2. Bipolar Disorder and Subtypes
Bipolar Disorder-I (BD-I)
• Cyclic changes between mania and major depressive episodes
Bipolar Disorder-II (BD-II)
• Episodes of major depression and hypomania
Cyclothymia
• Episodes of hypomania and depressed mood but not
major depression
Bipolar Disorder Not Otherwise Specified (BD-NOS)
• Sub-threshold (eg shorter) episodes of mania or hypomania with or without
depression
3. The DSM 5 Basics: Mania
• Abnormally & persistently elevated, expansive or irritable mood & abnormally
or persistently increased goal-directed activity
• Lasting at least one week
• Most of the day, nearly every day (unless hospitalized)
• 3 or more of the following; 4 if irritable:
Inflated self esteem or grandiosity
Decreased need for sleep
More talkative than usual
Flight of ideas or racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Activities with painful consequences
• Marked impairment, hospitalization needed, or psychosis
• Not due to substance or other medical condition
4. The DSM 5 Basics: Depression
• 2 week period with change in functioning
• 5 or more of the following (at least one is either depressed mood or loss of
interest or pleasure):
Depressed mood most of the day nearly every day (in children and
adolescents can be irritable mood)
Decreased interest or pleasure
Inadvertent change in weight or appetite (in children failure to make
expected gain)
Insomnia or hypersomnia
Worthlessness or guilt
Decreased ability to concentrate or indecisiveness
Recurrent thoughts of death, suicidal ideation or action
• Significant distress or impairment
• Not due to substance or other medical condition
5. Treatment
Selective Serotonin Reuptake Inhibitors (SSRIs):
• May be helpful for bipolar depression
• Should be used in combination with a mood stabilizer
• Watch for manic switch, hypomania, mixed episodes or rapid cycling
• Possibility of increased risk for suicide, agitation, or serotonin syndrome
• Start low and go slow
10. WHO Definition
“a condition of arrested or incomplete development of the mind, which is
especially characterized by impairment of skills manifested during the
developmental period, which contribute to the overall level of intelligence, i.e.,
cognitive, language, motor, and social abilities”
• Core symptoms
– Low intellectual functioning IQ <70 (i.e., 2 SD below mean)
AND
– Impaired adaptive behavior
• Types: Mild ID (IQ 50-69), Moderate (IQ 35-49)
Severe (IQ 20-34), Profound (IQ 0-20)
• Borderline Intellectual Functioning
13. Etiology
• Heterogeneous
• Mild ID: no specific cause in 40% of cases
– Genetic causes, injury, infections, poor nutrition
• Marked ID: specific cause found more often
– Genetic: Trisomy 21, Fragile X, single gene disorders
– Prenatal: fetal alcohol syndrome, maternal infection like HIV
– Perinatal: placental dysfunction, birth trauma, septicemia, jaundice
– Postnatal: brain infection, head injury
15. Diagnosis
• IQ below 70
• Impairment of adaptive functioning
• Onset before age 18
• Interview: family medical history, pregnancy, development,
environment of home
• Physical exam
• IQ measurement
• Adaptive behavior: clinical judgment and scales
• Labs and genetic testing
16. Further Considerations
• Parental mental health issues
– Always check how parents are coping
– Depression in mothers is common
• Severe marital discord/ domestic violence/recent divorce
– Raising a child with ID is hard, are parents working together?
– Often one parent blames the other and/or withdraws
• Child abuse or neglect
• Severe bullying or exclusion by peers
• Severe deprivation or poverty
17. Evidence-Based Treatments:
• Etiological treatment if cause is known and treatable (e.g., PKU,
hypothyroidism)
• Parent skills training
• Behaviour intervention for challenging behaviour
• Psychoeducation
• Physio/speech/occupational therapy (when available)
• Education plan
• Community based rehabilitation
18. Overview of Management
• Family psychoeducation
explain problem to carers
give parents skills to support child development
promote participation in family, school and community life
address psychosocial needs of carers
• Advice for teachers
• Manage risk/contributing factors
hearing and vision problems
nutrition
maternal depression
lack of stimulation
• Manage co-occurring epilepsy, depression and behaviour problems
19. Medication
• Not much evidence for effectiveness
• Only use after comprehensive assessment and in combination with
psycho-social treatment
• Antipsychotics sometimes useful in crisis situations, short-term
use safer
• Doses: start low – go slow!
– Sensitivity to medication common in ID
• Co-morbidity (e.g. depression, ADHD) can be treated in the same
way as in non-ID children
20.
21.
22. Attention Deficit Hyperactivity Disorder
ADHD
• Inattention, hyperactivity and impulsivity
• Two Diagnoses:
– ADHD (DSM)
– Hyperkinetic Disorder (ICD)
• Affects 3-5% of children
• Abnormal neuro-psychological functioning and neurobiological
correlates
23. ADHD:
• Is common
• Can be serious
• Can persist
• Is stigmatizing
• Is treatable
25. Epidemiology
• Prevalence
– 6% for children
– 3% for adolescents
• Male>Female
• ADHD (DSM definition) > HKS (ICD definition)
26. Differences According to Age
• Pre-school: play < 3mins, not listening, no sense of danger
• Primary school: activities < 10 mins, forgetful, distracted, restless,
intrusive, disruptive
• Adolescence: attention< 30 mins, no focus/planning, fidgety,
reckless
• Adult: incomplete details, restless, forgetful, impatient, accidents
27. Associations with Durability of Symptoms
• Lower academic achievement
• Marital problems and dissatisfaction
• Divorce
• Difficulties dealing with offspring
• Lower job performance
• Unemployment
• Employment below potential
• Traffic accidents
• Other psychiatric disorders
28. Etiology & Risk Factors
• Strong genetic component (76%)
• Perinatal factors – some evidence
• Neurobiological deficits – growing evidence
• Deprivation and family factors – important for course and
outcome
29. Etiology & Risk Factors
• Frontal-striatal dysfunction
–mediated by GABA
–modulated by catecholamines
• Catecholaminergic dysregulation
• Delay in cortical maturation
30. Clinical Presentation/Diagnosis
Inattention:
Distractibility, forgetfulness, inability to finish what they start etc.
Hyperactivity:
On the go all the time, restlessness, fidgeting, talking too much,
inability to play quietly etc.
Impulsivity:
Difficulty in delaying gratification, taking turns in play, acting without
thinking
Symptoms need to be pervasive (need for multiple informants! School!)
Duration/Age of onset
Impairment or distress
31. Clinical Assessment
• Information from at least two contexts
– Teachers are key
• Medical and psychiatric assessment
• Assess co-morbidity
• No additional tests necessary
33. Psychosocial Treatments
• Behavior therapy
– Individual, not always generalize
– Parent management training: particularly useful in younger children and for
associated behavior problems
– School based: child in front of class, short tasks etc.
• Generally effective, but smaller effect size than medication
• First line treatment in younger children or milder
cases
34. Stimulant Medication
Methylphenidate or Amphetamines
– Efficacy and safety well established
– clinical response in 70%
– Dose: titrate for optimum response
– Short/long acting (sustained release) available
– NOT on WHO list of essential medicines
• Common side effects: nausea, weight loss, insomnia, agitation
• More serious side effects: tics, psychotic symptoms,
raised blood pressure, growth retardation
35. Non-Stimulant Medication
• Atomoxetine
• Clonidine
– Start dose 0.1mg at bedtime
– Increments by 0.05-0.1mg, max. 0.4mg
• Imipramine
– 2-3 times/day; 1-4mg/kg/day
– 30-50% response rate in 10 studies
– ECG recommended prior to treatment (cardiotoxicity)
*Non-stimulants: less effective, more side effects, try only
when stimulants not available, not tolerated or not appropriate
37. ODD
• A child with ODD is consistently
•negative,
• disobedient,
•argumentative, & hostile.
• He behaves in a provocative manner deliberatively
meant to annoy & upset
38. ODD
• All children sometimes talk back, argue, disobey,
&defy their parents or teachers – especially when
they’re hungry, tired, or stressed.
• In fact, for toddlers age 2 or 3 & for young
adolescents, such oppositional behavior may be a
normal part of development.
39. CAUSES
• No known biological basis for ODD exists.
• Risk Factors:
• Parental rejection
• Inconsistent, unsupervised child rearing.
• Inconsistent or punitive discipline or limit setting
• Parental modeling of defiant interactions with others
• Family conflict
• Marital discord between the child’s parent
• Disrupted child care with a succession of different caregivers
40. SIGNS AND SYMPTOMS
• Persistent or consistent pattern of defiant, disobedient, hostile
behavior.
• Disobeying directly by not following rules
• Disobeying indirectly by procrastinating & being sneaky
• Refusing to cooperate
• Being touchy & easily annoyed
• Frequent bouts of anger & resentment
41. C/f
• Persistent fighting
• Excessive arguing
• Stubbornness
• Testing of behavior limits
• Temper tantrum
• Deliberate attempts to upset or annoy people
• Vindictiveness
• Blaming others for his own misbehavior
• Violating other’s rights
43. Conduct disorder
• A repetitive and persistent pattern of behavior in which the basic rights of others or major age-
appropriate societal norms or rules are violated,
• manifested by the presence of at least three of the following 15 criteria in the past 12 months
from any of the categories below, with at least one criterion present in the past 6 months:
• Aggression to People and Animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick,
broken bottle, knife, gun).
44. Conduct disorder
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery).
7. Has forced someone into sexual activity.
45. Conduct disorder
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing serious damage.
9. Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or Theft
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods or favours or to avoid obligations (i.e., “cons” others).
12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without
breaking and entering: forgery).
46. Conduct disorder
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions, beginning before age 13
years.
14. Has run away from home overnight at least twice while living in the parental or
parental surrogate home, or once without returning for a lengthy period.
15. Is often truant from school, beginning before age 13 years.
