Child psychiatry

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Child psychiatry

  1. 1. Psychiatry department Beni Suef University
  2. 2. cdepression,  phobia,  anxiety and  psychoses  pervasive developmental disorders  attention deficit/hyperactivity disorder,  conduct disorder and  mental retardation.  functional enuresis,  functional encopresis, and  separation anxiety. 
  3. 3.  This is a form of disruptive behavior in which the basic rights of others and age appropriate societal norms or rules are violated.  Epidemiology  It usually starts before the age of 18 years  male: female ratio 10:1.  6-16 % of boys and 2-9 % of girls below 18y have conduct disorder.
  4. 4.  The disorder is either conducted solitary or in a group (gang).  Aggression may be either direct (overt) or indirect.  A- Overt aggression is directed to people, animals or property with the aim of deliberate injury or destruction.  B- Indirect aggression as shoplifting, lying, and staying out late at night despite of parental prohibition.
  5. 5.  It  1. is a multifactorial disorder: Genetic factors  2. Organic factors  3. Environmental factors  4. Family factors  5. Social Modeling
  6. 6. Family factors • Neglecting unavailable mother with absence of support  • drug abuse or antisocial father  • Higher psychiatric morbidity among parents with personality deviation  •Frequent inconsistent punishment  • Increased marital discord  • Disturbed family structure, increased marital conflicts, divorce and parental violence. 
  7. 7. 1-For the Child  • Behavioral therapy  • Group therapy  • Pharmacotherapy (to control aggression & impulsivity)  a. Lithium carbonate  b. Clonidine  c. Anticonvulsants 2- Family therapy 3- Parental training 4- Institutionalization
  8. 8.  Epidemiology  This disorder is more common in males than in females in the ratio 3-5 : l.  In the United States, its incidence is 3-5 % of primary school children.  In Britain, it is less than 1 %.
  9. 9. It includes three main criteria:  1- Disturbed attention or concentration:  2- Hyperactivity  3- Impulsivity
  10. 10.  1. Genetic factors  2. Organic factors (frontal lobe)  3. Environmental factors (food additives, preservatives, toxins)
  11. 11. 1. Pharmacotherapy:  a. Psychostimulants, e.g., dextroamphetamine, methylphenidate (Ritalin)  b. Antidepressants  c. Antipsychotics  d. Lithium carbonate 2. Special education programs 3. Family therapy
  12. 12.  This is a group of psychiatric conditions in which the expected social skills, language behavior and behavioral repertoire are either not developed or are lost in early childhood before the age of 3 years.  The most common type is Autistic Disorder.
  13. 13.  Epidemiology  Autistic Disorder occurs at the rate of 2-5 per 10,000 children under the age of 12. Male to female ratio is 3-5 to 1.
  14. 14.  1. Inability to develop relationship with people.  2. Delayed development of language skill,  3. Repetitive or stereotyped movements,
  15. 15. It is multifactorial including  1. Psychogenic factors  2. Genetic factors  3. Perinatal complications, especially during the first trimester.  4. Biochemical factors  5. Neurologphysiology: EEG changes in 10-85 % of autistic children
  16. 16.  The goal is to decrease the behavioral symptoms and to help the development of the delayed functions.  1. Supportive home environment  2. Special educational programs  3. Pharmacotherapy: useful in modifying and controlling behavior high potency neuroleptics Selective Serotonin Reuptake Inhibitors (SSRI)
  17. 17. Functional Enuresis  Enuresis is the repeated voiding of urine into the child's clothes or bed.  It may be involuntary or intentional. Nocturnal bed wetting is the most common form.  Daytime control usually precedes nocturnal control by 1-2 years. 
  18. 18.  Prevalence of enuresis varies greatly in different groups, in the States 7 % of 5 year olds are enuretic.
  19. 19.  To  1. diagnose functional enuresis: The child must be at least 5 years old  2. Wetting is repetitive  3. Medical causes should be ruled out particularly in secondary enuresis.  Most common medical causes are urinary tract infection, diabetes, seizure disorders and congenital abnormalities.
  20. 20. • Primary: if bladder control has never been achieved • Secondary: if urinary incontinence reappearance after maintainmg competent functions for 1 year.
  21. 21.  1.Restricting fluids before bedtime  2.Waking the child during the night.  3. Rewarding successful dry nights.  4. Bladder training during the day, i.e., delaying bladder emptying  5. Medications: given before going to bed, such as: imipramine (Tofranil), desmopressin (synthetic ADH) anticholinergic drugs.
  22. 22.  It is characterized by fecal soiling of clothes. Medical evaluation is necessary before labeling the disorder as functional.  Epidemiology After the age of four years, encopresis occurs 3-4 times more in boys than in girls. There is a significant relation between encopresis and enuresis.
  23. 23.  Diagnosis  1. The child is at least 4 years old.  2. Encopresis occurs at least once a month for at least 3 months.  3. Medical causes should be excluded.
  24. 24.  a. Primary or secondary: primary if no bowel control has been achieved, and secondary if the child has learned control for one year. b. With constipation and overflow, or without constipation:  75 % of encopretic children have constipation.  There is fecal concretion with overflow of fluid fecal matter.  Incontinence without constipation results in intermittent production of formed stools. 
  25. 25.  1. For encopresis without constipation, a behavioral program gives rewards for just sitting on the toilet then later for moving bowels appropriately.  2. For children with severe retention or impaction cleaning out the bowel initially ( enemas), followed by retraining the bowel (high roughage diet, developing of a toilet routine) are used in addition to behavioral program  3. In resistant cases individual and family psychotherapeutic interventions are needed.
  26. 26.  These disorders are termed academic skills disorders.  These children usually present with one of the basic psychological problems involved in understanding or in using spoken or written language.  They usually present with poor scholastic achievement despite their average intelligence as assessed by the individually administered standardized intelligence tests.
  27. 27.  Impairment in the academic areas includes disorders in:  • Reading  • Mathematics  • Written expression.  It might be associated with:  1. Delayed speech  2. Anxiety and other emotional problems.  3. They may as well present behavioral problems such as alienation or rebellion.
  28. 28.  Etiology  It includes a variety of neurocortical deficits resulting in various  disruptions of cognitive processing, e.g. difficulty in visual spatial or linguistic processing.
  29. 29.  Management  1. Special assessment including 1Q, EEG, plain X ray skull, and CT scan brain  2. Special educational programs with special scholastic placements.  3. Family counseling and training programs to help in the education.  4. Teacher's education to help in the education progress  5. Psychotherapy for the patient and family.
  30. 30.  The diagnosis of Mental Retardation MR requires both low intelligence (IQ less than 70) and  deficits in adaptive functions i.e. impairment of skills manifested during the developmental period (before the age of 18 years)  including cognitive, language, motor and social abilities.
  31. 31.  Classification  The intelligence quotient was calculated from the following formula:  IQ= mental age/ chronological age x 100  On basis of IQ : mental retardation is classified into:  Mild: IQ 50-69  Moderate: IQ 35-49  Severe: IQ 20-34  Profound: IQ below 20
  32. 32. a. Biological Causes:  Genetic Factors  Prenatal Factors  Perinatal Factors  Causes during Infancy or childhood b. Psychosocial Causes
  33. 33. Majority (85%) of those with M.R. • Self care and living skills:  Most have no difficulty in achieving full independence in self-care (eating, washing, dressing, and sphincteric control).  They may need help with planning a budget. • Language and communication skills:  Most achieve the ability to use speech for everyday purposes and can hold conversations in normal circumstances. • Education and occupation:  Educable, many have difficulties reading and writing, but can achieve an academic level of grade 6.  They can hold a job. 
  34. 34. 10% of those with M.R. • Self care and living skills:  Achievement of self care and motor skills is retarded, yet they can be trained to attain considerable independence in daily living but they need supervision.  They are usually capable of managing pocket money but find difficulty in calculating the change due. • Language and communication skills:  Slow in developing comprehension and use of language, however they are usually able to communicate adequately. • Education and occupation:  Limited progress with school work, usually not beyond the academic level of grade 2,  They are trainable.  Some adults can carry out simple manual work. 
  35. 35.  4% of those with M.R.  • Self care and living skills: They need a great deal of supervision as their self-care and motor skills are markedly impaired.  They are dependent on others for money arrangement  • Language and communication skills: The development of comprehension and use of language is very limited and communication is often not by speech.  • Education: Below first grade. They are not trainable.
  36. 36. Profound M.R. (IQ below 20): 1% of MR • Self care and living skills: Constant help and supervision is needed for basic needs. • Language and communication skills: Severely limited in ability to understand language. They communicate in a very limited nonverbal way. • Education: Extremely limited
  37. 37.  For mental retardation at all levels of severity, the developmental course is SLOW but not deviant.  Although the normal sequence of developmental stages occurs, the speed of developmental change is slow and there is a ceiling on ultimate achievement.
  38. 38. Mentally retarded children are four to five times at a higher risk to have a psychiatric disorder than children with normal intelligence.  The most common constellation of symptoms includes:  irritability,  hyperactivity,  impulsivity,  short attention span and  language delay.  aggressive temper outbursts. 
  39. 39.         1. Early detection of treatable causes as hypothyroidism and malnutrition. 2. Proper comprehensive evaluation to address the multiple disabilities and complications associated with MR whether medical or psychiatric. 3. Parental guidance: support, education, genetic. 4. Detecting strengths and weaknesses 5. Specialists for speech therapy. 6. Behavior modification 7. Psychotherapy (mild MR) to enhance self-esteem, social and emotional development and behavioral control. 8. Treatment of co-morbid conditions e.g. depression or ADHD.

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