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PSYCHIATRIC DISORDERS IN CHILDREN ATTENTION-DEFICIT / HYPERACTIVITY DISORDER • Most common mental disorder in children • Estimates of 3-5% of preschool and school-age children have ADHD (2 mil. in USA)(NIMH) • 1 in a class of 25-30 • Begins in preschool and elementary school • Often lasts into adulthood: 30-70% of children with ADHD will continue to have symptoms as adults • Boys diagnosed 3x girls--probably because boys more hyperactive and disruptive AACAP, 2009 NORMAL BEHAVIOR Vs. ADHD • Lasts more than six months • Occurs in more than just one setting (typically at home and at school) • Regularly disrupts school, play, and other daily activities • Causes problems in relationships with adults and other children • Consider age and cognitive development ADHD: INATTENTION SYMPTOMS Fails to pay close attention to details or makes careless mistakes in schoolwork or other activities Trouble sustaining attention during tasks or play Seems not to listen even when spoken to directly Difficulty following through on instructions and often fails to finish schoolwork, chores or other tasks Has problems organizing tasks or activities Avoids or dislikes tasks that require sustained mental effort, such as schoolwork or homework Frequently loses needed items, such as books, pencils, toys or tools Easily distracted Often forgetful ADHD: Hyperactivity symptoms Fidgets or squirms frequently Often leaves his or her seat in the classroom or in other situations when remaining seated is expected Often runs or climbs excessively when it's not appropriate or, if an adolescent, might constantly feel restless Frequently has difficulty playing quietly Always seems on the go Talks excessively Blurts out the answers before questions have been completely asked Frequently has difficulty waiting for his or her turn Often interrupts or intrudes on others' conversations or games ADHD: Girls vs. boys • Boys are more likely to be hyperactive, whereas girls tend to be inattentive. • Girls who have trouble paying attention often daydream, but inattentive boys are more likely to play or fiddle aimlessly. • Boys tend to be less compliant with teachers and other adults, so their behavior is often more conspicuous. ADHD: treatment Without treatment children fall behind in school, have social problems, higher rates of: substance abuse, conduct disorder, accidents, divorce, job loss. Combination of behavioral and medication therapy. Behavior therapy: point systems or charts to reward good behavior, “time out,” family time and positive attention. Individual therapy: examine upsetting thoughts or feelings, learn alternative ways of handling emotions, change or better cope with ADHD symptoms-- organizing schoolwork or dealing with emotional experiences. Social skills training: model social skills--waiting for a turn, sharing toys, or asking for help, reading others’ facial expression or tone; Structured play dates. Medications: Stimulant and non-stimulant meds. Oppositional Defiant Disorder • Occasional oppositionality is common especially when hungry, tired, or stressed—especially age 2-3 and early adolescence. • ODD is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with a child’s day to day functioning. ODD: symptoms Frequent temper tantrums Excessive arguing with adults Often questioning rules Active defiance and refusal to comply with adult requests and rules Deliberate attempts to annoy or upset people Blaming others for his or her mistakes or misbehavior Often being touchy or easily annoyed by others Frequent anger and resentment Mean and hateful talk when upset Spiteful attitude and revenge seeking ODD: frequency & causes Multiple settings—home, school, after-school activities 1-16 % of all school-age children and adolescents have ODD No clear causes, but some factors are: The child's inherent temperament The family's response to the child's temperament A genetic component that when coupled with certain environmental conditions — such as lack of supervision, poor quality child care or family instability — increases the risk of ODD A biochemical or neurological factor The child's perception that he or she isn't getting enough of the parent's time and attention Mayo Clinic, 2007 ODD: risk factors A parent with a mood or substance abuse disorder Being abused or neglected Harsh or inconsistent discipline Lack of supervision Poor relationship with one or both parents Family instability such as occurs with divorce, multiple moves, or changing schools or child care providers frequently Financial problems in the family Exposure to violence Substance abuse in the child or adolescent Parents with a history of ADHD, oppositional defiant disorder or conduct problems Mayo Clinic, 2007 ODD: treatment Parent Management Training Programs to help parents and others manage the child’s behavior. Individual Psychotherapy to develop more effective anger management. Family Psychotherapy to improve communication and mutual understanding. Cognitive Problem-Solving Skills Training Therapies to assist with problem solving and decrease negativity. Social Skills Training to increase flexibility and improve social skills and frustration tolerance with peers. Medication for ADHD, anxiety, mood disorders AACAP Depression Sadness over loss, disappointments, or stress is normal Depression is an illness when the feelings of depression persist and interfere with a child or adolescent’s ability to function. About 5 percent of children and adolescents in the general population suffer from depression at any given point in time. Children under stress, who experience loss, or who have attentional, learning, conduct or anxiety disorders are at a higher risk for depression. Depression also tends to run in families. Depression: symptoms Frequent sadness, tearfulness, crying Decreased interest in activities; or inability to enjoy previously favorite activities Hopelessness Persistent boredom; low energy Social isolation, poor communication Low self esteem and guilt Extreme sensitivity to rejection or failure Increased irritability, anger, or hostility Difficulty with relationships Frequent complaints of physical illnesses such as headaches and stomachaches Frequent absences from school or poor performance in school Poor concentration A major change in eating and/or sleeping patterns Talk of or efforts to run away from home Thoughts or expressions destructive behavior of suicide or self Depression: treatment Individual Therapy • Cognitive Behavior Therapy (CBT): changing unhealthy patterns of thinking. The therapist then helps the child replace this thinking with thoughts that result in better feelings and behaviors. • Interpersonal Therapy (IPT) helps improve mood by improving interpersonal relationships. Family Therapy focuses on helping the family function in more positive and constructive ways by looking at patterns of communication and providing support and education. Group Therapy Medications Antidepressants, mood stabilizers Bipolar Disorder Manic +/- depressive symptoms. Some may have mostly depression and others a combination of manic and depressive symptoms. Highs may alternate with lows. Bipolar disorder can begin in childhood and during the teenage years, although it is usually diagnosed in adult life. The illness can affect anyone. However, if one or both parents have Bipolar Disorder, the chances are greater that their children may develop the disorder. Family history of drug or alcohol abuse also may be associated with greater risk for Bipolar Disorder. Bipolar disorder: symptoms • Severe changes in mood-either unusually happy or silly, or very irritable, angry, agitated, or aggressive • Unrealistic highs in self-esteem – e.g., a teenager who feels all powerful or like a superhero with special powers • Great increase in energy and the ability to go with little or no sleep for days without feeling tired • Increase in talking - the adolescent talks too much, too fast, changes topics too quickly, and cannot be interrupted • Distractibility - the teen's attention moves constantly from one thing to the next • Repeated high risk-taking behavior; such as, abusing alcohol and drugs, reckless driving, or sexual promiscuity • Overlaps with symptoms of: drug abuse, delinquency, ADHD, or even schizophrenia. Bipolar Disorder: treatment • Education of the patient and the family about the illness • Psychotherapy helps the child understand himself or herself, adapt to stresses, rebuild self-esteem and improve relationships. • Medications: Mood stabilizing medications such as lithium, valproic acid, or “atypical antipsychotic”, and psychotherapy. Mood stabilizing medications often reduce the number and severity of manic episodes, and also help to prevent depression. ANXIETY DISORDERS Separation anxiety • Constant thoughts and intense fears about the safety of parents and caretakers • Refusing to go to school • Frequent stomachaches and other physical complaints • Extreme worries about sleeping away from home • Being overly clingy • Panic or tantrums at times of separation from parents • Trouble sleeping or nightmares Phobias • Extreme fear about a specific thing or situation (ex. dogs, insects, or needles) • Fears cause significant distress and interfere with usual activities Social anxiety • Fears of meeting or talking to people • Avoidance of social situations • Few friends outside the family Obsessive-compulsive disorder • Obsessions: undesirable, unpleasant, intrusive thoughts, images, or impulses that reoccur uncontrollably; over and over again and feel out of your control. Contamination, illness, harm, sexual ideas, order. • Compulsions: acts performed repeatedly (often according to "rules”) to reduce anxiety of obsessions; not pleasurable. Hand washing, checking locks, excessive & useless orderlines. PTSD • Children usually quite resilient and recover from stressful events • Catastrophic, life-threatening, or repeated trauma may lead to PTSD in vulnerable individuals • Initially show agitated or confused behavior; intense fear, helplessness, anger, sadness, horror or denial. • Repeated trauma may produce emotional numbing that deaden or block the pain and trauma: dissociation. • May become less responsive emotionally, depressed, withdrawn, and more detached from their feelings • Avoid situations or places that remind them of the trauma. • Symptoms last months to years AACAP, 1999 PTSD: symptoms • Frequent memories of the event, or in young children, play in which some or all of the trauma is repeated • Upsetting and frightening dreams • Acting or feeling like the experience is happening again • Repeated physical or emotional symptoms when the child is reminded of the event Other symptoms of anxious children • Many worries about things before they happen • Constant worries or concerns about family, school, friends, or activities • Repetitive, unwanted thoughts (obsessions) or actions (compulsions) • Fears of embarrassment or making mistakes • Low self esteem and lack of self-confidence Anxiety disorders: treatment • Cognitive Behavioral Therapy (CBT) • Exposure and response prevention (ERP) • Medications: antidepressants (SSRIs), antianxiety meds Schizophrenia • A serious psychiatric illness that causes strange thinking, strange feelings, and unusual behavior. • Uncommon in children and is hard to recognize in its early phases. • Cause of schizophrenia is not known. Current research suggests a combination of brain changes, bio-chemical, genetic and environmental factors may be involved. • Early diagnosis and medical treatment are important. • Schizophrenia is a life-long disease that can be controlled but not cured. Schizophrenia: symptoms • Seeing things and hearing voices which are not real (hallucinations) • Odd and eccentric behavior, and/or speech • Unusual or bizarre thoughts and ideas • Confusing television and dreams from reality • Confused thinking • Extreme moodiness • Ideas that people are out to get them or talking about them (paranoia) • Severe anxiety and fearfulness • Difficulty relating to peers, and keeping friends • Withdrawn and increased isolation • Decline in personal hygiene Schizophrenia • The behavior of children with schizophrenia may change slowly over time. • Children who used to enjoy relationships with others may start to become more shy or withdrawn and seem to be in their own world. • Talking about strange fears and ideas. • Cling to parents or say things which do not make sense. • May first be noticed by the child's school teachers. Schizophrenia: treatment • Need a comprehensive treatment plan. • Combination of medication, individual therapy, family therapy, and specialized programs (school, activities, etc.) is often necessary. • Anti-psychotic medication can be helpful for many of the symptoms and problems identified. Alcohol and substance abuse • Use is common in teens: 50-80% have used some drug recreationally • For many this is short lived • For some leads it to abuse (maladaptive pattern of use) or dependence (physiological tolerance and withdrawal) • Average age of first marijuana use is 14 (26% HS seniors have used) • Alcohol use can start before age 12 (88% seniors have used) • Annually, 10,000 young people in the United States are killed and 40,000 injured in alcohol-related automobile accidents. AACAP 2009 Substance abuse: risk factors • • • • • Family history of substance abuse Depression Low self-esteem More anxious, less assertive, more impulsive Feel like they don't fit in or are out of the mainstream • Vulnerable to peer pressure • Associated with ADHD and conduct disorder • Stimulant treatment for ADHD not associated with adult drug use Substance abuse: consequences • Increased risk of serious drug use later in life • Truancy, school failure • Antisocial behavior, conduct disorder • Poor judgment which may put teens at risk for accidents, violence, unplanned and unsafe sex, and suicide. • Sexual violence and victimization Substance abuse: warning signs • Physical: Fatigue, repeated health complaints, red and glazed eyes, and a lasting cough. • Emotional: Personality change, sudden mood changes, irritability, irresponsible behavior, low self-esteem, poor judgment, depression, and a general lack of interest. • Family: Starting arguments, breaking rules, or withdrawing from the family. • School: Decreased interest, negative attitude, drop in grades, many absences, truancy, and discipline problems. • Social problems: New friends who are less interested in standard home and school activities, problems with the law, and changes to less conventional styles in dress and music. Autism & PDD • A neurodevelopmental condition usually diagnosed in the first 3 years of life. • Delays in speech development, limited social relatedness, and restricted interests and activities. • Child may avoid direct eye contact and exhibit odd behaviors such as focusing on parts of objects (e.g. the spinning wheel of a toy car). • Unusual motor movements such as hand flapping, self stimulation, or walking on toes. • Cause is unknown, but believed due to genetic, environmental, metabolic and neurological conditions AACAP 2009 Autism & PDD: diagnosis 3 domains 1. Social relatedness includes marked impairment in non-verbal communication, peer relationships and social-emotional reciprocity. 2. Communication/play includes either a delay or total lack of spoken language and lack of developmentally-appropriate make-believe or social play. 3. Restricted/stereotyped interests and activities includes encompassing preoccupations, adherence to non-functional routines or rituals, stereotypies and motor mannerisms. AACAP 2009 Autism & PDD: social communication deficits • Laughing (and/or crying) for no apparent reason; showing distress for reasons not apparent to others • Prefers to be alone; aloof manner evident to strangers and family members • Tantrums and low frustration tolerance • Difficulty in initiating social contact with others • Uncomfortable with physical contact even when given with affection such as a hug AACAP 2009 • Little or no eye contact even when spoken to directly • Unresponsive to normal teaching methods (S) • Apparent over-sensitivity or under-sensitivity to pain • No real fears of danger despite obvious risks of harm. • Noticeable physical over-activity or extreme under-activity • Impaired fine motor and gross motor skills Autism & PDD: communication deficits • Difficulty in expressing needs verbally, using gestures or pointing instead of words • Repeating words or phrases in place of normal, responsive language • Non-responsive to verbal instructions; often appears as if child is deaf although hearing tests in normal range (C) • May not have mental retardation AACAP 2009 Autism & PDD: Stereotypies • Insistence on sameness in routines • Focus on spinning objects such as a fan or the propeller of a toy helicopter • Obsessive attachment to particular objects • Rocking, flapping hands • Repetitive use of language AACAP 2009 Autism vs. Asperger Syndrome • Children with Asperger disorder do not present with delays in language acquisition or with marked unusual behaviors and environmental responsiveness during the first years of life. • May achieve developmental milestones in first 3 years • Speech patterns may be unusual and lack inflection or may be formal, but excessively loud or high pitched • Conversation is one way, self-centered, unresponsive to others • Restricted and obsessive interests AACAP 2009 Autism & PDD: treatment • No cure • Behavioral & educational interventions to address specific cognitive, linguistic, & social deficits • Medication to treat symptoms • Aggression, self-injurious behavior -Risperidone • ADHD • Anxiety, OCD • Mood disorder and mood lability AACAP 2009 Cutting & self-injurious behavior • Self-injury is the act of deliberately destroying body tissue, at times to change a way of feeling or relieve painful feelings. • Carving, scratching, branding, marking, picking and pulling skin and hair, burning/abrasions, cutting, biting, head banging, bruising, hitting • To take risks, rebel, reject their parents' values, state their individuality or merely be accepted. • Desperation or anger to seek attention, to show their hopelessness and worthlessness, or because they have suicidal thoughts. • Associated with: depression, psychosis, PTSD and bipolar disorder. • Some may develop Borderline Personality Disorder as adults. AACAP, 1999