Disorders in childhood and adolescents, clinical features and management

2. Why children are special?
 Children are not miniature adults
 Several disorders occur exclusively in children
 Symptom normal in child may be abnormal in adult
 Attention must be paid to stage of development and
duration of disorder
 Children are less able to express themselves in words
 Child’s behavior affected by and seen in context of
their environment
 Also management requires working with both children
as well as their families

3. Normal development
First year of life –
 Period of rapid development of motor and social
functioning
 Social smile, selective smiling towards parents,
stranger anxiety, separation anxiety
 Attachment and bonding to mother and other close
caregivers
 Child begins learning about objects outside himself
through his senses
 Language development – bisyllables

4. Year two –
 Attachment behavior well established
 Exploratory behavior about external environment
 Child begins to learn to control his behavior as parents
start making constraints
 Temper tantrums appear – short lasting
 Further language and motor development

5. Preschool years (2-5 yrs) –
 Rapid increase in intellectual abilities and exploratory
behavior
 Social development – begin to identify with parents,
adopt their standards in mater of conscience
 Interaction with siblings – sibling rivalry
 Fantasy life is rich and vivid – imaginary friends,
animistic thinking, transitional objects
 Child begins to learn about his own sexual identity-
sexual play and exploration are common

6. Middle childhood (5-11 yrs) –
 Firm understanding about identity as boy or girl and
his position in family
 Learn to cope with school and acquiring new
educational skills
 Teacher and peers become important in child’s life
 Child gradually learns about his limitations
 Common problems include school related problems,
oppositional behavior

7. Adolescence –
 Period bridging childhood and maturity
 Most obvious feature – physical changes of puberty
 Increased awareness of personal identity and
individual characteristics
 Concerned to know who they are and where they want
to go in life
 Peer group relations are important
 Membership of a group
 Common problems - moodiness, anxiety, relationship
problems with peers, rebellious behavior

8. Interview process
 No single set technique or format
 Invite whole family hear their views and then decide
on subsequent interviews
 Children who can express themselves may be given a
chance separately
 More than one session is required to evaluate a child
 Anxiety and inhibition lessens in subsequent and
familiar grounds

9. Interviewing a child
 Young Children may not be able or willing to
communicate verbally (Use pictures and toys)
 First and foremost requirement is to establish a
friendly relationship with the child
 Encourage the child to talk freely.
 Observe the child during the play. Gives more info
about his concentration cognitive and symbolic
capacity and styles of dealing with external world .
 Interview is conducted in play room.

10. Interviewing the parents and family
 Parents are preferably seen together :- Has two
advantages->
 1 Collect info on present problems, family
history, personal details of the child.
 2 Evaluate them as people and parents, biases and
prejudices, feelings and attitudes to the child
symptoms
 Other Family members also contribute significantly
 Sometimes information from teacher can be gathered

11. Childhood Disorders - ICD 10 (F70-98)
 Disorders of Psychological development (F80-89)
a) Specific dev disorders of speech and language
b) Disorders of scholastic skills
c) Disorders of motor functions
d) Pervasive development disorders
 Behavioral and emotional disorders(F90-98)
with onset usually occurring in childhood and adolescence
a) Hyperkinetic disorders
b) Conduct disorders
c) Emotional disorders specific to childhood
d) Disorders of social functioning with onset specific to
childhood and adolescence
e) Other disorders
 Mental Retardation (F70-79)

12. Specific developmental disorders of speech
and language
 Also called as developmental language disorders,
communication disorders or dysphasias
 1 % seriously affected with speech problems at the time of
joining school and 5% have difficulty in making themselves
understood by others.
 Boys are generally more affected than girls
 Child having no neurological or sensory deficit, as well as
MR or environmental factors as a causative factors should
be ruled out
 Several subcategories :
i) Speech articulate disorder,
ii) Expressive language disorder,
iii) Receptive language disorder,

13. Articulation disorder( Phonation disorder)
 Child has bellow par ability in the use of speech
sounds despite normal language skills
 Problem include severe articulation errors that makes
it difficult for others to understand speech.
 Speech sounds are omitted, distorted or substituted.
 E.g. ca for car, bu for blue, wabbit for rabbit

14. Expressive language disorder .
 Language comprehension is normal.
 Expressive ability is defective.
 There may not be articulation defects.
 Inability to use single words by 2 yrs or 2 word phrases
by 3 yrs is abnormal (indicates expressive language
disorder.
 Vocabulary is extremely limited. Words are selected
inappropriately with omissions of suffixes and prefixes,
syntactical and grammatical errors are common

15. Receptive language disorder-
 Child’s understanding of the language is defective.
 When expression is also involved which is usually the
case it is called “receptive-expressive language
disorder”. There are articulation abnormalities too
 By 18 mths child should identify some familiar objects,
follow simple verbal instructions by 2yrs.Failure of
these in the absence of organic cause indicate
receptive language disorder.
 Problems include failure to respond to simple
instructions
 Other features include inability to understand
grammatical structures

16. Specific Developmental disorders of
Scholastic skills
 Child has inadequate acquisition of only one of the
scholastic skills
 It may include reading skill, writing skill or arithmetic skill
 Child having no neurological or sensory deficit, as well as
MR or environmental factors as a causative factors should
be ruled out
 Deficit causes impairment in academic functioning or
impairment in daily activities
 Approximately 3-4% of school going children are affected,
among these 75% are affected by reading disorder alone
 Boys are generally more affected than girls

17. Specific reading disorders (Dyslexia) –
 Refer to significant impairment of reading skills in the
absence of MR, Visual problems or lack of schooling.
 Problems include omissions, additions, distortions,
substitution of words, slow reading or reversal
(backward reading)
 Pronounce wrongly like felt for left, act for cat
 May swallow words like rember for remember, amision for
admission
 Reversal - was for saw, net for ten
 Comprehension is poor, inability to draw conclusion

18. Specific writing disorder (Dysgraphia) –
 Child has specifically problem in written
expression
 Though the reading comprehension is intact in
writing encounters problems like poor spelling,
poor sentence formation, inaccurate use of
symbols
 May not use capital & lower cases appropriately
like inDia, ramA
 Writing is poor, sizes differ, lines are not straight

19. Specific arithmetic disorder (Dyscalculia) –
 Child presents with arithmetic abilities well bellow the
level expected for the mental age
 Problems may include failure to understand simple
arithmetic concepts, failure to recognize mathematical
signs or numerical symbols, difficulty in carrying out
mathematical manipulations and difficulty in learning
mathematical tables

20. Specific developmental disorders of motor
functions
 Also called as motor skills disorders, developmental
coordination disorder, clumsy child syndrome
 Impaired motor functions in absence of Neurological
disorder
 Milestones are delayed, slow to learn, run, hop, climb
stairs up and down.
 Child is clumsy, drops things, stumbles, difficulty in
throwing and catching, fastening the shoe laces
 Poor coordination in daily activities – dressing,
feeding, playing

21. Management of specific developmental
disorders
 Evaluation of a child – for visual or auditory defect, mental
retardation, specific nature and severity of problem using
interview, physical and neurological examination as well as
some standardized psychological testing
 Treatment involves many specialized faculties –
psychiatrist, psychologist, speech therapist, occupational
therapist, physiotherapist etc.
 Individualized treatment plan is drawn for each child
 It involves special remedial teaching
 Comorbid psychiatric problems are dealt with drugs or
psychotherapy if necessary
 Family is involved in treatment plan

22. Pervasive developmental disorders
 Also called infantile autism, childhood autism
 Syndrome is more common in males
 Prevalence – 8 per 10,000 in general population
 Typically the onset is before the age of 3 yrs
Clinical features –
i. Marked impairment in reciprocal social and
interpersonal interactions –
 Absent social smile, low eye to eye contact
 Lack of empathy, lack of attachment, feelings
 Marked impairment in making friends

23. ii. Marked impairment in language and nonverbal
communication –
 In infancy lack of verbal or facial response to sounds or
voices
 Absent or delayed speech development
 Abnormal speech patterns and content – echolalia,
perseveration, poor articulation and pronouncial
reversal (I – You)
iii. Abnormal behavioral characteristics –
 Mannerisms, stereotyped behavior like hand flicking,
rocking, body spinning etc.
 Ritualistic or compulsive behavior
 Resistance to even slightest change in environment
 Attachment to inanimate objects

24. iv. Other features –
 More than 50% are mild to moderately mentally
retarded
 Few may be having above average ability in certain
tasks like music, calculation, memory etc. – called
Idiotic savants
 Course of autism usually chronic and many times only
few of them can have normal social, occupational
functioning

25. Treatment –
Behavioral therapy –
 Structured class room training
 Positive reinforcement to learn new skills, self care and
other functions
 Speech therapy and/ or sign language teaching
 Behavioral techniques to encourage interpersonal
interactions
Pharmacotherapy –
 Antipsychotics, lithium, anticonvulsants, SSRIs to
treat aggressive, impulsive behavior and other
comorbid psychiatric problems
Family therapy

26. Hyperkinetic disorder (Attention Deficit
Hyperactivity Disorder)
 Characterized by a pattern of diminished sustained
attention and higher levels of impulsivity
 Prevalence 3-7% in school going children
 More prevalent in boys than girls
 Symptoms of ADHD are often present by age 3 years,
but the diagnosis is generally not made until the child
is in a structured school setting

27. Clinical Features -
 Poor attention span:
i)Fails to finish any task given
ii)Shifts from one uncompleted activity to another
iii)Does not seem to listen
iv)Easily distracted by external stimuli
v)Often loses things
 Hyperactivity :
i) Fidgety
ii) Does not sit in one place for long
iii) Moves excessively here and there
iv) talks too much
v) interferes in others’ activities

28. Clinical Features -
 Impulsivity :
i) Acts before thinking
ii) Difficulty in waiting his turn at work or play
 Some symptoms present before age 7 years
 Symptoms present in two or more social settings
 Impairment in social, academic activity.
 School work is careless and messy with several
mistakes and is often incomplete
 Impulsivity, recklessness - reflect in accidents
 Disinhibited in social settings
 may show a secondarily depressed mood

29. Course:
 Most improve with age by puberty
 In few symptoms may persist in adulthood – Adult
ADHD
 Diagnosis is made on teachers report, History from
parents and observation by psychiatrist himself.
Treatment –
 Stimulant drugs - Amphetamine and methylphenidate
 Non stimulant drugs – Atomoxetine, Clonidine,
Bupropione, Tricyclic antidepressants, Lithium
 Remedial teaching
 Behaviour therapy
 Support for parents who are distressed

30. Oppositional Defiant Disorder
 Negativistic, hostile, and defiant behavior
 often loses temper
 often argues with adults
 often actively defies or refuses to comply with adults'
requests or rules
 often deliberately annoys people
 often blames others for his or her mistakes or
misbehavior
 Symptoms invariably present at home but may be
absent outside home
 These children are often friendless
 Poor school performance

31.  Secondary Complications –
 low self-esteem,
 poor frustration tolerance, depressed mood, and temper
outbursts.
 Adolescents may abuse alcohol and illegal substances.
 Often, the disturbance evolves into a conduct disorder
or a mood disorder.
 Disorder may remit as age progresses
 Treatment –
 Family intervention using both direct training of the
parents in child management skills and careful
assessment of family interactions.
 Behavioral Therapy

32. Conduct Disorders
 Repetitive and persistent forms of dissocial, aggressive
or defiant behaviour which are more severe than the
pranks and rebelliousness of childhood and
adolescence.
 Onset occurs much before 18 years of age usually
before puberty. Steals money and runs away from the
house
 Epidemiology: 2-9% in females and 6-16% in Males.
More common in unstable, insecure and rejecting
families.
 Other psychiatric conditions may at times underlie
this behaviour. Conduct disorders may overlap
hyperkinetic or emotional disorders.

33. Clinical Features:-
 Physical violence like fighting, aggressiveness, bulling
other children
 cruelty to animals, people
 destruction of property, fire setting
 Stealing, lying
 Running away from home, school truancy
 In unsocialized conduct behavior the child's relationships
with other children are totally disturbed as shown by
persistent bullying and fighting, rudeness and violent
assaults.
 Conduct disorders may be socialized. Child joins a peer
group of gangsters and indulges in group violence.

34.  Complications of Conduct Disorder: Drug abuse,
Unwanted pregnancies, HIV, suicide, homicide.
 Treatment –
 Treatment is difficult and child often requires to be put in
corrective institutions
 Requires careful handling, multidimensional approach is
involved.
 Behavioral interventions in which rewards may be earned
for prosocial and nonaggressive behaviors, social skills
training, family education and therapy
 pharmacologic interventions for aggressive, impulsive
behaviour
 Prognosis: Long and protracted course. Some do recover.

35. Separation anxiety disorder
 Marked by severe anxiety when there is a real threat of
separation from the people to whom the child is attached.
 Child intensely afraid of being left alone
 refuses to go to school,
 fears from being kidnapped, harmed or killed.
 Cannot sleep alone, gets nightmares about separation.
 Separation causes intense emotional reactions like crying,
misery and tantrums.
 Treatment - A multimodal comprehensive treatment
approach may include CBT, family education, family
psychosocial intervention, and pharmacologic
interventions.

36. Social anxiety disorder
Stranger anxiety occurs around 2 yrs of age which is
normal. When it persists beyond six years and is
persistent to so as to cause social dysfunction then it is
called Social anxiety disorder. Child is markedly fearful
of any social situation or interaction with strangers.
Sibling rivalry
Sibling rivalry is shown by marked competition with
the sibling so as to get attention and affection solely
for himself, from parents. The child is hostile to his
sibling and exhibits' jealousy and open rivalry

37. Elective mutism
 Selective gross disparity in the use of language in
certain social situations.
 Child is fluent in many situations such at home or
with close friends but is mute in others such as school
or with strangers.
 Selectivity in speaking is emotionally determined. It is
possible to predict situations which block his speech.
 Treatment includes behavioral therapy ,
psychoeducation , family therapy or SSRIs

38. Tic disorders
 Tics are abrupt, nonpurposive, stereotyped and
repetitive movements involving circumscribed groups
of muscles
 are seen as eye blinking, neck jerking, shrugging of
shoulders, facial grimacing etc. Throat clearing,
grunting, sniffing and barking sounds are tics
involving vocal muscles.
 Multiple motor tic disorder>Also known as Guilles
de la Tourette’s syndrome, characterized by multiple
motor and vocal tics
 Neuroleptics may be effective

39. Enuresis
 Involuntary voiding of urine which persists even after the
age of 5 yrs.
 Organic causes should be ruled out
 Primary if the child has never attained bladder control
 Secondary if enuresis occurs after a period of one year of
dryness.
 It may be diurnal(Daytime),nocturnal or both. Nocturnal
enuresis is more common.
 Causes: Genetic predisposition.70% have first degree
relatives who had the disorder. Linkage studies indicate
chromosome 13q . etc. Bladder smaller than normal
Emotional stress : Birth of sibling, parental separation,
family discord

40. Treatment:
 Following measures help i)Restriction of fluid intake
after 8 pm ii)Bladder training during day time aimed
at increasing the holding time. This is carried out step
by step.iii) interruption of sleep before the expected
time of bed wetting. Child should fully woken up and
made aware of passing urine. iv) Conditioning devices
like alarm bell rings when the child voided urine
touches the bed sheet. It causes inhibition of further
micturition and the child awakes.
 Supportive psychotherapy
 Pharmacotherapy - Drug of choice is Imipramine 75
mg / day. Long term success rate is 25%.Desmopressin
intranasal use one off measure.