Gangguan Psikologis Pada Anak

CLINICAL SCIENCE SESSION

Preceptor:
Tatang Muchtar S., dr., SpKJ (K)
Disusun oleh:
Jeevanisha A/P Patmanathan
Fitrie Desbassarie W

1301-1212-3511
1301-1212-0550

BAGIAN ILMU KEDOKTERAN JIWA

FAKULTAS KEDOKTERAN
UNIVERSITAS PADJADJARAN
RUMAH SAKIT Dr. HASAN SADIKIN BANDUNG
2013

I. Attention Deficit and Hiperactivity Disorder

Attention Deficit and Hiperactivity Disorder (ADHD) dalam disebut juga sebagai
Gangguan Hiperaktivitas dan Defisit Perhatian (GHDP). Gejala GHDP sering muncul
pada usia tiga tahun, namun diagnosis umumnya baru dapat ditegakkan setelah anak
masuk sekolah (TK atau Play group), berdasarkan hasil dari pengamatan oleh guru di
sekolah yang membandingkan atensi dan impuls anak dengan teman sebayanya.
1. Definisi
Adalah gangguan perilaku yang paling sering ditemukan pada anak. GHDP ditandai
dengan berkurangya kemampuan untuk mempertahankan perhatian, walaupun tidak ada
stimulus pengalihan perhatian dari luar.
Anak dengan gangguan GHDP mengalami hiperaktivitas (karena adanya impulsivitas
yang tinggi), dan sering tampak resah dan gelisah.
2. Epidemiologi
Sedikitnya sekitar 3-7% dari anak-anak sekolah dasar di dunia menderita ADHD.
Prevalensi GHDP lebih besar pada anak laki-laki dibandingkan dengan anak perempuan
dengan rasio dari 2:1 sampai dengan 9:1.
3. Etiologi
Penyebab pasti hiperaktivitas pada anak tidak dapat disebutkan dengan pasti,pada
beberapa referensi penyebab terjadinya hiperaktivitas dikatakan bersifat multifaktorial.
Dari faktor genetik, perkembangan otak saat kehamilan, perkembangan otak saat
perinatal, tingkat kecerdasan (IQ), terjadinya disfungsi metabolisme, ketidakteraturan
hormonal, lingkungan fisik, sosial dan pola pengasuhan anak oleh orang tua, guru dan
orang-orang yang berpengaruh di sekitamya.
4. Diagnosis, signs, and symptoms.
Menurut Diagnostic and Statistical Manual of Mental Disorder edisi keempat (DSM
IV), diagnosis dibuat dengan menegakkan sejumlah gejala dalam bidang inatensi atau
bidang hiperaktifitas-impulsifitas atau keduanya :

Untuk memenuhi kriteria diagnostik, gangguan harus terjadi sekurang kurangnya

selama 6 bulan, menyebabkan gangguan dalam fungsi akademik atau sosial, dan terjadi
sebelum usia 7 tahun.

Table 43-1
DSM-IV-TR Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder
A. Either (1) or (2):
1. six (or more) of the following symptoms of inattention have persisted for at
least 6 months to a degree that is maladaptive and inconsistent with
developmental level:
Inattention
a. often fails to give close attention to details or makes careless mistakes in
schoolwork, work, or other activities
b. often has difficulty sustaining attention in tasks or play activities
c. often does not seem to listen when spoken to directly
d. often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to oppositional
behavior or failure to understand instructions)
e. often has difficulty organizing tasks and activities
f. often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
g. often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books, or tools)
h. is often easily distracted by extraneous stimuli
i. is often forgetful in daily activities
2. six (or more) of the following symptoms of hyperactivity-impulsivity have
persisted for at least 6 months to a degree that is maladaptive and
inconsistent with developmental level:
Hyperactivity
a. often fidgets with hands or feet or squirms in seat
b. often leaves seat in classroom or in other situations in which remaining
seated is expected
c. often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective
feelings of restlessness)
d. often has difficulty playing or engaging in leisure activities quietly
e. is often on the go or often acts as if driven by a motor
f. often talks excessively

Impulsivity

H.
I.
J.
K.

a. often blurts out answers before questions have been completed

b. often has difficulty awaiting turn
c. often interrupts or intrudes on others (e.g., butts into conversations or
games)
Some hyperactive-impulsive or inattentive symptoms that caused impairment were
present before age 7 years.
Some impairment from the symptoms is present in two or more settings (e.g., at
school [or work] and at home).
There must be clear evidence of clinically significant impairment in social,
academic, or occupational functioning.
The symptoms do not occur exclusively during the course of a pervasive
developmental disorder, schizophrenia, or other psychotic disorder and are not
better accounted for by another mental disorder (e.g., mood disorder, anxiety
disorder, dissociative disorder, or a personality disorder).

Code based on type:

Attention-deficit/hyperactivity disorder, combined type:
if both Criteria A1 and A2 are met for the past 6 months
Attention-deficit/hyperactivity disorder, predominantly inattentive type:
if Criterion A1 is met but Criterion A2 is not met for the past 6 months
Attention-deficit/hyperactivity disorder, predominantly hyperactive-impulsive
type:
if Criterion A2 is met but Criterion A1 is not met for the past 6 months
Coding note: For individuals (especially adolescents and adults) who currently have
symptoms that no longer meet full criteria, in partial remission should be specified.
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright
2000, with permission.)

5. Differensial Diagnosis
Anak dengan tingkat aktifitas yang tinggi dan rentang perhatian yang pendek harus
dicurigai menderita GHDP. Membedakannya GHDP dengan gejala gangguan deficit
atensi-hiperaktifitas sebelum usia 3 tahun sulit. Diferensial diagnosisnya antara lain :
Kecemasan mungkin menyertai gangguan defisit atensi-hiperaktifitas sebagai ciri
sekunder dan dimanifestasikan oleh overaktifitas dan distrakbilitas.

 Depresi sekunder pada anak dengan gangguan defisit atensi-hiperaktifitas harus

dibedakan dari gangguan depresi primer yang

kemungkinan dibedakan oleh

hipoaktivitas dan menarik diri.

Gangguan konduksi dimana anak-anak tidak mampu membaca atau mengerjakan
matematika karena gangguan belajar bukan inatensi. Akan tetapi, gangguan defisit
atensi-hiperaktifitas juga sering ditemukan bersamaan gangguan konduksi ini.
Stres yang dialami anak dalam keluarga seperti kematian anggota keluarga, perceraian
orangtua, ketidakharmonisan dalam keluarga, penggunaan obat-obatan terlarang oleh
orangtua ataupun hubungan anak-orangtua yang buruk dapat menimbulkan gejala yang
mirip dengan gangguan GHDP.
6. Manajemen
Penatalaksanaan bergantung terhadap orang tua dan guru sebagai agent of change. Penting
untuk menolong anak terutama dalam fungsi sosial dan fungsi akademis serta
mengutamakan pentingnya harga diri (self esteem), oleh karena itu usaha yang dilakukan
pertama-tama adalah menyediakan intervensi secara psikologis dan sosial sebelum
menggunakan obat-obatan. Intervensi yang terbukti berguna antara lain:

CBT (Cognitive and Behavioral Therapy) methods, terutama terapi tingkah laku,
ditemukan cukup efektif.

Pelatihan keterampilan sosial (social skills training)

Pelatihan penatalaksanaan orang tua (parent management training)

Terapi individu/keluarga/kelompok

Intervensi pendidikan.

Terapi tingkah laku dapat juga diberikan. Tujuan dari terapi tingkah laku adalah untuk
mengurangi tingkah laku yang bermasalah dan menambah tingkah laku yang diinginkan.
Parent management training, adalah metode yang paling sering digunakan agar orang tua
dapat menjadi agent of change. Orang tua sebaiknya dapat menemukan sesuatu yang
positif daripada menggunakan kalimat negatif (positive reinforcement) untuk dapat
mengontrol anak, contoh Ini akan lebih baik jika... dibandingkan dengan ini akan jadi
jelek jika.

Selain itu, sebaiknya hindari hukuman atau membuat urutan hukuman dan hadiah
(hierarchy of rewards and punishments), dan diterapkan secara nyata.
Contoh CBT antara lain self monitoring, anger control dan self-reinforcement. Selain
intervensi di rumah, intervensi juga dilakukan di sekolah, dan konsisten dengan yang
dilakukan di rumah.
Terapi yang selanjutnya adalah dengan menggunakan obat-obatan. Pengobatan terbukti
efektif untuk 70% kasus. Pengobatan tidak menyembuhkan secara keseluruhan.
Sampai saat ini obat pilihan untuk GHDP adalah stimulan, contoh Methylphenidate
(Ritalin; dextroamphetamine; pemoline), karena efikasi yang tinggi dan morbiditasnya
yang rendah. Stimulan dapat meningkatkan jumlah reseptor adrenergik yang menstimulus
attention and inhibitory centre. Stimulants mengurangi symptoms sekitar 75% , juga
meningkatkan self-esteem, karena dapat memperbaiki rapport pasien dengan orangtua dan
guru.

Table 43-2 Stimulant Medications in the Treatment of AttentionDeficit/Hyperactivity Disorder (ADHD)

Preparation
Approx.
Medication
(mg)
Duration (hr)
Recommended Dose
Methylphenidate preparations
Ritalin
5, 10, 15, 20
3 to 4
0.31 mg/kg t.i.d; up to 60
mg/d
Ritalin-SR
20
8
Up to 60 mg/d
Concerta
18, 36, 54
12
Up to 54 mg/q AM
Metadate ER
10, 20
8
Up to 60 mg/d
Metadate CD
20
12
Up to 60 mg/q
Ritalin LA
5, 10, 15, 20
8
Dexmethylphenidate preparation
Focalin
2.5, 5, 10
3 to 4
Up to 10 mg
Focalin XR
5, 10, 20
6 to 8
Up to 20 mg
Dextroamphetamine preparations
Dexedrine
5, 10
3 to 4
0.15 to 0.5 mg/kg b.i.d.; up to
40 mg/d
Dexedrine
5, 10, 15
8
Up to 40 mg/d
Spansule
Dextroamphetamine and amphetamine salt preparations
Adderall
5, 10, 20, 30
4 to 6
0.15 to 0.5 mg/kg b.i.d.; up to
40 mg/d
Adderall XR
10, 20, 30
12
Up to 40 mg q AM
t.i.d., three times daily; q, every; b.i.d., twice daily.

Table 43-3 Nonstimulant Medications for Attention-Deficit/Hyperactivity Disorder

(ADHD)

Preparation
Medication
(mg)
Atomoxetine HCL
Strattera
10, 18, 25, 40
Bupropion preparations
Wellbutrin
75, 100
Wellbutrin SR

100, 150

Recommended Dose
(0.5 to 1.8 mg/kg) 40 to 80 mg/d, may use b.i.d.
dosing
(3 to 6 mg/kg) 150 to 300 mg/d; up to 150 mg/dose
b.i.d.
(3 to 6 mg/kg) 150 to 300 mg/d; up to 150 mg q AM;
>150 mg/d, use b.i.d. dosing

Venlafaxine
Effexor

25, 37.5, 50, 75, 25 to 150 mg/d; use b.i.d. dosing

100
Effexor XR
37.5, 75, 150
37.5 to 150 mg q AM
-Adrenergic agonists
Clonidine (Catapres)0.1, 0.2, 0.3
3 to 10 g/kg/d divided t.i.d.; up to 0.1 mg t.i.d.
Guanfacine (Tenex) 1, 2

0.5 to 1.5 mg/d

b.i.d, twice daily; q, every; t.i.d., three times daily.

7. PROGNOSIS OF GHDP
Sekitar 80% pasien GHDP mengalami perbaikan bila mendapat penanganan yang tepat.
Umumnya, pada saat menjelang dewasa gejala inattention (kurang perhatian) cenderung
lebih menetap, sementara gejala hiperaktivitas-impulsif semakin lama cenderung menurun.
Pada pasien GHDP yang menetap hingga dewasa, dapat muncul beberapa gejala :
Tingginya perilaku deliquent (25-50%)
Rendahnya pertahanan diri
Rendahnya tingkat pendidikan
Meningkatnya penyalahgunaan obat atau zat lain
Pada sekitar 60-80% anak dengan GHDP gejala akan membaik saat dewasa.
GHDP menetap pada 10-50% pasien dewasa muda, namun sebagian besar hanya berupa
satu gejala minimal.
Pada anak yang tidak agresif, IQ tinggi, kalangan ekonomi menengah ke atas biasanya
prognosisnya baik.

II. Conduct disorder.

1.

Definisi
Suatu pola perilaku yang berulang dan menetap, yang melanggar norma sosial serta
hak-hak orang lain.
Berdasarkan DSM IV-TR, diperlukan 3 (tiga) dari 15 kriteria, yaitu antara lain :
bullying, mengancam atau mengintimidasi orang lain, dan pulang larut malam atau
bahkan tidak pulang ke rumah tanpa ijin dari orangtua, yang bermula sejak <13
tahun. Terjadi dalam 12 bulan terakhir, dengan minimal 1 kriteria dalam 6 bulan
terakhir.

2.

Epidemiologi
Prevalennsi 5-15% di dunia, lebih sering terjadi di daerah perkotaan, dan lebih sering
pada anak laki-laki, dengan rasio 4:1 - 12:1.

3.

Etiologi
Biopsikososial faktor yang berperan, antara lain :
- Parental Factors
Orangtua yg kasar dan suka menghukum, serta perceraian orangtua

4.

Sociocultural Factors,
Sosioekonomi rendah, konsumsialkohol atau narkoba

Psychological Factors,
Anak yg tumbuh dalam suasana rumah yang chaotic, dan negligent conditions
biasanya memiliki lebih banyk emosi anger, frustration, and sadness.

Child Abuse and Maltreatment

Anak yang terekspose pada kekerasan dalam waktu lama baik sebagai korban
maupun saksi dari kekerasan dalam rumah tangga.

Neurobiological dan Neurologic Factors

Diagnosis, signs, and symptoms.

Table 44-2 DSM-IV-TR Diagnostic Criteria for Conduct Disorder

A. A repetitive and persistent pattern of behavior in which the basic rights of others or
major age-appropriate societal norms or rules are violated, as manifested by the
presence of three (or more) of the following criteria in the past 12 months, with at
least one criterion present in the past 6 months:
Aggression to people and animals
1. often bullies, threatens, or intimidates others
2. often initiates physical fights
3. has used a weapon that can cause serious physical harm to others (e.g., a
bat, brick, broken bottle, knife, gun)
4. has been physically cruel to people
5. has been physically cruel to animals
6. has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery)
7. has forced someone into sexual activity
Destruction of property
1. has deliberately engaged in fire setting with the intention of causing serious
damage
2. has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft
1. has broken into someone else's house, building, or car
2. often lies to obtain goods or favors or to avoid obligations (i.e., cons
others)
3. has stolen items of nontrivial value without confronting a victim (e.g.,
shoplifting, but without breaking and entering; forgery)
Serious violations of rules
1. often stays out at night despite parental prohibitions, beginning before age
13 years
2. has run away from home overnight at least twice while living in parental or
parental surrogate home (or once without returning for a lengthy period)
3. is often truant from school, beginning before age 13 years
N. The disturbance in behavior causes clinically significant impairment in social,
academic, or occupational functioning.
O. If the individual is age 18 years or older, criteria are not met for antisocial
personality disorder.

Code based on age at onset:

Conduct disorder, childhood-onset type:
onset of at least one criterion characteristic of conduct disorder prior to age 10 years
Conduct disorder, adolescent-onset type:
absence of any criteria characteristic of conduct disorder prior to age 10 years
Conduct disorder, unspecified onset: age at onset is not known

5.

Differe

Table 44-4 ICD-10 Diagnostic Criteria for Conduct Disorders

G1. There is a repetitive and persistent pattern of behavior, in which either the basic rights of
others or major age-appropriate societal norms or rules are violated, lasting at least 6
months, during which some of the following symptoms are present (see individual
subcategories for rules or numbers of symptoms).
Note: The symptoms in 11, 13, 15, 16, 20, 21, and 23 need only have occurred once for
the criterion to be fulfilled.
The individual:
1. has unusually frequent or severe temper tantrums for his or her developmental level;
2. often argues with adults;
3. often actively refuses adults' requests or defies rules;
4. often, apparently deliberately, does things that annoy other people;
5. often blames others for his or her own mistakes or misbehavior;
6. is often touchy or easily annoyed by others;
7. is often angry or resentful;
8. is often spiteful or vindictive;
9. often lies or breaks promises to obtain goods or favors or to avoid obligations;
10. frequently initiates physical fights (this does not include fights with siblings);
11. has used a weapon that can cause serious physical harm to others (e.g., bat, brick,
broken bottle, knife, gun);
12. often stays out after dark despite parental prohibition (beginning before 13 years of
age);
13. exhibits physical cruelty to other people (e.g., ties up, cuts, or burns a victim);
14. exhibits physical cruelty to animals;
15. deliberately destroys the property of others (other than by fire-setting);

16. deliberately sets fires with a risk or intention of causing serious damage;
17. steals objects of nontrivial value without confronting the victim, either within the
home or outside (e.g., shoplifting, burglary, forgery);
18. is frequently truant from school, beginning before 13 years of age;
19. has run away from parental or parental surrogate home at least twice or has run away
once for more than a single night (this does not include leaving to avoid physical or
sexual abuse);
20. commits a crime involving confrontation with the victim (including purse-snatching,

extortion, mugging);
21. forces another person into sexual activity;
22. frequently bullies others (e.g., deliberate infliction of pain or hurt, including
persistent intimidation, tormenting, or molestation);
23. breaks into someone else's house, building, or car.

5. Differensial Diagnosis

6. Manajemen

a. Pharmacological.
Stimulants dapat mengurangi perilaku aggresif pada conduct disorder (comorbid with
ADHD). Lithium dan haloperidol terbukti efektif dalam menangani explosive,
aggressive behavior pada anak dengan conduct disorder. However, the atypical
antipsychotics also diminish aggression and have better side effect profile than
haloperidol. -adrenergic agonists may help; -adrenergic receptor antagonists
deserve study.
b. Psychological.
Meditasi, behavioral technique, psikoterapi individu, terapi keluarga, parenting
classes, tutoring. Jika lingkungan tempat tinggal anak bermasalah, namun tidak dapat
diintervensi, sementara conduct disorder yang terjadi sudah parah, maka placement
away from home mengeluarkan anak dari rumah mungkin diperlukan.

Pharmacotherapy for Conduct Disorder

Medication

Dosage range

Common adverse
effects

Monitoring/special
considerations

Anorexia,
nervousness, sleep
delay, restlessness,
dysrhythmias,
palpitations,
tachycardia, anemia,
leukopenia

Periodic CBC with

differential and platelet
count, blood pressure,
height, weight, heart rate
Tolerance or dependence
can occur. Drug holidays
should be considered.

Stimulants
Methylphenidate
(Ritalin)

For children six years

and older: 2.5 to 5.0
mg per dose given
before breakfast and
lunch to maximum
dosage of 2 mg per kg
per day or 60 mg per
day
Additional dose of 2.5
mg may be required,
not to be given after 4
p.m.

Dextroamphetamine Amphetamine therapy Anorexia, dependence,

(Dexedrine)
is not recommended for hyperactivity, sleep
children younger than delay, restlessness,
three years. 3 to 5
talkativeness,
years: 2.5 mg per day; palpitations,
increased by 2.5 mg at tachycardia
weekly intervals (not to
exceed 0.5 mg per kg
per day) > 6 years: 5
mg three times daily;
increase by 5 mg at
weekly intervals;
maximum dosage of 40
mg per day

CNS activity, height,

weight, blood pressure
Tolerance or dependence
can occur. Do not
discontinue abruptly.

Antidepressants
Bupropion
(Wellbutrin)*

50 to 150 mg every day Agitation, anxiety,

Adolescents and
confusion,
children older than six headache/migraine,
years: 1.4 to 6.0 mg per insomnia, seizures,
kg per day in divided arrhythmias, nausea,
doses
vomiting

Fluoxetine (Prozac) 5 to 20 mg per day:

dose should be titrated
slowly; maximum
dosage in adults is 80
mg per day; no dosage
information in children
< 5 years

Anxiety, dizziness,
drowsiness, fatigue,
headache, insomnia,
nervousness, tremor,
anorexia, diarrhea,
dyspepsia

Drug interactions
(metabolized by the
CYP450 pathway)

Medication

Dosage range

Common adverse
effects

Monitoring/special
considerations

Dizziness, psychiatric
changes, slurred
speech, gingival
hyperplasia,
constipation, nausea,
vomiting

Serum concentrations,
CBC with differential,
liver enzymes Drug
interactions

Anticonvulsants
Phenytoin (Dilantin) 5 mg per kg per day in
2 to 3 divided doses to
a maximum of 300 mg
per day

Carbamazepine
(Tegretol)

< 6 years: 10 to 20 mg Ataxia, drowsiness,

CBC with platelet count,
per kg per day in 2 to 3 constipation, diarrhea, liver function tests
divided doses;
nausea
maximum dosage of 35
mg per kg per day 6 to
12 years: 100 mg twice
daily; increase by 100
mg at weekly intervals;
maximum dosage of
1,000 mg per day

Valproic acid
(Depakene)

10 to 15 mg per kg per Drowsiness, sedation, Liver function tests,

day in 1 to 3 divided constipation, diarrhea, bilirubin, CBC with
doses; increase by 5 to heartburn, nausea,
platelet count
10 mg per kg per day at vomiting, rash
weekly intervals

Other
Lithium

Children: 15 to 60 mg
per kg per day in 3 to 4
divided doses
Adolescents: 600 to
1,800 mg per day in 3
to 4 divided doses

Dizziness, drowsiness,
fine hand tremor,
headache,
hypotension, anorexia,
diarrhea, dry mouth,
nausea, vomiting,
polyurea

Clonidine (Catapres) 0.05 mg per day;

Dizziness, drowsiness,
increase every 3 to 7 sedation, constipation,
days by 0.05 mg per
dry mouth
day to 3 to 5 g per kg
per day in 3 to 4
divided doses
Maximum dose: 0.3 to

Drug interactions Serum

lithium concentrations
prior to next dose, monitor
biweekly until stable then
every 2 to 3 months;
serum creatinine, CBC,
urinalysis, serum
electrolyte, fasting
glucose, echocardiogram,
TSH
Blood pressure, heart rate
Do not discontinue
abruptly or withdrawal
symptoms may occur.

Medication

Dosage range

Common adverse
effects

Monitoring/special
considerations

0.4 mg per day

CBC = complete blood count; CNS = central nervous system; TSH = thyroid-stimulating
hormone.
*

Data on pediatric safety are not extensive.

Referensi :
1.

Kaplan&Sadock's Synopsis of Psychiatry 10th Ed.

2.

http://www.aafp.org/afp/2001/0415/p1579.html

3.