Child Psychiatry Prof MUDr Ivana Drtlkov CSc Dept

Child Psychiatry Prof. MUDr. Ivana Drtílková, CSc. Dept. of Psychiatry, Masaryk University , Brno

Child Psychiatry Conduct Disorder q q genetic and environmental components more common among boys(6 -16%) than girls (2 -9%)

Child Psychiatry Diagnosis : repetitive and persistent pattern of behavior in which the rights of others or basic social rules are violated. § Aggressive behavior that causes or threatens harm to other people or animals, ( bullying or intimidating others, initiating physical fights. . ), § Non-aggressive conduct ( property loss or damage, fire-setting. . ) § Deceitfulness or theft § Serious rule violations, ( running away from home overnight, often being truant from school. )

Child Psychiatry Treatment: family therapy, and cognitive behavioral approaches which focus on building skills such as anger management. Pharmacological intervention alone is not sufficient. .

Bed-Wetting (Primary Nocturnal Enuresis) Bed-wetting is accidental urination during sleep. § children over age 5 or 6 ( age at which continence could definitely be expected) § Bed-wetting that develops after a child has been dry for a period of time (secondary nocturnal enuresis)

Bed-Wetting (Primary Nocturnal Enuresis) Cause for bed-wetting: o o o Delayed growth and development. Small bladder capacity. Lack of enough antidiuretic hormone (ADH). Sound sleeping. Psychological and social factors.

Bed-Wetting (Primary Nocturnal Enuresis) Medications : o that either increase the amount of urine that the bladder can hold bladder capacity- (imipramine) o or decrease the amount of urine released by the kidneys ( desmopressin).

TIC DISORDERS Tics are : abrupt, purposeless, and involuntary vocal sounds or muscular jerks. They are sudden, rapid, and recurrent. 1. Transient tic disorder - the most common type , with symptoms lasting at least four months, but no longer than one year. Onset - nearly 10 percent of school childrenmore prevalent in periods of stress, fatigue, or as a result of certain types of medications ( stimulants)

TIC DISORDERS 2. Chronic tics- lasting more than one year 3. Tourette's disorder (TD) Tourette's disorder is an autosomal dominant disorder with incomplete penetrance. Non-genetic cause in 10 to 15 percent of children (complications of pregnancy, low birthweight, head trauma, carbon monoxide poisoning, and encephalitis. . ).

TIC DISORDERS 3. Tourette's disorder (TD) Tourette's disorder (TD multiple repeated tics (abrupt, purposeless, and involuntary vocal sounds or muscular jerks. ) Begin : between the ages of 5 and 10 years of age

TIC DISORDERS Tourette a disorder - symptoms may include: involuntary, purposeless, motor movements (the face, neck, shoulders, trunk, or hands) § head jerking § squinting § blinking § shrugging § grimacing § nose-twitching

TIC DISORDERS Tourette a disorder - symptoms may include: § § § any excessively repeated movements (i. e. , foot tapping, leg jerking, scratching) kissing pinching sticking out the tongue or lip-smacking making obscene gestures

TIC DISORDERS Tourette a disorder is also characterized by one or more vocal tics : § § § § grunting or moaning sounds barks tongue clicking sniffs hooting obscenities throat clearing, snorts, or coughs

TIC DISORDERS Tourette a disorder is also characterized by one or more vocal tics : § § § squeaking noises hissing spitting whistling gurgling echoing sounds or phrases repeatedly

CHILDHOOD SCHIZOPHRENIA Definition: Same diagnostic criteria apply to children, adolescents, and adults Based symptoms : deficits in adaptive functioning, and duration of six months Incidence : less than 1/10, 000 births

CHILDHOOD SCHIZOPHRENIA General Characteristics: 1. Slight male predominance 2. Less educated and professionally successful families 3. Patients have low-average to average range of intelligence 4. Patterns of behavior before a formal diagnosis: attention/conduct problems, earlier patterns of inhibition, withdrawal and sensitivity

CHILDHOOD SCHIZOPHRENIA General Characteristics: 5. Disease is rarely observed before age 5 6. 80% of children have auditory hallucinations; 50% have delusional beliefs 7. Can be observed with additional conditions such as: conduct disorder, learning disabilities, mental retardation, and autism 8. Poor prognosis if onset before age 10 with above personality difficulties

CHILDHOOD SCHIZOPHRENIA CHARACTERISTIC SYMPTOMS : Positive symptoms ( productive ) : Delusions Hallutiations Disorganised speech (often incoherence ) Grossly disorganized or catatonic behavior

CHILDHOOD SCHIZOPHRENIA CHARACTERISTIC SYMPTOMS : Negative symptoms ( nonproductive ) : affective flattening social dysfunction Problematic in children - fantasy figures, which would not of themselves suggest psychosis. The content of hallutiations and delusions varies with age.

CHILDHOOD SCHIZOPHRENIA TREATMENT : Antipsychotics are the drugs of first choice in chilhood for schizofrenia Imortance : minimizing any cognitive dulling in school children , atypical antipsychotics are preferred (risperidone, olanzapine).

DEPRESSION IN CHILDERN Risk factors in their lives which could predispose: family history of mental illness or suicide, • abuse (physical, emotional or sexual), • chronic illness and the loss of a parent at an early age to death, • divorce or abandonment. • The depression could be wholly chemical, wholly due to psychological factors, or combination of the two.

DEPRESSION IN CHILDERN Symptoms of Depression in Children • • • Persistent sadness and/or irritability. Low self-esteem or feelings or worthlessness. A child may make such statements as, "I'm bad. I'm stupid. No one likes me. " Loss of interest in previously enjoyed activities. Change in appetite (either increase or decrease). Change in sleep patterns (either increase or decrease).

DEPRESSION IN CHILDERN Symptoms of Depression in Children • • • Difficulty concentrating. Anger and rage Headaches, stomachaches or other physical pains that seem to have no cause. Changes in activity level( more lethargic or more hyperactive. ) Recurring thoughts of death or suicide.

DEPRESSION IN CHILDERN If the child has bipolar disorder, also known as manic depression, these symptoms could be present: • abrupt, rapid mood swings • periods of extreme hyperactivity • prolonged, explosive temper tantrums or rages • exaggerated ideas about self or abilities Bipolar disorder is often mis-diagnosed as attention-deficit disorder with hyperactivity (ADHD), obsessive-compulsive disorder (OCD), oppositional defiant disorder or conduct disorder.

AUTISM IN CHILDREN First described : Leo Kanner in 1943 as a disturbance of affective contact Prevalence: 4 -5 cases per 10000 The basic criteria : 1) early onset (before 3 -5 years of age), 2) severe abnormality of reciprocal social relatedness, 3) severe abnormality of communication development, 4) restricted, repetitive and stereotyped patterns of behavior, interests, activities, and imagination; 5) abnormal responses to sensory stimuli.

AUTISM IN CHILDREN SOCIAL DISTURBANCE The human face holds little interest for the autistic infant § lack of eye contact, poor or absent attachments § general lack of social interest COMMUNACATIVE DISTURBANCE echolalia, pronoun reversal, inappropriate cadence and intonation, impaired semantic development

AUTISM IN CHILDREN COGNITIVE DEVELOPMENT Most ( approximately three-fourths ) autistic children scored in the mentally retarded range A few autistic individuals exhibit truly remarkable abilities( musical or drawing ability. memory BEHAVIOR FEATURES Restricted repetitive and stereotyped patterns of behavior, interests and activities. Interest in nonfunctional aspects of objects ( taste or feel )

AUTISM IN CHILDREN Stereotyped movements ( hand flapping, toe walking, spinning objcts and the like). Bizare affective responses - panicked in response to new situations. Deficits in imaginative play.

AUTISM IN CHILDREN ETIOLOGY AND PATHOGENESIS There may be a genetic basis to the disorderfamily members with other related disabilities Autistic children exhibited : an increased frequency of physical anomalies, persistent primitive reflexes, various neurological soft sings and increased abnormalities on EEG. Treatment Drug treatments ( risperidone ) Otherapies : behavioral treatments (teaching autistic "appropriate" behaviors).

Attention deficit hyperactivity disorder ( ADHD) CHARACTERISTIC : 1). INAPPROPRIATE OR EXCESSIVE ACTIVITY 2). POOR SUSTAINED ATTENTION 3). DIFFICULTIES IN INHIBITING IMPULSES IN SOCIAL BEHAVIOR AND ON COGNITIVE TASKS. 4). DIFFICULTIES GETTING ALONG WITH OTHERS 5). SCHOOL UNDERACHIEVEMENT PREVALENCE : 8 % OCCURS BETWEEN 6 - 8 YEARS IN BOYS - 9 % IN GIRLS - 3 %

Attention deficit hyperactivity disorder ( ADHD) Type of disorder ADHD combined type ADHD predominantly inattentive type ADHD predominantly hyperactive-impulsive type

Attention deficit hyperactivity disorder ( ADHD) Cause of ADHD suspected contributing factors may include: Neurophysiology - differences in brain anatomy, electrical activity and metabolism. Catecholamine function are very probably involved in the pathogenesis of hyperactivity. Genetics - possible gene mutations may be present.

Attention deficit hyperactivity disorder ( ADHD) Cause of ADHD suspected contributing factors may include: Drugs - drug use (nicotine and cocaine) by the mother during pregnancy. Lead - chronic exposure - influence behaviour and brain chemistry. Lack of early attachment - traumatic experiences related to the attachment

Attention deficit hyperactivity disorder ( ADHD) Therapy of ADHD • behavioural management, psychological counselling • drugs target the brain's neurotransmitters ( stimulants, antidepressants. . ) Stimulant drugs Dexamphetamine and methylphenidate (Ritalin) work by acting on the neurotransmitters that release the chemical dopamine. About 7 O % of children with hyperactivity improve on a stimulant regimen.

Attention deficit hyperactivity disorder ( ADHD) Inattention criteria • Fail to give close attention to details or make careless mistakes in school work. • Have difficulty sustaining attention in tasks or play activities. • Not seem to listen when spoken to directly. • Not follow through on instructions and fail to finish school work, chores or duties in the workplace

Attention deficit hyperactivity disorder ( ADHD) Inattention criteria • Have difficulty organising tasks and activities. • Avoid, dislike or be reluctant to engage in tasks that require sustained mental effort • Lose things necessary for tasks or activities (for example: toys, school assignments, pencils, books or tools). • Be easily distracted. • Be forgetful in daily activities.

Attention deficit hyperactivity disorder ( ADHD) Hyperactivity-impulsivity criteria Hyperactivity • Often fidgets with hands or feet or squirms in seat. • Often leaves seat in classroom or in other situations in which remaining seated is expected. • Often runs about or climbs excessively in situations in which it is inappropriate

Attention deficit hyperactivity disorder ( ADHD) Hyperactivity-impulsivity criteria Hyperactivity • Often has difficulty playing or engaging in leisure activities quietly. • Is often 'on the go' or often acts as if 'driven by a motor'. • Often talks excessively

Attention deficit hyperactivity disorder ( ADHD) Hyperactivity-impulsivity criteria Impulsivity • Often blurts out answers before questions have been completed. • Often has difficulty waiting in turn. • Often interrupts or intrudes on others (for example, 'butts into' conversations or games).

Child Psychiatry References : Child and Adolescent Psychiatry, edited by Melvin Lewis, Wiliams and Wilkins, 1996, 1260 pp.