presentation about disorders

1. CHILDHOOD ONSET PSYCHIATRIC
DISORDERS
MED II
Youmna Cassir Haddad, D.E.S.S
Child and Adolescent psychologist

2. CLINICAL DIAGNOSIS FOR CHILDREN
1. Major Depressive Disorder
2. Dysthymic Disorder
3. Adjustment Disorder
4. Anaclitic Depression
5. Generalized Anxiety Disorder
6. Separation Anxiety Disorder
7. Obsessive Compulsive Disorder
8. Specific Phobia
9. Attention Deficit and Hyperactivity Disorder
10. Conduct Disorder
11. Posttraumatic Stress Disorder
12. Elimination Disorders
13. Autism Spectrum Disorder
14. Social Communication Disorder

3. 1. MAJOR DEPRESSIVE DISORDER
Prevalence
• Depression in children : 2 % ( males more than females))
• Depression in adolescents: 10 to 20% ( Females more than
males)

4. Diagnostic Criteria for Major Depressive Disorder
The Child presents at least five symptoms during the same two
week period and represent a change from previous
functioning:
1- Depressed Mood
2- Markedly diminished interest in pleasure in almost all activities
3- Significant weight loss or weight gain, or decrease or increase in
appetite nearly everyday.
4- Insomnia or hypersomnia
5- Psychomotor agitation or retardation nearly every day
6- Fatigue or loss of energy nearly every day
7- Feelings of worthlessness or excessive or inappropriate guilt
8- Diminished ability to think or concentrate
9- Recurrent thoughts of death or recurrent suicidal ideation

5. Caracteristic of Depression in Children :
• Depressed mood is manifested in children by irritability and
constant expression of boredom.
• Loss of concentration is shown by loss of interest in
homework or school related activities.
• Agitation is translated in children by behavioral problems at
home: Child suddenly appear to be restless, aggressive and
oppositional.
• Fatigue is expressed by a decreased in energy level: a simple
task could appear very difficult to complete ( teeth brushing,
fixing school bag).

6. Other kinds of depression:
• The diagnosis of chronic depression or depression with
melancholia is suggested when symptoms are very
severe and last more than 1 year in children and more
than 2 years in adults.
• The diagnosis of atypical depression is suggested when
mood symptoms specifically sadness is not apparent at
first and when there is a quick positive mood reactivity.
Depression in children is often expressed by somatic
complains (stomach aches, nausea).

7. 2. DYSTHYMIC DISORDER
• Child shows depressed mood practically all day long, more
days than not. This depressed mood must be addressed
individually (by the person himself) or observable by
others.
• In children and adolescents, depressed mood could be
manifested by irritability.
• It calls for an immediate and particular attention and
psychological intervention.

8. Diagnostic Criteria for Dysthymic Disorder:
Child shows at least 2 of the following symptoms during a
period of 1 year:
• Poor appetite or overeating.
• Insomnia or hypersomnia.
• Low energy or fatigue.
• Low self esteem.
• Poor concentration or difficulty making decisions.
• Feelings of hopelessness.

9. 3. ADJUSTMENT DISORDER
• It is a reaction to a stressful life event (moving, divorce,
sickness of a loved one, change of school, surgery).
• Adjustment disorder is frequent in children and is
manifested more by behavioral problems than sadness.

10. • The development of emotional or behavioral symptoms
is in response to an identifiable stressor(s) occurring
within 3 months of the onset of the stressor (s).
• Acute < 6 months ; chronic > 6 months
Diagnostic Criteria for Adjustment Disorder:
• Marked distress that is in excess of what would be
expected from exposure to the stressor.
• Significant impairment in social or occupational
(academic) functioning.

11. Subtypes of Adjustment Disorder:
• With depressed mood ( predominant manifestations are
symptoms such as depressed mood, tearfulness or feelings of
hopelessness).
• With anxiety (predominant manifestations are symptoms
such as nervousness, worry or in in children fears of
separation from major attachment figures).
• With mixed anxiety and depressed mood ( predominant
manifestations is a combination of depression and anxiety).
• With disturbance of conduct ( predominant manifestation is
a disturbance in conduct in which there is violation of the
rights of others).
• With mixed disturbance of emotions and conduct
(predominant manifestations: both emotional symptoms eg
depression, anxiety and a disturbance of conduct).

12. 4. ANACLITIC DEPRESSION
• It usually occurs in new born of 6 months of age and
more who has been deprived of physical and emotional
attention by his primary care giver. It is usually
prevalent in mothers who have just given birth in the
context of post partum depression.
Diagnostic criteria for analytic depression
• Non reactive to environment.
• Insomnia.
• Continuous loss of weight.
• Growth retardation.
• Mental growth retardation.
• Regression in acquired motor skills.
• Increased sensitivity to infection.

13. Alarm signs
Somatic manifestations:
• Anorexia
• Growth retardation
• Insomnia
Behavioral manifestation
• Loss of interest in activities and games.
Growth retardation in psychomotor development
• Speech delay that occurs after few weeks.

14. 5. GENERALIZED ANXIETY DISORDER
Prevalence:
• Generalized Anxiety Disorder: 12 %
• Separation Anxiety Disorder: 4 to 5 %
• Obsessive Compulsive Disorder : 2 %
• Social Phobia: 13 %
• Specific Phobia: 11 %
Diagnostic Criteria of Generalized Anxiety Disorder
Child presents 3 or more of the following 6 symptoms
present for more days than not for the past 6 months:
• Restlessness
• Being easily fatigued.
• Difficulty concentrating or mind going blank
• Irritability.
• Muscular tension.
• Sleep disturbance.

15. 6. SEPARATION ANXIETY DISORDER
Prevalence: 4 to 5 %
Onset: Before age of 18 years
Early onset < 6ans
Diagnostic Criteria for Separation Anxiety Disorder
Child presents at least 3 from the following symptoms
during a period of 4 weeks:
• Recurrent excessive distress when separation from home
or major attachment figures occurs or anticipated.
• Persistent and excessive worry about losing, or about
possible harm befalling, major attachment figure.

16. • Persistent and excessive worry that an event will lead to
separation from a major attachment figure.
• Persistent reluctance or refusal to go to school or
elsewhere because of fear of separation.
• Persistently and excessively fearful or reluctant to be
alone or without major attachment figures at home or
without significant adults in other settings.
• Persistent reluctance or refusal to go to sleep without
being near a major attachment figure or to sleep away
from home.
• Repeated nightmares involving the theme of separation.
• Repeated complaints of physical symptoms when
separation from major attachment figures occurs or
anticipated.

17. 7. OBSESSIVE COMPULSIVE DISORDER
Prevalence: 2%
Diagnostic criteria for Obsessive Compulsive Disorder :
1. Either obsessions or compulsions:
Obsessions:
• Recurrent and persistent thoughts, impulses or images that
are experienced, at some time during the disturbance , as
intrusive and inappropriate and that cause marked anxiety
or distress.
• The thoughts, impulses, or images are not simply excessive
worries about real-life problems.
• The person attempts to ignore or suppress such thoughts,
impulses, or images, or to neutralize them with some other
thought or action.
• The person recognizes that the obsessional thoughts,
impulses or images are a product of his or her own mind.

18. Compulsions :
• Repetitive behaviors or mental acts that the person
feels driven to perform in response to an obsession, or
according to rules that must be applied rigidly.
• The behaviors or mental acts are aimed at preventing
or reducing distress or preventing some dreaded event
or situation: however, these behaviors or mental acts
either or not connected in a realistic way with what
they are designed to neutralize or prevent or are
clearly excessive.
2- The obsessions or compulsions cause marked distress,
are time consuming, or significantly interfere with the
person’s normal routine, occupational functioning or
usual social activities or relationships.

19. 8. SPECIFIC PHOBIA
Prevalence: 11%
Diagnostic criteria for specific phobia:
• Marked and persistent fear that is excessive or unreasonable,
cued by the presence or anticipation of a specific object or
situation.
•Exposure to the phobic stimuli almost invariably provokes an
immediate anxiety response, which may take the form of a
situationally bound or situationally predisposed Panick Attack.
(In children , the anxiety may be expressed by crying,
tantrums, freezing or clinging).

20. • The person recognizes that the fear is excessive or
unreasonable. In children, this feature may be absent.
• The phobic situation is avoided or else is endured with
intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the
feared situation interferes significantly with the person’s
normal routine, occupational (or academic) functioning,
or social activities or relation ships, or there is marked
distress about having the phobia.
• In individuals under age 18 years, the duration is at least
6 months.

21. Subtypes of Specific Phobia
• Animal Type( insects, dogs…)
• Natural environment Type (e.g, heights, storms, water)
• Blood-injection-Injury Type ( blood accident)
• Situational Type (Airplanes, elevators, enclosed places)
• Other Type (e.g, phobic avoidance of situations that
may lead to choking, vomiting or contracting an illness.
In children, avoidance of loud sounds or costumed
characters)

22. 9. ATTENTION DEFICIT AND HYPERACTIVITY DISORDER:
Prevalence: 3 to 8 %
Attention deficit and hyperactivity disorder is:
• A neuro-developmental disorder
• Appears before 12 years old
• Causes a significant impairment in social, and academic
functioning

23. Diagnostic criteria of Attention Deficit and Hyperactivity
Disorder:
Child presents 6 symptoms or more of INATTENTION that last at
least for a period of 6 months:
• Often fails to give close attention to details.
• Often has difficulty sustaining attention in tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow through on instructions and fails to finish
school work.
• Often has difficulty organizing tasks and activities.
• Often avoids, dislikes or is reluctant to engage in tasks that
require sustained mental effort.
• Often loses things necessary for tasks or activities.
• Is often easily distracted by extern stimuli.
• Is often forgetful in daily activities.

24. Diagnostic criteria of Attention Deficit and Hyperactivity Disorder:
Child presents 6 symptoms of HYPERACTIVITY-IMPULSIVITY that last
for a period of at least 6 months.
Hyperactivity:
• Often fidgets with hands or feet or squirms in seat.
• Often leaves seat in classroom or in other situations in which
remaining seated is expected.
• Often runs or climbs excessively in situations in which it is
inappropriate.
• Often has difficulty playing or engaging in leisure activities quietly.
• Is often «on the go » or often acts as if « driven by a motor ».
• Often talks excessively.

25. Impulsivity:
• Often blurts out answers before questions have been
completed.
• Often has difficulty awaiting turn.
• Often interrupts or intrudes on others.

26. ADHD Criteria: Three Axes of Problem:
 Inattention / Distractibility.
 Hyperactivity.
 Impulsivity.
 Problem with the "Maestro".

27. 27
10. CONDUCT DISORDER :
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-
appropriate societal norms or rules are violated, as 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).
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.

28. 28
10. CONDUCT DISORDER Cont’d :
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).
Deceitful ness or Theft
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods or favors 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).
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.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or
occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

29. 11. POST-TRAUMATIC STRESS DISORDER:
1. The person has been exposed to a traumatic event in
which both of the following were present:
• The person experienced, witnessed, or was confronted
with an event or events that involved actual or
threatened death or serious injury or a threat to the
physical integrity of self or others.
• The person’s response involved intense fear,
helplessness or horror. In children, this may be
expressed instead by disorganized or agitated behavior.

30. 2. The traumatic event is persistently reexperienced in
one (or more) of the following ways:
a) Recurrent and intrusive distressing recollections of
the event including images, thoughts or
perceptions. In young children, repetitive play may
occur in which themes or aspects of the trauma are
expressed.
b) Recurrent distressing dreams of the event. In
children, there may be frightening dreams without
recognizable content.
c) Acting or feeling as if traumatic event were recurring
(flash back episodes).

31. d) Intense psychological distress at exposure to internal or
external cues that symbolize an aspect of the traumatic
event.
e) Physiological reactivity on exposure to internal or external
cues that symbolize an aspect of the traumatic event.
3. Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness (not present
before the trauma) as indicated by three (or more) of the
following:
a) Efforts to avoid thoughts, feelings, or conversations
associated with the trauma.

32. b) Efforts to avoid activities, places or people that arouse
recollections of the trauma.
c) In ability to recall an important aspect of the trauma.
d) Markedly administered interest or participation in
significant activities.
e) Feeling of detachment or estrangement from others.
f) Restricted range of affect (eg: unable to have loving
feelings).
g) Sense of a foreshortened future (e.g: Does not expect to
have a career, marriage, children, or normal life span)

33. 4. Persistent symptoms of increased arousal (not present
before the trauma) as indicated by two (or more) of the
following:
a) Difficulty falling or staying asleep.
b) Irritability or outbursts of anger.
c) Difficulty concentrating.
d) Hypervigilance.
e) Exaggerated startle response.
5. Duration of the disturbance (symptoms in criteria B, C, and
D) is more than one month.
6. The disturbance causes clinically significant distress or
impairment in social, occupational or other important areas
of functioning.

34. 12. ELIMINATION DISORDER (ENURESIS)
Diagnostic Criteria for enuresis:
A. Repeated voiding of urine into bed or clothes, whether involuntary or
intentional.
B. The behavior is clinically significant as manifested by either a frequency
of at least twice a week for at least 3 consecutive months or the
presence of clinically significant distress or impairment in social,
academic or other important areas of functioning.
C. Chronological age is at least 5 years.
D. The behavior is not attributable to the physiological effects of a
substance (medication) or another medical condition (e.g., a diabestes,
spinabifidia, a seizure disorder).
Specify whether:
-Nocturnal only: Passage of urine only during nighttime sleep.
- Diurnal only: Passage of urine during waking hours.
- Nocturnal and diurnal: A combination of the two subtypes above.

35. 12. ELIMINATION DISORDER (ENCOPRESIS)
Diagnostic Criteria for encopresis:
A. Repeated passage of feces into inappropriate places (e.g., clothing,
floor), whether involuntary or intentional.
B. At least one such event occurs each month for at least 3 months.
C. Chronological age is at least 4 years.
D. The behavior is not attributable to the physiological effect of a
substance (e.g,. Laxatives) or another medical condition except through
a mechanism involving constipation.
Specify whether:
-With constipation and overflow incontinence: There is evidence of
constipation on physical examination or by history.
- Without constipation and overflow incontinence: There is no evidence of
constipation on physical examination or by history.

36. 13. AUTISM SPECTRUM DISORDER:
Prevalence:
1% of the population with similar estimates in child
and adult samples.
 Autism spectrum disorder is diagnosed four times
more often in males than in females.

37. Diagnostic criteria Autism Spectrum Disorder:
A- Persistent deficits in social communication and social interaction across
multiple contexts, as manifested by the following, currently or by history:
1- Deficits in social-emotional reciprocity, ranging, for example, from abnormal
social approach and failure of normal back-and forth conversation; to
reduced sharing of interests, emotions, or affect; to failure to initiate or
respond to social interactions.
2- Deficits in nonverbal communicative behaviors used for social interactions,
ranging for example, from poorly integrated verbal and nonverbal
communication; to abnormalities in eye contact and body language or
deficits in understanding and use of gestures; to total lack of facial
expressions and nonverbal communication.
3- Deficits in developing, maintaining, and understanding relationships, ranging,
for example, from difficulties adjusting behavior to suit various social
contexts; to difficulties in sharing imaginative play or in making friends; to
absence of interest in peers.

38. B- Restricted, repetitive patterns of behavior, interests, or
activities, as manifested by at least two of the following,
currently or by history:
1- Stereotyped or repetitive motor movements, use of objects, or
speech (e.g., simple motor stereotypes, lining up toys or
flipping objects, echolalia, idiosyncratic phrases).
2- Insistence on sameness, inflexible adherence to routines, or
ritualized pattern of verbal or nonverbal behavior (e.g.,
extreme distress at small changes, difficulties with transitions,
rigid thinking patterns, greeting rituals, need to take same
route or eat some food every day).

39. 3- Highly restricted, fixated interest that are abnormal in intensity or
focus (e.g., strong attachments to or preoccupation with unusual
objects, excessively circumscribed or perseverative interests).
4- Hyper- or hyporeactivity to sensory input or unusual interest in
sensory aspects of the environment (e.g., apparent indifference to
pain temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with
lights or movement).

40. C- Symptoms must be present in the early developmental period (but may
not become fully manifest until social demands exceed limited capacities,
or may be masked by learned strategies in later life).
D- Symptoms cause clinically significant impairment in social, occupational,
or other important areas of current functioning.
E- These disturbances are not better explained by intellectual disability
(intellectual developmental disorder) or global developmental delay.
Intellectual disability and autism spectrum disorder frequently co-occur.
To make comorbid diagnoses of autism spectrum disorder and intellectual
disability, social communication should be below that expected for
general developmental level.

41. Notes about Autism Spectrum Disorder:
 Individuals who have marked deficits in social communication, but
whose symptoms do not otherwise meet criteria for autism spectrum
disorder, should be evaluated for social communication disorder.
Specification:
-With or without accompanying intellectual impairment
- With or without accompanying language impairment
- Associated with a known medical or genetic condition or environmental
factor
- Associated with another neurodevelopmental, mental, or behavioral
disorder
- With catatonia

42. Severity:
Severity should be recorded as level of support needed for each of the
two psychopathological domains
-Requiring support
- Requiring substantial support
- Requiring very substantial support

43. AUTISM SPECTRUM DISORDER
Development and course:
 Symptoms are typically recognized during the second year of
life (12-24 months of age) but may be seen earlier than 12
months if developmental delays are severe, or noted later
than 24 months if symptoms are more subtle.
 “Red flag” for autism spectrum, disorder: Some children with
autism spectrum disorder experience developmental
regression, with a gradual or relatively rapid deterioration in
social behaviors of use of language, often during the first 2
years of life.

44. AUTISM SPECTRUM DISORDER
Prognostic Factors
 The best established prognostic factors for individual outcome
within autism spectrum disorder are:
- presence or absence of associated intellectual disability
- language impairment.

45. AUTISM SPECTRUM DISORDER
Differential diagnosis
1- Selective mutism:
 early development is not typically disturbed.
 The affected child usually exhibits appropriate communication
skills in certain context and setting.
 Even in settings where the child is mute, social reciprocity is
not impaired, nor are restricted or repetitive patterns of
behavior present.

46. AUTISM SPECTRUM DISORDER
Differential Diagnosis
2- Language disorders and social communication disorder.
When an individual shows impairment in social communication and social
interactions but does not show restricted and repetitive behavior or interests,
criteria for social communication disorder instead of autism spectrum Disorder
may be met.
3- Intellectual disability without autism spectrum disorder.
 A diagnosis of autism spectrum disorder in an individual with intellectual
disability is appropriate when social communication and interaction are
significantly impaired relative to the developmental level of the individual’s
nonverbal skills (e.g., fine motor skills, nonverbal problem solving).
In contrast, intellectual disability is the appropriate diagnosis when there is no
apparent discrepancy between the level of social communicative skills and other
intellectuals skills.

47. AUTISM SPECTRUM DISORDER
Differential Diagnosis
4- Stereotypic movement disorder
 Motor stereotypies are among the diagnostic characteristics of autism
spectrum disorder, so an additional diagnosis of stereotypic movement disorder is
not given when such repetitive behaviors are better explained by the presence of
autism spectrum disorder.
 However, when stereotypies cause self-injury and become a focus of
treatment, both diagnosis may be appropriate.
5- Attention-deficit/hyperactivity disorder.
 A diagnosis of attention-deficit/hyperactivity disorder (ADHD) should be
considered when attentional difficulties or hyperactivity exceeds that typically
seen in individuals of comparable mental age.

48. AUTISM SPECTRUM DISORDER
Comorbidity
 Autism spectrum disorder is frequently associated with intellectual
impairment and structural language disorder (i.e., inability to understand and
construct sentences with proper grammar).
 Many individuals with autism spectrum disorder have psychiatric symptoms
that do not form part of the diagnostic criteria for the disorder (about 70% of
individuals with autism spectrum disorder may have one comorbid mental
disorder, and 40% may have two or more comorbid mental disorders).

49. 14. SOCIAL COMMUNICATION DISORDER
Diagnostic Criteria for social communication disorder:
A. Persistent difficulties in the social use of verbal and nonverbal
communication as manifested by all of the following:
1- Deficits in using communication for social purposes, such as greeting
and sharing information, in a manner that is appropriate for the social
context.
2- Impairment of the ability to change communication to match context or
the needs of the listener, such as speaking differently in a classroom than
on a playground, talking differently to a child than to an adult, and
avoiding use of overly formal language.
3- Difficulties following rules of conversation and storytelling, such as
taking turns in conversation, rephrasing when misunderstood, and
knowing how to use verbal and nonverbal signals to regulate interaction.

50. 4- Difficulties understanding what is not explicitly stated (e.g., making inferences)
and nonliteral or ambiguous meanings of language (e.g., idioms, humor,
metaphors, multiple meanings that depend on the context for interpretation).
B. The deficits result in functional limitations in effective communication, social
participation, social relationships, academic achievement, or occupational
performance, individually or in combination.
C. The onset of the symptoms is in the early developmental period (but deficits
may not become fully manifest until social communication demands exceed
limited capacities).
D. The symptoms are not attributable to another medical or neurological
condition or to low abilities in the domains of word structure and grammar, and
are not better explained by autism spectrum disorder, intellectual disability
(intellectual developmental disorder), global developmental delay, or another
mental disorder.

51. END