Download Child and Adolescent Psychiatry Overview

Child and Adolescent Psychiatry
Overview
Dr. Mahmoud Bashtawi , M.D.
Child & Adolescent Psychiatrist
Division of Psychiatry -JUST
Introduction
• Child psychiatric assessment requires attention to details of
a child's development stages, family structure and
dynamics, as well as normative age-appropriate behavior.
• Consulting with parents and obtaining reports from
schools, teachers, and other involved parties are essential
for proper assessment.
• Psychiatric assessment is not easily in children as they are
in adults because children, especially, young express
emotion in a less abstract way than adults. So interviews
require more concrete queries.
• Children have more comorbid psychiatric disorders than
adults, making diagnosis and treatment more complicated.
Common Child and Adolescent Psychiatric
Disorders
• Mental Retardation (Intellectual disability)
• Learning Disorders
• Autism Spectrum Disorder(ASD) once called
Pervasive Developmental Disorders(PVD)
• Attention-Deficit and Disruptive Behavior
Disorders
• Other Child and Adolescent Psychiatric
Disorders
Intellectual disability(ID)
• (ID), once called mental retardation, is characterized by below
average intelligence or mental ability and a lack of skills necessary
for day to day living.
. People with intellectual disabilities can and do learn new skills, but
they learn them more slowly. There are varying degrees of
intellectual disability, from mild to profound.
• Someone with intellectual disability has limitations in two areas.
These areas are:
• Intellectual functioning. Also known as IQ, this refers to a person’s
ability to learn, reason, make decisions, and solve problems.
• Adaptive behaviors. These are skills necessary for day-today life, such as
being able to communicate effectively, interact with others, and
take care of oneself.
Mental Retardation(Intellectual disability)
• Characterized by subaverage (IQ below 70)
intellectual functioning (IQ below 70) and
concurrent deficits or impairments in adaptive
functioning.
• low IQ is not sufficient evidence of mental
retardation. Necessary, but not sufficient.
• Onset before age 18.
Mental Retardation(MR)
Degrees of Retardation
• Mild (IQ 50-55 to 70): By family support and special education
the children can usually learn to read, write and to hold some
type of job in the community.
• Moderate (IQ 35 to 50): With training, the children can learn
to talk, to recognize their name and a few simple words, and
to perform activities of daily living without assistance.
• Severe (IQ 20 to 35)
• Profound (IQ below 20-25)
Children with severe or profound mental retardation typically
require care in institutional settings.
Mental Retardation
• Etiology
• Mental retardation can be thought as a final common
pathway of a number of childhood or perinatal disorders.
• The most common cause of mental retardation is Down's
syndrome (trisomy 21).
• Fragile X syndrome is the most common cause of heritable
mental retardation.
• Pregnancy or perinatal problems(fetal malnutrition, hypoxia,
infections, and trauma)
• Medical conditions of infancy (infection or lead poisoning)
• Early alterations of embryonic development maternal
alcohol consumption can all cause mental retardation
Learning Disorders
• Learning disorders(LD) are characterized by performance in a
specific area of learning (e.g., reading, writing, arithmetic)
below the expectation of a child's chronologic age, formal
education, and level of intelligence.
LD diagnosis is confirmed through specific intelligence and
achievement testing.
• Physical factors like hearing or vision impairment must be
ruled out.
• The diagnosis of learning disorder is confirmed through
specific intelligence and achievement testing.
• LD diagnosis is made when the full clinical picture is not
explained by other comorbid conditions such as pervasive
developmental disorder, MR, and communication disorders.
PERVASIVE DEVELOPMENTAL DISORDERS
• Overview
1. Pervasive developmental disorders (Autistic disorder,
Asperger disorder, Rett disorder, Childhood disintegrative
disorder)are characterized by the failure to acquire or the
early loss of social skills and difficulties with language,
resulting in long term problems in social and occupational
functioning.
2. Treatment involves behavioral therapy to increase social
and communicative skills, decrease behavior problems (e.g.,
self-injury, aggressiveness ), and improve self-care skills, as
well as supportive therapy and counseling to parents.
PERVASIVE DEVELOPMENTAL DISORDERS
(PVD)
•
•
•
•
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Types:
Autistic disorder
Asperger's disorder
Rett's disorder
Childhood disintegrative disorder
Those types are also called autism spectrum
disorders (ASD)because of overlapping
aspects of their clinical manifestations.
ASD
-Autistic Disorder (a severe form of ASD), includes:
1. Significant problems with communication (despite normal
hearing)
2. Significant problems forming social relationships
3. Repetitive, purposeless behavior
4. Low IQ about 75% of autistic children
5. Unusual abilities in some children as exceptional memory
or calculation skills.
- Asperger's disorder(a mild form of ASD). In contrast to
autistic disorder, there is normal cognitive development and
little or no developmental language delay. However,
conversational language skills are impaired.
ASD
- Rett's syndrome
1. Children with Rett's syndrome appear normal for several
months after birth and then develop specific problems ;
(decrease in the rate of head growth between months 5 and
48,diminished social, verbal, and cognitive of normal
functioning, motor problems later in the illness)
2. Occurrence only in girls (Rett disorder is X-linked and
affected males die before birth)
3. Stereotyped, hand-wringing movements
4. Breathing problems
5. Mental retardation
-Childhood disintegrative disorder (diminished social, verbal,
cognitive, and motor development after at least 2 years of
normal functioning.
Attention Deficit Hyperactivity Disorder (ADHD) and
Disruptive Behavior Disorders of
Childhood
• Overview
• ADHD and the disruptive behavior disorders ( conduct
disorder and oppositional defiant disorder) are characterized
by disruptive behavior that causes problems in social
relationships and school performance.
• These disorders are not uncommon and are higher in boy
than girls.
• The differential diagnosis are mood disorders and anxiety
disorders.
• There is no obvious mental retardation (MR).
ADHD
• Characteristics:
• Persistent and dysfunctional pattern of hyperactivity,
impulsiveness, inattention, and distractibility.
• A child must evidence the onset of inattentive or hyperactive
symptoms before age 7. In DSM 5 before age 12.
• Features must be present in two or more settings (e.g.,
school, home).
• Symptoms in only one setting suggest an environmental or
psychodynamic cause, and it is important to distinguish ADHD
from normal, active behavior, or other psychiatric disorders
such as bipolar disorder.
ADHD
• Typically, children stay up late, wake up early, and spend most
of their times in various hyperactive and impulsive activities.
• They may run about the house and cause damage
• They have tendency for accidents.
• When they enter school, their difficulties with attention
become more obvious. They appear not to follow directions,
forget important school supplies, fail to complete homework
or tasks and attempt to blurt out answers to teachers before
their questions are completed .
• They fall behind their peers academically and socially.
ADHD
• Etiology
• The etiology of the disorder is unknown, but perinatal injury,
malnutrition, substance exposure, environmental toxins,
heredity and damage to brain structure and functions have all
been implicated.
• Management: combination of pharmacotherapy and
behavioral treatments.
• Prognosis:
Hyperactivity is the first symptom to disappear as the child
reaches adolescence and the most show remission by
adulthood.
Conduct Disorder (CD) and Oppositional Defiant
Disorder (ODD)
• Conduct disorder (CD)
• Persistent pattern of behavior in which the basic rights of
others ,norms or rules are violated. Behaviors include
aggression toward people or animals, destruction of
property, deceitfulness, theft, or serious violations of rules
(e.g., torturing animals, stealing, truancy, fire setting).
• Studies show a genetic predisposition and psychosocial
factors play a major role. Parental separation or divorce,
parental substance abuse, severely poor or inconsistent
parenting, and association with a delinquent peer group have
been shown to have some relationship to the development of
conduct disorder.
Conduct disorder (CD)
• CD can begin in childhood or adolescence.
• CD,ODD as well as ADHD are more likely to be abused by
caretakers.
• Risk for substance abuse, mood disorders and criminal
behavior; 40% go on to have adult antisocial personality
disorder.
• Treatment involves individual and family therapy. Medications
are used to treat behavioral problems and comorbid ADHD or
mood disorder.
• The long-term outcome depends on the severity of the
disorder and the degree and type of comorbidity.
Oppositional Defiant Disorder(ODD)
• ODD is diagnosed in a child with annoying, difficult, or
disruptive behavior when the frequency of the behavior
significantly exceeds that of other child`s particular culture.
• Behavior such as anger, argumentativeness, resentment and
history of excessive crying and resentment toward authority
figures.
• Behavior does not grossly violate social norms
• Gradual onset, usually before age 8.
• A significant number of cases progress to conduct disorder
• Most children show remission by adulthood
• Management emphasizes individual and family counseling.
Other disorders of childhood
• Tourette's Disorder TD
• Child demonstrates multiple involuntary motor and vocal tics.
• These behaviors can be controlled briefly.
• A tic is a sudden, rapid, recurrent and nonrhythmic motor
movement or vocalization.
• The disorder is lifelong, chronic, and begins before age 18.
• It usually starts with a motor tic (e.g., facial grimacing) that
appears between ages 7 and 8.
• While the manifestations are behavioral, the etiology of TD is
neurologic. It is believed to involve dysfunctional regulation
of dopamine in the caudate nucleus.
TD
• The disorder is a 3:1 male: female ratio and has a strong
genetic component.
• There is a genetic relationship between Tourette disorder and
both ADHD and Obsessive Compulsive Disorder.
• Atypical antipsychotic agents and typical agents are the most
effective treatments for Tourette disorder.
• In milder cases, medication such as clonidine also are helpful.
• The children and their family should receive education and
supportive psychotherapy aimed at minimizing the negative
social consequences (e.g., embarrassment, shame, isolation)
that occur with this disorder.
Separation anxiety disorder
• The child refuses to go to school.
• Characterized by an overwhelming fear of loss of a major
attachment figure, particularly the mother.
• The child often complains of physical symptoms such as
stomach pain, vomiting or headache to avoid going to school
and leaving the mother.
• The most effective management of a child with this disorder is
to have the mother accompany the child to school and when
the child is more comfortable, gradually decrease her time
spent at school.
• They are at greater risk for anxiety disorders in adulthood.
Selective mutism
• Children with this disorder speak in some social situations
but not in others. The children may whisper or communicate
with hand gestures.
• Children with this disorder more commonly girls.
• Children usually have social anxiety disorder.
• Selective mutism must be distinguished from normal shyness.
• Management by pharmacotherapy and psychotherapy.
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