Child Psychiatry

Samah Khan #1001221

Moaz Allababidi #11000961
Group C

Index

Introduction
ICD-10 Classification
Child Assessment
Pervasive Developmental Disorders
Learning Disorders
Disruptive Behavior Disorders
Psychotic Disorders
Mood Disorders
Anxiety Disorders

Introduction

Definition (WHO): Child and adolescent

Mental Health is the capacity to achieve and
maintain optimum psychological functioning
and well being. It is directly related to the
level reached and competency achieved in
psychological and social functioning

ICD-10 classification

F80 - F89: Disorders of Psychological Development

F80 Specific developmental disorders of speech and language
F80.0 Specific speech articulation disorder
F80.1 Expressive language disorder
F80.2 Receptive language disorder
F80.3 Acquired aphasia with epilepsy [Landau-Kleffner syndrome]
F80.8 Other developmental disorders of speech and language
F80.9 Developmental disorder of speech and language, unspecified
F81 Specific developmental disorders of scholastic skills
F81.0 Specific reading disorder
F81.1 Specific spelling disorder
F81.2 Specific disorder of arithmetical skills
F81.3 Mixed disorder of scholastic skills
F81.8 Other developmental disorders of scholastic skills
F81.9 Developmental disorder of scholastic skills, unspecified

ICD-10 classification

F82 Specific developmental disorder of motor function

F83 Mixed specific developmental disorders

F84 Pervasive developmental disorders

F84.0 Childhood Autism
F84.1 Atypical Autism
F84.2 Retts syndrome
F84.3 Other childhood disintegrative disorder
F84.4 Overactive disorder associated with mental
retardation and stereotyped movement
F84.5 Aspergers syndrome
F84.8 Other pervasive developmental disorders
F84.9 Pervasive developmental disorder, unspecified

ICD-10 classification

F90 - F98: Behavioural and emotional

disorders with onset usually occurring in
childhood and adolescence

F90 Hyperkinetic disorders (ADHD)

F91 Conduct disorders
F92 Mixed disorders of conduct and emotions
F93 Emotional disorders with onset specific to
childhood
F94 Disorders of social functioning with onset in
childhood and adolescence
F95 Tic disorders

Child Assessment

Just like any other psychiatric history with focus on:

Detailed school history

Developmental history
Family interview
Collateral from the childs school (ABC)
1. Academic performance
2. Behaviour in school
3. Classmate relationship

Broad Classification of
Disorders
1. Developmental disorders

Autistic spectrum disorders including: Asperger's disorder

Retts syndrome
Learning disorders

2. Disorders of attention and behavior

Attention deficit hyperactivity disorder (ADHD)
Oppositional defiant disorder
Conduct disorder

3. Psychotic disorders
Childhood onset schizophrenia

4. Mood disorders
Depression
Bipolar disorder

5. Anxiety disorders
Panic disorder
Phobias
Obsessive Compulsive Disorder

6. Eating disorders
Anorexia nervosa
Bulimia nervosa

1 - (Pervasive) Developmental
disorders

Pervasive developmental disorders: Impairment across multiple domains

(impairment is global):
Psychological Impairment
Social Impairment
Academic Impairment
They are referred to as developmental disorders because they reveal
themselves in early childhood (generally before 3 years of age), often as
delays in normal development.
It significantly affects verbal, nonverbal, or logical communication and
social interaction skills .
Other characteristics often associated include the following :
Engagement in Repetitive activities and Stereotyped movements
Resistance to Environmental change or Change in daily routines
Unusual responses to sensory experiences

Characteristics of Autism
(Social Interaction)

Marked impairment in the use of nonverbal behaviours for social

interaction:

Avoid eye contact

Inappropriate use of facial expression: may smile or laugh at inappropriate

times, or cry at something silly or funny

Unable to read other peoples nonverbal gestures and body language

Invade personal space

Resist physical affection

Not showing, bringing, or pointing out things they like

Prefer solitary activity and not actively participate in simple social play

Lack of awareness of other children, even siblings and does not understand
the needs of others or someones distress

Failure to develop peer relationships appropriate to developmental

level:

Does not seek other children to play with

In younger child, shows little or no interest in developing friendships

In an older child, may wish to develop friendship but have lack of

understanding for social conventions of friendship.

Characteristics of Autism
(Communication)

Impaired ability to sustain conversation

Making irrelevant comments
Stereotyped, repetitive or idiosyncratic* use of
language:
May be echolailic** aka "movie talk
Verbal rituals such as saying Im fine whenever
they meet someone whether or not they are asked.
Imagination play may be absent or very impaired,
usually do not engage in simple imitation games
May display inappropriate use of toys

*Idiosyncratic language refers to language with private meanings or meaning that only
makes sense to certain people it may be used repeatedly but be inappropriate to
conversation. It can be something heard on tv, or could be made-up words.
**Echolalia (aka echologia) is the automatic repetition of vocalizations made by another
person (by the same person is called palilalia)

Characteristics of Autism
(Language)

Abnormalities in pitch, intonation, rate, rhythm or stress

May speak too loudly or too softly;

May not know when to use loud or soft voice (intonation)
Speech may be monotonous
May contain question-like rises at the end of sentences

Immature grammatical structures:

Inappropriate use of pronouns: I, you, she, he, it, his, her,
they, my, mine etc.
May use incorrect verb tense, such as he doed good, he
goed to the park, me be gooder

Disturbance in language comprehension

May be unable to understand simple questions, directions
or jokes.

Characteristics of Autism
(Activities & Interests)

Specific interests:

child may display limited interests and know everything

there is to know about that particular interest and conversation will only revolve
around that area of interest

Unusual preoccupations:

e.g. Road signs, toilet brushes, vacuum

cleaners, labels from cans etc.

Repetitive use of objects & compulsions/rituals:

may fixate

on spinning or moving items; arranging things in a certain order etc

Unusual sensory interests:

may touch, feel, smell, taste all items in

their environment, e.g. licking puzzle pieces or putting them in their mouth or
smelling blocks etc. Often they are hypersensitive to sound or touch

Repetitive motor mannerisms and self-stimulation:

hand/finger flicking, flapping or complex whole body movements

Self injury:

Special skills:

e.g. biting, smacking, pinching, poking

unusual talents in one or more areas

Aspergers
Syndrome

Previouslyknownashighfunctioningtypeofautism
higherperformingchildrenandlesslikelytobeintellectually
disabled
Communicationhandicapislesssevere
Abnormalspeechintonation
Appropriatelanguagecomprehension
Socialinteractionsimpaired
Impairedreadingofsocialcues
Clumsy
Difficultywithtransition
Preoccupationwithmattersofprivateinterest

Treatment

No specific treatment
Usually require special schooling or residential
schooling but also with attempts to integrate
them with regular students
Special techniques for teaching autistic
children and special psychotherapeutic
approaches
Antipsychotic drugs and antidepressants are
used to cope with aggressive behaviour and
depression

Retts Syndrome

Previously cerebroatrophic hyperammonaemia

Postnatal progressive neurodevelopmental disorder
almost exclusively in girls
Clinical features & characteristics:
Small hands and feet
Microcephaly
Repetitive stereotyped hand movements eg. hands
wringing or repeatedly putting hands in mouth
Usually no verbal skills and 50% dont walk
Prone to GI disorders, esp. constipation
Seizures 80%
Scoliosis
FTT

Learning Disorders

Common indicators of learning disorders that parents should

watch for in their child include the following:
Difficulty understanding and following instructions
Trouble remembering what someone just told him or her
Fails to master reading, spelling, writing, and/or math skills, and
thus fails
Difficulty distinguishing right from left; difficulty identifying words
or a tendency to reverse letters, words, or numbers; (for
example, confusing 25 with 52, "b" with "d," or "on" with "no").
Lacks coordination in walking, sports, or small activities such as
holding a pencil or tying a shoelace.
Easily loses or misplaces homework, schoolbooks, or other items.
Difficulty understanding the concept of time; is confused by
"yesterday, today, tomorrow."

Symptoms

READING

WRITING

MATHEMATICS

Slow, hesitant
word by word
reading
Reading without
punctuation
Mirror reading,
word guessing
Omission
substitution,
addition of words
Understanding,
recall and drawing
inference

Avoiding or slow
writing
Awkward pencil
holding
Poor handwriting,
spelling, size
inconsistency,
mixing small and
capital letters
Transposition,
mirror writing, add
or omit letters in
words

Longer time
Mistakes in sums
involving 0
Difficulty in
keeping tenth,
hundredth or
thousand place
Carry over or
borrowing problem
Difficulty in word
problems

SN

Management

PROFESSIONALS

MANAGEMENT

Clinical Psychologists

Psychoeducation
Provide psychotherapy for the emotional
problems, anxiety, behavioural problems,
poor self esteem
Address the neuropsychological problems

Psychiatrists

Provide psychotherapy
Medications if required for the
comorbidities

Special educators

Major role in providing training and

special education as per need of the child

2 - Disruptive Behaviour Disorders

ADD
Attention Deficit Disorder (Hyperactive type) ADHD
Attention Deficit Disorder (Withdrawn type)

Oppositional Defiant Disorder

Conduct Disorder

Attention Deficit
Hyperactivity Disorder
(ADHD)

Characterized by:
Developmentally inappropriate inattention
Impulsivity
Over-activity

Restless, overactive, distractible, reckless, disruptive behaviour,

accident-prone
Up to 11% of school age children

Possible etiology:
Subtle Dysfunction in the Frontal Lobe (which is responsible for
planning, attention, regulation of motor activity brain under-active
in these children)

Reduced metabolic activity

Hypoperfusion

Not enough dopamine

Medications for ADHD

stimulants

Medication: Stimulants
Ritalin (methylphenidate)
Dexedrine (dextroamphetamine)
Adderall (D,L dextroaamphetamine)

Extended release Ritalin LA; Metadate CD, Concerta

and decrease dosing to once daily
Adderall XR Vyvanse is also extended release
Side effects
Anorexia, Weight loss, Lowers the seizure threshold, Abnormal
movements, Labile mood, Insomnia, Hyper-focused, Agitation

Medications for ADHD

nonstimulants

Tricyclic Antidepressants
Imipramine, Desipramine, Clomipramine
Concern about cardiac conduction

Clonidine (Catapress)
Developed as an antihypertensive
Reduce norepinephrine activity in the brain
Side effects
Most common: dyspepsia, nausea, vomiting, fatigue, appetite
decreased, dizziness, and mood swings
Less common: insomnia, sedation, depression, tremor, itching, dry
eyes,
Adverse events: Increased heart rate and blood pressure; ventolin
inhalers can increase
Drug interactions: Paxil and Prozac

Oppositional Defiant
Disorder

Characterized by:

Enduring pattern of disobedience

Argumentative
Explosive (Impulsive)
Frequently in conflict with adults
Tendency to blame others

Comorbid Diagnosis with ADHD, anxiety and mood disorders

Conduct Disorder

Characterized by:
A repetitive and persistent pattern of behavior
in which the basic rights of others or major ageappropriate social rules are violated (antisocial
behaviors)
Higher than expected rates of associated ADHD,
depression and learning disorders
Considered a precursor to Antisocial Personality
Disorder (must intervene and change childs
behavior to avoid this), which is not diagnosed
till age of 18.

3 - Psychotic disorders
Childhood onset
Schizophrenia

Onset before age 18 (early onset)

Onset before age 13 (very early onset)
Typically presents after age 7
Presentation:

Earliest: delays in language and motor development

Auditory (most common positive symptom) and visual
hallucinations
Prodormal phase preceding psychotic symptoms: deterioration in
academics, social withdrawal, disorganized or unusual behavior,
decreased ability to perform daily activities, deterioration in selfcare, bizarre hygiene & eating behaviors, change in affect, lack of
impulse control, hostility & aggression and lethargy
Delusions in >50%, but less complex than adults

Diagnostic criteria similar to that of adults and based on

observed behavior by caretakers or self reports if child is old
enough

4 - Mood Disorders
Depression

Frequent vague, non-specific physical complaints eg. Headaches,

muscle aches, stomach-aches or fatigue
Frequent school absences or poor performance in school
Talk/efforts to run away from home
Outbursts of shouting, crying, unexplained irritability, complaining
Being bored
Lack of interest in playing with friends
Alcohol or substance abuse (adolescents)
Social isolation, poor communication
Fear of death
Extreme sensitivity to rejection or failure
Increased irritability, anger or hostility
Reckless behaviour
Difficulty with relationships

Diagnostic Criteria for Major

Depressive Disorder

5 of the following symptoms, must include first

2, occurring almost everyday for 2 weeks

Depressed mood
Anhedonia
Appetite loss or increase
Sleep disturbance too much or too little
Fatigue
Feelings of worthlessness or guilt
Difficulty concentrating or deciding
Recurrent thoughts of death

Treatment

Antidepressant medication
Cognitive-Behavioral Therapy (CBT)
Family Therapy
Other therapies (interpersonal therapy, group
therapy, supportive psychotherapy)

Bipolar Disorder

Characteristics of bipolar disorder in children:

Tend to move rapidly from cycle to cycle, even in one day, with
few well periods
May experience both mania and depression together
Moody and behavioral traits such as temperamental, rigid,
opposition, extreme irritability, episodic rage/tantrums
Extreme separation anxiety as a baby
Less sleep, very high energy, extremely talkative
Teenagers may believe they have superhero powers, highly
distractible, high risk-taking behavior including substance abuse
and sexual indiscretions
Treatment: atypical antipsychotics (Risperdal, Zyprexa,
Seroquel) and mood stabilizers (lithium or anticonvulsants like
sodium valproic acid, Carbamazepine, Oxcarbazepine,
Lamotrigine)

5 - Anxiety Disorders
Panic disorder

PA is an acute anxiety episode in which the child or adolescent

experiences a set of emotional, cognitive and somatic symptoms in
the absence of real danger that are similar to those triggered by
objectively life-threatening situations
Emotional symptoms: sense of unreality or being detached from
oneself, feelings of choking, intense fearfulness
Somatic symptoms: palpitations, sweating, dizziness, trembling or
shaking
Cognitive symptoms: fear of losing control or going crazy, fear of
dying
Peak intensity: within few minutes ie 5-10mins and subsides 15-30
minutes later
Treatment: CBT, counseling psychotherapy; medical:
antidepressants (SSRIs) and benzodiazepines

Phobias

Developmentally normal fears:

Age

Normal Fear

Birth - 6 Months

Loud noises, loss of physical support, rapid

position changes, rapidly approaching other
objects

7 - 12 Months

Strangers, looming objects, unexpected objects

or unfamiliar people

1 5 Years

Strangers, storms, animals, dark, separation

from parents, objects, machines loud noises,
the toilet

6 12 Years

Supernatural, bodily injury, disease, burglars,

failure, criticism, punishment

12 18Years

Performance in school, peer scrutiny,

appearance, performance

Phobias

Intense, irrational fears of certain things or situations

3 main types of phobias:
Specific Phobia: Intense fear of a particular object thats
harmless.
Social Phobia: The fear of embarrassment in front of
people.
Agoraphobia: characterized as being in places or
circumstances that prove to be difficult or humiliating
to escape
Specific phobias are grouped under four main types:

Animal (e.g. dogs, spiders),

Natural environment (e.g. heights, water),
Blood-injection-injury
Situational (e.g. airplanes, elevators).

Phobias

Symptoms:
Avoidance or distress over the object of fear results in
significant disruption of routine, school functioning, family
or social relationships
Crying, tantrums, trembling, freezing or clinging
Tachycardia, dizziness, sweaty palms, shortness of breath,
looking flushed
Feeling of choking
Chest pain/discomfort
Upset stomach
Numbness
Treatment: CBT (relaxation training, imagery techniques,
token reinforcements by parents etc), exposure therapy

Obsessive Compulsive
Disorder

Obsessions as defined by: (DSM IV)

Recurrent and persistent thoughts, impulses, or images which
are intrusive and cause marked anxiety or distress
Thoughts, images, or impulses are not simply excessive worries
about real problems
The person attempts to suppress the thoughts, images, or
impulses, with some other thought or action
The person recognizes that his obsessions are a product of his/her
own mind (insight)
Compulsions as defined by: (DSM IV)
Repetitive behaviors that the person is driven to perform in
response to an obsession
The behaviors of mental acts are aimed at reducing or
preventing distress or some dreaded event

Obsessive Compulsive
Disorder

Symptoms at home:
Repeated actions to prevent a feared
consequence
Consuming obsessions and compulsions
Distress if ritual is interrupted
Difficulty explaining unusual behavior
Attempts to hide obsessions or compulsions
Resistance to stopping the obsessions of
compulsions
Concern that they are crazy because of their
thoughts

Obsessive Compulsive
Disorder

Symptoms at school: (parents usually seek help when academic

performance affected):
Difficulty concentrating problem finishing or initiating school
work
Social Isolation
Low self-esteem
Co-morbid conditions eg. ADHD, learning disorders/cognitive
problems
Daydreaming the child may be obsessing
Constant need for reassurance
Rereading and re-writing, repetitively erasing
Repetitive behaviors touching, checking, tracing letters
Fear of doing wrong
Avoid touching certain unclean things
Withdrawal from activities or friends

Obsessive Compulsive
Disorder

Treatment:
Family-based CBT
Younger children need parental guidance
Need to educate them that its not their fault
(reduce self-blame)
Exposure therapy (therapist and parents)
Constant praise for good behavior and
achievements
Interaction with school and working with them
flexibility and supportive environment

Conclusion

Epidemiological research shows that anywhere from 318% of children have a psychiatric disorder that causes
significant functional impairment
Treatment will usually involve one or more of the
following: behavior therapy, cognitive behavior therapy,
problem-solving therapies, psychodynamic therapy,
parent-training programs, family therapy and/or the use
of medications.
Children are more resilient than adults and so early
intervention at this critical period is possible with the
potential for making a lifelong difference to those being
seen.