Child Psychiatry

1. Child Psychiatry Prof. MUDr. Ivana Drtílková, CSc. Dept. of Psychiatry, Masaryk University , Brno

2. Child Psychiatry Conduct Disorder genetic and environmental components more common among boys(6-16%) than girls (2-9%)

3. Child Psychiatry Diagnosis : repetitive and persistent pattern of behavior in which the rights of others or basic social rules are violated. Aggressive behavior that causes or threatens harm to other people or animals, ( bullying or intimidating others, initiating physical fights..), Non-aggressive conduct ( property loss or damage, fire-setting ..) Deceitfulness or theft Serious rule violations, ( running away from home overnight, often being truant from school.)

4. Child Psychiatry Treatment: family therapy, and cognitive behavioral approaches which focus on building skills such as anger management. Pharmacological intervention alone is not sufficient..

5. Bed-Wetting (Primary Nocturnal Enuresis) Bed-wetting is accidental urination during sleep. children over age 5 or 6 ( age at which continence could definitely be expected) Bed-wetting that develops after a child has been dry for a period of time (secondary nocturnal enuresis)

6. Bed-Wetting (Primary Nocturnal Enuresis) Cause for bed-wetting: Delayed growth and development. Small bladder capacity. Lack of enough antidiuretic hormone (ADH). Sound sleeping. Psychological and social factors.

7. Bed-Wetting (Primary Nocturnal Enuresis) Medications : that either increase the amount of urine that the bladder can hold bladder capacity- (imipramine) or decrease the amount of urine released by the kidneys ( desmopressin).

8. TIC DISORDERS Tics are : abrupt, purposeless, and involuntary vocal sounds or muscular jerks. They are sudden, rapid, and recurrent. 1. Transient tic disorder - the most common type , with symptoms lasting at least four months, but no longer than one year. Onset - nearly 10 percent of school children- more prevalent in periods of stress, fatigue, or as a result of certain types of medications ( stimulants)

9. TIC DISORDERS 2. Chronic tics- lasting more than one year 3. Tourette's disorder (TD) Tourette's disorder is an autosomal dominant disorder with incomplete penetrance. Non-genetic cause in 10 to 15 percent of children (complications of pregnancy, low birthweight, head trauma, carbon monoxide poisoning, and encephalitis..).

10. TIC DISORDERS 3. Tourette's disorder (TD) Tourette's disorder (TD multiple repeated tics (abrupt, purposeless, and involuntary vocal sounds or muscular jerks.) Begin : between the ages of 5 and 10 years of age

11. TIC DISORDERS Tourette a disorder - symptoms may include: involuntary, purposeless, motor movements (the face, neck, shoulders, trunk, or hands) head jerking squinting blinking shrugging grimacing nose-twitching

12. TIC DISORDERS Tourette a disorder - symptoms may include: any excessively repeated movements (i.e., foot tapping, leg jerking, scratching) kissing pinching sticking out the tongue or lip-smacking making obscene gestures

13. TIC DISORDERS Tourette a disorder is also characterized by one or more vocal tics : grunting or moaning sounds barks tongue clicking sniffs hooting obscenities throat clearing, snorts, or coughs

14. TIC DISORDERS Tourette a disorderis also characterized by one or more vocal tics : squeaking noises hissing spitting whistling gurgling echoing sounds or phrases repeatedly

15. CHILDHOOD SCHIZOPHRENIA Definition: Same diagnostic criteria apply to children, adolescents, and adults Based symptoms : deficits in adaptive functioning, and duration of six months Incidence : less than 1/10,000 births

16. CHILDHOOD SCHIZOPHRENIA General Characteristics: 1. Slight male predominance 2. Less educated and professionally successful families 3. Patients have low-average to average range of intelligence 4. Patterns of behavior before a formal diagnosis: attention/conduct problems, earlier patterns of inhibition, withdrawal and sensitivity

17. CHILDHOOD SCHIZOPHRENIA General Characteristics: 5. Disease is rarely observed before age 5 6. 80% of children have auditory hallucinations; 50% have delusional beliefs 7. Can be observed with additional conditions such as: conduct disorder, learning disabilities, mental retardation, and autism 8. Poor prognosis if onset before age 10 with above personality difficulties

18. CHILDHOOD SCHIZOPHRENIA CHARACTERISTIC SYMPTOMS : Positive symptoms ( productive ) : Delusions Hallutiations Disorganised speech (often incoherence ) Grossly disorganized or catatonic behavior

19. CHILDHOOD SCHIZOPHRENIA CHARACTERISTIC SYMPTOMS : Negative symptoms ( nonproductive ) : affective flattening social dysfunction Problematic in children - fantasy figures, which would not of themselves suggest psychosis. The content of hallutiations and delusions varies with age.

20. CHILDHOOD SCHIZOPHRENIA TREATMENT : Antipsychotics are the drugs of first choice in chilhood for schizofrenia Imortance : minimizing any cognitive dulling in school children , atypical antipsychotics are preferred (risperidone, olanzapine).

21. DEPRESSION IN CHILDERN Risk factors in their lives which could predispose: family history of mental illness or suicide, abuse (physical, emotional or sexual), chronic illness and the loss of a parent at an early age to death, divorce or abandonment. The depression could be wholly chemical, wholly due to psychological factors, or combination of the two.

22. DEPRESSION IN CHILDERN Symptoms of Depression in Children Persistent sadness and/or irritability. Low self-esteem or feelings or worthlessness. A child may make such statements as, "I'm bad. I'm stupid. No one likes me." Loss of interest in previously enjoyed activities. Change in appetite (either increase or decrease). Change in sleep patterns (either increase or decrease).

23. DEPRESSION IN CHILDERN Symptoms of Depression in Children Difficulty concentrating. Anger and rage Headaches, stomachaches or other physical pains that seem to have no cause. Changes in activity level( more lethargic or more hyperactive. ) Recurring thoughts of death or suicide.

24. DEPRESSION IN CHILDERN If the child has bipolar disorder, also known as manic depression, these symptoms could be present: abrupt, rapid mood swings periods of extreme hyperactivity prolonged, explosive temper tantrums or rages exaggerated ideas about self or abilities Bipolar disorder is often mis-diagnosed as attention-deficit disorder with hyperactivity (ADHD), obsessive-compulsive disorder (OCD), oppositional defiant disorder or conduct disorder.

25. AUTISM IN CHILDREN First described : Leo Kanner in 1943 as a disturbance of affective contact Prevalence: 4-5 cases per 10000 The basic criteria : early onset (before 3-5 years of age), severe abnormality of reciprocal social relatedness, severe abnormality of communication development, restricted, repetitive and stereotyped patterns of behavior, interests, activities, and imagination; abnormal responses to sensory stimuli.

26. AUTISM IN CHILDREN SOCIAL DISTURBANCE The human face holds little interest for the autistic infant lack of eye contact, poor or absent attachments general lack of social interest COMMUNACATIVE DISTURBANCE echolalia, pronoun reversal, inappropriate cadence and intonation, impaired semantic development

27. AUTISM IN CHILDREN COGNITIVE DEVELOPMENT Most ( approximately three-fourths ) autistic children scored in the mentally retarded range A few autistic individuals exhibit truly remarkable abilities( musical or drawing ability . memory BEHAVIOR FEATURES Restricted repetitive and stereotyped patterns of behavior, interests and activities. Interest in nonfunctional aspects of objects ( taste or feel )

28. AUTISM IN CHILDREN Stereotyped movements ( hand flapping, toe walking, spinning objcts and the like). Bizare affective responses - panicked in response to new situations. Deficits in imaginative play.

29. AUTISM IN CHILDREN ETIOLOGY AND PATHOGENESIS There may be a genetic basis to the disorder- family members with other related disabilities Autistic children exhibited : an increased frequency of physical anomalies, persistent primitive reflexes, various neurological soft sings and increased abnormalities on EEG. Treatment Drug treatments ( risperidone ) Other therapies : behavioral treatments (teaching autistic "appropriate" behaviors).

30. Attention deficit hyperactivity disorder ( ADHD) CHARACTERISTIC : 1). INAPPROPRIATE OR EXCESSIVE ACTIVITY 2). POOR SUSTAINED ATTENTION 3). DIFFICULTIES IN INHIBITING IMPULSES IN SOCIAL BEHAVIOR AND ON COGNITIVE TASKS. 4). DIFFICULTIES GETTING ALONG WITH OTHERS 5). SCHOOL UNDERACHIEVEMENT PREVALENCE : 8 % OCCURS BETWEEN 6 - 8 YEARS IN BOYS - 9 % IN GIRLS - 3 %

31. Attention deficit hyperactivity disorder ( ADHD) Type of disorder ADHD combined type ADHD predominantly inattentive type ADHD predominantly hyperactive-impulsive type

32. Attention deficit hyperactivity disorder ( ADHD) Cause of ADHD suspected contributing factors may include: Neurophysiology - differences in brain anatomy, electrical activity and metabolism. Catecholamine function are very probably involved in the pathogenesis of hyperactivity. Genetics - possible gene mutations may be present.

33. Attention deficit hyperactivity disorder ( ADHD) Cause of ADHD suspected contributing factors may include: Drugs - drug use (nicotine and cocaine) by the mother during pregnancy . Lead - chronic exposure - influence behaviour and brain chemistry. Lack of early attachment - traumatic experiences related to the attachment

34. Attention deficit hyperactivity disorder ( ADHD) Therapy of ADHD behavioural management, psychological counselling drugs target the brain's neurotransmitters ( stimulants, antidepressants..) Stimulant drugs Dexamphetamine and methylphenidate (Ritalin) work by acting on the neurotransmitters that release the chemical dopamine. About 7O % of children with hyperactivity improve on a stimulant regimen.

35. Attention deficit hyperactivity disorder ( ADHD) Inattention criteria Fail to give close attention to details or make careless mistakes in school work. Have difficulty sustaining attention in tasks or play activities. Not seem to listen when spoken to directly. Not follow through on instructions and fail to finish school work, chores or duties in the workplace

36. Attention deficit hyperactivity disorder ( ADHD) Inattention criteria Have difficulty organising tasks and activities. Avoid, dislike or be reluctant to engage in tasks that require sustained mental effort Lose things necessary for tasks or activities (for example: toys, school assignments, pencils, books or tools). Be easily distracted. Be forgetful in daily activities.

37. Attention deficit hyperactivity disorder ( ADHD) Hyperactivity-impulsivity criteria 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 about or climbs excessively in situations in which it is inappropriate

38. Attention deficit hyperactivity disorder ( ADHD) Hyperactivity-impulsivity criteria Hyperactivity 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

39. Attention deficit hyperactivity disorder ( ADHD) Hyperactivity-impulsivity criteria Impulsivity Often blurts out answers before questions have been completed. Often has difficulty waiting in turn. Often interrupts or intrudes on others (for example, 'butts into' conversations or games).

40. References : Child Psychiatry Child and Adolescent Psychiatry, edited by Melvin Lewis, Wiliams and Wilkins, 1996, 1260 pp.