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CHILD AND ADOLESCENT
PSYCHIATRY
Child Psychiatry: List of disorders
(International Classification of Diseases)
F80-F89:Disorders of
Psychological Development
F90-98: Behavioural and
Emotional Disorders with
Onset Usually Occurring in
Childhood and Adolescence
F 20, 30, 50: Mental disorders with
childhood onset
F 70-79: Mental retardation
Child x adult psychiatry
• Age - developmental stages and milestones (smile 4-10
weeks, first words 12 months)
• Influence of family and environment („normality“,
development, hyperprotective x abusing parents)
• Secondary symptoms (ADHD – neurotization) X
impaired development and  prognosis (SCH)
• Children are less able to express themselves in words nonverbal behavior, objective reports (parents, school)
• Pharmacotherapy – different pharmacokinetics and
pharmacodynamics
• Treatment - family psychotherapy, special education,
training of social skills
Pervasive Developmental
Disorders
• Complex neuropsychiatric disorders – impaired global development
– behavior, basic functions including socialization and
communication
• Lack of normal development or loss of acquired skills
• 6-60/10 000
• more common in boys than in girls
• Prognosis :
M:F 4:1
1-2 % „normal“ life - high functioning autism (Asp.sy)
5-20 % varying degree of independence
70 % need support - unable to lead independent life
• IQ level may be normal
Childhood Autism
Clinical features - onset before age 3 :
• Disturbed social interaction (response to emotion, reciprocal
emotional and social interactions, poor eye contact, impaired
non verbal beh., no peer relationship, lack of empathy,
attachement to unusual objects,…)
• Disturbed speech development and communication (lack of
spoken language, difficulties in communication, no fantasy,
symbolic or social play,…)
• Stereotyped behaviour, activities, interests - restricted,
repetitive or (non functional routine or rituals, resistence to
change, steretypies and mannerism, interest in parts of
objects, stereotyped movements, …)
• Savants – isolated abillities
IQ < or normal
Pervasive Developmental Disorders
X linked, F only
Rett's Syndrome
Normal early development, btw 6 and 24 months – partial or complete loss of speech
and motor skills (hand movements), with deceleration in head growth
Typical loss of hand movement, hand-wringing stereotypies, abnormal movements,
loss of language, seizures, hyperventilation
Result: Severe mental retardation
Motor functioning is more affected in middle childhood, muscles are hypotonic,
kyphoscoliosis and rigid spasticity in the lower limbs occurs in majority of cases
Aggressive behaviour and self injury are rare, the antipsychotic drugs for the control
of challenging behaviour are not often needed.
Asperger's Syndrome
• stereotyped interests and behaviour, marked motor clumsiness
• ! no delay of speech and cognitive development, prognosis is better
• Later onset and diagnosis, in later life lften mis-diagnosed with atyp. sch,
personality disorder
IQ normal or >
Autism: etiology
• Genetic factorsReelin
– polygennic
disorderproteins
and neurolignin:
important
for synapses
holding together
• Concordance
of MZ twins:
40-96 %
–autism:
after synaptic
DZ twins:
0-30 % connection there
is no firm holding of synapses; they
• Family studies
– risk less
for siblings
50-100x
higher
become
tight – autistic
regression
than in general population – recurrence in cca 5 %
siblings
Mol. genetic studies – linkage study chr. 7, FRAXA
Asociation studies – reelin and neurolignin – neuronal
migration, cortex layers development,
synaptogenesis
Environmental influences
Lancet formally retracts paper linking vaccine to
autism.
ABC World News (2/2, story 7, 0:30, Sawyer) reported
that "one of the world's most respected medical
journals," The Lancet, is "formally retracting an article
that...sparked a fierce debate." The "1998 study...linked
the vaccine for mumps, measles and rubella to autism,"
which "led to a drop in vaccinations and a jump in
measles cases," the CBS Evening News (2/2, story 9,
0:30, Couric) reported. But, "25 studies in all have
found no link between the vaccine and autism."
• Perinatal complications
• Toxic: thalidomid, valproate, alcohol in
pregnancy
• Autoimune: AI diseases in family (DM I,
revmat. arthritis, SLE)
• Infectious: Rubella inborne –7% children
suffer from autism
• Vaccination against rubella-mumpsmeasles is not risk factor for autism
Neuroanatomical abnormalities
Social deficit:
association of
reward with activity
• Smaller head size after delivery
• Sudden and quick growth in 1-2 m and in
6-14 m
• Quick brain growth - frontal lobes,
cerebellum, limbic structures
(hippocampus, amygdala) between 2-4
years, followed by abnormal slowing down
of growth
• Cytoarchitectonic abnormalities
http://whyfiles.org/209autism/4.html
Treatment
• No causal tr.  symptoms – agressive
beh., depression, stereotypies, self-harm
• Speciální education, day care
syndrome
medication
Rituals, obsessions
SSRI
Hyperkinetic sy/ impulzivity
AP, stimulants
agressivity
AP, Li
self-harm
SSRI, AP, Li
depression
SSRI
anxiety
SSRI, buspiron
Disorders of Psychological Development
Specific developmental disorder of
scholastic skills
Specific and significant impairment in learning of scholastic
skills
Not the direct result of subnormal intelligence, visual or
hearing defects, physical disorders, emotional
disturbances or lack of adequate opportunities for
learning.
Performance in school bellow that expected for IQ, from the
beginning of school
Specific reading dis. – DYSLEXIA
Specific spelling dis.– DYSGRAFIE
Specific dis. disorder of arithmetical skills –
DYSKALCULIA
Mixed dis.
Specific Reading Disorder
dyslexia - dilsekse
Biological
disorder!
• Specific inability to read
Childood: difficulties in reciting ABCs,
reading is slow with missing words, poor
understanding of texts.
• Under-activation of left occipital-temporal
cortex
• Smaller brain volume in „reading area“ (left
occipital-temporal cortex
When people with dyslexia try to read, a front part of the brain is over-stimulated while crucial portions in the center and back are under-stimulated
The diagrams show stimulated during reading.
Specific Spelling Disorder
Specific Spelling Disorder
• Can read but not write
• Imaiped formation of words, grammar,
composition
• Mirror litters – b,d, m, n
• Difficulty keeping on the lines
Problem to use writing as a means of
communication!
8 year old boy – before
and after treatment
Drawing of a girl 10 years old
suffering from dysgraphia
Awkward and uncomfortable style
Slow rate of writing
Poorly formed/not easily read
letters
Writing is too large or small
Difficulty keeping within the
margins and on the lines
Behavioural and Emotional Disorders
Hyperkinetic Disorders
• Definition: Persistent pattern of inattention and/or
hyperactivity, developmentally inappropriate, 2 settings, 6
months - kindergarden, school
• Symptoms:
– Inattention short attention span, distractibility
(can not sustain attention, easily distracted, poor task completion,
does not listen, is forgetful,…)
– Impulsivity
– Hyperactivity (moving, running, climbing, interrupting,
unable to play quietly, talking too much,…)
mis-organised and excessive activities
 neurotisation, accidents, stress on interpersonal relations
Hyperkinetic Disorders
ADHD = Attention-Deficit Hyperactivity Disorder
Epidemiology: Prevalence – 5 % of elementaryschool children, 3 % of adults
M:F 3-4:1
Etiology: Polygenetic dis. – heritability 60-80 %
• dopamine transporter DAT - PET: overactivity of
DAT in 70 % adult ADHD cases
• dopamine receptor D4 DRD4
Pre- and perinatal factors - dopaminergic system
is sensitive to hypoxia! (mathernal smoking)
ADHD: Etiology
- genetic and perinatal factors
• Gens - dopamine transporter DAT - PET:
overactivity of DAT in 70 % adult ADHD cases
Dopamine receptor D4 DRD4
•
•
•
•
•
Prenatal
and perinatal
Fetal alcohol syndrome
(FAS)
dopaminergic system
Smoking during pregnancy
is sensitive to hypoxia!
Diabetes during pregnancy
Neonatal hyperbilirubinemia
Injury to medial temporal lobe
ADHD: Etiology
• Delay in right hemisphere CNS development
• „disorder of neurotransmission“
– deficit or
medication
delayed maturation
of NA and
DA systems in
↑ central dopaminergic
function:
prefrontalpsychostimulans
cortex and basal
ganglia
(methyfenidate)
dopamine
transporter
• Dopamine:inhibits
regulation
of learning,
motivation,
working memory, is responsible for „za holding
↑ noradrenergic function: atomoxetin
somethingInhibits
in head“
for
a
short
moment
noradrenaline reuptake
• Noradrenaline: regulation of vigility and
concentration
Hyperkinetic disorder in
adults
!! Hyperactivity/impulsivity tend to decrease
with age, sy of inattention persist
+ emotional dysregulation
 sy in adulthood: disorganisation,
procrastination, no plans, forgetfulness,
does not complete tasks, misjudging how
much it takes to completete tasks, difficulty
keeping jobs, unstable relationships, failure
to live up to potential (occupational)
Conduct Disorders
Child is showing repetitive and persistent pattern of behavior in
which the basic rights of others or major age-appropriate norms
are violated
aggressive behaviour to animals or other people
destructiveness to property
dishonesty or stealing
serious agressive violation of rules
ETIOLOGY: disharmonic family background, low social class
and SE level, antisocial beh. in parents, unemployment, alcohol
addiction, divorce…
EPIDEMIOLOGY:
5 – 10% children and adolescents, MF
Conduct Disorders
2 types of course:
good prognosis Socialized c.d. – peer acceptance ,
C.d. confined to the family context
bad prognosis Unsocialized c.d. – peer rejection,
Oppositional defiant disorder - persistently negativistic,
provocative and disruptive behaviour (precursor of
dissocial personality disorder - 25-40% of youths with
conduct disorder )
THERAPY:
interventions include family and social
surroundings (family th., group th. for family members,
CBT, Multisystemic Treatment)
safeguarding educational institutes.
Psychopharmacotherapy exeptionally
Emotional Disorders with Onset
Specific to Childhood
-
anxiety symptoms
somatic presentation
F>> M
Hyperprotective parents
good prognosis
Emotional Disorders in Childhood
Separation anxiety disorder of childhood
- Anxiety when being separated from emotionally important persons - parents,
family members – they are often overprotective
between 5 and 11 years
Somatic symptoms – headache, abdominal pain, vomiting, crying, anger
School refusal - often a symptom of separation anxiety disorder
Phobic anxiety disorder of childhood
-
Fear of animals, insects, dark, strangers...
Social anxiety disorder of childhood
Sibling rivalry disorder
Course and prognosis:
FM, parents often hyperprotective or divorced, onset around 5-6 y, in
separation a.d. around 11 y, most cases do not develop into anxiety disorders
in adulthood
Treatment:
Family therapy, individual psychotherapy, CBT
Tic Disorders
• TIC = involuntary, rapid, recurrent, nonrhythmic motor
movement (usually involving circumscribed muscle groups)
or vocal production that is of sudden onset and that serves
no apparent purpose
• Repetitiveness, disappearance during sleep, lack of
rhythmicity, and lack of purpose
• Irresistible, but can be suppressed for short time
• Exclusion criteria - neurological disorder
Tic Disorders
• Simple motor tics: eye-blinking, neck-jerking, shoulder-shrugging,
facial grimacing
• Simple vocal tics: throat clearing, barking, sniffing, hissing
• Complex motor tics: jumping and hopping
• Complex vocal tics: repetition of particular words or sentences, use
of socially unacceptable (obscene) words (coprolalia), repetition of
one's own sounds or words (palilalia)
Transient tic dsiorder
• Up to 12 months, age 4-6 y, blinking, grimacing. Long remissions,
one kind of tic may be replaced by another.
Chronic tic disorder
Treatment: AP, SSRI, psychotherapy
Tourett´s syndrome
• Simple and complex motor and vocal tics
• Vocal tics including obscene words, echopraxia,
coprolalia
• M more than F
• Pathogenesis: dopaminergic system dysbalance
in basal ganglia
• Aetiology: inflammatory triggered imunity
response (poststreptoccoc?)
• Terapie: Atypická antipsychotika, rTMS, hluboká
mozková stimulace
http://www.youtube.com/watch?v=HPmpIY7XJVE
http://www.youtube.com/watch?v=H5oHz_melCY&feature=related
Depression
1 % of prepubertal kids
- no happiness, sadness, introversion, masked depression absences from school
Sy in preschoolers
Sy in school age kids Sy in adolescents
Lack of curiosity
Regression
Somatisation
Social isolation
Apathy/hyperactivity
Affective irritability
Nesoustředěnost
Bad school
performance
Somatisation
Emotional lability
Agitation/ aggresion
Social maladaptation
Mood changes
Anhedonia
/hopelessness
Agitation/ aggresion
Hypersomnia
Drug use
Suicide rare F=M, parasuicide common F>M
Th – antidepresants
SCHIZOPHRENIA
• Rare
• 5% of SZ starts before 15 y (typical 2 1/2 –
4 a 11-16). Genetic predisposition
• Hallucinations with ¨“kids“ content,
dellusions, thought disorder, catatonia
• Acute onset or prodromes of
developmental delay
• Later onset -> better prognosis (disturbed
development)
TH: Antipsychotics
Mental Retardation
• Complex impairment of cognitive
functioning with disturbed development of
personality since the beginning of mental
development (2-4 y)
• Abstract thinking, judgement, attention,
motivation, speech, behavior, emotions a
motor function
• 1-3 % of population
IV: MENTAL RETARDATION
•
•
•
•
Mild: IQ 50-70
Moderate: IQ 35-50
Severe: IQ 20-35
Profound: IQ under 20
Genetic predisposition
85 % of MR is in mild category
MR: causes
• known
– Genetic factors
Chromosomal aberrations
•
•
•
•
Down syndrome
Fragil X Syndrome
Prader-Willi Syndrome
Rett’s Disorder
Metabolické vady
• Phenylketonuria
– Prenatal factors
• FAS
• AIDS, Rubella, Herpes
Simplex, complicated
pregnancy (diabetes)
• Fetální alkoholový syndrom
– Perinatal impairment
• hypoxia, hemorrhagia
• unknown (idiopathic)
– 45-62% cases of mild MR
– 25-40% cases of severe MR
Mild mental retardation
IQ 50-69
• Oligofrenia
• Delayed speech
• Able to care about themselves and maintain
hygiene
• Concrete thinking
• Educable – special schools
• Comorbidity: hyperactivity, conduct disorders,
epileptic seisures, impaired speech
• Manual employment
Moderate mental retardation
IQ 35-49
• Imbecility
• Limitid communication, selfcare, skills
• Life-long support
• Partly edukable – basics of reading, writing,
counting
• Manual employment under supervision
• Often organic impairment, neurological and
somatic impairments
Severe mental retardation
• Q 20-34
• Disturbancies in motoric function – organic
impairment of CNS
• Not educable
• Trainable – basic skills
Profound mental retardation
IQ under 20
• Idiocy
• May understand basic directions
• Prominent impairment of motoric function,
incontinence, rudimentary non-verbal
communication
• Continuus surveillance and care
• Neurological and somatic impairments
MR - comorbidity
• Epilepsy
• Conduct disorder – aggresivity,
hyperactivity, impulsivity, self injurious and
self harming beh.
• Stereotyped movements, pica, rumination,
excessive masturbation
• Schizophrenia (bizzar behavior, decline in
mental abilities, susp. hallucinations)
MR in families a society
• To develop intellectual and functional skills to
the maximum possible level
• Family burden, stigmatisation
• Home X institutional care – emotional and
stimulus deprivation
• Day care, sheltered employment, school
integration, counseling, basic skills, such as
bathing and feeding themselves, training in
independent living and job skills.
• legal capacity restriction - curator
• Prevention !!!
MR - treatment
• Nootropics – in postinfectious or
posttraumatic psychosyndromes
• Neuroleptics – aggressivity, self harming
beh., stereotypies, excessive sexual
activity. ! Apathy, sedation, obezity, tardive
dyskinesis
• Antiepileptics – aggressivity, + Li, SSRI ?