ,and schizophrenia are often missed and should be the
central focus of treatment
• Mostly physical or medical condition in MR first present as behavior
change
• Treatment should be muiltimodel including medical ,psychiatric
,parental education and behavior intervention
• This should always include long term planninig

COURSE AND PROGNOSIS
• A life long problem
• Reversible causes should be addressed adquately
• Preventive measures should be emphasised such as infections
,drugs, malnutrition etc

PERVASIVE DEVELOPMENTAL DISORDER
• PDD conditions that become apparent early in a child’s life,
affecting major developmental systems ie social ,cognitive and
language
• These disorder includes
1;Autistic disorder
2;Asperger’s disorder
3;Chilhood disintegrative diisorder
4;Rett’s disorder

AUTISTIC DISORDER(infantile autism)
• Autistic disorder is characterised by impairment in social interaction,
communication and stereotypical behavior patterns
-IMPAIR MENT IN SOCIAL INTERACTION
Includes impairment in use of non verbal behavior such as
(1) facial expression
(2)eye to eye contact
,(3)failure to develop peer relationship
(4)lack of interest in sharing enjoyment or
achievement with other people
(5)lack of social or emotional reciprocity(you smile at
them they don’t smile back)

CONT-
• IMPAIRMENT IN COMMUNACATION
(1)Delayed or total lack of development of spoken language
(2)In those with adquate speech they are unable to intiate or
sustain a conversation with others
(3)Stereotyped and repetitive use of language
(4)Lack of social imitative play appropriate to developmental
level

CONT-
• RESTRICTED STEREOTYPICAL BEHAVIOUH PATTERN
(1)Inflexible adherence to specific routines or rituals
(2)Repetitive motor mannerism such as hand or finger flapping
or twisting or may have complex whole body movement
(3)Persistent preoccupation with parts of object

EPIDEMIOLOGY
• Found world wide in all racial ,ethnic, religious and economic
back ground
• Affect 1-2 children in every 1000
• Male;female ratio 4;1
• 50% of autistic children have severe mental disorder
• 30% have mild to moderate MR
• 20% have IQ in the normal range

ETIOLOGY
• It is an organic neuro developmental disorder
• GENETIC FACTORS
• Sibling of Autistic children are 3-4 times likely chances of getting
the disoder as compared to the general population
• Twin studies indicate high concordance rates in monozygotic twin
than in dyzygotic twin
• ORGANIC FACTORS
• Trauma to the developing CNS
• Specific viral infections
• Dilatation of anterior ventricle

Course and prognosis
• Autistic disorder is a chronic severe disorder
• 2/3 of pt AD remain severely handicapped
• 1/2 remain without spoken language
• 1/3 develop seizure disorder during adolescence
• Only about 1/6 make fair social adjustment

TREATMENT
• Behavioural therapy to increase skills as well as reducing the
severity and frequency of disruptive behavior
• Education programmes which can expand their capacity to
learn, communicate and relate to others
• Medication can be used to help alleviate certain symptoms
• Family education and support is essential

ASPERGER’S DISORDER
• In AD language,curiosity and cognitive development proceeds
normally
• There is substantial delay in social interaction
• Have restricted ,repetitive patterns of behaviour interest and
activities
• There is no clinically significant delay in language-eg single
words used by 2yrs ,communicative phrases used by age 3yrs

CHILDHOOD DISINTEGRATIVE DISORDER
• Children with this disorder have normal development for at
least the first 2yrs after birth as manifested by
-presence of age appropriate verbal and non verbal
communication
-normal social relationship
-appropriate play and adaptive behaviour

CONT-
• After 2yrs there is clinically significant loss of previously
acquired skills such as
-expressive or receptive language
-social skills or adaptive behaviour
-loss of bowel or bladder control
-development of restricted repetitive and stereotyped pattern of
behaviour interest activities and mannerisms

RETT’S DISORDER
• Children with RD have normal prenatal and perinatal
development
• Normal psychomotor development in the first 5 months after
birth
• Normal head circumference at birth

CONT-
• Onset of the following after a period of normal development
- Deceleration of head growth between the ages of 5-48months
- Loss of previously acquired purposeful hand skills between the ages
of 5-30months
- With subsequent development of stereotyped hand movement eg
hand flapping
- Loss of social engagement
- Appearance of poorly co-ordinated gait or trunk movements
- Severely impaired expressive-receptive language development with
severe psychomotor retardation

DISRUPTIVE BEHAVIOUR DISORDER
• DBD INCLUDES;
• ATTENTION DEFICIT HYPER ACTIVITY DISORDER (ADHD)
• OPPOSITIONAL DEFIENT DISORDER
• CONDUCT DISORDER

ADHD
• The core symtoms includes
-Poor sustained attention
-Impulsivity
-hyperactivity
DIAGNOSIC CRITERIA(DSM IV)
-Onset of symptoms before 7yrs
-Duration of symptoms at least 6 months
-Pervasiveness of symptoms in multiple settings

EPIDEMIOLOGY
• Affect 2-9% of childhood population
• Age of onset 3-4yrs
• Gender ratio boy;girls 3;1
• It is pervasive in all settings
• ADHD and other disruptive behaviour disorder account for 30-
40% of all child psychiatric disorder

ETIOLOGY
• Family factors –monozygotic twins have higher concodance
rate as compared to dizygotic twins
• 11% of parent with ADHD have antisocial personality disorder
• 25% have 1st degree relatives with ADHD

CONT-
• PERINATAL FACTORS
-Martenal alcohol and drug use
- Prolonged labour
- pre or post maturity
- -poor martenal nutrition
- Brain trauma/infection
- -lead poisoning
- Glucose 6 phosphate dehydrogenese deficiency

TREATMENT APPROACHES
• Muilti-model treatment produces best results
• A chronic disoder and treatment planning must reflect this reality
• In adolescence 70-80% have symptoms and in adulthood 50-60%
have symptoms
EDUCATIONAL APPROACHES(Special education)
-Break insructions into smaller steps
-Provide structured learning environment
-prescribing more immediate consequences for action in the
classroom
-use of cues to remind child of homework

PSYCHOLOGICAL AND BEHAVIOUR APPROACHES
• Parent and teachers should use the same behavior
modification
• Parent support group are highly effective
• Social skill training may be helpful
• Behavioral based family therapy is recommended

PSYCHOPHARMACOLOGICAL APPROACHES
• Psychostimulant such as methyl phenidate(ritalin)70-80%
response,dextroamphetamine is also effective
• Tricyclic antdepressant-imipramine ,desipramine
nortryptiline(60-70%)response
• Atomoxetine(strattera)norepinephrine re-uptake inhibitor is
also effective

CONDUCT DISORDER (CD)
• Childrens with CD has a repetitive and persistent pattern of
behavior in which
-basic rights of others are violated
-major age appropriate societal norms or rules are violated
SUCH BEHAVIORS INCLUDES
-Agressive tendencies
-property damage or loss
-deceitifulness or theft
-serious violations of rules

AGGRESIVE TENDENCIES DIRECTED TO PEOPLE OR ANIMALS
• -often bullies,threaten or intimidates others
-intiates physical fights
-has used a weapon which cause serious injury to others eg a
knife, a gun or a broken bottle
-has been physically cruel to peoples or animals
-has stolen while confronting a victim eg purse
snatching,mugging or armed robbery
-has forced some one into sexual activity

DESTRUCTION OF PROPERTY
• -has deliberately engaged in fire setting with intention of
causing serious damage
-has deliberately destroyed others’’ property

DECEITFULNESS OR THEFT
• Has broken into someone house,building or a car
• Often lies to obtain goods or favours(cons others)
• Has stolen valuable items without confronting a victim

SERIOUS VIOLATION OF RULES
• -Often stay out at night despite parental prohibition before the
age of 13yrs
• Has run away from home overnight at least in a month while
living in parental home(or once without returning for a
lengthy period)
• Is often truant from school beginning before the age of 13yrs
• NB –PRESENCE OF 3 OR MORE OF THE ABOVE SYMPTOMS IN
PAST 12MON WITH AT LEAST ONE CRITERIA PRESENT INTHE
LAST 6MON

TYPES AND SEVERITY OF CD
• CD-childhood onset type(onset prior to 10yrs)
• CD-adolescence onset type(onset after 10yrs)
• CD-unspefied onset type(age of onset is not known)
• SEVERITY –mild cd –mild harm to others eg lying, trauncy or staying out without
permission
• -moderate- causes mild harm to severe harm to others eg stealing without
confronting a victim
• Severe-causes considerable harm to others eg forced sex or physical cruelty
-use of a weapon
- stealing when confronting a victim
-breaking and entering

EPIDEMILOGY
• Prevalence rate 3-7%
• Male predominate
• It is associated with impaired and chaotic families
• ADHD is a risk factor or co-morbid psychitric disorder

ETIOLOGY
• Genetic predisposition
• Marital conflicts at home
• Frequent moves during pre-school period
• Poverty
• low IQ or brain damage
• Negative peer pleasure

TREATMENT APPROACHES
• INCLUDES-Psychotherapy
-Behavior modification
-Pharmacotherapy
PSYCHOTHERAPY –Group and family therapy and also parent training produce
better results than individual psychotherapy
BEHAVIOR MODIFICATION-Cognitive-behavior modification in the child and parent
management training in combination may produce the disired effect
PHARMACOLOGY-Antpychotic drugs eg haloperidol,mood stabilizers eg lithium and
carbamazine are effective in controlling aggressive behavior
Other drugs are used to treat co-morbid psychiatric disorder egstimulant
ADHD,Antidepressant

OPPOSITIONAL DEFIANT DISODER
• This children have a chronic pattern of behavior characterised
by
-stubborn attitute
-negativism
-hostility
-defiant behavior without violating the right of others
The problems initilly manifest at home and then progress to
school and the larger community

DIAGNOSIS
• The diagnosis of ODD is based on negativistic,hostile and defiant behavior
lasting at least 6mons during which four or more of the following are
present
• The child often-loses temper
-argues with adults
-defies or refuses to comply with adult’s request or rules
-deliberately annoys peoples
-blames others for his or her mistakes
-often angry or resentful
- easily annoyed by others

ANXIETY DISORDERS IN CHILDHOOD AND ADOLESCENCE
• Anxiety disorder are among the commonest psychiatric
disorder in children and adolescent
• Anxiety – is an alerting signal it warns of impending danger and
enables the person to take measures to deal with the threat
• Anxiety is in response to a theat that is unknown internal
,vague or conflictual in origin
• Fear –is in response to threat that is known ,external,definite
or non-conflictual in origin

CLASSIFICATION OF AD
• SEPARATION ANXIETY DISORDER
• GENERILISED ANXIETY DISORDER
• PHOBIA
• PANIC ATTACK
• ACUTE STRESS DISORDER
• POST TRUMATIC STRESS DISORDER
• OBSESSIVE –COMPULSIVE DISORDER

SEPARATION ANXIETY DISORDER
• Children with SAD has excessive worry about separation from attachment figures
• Reluctance or refuses to go to school or elsewhere because of fear of separation
• Refuses to go to sleep without being near amajor attachment figure
• Repeated complaints of physical symptoms (such as headache stomachache,vomiting when
separation from major attachment figure occurs or is anticipated
• Mean age ofpresentation 9yrs
• Common in chldren from lower social economic class and from single families
• Gender ratio 1.1
• As adult may develop depression or anxiety disorder
• The duration of symptoms is at least 4wks
• Onset before age 18yrs

GENERALISED ANXIETY DISORDER
• Characterised by excessive worry about the future
• Over concern about compentence in a variety of areas
• Diagnosis-only 1 out of the following 6 symptoms is required to
make a diagnosis in children
• Restlessness
• Fatigue
• difficulty with concentration
• Irritability
• Muscles tension or
• sleep disturbance

GAD CONT-
• GAD start at an older age than SAD
• Sex ratio 1.1
• Affect middle and upper class families
• 85% of children with anxiety disorder has GAD
• Mean age of onset 10yrs
• In adolescence females are more predominant than males

SOCIAL PHOBIA
• The condition is characterised by persistant fear of social or
performance situations in which the the person is exposed to
unfamiliar people
• Sex ratio 1.1
• Common in middle and upper class
• Has onset in early or mid adolescence

PANIC DISORDER
• This conditon is characterised by reccurent sponteneous
episodes of panic attack associated with physiological
symptoms eg sweating, palpitation,trembling, feeling of
choking,chest pain /discomfort
• Age of onset peak at 15-19yrs

SELECTIVE MUTISM
• Characterised by lack of use of speech in certain situations eg
public places or with strangers
• More common in girls than in boys
• This children are often shy and have overprotective mothers

POST –TRAUMATIC STRESS DISORDER
• Occurs when one has been exposed to a traumatic events in
which both of the following were present
• The person experinced or witnessed or was confronted with an
event that involved actual death or threatened death or
serious injury or threat to the physical integrity of self or others
• The person response involved intense fear helplessness or
horror(in children this is expressed by disorganised or agitated
behavior

PTSD CONT-
• The traumatic event is persistetly re-experienced through
thoughts,images or,dreams
• Persistant avoidance of stimuli associated with the trauma eg
thoughts,conversations activities ,people or place(that may
arouse recollection of the trauma)
• Persistent symptoms of increased arousal eg difficulty in falling
asleep,outburst of anger, difficulty in concentration,
hypervigilance ,or exaggerated startle response.

PTSD CONT-
• Duration of syptoms >1mon
• Acute PTSD-duration of smptons<3mons
• Chronic PTSD-duration of smptoms>3mons
• With delayed onset –if onset of symptoms is at least 6months
after the stressor
• ACUTE STRESS DISORDER the duration of smptoms is less
than 1months

TREATMENT OF PTSD
• PHARMACOTHERAPY- antdepressant,SSRI ,TCA
-mood stabilizer ,lithiam or
cabamazapines
PSY CHOTHERAPY- behavior therapy,cognitive therapy
Combination of pharmacotheraphy and psychotheraphy

OBSESSIVE- COMPULSIVE DISORDER
• Has 2 distinct phenomena obsessions and compulsions
• Obsession- is defined by recurrent and persistent thought or
images that are intrusive and inappropriate and causes much
anxiety and distress
• They are not due to real life problem
• The individual tries to neutralize them with some other thoughts
or actions
• The individual recognises that obsessional thought or images are a
product of his or her own mind(not imposed from without as in
thought insertion

OCD CONT-
• COMPULSIONS-defined as arepetitive behavior eg washing of
hands, ordering or checking
• Or mental acts eg praying, counting ,repeating words silently
• The individual recognises that the obsessions or compulsive are
excessive and unreasonable
• The obsession and compulsion causes
(a) marked distress
(b)are time consuming
(c) interfere with a person normal routine or occupation,academic
work, social activities and relationship

EPIDEMIOLOGY
• Anxiety disorder are among the commonest psychiatric disorder in children and
adolescents
• Predisposing factors
(a)attachment- insecure attachment especially in those brouught up by non
biological mothers
(b)temperament-those who are shy ,fearful or withdrawn are likely to develop
anxiety disorder
(c)those with low self esteem ,less flexibility and more resistance to change are at
a high risk of developing anxiety disorder
(d)stress- environmental stress is associated with anxiety disorder eg PTSD
,PHOBIA
(c)familial factors-the risk of developing AD is higher if ones parent have anxiety
disorder or depression

TREATMENT
• PHARMACOLOGICAL
(a)Antidepressant agent SSRI quite effective with minimal side
effects
(b)betablokers- are also effective especially in panic attacks
(c)Benzodiazepines should be avoided in children

RX CONT-
• COGNITIVE BEHAVIOR THERAPY
Systematic desensitization and graded exposure both work as
well as does operant conditioning and flooding
Other includes relaxation training, modelling and role playing

MOOD DISORDERS IN CHILDREN AND ADOLESCENCE
• Children with mood disorder may present with somatic symptoms
• Adolescence present with symptoms similar to adults
CLASSIFICATION
-Major depressive disorder(MDD)
-Bipolar type 1 disorder(BMD1)
-Bipolar type2 disorder(BMD11)
-Dysthymic disorder
-Cyclothymic disorder

MAJOR DEPRESSIVE DISORDER
• Children present with irritable mood rather than depressed
mood
• Failure to make expected weight gain
• Has insidious onset while in adult onset is episodic

EPIDEMIOLOGY(MDD)
• MDD
• Rare in pre-school children
• Increases in frequency with age
• School age affect 0.5-2.5%
• Adolescence 2-8%
• More common in boys
DYSTHYMIC DISORDER
-school age 2-5%(likely to become MDD)
-Disorder start early and last for over a year
-in adolescence prevalence of DD is less than MDD as it is in adult
BMD-Starts in adolescence

ETIOLOGY
• GENETICS
• The risk in 1st degree relatives i s higher than in general
population
• if a parent has a mood disorder a child has 12% chance of
having the same disorder
• If parents have the disoder the chance of the disorder is 47 %
• High concodance rate in monozygotic twins as compared to
dizygotic twins

ETIOLOGY CONT-
• BIOLOGICAL FACTORS
• The evidence for abnormalies in neurotrasmitter
system and the hypothalamo-pituitary axis is weak in
children
• Thyriod function involvement is not evident as in adults
• SOCIAL FACTORS
• Stressful life events ,loss or bereavement or viral
infection contribute to the development of mood
disorder
• The most conclusive evidence is that the loss of parent
before the age of 13yrs

CLINICAL FEATURES
• MDD
• Onset insidious
• PREPURBERTY
• -somatic complains
-psychomotor agitation
-mood congruent with affect
-poor self esteem
-low mood
Adolescence-psy chomotor retardation
-hopelessness
- pervasive anhedonia
-delusion/psychosis
Common to both-suicidal ideation
-depressed or irritable mood
-decreased concentration and
-insomnia

CLINICAL FEATURES CONT-
• BIPOLAR DISORDER
-Rare in pre-puberty children
-often start with depressive episode and later manic episode in
adolescence
-manic episode in children are atypical,less clearly episodic and
resistant to treatment
-it may overlap or share features with ADHD

• The younger children with a more severe initial episode have worse prognosis
• Comorbid condition result in poor prognosis
MDD
-an episode has a duration of 9months
-recurrence is very likely
-conversion to BMP over time is a possibilty
-probability of recurrence is 40% within 2yrs and is 70%within 5yrs
-adolescence with MDD 40-70% have a diagnosis of BMD within 5yrs
-psychosocial stressors worsen the prognosis
-children with MDD often have peer relationship problems,academics difficulties and self
esteem problem
BMD-mean duration is 3-7yrs often mixed and rapid cycling,resistant to treatment and
recurrence common

TREATMENT
• PHARCOTHERAPY
- A wide range of agents ie antdepressants(TCA ,SSRI)
- -mood stabilisers
- -antpsychotics
- -are used in treating a wide spectrum of mood disorder
- Among antdepressant the SSRI are the 1st line drugs for depressive disorder
- -they are effective
- have low benign side effect profile
- have low letharlity in overdose
- Mood stabilizers –mainstay of treatment for BMD(Lithium,carbamazepine and valproate)
are all used
- Ant psychotics-used in mania or depressive states with psychotic features
- Physical treatment eg ECT(severe depression,suicidal risks , catatonia,and in psychosis

TRETMENT CONT-
• PSYCHOTHERAPY
• Cognitive hehavior therapy
• Family therapy
• Social skill training
• relaxation therapy
• Problem solving
• self modelling stategies
• All this are useful and should be tailored to individual patient

PSYCHOTIC DISORDER IN CHILDHOOD AND ADOLESCENCE
• EARLY ONSET SCHIZOPHRENIA
-Early onset is defined as onset before the age 18yrs
-very early onset before the age of 12yrs
Very early onset of schizophrenia is rare and symptoms of
psychosis in a child under age of 12yrs should be assumed to
be secondary to a general medical condition until proven
otherwise

DIAGNOSTIC CRITERIA
• Same as for adult
• If illness last > 6months schizophrenia
• <6mon and>1mon –schizophreniform disorder
• <1month –brief psychotic disorder

EPIDEMIOLOGY
• Very early onset of schizophrenia occur <1 in 20,000children
• Male predominate 1.5-1
• Early onset 1-2 pre 1000 adolescence
• More common in low income community
• The IQ range of the affected children is average or below
average

ETIOLOGY
• Genetic factors
• Dopamine hypothesis
• neuropathology-decrease in brain volume
• Neuroimaging-ventricular enlargement
• Psychoneuroimmnology –presence of brain directed ant bodies
• Psychosocial factors –family with highly expressed emotions –
increases relapse rate

CLINICAL PRESENTATION
• Frequently encounted symptoms includes
-auditory hallucinations(usually persecutory in nature)which give
commands,or a voice conversing with each other;or commenting on pt
activities
-50% have delusion mostly persecutory,somatic, grandiose or religiose
-Affective blunting
-Ideas of reference are common
• -

TREATMENT
• DRUGS
-Antipsychotic drugs
(a)Atypical antpsychotic-have less advese effects profile than
traditional or typical ant psychotics
Atypical antipsychotic are effective in treating negative and
positive symptoms of schizophrenia
Ideally this are the medication of choice in young pt but they are
expensive

TREAMENT CONT-
• PSYCHOTHERAPY
Psychoeducation to the individual and family is important (for them
to know the course mode of treatment and prognosis)
-ongoing supportive psychotherapy
-cognitive behavior therapy –can be used to help the young pt deal
with active psychotic symptoms
Support gp- for pt and relatives play an import ant role in the
provision of an optimal environment for recovering pts
Ideally pt with schizophrenia should continue to attend school in
order to allow for maximum academic and social development

PROGNOSIS
• A better prognosis is associated with
- a later onset
- An acute onset
- Better premorbid functioning
- A greater degree of affective symptom

TICS DISORDERS
• Tics are involuntary,sudden, rapid and recurrent movement(motor tics)
• There are also vocal tics
• They may be simple(simple movement or words)
• Or complex (gp of movement or phrases)
• Some may be dramatic and socially impairing eg coprolalia in which a vocal
tic consist of an obscenity(coprolalia compulsive utterance of abscene
words)
• Echolalia where pt repeats what he has just said
• Tics can sometimes be suppressed during sleep or focused activity
• They tend to worsen with stress

TYPES OF TICS
• TUORETTE’S DISORDER
• CHRONIC MOTOR OR VOCAL TICS
• TRANSIENT TICS DISORDER

TOURETTE’S DISORDER
• A type of tic disorder described by Georges de la tourette in
1885
• It comprises multiple motor and vocal tics for more than 1year
with onset before the age of 18yrs
• DIAGNOSIS-they must cause impairment of functioning or
distress and general medical condition or substance use must
be ruled out

EPIDEMIOLOGY
• Affect 4-5children per 10,000 of general population
• Onset is usually before 7yrs for motor tics and 11yrs for vocal
tics
• Ratio boys.girls 3.1

ETIOLOGY
• Has genetic component,more common in monozygotic twins
than in dizygotic twins
• They is a genetic link between obsessive- compulsive disorder
and Tourette’s disorder
• Dopamine trasmission appears to be increased in some areas
of the brain in pt with Tourette’s disorder

CLINICAL FEATURES
• They can affect any part of the body
-face and head
-arms and hands
- Body and legs
- -respiratory and gastro intestinal systems
- Some tics are so forceful that they cause injury to the pt

• Extrapyramidal side effecte of neuroleptics drugs(occurs after a
prolonged use of neuroleptic)
• Mannerism
• Stereotypical movement found in autistic disorder or mental
retardation
• Compulsive disorder
• Huntington’s chorea
• Wilson’s disease

Course and prognosis
• The disorder is life long with remission and exacerbations
• Children may have serious emotional ,social,academic or
occupational dificulties
• This may lead to depression or suicide
• Most pt with tics are mild and requires no treatment
• The outcome is improved if the family,the school and friends
understand that the disorder is involuntary and children should not
be punished for what may be perceived as intentional and
irritating movements and noises

TREATMENT
• Neuroleptics medication are effective against tics
-haloperidal reduces tics by 80%
-risperidone also effective with benign side effects profile
-psychological RX
-behavioral therapy-which includes habit reversal or relaxation
techniques may reduce tics frequency

CHRONIC MOTOR OR VOCAL TIC DISORDER
• The disorder present with either motor or vocal tics but not both
for >1year
• Have onset before the 18yrs of age
• Prevalence 1-2% in general population
• Boys are more often affected than girls
• symptoms last for 4- 6yrs and cease in early adolescence
• Medication is necessary if impairment is severe
• Psychotherapy- behavior method may be effective in teaching the
child to control tics to some extent

TRANSIENT TIC DISORDER
• Diagnosis is made when tics are present >4weeks<1yrs
• Tics occur in 5-24% children and in most cases remit
sponteneosly
• Such tics may be precipitated by stressor
• Medication is used only in very severe exceptional cases

LEARNING DISORDER
• READING DISORDER
• MATHEMATICS DISORDER
• DISORDER OF WRITTEN EXPRESSION

READING DISORDER
• Characterised by impaired ability to recognise words ,slow
reading or inaccurate reading and poor comprehension
• This occur in children with normal intelligence and has no
sensory deficit
• The disorder seem to run in families
• It is also associated with disorder of written
expression,mathematics disorder or communication disorder
• Children with ADHD are at ahigher risk of reading disorder

READING DISORDER CONT-
• EPIDEMIOLOGY
-Prevalence studies find rates ranging between 2-8%
-Sex ratio 3-4 .1 boys .girls
-Adult no sex differences in reading disorder

RD CONT-
• ETIOLOGY
-Cause unknown
-It is more prevalent among family members of persons affected by the disorder as
compared with the general population an indication of genetic origin
-Twin studies has not been conclusive
-High incidence of reading disorder is found among children with cerebral palsy
who have normal intelligence
-Slightly increased incidence is seen among epileptic children
-Complication during pregnancy,prenatal and perinatal difficulties including
prematuarity and low birth weight are associated with reading disorder
-Secondary reading disorder occur in malnourished childen which causes cognitive
impairment

RD CONT-
• TREATMENT
• -Treatent of choice in reading disorder is
remedial education approach
• Co-existing emotional and behavioral
problem should be treated by appropriate
psychotherapeutic means
• Perantal counselling may also be helpful

MATHEMATICS DISORDER
• Mathematics diorder is inability in achieving arthmentic skills that are expected for a person
intelletual capacity and educational level
• EPIDEMIOLOGY –prevalence rate is estimated at 6%
• ETIOLOGY-
• -The cause is not known
• One theory proposes a neurological deficit in the rt cerebral hemisphere(particularly in the
occipital lobe)
• This region is involved in processing visual - spatial stimuli that is reponsible for
mathematics skills
• The current view is that the cause is muilt factorial emotional,poor quality of instructions or
cognitive problem
• Treatment- most effective treatment is remedial education

DISORDER OF WRITTEN EXPRESSION
• Disorder of written expressionis characterised by written skills
that are below the expected level for person age,intellectual
capacity and education
• The disorder interferes with the persons school performances
and demands of writing in everyday life
• The disorder is not due to a neurological or sensory deficit
• The component of this disorder include poor spelling ,errors in
grammar and poor hand writing

TREATMENT
• The best treatment to date is remedial education
• Teachers should devote as much as 2hrs a day to such writing
instructions
• Perantal counselling is essential

ELIMINATION DISORDER
• Conditions characterised by problems with bowel or bladder
control
• Types ;
-Enuresis
-Encopresis

ENURESIS
• Children with enuresis has ongoing bed wetting with a failure of the
child to achieve appropriate nocturnal bladder control
• A range of ages exist when this milestone is achieved
• Epidemiology
-85% of 2yrs old are enuretic
-49% of 3yrs old ‘’ ‘’
-26% of 4yrs old ‘’ ‘’
-1.5% of 14yrs old ‘’ ‘’
-1% of adult ‘’ ‘’

ETIOLOGY
• 75% of enuretic children have a 1st degree relative who is or was
enuretic
• The concordance rate is higher in monozygotic twins than in
dizygotic twins
• Psychosocial stressor may precipitate some cases of enuresis
• In young children the disorder has been associated with
• (a)the birth of a sibling
(b) the start of school
(c)the break up of a family because of divorce or death
(d) move to a new home

CLINICAL FEATURES
• Enuresis is repeated voiding of urine into the pt clothes or bed
• The voiding may be involuntary or intentional
• The diagnosis is made when the age is 5yrs and above
• The behavior must occur twice weekly for a period of at least
3 mons
• The diagnosis is made if the behavior is not due to a medical
condition

• Possible organic cause must be ruled out eg genito urinary pathology
-structural ;obstructive uropathy
-neurological .spina bifda
- Infections .cystitis
Other organic cause s which cause polyuria
-diabetes mellitus
diabetes insipidus
Disturbances of consciouness and sleep such as
-seizures
-sleep walking or side effect of medication eg mellaril

• Enuresis is usually self limiting
• 80% of affected children have never achieved a year long period of
dryness
• Enuresis after at least one dry year usually begin between ages 5-
8yrs
• If it accurs much later especially in adulthood organic cause must
be investigated
• Emotional and social difficulties associated with enuretic childen
include poor self image, low self esteem,social embarrassment,
restrictions and intrafamilial conflicts

TREATMENT
• Appropriate toilet training
• This should be attempted especially in children who have not experienced
urine continence
• If toilet training was not attempted the parent and the pt should be guided
in that under taking
• Behavior techniques such as starchart where a child places a star on a
chart for dry night
• Such record keeping is helpful in determining a baseline and following the
child’s progress and may by itself be a reinforcer
• Other techniques includes restricting fluid intake before bed and night
lifting to toilet train the child

TRETMENT CONT-
• BEHAVIOR THERAPY
• Classical conditioning with a bell and a pad apparatus is effective
treatment for enuresis(these are mechanical devices which consist
of an alarm which is connected to a moisture sentive blanket and
awaken the child from sleeping after voiding)
• This result in dryness in up 50% of cases
• Bladder training –encouragement or rewards for delayed
micturation for increasing length of time during waking hours is
also effective

TREATMENT CONT-
• PHARMACOTHERAPHY
- Drugs should be used rarely as a last resort
- -imipramine(tofranil) can be used on a short term basis ,30% of
enuretic stay dry,80% has reduced frequecy
- Tolerance often develop after 6months of theraphy
- Once the drug is withdrawn relapses occur within a few months
- Desmopressin an antdiuretic compound is also effective
- Psychotherapy- may be useful in dealing with emotional and family
difficuilties that arise secondary to the disoder or if there is co-
existing psychiatric problem

ENCOPRESIS
EPIDEMIOLOGY
About 95% of children has established bowel control by the age
of 4
-95% by 5th birthday
-At age of 4 encopresis is 4 times as common in boys as in girls
-At age 7-8 boys.girls 1.5-0.5

ETIOLOGY
• Lack of appropriate toilet training
• Inefficient and in effective sphincter control
• Encopresis after a long period of fecal continence may be due
to regression after a life events such as parental separation,
start of school, or move to new home or birth of a sibling

Clinical features
• Diagnosis of encopresis is made when child passes feces into
inappropriate places on regular basis(at least once in a month for
3months)
• Encopresis can be present in children who has normal bowel
control and intentionally deposit feces in their clothes or other
places due to emotional problems
• Some children engage in the behavior while angry at parental
figures or as a part of oppositional defient disoder
• Soma children soil due to chronic retaining of stool resulting in
liquid overflow

PROGNOSIS
• Depend on cause
• In most cases it is self limiting and rarely continues beyond middle adolescence
TREATMENT
-Reduce family tension associated with encopresis
-non punitive atmosphere must be created
-Effort should be made to reduce child embarrassment at school
Many changes of underwear with minimum of fuss should be arranged
-psychotherapy is useful for easing family tension,dealing with child’s low
selfesteem and social isolation
-behavior technigues such as star chart where a child places a star on a chart for a
dry night

COMMUNICATION DISORDER
TYPES
-Expressive language disorder
-Mixed receptive expressive language disorder

EXPRESSIVE LANGUAGE
• Diffculties in putting thought into words due to low
vocubulary,inability to use correct tenses and inability to recall
words
• Language disability can be acquired in childhood or in
adulthood through neurological disorder or traumas
• It can be developmental or congenital with no obvious cause
• Expressive language diorder occur in absence of
comprehensive difficulties

EPIDEMIOLOGY
• 3-10% 0f all school age children
• 2-3 times more common in boys than girls
• more prevant among children with family history of
communication disorder

ETIOLOGY
• Genetics factors have been implicated
• left handedness appear to increase the risk
• CLINICAL FEATURES
• Severe form are evident by age of 3yrs
• Less severe form become evident in early adolescence when language become
more complex
• Very severe form become evident at 18mons when child is unable to echo single
words or sounds eg mama,dada or baba
• The child may seems to want to communicate, maintain eye contact but the
child uses gestures to indicate desires
• When the child finally begin to speak the language deficit becomes apparent

• 5% of children with expressive languge disorder recover
spontenously
• Severe disorder may display the features of moderate or mild
language impairment
• The degree of recovery depends on timely institution of
therapy,child motivation to participate in therapy and absence
of other developmental or emotional or psychiatric disorder

TREATMENT
• Therapy should begin immediately the diagnosis is made
• Behaviorally reinforced exercises with phonemes(sound units)
vocabulary and sentence construction
• The goal is to increase the number of phrases by using block
building method
• Supportive parental counseling is indicated to reduce
intrafamilial tension and increase their awareness and
understanding of the child disorder

MIXED RECEPTIVE EPRESSIVE LANGUAGE DISORDER
• In this disorder the child is impaired in both the understanding
and the expression of language
• Receptive language is always accampanied by expressive
language disorder
• MRELD can be developmental or congenital or acquired

MRELD CONT-
• EPIDEMIOLOGY 3-5%of children are affected
• ETIOLOGY –genetic factors or cerebral damage
• CLINICAL FEATURES
-have defects in language comprehesion and language understanding
the expressive component seen in this disorder is similar to the one
seen in expressive language disorder but can be more severe
Clinical features of receptive component appear before age of 4yrs
Severe form by 4yrs
Mild forms become evident at 7yrs

CLINICAL FEATURES CONT-
• A child with mixed receptive expressive language disorder are
unable to
-obey simple commands
-appears to be deaf
-but the child hears and respond appropriately to non language
sound from the environment

PROGNOSIS
• Child with MRELD has a poorer prognosis than those with
expressive language disorder
• Children with this disoder are likely to have co-morbid disorder
eg learning disorder

TREATMENT
• Individual linguistic instruction is helpful done in a low stimuli
settings
• Specialized educational setting may be beneficial in maximizing the
result
• Psychotherapy is necessary to deal with emotional and behavioral
problems
• Attention should be paid to improving the child’s self image and
social skills
• Family therapy in which the parents are taught apprroprite pattern
of interations with the child can also be helpful

THE END

11. CHILD AND ADOLESCENT PSYCHIATRY.pptx

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