Psychiatric Disorders in Childhood and Adolescence Dr Ravichandra

Psychiatric Disorders in Childhood and Adolescence Dr. Ravichandra Karkal Assistant Prof. Psychiatry Yenepoya University

Objectives – Acknowledge unique variations in psychiatric symptoms in this age group – The child’s existence and emotional development depends on the family or care givers – The developmental stages are very important in assessment of the diagnosis – Children are less able to express themselves in words

• A 5 -year-old boy has difficulty paying attention in school. He fidgets and squirms and will not stay seated in class. At home he talks excessively and has difficulty waiting for his turn. His language and motor skills are appropriate for his age. Which is the most likely diagnosis?

Attention deficit hyperactivity disorder • Syndrome characterized by – inattention – impulsivity – hyperactivity • Onset of impairment must be before age 6, even if it was not diagnosed until later

ADHD Inattention Symptoms (6 of 9): Careless mistakes Attention difficulty Listening problem Loses things Fails to finish things Organizational skills lacking Reluctance in tasks requiring sustained mental effort Forgetful in Routine activities Easily Distracted

ADHD • Hyperactive-Impulsive Sx (6 of 9): Runs about or is restless Unable to wait his/her turn Not able to play quietly On the go Fidgets with hands or feet Blurts out answers Staying seated is difficult Talks excessively Tends to interrupt

ADHD Epidemiology • Occurs in 3 -12% of school-aged children • Boys 4 -9 x > girls • Most common type is combined type

ADHD Boys are diagnosed with all subtypes more often than girls, but when girls are diagnosed, they are most often diagnosed inattentive type

Treatment Stimulants, first line: Methylphenidates 0. 3 -1 mg/kg/day Amphetamines preferred in seizuredisordered patients Common side effects include appetite loss, sleep disturbance, and some changes in pulse and blood pressure.

Treatment • Atomoxetine – Dose: 0. 5 -1. 2 mg/kg/day; max dose 1. 4 mg/kg/day or 100 mg. (whichever is less) – Advantage: 24 hour effect – Common side effects: nausea, headache, anorexia, insomnia

Treatment • Clonidine – Dose: 3 -10 mcg/kg/day, divided tid – Side effects: dry mouth, dizziness, drowsiness, fatigue, constipation, arrhythmias – Monitor ECG, BP, Pulse – Slow taper to avoid rebound hypertension

• A 15 -year-old boy is arrested for shooting the owner of the garments store he tried to rob. He has been caught several times for a variety of crimes against property, possession of illegal substances, and assault. He is cheerful and unconcerned during the arrest, more worried about losing his leather jacket than about the fate of the man he has injured. Which is the most likely diagnosis in this case?

Conduct Disorder Repetitive behaviors that violate the rights of others and/or societal laws: – – – Aggression or cruelty to people or animals Destruction of property Theft Truancy Running away

Conduct Disorder -Affects 12% of boys and 7% of girls -2 -3 fold likelihood of becoming juvenile offenders

Conduct Disorder. Psychosocial Correlates • Harsh punishment • Institutional living • Inconsistent parental figures (living with different relatives for years) • Poor parental monitoring in early childhood • Parental conflict • Maternal depression • Paternal alcoholism

Conduct Disorder Risk Factors Fetal Alcohol Syndrome, Prenatal drug exposure, ADHD Note: A child with ADHD + Conduct Disorder is more likely to develop antisocial behavior persisting into adulthood than a child with Conduct Disorder alone

Conduct Disorder • Conduct Disorder develops as a result of biological risk and childhood experiences, so there are opportunities for early intervention • Treatment includes family therapy, behavior management training, social skills group, and teaching problem-solving skills

• A 13 -year-old girl grunts and clears her throat several times in an hour, and her conversation is often interrupted by random shouting. She also performs idiosyncratic, complex motor activities such as turning her head to the right while shuts her eyes and opens her mouth. She can prevent these movements for brief periods of time, with effort. Diagnosis?

Tourette’s Disorder • Multiple motor and one or more vocal tics lasting at least 1 year, many times a day, nearly every day, without a tic-free period of more than three consecutive months Georges Gilles de la Tourette

Recognizing Tics Typically, brief clonic movements of eyes, face, neck and shoulders Most common: eye-blinking, facial grimacing and head-jerking Typically, vocal tics involve throatclearing, grunting or barking Tics may be simple (brief) or complex (elaborate)

Tourette’s Disorder • Onset before age 18; peak onset at age 5 to 8 years • Severity tends to peak around 8 to 11 years, with improvement or even resolution during puberty

Prevalence • Transient tics occur in 6 -13% of all children • Chronic tic disorder occurs in 1 -2%, with 3: 1 ratio of boys: girls • Tourette’s is much less common, occurring in 5 -10/10, 000

Co-morbidity of Tourette’s Disorder • 40% of Tourette’s children also meet criteria for OCD • >20% of children with any tic disorder have OCD

Co-morbidity of Tourette’s Disorder • Many children with Tourette’s Disorder have depression or anxiety • 8 -27% of children with Tourette’s also have ADHD, but most have impulsivity

Pervasive developmental disorders • Qualitative abnormalities – reciprocal social interactions – patterns of communication (language delay) • Restricted, stereotyped, repetitive repertoire of interests and activities.

• A 5 -year-old boy shows no interest in other children and ignores adults other than his parents. He spends hours lining up his toy cars or spinning their wheels but does not use them for “make-believe” play. He rarely uses speech to communicate, and his parents state that he has never done so. Physical examination indicates that his head is of normal circumference and his gait is normal. Which is the most likely diagnosis for this boy?

Childhood autism • 3 years • Boys 3 -4 x • Inadequate appreciation of socio-emotional cues • Lack of modulation of behaviour according to social context Leo Kanner

• impairment in make-believe and social imitative play • poor synchrony and lack of reciprocity in conversational • lack of emotional response to other people's verbal and nonverbal overtures

• tendency to impose rigidity and routine • stereotyped preoccupations with interests such as dates, routes or timetables • specific interest in nonfunctional elements of objects (such as their smell or feel)

• Nonspecific problems – Fear/phobias, sleeping and eating disturbances, temper tantrums, and aggression – Self-injury

• Asperger's syndrome – No delay in language development

• A 4 -year-old girl is brought to her pediatrician because her parents think she does not seem to be “developing normally. ” The girl’s mother states that her daughter seemed normal for at least the first 2 to 3 years of her life. She was walking and beginning to speak in sentences. She was able to play with her mother and older sister. The mother has been noticing that over the past 2 months her daughter has lost these previously acquired abilities. She will no longer play with anyone else and has stopped speak- ing entirely. She has lost all bowel control, when previously she had not needed a diaper for at least a year. Which is the most likely diagnosis?

• Rett’s syndrome – onset is between 7 and 24 months – apparently normal or near-normal early development – loss of purposive hand movements and acquired fine motor manipulative skills – loss, partial loss or lack of development of language – distinctive stereotyped tortuous wringing or "hand-washing" movements

• The parents of an 8 -year-old boy with a normal IQ are concerned because he is a very slow reader and does not appear to understand what he reads. When the boy reads aloud, he misses words and changes the sequence of the letters. They also note that he has problems with spelling, though he is otherwise quite creative in his ability to write stories. On examination, the child displays verbal language defects as well, though pri- marily he communicates clearly. His hearing and vision are normal and he has no trouble with motor skills. Which is the most likely diagnosis for this child?

Specific Learning Disability (Dyslexia) • A child with Specific Learning Disability (SLD) is one who does poorly in schooling because of impaired ability in learning the academic skills of reading, writing, arithmetic, and spelling.

• Reading problems: slowness, hesitancy, omission, substitution, reading by guessing, reading the words backwards (on for no), misreading (put for but) • Writing problems: slowness, lack of regard for even basic rules of grammar such as capitals and full stop, poor handwriting, poor organization of the writing space, poorly formed letters, words, and sentences. • Spelling problems: writing letters in wrong order (child for child), reversal of letters (b for d), inversion of letters (u for n), mirror writing (no for on), omission (wet for went); these are best elicited by asking the child to write to dictation. • Arithmetic difficulties: this is best elicited by asking the child do simple mental arithmetic or written problems.

• Deficit in Phonological processing. In simple words, this processing involves splitting the words into simpler speech units called phonemes and then associating them with the appropriate symbols (development of sound-symbol correspondence). • Left parieto-temporal region