Download Sarcoidosis to Psychosis

Normal Childhood Development
and Symptoms of Bigger Issues
Pupus with the Principal
Facilitated By
Victor L. Ruterbusch, MD
LCDR/MC/USN
La Jardin Academy, Lower School
03NOV2010
DISCLAIMER
The views expressed by this presenter are
not necessarily those of the military or of
Tripler Army Medical Center.
Dr. Ruterbusch is a Child and Adolescent
Psychiatry Fellow, not yet board eligible.
I have no financial interests to disclose.
My daughter attends 2nd grade at LJA.
Overview
Children are all different…
Good parenting is about being creative,
yet consistent and providing the “best fit”.
Children are NOT a diagnosis, but rather a
“moving target” that you need to really
focus on…
Spring Metaphor
Your hard work at this stage will make your
whole life better….
Stage Theory
for Normal Development
Put forth by Piaget, Kohlberg, Erikson, Freud
and others
Based upon assumption that development
takes place in stages that follow the same basic
criteria:
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Describe Qualitatively different behaviors
Refer to general issues
Unfold in an invariant sequence
Are culturally universal
Cognitive Development (80%)
Piaget
Sensorimotor: (0-2) Intentional behavior, “trial
and error”, beginning of mental pictures
Pre-Operational: (2-6) imaginative play,
categorize, weights and numbers
Concrete Operations: (6-11) “black and white”
conservation of mass, beginning of logic.
Formal Operations (11-20) capable of Abstract
Thought “If /then propositions” comparisons and
deductions made from information NOT
concretely presented, “scientific thought”.
Piaget
Concrete Operations: (6-11)
Seriation—the ability to sort objects according to size,
shape, or any other characteristic.
Transitivity- If A is taller than B, and B is taller than C, then
A must be taller than C).
Classification—ability to name and identify sets of objects
according to appearance, size or other characteristic
Decentering—the child takes into account multiple aspects
of a problem to solve it.
Reversibility—the child understands that numbers or
objects can be changed, then returned to their original state.
Conservation—understanding that quantity, length or
number of items is unrelated to the arrangement or
appearance of the object or items.
Elimination of Egocentrism—the ability to view things
from another's perspective (the “mountain experiment”)
Eriksonian Tasks
Erikson viewed the whole life span as a series of
“tasks” that have to be successfully “mastered”.
Their success is measured as a ratio.
Individuals who master a task gain a “virtue”
Individuals who fail to master these tasks along
the same time course as their peers suffer the
“opposite” consequence, or maladaption.
Eriksonian Tasks
“Basic Trust vs. Mistrust” birth to 1 year: If child’s
primary caregiver consistently meets the child’s
needs, the child masters basic trust with virtue of
Hope and Drive, or suffers the consequence of
proceeding through life “mistrusting” people.
“Autonomy vs. Shame and Doubt” (18 mo. to 3)
Child learns to walk and talk, “I am what I will”
(Self Control vs. Impulsivity)
“Initiative vs. Guilt” (3 to 6) Child builds
sentences, parental ideals, toileting, and a
superego, (Purpose and direction vs. Inhibition)
Eriksonian Tasks (continued)
“Industry vs. Inferiority” (6 to 11) Child searches
for achievement in academics, sports, clubs,
especially in comparison with their peers.
(Competence and Method vs. Inertia)
“Ego Identity vs. Role Confusion” (11 to 20) ,
peers become more important than parents, “I
know WHO I am”. (Fidelity vs. Fanaticism)
“Intimacy vs. Isolation” (20 to 40)
“Generativity vs. Self-absorption” Adulthood
“Integrity vs. Disgust and Despair” Old age.
Kohlberg’s Morality
Posed as a series of “dilemmas”.
Answering yes or no to the dilemma did
not matter. The moral development is
revealed in the reasoning behind the
answer. Hans und das medicine...
Kohlberg stages 1 and 2 (pre-conventional,
might is right)
Kohlberg stages 3 and 4 (conventional,
moral relativism)
Kohlberg stages 5 and 6 (universal
principles)
Bigger Issues
Clinical/Differential Diagnosis/Comorbidity
ADHD
Oppositional Defiant Disorder
Conduct Disorder
Anxiety Disorder
Depressive Disorder
Bipolar Disorder
Learning Disability
Medical Problem (hyperthyroid, lead poisoning,
hearing or vision problem)
Epidemiology of ADHD
General Population:
- 3-12% in 6-12yo school age children
- 2-4% in adults
- Inattentive > Hyperactive > Combined
Clinically referred population:
-2-10% in pediatric primary care
-40-60% in Child/Adolescent Psychiatry
-Combined > Inattentive > Hyperactive
Etiology of ADHD
Disorder of catecholamine UNDERACTIVITY
(epinephrine, norepinephrine, dopamine)
Behavioral disinhibition + impaired executive
function (FRONTAL LOBES)
Neuroimaging shows involvement in frontal
cortex, striatum, and cerebellum
(usually smaller volumes, decreased blood flow
PET scan)
May be predisposed if there are early neurodevelopmental problems (esp. 2nd trimester)
ADHD - Inattentive
Six or more of the following symptoms have been present for at
least 6 months to a point that is disruptive and inappropriate
for developmental level:
OFTEN…
1) Has poor attention to details or makes careless mistakes in
schoolwork, work, or other activities.
2) Has trouble keeping attention on tasks or play activities.
3) Does not seem to listen when spoken to directly.
4) Does not follow instructions, fails to finish schoolwork, chores, etc
(not oppositional behavior or failure to understand)
5) Has trouble organizing activities.
6) Avoids, dislikes or doesn't want to do things that take a lot of
mental effort
7) Loses things needed for tasks and activities (e.g. pencils, books,
tools)
8) Easily distracted.
9) Forgetful in daily activities.
ADHD - Hyperactive & Impulsive
Six or more of the following symptoms have been present for at
least 6 months to a point that is disruptive and inappropriate
for developmental level:
OFTEN…
1) Fidgets with hands or feet or squirms in seat.
2) Gets up from seat when remaining in seat is expected.
3) Runs about or climbs when and where it is not
appropriate (adolescents or adults may feel very restless).
4) Has trouble playing or enjoying leisure activities quietly.
5) “On the go" or often acts as if "driven by a motor".
6) Talks excessively.
7) Blurts out answers before questions have been finished.
8) Has trouble waiting one's turn.
9) Interrupts or intrudes on others (e.g., butts into
conversations or games).
Assessment
COLLATERAL INFORMATION!!!
(need symptoms in 2 settings)
ADHD is a CLINICAL DIAGNOSIS
Other assessment tools include Connors scales,
Continuous Performance Test, Vanderbilt scales….
…But should not be used solely for diagnostic purposes
(most helpful with charting progress over time)
Any
Questions?
References
1. Theories of Development, William Crain.
2. Childhood and Society, Erik H. Erikson.
3. Textbook of Child and Adolescent
Psychiatry, Dulcan and Wiener.
Recommended Reading
1. Theories of Development, William Crain.
2. Between Parent and Child, Ginott.