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ِب ْس ِم ه ِ الر ِح ِيم الر ْحمـ َ ِن َّ اّلل َّ ْال َح ْمدُ ه ِ ين ب ْالعَالَ ِم َ ّلل َر ه ِ الر ِح ِيم مـن َّ َّ الر ْح ِ ين َمـا ِل ِك يَ ْو ِم ال ِده ِ َّاك نَ ْست َ ِع ُ ين َّاك نَ ْعبُدُ و ِإي َ ِإي َ ص َرا َ يم اه ِدنَــــا ال ِ ه ط ال ُمست َ ِق َ ص َرا َ ين ض ِاله َ ط الَّ ِذ َ علَي ِه ْم َواَ ال َّ ين أَنعَ َ َير ال َمغ ُ ضو ِ ب َ مت َ ِ علَي ِه ْم غ ِ Child Psychiatry The Basics Dr. M.Nasar Sayeed Khan 13-B, Aibak Block, garden town 03328440242 [email protected] Is Infant &Toddler Mental Health Really a Problem? • Yes! • Young children do experience problems in social emotional competency and even psychopathology • We are better able to understand and measure these problems Why we resist this… • We are too worried about cognitive skills (“ready to learn”) • Stigma associated with mental health issues • Myth of childhood • Our own discomfort with the idea Prevalence • Best estimates of serious behavior concerns in children 2 to 3 years fall between 10 to 15% • Parent and pediatrician report behavior problems in 10% of 1 to 2 year olds But won’t these problems go away? • No! • 37% of 18 mos with extreme behavior/emotional problems continue to have problems at 30 mos • Over ½ of 2-3 with psychiatric d/o still have symptoms 2 years out Long Term Effects • Exposure to poor caregiving, abuse, or domestic violence can lead to developmental and mental health problems in young children • Babies, toddlers, and preschoolers can demonstrate depression, PTSD, and disruptive behaviors The Science of Early Childhood Development • Babies brains are growing at a phenomenal rate • The infant brain is “experience expectant” • Both positive and negative experiences have significant and long lasting effects The Science of Early Childhood Development • Experience, especially social experiences, change the way the brain is shaped and functions • Babies who experience or witness violence have behavioral and physiological changes MH Challenges in Young Children • Are real • Involve a substantial number of babies • Can be assessed and treated Areas to Consider When Assessing Young Children • Developmental Levels of Infant or Child • Quality of Important Relationships • Parent Status (Capacity for Relationship) • Family Situations Infant & Child Development • A good working knowledge of typical development is needed when you assess young children • You can’t tell what is atypical if you don’t know what is typical Infant & Child Development • Expected order of milestones is known Skills are traditionally divided into 5 areas There is much overlap between the areas Uneven development across areas is concerning Infant & Child Development Ways to learn about development • Have a great memory from college • Get a child development text • Watch some babies • Review some developmental checklists online Infant & Child Development • Cognitive • Receptive, Expressive, and Pragmatic Communication • Fine & Gross Motor • Social-emotional and behavior • Adaptive Skills (Self Help) Cognitive Skills • • • • • Thinking Problem Solving Memory Attention Imitation Communication • • • • Use of gestures and facial expressions Understanding speech Expressive language Social or pragmatic aspects of communication Fine & Gross Motor Skills • Use of hands and arms to manipulate objects • Balance • Strength and tone • Walking, running, jumping Social-emotional and behavior • Eye contact • Social smile • Relationships/ attachment • Regulation • • • • Sleep Feeding Aggression Compliance Self-Help/Adaptive • • • • Eating Dressing Participation in grooming Toileting Ways development can be atypical • Global delays in development • Inconsistent development • Atypical, unusual behaviors—red flags Red Flags in 6 Month Olds: • Inability to Read Signals • Persistent Sleep Problems • Lack of Predictability • Failure to Imitate Sounds and Gestures • No Affect, Range of Feelings • Lack of Stranger Anxiety (8 months) Red Flags 12-18 Month Olds: • No Words • No Separation Distress • Persistent Sleep Problems • Immobile, Low Activity • Withdrawn • Excessive Rocking • Prolonged Fears • No Social Engagement • Predominant Anger and Outbursts Red Flags in 18 Months to 3 Year olds • Eating Problems • No Enjoyment in Play • Non Speaking • Poor Problem Solving • Extreme Shyness • Total Lack of Self Control • Lack Autonomy • Failure in Gender Identification • Chaotic Behavior Screening & Referral • Screening methods tell you if the child needs further assessment in a given developmental area • Many screening tools use caregiver report • Do not use social-emotional screener for CPS population Do’s and Don’ts • Infants and Toddlers must be evaluated within the context of relationships with their primary caregivers • Assessment should always include collaboration with parents and caregivers • Multiple assessments over time are recommended • Information from Multiple sources is recommended Do’s and Don’ts •Standardized Instruments May be used but not be the sole basis of the Evaluation •Young Children Should Never be Challenged by Separation from Primary Caregivers •Evaluation should utilize the DSM V Etiology • • • • • Brain damage Lead intoxication Family Divorce Death Problems with preschoolers • • • • • • • Bed wetting Over activity Difficulty in settling at night Fears Disobedience Attention Seeking Temper tantrums Poor prognosis if persists beyond 3 and require intervention • • • • • over-activity conduct disorder speech difficulty effeminacy autism Pica • Is the eating of items considered as inedible Common causes include: • brain damage • autism • mental retardation • emotional distress • usually diminishes as the child grows Hyperkinetic and Attention Deficit disorders Classification • F90 Hyperkinetic disorders • F90.0 Disturbance of activity and attention • F90.1 Hyperkinetic conduct disorder • F90.8 Other hyperkinetic disorders • F90.9 Hyperkinetic disorder, unspecified Conduct and Oppositional disorders Classification • • • • • • Conduct disorder confined to the family Unsocial zed conduct disorder Socialized conduct disorder Oppositional defiant disorder Other conduct disorders Conduct disorder, unspecified F84 Pervasive Developmental Disorders • • • • • • • • • • F84.0 Childhood Autism (Kanner, 1943) Epidemiology prevalence of 2 per 10,000 M:F=3:1 Clinical features Kanner described four main features of autism: autistic aloneness delayed or abnormal speech an obsessive desire for sameness onset in the first two years of life F93Emotional Disorders with specific onset in childhood • Maternal overprotection (Levy, 1943) – – – – – excessive contact prolongation of infantile care prevention of independence fathers were generally submissive overprotected children had three times as many operations • Separation Anxiety Disorder – onset is before the age of six – diagnosis is not made when there is a generalized disturbance of personality development School refusal • Clinical features: – there are often somatic symptoms - complaints occur on school days but not at other times – the final refusal may occur after several events: – following a period of increasing difficulty – after an enforced absence such as respiratory infection – after an event at school such as change of class – following a problem in the family such as illness of another family member • Treatment – – – – an early return to school is important (The Kennedy Approach) discussion with teachers is needed depressive disorder should be treated it has been reported that antidepressants are effective for school refusal, even when there is no depression • Prognosis Elective Mutism • The child refuses to speak in certain circumstances, although he does so normally in others • usually, speech is normal in the home but lacking in school • often associated with other negative behaviours such as refusing to sit down or play when invited to do so • Epidemiology • usually begins between 3 and 5 years, after normal speech has been acquired • prevalence of approx. 1 in 1000 • Treatment • no evidence that treatment is effective • Prognosis • can persist for months or years • a five- to ten-year follow-up showed that only 50% had improved Stammering Disturbance of the rhythm and fluency of speech • Epidemiology • M:F = 4:1 • affects about 1% of children • Treatment • speech therapy • Prognosis • most children improved whether treated or not Mujtaba Nasar 43