CHILD PSYCHIATRY tutorial slides shows ppt
- 1. CHILD PSYCHIATRY I By Dr Emmanuel
- 2. Introduction • Child psychiatry is a specialty that deals with the recognition, diagnosis and treatment of problems in thinking, feeling or behaviour that affect children, teenagers and their families. • Child psychiatry employs an integrated approach to the treatment of mental health concerns. • Early onset of psychiatric disorder has poor prognosis • Mental illness can impact negatively the development a child for the rest of their life. • Early intervention improves the prognosis
- 3. Con't Child psychiatry differs from that of adult psychiatry in a number of important ways. Children are usually dependent on an adult to help them access services. The child’s difficulties may reflect the problems of other people. (e.g. parental physical or mental illness) The child’s stage of physical and cognitive development must be considered when deciding what is abnormal. Children are generally less able to express themselves in words. For this reason, evidence of disturbance often comes from observations of behaviour made .
- 4. Con't The emphasis of treatment is different. Medication is used considerably less in the treatment of children than in the treatment of adults. Instead, there is more emphasis on: psychological interventions, working with the parents and the whole family, reassuring and retraining children, coordinating the efforts of others who can help children, especially at school.
- 5. Con't • The causes are mainly biological and environmental • Children not responsible for the causation of illness • Parents need to know that every child is diff. even in normal development • Everyday stress causes change in behaviour, e.g. birth of a sibling may cause a child to temporarily act much younger • Important to differentiate normal & signs of serious problems
- 6. Con't The practice of child psychiatry calls for some knowledge of the normal process of development from a helpless infant into an independent adult. To judge whether any observed emotional, social, or intellectual functioning is abnormal, it has to be compared with the corresponding normal range for the age group. The stage of development determines whether behaviour is normal or pathological. Psychopathology may change as the child grows older.
- 7. Assessment • The psychiatric assessment of children differs in several ways from that of adults. • This evaluation is often done with the parents for school-age children, whereas we may choose to see adolescents first, to get their perception of the situation. • A direct interview and observation of the child are usually next, followed by psychological testing when indicated. • interviews from different sources, such as parents, teachers, and school counselors.
- 8. Assessment • Introduce yourself • Obtain consent from parent(s) and assent from child where applicable • Interview both child and parents, separately and together according to the age. • Younger children may not be able or willing to express their ideas and feelings in words, therefore observations of their behaviour and interactions during the interview are especially important. • With very young children, drawing and the use of toys may be helpful. • Difficult to use open-ended questions in children, begin by close-ended questions
- 9. Assessment • Full History from parents and child. • Mental State Examination of child. • Physical examination – should include neurological exam and full examination of any systems related to suspected psychiatric diagnosis e.g thyroid and cardiovascular in depression. • Differential Diagnosis. Risk Assessment. Management plan.
- 10. Assessment • Developmental History • Pregnancy: maternal illness, medications, drugs and alcohol, birth,… • Developmental milestones: motor, language & speech, psychological,… • Social functioning in early childhood. • Problems with separation from mother. Academic, social and behavioural progress at school. Activities of Daily Living. Relationships. Social circumstances of family. • Premorbid personality. • What was the child like before the current problem?
- 11. Classification Neurodevelopmental Disorders Intellectual Disability Communication Disorders Autism Spectrum Disorder Attention-Deficit/Hyperactivity Disorder Specific Learning Disorder Motor Disorders Developmental Coordination Disorder Stereotypic Movement Disorder Tourette’s Disorder Persistent (Chronic) Motor or Vocal Tic Disorder Provisional Tic Disorder Disruptive Behaviors of Childhood Intermitent explosive disorder conduct disorder oppositional defiant disorder
- 12. Anxiety Disorders of Infancy, Childhood, and Adolescence: Separation Anxiety Disorder, Selective Mutism Obsessive-Compulsive Disorder in Childhood and Adolescence Depressive Disorders and Suicide in Children and Adolescents Major depressive disorder Persistent depressive disorder Disruptive Mood Dysregulation Disorder Early-Onset Bipolar Disorder Early-Onset Schizophrenia Adolescent substance use disorders Eating Disorders of Infancy or Early Childhood Avoidant/restrictive food intake disorder, Rumination disorder Pica Elimination disorders Enuresis Encoprosis Trauma- and Stressor-Related Disorders in Children Reactive attachment disorder Disinhibited social engagement disorder
- 13. Aetiology Most childhood disorders are likely to emerge from a complex interaction between emerging neurodevelopmental vulnerabilities and aspects of the child’s prenatal and postnatal environment. There is also a developmental aspect; children mature psychologically and socially as they grow up, and their disorders reflect this maturation.
- 14. Mental illness raising from childhood can result from many etiology including Psychological factors like Temperament and individual differences Maturational changes and delayed effects Social factors like Traumatic life events Prolonged separation from or loss of parents Domestic violence Low social status Parental psychiatric disorders Verbal,physical and sexual abuse Neglect etc Biological factors like : Genes Brain disorders Medical disorders Congenital disordersr Prenatal complications peri-natal complications Post-natal complications
- 16. Neurodevelopmental disorders Intellectual Disability Deficits in intellectual functioning, such as reasoning, problem solving, planning, abstract thinking, judgment, and learning. Deficits in adaptive functioning, such as communication, social participation, and independent living. Deficits affect multiple domains: conceptual, practical, and social. Onset occurs during the developmental period. Intellectual deficits are confirmed by clinical assessment and standardized intelligence testing (scores at least two standard deviations below the population profound. Adaptive functioning deficits require ongoing support for activities of daily life. Severity levels: mild, moderate, severe, and profound.
- 17. Severity Criteria for Intellectual Disability DSM-IV Severity Criteria for Intellectual Disability • Mild: IQ level 50–55 to approximately 70 • Moderate: IQ level 35–40 to 50–55 • Severe IQ: level 20–25to35 • Profound: IQ level below 20– 25 In DSM-5 and DSM-V-TR, IQ scores are less valid. DSM-5, includes an assessment of functioning in - conceptual domain (e.g., academic skills), - social domain (e.g., relationships), - practical domain (e.g., personal hygiene).
- 18. Laboratory Examination •Laboratory tests that may elucidate the causes of intellectual disability include chromosomal analysis, urine and blood testing for metabolic disorders, Electroencephalography neuroimaging.
- 19. Management • Interventions for children and adolescents with intellectual development disorder are psycho-social which incorporate an assessment of social, educational, psychiatric, and environmental needs. • The disorder is associated with a variety of comorbid psychiatric disorders that often require specific treatment, in addition to psychosocial support. • When preventive measures are available, the optimal approach includes primary, secondary, and tertiary interventions.
- 20. Psychopharmacologic Interventions for Comorbid Disorders and Symptoms • Indication Drugs Aggression Irritability Self-injurious Behavior. Antipsychotic anticonvulsants antioxidants ADHD Methylphenidate ,antipsychotics, clonidine ,Atomoxetine Depressive Disorders. SSRIs Stereotypical Motor Movements. Antipsychotic SSRIs Explosive Rage Behavior Antipsychotic (risperidone) Propranolol
- 21. Communication Disorders Language disorder Difficulty acquiring and using language due to expressive and/or receptive impairment (e.g., reduced vocabulary, limited sentence structure, impairments in discourse). Increased risk in families of affected individuals. Speech sound disorder (phonological disorder) Difficulty producing articulate, intelligible speech Childhood-onset fluency disorder (stuttering)—dysfluency and speech motor production issues. Increased risk of stuttering in first-degree relatives of affected individuals. Social (pragmatic) communication disorder challenges with the social use of verbal and non verbal communication. If restricted/repetitive behaviors, activities, or interests are also present, consider diagnosis of ASD. Increased risk with family history of communication disorders, ASD, or specific learning disorder.
- 22. Autism Spectrum Disorder (ASD) .Problems with social interaction and communication: - Impaired social/emotional reciprocity (e.g., inability to hold conversations). - Deficits in nonverbal communication skills (e.g., decreased eye contact). - Interpersonal/relational challenges (e.g., lack of interest in peers). . Restricted, repetitive patterns of behavior, interests, and activities: - Intense, peculiar interests (e.g., preoccupation with unusual objects). - Inflexible adherence to rituals (e.g., rigid thought patterns). - Stereotyped, repetitive motor mannerisms (e.g., hand flapping). . Hyperreactivity/hyporeactivity to sensory input (e.g., hypersensitive to particular textures). . Abnormalities in functioning begin in the early developmental period. . Not better accounted for by ID or global developmental delay. When ID and ASD co-occur, social communication is below expectation based on developmental level. . Causes significant social or occupational impairment.
- 23. TREATMENT • Psychosocial treatment interventions aim to help children with autism spectrum disorder to develop skills in social conventions, increase socially acceptable and prosocial behavior with peers, and to decrease odd behavioral symptoms. • Applied behavioral analysis (ABA) is somewhat effective in reducing some repetitive behaviors in children and adolescents with autism spectrum disorder • Psychopharmacological interventions in autism spectrum disorder help ameliorate behavioral symptoms rather than core features of autism spectrum disorder:
- 24. Specific Learning Disorder • Specific learning disorder in youth is a neurodevelopmental disorder produced by the interactions of heritable and environmental factors. • Those factors influence the brain’s ability to perceive or process verbal and nonverbal information efficiently. • Children with the disorder have persistent difficulty learning academic skills in reading, written expression, or mathematics, beginning in early childhood • There is an increased risk of 4 to 8 times in first-degree relatives for reading deficits, and about 5 to 10 times for mathematics deficits
- 25. Types of Learning Disorders most common types: • Dyslexia affects reading ability. • Dysgraphia affects writing ability. • Dyscalculia affects math ability.
- 26. TREATMENT • Treatment of SLD is typically carried out in education settings or specialized psychology clinics, and so is not the primary responsibility of psychiatrists or primary care providers. • Treatment for learning disorders involves education. ensures that schools offer specialized instruction to children with learning disorders. • students may videotape lectures instead of taking notes. • special memorization techniques. • more time to complete work. • Learning disorders are not treated with medication. If additional issues exist, such as attention-deficit hyperactivity disorder (ADHD), medication may be recommended
- 27. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER • ADHD is a neurodevelopmental disorder defined by impairing levels of inattention, disorganization, and/or hyperactivity-impulsivity. • Inattention and disorganization entail inability to stay on task, seeming not to listen, and losing materials necessary for tasks, at levels that are inconsistent with age or developmental level. • inattentive or hyperactive-impulsive symptoms were prior to age 12 years • are present in two or more settings(e.g at home,school,work with friends or relatives,in other activities) • with resultant impairments of social, academic, and occupational functioning. • ADHD is more frequent in males than in females in the general population, with a ratio of approximately 2:1 in children and 1.6:1 in adults.
- 28. Treatment • Psychosocial Interventions: psychoeducation, parent training, Behavior modification, Cognitive behavioral therapy (CBT), and social skills training. • Pharmacotherapy (ADHD is the only childhood disorder with specific medications) • Central nervous system stimulants:methylphenidate ,dextroamphetamine, and dextroamphetamine and amphetamine salt combinations • Nonstimulant medications approved by the FDA:atomoxetine (Strattera), a norepinephrine uptake inhibitor. • A-agonists including clonidine (Catapres) and guanfacine (Tenex)
- 29. TOURETTE’S SYNDROME AND OTHER TIC DISORDER • Tics are neuropsychiatric events characterized by brief, rapid motor movements or vocalizations in response to irresistible premonitory urges. • Tics may be transient or chronic, with a waxing and waning course. • Tics typically emerge at age 5 to 6 years of age and tend to reach their highest severity between 10 and 12 years. • Motor tics most commonly affect the muscles of the face and neck, such as eye-blinking, head-jerking, mouth-grimacing, or head-shaking.
- 30. Tourette’s Disorder A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. C. Onset is before age 18 years. D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, post viral encephalitis).
- 31. Other Tics disorders Persistent (Chronic) Motor or Vocal Tic Disorder : Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal, Criteria have never been met for Tourette’s disorder. Provisional Tic Disorder: Single or multiple motor and/or vocal tics. The tics have been present for less than 1 year since first tic onset, Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder. R/O other mvts disorders:Akathisia, Chorea, Spasm, Tremor, Compulsion, Dystonia
- 32. MANAGEMENT Psychotherapy: Psychoeducation, Individual supportive therapy, Family therapy , Group therapy • Indications for pharmacological treatment of tics include: Physical pain or discomfort, Interference with social interactions, impairment in any aspect of educational or occupational functioning.
- 33. Pharmacotherapy: Class of drugs Dosage (mg) Antipsychotics Haloperidol 0.25–5.0 Pimozide 1–6 Ziprasidone 20-160 Aripiprazole 2.5–20 α2-adrenergic agonists Clonidine 0.05–0.45 Guanfacine 1.0-4 Class of drugs Dosage (mg) Antidepressant Desipramine 25–300 TCA Clomipramineb 50-300 SSRI Fluoxetine 5.0–80 Sertraline 25–300 Paroxetin 10–60 Fluvoxamine 50–300
- 34. References 1 Kaplan and Sadock‘s comprehensive textbook of psychiatry tenth edition Wolters Kluwer 2017 New York 2 Rutter’s Child and Adolescent Psychiatry fifth edition Blackwell 2008 Oxford.