Child Psychiatry Niloufar Mahdavi Shaheed Beheshti university of Medical sciences

1. Child PsychiatryNiloufarMahdaviShaheedBeheshti university of Medical sciences

2. Child psychiatric evaluation History: Chief complaint, present illness, developmental his., psychiatric his., medical his., family social his. & parents’ marital status, educational his. & current school functioning, peer relationship , current family functioning, family psychiatric & medical his. Physical examination Neuropsychiatric examination

3. Mental status examination: Physical appearance, parent-child interaction, separation & reunion, orientation to TPP, speech & language, mood, affect, thought process & content, social relatedness, motor behavior, cognition, memory, judgment & insight.

4. Mental retardation MR is the result of a pathological process in the brain characterized by limitations in intellectual and adaptive function. According to DSM-4-TR:MR is significantly sub average general intellectual functioning resulting in, or associated with, concurrent impairment in adaptive behavior & manifested during the developmental period, before the age of 18.

5. Levels of mental retardation Mild MR (IQ of 55 to 70): The largest group of people with MR (about 85% of all persons with retardation). Appear similar to nonretarded. Many achieve academic skills at the 6th grade or higher, and some graduate from high school. Many of them hold jobs, and marry, but may appear slow or need extra help for life’s problems & tasks.

6. Levels of mental retardation Moderate MR ( IQ of 40 to 55): Approximately 10% of all MR population. People with more impaired cognitive & adaptive functioning. Typically diagnosed in their preschool years. Require special education services, achieving academic skills at the second to third grade level. Need for supportive services throughout life.

7. Levels of mental retardation Severe MR (IQ of 25 to 40 ): Occurs in 3% to 4% of MR population. Often have one or more organic causes for their delay, & many show concurrent motor, ambulatory, and neurological problems. Most of them require close supervision & specialized care throughout their lives. Some of them learn to perform simple tasks & facilitate their self-care.

8. Levels of mental retardation Profound MR (IQ of 25 and below) Affects 1% to 2% of MR population. Pervasive deficits in cognitive, motor, & communicative functioning. Impairments in sensory-motor functioning are often seen from early childhood, & most individuals require extensive training to complete even the most rudimentary aspects of self-care, such as eating & toileting. Show organic causes for their delay & need total supervision & care throughout life.

9. Etiology Parental cause: Genetic dis. (Down syndrome, phenylketonuria & other metabolic dis., fragile X syndrome, …) Congenital malformations (neural tube defects) Exposure (congenital rubella, fetal alcohol syn., radiation, trauma) Perinatal cause: infections, delivery problem (asphyxia) Postnatal causes: Infections, toxins( Encephalitis, lead poisoning, traumas, …)

10. Pervasive Developmental Disorder A group of conditions in which there are delay & deviance in the development of social skills, language & communication, and behavioral repertoire. Unusual intense interest in a narrow range of activities, resist change, & are not appropriately responsive to the social environment. Affect multiple areas of development, are manifested early in life, and cause persistent dysfunction.

11. Autistic disorder Sustained impairment in comprehending & responding to social cues, aberrant language development & usage, and restricted, stereotypical behavioral patterns. Prevalence:0.05%, 4-5 time more frequent in boys. The onset is before the age of 3, but in some cases, recognized until a child is much older. Patient with IQs above 70 and those who use communicative language by age 5 to 7 tend to have the best prognosis. About two thirds of autistic adults remain severely handicapped & are completely dependent or semidependent.

12. Rett’s disorder A development of several specific deficits following a period of normal functioning after birth. Normal growth & development in first 6 months after birth, between 6m to 2y of age, develop progressive encephalopathy with characteristic features (loss of purposeful hand movements, replaced by stereotypic movements, loss of previously acquired speech, psychomotor retardation, and ataxia, decrease head-circumference growth ( cause microcephaly) . Prevalence: 6-7 per 100000 girls. It is progressive and patient who live into adulthood remain at a cognitive & social level equivalent to that in the first year of life.

13. ATTENTION DEFICIT/HYPER ACTIVITY DISORDERS Persistent pattern of inattention &/or hyperactive and impulsive behavior that is more severe than expected in children of that age & level of development. To meet the diagnostic criteria of ADHD, some symptoms must be present before the age of 7y, although many children are not diagnosed until they are older than 7y ( cause problems in school). Symptoms must be present in at least 2 settings.

14. ADHD Incidence:2%-20% of school children. More prevalent in boys. Symptoms are present by age 3y, but diagnosis is made later.

15. Clinical feature Infancy: Sensitive to stimuli & easily upset by noise, light, temperature, & other environmental changes. Sleep little & cry a great deal (some times reverse, sleep much of the time, and develop slowly). School age: Unable to wait, impulsive response & behavior, explosive or irritable, emotionally labile, inability to delay gratification, accident-prone, hyperactivity, attention deficit (distractibility, failure to finish tasks, poor concentration)

16. Course & prognosis Course is variable. Symptoms may persist into adolescence or adult life(15%-20%), they may remit at puberty, or hyperactivity may disappear, but the decrease attention span & impulse control problems persist. Over activity is usually the first symptom to remit, & distractibility is the last. Children whose symptoms persist into adolescence are at risk for developing conduct disorder. Children with both ADHD & conduct dis. Are also at risk for substance-related dis.

17. Treatment psychosocial intervention Pharmacotherapy: Central nervous system stimulants are the first choice of agents : e.g. Ritalin 0.3-1 mg/kg tid; up to 60mg/d, Second-line agents with evidence of efficacy for some children and adolescents : Atomoxetine (a norepinephrine uptake inhibitor), antidepressants, such as bupropion, venlafaxine; and the α-adrenergic receptor agonists clonidine. FDA approved the use of dextroamphetamine in children 3 years of age and older and methylphenidate in children 6 years of age and older. .

18. Enuresis Enuresis is the repeated voiding of urine into a child's clothes or bed; the voiding may be involuntary or intentional. For the diagnosis to be made, a child must exhibit a developmental or chronological age of at least 5 years. According to DSM-IV-TR, the behavior must occur twice weekly for a period of at least 3 months or must cause distress and impairment in functioning to meet the diagnostic criteria. Enuresis is diagnosed only if the behavior is not caused by a medical condition.

19. Enuresis - Genetic factors children with enuresis with a normal anatomic bladder capacity report urge to void with less urine in the bladder than children without enuresis. nocturnal enuresis occurs when the bladder is full because of lower than expected levels of nighttime antidiuretic hormone. - Psychosocial stressors appear to precipitate enuresis in a subgroup of children with the disorder. In young children, the disorder has been particularly associated with the birth of a sibling, hospitalization between the ages of 2 and 4, the start of school, the breakup of a family because of divorce or death, and a move to a new home.

20. No single laboratory finding is pathognomonic of enuresis; but clinicians must rule out organic factors, such as the presence of urinary tract infections, that may predispose a child to enuresis. Structural obstructive abnormalities may be present in up to 3 percent of children with apparent enuresis.

21. Treatment A treatment plan for typical enuresis can be developed after organic causes of urinary dysfunction have been ruled out. Modalities that have been used successfully for enuresis include both behavioral and pharmacological interventions. The first step in any treatment plan is to review appropriate toilet training. Other useful techniques include restricting fluids before bed

22. Behavioral Therapy: Classic conditioning with the bell and pad apparatus is generally the most effective treatment for enuresis Pharmacotherapy:Imipramine has been approved for short-term. Desmopressin (DDAVP), an antidiuretic compound . The most serious adverse effect reported with the use of desmopressin to treat enuresis was a hyponatremic seizure experienced by a child.

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