Download introduction to child psychiatry

Medical student lecture:
introduction to child psychiatry
Regina Bussing, MD, MSHS
Associate Professor and Chief
Division of Child and Adolescent
Psychiatry
LECTURE FOCUS
1.
2.
3.
4.
Child Development
Evaluation Strategies
Treatment Modalities
Childhood Disorders
MAJOR DEVELOPMENTAL
STAGES
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Prenatal/Birth
Infancy (Birth –18 months) Trust - form
attachment/bond
Toddler (1.5 - 3 years) Autonomy walk/talk/tolerate separation
Early childhood (3-5 years) Initiative - build
vocabulary, build superego
Middle childhood (6-12 years) Industry - build
peer-relations and competencies
Adolescence (12-adult) Identity
MILESTONES:
Developmental Markers*
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Sitting
Walking
Talking
Toilet Training
Rides Tricycle
Dresses Self
Draws a person (main parts)
Rides Bicycle
6 months
1 year
1 year
2 years +
3 years
5 years
5 years
6 years
* Normal variation is present; Denver II-R
REASONS TO LEARN ABOUT
NORMAL DEVELOPMENT
• To identify and be supportive of age-appropriate
emotional expressions (e.g. expressions of
autonomy; stranger anxiety) - these are healthy.
• To better identify what is really abnormal so
treatment is focused on psychopathology - e.g.,
adolescent suicide attempts, drug use.
• To better understand adult psychopathology.
• To better understand common patterns of
regression (a return to earlier developmental
behaviors) that may occur with illness or stress.
CONCEPT OF REGRESSION
STRESS ----> Return to earlier developmental stage
EXAMPLES:
• A 7yr old child with previous normal development
now hospitalized with leukemia begins bedwetting,
thumb sucking, and using “baby talk”.
• A 42 year old previously healthy male becomes
totally dependent on his wife for ADLs following a
mild heart attack.
EVALUATION STRATEGIES
Patient Interview
Collateral Information
(Parents, School)
Observation
Testing
(IQ, Education, Projective,
Personality, Neuropsych,
labs, EEG, MRI)
SHIFTING FOCUS
OF ASSESSMENT
• Infants and toddlers: History; observation
– gross and fine motor functions
– language and communication
– social behavior
– bonding
• Usual Concerns:
– delayed development (e.g., MR),
– abnormal development (e.g., PDD)
– poor bonding (e.g., neglect, abuse)
SHIFTING FOCUS
ShiftingOF
Focus
of Assessment
ASSESSMENT
• Preschoolers: Observation, personal
interview, parent interview
– observe milestones
– assess what child talks and thinks about (e.g.
through play)
– Parent-child relation
• Possible concerns: as before, plus
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speech-language delays,
hyperactivity,
aggressive/defiant behaviors,
excessive anxiety,
toilet training
SHIFTING FOCUS
ShiftingOF
Focus
of Assessment
ASSESSMENT
• School-age child: Observation, interviews,
reports from school
– how does child function in family?
– how does child function in school?
(behavior and academics)
– what kind of peer relations?
– formal psychological and academic testing
• Common concerns:
– learning problems
– externalizing conditions
– separation anxiety
IMPROVING THE ODDS FOR
SUCCESSFUL
DEVELOPMENTAL OUTCOMES
PROTECTIVE FACTORS
•Good parent-child relationship
•Easy, outgoing temperament
•Positive peer influence
•Successful school experiences
•Caring adult role models
•Participation in pro-social groups
• Access to needed services, e.g.
healthcare, mental health, crisis
intervention
TREATMENT MODALITIES*
*(Usually 2 or more modalities are used simultaneously)
• Individual Therapies (play, behavioral, cognitive, supportive,
dynamic)
• Family Therapy & Parent Training
• Group Therapy - especially important for adolescents
• Examples of Pharmacotherapy:
ADHD
Stimulants (e.g., Ritalin)
MDD & Anxiety
SSRIs (e.g., Prozac, Zoloft)
Bipolar Disorders
Valproate, Lithium
Enuresis
DDAVP, TCAs (IMI)
Psychosis
Antipsychotics
CHILD ABUSE
1-800-96ABUSE
"Abuse" means any willful act or threatened act that results in any
physical, mental, or sexual injury or harm that causes or is likely to
cause the child's physical, mental, or emotional health to be
significantly impaired. Abuse of a child includes acts or omissions.
Corporal discipline of a child by a parent or legal custodian for
disciplinary purposes does not in itself constitute abuse when it
does not result in harm to the child. [Subsection 39.01 (2), F.S.]
The Florida Abuse Hotline will accept a report when:
1.
2.
3.
4.
There is reasonable cause to suspect that a child (less than
18 years old)
who can be located in Florida, or is temporarily out of the
state but expected to return in the immediate future,
has been harmed or is believed to be threatened with harm
from a person responsible for the care of the child.
Know state reporting laws and procedures
(http://www5.myflorida.com/cf_web/myflorida2/healthhuman/childabuse/)
DISORDERS OF CHILDHOOD
AND ADOLESCENCE
• Basically all adult Axis I disorders can occur in
children and adolescents (Depression, Bipolar,
Schizophrenia, Anxiety, etc.).
• Personality Disorders (Axis II) are usually not
diagnosed (and ASPD can’t be), although
personality traits are often identified.
• Specific disorders with childhood onset are listed
separately in DSM-IV (ADHD, Conduct Disorder,
Learning Disorders, MR, etc). These may persist
into adulthood.
• Comorbidity is common.
• Epidemiology: 1 in 5 children involved
MENTAL RETARDATION
Diagnostic Criteria
• IQ 70 or less on an individually administered IQ test
• Onset before age 18 years
• Concurrent deficits or impairments in adaptive
functioning in at least two of these areas:
communication, self care, home living, social and interpersonal skills, use
of community resources, self direction, functional academic skills,
work, leisure, health, or safety.
• Epidemiology: 1-3% in US
• Causes:
– Unknown (50% of mild MR)
– Known (75% of severe MR) – Hereditary (Down’s, fragile X;
PKU);Toxins; Birth Trauma; Infection.
MILD MR:
IQ 50/55 to 70 (~ 85%)
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School: may acquire skills up to 6th grade level.
Social and Communication Skills: develop spontaneously.
May first be detected in school.
May acquire vocational skills and be self-supportive.
MODERATE MR:
IQ 35/40 to 50/55 (~ 10%)
•Social and Communication Skills: develop, but impaired.
•Early detection (i.e., before entering school).
•School: unlikely to progress past 2nd grade level.
•May work under close supervision (sheltered workshop).
SEVERE MR:
IQ 20/25 to 35/40 (~ 3%)
• School: May learn to sight-read (survival
words)
• Social/Communication Skills: little or no
communicative speech. Often display
poor motor development.
• May acquire elementary hygiene skills
and perform simple tasks; unable to
benefit from vocational training
PROFOUND MR:
IQ Below 20/25 (~ 1-2%)
•Social and Communication Skills: rarely have communicative
speech efforts; minimal sensorimotor abilities.
•Require constant aid and supervision; nursing care.
TREATMENT CONSIDERATIONS
Family is coping with loss of “ideal” child
Grief and loss issues.
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Appropriate placement essential:
- School setting, day care, group homes,
sheltered workshop and respite care.
Specific problems may be responsive to medications
- Seizures; depression; hyperactivity; aggression.
May experience “independent” psychiatric disorders,
including schizophrenia, bipolar disorder, etc.
Pervasive Developmental Disorder
Developmental disorders with severe and pervasive
impairment in essential developmental areas
• Reciprocal social skills
• Language development
• Range of behavioral repertoire
DSM-IV includes the following under PDD:
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5.
Autism
Rett’s Disorder
Childhood Integrative Disorder
Asperger’s Disorder
PDD, not otherwise specified
Autism
Autism
• Prevalence estimates: variable and increasing
• Boys are effected 3 to 5 times more than girls
• 50 to 70% have some degree of MR
• Associated with Congenital Rubella, PKU,
Tuberous Sclerosis and Fragile X Syndrome
• 20 to 25% have grand-mal seizures and about
50% have non-specific EEG abnormalities
• MRI, EEG, Karyotyping indicated in almost all
cases
INTERVENTIONS IN AUTISM:
Presently no curative treatment available;
symptomatic interventions focus.
Mainstay: Early intervention; speech and language
services; structured behavioral and educational
programs; OT, PT.
Medications: To control seizures, hyperactivity,
severe aggression, SIB, repetitive behaviors or mood
disorders.
CARD PROGRAM: http://card.ufl.edu
Retts Disorder
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Normal growth for the first few months of life
Deceleration of head growth between 5-48 months
Truncal incoordination
Lack of purposeful hand movements; flapping
Disorder of females
Similar criteria as PDD
Over 80 percent of patients diagnosed with Rett's have a
specific mutation in the MeCP2 gene on the X chromosome.
This mutation is not inherited, but occurs after conception.
http://dukemednews.duke.edu/news/article.ph
p?id=5085
“I Have the Courage “
I cannot speak,
but you understand me.
I cannot walk, so you push me.
I cannot sing, but I love music.
I cannot crawl, so you carry me.
I cannot tell jokes, but I love to laugh.
I cannot wash myself, so you bathe me.
I cannot play with Barbies,
but I can push a switch.
I cannot wave bye-bye,
so you do that for me.
I cannot dress myself,
so you make me pretty.
I cannot read, so you tell me stories.
I cannot touch, but I can feel.
I cannot go up the stairs,
so you put me on the lift.
I cannot tell you how much I love you,
so look into my eyes and you will
see.
I cannot tell what the future will hold,
but I have the courage to go on
Childhood Disintegrative Disorder
• Normal Development for at least two years of life.
• Clinically significant loss of previously acquired
skills prior to age 10 years in two or more of the
following areas:
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Language
Social Skills Or adoptive behavior
Bowel or bladder control
Play
Motor skills
• Abnormal functioning in at least two areas:
– Social interaction; communication; patterns of
behaviors/interests
Asperger’s Disorder
• “High functioning autism”
• Impaired use of non-verbal communication (gaze, posture,
gestures regulating social interaction)
• Lack of interactive play, impaired peer relations
• Stereotypic, repetitive mannerisms
• No delays in language and cognitive development
PDD NOS
Diagnosis assigned when there is a severe and pervasive
impairment in the development of reciprocal social interaction,
or communication skills, or when stereotyped behaviors and
activities are present but the criteria are not met for a specific
pervasive developmental disorder.
LEARNING, MOTOR SKILLS, &
COMMUNICATION DISORDERS
• Measured achievement in a specific (academic, motor,
speech) area is substantially below that expected based on
the age/IQ of the individual. This differs from MR where
the deficits are global in nature.
• Types:
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Reading Disorder
Mathematics Disorder
Disorder of Written Expression
Developmental Coordination Disorder
Expressive Language Disorder
Mixed Receptive-Expressive Language Disorder
Phonological Disorder
Stuttering
ELIMINATION DISORDERS
• Encopresis (incontinence of feces)
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Repeated passage of feces into inappropriate places
Age at least 4 years
Frequency at least 1x per month x 3 months
Not due to laxatives or medical problem
Specify: with or without overflow incontinence and constipation
• Enuresis (incontinence of urine)
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Repeated voiding into bed or clothes
Age at least 5 years
Frequency 2x per week x 3 months
Not due to medical problem
Specify: nocturnal, diurnal, or both
More common in males
ADHD
• Persistent pattern of inattention and/or
hyperactivity more frequent and severe than
is typical of children at a similar level of
development.
• Onset before age 7
• Impairment in at least two settings:
social, academic, or work
• Duration at least six months
• Inattention, Hyperactivity, Impulsivity
ADHD Continued
Epidemiology
Incidence: 2 to 20% of grade-school children
Boys > Girls; Ratio 3-5:1
Family members (siblings and parents) of affected children
are at higher risk
Etiology
Specific etiology unknown; contributory factors
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Genetics
Pre and perinatal complications
Neurological
Environmental toxins
ADHD Continued
Types
1.
Predominantly Inattentive type
2.
Predominantly Hyperactive type
3.
Combined type
Treatment
Pharmacotherapy
Stimulants: Methylphenidate, Dextroamphetamine, (Pemoline)
Non-Stimulants: Atomoxetine (Strattera); Clonidine and Guanfacine;
Bupropion; TCAs; (atypical antipsychotics for treatment unresponsive
cases)
Psychotherapy
Behavioral modifications; environmental structuring; parental Education and
training; social skills training
Tic Disorders
Tics are sudden, rapid, recurrent, nonrhythmic,
stereotyped motor movements or vocalizations
DSM-IV Diagnoses:
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Tourette’s Syndrome
Chronic Motor Tic Disorder
Chronic Vocal Tic Disorder
Transient Tic Disorder
Tic Disorder NOS
Oppositional Defiant Disorder
• Recurrent pattern of negativistic, defiant,
disobedient & hostile behavior towards authority
figures
• Duration > 6 Months
• Impairment in social, academic and work settings
• Symptoms not part of the mood or thought
disorder
• Treatment: Parent training (PCIT)
Individual psychotherapy
Family Therapy
Conduct Disorder
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Aggression to people and animals
Destruction of property
Deceitfulness or theft
Serious violation of rules
Treatment: Multimodality treatment programs
Environmental structuring
Family Therapy
Group Therapy
Ind. Therapy – problem solving skills
Medications as adjuncts
ANXIETY DISORDERS
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Common in childhood: 15%
Comorbidity is common
All adult anxiety disorders may be seen in children.
PTSD - may be a result of abuse
Separation Anxiety Disorder
– Developmentally inappropriate and excessive anxiety about
separation from caretakers or home, of at least 4 weeks duration
with onset before 18 years
– Can lead to school refusal (school phobia)
– Associated with physical complaints, fear of sleeping alone,
worries about parent’s safety
Mood Disorders
• Childhood Depression
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irritability
sleep cycle disturbance
oppositional behavior
social isolation
crying spells
• Dysthymia
– symptoms at least 1 year
Adolescents and Suicide
• In 1998, 4,153 young people, ages
15-24, committed suicide in the United States
an average of 11.3 per day.1
• Suicide is the third leading cause of death in
this age group following unintentional injury
and homicide2
• Suicide accounts for 13.5% of all deaths in
this age-group1
1 Murphy,
SL, 1998 2 The Surgeon General’s Call to Action to Prevent Suicide, 1999
Suicide-Related Fatalities
by Cause
1400
1200
1000
800
600
400
200
0
1211
393 320
34
41
47
49
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Suicide Prevention
• Don’t dismiss suicidal ideation,
severe depression, runaway,
significant substance abuse, etc.
as just “normal” for age.
• Educate families to control
access to potentially lethal
methods of self-harm (Guns;
OTC).
• Provide crisis hotline information.
GAINESVILLE
24 hours / 7 days
(352) 264-6789