1. IzBen C. Williams, MD, MPH Instructor

2. Psychiatric Disorders in Children  Intro  Child and adolescent psychiatry is the study and treatment of the mental, developmental, and behavioral problems of childhood  An understanding of standard childhood psychological development is essential to the understanding of childhood psychopathology

3. Psychiatric Disorders in Children  Childhood Psychopathology  Most disorders are more common in boys  Psychopathology is usually the result of chronic, maladaptive interactions between child and environment, often combined with some genetic, physiologic, or temperamental propensity towards developing a mental illness  Misbehavior may be the result of the parents’ conscious or unconscious prompting

4. Psychiatric Disorders in Children  Feeding and eating disorders of infancy and childhood  Pica: persistent eating of non-food products  Rumination disorder: purposeful expulsion and re-chewing of previously ingested food  Failure to thrive: feeding disorder of infancy or early childhood

5. Psychiatric Disorders in Children  Pervasive developmental disorders of childhood  Autistic spectrum disorders (autism disorder and Asperger disorder)  Rett disorder,  Childhood disintegrative disorder

6. Psychiatric Disorders in Children  Pervasive developmental disorders of childhood  These disorders are characterized by failure to acquire, or the early loss of, social skills and difficulties with language resulting in lifelong problems in social and occupational functioning  They are not reversible

7. Psychiatric Disorders in Children  Autistic Disorder  Autistic disorder is an illness in which the child is:  Is relatively unresponsive to human beings  Demonstrates bizarre responses to his environment  Has unusual language development

8. Psychiatric Disorders in Children  Autistic Disorder  Characteristics include:  Severe problems with communication (despite normal hearing)  Significant problems with social relationships  Repetitive behavior (eg spinning, self-injury)  Subnormal intelligence in many (26% to 75%)  Unusual abilities in some children (savant skills)

9. Psychiatric Disorders in Children  Autistic Disorder  Autism is also a symptom of several disorders (eg schizophrenia)  As a symptom autism refers to a preoccupation with the internal world of the individual to the exclusion of external reality  Autistic children treat other individuals indifferently, almost as though they were inanimate objects  Social development is invariably abnormal

10. Psychiatric Disorders in Children  Autistic Disorder characteristics:  Usually begins before age 3 yrs  Occurs in about 17 per 10,000 children  Five times more common in boys  Autism is also a symptom of several disorders (eg schizophrenia)  As a symptom autism refers to a preoccupation with the internal world of the individual to the exclusion of external reality

11. Psychiatric Disorders in Children  Asperger Disorder  Asperger disorder is a mild form of autism involving  Significant problems forming social relationships  Repetitive behavior and intense interest in obscure subjects  In contrast to autistic disorder, in Asperger’s there’s normal cognitive development and little or no developmental language delay but conversational language skills are impaired

12. Psychiatric Disorders in Children  Rett disorder  Clinical characteristics:  Diminished social, verbal, and cognitive development after up to four years of normal functioning  Occurrence only in girls (Rett disorder is X-linked and affected males die before birth)  Stereotyped hand wringing movements, ataxia  Mental retardation, breathing problems

13. Psychiatric Disorders in Children  Elimination Disorders  Enuresis: child continues to urinate at inappropriate times and places, past the time after which he should have ceased  May be primary or secondary  Etiology: Organic disorders, Psychological factors  Treatment:  Usually self limiting  Medication Tricyclic antidepressant imipramine  Treat any underlying stress

14. Psychiatric Disorders in Children  Elimination Disorders  Encopresis: Fecal incontinence past the period when bowel control should have been established.  Most encopresis is unconscious and involuntary; only occasionally does it occur deliberately.  May ne primary of secondary

15. Psychiatric Disorders in Children  Elimination Disorders  Etiology of Encopresis:  Organic disorders  Psychological Factors  Unresolved anger at parent  Regressive wishes  Psychotic symptoms  When autonomy and control battles focus on toilet training……  Treatment: Appropriate to cause

16. Psychiatric Disorders in Children  Thumb sucking  More common in girls than boys  Is normal at traditional periods in child’s life (eg at bedtime, at times of separation from the parent)  If it is persists after age 3yrs it can cause changes in dentition  Exploration of child’s relationship with parent is usually indicated.  In older child behavior modification may be useful (eg where child is insecure or withdrawn)

17. Psychiatric Disorders in Children  Masturbation  Childhood masturbation involves general manipulation and fondling. Parents may complain  It is a universal behavior and not restricted to children (as we all know).  An open attitude by physician is important  Any notion that may cause growth retardation, mental retardation, or any other adverse physical consequences should be dispelled

18. Psychiatric Disorders in Children  Masturbation  Masturbation occurs in all children.  It can develop before age 1 year. During the oedipal period (3-6yys) there may be heightened genital focus.  Continuous masturbation may be a sign of severe understimulation, environmental deprivation, excessive sexual stimulation, or sexual abuse.

19. Psychiatric Disorders in Children  Tourette Disorder:  Clinical data. Tourette disorder consists of recurrent, involuntary, purposeless, motor movements accompanied by verbal tics (eg. Coprolalia, involuntary swearing, barking and grunting).  Psychological stress exacerbates the symptoms, but the cause, although unknown, is probably organic  ADHD & OCD occur with increased frequency in these patients

20. Psychiatric Disorders in Children  Tourette Disorder  Epidemiology:  More common in boys,  Onset before age 21  Occurs in all socioeconomic classes  Treatment:  Psychotherapy  Education  Medical treatment

21. Psychiatric Disorders in Children  Attention Deficit Hyperactivity Disorder  Key symptoms of ADHD include:  A short attention span  Difficulty concentrating  Impulsivity  Distractibility  Excitability and  Hyperactivity

22. Psychiatric Disorders in Children  Attention Deficit Hyperactivity Disorder  Three types recognized: i. ADHD predominantly inattentive ii. ADHD predominantly hyperactive –impulsive iii. ADHD combined  Seen more often in boys

23. Psychiatric Disorders in Children  Attention Deficit Hyperactivity Disorder  Etiology: i. Medication eg sedative hypnotics (paradoxical) ii. Depression. Sad feelings …..hyperactivity iii. Anxiety iv. Constitutional hyperactivity (from birth) v. Intolerant parent, teacher or supervisor vi. Severe CNS disease vii. Specific learning disabilities….etc.

24. Psychiatric Disorders in Children  Attention Deficit Hyperactivity Disorder  Treatment: i. Medication: stimulants, clonidine, antidepressants ii. Diet eg decrease sugar intake iii. Behavior modification programs iv. Environmental engineering

25. . PROBLEMS OF ADOLESCENTS

26. Psychiatric Disorders in Children  Problems of adolescents A. Identity Disturbances B. Adult sexual development C. Separation D. Treatment

27. Psychiatric Disorders in Children  Problems of adolescents A. Identity Disturbances  Adolescents struggle to achieve a stable identity. Certain problems result when this aspect of development breaks down.  Identity diffusion  Peer-related disorders  Problems with successfully resolving this developmental task my contribute to the development of identity disorder, narcissistic and borderline personality disorders

28. Psychiatric Disorders in Children  Problems of adolescents B. Adult sexual development  Homosexual behaviors: found commonly in early adolescence. However, when they persist through early adulthood it usually represents true homosexual preference  Paraphilias  Pregnancy  Sexually transmitted diseases

29. Psychiatric Disorders in Children  Problems of adolescents C. Separation: Adolescents negotiate their emancipation from family and redefine the parent-child and sibling roles and boundaries  Difficulty with emancipation  Schizophrenia  Anorexia  Depression  Mobilization of aggression (emancipation ritual)  Incest (can develop to prevent emancipation)

30. Psychiatric Disorders in Children  Problems of adolescents D. Treatment: Special problems in psychotherapy with adolescents  Labile allegiances good/bad from day to day  Labile moods hormonal and psyc’al turbulence  Communication difficulties (many adolescents communicate by means of their behavior)  Overprotective parents