introduction and brief description of disorders of child psychiatry

1. CHILD
PSYCHIATRY

2. OVERVIEW
• Autism
• ADHD
• Learning Disorders
• ODD – oppositional Defiant Disorder
• CD – Conduct Disorder

3. AUTISM

4. HISTORY
• Dr. Leo Kanner introduced the label- early
infantile autism – in 1943.
• Hans Asperger was a pediatrician treating and
researching autism. Asperger syndrome is
named after him.

5. TRIAD OF IMPAIRMENTS IN
AUTISM
• SOCIAL RELATEDNESS
• LANGUAGE AND COMMUNICATION
• REPERTOIRE OF INTERESTS

6. CO OCCURRING
CONDITIONS
• MENTAL RETARDATION
• EPILEPSY
• ATTENTION DEFICIT HYPERACTIVITY
DISORDER
• ANXIETY

7. INCLUDED UNDER ASD
ARE:
• Autistic disorder
• Asperger’s disorder
• Pervasive developmental disorder (PDD) older
nomenclature as per DSM IV TR

8. ASSOCIATION WITH
FRAGILE-X SYNDROME
• Between 2% and 6% of all children diagnosed
with autism, the cause is the Fragile X gene
mutation.
• Approximately one-third of all children diagnosed
with fragile X syndrome also have some degree of
autism.
• Fragile X syndrome is the most common known
single gene cause of autism.

9. AREAS OF IMPAIRMENT
• Communication
• Socialization
• Ritualistic and repetitive behaviour

10. FEATURES OF
DEVELOPMENTAL
DISORDERS
• Its neurodevelopmental disorder
• Can be recognized early in Life
• Has its impact across the Life-Span of the
affected Individual
• On a continuum of mild , moderate and severe
• No cure for core features
• Will improve with training
• Early intervention helps
• Comorbid conditions present
• Tends to run in families

11. PROCESS OF EVALUATION
• Exhaustive history including family history,
developmental history, temperament, medical
history and the progress of core symptoms
• Physical examination
• Assessment of current behavior and functioning
• Assessment of comorbid conditions
• MR, ADHD, epilepsy, mood and anxiety disorders

12. SPECIFIC TOOLS
• Checklist for Autism in Toddlers (CHAT)
• Childhood Autism Rating Scale (CARS)
• Autism Diagnostic Observation Schedule (ADOS)
• Autsim Diagnostic Interview –Revised (ADI-R)

13. HIGH FUNCTIONING
AUTISM
• About 20% of all children with PDD
• Many terminologies used
• HFA, Mild Autism, Autistic Like, PDD NOS, Atypical
PDD, Aspergers Syndrome
• Savant ability
• Average or above IQ
• Superior vocabulary skills
• Higher rate of unusual obsessions
• Motor deficits (clumsiness)
• Speech less commonly delayed

14. TREATMENT
• There are as yet no medications to treat the core
features of ASD
• Need for non- pharmacological interventions
along with pharmacological if needed. The
proportion of time and effort and economic inputs
for both.

15. MOST EFFECTIVE
STRATEGY
• Early intervention studies
• combined developmental +educational + behavioral
approach.
• May be school or home based or both.
• Special schooling / Autism Intervention Centres
• Parental counseling
• Role of Occupational Therapy – Sensory
Integration

16. EARLY INTERVENTION
• Most beneficial
• Begun between ages 2 – 4 years
• Intensive, 15-40 or more hours per week
• Needs to have a schedule through the day
• One to one or low child:adult ratio
• Over 1-2 years or more
• Available evidence suggests that it is the most
effective intervention.

17. WHAT TO TEACH
• Attending skills
• Imitation skills
• Communication skills
• Pre-academic skills
• Self help skills

18. MEDICATIONS
• Risperidone for aggression and irritability in
ASD is approved by FDA.
• Small doses for three to six months.
• Start low go slow.
• With trial discontinuations after 3-4months.
• Medication must be used along with other
psychosocial methods. Medication cannot be a
stand alone treatment.

19. LEARNING DISORDERS

20. • A disorder in one or more of basic psychological
processes involved in understanding or in using
language, spoken or written, that may manifest
itself in imperfect ability to listen, think, speak,
read, write, spell, or to do mathematical
calculations, including conditions such as
perceptual disabilities, brain injury, minimal
brain dysfunction, dyslexia, and developmental
aphasia.

21. TYPES OF LEARNING DISORDERS
• Dyslexia
• A language and reading disability
• Dyscalculia
• Problems with arithmetic and math concepts
• Dysgraphia
• A writing disorder resulting in illegibility
• Dyspraxia (Sensory Integration
Disorder)
• Problems with motor coordination

22. SPECIFIC LEARNING DISORDER
• Neurodevelopmental disorder produced by the
interactions of heritable and environmental
factors that influence the brain’s ability to
efficiently perceive or process verbal and
nonverbal information.
• Persistent difficulty learning academic skills in
reading, written expression, or mathematics,
beginning in early childhood, that is inconsistent
with the overall intellectual ability of a child.

23. • Specific learning disorder in reading, spelling,
and mathematics appears to aggregate in
families.
• Increased risk of four to eight times in first-
degree relatives for reading deficits, and about
five to ten times for mathematics deficits,
compared to the general population.
• two to three times more often in males than in females.

24. DIFFERENTIAL DIAGNOSIS
• Language disorder
• Disability in written expression
• ADHD

25. TREATMENT
• Remediation strategies focus on direct
instruction that leads a child’s attention to the
connections between speech sounds and spelling.
• Teaching the child to make accurate associations
between letters and sounds.
• Remediation can target larger components of
reading such as syllables and words.
• Positive coping strategies include small,
structured reading groups that offer individual
attention and make it easier for a child to ask for
help.

26. EXTERNALIZING
DISORDERS

27. OVERVIEW
• Persistent, easily noticeable troublesome
behaviors
• Commonly encountered problem in clinics
• Cause functional impairment
• Individual / family / social implications
• High level of continuity
ADHD - ODD – CD – delinquency – ASPD/
substance abuse

28. TYPES OF EXT. DISORDERS
• Attention deficit hyperactivity disorder (ADHD)
• Oppositional defiant disorder (ODD)
• Conduct disorder (CD)

29. INTRODUCTION
• Population prevalence:
• ADHD: 1.6 %
• ODD: 0.9 %,
• CD: 0.3 %
• Difficult to treat – needs multi-disciplinary
approach

30. SYMPTOMS OF ADHD
• Poor attention / concentration
• Leaving tasks unfinished; Poor capacity for sustained
goal-directed attention
• Distractibility, ‘daydreaming’, tends to lose or spoil
things, ‘forgetful’, ‘careless’
• Hyperactivity
• Restlessness, doesn’t sit in a place, on the move,
fidgetiness, excessive talking,

31. SYMPTOMS OF ADHD
• Impulsivity
• Acting before thinking, risky behaviors, accident-
proneness, intrusiveness, unpredictable, impatient, can’t
wait for his turn
• Other symptoms
• Erratic sleep and appetite, excitable, quick mood
changes…
• Impairments: peer, school, academic, personal

32. TREATMENT OF ADHD
• Medications –
Methylphenidate, Atomoxetine, Clonidine, Bupropion, low dose
APD
Play Therapy
Occupational Therapy
Parental counselling
Coordinating with school teachers

33. SYMPTOMS OF ODD
• Disobedience, non-compliance, defiance, temper
tantrums, argumentative
• Negativistic, oppositional behaviors
• Provocative, vindictive behaviors

34. SYMPTOMS OF CD
• Aggression / destructiveness
• Persons, property
• Antisocial / dissocial behaviors
• Lying, stealing, truancy, burglary, vandalism, staying
away overnight without parents’ knowledge, running
away from home, sexual offences
• Other forms of rule-breaking

35. ETIOLOGIC / PREDISPOSING
/ MAINTAINING FACTORS
• Child
• Family
• Environment

36. CHILD FACTORS
• Biological / genetic predisposition
• Neuro-anatomic / neuropsychological markers
• Temperamental difficulties
• Negative emotionality, intense / reactive responding,
impulsivity, behavioral disinhibition

37. CHILD FACTORS
• Social / emotional / cognitive processing
• Pro-social skills, social skill deficits, social information
processing
• Co-morbidity
• SLD
• depression, anxiety, OCD
• Substance abuse, affective disorders
• Low self-esteem

38. SOCIAL INFORMATION
PROCESSING PROBLEMS
• Attributional bias – hostile intent to neutral
social cues
• Poor anger regulation
• Low flexibility
• Language / communication deficits
• Choosing aggressive responses to solve problems

39. FAMILY FACTORS
• Dysfunction / Discord / disorder
• Parenting practices
• Inconsistent discipline, overindulgence, polarization of
rearing functions, importance of special position of the
child
• Parent child interactions / relationships
• Lack of warmth
• Disturbed communication patterns
• Rejection / hostility

40. SOCIAL / ENVIRONMENTAL
FACTORS
• Disorganized neighborhood
• Deviant peer group
• Lack of basic living conditions
• Film / Media exposure

41. CLINICAL EVALUATION-
OVERVIEW
• History from multiple sources
• Over many sessions
• School report
• Child interview
• Physical examination
• Rating scales / checklists
• Psychological testing
• Period of ward observation

42. MANAGEMENT
APPROACHES
• Child therapy
• Parent management training
• Family therapy
• Academic / school based interventions
• Pharmacotherapy
• Inpatient management

43. PHARMACOTHERAPY
IN ODD / CD
• Has a limited role in ODD /CD per se
• Co-morbid conditions may need medication
• Severe persistent aggression may need short-
term medication – lithium, neuroleptics,
clonidine, SSRI’s
• Emergencies involving aggression may need
parenteral medication such as intravenous
lorazepam

44. IN CONCLUSION..
• Externalizing disorders need careful, multi-
dimensional evaluation
• Factors contributing to the problem in a given
child need to be identified
• Important to make a multi-axial diagnosis
• Management needs to be individualized
• Adverse outcomes can be minimized by an
appropriate, intensive, intervention