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Child psychiatry




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  2. 2. DEFINITION MENTAL RETARDATION.AAMD and DSM-1V defines mental retardation as significantly subaverage general intellectual functioning resulting in or associated withconcurrent impairment in adaptive behavior and manifest during thedevelopmental period –that is before the age of 18Definition
  3. 3. CLASSIFICATION Mild mental retardation IQ level 50-55 to approx 70. Moderate retardation IQ level 35-40 to 50-55. Severe mental retardation IQ level 20-25 to 35-40. Profound mental retardation IQ level below 20-25. Mental retardation severity unspecified: when there is astrong presumption of mental retardation but the person’sintelligence is untestable by standard test.
  4. 4. EFFECTS OF MENTAL RETARDATION ON FAMILY Distress and feeling of rejection Depression guilt shame or anger Rejection of child Overindulgence Social problems Marital disharmony Burden of care for their child Dissatisfaction among medical and social services
  5. 5. CLINICAL PICTURE OF MENTALLY RETARDED: Mouth –small mouth and teeth, furrowed tongue, high archedpalate. Eyes-oblique palpebral fissures, epicanthic folds. Head –flat occiput Hands –short and broad, curved fifth finger ,single transversecrease Joints –hyper extensibility or hyper flexibility,hypotonia poorMoro reflex Others –CHD especially ASD,VSD PDA and arterioventricalarcommunes in about 40% cases Burchfield spots (whitish spacklings on the iris) Flat facieses Small dysplastic ear Impaired hearing and intestinal abnormalities(speciallyduodenal obstruction) Hypothyroidism Epilepsy Ocular disturbances
  6. 6. IMPORTANT CAUSES OF MENTALRETARDATION: Prenatal causes: Intranatal causes: Postnatal damage: GeneticChromosomal abnormalities:Metabolic disorders affectingGross disease of brainCranial malformationSociocultural causesPsychiatric condition
  7. 7. DIAGNOSIS OF MENTALRETARDATION: History General physical examination Detailed neurological examination Mental status examination
  8. 8. MANAGEMENT OF MENTALRETARDATION: Primary prevention: Secondary prevention (early diagnosis andtreatment) Tertiary prevention:
  9. 9. SPECIFIC DEVELOPMENTALDISORDERSReadingLanguageArithmetic ormathematicsArticulationCo-ordination
  10. 10. DEVELOPMENTAL LANGUAGEDISORDERExpressive languagedisorderMixed receptive-expressive languagedisorder
  11. 11. ETIOLOGYAcquired type-due todemonstrable neurologicdisorder or head traumaDevelopmental typewhich has no knowncause
  12. 12. CLINICAL FEATURES The essential feature of Expressive languagedisorder is a specific deficit in the development ofExpressive language abilities. Nonverbalintelligence and receptive language developmentare not affected.
  13. 13. MIXED RECEPTIVE Etiology Genetic Tendency Left hemispheric dysfunction Socio economic factors like large family, lowersocial class, late birth order and environmentaldeprivation
  14. 14.  Clinical features-developmental type Vocabulary comprehension difficulties occur withprepositions, adjectives, adverbs and pronouns Grammatical comprehension deficits occur withmisinterpretation of grammatical units ormorphemes(such as noun plurals, verb. tenses etc) Pragmatic comprehension deficits are manifested byabnormalities with conversational skills such as turntaking, maintaining a topic and being polite. There is alsoa delay in speech-language mile stones(babbling, sayingthe I word, the I sentences etc)
  15. 15. Acquired type-the effects ofcerebral trauma vary inseverity, locus and extent.Right hemisphere damage ispredictive of comprehensionimpairment, unilateral lefthemisphere lesion results inexpressive or phonologicalproblems
  16. 16. DEVELOPMENTAL READINGDISORDERS Etiology Unknown Prenatal /postnatal factors such as prematurity, lowbirth weight, toxemia ofpregnancy, hyperbilirubinemia, recurrentotitis, meningitis, encephalitis and anemia.
  17. 17.  Clinical features Inaccurate reading, slow reading and poor readingcomprehension Word recognition is poor The misreading may be distortions, substitutions oromissions of words Course Recognition is at 5 yrs of age. The disorder tends toimprove overtime with or without treatment but it is veryslow and never complete.
  18. 18.  Treatment Remedial education-direct instruction in reading ,practicewith letter sound associations, word recognition tasksand reading comprehension Medical approaches include stimulants,anti-anxiety drugsand special diets Psychosocial approaches are supportivepsychotherapy, parent guidance and training, social skillstraining, relaxation therapy and behavior modificationapproaches.
  19. 19. DEVELOPMENTAL ARITHMETICDISORDER It is impairment in the development of arithmeticalor mathematical skills that is sufficiently serious tointerfere with academic achievement of daily living.The impairment cannot be explained by thepersons measured intelligence levels, educationalbackground, visual acquity. Etiology –is unknown
  20. 20.  Clinical features Symptoms include difficulties in performing basicarithmetical operations, memorizing numericalfacts, following sequences of mathematicalsteps, counting objects and multiplying. Attention symptoms include inaccurate copying ofnumbers, omitting digits, decimals or symbols whenwriting answers, forgetting to add in carried numbersduring addition and addition and filing to note arithmeticalsigns. Course Mathematical difficulties’ may be apparent in thekindergarten stage but a diagnosis can be made onlywhen the child comes to the 2nd or 3rd grade.
  21. 21.  Treatment Various options are special classroom placement,supplemental remedial tutoring, perceptual skills training(focusing on skills such as matching, sorting andarranging objects) diagnostic –prescriptive teaching (i.e.focusing on actual mathematics deficits) and cognitive –developmental teaching (i.e. where the teacher facilitateslearning through areas of cognitive strength in the child.
  22. 22. ARTICULATION DISORDER(PHONOLOGICAL DISORDER) Etiology Causes can be hearing impairment, structuraldeficits of the oral peripheral speech mechanism(cleft palate), neurological disorders (cerebralpalsy) cognitive limitations (M.R) and psychosocialdeprivation
  23. 23. DIAGNOSIS AND CLINICAL FEATURES Speech sound disorders are characterized byomissions, substitutions and distortions of speechsounds. In phonological disorder, the speechsounds that are most frequently misarticulated arethose that tend to be acquired last in the normallanguage acquisition process (e.g. soundsrepresented by the letters S, Z, sh, ch, dg, th, dzand r)
  24. 24. TREATMENT1. A child needs speech therapy if Speech intelligibility is poor The child is older than 8 years The articulation problem is apparently contributing to or causingproblems with peers self image or learning. The articulation impairment is severe2. In addition, peer relationships, school behaviors and learningprocess also has to be monitored
  26. 26. PERVASIVE DEVELOPMENTALDISORDER: Autistic disorder: Etiology:GeneticNeurologicalMetabolicImmunologicEnvironmental factorsComplications from birthAbnormality in the structure and functioning of thebrain.
  27. 27.  EPIDEMIOLOGY: Clinical description: Behavioral symptoms such as: Hyperactivity Short attention span Impulsivity Aggressivity Self injurious behavior Temper tantrum Abnormal eating patterns
  28. 28.  Abnormal sleeping patterns Repeatitive, restricted, stereotypic patterns of behavior Do not actively indulge in normal play Fascinated with revolving objects like revolvingfans,opening and clocing the door ,constantly turning thelight on and off. Approximately 8o% of individuals with autistic disorderhave some degree of mental retardation,50% havesevere or profound and 30% have mild mentalretardation Affects the cognitive areas such as judgment, insight andreasoning Communication problems and both verbal and non verbalareas are affected
  29. 29.  Prognosis: There is no cure for autism evidence demonstrate thatearly intense educational interventions using highlystructured progrrammes helps the clients to achieve thehighest level of functioning in social, communication andcognitive skills.
  31. 31. ATTENTION DEFICIT AND DISRUPTIVEBEHAVIOUR DISORDER: Attention deficit hyperactivity disorder: It is a disorder characterized byinattentiveness, over activity and impulsiveness .itis a common disorder especially in boys andprobably accounts for more referrals of childhooddisorder than any other disorder (Hetchman, 2005)
  32. 32. ONSET AND CLINICAL COURSE:ETIOLOGY:Environmental toxinsPrenatal influencesHereditaryDamage to brain structure and functionPrenatal exposure to alcohol ,tobacco andleadSevere malnutritionDecreased metabolism in the frontal lobeDecreased blood perfusion to the frontalcortex
  33. 33. TREATMENT:
  34. 34. CONDUCT DISORDER: It is characterized by persistent antisocial behaviorin children and adolescents that significantlyimpairs their ability to function in social, academicor occupational areas.
  35. 35. SYMPTOMS: Symptoms are clustered in four main areas: Aggression to people and animals. Destruction of property Deceitfulness and theft Serious violation of rules
  36. 36.  ONSET AND CLINICAL COURSE: CLASSIFICATON OF CONDUCT DISORDER: MILD: some conduct problems relatively minorharms MODERATE: number of conduct problemsincreases as the harm to others also SEVERE: person has many conduct problems andconsiderable harm to others
  37. 37. ETIOLOGY: Genetic vulnerability environmental adversity poor parenting low academic achievement poor peer relationship low self esteem resilience poor family functioning marital discord family history of substance abuse
  38. 38. TREATMENT: Parenting education Social skill training Improving peer relationship Attempts to improve academic performance Family therapy Individual therapy Conflict resolution Anger management Teaching social skills Antipsychotic medication with therapy if the patientis very violent
  39. 39. OPPOSITIONAL DEFIANT DISORDERS: This disorder consists of an enduring pattern ofuncooperative, defiant and hostile behavior towardsauthority figures without major antisocial violation. It can only be diagnosed when the behavior isintense and more frequent found in about 5% o0fpopulation and equal in both the males and femalescauses dysfunction in social, academic and worksituation and 25% of them develop conductdisorder and the treatment is as same as conductdisorder.
  40. 40. FEEDING AND EATING DISORDER: The disorder of feeding and eating included in thiscategory are persistent in nature and not explainedby underlying medical condition: PICA: RUMINATION DISORDER: FEEDING DISORDER:
  41. 41. TIC DISORDER: A tic is asudden, rapid, recurrent, nonrhythmic, stereotypedmotor movement or vocalization. Tics can besuppressed but not indefinitely a stress exarbatestic which diminishes during sleep and when theperson is engaged in an absorbing activity. TOURETT’ S DISORDER: CHRONIC MOTOR OR TIC DISORDER:
  43. 43. ENURESIS Definition: Enuresis is defined as the repeatedvoiding of urine into clothes or bed, whether thevoiding is involuntary or intentional. The child’schronological or developmental age must be atleast 5 years. (DSM IV).
  44. 44.  Types: Based on the Onset: Primary enuresis: Secondary enuresis: Based on the time: Nocturnal enuresis: Diurnal enuresis: Both diurnal and nocturnal When it occurs both the times primary and nocturnaltypes of enuresis are more common than the others.
  45. 45. ETIOLOGY Genetic factor Disorder of genitourinary tractAssociation with UTI Urinary tract obstruction Bladder size and functions Developmental changes in the bladder neck Urinary circadian rhythm Disorders of CNS Depth of sleep Epilepsy and EEG abnormalities Neuroleptic-induced enuresis-for e.g. thiothixene andthioridazine.incontinence with phenothiazine induced catatonicstates and stress incontinence in patients receivingchlorpromazine Developmental delays Enuresis is a disorder arising from disturbances in early life.
  46. 46.  i) Toilet training ii) Stressful life events in early childhood Diagnosis Criteria for non-organic enuresis The child’s chronological and mental age is at least 5years Involuntary or intentional aged under 7 years and at leastonce a month in children aged 7 years or more The enuresis is not a consequence of epileptic attack orof neurological incontinence and are not a directconsequence of structural abnormalities of the UT or anyother psychiatric condition There is no evidence of any other psychiatric disordersthat meets the criteria for other ICD-10 categories Duration of the disorder is at least 3 months
  47. 47.  COURSE AND PROGNOSIS TREATMENT 1. Behavioral interventions 2. Retention control training ( RCT) 3. Dry bed training Drug treatment Psychotherapy
  48. 48. ENCOPRESIS: Types 1. Primary type-where toilet training has never beenachieved 2. Secondary type-where Encopresis emergesoften a period of fecal continence. This typetypically occurs between the ages of 4 &8
  49. 49.  Etiology Inadequate, inconsistent toilet training Ineffective and inefficient sphincter control Neuro developmental problems-easy distractibility ,shortattention, span, low frustration tolerance, hyperactivity etc Fear of toilet Emotional reasons-fear, anxiety, anger etc Sibling rivalry Maturational lag Mental retardation Childhood schizophrenia Autistic disorder
  50. 50. DIAGNOSIS
  51. 51. CLASSIFICATION : Classification Treatment.
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