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CHILDHOOD CHILDHOOD PSYCHIATRIC PSYCHIATRIC DISORDERSDISORDERS

Dr. Rebwar Ghareeb HamaPsychiatristUniversity of SulaimaniSchool of Medicine

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ClassificationClassification 1. Learning Disorders2. Motor Skills Disorders3. Communication Disorders4. Pervasive Developmental

Disorders5. Attention Deficit Hyperactivity

Disorders6. Disruptive Behavior Disorders7. Feeding & Eating Disorders8. Tic Disorders9. Elimination Disorders10. Other Disorders: like separation

anxiety disorder, elective mutism ,etc…

11. Mood Disorders12. Substance Abuse

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Must be familiar with normal development and remember what is normal for one age may be a problem for another◦ Example: Tantrum Behavior

2 year old ~ normal and expected behavior 12 year old ~ not expected within normal

development

Confidentiality directly related to age of child/adolescent◦ Young child ~ all information shared with

caretaker◦ Adolescent ~ try to establish privacy

agreement between caretaker and adolescent with understanding of what must be shared (significant danger to self and/or others, abuse)4

Motor Skills DisordersMotor Skills Disorders

This is also called developmental coordination disorders

Its essential characteristic is a marked impairment in the development of motor coordination

It is characterized by imprecise or clumsy gross motor skill

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Communication DisordersCommunication Disorders This category includes disorders of speech & language They include:1. Expressive language disorder: the child skills in vocabulary ,the use of correct

sentences ,the production of complex sentences & the recall of words are below the expected level for his or her age & intelligence

2 . Mixed receptive –expressive language disorder: child is impaired in both understanding and expressing

language

3 . Phonological disorder: it is manifested by inappropriate or poor sound

production

4 . Stuttering or Stammering: disturbance in the fluency and time patterning of

speech that is inappropriate for the patient’s age 6

Pervasive developmental Pervasive developmental disordersdisorders

These disorders are severe ,pervasive impairment in developmental areas ,such as social interaction & communication ,or stereotyped behavior ,interests and activities

The impairments are deviant in comparison to a person’s mental or developmental level

These disorders include:

1. Autistic disorder2. Rett’s disorder3. Childhood disintegrative disorder4. Asperger’s disorder 7

Autistic disorderAutistic disorder Sometimes called “childhood

autism, early infantile autism, Kanner’s autism”

Prevalence is 0.02-0.05 %

In most cases it starts before the age of 36 months( 3 years)

It is more frequent in boys

The etiology of autistic disorder is not clear but there is more reliance on biological causes

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Clinical featuresClinical features

1. Impairment in social interaction: lacking social smile, fail to show the usual relatedness to their parents and other people, abnormal eye contact, …

2. Disturbance of communication &language

3. Stereotyped behavior :the activities &play are rigid ,repetitive & monotonous. Ritualistic and compulsive phenomena are common

4. Unstability of mood

5. Abnormal response to sensory stimuli( either exaggerated or decreased)

6. Other behavioral symptoms hyperkinesis or hypokinesis ,aggressive behavior ,temper tantrums, self injurious behavior

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Prognosis is generally unfavorable The patient needs a complicated

care which include:

1. Educational therapy

2. Behavioral therapy

3. Pharmacotherapy: no specific therapy is available. It can be only symptomatic like anti-obsessive, antipsychotic and antiepileptic

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In the absence of specific treatment, management has 6 main aspects:

Management of abnormal behaviorEducation and social servicesSpeech and language

therapy ,occupational therapy, dietary advice…

Treat medical conditions (e.g. epilepsy ,GIT problems)

Help for familiesPharmacotherapy :symptom

management (e.g. antipsychotic for stereotypes ),SSRI for compulsive and self harming behaviors and depression, and anxiety

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Aspergers Syndrome( AS)Aspergers Syndrome( AS)

A syndrome first described by Hans Asperger’s in 1944 ,and sometimes called autistic psychopath ,is characterized by:-

The child develops normally until about the third year when they begin to lack warmth in relationships, and speak in monotonous stilted ways

Severe persistent impairment in social interactions ,repetitive behavior patterns, and restricted interests

IQ and language are normal or in some cases, superior

Motor mannerisms such as hand and finger twisting, or whole body movements

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They are often clumsy and eccentricThey are more interested in others

than autistic childrenThe disorder is more common in boys

than girlsA family history of autism may be

presentThe cause of AS is unknownIt differ from autism in that there is no

general delay or retardation of cognitive development or language

They are solitary, and embark on and spend much time in narrow interests

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Attention Deficit / Hyperactivity Disorder Attention Deficit / Hyperactivity Disorder (ADHD(ADHD))

This disorder is common ,appears more often in boys than in girls and causes disruption in school and at home

It is characterized by:

1. Features of hyperactivity: age-inappropriate hyperactivity which is mostly purposeless & intolerable causing a lot of disturbance

2. Poor attention span3. Impulsivity These symptoms should be present for at

least 6 months before the diagnosis is made The symptoms should be present in more

than one setting ( home, school, work) And should be severe enough to cause

significant impairment14

3%-7% of children suffer from ADHDADHD is diagnosed approximately three times more often in boys than in girlsAs many as half of those with ADHD also have other mental disordersOver half of the children diagnosed with ADHD carry the disorder into adulthoodA large number of adults who were never diagnosed as a child show clear symptoms of ADHD

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The symptoms of ADHD are present since the early childhood (before the age of 7 years)

The causes of ADHD are unknown ,but the disorder is predictably associated with a variety of other disorders that affect the brain function ,such as learning disorders

The suggested contributory factors to ADHD include prenatal toxic exposure, prematurity, and prenatal mechanical insult to the fetal nervous system

Food additives ,colorings, preservatives, and sugar have been suggested as possible causes

There is evidence for a genetic cause 16

Symptoms of Inattention Symptoms of Inattention must have 6 or moremust have 6 or more

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

2. Often has difficulty sustaining attention in tasks or play activities

3. Often does not seem to listen when spoken to directly

4. Often does not follow through on instructions and fails to finish school-work, chores, or duties in the workplace (not oppositional)

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5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or is reluctant to engage in tasks that require a sustained mental effort

7. Often loses things necessary for tasks or activities

8. Often easily distracted by extraneous stimuli

9.Often forgetful in daily activities18

Symptoms of Hyperactivity-Symptoms of Hyperactivity-Impulsivity Impulsivity Must have 6 or moreMust have 6 or more

Hyperactivity 1. Often fidgets with hands or feet or squirms in seat2. Often leaves seat in classroom or in other

situations in which remaining seated is expected3. Often runs about or climbs excessively in

situations in which it is inappropriate (adolescents ~ may be subjective feelings of restlessness)

4. Often has difficulty playing or engaging in leisure activities quietly

5. Often “on the go” or often acts as if “driven by a motor”

6. Often talks excessively

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Impulsivity

1. Often blurts out answers before questions have been completed

2. Often has difficulty awaiting turn3. Often interrupts or intrudes on

others

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Treatment of ADHDTreatment of ADHD1. Pharmacotherapy: a. CNS stimulants:

dextroamphetamine, methylphenidate, and pemoline

b. Antidepressants

2. Psychotherapy : which include behavioral therapy ,

education of parents and teachers

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Disruptive behavior Disruptive behavior disordersdisorders

There are two types:1. Oppositional defiant disorder: described as a recurrent pattern of

negativistic, defiant, disobedient, and hostile behaviors toward authority figures

2. Conduct disorder: A repetitive & persistent pattern of

behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated 22

Elimination DisordersElimination Disorders1. Enuresis : The repeated voiding of urine into

clothes or bed ,whether, the voiding is involuntary or intentional .The behavior must occur twice weekly for at least 3 months or must cause clinically significant distress or impairment socially or academically. The child’s age must be at least 5 years

2. Encopresis: Passing feces into inappropriate places

whether the passage is involuntary or intentional. The pattern must be present for at least 3 months ; the child’s age must be at least 4 years 23

Separation Anxiety DisorderSeparation Anxiety DisorderDefined as an excessive anxiety about

separation from home or from those to whom the child is attached

This disorder must last for at least 4 weeks

Must begin before age of 18 years

Must cause significant distress or impairment

Separation anxiety requires the presence of at least three symptoms related to excessive worry about separation from the major attachment figures 24

The worries may take the form of refusal to go to school( school phobia, school refusal), fears & distress upon separation ,repeated complaints of such physical symptoms like headaches & stomach aches when separation is anticipated and night mares related to separation issues

The disorder is common and onset may occur during preschool years but is most common in 7-8 years old

Prevalence is 3-4% of all school children

It occurs equally in males and femalesTreatment : behavioral therapy

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Pediatric PsychopharmacologyPediatric PsychopharmacologySummarySummary::Substantial Empirical Evidence Currently

Supports◦Stimulants for ADHD◦SSRI’s for OCD

Well Designed Trials support◦Risperidone for aggression and self-

injurious behaviors in autism◦Fluvoxamine for Childhood Anxiety

Disorders◦Fluoxetine for Moderate – Severe Major

Depression26

Pediatric PsychotherapyPediatric PsychotherapySummarySummary::Best Evidence for;

◦CBT (cognitive behavioral therapy) for Depression, Anxiety

◦CBT/Behavioral Strategies for Conduct Problems

◦Parent Training for Conduct Problems

◦MST (multi systemic treatment) for Conduct Problems

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THANK YOU

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