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Overview of child and

adolescence
psychiatry
Dasinen Thiagarajan

Content
Anxiety and Depressive Disorders
Neurodevelopmental Disorders
Specific Learning Disorders
Conduct Disorders

Anxiety and Depressive Disorders


Commonest problem in children and adolescences.
Prevalence is 20%, but 75% are undiagnosed and untreated.
Anxiety may be a normal response and part of a childs
psychological development.
It is important to determine is its normal or pathological.
Response is exaggerated if:

Duration is prolonged and persistent


Functions is affected
Avoidance behaviour
No underlying organic basis

Older children may be able to say what is the problem but young children might not be
able to express their feelings.
The anxiety symptoms or disorders are seen in their behaviour, emotion and
temperament changes.
They might show these symptoms:

Irritability, short temper


Deterioration in function
Regress into previous developmental stage
Fearful
Clinging to parent/caregiver
Become quiet
Nervous habit
Failure to thrive
Stuttering
Easily startle
Deterioration in academic performance
Difficulty in concentrating
Involve in fights
Complaining of physical symptoms
Sleeping problem
Change in appetite

Manifestations of anxiety and


depressive symptoms among
adolescence.
Able to express anxious/worry/tense
Irritable
Easily tired
Having conduct problems/misbehave
Smoking
Abusing drugs/alcohol/tobacco
Having physical complaints
Poor concentration
Deterioration in academic performance
Suicide attempt

Causes of anxiety and depressive


disorders
Genetic
Psychosocial factors
External
Problems at school
Changes in family structure
Conflict with friend
Overly-packed schedules

Internal
Pressure of wanting to do well in school
Fit in with peers

Types of anxiety disorders among


children and adolescence
Separation anxiety disorder
Selective mutism
Generalized anxiety disorder
Panic disorder
Agoraphobia
Specific phobic disorder
Social anxiety disorder

Separation anxiety
Experience excessive fear and intensely distress of being
separated from attached ones.
Intense fear of safety of their loved ones
Overly clinging
Refuse to go to school
Complaint of physical symptoms
Refuse to go to school
Extremely worried of sleeping away from home
Panic, crying, screaming or tantrums at times of separation
Trouble sleeping or nightmares related to separation

For school refusal the child should be returned to school


Treatment is focused on family structure and recommendation in
the ways of upbringing, behaviour therapy i.e. operant
conditioning, systemic desensitization.
In severe cases, antidepressant is indicated especially those
associated with panic disorder.
DSM-5 requires at leas 4 weeks and problem must cause
impairment to child social functioning and academic.

Selective Mutism
Persistently not able to speak able to speak in situations where
they are expected to speak e.g. classroom or school but has no
language difficulties, knowledge or intelligence deficit to speak
in other situation.
May have mediator.
DSM-5 at least 1 months and cause problem to academic and
social functions.
Cannot speak due to intense anxiety, but does not look
anxious.
Assoc. with social anxiety disorder, separation anxiety
disorder, panic disorder, agoraphobia.

DSM-5 criteria for Selective Mutism


A: consistent failure to speak in specific social situations
in which there is an expectation in speaking despite
speaking in other situations
B: interferes with educational or occupational
achievement or social communication.
C: Must last for at least 1 month. (not 1st month of
school).
D: Not due to lack of knowledge or comfort with the
language in use.
E: Not better explained with communication disorder.

Generalised Anxiety Disorder (GAD)


Characterized as excessive, unrealistic worry and
anxious about multiple daily routine.
Experience anxiety sx:

Tense
Worries anxious
Restless
Poor concentration
Stomach aches

Panic Disorder
Anxiety symptoms are more severe than GAD
Child/Adolescence would experience:
Acute sudden intense attack of anxiety symptoms.
i.e shortness of breath, choking or smothering sensations,
pounding heartbeat, chest pain, nausea, light-headedness,
trembling, shaking and sweating
It come episodically
In between episode they will be symptom free
Classical symptom include
Feel like fainting
Fear of losing ones mind

Phobia
Simple
Fear of specific situation or subject

Social
Intense fear of meeting or talking to their peers and adult
fearing of being scrutinised and negatively evaluated i.e weak,
stupid, anxious
Avoidance of social situation
At school, they may have
Difficulties in answering questions in class
Imitating conversations
Talking/ interact with friends/teacher

Agoraphobia
Fear of going out, out fear that he could not escape or
get help if they get panic attack
Patient would avoid being away from home, using public
transport, being in an open, enclosed or crowded places

Depressive Disorder
Predominant symptoms are mood disturbances which
are low
Persistent for at least 2 weeks.
Mood disturbances are associated with disturbances in
thought, behaviour and perception.
Prevalence is 3% for pre-puberty and 10% adolescence.
Young children may feel depressed or sad feelings, as
such the depressive symptoms or disorders in children
are often manifested through their behaviour, emotion
and temperamental changes.

Depression in Young Children


Irritable, fearful, a short temper
Facial expressions
Isolating themselves
Becoming quiet
Loss of interest in things that use to give pleasure, a child seems not to care any longer for favourite toys
or activities
Development of a nervous habit, such as nail biting
Poor concentration
Deterioration in academic performance
Refuse to go to school
Complaint of physical symptoms
Feeling sad/ hopeless/worthless
Low energy level
Sleep and appetite disturbances
Regress/return to the behaviour of the previous development stage
Thumb sucking
Bedwetting/ enuresis
Encopresis

FTT

Depression in adolescence
Irritable
Feeling low
Hopeless/worthless/ suicidal thought, expresses his/her future is
black
Isolating themselves
Becoming quiet around friends, family and teachers
Lack of energy
Involve in fights
Poor concentration
Lack of energy

Neurodevelopmental disorder
Intellectual disability( Intellectual developmental
disorder)
Autism spectrum disorder
ADHD: Attention Deficit Hyperactivity Disorder (formerly
known MBD: minimal brain dysfunction)
Specific Learning Disorder(SLD)
Conduct Disorder

Intellectual Disability
Was previously referred as mental retardation in DSM IV.
It is characterized by deficits in intellectual (cognitive function)
adaptive functioning which occurs at a early stage of developmental
stages.
Cognitive assessments are based on both clinical and standardized
test
WISC (Wechsler Intelligent test)
Stanford Binet Test for Children

IQ below 70 is considered having ID


DSM-5 does not require IQ of below 100 to diagnose mental
retardation and severity is based on adaptive function and support
needed.

The deficits of individual functions include

Person ability to reasoning


Problem solving
Planning
Abstract thinking
Judgement
Making decisions
Risk assessment
Academic learning on adaptive function
Learning from experience

It is referred as failure to attain developmental and


socio-cultural standards with respect to the age
resulting in failure to be independent such as daily life
skills, accomplished social obligation,
Skills observed based on their age.

Following may be present in a child


with ID
Similar problem in the family. Genetichromosomal abnormalities.
Prenatal history
Birth history
Delays in language and motor development
Delay in learning
Childhood infection
History of severe head injury
Toxic substance
2/3 cause is unknown

Traditionally MR is classified by IQ test but is less emphasized in


DSM 5.

Mild mental retardation, IQ 70-55/50


Moderate MR, IQ 55/50-40/35
Severe MR IQ 40/35-25/20
Profound mental Retardation, IQ < 25/20

Mild ID
Not detected early but during school life but when the
child enters school.
Will have normal motor and language group but as
going gets though they tend to get left behind.
Individual with mild ID would be able to be independent
and have a semiskilled job.

Moderate ID
Recognised during first year of life
Often presented with speech delay.
Parents notice delay in learning to speak and interact
with others.
As an adult they may be able to perform unskilled job
with training and supervision
Usually lives with family.

Severe ID
Identified during infancy
Would have marked delay in development.
Usually unable to read and write but able to perform
simple daily life activity under supervision

Profound ID
Recognised during infancy
Skills of one years old during seven years old.
Often related with multiple physical abnormalities
indicating neurological damage.
As adults they require intense family and social support
throughout their life.

DSM 5 Diagnostic Criteria


ID is a disorder with onset during the developmental
period that includes both intellectual and adaptive
functioning deficits in conceptual, social, and practical
domains. The following three criteria must be met:
A. Deficits in intellectual functions confirmed with clinical
assessment and individual standardized intelligence testing.
B. Deficits in adaptive functioning that result in failure to meet
developmental and sociocultural standards for personal
independence and social responsibilities. Without ongoing
support, the adaptive deficits limit functioning in one or more
activities in daily life.
C. Onset of intellectual and adaptive deficits during the

Autism Spectrum Disorder


Replaces the group of disorders called pervasive
developmental disorders
The reason is because they have no consistent distinct
features among the disorders, but have common sets of
behaviours.
ASD includes:

Autistic disorder
Aspergers disorder
Pervasive developmental disorder
NOS Childhood disintegrative disorder
Rhett's disorder

Autism refers to a developmental disability involving social


and communication functions.
ASD is neurodevelopmental disorder characterized by
deficits in social communication, social interaction and
presence of restricted repetitive behaviour.
ASD affects social interaction. Communication, interest and
behaviour.
In children with ASD, the symptoms are present before 3
years of age, although some diagnosis are made after three
years old.
DSM 5 requires a total of 5 symptoms
3 from social deficit & communication
2 from repetitive behaviour.

Features required to diagnose


patient with ASD
1. Impairment of social communication and interaction
Problems of social reciprocating/engagement or emotional
interaction. Lack of

Sharing of interest
Sharing/reciprocating of affect
Sharing/reciprocating emotion/enjoyment
showing./sharing mid
Not response to call
Not aware/engaged/interact with surrounding

Lack/deficit of non verbal communication behaviour as absent of

Eye contact
Posture
Facial expressions
Tone of voice and gestures
Ability to read others body gestures

Delayed language development


Inability to initiate and maintain conversation
Lack of interest in making friends/interest in peers/others
Prefer to play alone
Absence of imaginative play/pretend i.e. feed others with bread toy

Limited or repetitive use of vocabulary/language

2. Repetitive behaviour, interest or activities


Stereotyped or mannerism of speech, motor movements i.e
hand flapping/head banging/body rocking or use of objects i.e
spinning/lining of objects
Inflexible adherence to certain activities i.e must be
conducted at the same time or same manner/ritual
Persistent/ intense focus with certain objects

Diagnostic Criteria
A.
Persistent deficits in social communication and social interaction across
multiple contexts, as manifested by the following, currently or by history
(examples are illustrative, not exhaustive, see text):
Deficits in social-emotional reciprocity, ranging, for example, from abnormal social
approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.
Deficits in nonverbal communicative behaviours used for social interaction, ranging, for
example, from poorly integrated verbal and nonverbal communication; to abnormalities
in eye contact and body language or deficits in understanding and use of gestures; to a
total lack of facial expressions and nonverbal communication.
Deficits in developing, maintaining, and understanding relationships, ranging, for
example, from difficulties adjusting behaviour to suit various social contexts; to
difficulties in sharing imaginative play or in making friends; to absence of interest in
peers.

Specify current severity:

Severity is based on social communication impairments and restricted repetitive


patterns of behaviour

B.
Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at
least two of the following, currently or by history (examples are illustrative, not exhaustive;
see text):
Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies,
lining up toys or flipping objects, echolalia, idiosyncratic phrases).
Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal
behaviour (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns,
greeting rituals, need to take same route or eat food every day).
Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or
preoccupation with unusual objects, excessively circumscribed or perseverative interest).
Hyper- or hypo reactivity to sensory input or unusual interests in sensory aspects of the environment
(e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with lights or movement).

Specify current severity:

Severity is based on social communication impairments and restricted, repetitive patterns of


behaviour

C.
Symptoms must be present in the early developmental period (but may not
become fully manifest until social demands exceed limited capacities, or may be
masked by learned strategies in later life).
D.
Symptoms cause clinically significant impairment in social, occupational, or
other important areas of current functioning.
E.
These disturbances are not better explained by intellectual disability
(intellectual developmental disorder) or global developmental delay. Intellectual
disability and autism spectrum disorder frequently co-occur; to make comorbid
diagnoses of autism spectrum disorder and intellectual disability, social
communication should be below that expected for general developmental level.
Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder,
Aspergers disorder, or pervasive developmental disorder not otherwise specified
should be given the diagnosis of autism spectrum disorder. Individuals who have
marked deficits in social communication, but whose symptoms do not otherwise
meet criteria for autism spectrum disorder, should be evaluated for social
(pragmatic) communication disorder.

Specify if:
With or without accompanying intellectual
impairment
With or without accompanying language
impairment
Associated with a known medical or genetic
condition or environmental factor
Associated with another neurodevelopmental,
mental, or behavioural disorder
With catatonia (refer to the criteria for
catatonia associated with another mental

ASD with autism


Severe form of neurodevelopmental disorder.
Like ASD is characterized as marked impairment in
social and communication skills, language as well a
presence of repetitive behaviour occurring before 3
years of age such as flipping objects, echolalia or
touching of objects.

Social skill impairment


May have poor social skills to connect with others. He/she may seems
to be preoccupied in his/her world.
Areas of difficulties include to:

Share the same object


Play with others and share toys
Understand feelings
Make friends

Behaviours
A child with autism may

Have trouble changing from one activity to another


Flap hands, rock and spin
Easily get upset for certain sounds
Like only a few food
Have unusual interests

Communication skills
Child may have problem in

Understand and using gestures


Following directions
Understanding words
Learning to read or write or
Child may read without understand the meaning called hypermedia

The child may also


Repeat words with umpteen times called echolalia
Talk with little expression
Expresses tantrums

Cause is unknown
Symptoms continue for whole life and majority unable to be
independent but IQ may be normal
Sometimes may have seizures and low muscle tone.

Treatment
Specific treatment is unknown.
Usually require special school
There are special techniques for teaching autistic
children and special psychotherapeutic approach is
needed,
Antipsychotics and antidepressants may be need for
child showing symptoms.

ASD with Retts Syndrome


Has some differences where child develops normally at
an early stage.
Sx commonly appears after 5-18 months of birth when
the child development starts to regress
Language and motor activity start to regress
Purposeful hand use is lost
Deceleration is head growth (microcephaly in certain cases)

Classical feature is stereotype movement of the hands


Genetic developmental disorder related to X
chromosome.
Almost always in girls , rarely boys

It affects areas of brain function that are involved:

Cognitive
Emotional
Motor
Sensory
Autonomic functions.

Generally the developmental slows and loss of previously


learned skills.
Early sx is low muscle tone and diminished eye contact.
Soon girls with this syndrome have difficulties in area of
communication skills and intentional use of their hands and
often make repetitive hand movements.
Many develops seizure and/or irregular breathing pattern.

ASD with Aspergers Syndrome (AS)


Milder version of autism or high functioning autism
Have similar features except language and cognitive is
preserved.
Prominent features are marked social and non verbal
communication deficits and presence of repetitive
behaviours.
AS is often detected after 2 years.
Psychotic episodes occasionally occur in early adult life.

ADHD
Most common neurobehavioral disorder in childhood.
Occurs mostly in first 5 years of life.
Common among developed countries, urban, lower
middle socioeconomic class and non-professionals.
More common in boys than girls 8:1
Symptoms decline with increasing age
Aetiology : genetic predisposition, maternal deprivation,
maternal alcohol abuse, environmental toxins or
intrauterine or postnatal brain damage.

ADHD presentations include


Inattentive
Hyperactivity-impulsive
Combined inattentive and hyperactive-impulsive.
Inattentive in girls while hyperactive in boys. Inattentive type are not overtly
active; cause less disruption to others , therefore problems may go unnoticed.
May have fewer sx of hyperactive-impulsivity.
Normally less likely to act out or have difficulties in getting along with others.
They may sit quietly but not pay attention to what they are doing.
Other sx include extreme distractibility, difficulty in paying attention or focusing
such as when reading or listening. The child has a tendency to overlook details,
leading to errors or incomplete task.
Child presented with hyperactive-impulsive and combination sx from both
categories will have main sx from hyperactive-impulsive category.
Combined type contributes to 90% of cases in ADHD.

DSM 5 requires 6 sx from inattentive or 6 sx from hyperactiveimpulsive to diagnose ADHD.

Inattentive
Poor persistent towards goals and tasks
Make careless blunders or mistakes
Poor inhibitions towards distract ability
Difficulty in re-engaging with previous task.
Has difficulties in organizing task
Doesn't listen when spoken to
Doesnt follow instruction
Frequently losses or misplaces belonging
Forgetful in daily activity

Hyperactive-impulsive
Fidgety
Leave seat/place when remaining seat/place are expected
Blurts answer in class before hearing the whole question
Interfere and intrudes others
Unable to engage play or activity quietly
Trouble keeping still
Always on the go as if driven by motor
Talk excessively
Cant wait for his or her turn in line or in game

People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that
interferes with functioning or development:
1.Inattention:
Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17
and older and adults; symptoms of inattention have been present for at least 6 months, and they
are inappropriate for developmental level:
a) Often fails to give close attention to details or makes careless mistakes in schoolwork, at
work, or with other activities.
b) Often has trouble holding attention on 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 (e.g., loses focus, side-tracked).
e) Often has trouble organizing tasks and activities.
f) Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period
of time (such as schoolwork or homework).
g) Often loses things necessary for tasks and activities (e.g. school materials, pencils, books,
tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h) Is often easily distracted
i) Is often forgetful in daily activities.

2.Hyperactivity and Impulsivity:


a) Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for
adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present
for at least 6 months to an extent that is disruptive and inappropriate for the persons
developmental level:
b) Often fidgets with or taps hands or feet, or squirms in seat.
c) Often leaves seat in situations when remaining seated is expected.
d) Often runs about or climbs in situations where it is not appropriate (adolescents or adults may
be limited to feeling restless).
e) Often unable to play or take part in leisure activities quietly.
f) Is often "on the go" acting as if "driven by a motor".
g) Often talks excessively.
h) Often blurts out an answer before a question has been completed.
i) Often has trouble waiting his/her turn.
j) Often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Several inattentive or hyperactive-impulsive symptoms


were present before age 12 years.
C. Several symptoms are present in two or more setting,
(such as at home, school or work; with friends or
relatives; in other activities).
D.There is clear evidence that the symptoms interfere
with, or reduce the quality of, social, school, or work
functioning.
E. The symptoms are not better explained by another
mental disorder (such as a mood disorder, anxiety
disorder, dissociative disorder, or a personality
disorder). The symptoms do not happen only during
the course of schizophrenia or another psychotic
disorder.

Treatment
Parents and teachers much be advised on how to cope
with hyperactive children
Nootropic drugs and mild doses of anti-psychotics are
sometimes prescribed
Stimulant drugs as methylphenidate sometime have the
paradoxical effect, according to theory, the stimulants
act by reducing the excessive, poorly synchronized
variability in the various dimensions of arousal and
reactivity seen in ADHD
Stimulants are drugs of first choice

Specific learning Disorder (SLD)


Persistent inability to learn or difficulties in acquiring
specific basic/key academic skills i.e mathematics,
reading and reading resulting in poor academic
performances
It is rather difficult to tell as child has normal
development in other areas including the intelligent
level.
The onset must be during the preschool and primary
school with the problems in learning new information
and skills

Features in learning abilities in


reading (dyslexia)
Symptoms are mainly due to
Difficulty in understanding the relationship between sounds,
letters and words.
Not able to understand what is read

As such the child will have problem with

Recognising and reading printed letters and words


Understanding words and ideas/what has been read
Impaired reading and fluency
Lack of vocabulary

Features of learning disability in


mathematics
Problems in memorizing and organizing numbers and
appreciating the magnitude
Recognising operation signs
Counting by principles.

Features of learning disability in


writing
Consistency in writing
Problem with spelling
Writing expression i.e lack of clarity or organization of
ideas, multiple grammatical errors.

Children with SLD can experience performance anxiety,


depression and low self-esteem and lose motivation.
The etiological factors for SLD are likely due to an interaction
of genetic and environmental factors
The prevalence is about 2% to 10%.
More in boys than girl 4:1
Causes may be familial, focal cerebral injury or toxins.
Often observed at preschool age and recognize during first
five years of primary school.

Treatment
A reading specialist, mathematics tutor or other trained
professional to guide on study skills.
Individualised education program
Therapy
If there is severe depression or anxiety SSRI would help.

Conduct Disorder
Is now classified under Disruptive, impulse control and conduct
disorders category in DSM-5.
A group behavioural problem thats usually begins during
childhood.
Children have chronic pattern of poorly controlled behaviour that
violates the rights of others and out of the major social norm.
Often patient brought in after conflict with authority and legal
actions.
DSM 5 requires 3 sx for at least 12 months and ! Sx for at least 1
month.
Must be before 18 years old.

Symptoms of Conduct Disorder


Violates rules or disobeys parents/ teacher/ other authority figures
Cruel and violence to human and animals
Truancy, lying and stealing
Substance abuse
Involve in gangsterism
Involve in physical fights and often using dangerous weapons
Law breaking behaviour
Run away from house
Lack of empathy
Other aggressive behaviour towards people, including bullying and
physical and sexual abuse

Genetic and environmental factors


Genetic causes
Frontal lobes regulates emotions and personality.
Frontal lobe lesion can cause impulsivity, lack of impulse
control and inability to learn from past experiences, the
impairment of the frontal lobe may be genetic

Environmental causes

Child abuse
Poverty broken home or marital disharmony
Parents with antisocial personality
Substance abuse

Treatment
Family therapy is useful to enhance emotional support
and understanding
In certain cases such as pathological family, abused or
neglected children, foster homes or special residence is
recommended .
In severe cases court intervention is sometimes
required for placement.