Ch psy

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Ch psy

  1. 1. Child Psychiatry A. Avramova
  2. 2. MAJOR DEVELOPMENTAL STAGES <ul><li>Prenatal/Birth </li></ul><ul><li>Infancy (Birth –18 months) </li></ul><ul><ul><ul><ul><ul><li>Trust - form attachment/bond </li></ul></ul></ul></ul></ul><ul><li>(development of motor functions and speech) </li></ul><ul><li>Toddler (1.5 - 3 years) </li></ul><ul><li>Autonomy - walk/talk/ Toilet Training / </li></ul><ul><li>tolerate separation </li></ul><ul><li>Early childhood (3-5 years) </li></ul><ul><li>Initiative - build vocabulary, build superego </li></ul><ul><li> (Dresses Self; Draws a person - main parts) </li></ul><ul><li>Middle childhood (6-12 years) </li></ul><ul><li>Industry - build peer-relations and competencies </li></ul><ul><li>Adolescence (12-adult) </li></ul><ul><li>Identity issues </li></ul><ul><li>(Normal variation is present) </li></ul><ul><li>Bio-psycho-social approach </li></ul>
  3. 3. REASONS TO LEARN ABOUT NORMAL DEVELOPMENT <ul><li>To identify and be supportive of age-appropriate skills and emotional expressions (e.g. expressions of autonomy; stranger anxiety) - these are healthy. </li></ul><ul><li>To better identify what is really abnormal - so treatment is focused on psychopathology. </li></ul><ul><li>To better understand common patterns of regression (a return to earlier developmental behaviors) that may occur with illness or stress. </li></ul><ul><li>To better understand adult psychopathology. </li></ul>
  4. 4. DISORDERS OF CHILDHOOD AND ADOLESCENCE <ul><li>Epidemiology: 1 in 5 children involved (20% of children need at least once in their life consultation with child mental health professional) </li></ul><ul><li>Specific disorders with childhood onset are listed separately in ICD X, DSM-IV (ADHD, Conduct Disorder, Learning Disorders, Mental Retardation, etc). These may persist into adulthood. </li></ul><ul><ul><li>Basically all adult disorders can occur in children and adolescents (Depression, Bipolar, Schizophrenia, Anxiety disorders, etc.) at particular level of development. </li></ul></ul><ul><li>Personality Disorders (Axis II, DSM-IV) are usually not diagnosed, although personality traits are often identified. </li></ul><ul><li>Comorbidity is common. </li></ul>
  5. 5. EVALUATION STRATEGIES <ul><li>Patient Interview </li></ul><ul><li>Collateral Information Testing </li></ul><ul><li>(Parents, School) (IQ, Education, Projective, </li></ul><ul><li> Personality, Neuropsych, </li></ul><ul><li> labs, EEG, MRI) </li></ul><ul><ul><ul><ul><ul><li>Observation </li></ul></ul></ul></ul></ul><ul><li> </li></ul>
  6. 6. Infants and toddlers (birth to 3y): <ul><ul><li>impairment of gross and fine motor functions </li></ul></ul><ul><ul><li>sleep and appetite disturbances </li></ul></ul><ul><ul><li>language and communication deficits </li></ul></ul><ul><ul><li>bonding and social behavior abnormalities </li></ul></ul><ul><li>Usual Concerns: </li></ul><ul><ul><li>delayed development (e.g., MR), </li></ul></ul><ul><ul><li>abnormal development (e.g., PDD), </li></ul></ul><ul><ul><li>poor bonding (e.g., attachment disorder - neglect, abuse) </li></ul></ul>
  7. 7. <ul><ul><li>observe milestones </li></ul></ul><ul><ul><li>assess what child talks and thinks about (e.g. through play) </li></ul></ul><ul><ul><li>parent-child relation </li></ul></ul>Preschoolers: <ul><li>Possible concerns: </li></ul><ul><ul><li>as before, plus </li></ul></ul><ul><ul><li>speech-language delays, </li></ul></ul><ul><ul><li>hyperactivity, </li></ul></ul><ul><ul><li>difficult temperament, law frustration tolerance, self-regulation difficulties </li></ul></ul><ul><ul><li>excessive anxiety, shyness </li></ul></ul><ul><ul><li>aggressive/defiant behaviors </li></ul></ul>
  8. 8. <ul><ul><li>how does child function in family? </li></ul></ul><ul><ul><li>how does child function in school? (behavior and academics) </li></ul></ul><ul><ul><li>what kind of peer relations? </li></ul></ul><ul><ul><li>formal psychological and academic testing </li></ul></ul>School-age child <ul><li>Common concerns: </li></ul><ul><ul><li>as before, plus </li></ul></ul><ul><ul><li>learning problems </li></ul></ul><ul><ul><li>externalizing conditions (hyperactivity disorders, behavioral and conduct disorders) </li></ul></ul><ul><ul><li>separation anxiety, obsessive compulsive disorder, tic disorders) </li></ul></ul>
  9. 9. Adolescents <ul><li>early biological onset </li></ul><ul><li>later socio-economical independency </li></ul><ul><li>identity crisis </li></ul><ul><li>authority crisis </li></ul><ul><li>autonomy </li></ul><ul><li>unspecific problems: </li></ul><ul><ul><li>school problems, school refusal, school failure </li></ul></ul><ul><ul><li>isolation </li></ul></ul><ul><ul><li>problematic peer relationships </li></ul></ul><ul><ul><li>parent-adolescent relationship crisis </li></ul></ul>
  10. 10. Adolescents <ul><li>depressive disorders </li></ul><ul><li>risk behaviours (suicidal, self harming behaviours) </li></ul><ul><li>substance abuse </li></ul><ul><li>eating disorders </li></ul><ul><li>personality disorders </li></ul><ul><li>psychotic disorders (bipolar disorder, schizophrenia) </li></ul>
  11. 11. MENTAL RETARDATION <ul><li>IQ 70 or less on an individually administered IQ test </li></ul><ul><ul><li>BORDRELINE intellectual functioning: IQ 71 to 85 </li></ul></ul><ul><ul><li>MILD MR: IQ 50/55 to 70; mental age 9 to under 12 years (~ 85%) </li></ul></ul><ul><ul><ul><li>May first be detected in school. </li></ul></ul></ul><ul><ul><ul><li>Social and Communication Skills: develop spontaneously. </li></ul></ul></ul><ul><ul><ul><li>May achieve autonomy. </li></ul></ul></ul><ul><ul><li>MODERATE MR: IQ 35/40 to 50/ 55; mental age 6 to 9 years (~ 10%) </li></ul></ul><ul><ul><ul><li>Social and Communication Skills: impaired. </li></ul></ul></ul><ul><ul><ul><li>Early detection (i.e., before entering school). </li></ul></ul></ul><ul><ul><ul><li>May work under close supervision (sheltered workshop) </li></ul></ul></ul><ul><ul><li>SEVERE MR: IQ 20/25 to 35/40; mental age 3 to 6 years (~ 3%) </li></ul></ul><ul><ul><ul><li>Social/Communication Skills: little or no communicative speech, few words. </li></ul></ul></ul><ul><ul><ul><li>Often display poor motor development. </li></ul></ul></ul><ul><ul><ul><li>May acquire elementary hygiene skills and perform simple tasks </li></ul></ul></ul><ul><ul><li>PROFOUND MR: IQ Below 20/25; mental age below 3 years (~ 1-2%) </li></ul></ul><ul><ul><ul><li>Social and Communication Skills: rarely have communicative speech efforts; minimal sensorimotor abilities. </li></ul></ul></ul><ul><ul><ul><li>Require constant aid and supervision; nursing care. </li></ul></ul></ul>
  12. 12. <ul><li>Onset before age 18 years </li></ul><ul><li>Deficits or impairments in adaptive functioning in at least two of these areas: </li></ul><ul><ul><li>communication, self care, home living, social and interpersonal skills, use of community resources, self direction, functional academic skills, work, leisure, health, or safety. </li></ul></ul><ul><li>Epidemiology: 1-3% </li></ul><ul><li>Causes: </li></ul><ul><ul><li>Unknown (50% of mild MR) </li></ul></ul><ul><ul><li>Known (75% of severe MR) – Hereditary (Down’s, fragile X); Toxins; Birth Trauma; Infection. </li></ul></ul>
  13. 13. Pervasive Developmental Disorder <ul><li>Developmental disorders with severe and pervasive impairment in essential developmental areas </li></ul><ul><ul><ul><li>Reciprocal social skills </li></ul></ul></ul><ul><ul><ul><li>Language development </li></ul></ul></ul><ul><ul><ul><li>Limited range of behavioral repertoire </li></ul></ul></ul><ul><li>Following disorders are included: </li></ul><ul><ul><li>Autism </li></ul></ul><ul><ul><li>Rett’s Disorder </li></ul></ul><ul><ul><li>Childhood Disintegrative Disorder </li></ul></ul><ul><ul><li>Asperger’s Disorder </li></ul></ul><ul><ul><li>PDD, not otherwise specified </li></ul></ul><ul><li>60/10 000 ? (1/166 – 1/80) </li></ul>
  14. 14. Autism <ul><li>Onset within first two years </li></ul><ul><li>Autistic aloneness – inability to make warm emotional relationships with people </li></ul><ul><li>Gaze avoidance, absence of eye to eye contact. </li></ul><ul><li>Speech and language disorder. </li></ul><ul><ul><li>Speech develops late or never appear or </li></ul></ul><ul><ul><li>develops normally until about age of two years and then disappears in part or completely. </li></ul></ul><ul><ul><li>echolalia, misuse of pronouns. </li></ul></ul><ul><li>Non-verbal communication is affected as well. </li></ul>
  15. 15. <ul><li>Interest can be provoked by sensor stimulus - spinning toys, specific shapes, sounds, lights. colors etc. </li></ul><ul><li>50 to 70% have some degree of MR </li></ul><ul><li>Obsessive desire for sameness –repetitive games, same food and clothes and etc. </li></ul><ul><li>Bizarre behaviour and mannerism – play with fingers, flapping hands. Sudden anger or fear, smile without apparent reason </li></ul>
  16. 17. Theory of mind
  17. 18. <ul><li>Prevalence estimates: variable and increasing ( 2,5 - 30,8/10 000, 10/10 000 children) </li></ul><ul><li>Boys are effected 3 to 5 times more than girls </li></ul><ul><li>Associated with Tuberous Sclerosis, Fragile X Syndrome </li></ul><ul><li>20 to 25% have grand-mal seizures and about 50% have non-specific EEG abnormalities </li></ul><ul><li>MRI, EEG, Karyotyping </li></ul>
  18. 19. INTERVENTIONS IN AUTISM <ul><li>Presently no curative treatment available; symptomatic interventions focus. </li></ul><ul><li>Mainstay : Early intervention; speech and language services; structured behavioral and educational programs. </li></ul><ul><li>Family is coping with loss of “ideal” child - Grief and loss issues. </li></ul><ul><li>Medications : To control seizures, severe aggression, hyperactivity. </li></ul>
  19. 20. Retts Disorder <ul><li>Normal growth for the first few months of life </li></ul><ul><li>Deceleration of head growth between 5-18 months </li></ul><ul><li>Regression – to the level of 8-10m., profound impairment of socio-communicative and cognitive abilities </li></ul><ul><li>Impairment of motor skills, coordination; impairment of joints </li></ul><ul><ul><li>Lack of purposeful hand movements; stereotypic movements </li></ul></ul><ul><li>Disorder of females </li></ul><ul><li>Similar criteria as PDD </li></ul><ul><li>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. </li></ul>
  20. 21. Childhood Disintegrative Disorder <ul><li>Normal Development for at least two years of life. </li></ul><ul><li>Clinically significant loss of previously acquired skills prior to age 10 years in two or more of the following areas: </li></ul><ul><ul><li>Language </li></ul></ul><ul><ul><li>Social skills or adoptive behavior </li></ul></ul><ul><ul><li>Bowel or bladder control </li></ul></ul><ul><ul><li>Play </li></ul></ul><ul><ul><li>Motor skills </li></ul></ul><ul><li>Abnormal functioning in at least two areas: </li></ul><ul><ul><li>Social interaction; communication; patterns of behaviors/interests </li></ul></ul><ul><li>0,1-0,6/10 000 </li></ul>
  21. 22. Asperger’s Disorder <ul><li>“ High functioning autism” – No delays in language and cognitive development </li></ul><ul><li>Lack of warmth and empathy, impaired interpersonal relations </li></ul><ul><li>Impaired use of non-verbal communication (gaze, posture, gestures regulating social interaction) </li></ul><ul><li>Lack of interactive play </li></ul><ul><li>Stereotypic, repetitive mannerisms </li></ul><ul><li>2,5/10 000 </li></ul>
  22. 23. PDD NOS <ul><li>Diagnosis assigned when there is </li></ul><ul><ul><li>a severe and pervasive impairment in the development of reciprocal social interaction, or communication skills, </li></ul></ul><ul><ul><li>or when stereotyped behaviors and activities are present </li></ul></ul><ul><ul><li>but the criteria are not met for a specific pervasive developmental disorder. </li></ul></ul>
  23. 24. <ul><li>New research: </li></ul><ul><li>Test, which uses magnetic resonance imaging (MRI) to measure deviations in brain circuitry </li></ul><ul><li>Diffusion tensor imaging - measures white matter microstructure by mapping directions of water diffusion in a local brain tissue </li></ul><ul><li>Study of white matter microstructure in regions of the brain responsible for language, emotion, and social cognition – focus on the superior temporal gyrus and temporal stem in 30 high-functioning males aged 7 to 28 years who were diagnosed as having autism by the standard subjective scoring system and in 30 matched controls </li></ul><ul><li>94% accuracy </li></ul><ul><li>Harvard University and University of Utah Autism Res.  November 29, 2010 </li></ul>
  24. 25. SPECIFIC LEARNING, MOTOR SKILLS AND LANGUAGE DISORDERS <ul><li>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. </li></ul><ul><li>Types: </li></ul><ul><ul><li>Receptive Language Disorder </li></ul></ul><ul><ul><li>Expressive Language Disorder </li></ul></ul><ul><ul><li>Mixed Receptive-Expressive Language Disorder </li></ul></ul><ul><ul><li>Developmental Coordination Disorder </li></ul></ul><ul><ul><li>Reading Disorder (Dyslexia) </li></ul></ul><ul><ul><li>Mathematics Disorder (Dyscalculia) </li></ul></ul><ul><ul><li>Disorder of Written Expression (Dysgraphia) </li></ul></ul>
  25. 26. ADHD <ul><li>Persistent pattern of inattention and/or hyperactivity more frequent and severe than is typical of children at a similar level of development. </li></ul><ul><li>Onset before age 7 </li></ul><ul><li>Impairment in at least two settings: at home, at school, with friends </li></ul><ul><li>Duration at least six months </li></ul><ul><li>Inattention, Hyperactivity, Impulsivity </li></ul><ul><ul><li>Types (DSMIV) </li></ul></ul><ul><ul><ul><li>Predominantly Inattentive type </li></ul></ul></ul><ul><ul><ul><li>Predominantly Hyperactive type </li></ul></ul></ul><ul><ul><ul><li>Combined type </li></ul></ul></ul><ul><li>Incidence: 2 to 20% of grade-school children </li></ul><ul><li>Boys > Girls Ratio 3-5:1 </li></ul>
  26. 27. Etiology <ul><li>Specific etiology unknown; </li></ul><ul><li>Contributory factors: </li></ul><ul><ul><li>Genetics </li></ul></ul><ul><ul><li>Pre and perinatal complications </li></ul></ul><ul><ul><li>Neurological </li></ul></ul><ul><ul><li>Environmental toxins </li></ul></ul><ul><li>Psychosocial correlates include: poverty, dysfunctional family , parental psychiatric disorder, living in the city environment. </li></ul>
  27. 28. Interventions – Multimodality treatment programs <ul><li>Environmental structuring; parental education and training </li></ul><ul><li>Behavioral modifications; social skills training </li></ul><ul><li>Pharmacotherapy </li></ul><ul><ul><li>Stimulants: Methylphenidate, Dextroamphetamine, (Pemoline) </li></ul></ul><ul><ul><li>Non-Stimulants: Clonidine and Bupropion; </li></ul></ul><ul><ul><li>atypical antipsychotics for treatment unresponsive cases </li></ul></ul>
  28. 29. Disinhibited attachment disorder <ul><li>A rises during the first five years of life </li></ul><ul><li>T ends to persist despite marked changes in environmental circumstances </li></ul><ul><li>D iffuse, nonselectively focused attachment behaviour, attention-seeking and indiscriminately friendly behaviour, poorly modulated peer interactions; depending on circumstances there may also be associated emotional or behavioural disturbance. </li></ul><ul><li>I nstitutional syndrome . Adoptive children.   </li></ul>
  29. 30. Reactive attachment disorder <ul><li>Starts in the first five years of life </li></ul><ul><li>P ersistent abnormalities in the child's pattern of social relationships that are associated with emotional disturbance and are reactive to changes in environmental circumstances </li></ul><ul><li>F earfulness and hypervigilance, poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases. </li></ul><ul><li>The syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. </li></ul>
  30. 31. Conduct Disorder <ul><li>Characterized by severe and persistent antisocial behaviour. </li></ul><ul><li>Largest group of psychiatric disorders in older children and adolescents. </li></ul><ul><li>Prevalence 3 – 6%, more common in boys. </li></ul><ul><li>Characteristics: </li></ul><ul><ul><li>Serious violation of rules </li></ul></ul><ul><ul><li>Destruction of property </li></ul></ul><ul><ul><li>Deceitfulness or theft </li></ul></ul><ul><ul><li>Aggression to people and animals </li></ul></ul>
  31. 32. Oppositional Defiant Disorder <ul><li>Young children </li></ul><ul><li>Recurrent pattern of negativistic, defiant, disobedient & hostile behavior towards authority figures </li></ul><ul><li>D oes not include delinquent acts or the more extreme forms of aggressive or dissocial behaviour </li></ul><ul><li>Duration > 6 Months </li></ul><ul><li>Impairment in social, academic and work settings </li></ul><ul><li>Symptoms not part of the mood or thought disorder </li></ul><ul><li>Multimodality treatment programs: </li></ul><ul><li>Environmental structuring; Family Therapy; Group Therapy; Ind. Therapy – problem solving skills; Medications as adjuncts </li></ul>
  32. 33. ANXIETY DISORDERS <ul><li>Common in childhood: 15% </li></ul><ul><li>Comorbidity is common </li></ul><ul><li>All adult anxiety disorders may be seen in children. </li></ul><ul><li>PTSD - may be a result of abuse </li></ul><ul><li>Separation Anxiety Disorder </li></ul>
  33. 34. Separation anxiety disorder <ul><li>developmentally inappropriate and excessive anxiety about separation from caretakers or home, of at least 4 weeks </li></ul><ul><li>first difficulties occur during the early years of childhood (with onset before 18 years) . </li></ul><ul><li>i t is differentiated from normal separation anxiety when it is of a n unusual degree (severity) and persistence beyond the usual age period, and when it is associated with significant problems in social functioning. </li></ul><ul><li>associated with physical complaints, fear of sleeping alone, worries about parent’s safety </li></ul><ul><li>can lead to school refusal (school phobia) </li></ul>
  34. 35. Phobic anxiety disorder <ul><li>Fears in childhood that show a marked developmental phase specificity and arise (to some extent) in a majority of children, but that are abnormal in degree. </li></ul><ul><li>Other fears that arise in childhood but that are not a normal part of psychosocial development (for example agoraphobia) should be coded under the appropriate category in section F40-F48. </li></ul>
  35. 36. Social anxiety disorder <ul><li>In this disorder there is a wariness of strangers and social apprehension or anxiety when encountering new, strange, or socially threatening situations. </li></ul><ul><li>This category should be used only where such fears arise during the early years, and are both unusual in degree and accompanied by problems in social functioning. </li></ul>
  36. 37. Sibling rivalry disorder <ul><li>Some degree of emotional disturbance usually following the birth of an immediately younger sibling is shown by a majority of young children. </li></ul><ul><li>A sibling rivalry disorder should be diagnosed only if the degree or persistence of the disturbance is both statistically unusual and associated with abnormalities of social interaction. </li></ul>
  37. 38. Mood Disorders <ul><li>Childhood Depression </li></ul><ul><ul><li>irritability </li></ul></ul><ul><ul><li>sleep cycle disturbance </li></ul></ul><ul><ul><li>oppositional behavior </li></ul></ul><ul><ul><li>social isolation </li></ul></ul><ul><ul><li>crying spells </li></ul></ul><ul><li>Dysthymia – symptoms last at least 1 year </li></ul>
  38. 39. PROTECTIVE FACTORS <ul><li>Good parent-child relationship </li></ul><ul><li>Easy, outgoing temperament </li></ul><ul><li>Positive peer influence </li></ul><ul><li>Successful school experiences </li></ul><ul><li>Caring adult role models </li></ul><ul><li>Participation in pro-social groups </li></ul><ul><li>Access to needed services, e.g. healthcare, mental health, crisis intervention </li></ul>

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