MEKELLE UNIVERSITY

COLLEGE OF HEALTH SCIENCE

SCHOOL OF NURSING

DEPATMENT OF PSYCHIATRY
Child and Adolescence psychiatry

Prepared by:- Tesfalem A. (BSc.PH, MSc Psychiatry)

April, 2018,
Mekelle, Ethiopia
Child and Adolescence
psychiatric
assessment
Introduction
Psychiatric assessment is the cornerstone
of Psychiatry
Assessment of children and adolescents is
difficult
 Need multiple source of information
 Need to use a range of techniques for
eliciting information

4
INTRODUCTION
 Discuss as much as possible with child and family together,
including the diagnosis and treatment plan

 If possible, always see the child alone, and in confidential

manner

 Assessment is the beginning of treatment

 During the assessment, engage the child and family in a

therapeutic relationship.
Child psychiatric assessment
 Psychiatric assessment of a child or adolescent includes

 Identifying the reasons for referral

 Assessingthe nature and extent of the child's

psychological and behavioral difficulties
Child psychiatric assessment
 Determining factors that may be influencing the
child's emotional well-being
 Family
 School
 Social
 Developmental
 A comprehensive evaluation of a child is
composed of interviews with the
 Parents
 The child
 Other family members
 Gathering information regarding the child's
current school functioning important
Child psychiatric assessment
 A standardized assessment of the child's intellectual
level and academic achievement.

 Interviews from different sources, such as parents,

teachers, and school counselors, may reflect
different or even contradictory information about a
given child
Child Interview techniques
 Settling the child
 Reassuring

 Ask carefully if she/he was told to come to hospital

 Exploration of the problem with the child

 Nonjudgmental approach
 Emphatic relations
Child Interview techniques
 Assessment of the emotional state of the child could be
done by Inquiry about
 Depression
 Aggression
 Worries
 Fears

 Exploring the unconscious world of the child

 Drawing
 Play
 Dreams
 Wishes
 Favorite stories
Child Interview techniques
 Concluding the interview
 Thank the child

 Express the hope that you can assist to find a solution

for the problem

 Reassurance is needed and the privacy to be kept

for the information except there is a need to disclose
History

12
Mental State Examination
• Intelligence and fund
 Physicalappearance of knowledge
 Manner of relating  Attention,
with examiner and concentration and
impulsivity
parent
• Neurological
 Affect function
 Motor  Judgement and
 Quality of thinking insight
and perception  Preferred modes of
 Speech and language communication

13
When needed
Physical
Examination
Neuropsychiatric Examination

14
Other assessment

 School
 Peers
 Home
 Emotions
 Relevant observations during interview
Classifications
&
Epidemiology
Child and adolescent psychiatric disorders
Neurodevelopmental disorders
Intellectual Disability
Communication Disorders
Autism Spectrum Disorder
Attention Deficit Hyperactivity Disorder
Motor disorders
Specific Learning Disorder
Eliminationdisorders
Feeding and eating disorders
Disruptive, impulse control and conduct
disorders
17
Child and adolescent cont. . .

□ Mood disorders
 Anxiety disorders

 Child hood onset schizophrenia and other

early onset psychotic disorders
 Relationship between child and adult
psychopathology
◦ Some disorders are unique to children
 e.g., separation anxiety disorder
◦ Some disorders are primarily childhood
disorders, but may continue into adulthood
 e.g., attention-deficit/hyperactivity disorder
◦ Some disorders are present in children and
adults
 e.g., depression
 DSM-5 splits childhood disorders into two
chapters:
◦ Neurodevelopmental Disorders
◦ Disruptive, Impulse Control, and Conduct
Disorder
 DSM-5 has new names for disorders
◦ e.g., mental retardation will now be called
intellectual developmental disorder
 DSM-5 will combine some disorders
◦ Autistic disorder, Asperger’s disorder, and
pervasive developmental disorder not otherwise
specified combined into Autism Spectrum
Disorder
 Key questions to answer in an
assessment
 Symptoms
What sort of problem is it?
 Impact
How much distress or impairment does it cause?
 Risks
What factors have initiated and maintained the
problem?
 Strengths
What assets are there to work with?
Explanatory model
What beliefs and expectations do the family bring
with them?
22
Common presenting symptoms
 Emotional symptoms
enquire more carefully about somatic equivalents
 Behavioral problems
defiant behavior, often associated with irritability
and temper outbursts
aggression and destructiveness
antisocial behaviors
 Developmental delays
 Relationship difficulties
relationships change with development

23
Psychiatric Interview
Developmental approach is very
important
Adult alone vs Child alone Vs Adult +
Child together

24
 Distinctive features of Childhood
Psychopathology
 Lackof developmental progress Vs specific
symptoms that are pathognomonic of adult
psychiatric disorders
Language disorder, Separation anxiety disorder
 Developmental states affect presentation
Depression
 Distressing
emotions and behaviors may be
normal part of development
Separation anxiety, oppositional behavior

25
 Distinctive features of Childhood
Psychopathology cont’
Need for treatment
Normal development or not
Level of distress, impairment in functioning,
persistence and effect on the child and others
Comorbidity is a rule
Adult definitions of psychopathology may not
work
Childhood symptoms affect development of
skills in multiple areas
Biological and environmental interaction

26
Distinctive features of Assessment
Not there by choice
Problem may be more distressing to
others than self
They think problem has purely external
cause
Have limited capacity to reflect,
conceptualize and report
Require other modes of interaction
Interview, play, stories, drawing, observation in
multiple settings
27
Conflicting Information
Accurate picture of the child in different
settings
Lack of awareness by one party
A desire to get the interview over with
Failure to admit difficulties
Multiple perspectives rather than one
single truth

28
Issues with Adolescents
Adolescents may be seen alone first
Confidentiality
Rapport
Multiple assessments
Developmental stage

29
Issues with children's
 The interviewer has to know and be familiar
with different aspects of development
 Are non-verbal so direct observation is
invaluable
 Cannot be evaluated separately from their
environment
 Several sessions are needed before making
the diagnosis
Parent only
• Parent + child to ease the child and observe child
caregiver interaction

30
Epidemiology
 Child Psychiatric Disorders

 2/5 – Behavioral disorders

 2/5 – Emotional Disorders
(anxiety, depression)
 1/5 – Miscellaneous Disorders
(Eating Disorders, Tic disorders, Psychosis , OCD etc)
Prevalence of Child/Adolescent Disorders (From Waddell et
al, 2002

Disorder Est. Prevalence % 95% CI

Any Anxiety Disorder 4.8 4.5-9.2

ADHD 4.2 2.7-7.3

Conduct Disorder 3.5 2.4-6.5

Any Depressive Disorder 0.8 1.0-7.1

Substance Abuse 0.8 0.5-1.3

PDD 0.2 -

OCD 0.1 0.1-0.3

Any Eating Disorder 0.1 0.1-0.2

Tourette’s Disorder 0.1 0.1-0.2

Schizophrenia <0.1 -

Bipolar Disorder 14.3 -

Any Disorder 11.4-17.6

Age of Onset of Psychiatric Disorders

Disorders Median Age at Onset

Anxiety Disorders 15 years

Major Depressive Episode MDE) 24 years

Drug Abuse or Dependence 19 years

Alcohol Abuse or Dependence 21 years

Age of Onset of Psychiatric Disorders

 Note
 1) Early-mid adolescence (13-16 years) is
commonest age of onset for MDE and Anxiety
Disorders and second most common age of onset for
schizophrenia and bipolar disorder.

 2) If 18-30 years of age plus MDE have 2 X risk of

later drug abuse/dependence.
Individual Risk Factors for Child Disorders

 Age/Sex
 Boys having higher prevalence in pre-adolescence (disruptive
behavior disorders, learning and developmental disorders)

 Girls in adolescence (emotional disorders).

 Equal rates of psychotic disorders in boys and girls.

 Ethnicity – complicated picture (? effects independent

of school failure and poverty).

 Brain development (malnutrition, pregnancy and

birth complications)
Individual Risk Factors for Child
Disorders
 Temperamental problems (difficult temperament,
behavioral inhibition, aggressive, impulsive)

 Chronic health problems (highest risk neurological

disorders)

 Low intelligence/learning disorders

 Exposure to stressors and losses (bereavement, victim

of bullying, victim of child maltreatment)
Family-Level Risk Factors for Child Disorders

 Inadequate early rearing environment (attachment,

interaction, emotional stability/warmth, cognitive
stimulation)

 Parental psychiatric disorder (both gene and

environmental effects evident)

 Poor parenting practices

 Marital discord

 Low SES
Thank you!!
Intellectual Disability---DSM 5
(Mental Retardation---DSM IV)
Neuro-developmental disorders

 Neuro-developmental disorders are a group of

conditions with onset in the developmental period.
• The disorders typically manifest early in development,
often before the child enters grade school,
• and are characterized by developmental deficits that
produce impairments of personal, social, academic,
or occupational functioning.
Neuro-developmental disorders
— Substantial delay in development of one or more of the
following domains
Motor (movement) skills/ development:-This is the
ability to use small muscles (fine motor), particularly
in the hands, and large muscles (gross motor) in the
body. Babies use fine motor skills to grasp objects.
Cognitive development:- This is the ability to think,
learn and solve problems.
Language development:- This is the ability to use and
understand language. For babies, this includes babbling.
Social development:-it means being able to ask for
help, show and express feelings and get along with
others.
Emotional development:- This is the ability to
relate to other people. That includes being able
to express and control emotions.
Intellectual Disability
 Intellectual disability:- is characterized by
significant limitations in both intellectual
functioning and in adaptive behavior that
emerges before the age of 18 years.
Deficits in intellectual functioning

This includes various mental abilities:

 Reasoning
 Problem solving
 Planning
 Abstract thinking
 Judgment
 Academic learning (ability to learn in school via
traditional teaching methods);
 Experiential learning (the ability to learn through
experience, trial and error, and observation).
 Conceptual skills :- understanding language, speaking,
reading, writing, counting, telling time, solving math
problems, the ability to learn and remember
information and skills
 Social skills:- interpersonal skills (e.g., making eye
contact when addressing others), following rules
(e.g., turn-taking during games), social problem-
solving (e.g., avoiding arguments), understanding
others (e.g., empathy), making and keeping friends
 Practical skills: activities of daily living including
personal care (e.g., getting dressed, grooming), safety
(e.g., looking both ways before crossing street),
home activities (e.g., using the telephone),
school/work skills (e.g., showing up on time),
recreational activities (e.g., clubs, hobbies), and using
money (e.g., paying for items at a store)
EPIDEMIOLOGY
• The highest incidence of intellectual disability is
reported in school-age children, with the peak at
ages 10 to 14 years.
• More common among males (1.5 times) than
females.
Epidemiology
 Estimated prevalence = 1% worldwide
 Boys : girls = 3:2
 Peak age of incidence = 10-14 years (reasons
include delayed diagnosis of mild retardation)
Aetiology
 DOWN SYNDROME
 The single most important prenatal genetic disorder
responsible for intellectual disability is down syndrome.
 The widely accepted causes that explains the genetic basis of
down syndrome trisomy 21 abnormalities.

FRAGILE X SYNDROME:-
 Fragile x syndrome is the second most common single cause
of ID.
 The syndrome results from a mutation on the x chromosome
at what is known as the fragile site (xq27.3).
 The mental retardation ranges from mild to severe.
 Fragile x syndrome is believed to occur in about 1 of every
1,000 males and 1 of every 2,000 females.
Prader-willi Syndrome

 prader-willi syndrome is postulated to result from a small

deletion involving chromosome 15, usually occurring
sporadically.
 Its prevalence is less than 1 of 10,000.
TUBEROUS SCLEROSIS:-
 Tuberous sclerosis is the common of the neuro-cutaneous
syndromes; a progressive mental retardation occurs in up to
two thirds of all affected persons because of mutation of
agene.
 It occurs in about 1 of 15,000 persons.
Inborn Errors Of Metabolism:-
o Phenylketonuria (pku):- occurs in about 1 of every10,000
to 15,000 live births of enzymatic defect affecting the
myelination of the CNS.
 MATERNAL INFECTIONS
RUBELLA (GERMAN MEASLES)
 The major cause of mental retardation caused by maternal
infection.
 The children of affected mothers may show several
abnormalities, including congenital heart disease, mental
retardation, cataracts, deafness, microcephaly, and
microphthalmia.
 The incidence rises to almost 50 percent when the infection
occurs in the first month of pregnancy.
 Cytomegalic disease
 Some children are stillborn, and others have jaundice,
microcephaly, hepatosplenomegaly, and radiographic findings
of intracerebral calcification.
 The diagnosis is confirmed by positive findings of the virus
 In throat and urine cultures.
SYPHILIS:-
 Syphilis in pregnant women was once the main
cause of various neuropathological changes in
their offspring, including mental retardation.
Toxoplasmosis:-
 It causes mild or severe mental retardation and,
in severe cases, hydrocephalus, seizures,
microcephaly, and chorioretinitis.
Herpes simplex:-
 The herpes simplex virus can be transmitted
transplacentally, it is one of the most common
mode of infection during birth.
 Microcephaly, mental retardation, intracranial
calcification, and ocular abnormalities may result.
Acquired immune deficiency syndrome (AIDS)
 Many fetuses of mothers with AIDS never come to term
because of stillbirth or spontaneous abortion.
 Of infants born infected with the human immunodeficiency
virus (HIV), up to half have progressive encephalopathy,
mental Retardation, and seizures within the first year of life.
Prenatal Use of Toxic Substances

Fetal alcohol syndrome:-

 The entire syndrome occurs in up to 15 percent of babies
born to women who regularly ingest large amounts of
alcohol.
teratogenic medications
COMPLICATIONS OF PREGNANCY
 Toxemia of pregnancy and uncontrolled maternal
diabetes result in mental retardation.
 Maternal malnutrition during pregnancy often results
in prematurity and other obstetrical complications.
 Placenta previa, premature separation of the placenta,
and prolapse of the cord can damage the fetal brain
by causing hypoxia.
PERINATAL CAUSES

 Premature infants and infants with low

birthweight are at high risk for neurological
and intellectual impairments that appear
during their school years.

 Infants who sustain intracranial hemorrhages

or show evidence of cerebral ischemia are
especially vulnerable to cognitive
abnormalities.
POSTNATAL CAUSES
 nutritional problems
 inadequate health care
 lack of early cognitive stimulation
 child abuse and neglect
 traumatic brain injury
 viral infections like meningitis or encephalitis
 heavy metal poisoning esp. lead poisoning
DIAGNOSIS
 History
• Physical and Neurological examination
• Using information from a standardized
intellectual assessment, and a standardized
measure of adaptive function indicating that a
child is significantly below the expected level
in both areas.
• Intellectual functioning :- Wechsler Intelligence,
Shipley scale
• The severity of the intellectual disability will
be determined on the basis of the level of
adaptive function.
Diagnostic Criteria:-

 Intellectual disability (intellectual developmental

disorder) 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, such as reasoning,

problem solving, planning, abstract thinking,
judgment, academic learning, and learning from
experience, confirmed by both clinical assessment
and individualized, standardized intelligence testing.
Diagnostic Criteria Cont. . .
B. Deficits in adaptive functioning that result in failure to
meet developmental and socio cultural standards for personal
independence and social responsibility.
Without ongoing support, the adaptive deficits limit
functioning in one or more activities of daily life, such as
communication, social participation, and independent living,
across multiple environments, such as home, school, work,
and community.

C. Onset of intellectual and adaptive deficits during the

developmental period. Intellectual disability replaces the term
mental retardation.
Classification and clinical features
 Based upon the intensity of supports needed,
 – Intermittent Support
 – Limited Support
 – Extensive Support
 – Pervasive Support
—Mild intellectual disability
• Represents approximately 85 percent of persons with
intellectual disability.
• For school age children and adults, there are difficulties
in learning academic skills
• In adults, abstract thinking, executive function, short
term memory is also impaired
• They often acquire academic skills at approximately a
sixth-grade level.
Mild intellectual disability Cont. . .

 There is some what tangible approach to problems

and solutions compared with age-mates.
• Immature in social interactions
• Communication, conversation, and language are
more real or immature than expected for age.
• Many adults with mild intellectual disability can live
independently with appropriate support and raise
their own families.
Mild intellectual disability Cont. . .

 The person is at risk of being manipulated by others.

• The individual may function age-appropriately in
personal care.
• Needs support in complex daily living tasks in
comparison to peers.
• Recreational skills resemble those of age-mates
 In adulthood, competitive employment is often seen
in jobs that do not emphasize conceptual skills.
• Individuals generally need support to make health
care decisions and legal decisions
• Support is typically needed to raise a family.
 Difficulties in learning (reading, math, writing)
 immature in social interactions, poor social
judgement and assessment of risk
 language more concrete
 difficulty regulating emotions and behaviour
 need support in complex daily living tasks (i.e.
grocery shopping, child-care, banking)
Moderate intellectual disability

 Represents about 10 percent of persons with

intellectual disability.
• Most children acquire language and can
communicate adequately during early childhood.
• Fair motor development and poor social awareness
• They are challenged academically and often are not
able to achieve above a second to third grade level
Moderate intellectual disability Cont . . .

 Spoken language is typically a primary tool for social

communication but is much less complex than that
of peers
• Capacity to form relationship is evident
• Social judgment and decision-making abilities are
limited
• During adolescence, socialization difficulties often
set these persons apart, and a great deal of social
and vocational support is beneficial
• Can benefit from individual attention focused on the
development of self-help skills.
Moderate intellectual disability Cont . . .

 As adults, individuals with moderate intellectual

disability may be able to perform semiskilled work
under appropriate supervision.
• Ongoing assistance on daily basis is needed to
complete conceptual tasks of day-to day life
• The individual can care for personal needs and can
participate in all household tasks, although extended
period of teaching and support is needed.
• A variety of recreational skills can be developed.
Severe intellectual disability

• Represents about 4 percent of individuals with

intellectual disability.
• In the preschool years there is poor motor
development, speech is minimal with little or no
communication skills
• They may be able to develop communication skills in
childhood and often can learn to count as well as
recognize words that are critical to functioning.
• Spoken language is quite limited in terms of
vocabulary and grammar.
Severe intellectual disability Cont . . .
 Individuals understand simple speech and
gestural communication.
 Relationships with family members and familiar
others are source of pleasure and help.
 In adulthood, persons with severe intellectual
disability may adapt well to supervised living
situations, such as group homes, and may be
able to perform work-related tasks under
supervision
• May contribute partially to self maintenance
under complete supervision
• They require support for all activities of daily
activities and supervision at all times
Severe intellectual disability Cont . . .

 Can develop self- protection skills to a minimal

useful level in controlled environment
• Skill acquisition in all domains involves long term
teaching and ongoing support
• Maladaptive behaviour, including self injury, is
present in significant minority.
Profound intellectual disability
 Constitutes approximately 1 to 2 percent of
individuals with intellectual disability.
• The individual may use objects in goal-directed
fashion for self care, work, and recreation.
• Co-occurring motor and sensory impairments may
prevent functional use of objects
• Very limited understanding of symbolic
communication in speech or gestures.
• May understand some simple instructions or
gestures.
• The individual enjoys relationships with well-
known family members, or other familiar people.
• Some recreational activities may be involved with
the support of others.
Profound intellectual disability cont . . .

 Children with profound intellectual disability

may be taught some self-care skills and learn
to communicate their needs given the
appropriate training.
 The individual is dependent on others for all
aspects of daily physical care, health and
safety.
 Individuals without physical impairments may
assist with some daily work tasks at home.
 Describing the Severity of Intellectual Disability
Severity Conceptual Domain Social Domain Practical Domain

Preschoolers may show no Communication, The child may

obvious conceptual differences. conversation, and function in an age-
Mild language are more expected manner
School-aged children show concrete or immature with regard to
difficulties in acquiring academic than the skills of peers. personal care.
skills (e.g., reading, writing,
arithmetic, telling time, using The child may have In adolescence,
money). difficulty accurately assistance may be
understanding the social needed to perform
Abstract thinking and planning cues of others. more complex daily
may be impaired; thinking tends living tasks like
to be concrete There may be difficulties shopping, cooking, and
regulating emotion and managing money.
behavior compared to
peers
  Preschoolers’ language  The child shows  The child needs
and pre academic skills marked differences inmore time and
develop slowly. social and practice learning
Moderate communicative skills self-care skills, such
 School-age children compared to peers. as eating, dressing,
show slow progress in toileting, and
academic skills. hygiene, than
 Spoken language is peers.
 Academic skill simplistic and
development is usually at concrete.
the elementary school  House hold skills
level.  Social judgment can be acquired by
and decision making adolescent with
are limited. ample practice

 Friendships with
peers are often
affected by social or
communicative
deficits
 The child generally has There are limited The child needs
little understanding of spoken language skills ongoing support
written language or with simplistic for all activities of
numbers. vocabulary and daily living: eating,
Severe grammar. dressing, bathing,
Care takers must provide elimination.
extensive support for Speech may be single
problem solving words/phrases. Caregivers must
throughout life. supervise at all
The child times.
understands simple
speech and gestures. Some youths
show challenging
Relationships are behaviors, such as
with family members self-injury.
and other familiar
people.
 Conceptual skills generally
involve the physical world
rather than symbols (e.g.,
Profound letters, numbers).
Some visual spatial skills,
such as matching and
sorting, may be acquired
with practice.
Co-occurring physical
problems may greatly limit
functioning.
The child has limited The child is
understanding of dependent on
symbolic others for all
communication. aspects of physical
care, health, and
The child may safety, although he
understand some or she may
simple instructions participate in
and gestures. some aspects of
self care.
Communication is
usually through Some youths show
nonverbal, non- challenging
symbolic means. behaviors, such as
self-injury.
Relationships are
usually with family Co-occurring
members and other physical problems
familiar people. may greatly limit
functioning
Co-occurring physical
problems may greatly
limit functioning.
Comorbidity
 Psychiatric disorders among persons with
intellectual disability are varied, and include
o Mood disorders, Epilepsy
o Schizophrenia,
o Attention-deficit/hyperactivity disorder (ADHD), and
o Conduct disorder.
Frequent psychiatric symptoms that occur in
children with intellectual disability include
o Hyperactivity and short attention span,
o Self-injurious behaviours (e.g., head-banging and
self-biting), and
 In children and adults with milder forms of intellectual
disability
o Negative self-image,
o Low self-esteem,
o Poor frustration tolerance, Interpersonal dependence,
and
o A rigid problem-solving style are frequent.
Treatment I

 Primary prevention:
◦ Special education , language therapists, behavioral
therapists, occupational therapists, and community
resources that are all vital in the management of this
disorder
◦ Improved medical care & infection prevention
 Secondary/tertiary prevention:
◦ Correct diagnosis
◦ Symptom relief/treatment of co morbidity
◦ Optimal education/training
◦ Psychosocial support for affected individual and careers
Treatment II
 Family support:
◦ Parental reactions to diagnosis may include grief,
anger, guilt, denial, overprotection, rejection
(negative response), social isolation or abuse
◦ Education around appropriate expectations
◦ Emotional support and chance to ventilate
◦ Support groups
◦ Assistance with home programms
Medications based on the clinical presentation
different drugs could be prescribed
Case Scenario - A
- A 23 years old unmarried woman has
been present to psychiatry clinic
- Since childhood she is unable to
communicate
- She did not yet develop self care practice,
and
- She has been cared by her mother for
dressing, eating, bathing, etc
- She spends her time by playing with 3-5 yrs
old children
- When given different trainings, her progress
80
Case scenario-B
 A 17 yrs old boy has been unable to
pass from grade 7th repetitively, with
this complaint the client was brought
to you
 He has Downs syndrome on medical
evaluation
 With moderate level of training he can
accomplish certain activities,
 He can practice self care;
communicates effectively 81
Next
DEVELOPMENTAL MILE STONES

By:- Tesfalem A. (BSc.PH, MSc Psychiatry)

April, 2018,
Mekelle, Ethiopia

83
DEVELOPMENTAL MILESTONES
At 2 Months:
- Begin to smile
- Turns towards sound
- Follow things with eyes
At 6 months:
- Knows familiar faces
- Plays with parents
- Responds to own name
- Sit without support

84
Developmental…
At 9 months:
- Say a two word sentence; like ‘mamma’, ‘babaa’
- Point to things with fingers
- Can stand and sit without support
At 12 months:
- Responds to simple questions
- Points to the right picture when named
- Follows simple directions

85
Developmental…
At 18 months:
- Shows affection to familiar people
- Plays simple games
- Walks alone
- May run
- Drinks from a cup
- Eats with spoon

86
Developmental…
At 24 months:
- Names pictures in a book
- Follows 2 step instructions, e.g. “pick up your
shoes and give them to me”
- Kicks a ball
At 5 years:
- Can use toilet by his/her own
- Tells a simple story with sentences
- Likes singing, dancing and acting

87
Next
AUTISM SPECTRUM DISORDERS

By:- Tesfalem A. (BSc.PH, MSc. Psychiatry)

April, 2018,
Mekelle, Ethiopia

89
Learning objectives
After completion of this chapter, the students should
be able to:
 Describe what Autism is
 Discuss common features of ASD
 Elaborate DSM – 5 diagnostic criteria
 Clarify management of ASD

90
 Introduction
 Previously called ‘Pervasive Developmental disorders’
 Deficits in social communication and
restricted/repetitive behavior/interest are main
features
 One-third had co-morbid intellectual deficit
 Prevalence: 0.08%
 Boys: Girls => 4: 1

91
Introduction…
 Etiology
◦ Genetic factors
◦ Immunological factors
◦ Prenatal & per natal factors
◦ Co-morbid neurological factors

92
Geneti c Fa cto rs
 Up to 15 percent of cases of autism spectrum disorder
appear to be associated with a known genetic
mutation,
 The most common of these inherited disorders is :-
*. fragile X syndrome,
*. X-linked recessive disorder
*. Tuberous sclerosis.

93
 Immunological Factors:- immunological incompatibility
(i.e., maternal antibodies directed at the fetus)
Prenatal and Perinatal Factors:-
prenatal factors:- advanced maternal and paternal age at birth,
maternal gestational bleeding, gestational diabetes, and firstborn
baby.
Perinatal risk factors:- umbilical cord complications, birth
trauma, fetal distress, small for gestational age, low birth weight,

94
Coo morbid Neurological
Disorders
 Electroencephalography (EEG)
abnormalities and seizure disorders occur
with greater than expected frequency in
individuals with autism spectrum disorder.
 Four percent to 32 percent of individuals
with autism spectrum disorder have grand
mal seizures at some time, and about 20
to 25 percent show ventricular
enlargement on computed tomography
(CT) scans.

95
 Introduction…
Clinical features
I . Persistent Deficits In Social Communication and
Interaction
Poor reciprocal (give--and–take) social skills and
spontaneous nonverbal social interactions
Infants may not develop a social smile, and as older babies
may lack the anticipatory posture for being picked up by a
caretaker
Less frequent and poor eye contact is common during
childhood and adolescence
A child may not differentiate the most important persons
in their lives—parents, siblings, and teachers
May not react as strongly to being left with a stranger
compared to others their age.
96
Introduction…/Clinical Features/

awkward (uncomfortable) and may have

inappropriate social behavior at school
Fewer shared interest, fewer body and facial
gesture,
More skilled in visual spatial tasks than tasks
requiring verbal reasoning
difficulty with making attributions about the
motivation or intentions of others
Lack empathy( understanding)
97
Introduction…/Clinical Features/

ii. Restricted (limited), Repetitive Patterns of

Behavior, Interests, and Activities
 Stereotyped or repetitive motor movements, use of
objects, or speech
◦ e.g., simple motor stereotypes',
◦ lining up toys or flipping(turnover) objects,
◦ echolalia, idiosyncratic/unusual phrases

98
 Introduction…/Clinical Features/
 Insistence on sameness,
 inflexible adherence to routines, or
 ritualized patterns of verbal or nonverbal behavior
◦ e.g., extreme distress at small changes,
◦ difficulties with transitions,
◦ rigid thinking patterns,
◦ greeting rituals,
◦ need to take same route or eat same food every
day 99
Introduction…/Clinical Features/

 Highly restricted, fixated interests that are

abnormal in intensity or focus
◦ e.g., strong attachment to or preoccupation with
unusual objects,
◦ excessively circumscribed or preservative
interests

100
 Introduction…/Clinical Features/

 Hyper- or hypo-reactivity to sensory input or

unusual interest 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
101
 Introduction…/Clinical Features/
 Associated behavioral symptoms in Autism
spectrum disorder
◦ Disturbances in language development and usage
◦ Intellectual disability
 30% of autistic children have co morbid intellectual
disability
◦ Irritability
◦ Instability of mood
◦ Inconsistent response to sensory stimuli
◦ Hyperactivity and inattention
◦ Precocious(gifted) skills
102
DSM-5 Diagnostic Criteria for Autism Spectrum Disorder

A. Persistent deficits in social communication and social

interaction across multiple contexts, as manifested by
the following, currently or by history
1. Deficits in social-emotional reciprocity,
 abnormal social approach and failure of normal
back-and-forth conversation;
 reduced sharing of interests, emotions, or
affect;
 failure to initiate or respond to social
interactions
103
DSM-5 Autism…

2. Deficits in nonverbal communicative behaviors

used for social interaction
3. Deficits in developing, maintaining, and
understanding relationships
 Difficulties in adjusting behavior to suit various social
contexts;
 Difficulties in sharing imaginative play or in making
friends;
 absence of interest in peers

104
 DSM-5 Autism…
B. Restricted, repetitive behavior as
manifested by > 2 of the following:
currently or by history
1. Stereotyped or repetitive motor
movements, use of objects, or
2. Insistence on sameness, inflexible
adherence to routines, or ritualized
patterns of verbal or nonverbal
behavior
105
DSM-5 Autism…

3. Highly restricted, fixated interests that

are abnormal in intensity or focus
4. Hyper- or hypo reactivity to sensory
input or unusual interest in sensory
aspects of the environment

106
 DSM-5 Autism…

C. Symptoms must be present in early

development
D. Impairment in different areas of life
E. Symptoms are not due to intellectual
disability

107
Severity level of Autism spectrum disorder
Severity Level Social Communication Restricted behavior

1 - Without support, social -Difficulty switching between

“Requiring communication deficit activities
Support” - Difficulty in initiating social - problems in planning and
interaction organization

2 -Deficits in verbal & non-verbal -Inflexible behavior

“Substantial communications -Difficulty coping with change
Support” -Social impairment even with support -Repetitive behavior interferes
-Limited or abnormal response to with functioning
social approaches from others -Difficulty changing focus/action

3 -Severe deficits in verbal and non -Inflexibility of behavior

“Very verbal communication -Extreme difficulty coping with a
substantial -Very limited initiation of social change
support” interaction -Great difficulty changing focus
-Minimal response to social overtures or action

108
Differential Diagnosis
 Social communication disorder
 Early onset schizophrenia
 Intellectual disability
 Social phobia( social anxiety disorder)

109
Social communication disorder
 Social communication disorder is
diagnosed for children with difficulty in
the social uses of verbal and nonverbal
communication but who do not have
restricted repetitive behavior or
activities.
 Social communication disorder is
described as an impairment of
pragmatics.
Intellectual disability
 There must also be impaired
adaptive functioning in
communication, social participation,
school or work, or personal
independence at home or in
community settings.
Sensory processing disorder
 Sensory processing disorders refer to
individuals who perceive, process, and
respond to sensory information with
difficulty.
 This processing difficulty can lead to severe
sensitivity to sensory input (input from
inside the body, and input from the external
world), leading to traumatically anxious over
stimulation.
social anxiety disorder
 When shy children fail to develop peer
relations and
 stop trying to share their interests with
others, these two symptoms are enough to
achieve the autism spectrum diagnosis'
criterion for qualitative impairment in social
interaction, even though the symptoms may
reflect shyness or social anxiety rather than
an autistic problem.
Obsessive-compulsive disorder
 The diagnoses of OCD and autism both
require the presence of recurrent and
persistent thoughts or behaviors.
 Yet in OCD the recurrent thoughts cause
anxiety, and in autism this is not necessarily
the case, or it is hard to know if this is the
case.
 Further, in autism there must also be
impairment in socialization and
communication, whereas this is not required
for the OCD diagnosis.
Course and Prognosis of ASD
 It is a lifelong, disorder with a highly variable
severity and prognosis
 Children with IQs above 70 with average
adaptive skills, have the best prognoses
 Positive changes in communication and social
domains over time are possible with higher
IQ
 Repetitive behavioral symptoms have poor
progress over time
115
Management of ASD
Target core behaviors:
 to improve
social interactions,
communication,
to integrate into schools,
develop meaningful peer relationships,
and increase long-term skills in independent
living

116
Management of ASD…
 Psychosocial treatment interventions
◦ To develop skills in social conventions,
◦ To increase socially acceptable and pro social
behavior with peers, and
◦ To decrease odd behavioral symptoms
 language and academic remediation
 reduction of irritable and disruptive
behaviors

117
Management of ASD…
For parents
◦ Psycho education,
◦ support, and counseling
 In order to optimize their relationships
and effectiveness with their children

118
Management of ASD…
Comprehensive treatment plans
 Intensive behavioral programs,
 Parent training and participation, and
 Academic/educational interventions

119
Management of ASD…
Common interventions
 expanding social skills, communication,
and language,
 through
◦ practicing imitation,
◦ Joint attention,
◦ social reciprocity, and
◦ play in a directed but child-centered manner

120
Famous people with Autism
 Leonardo Da Vinci
 Mahtma Gandhi
 Cleopatra
 Princess Diana
 Adolf Hitler
 ?Einstein

121
 ATTENTION DEFICIT
HYPERACTIVITY
DISORDER
/ADHD/

By:- Tesfalem A. (BSc.PH, MSc Psychiatry)

April, 2018,
Mekelle, Ethiopia

123
 Learning Objectives
After completion of this course, the students
should be able:
 To define what ADHD is
 To describe epidemiology and etiology of ADHD
 To list out clinical features of ADHD
 To explain DSM diagnostic criteria for ADHD
 To deal with management of ADHD

124
ADHD
ADHD is characterized by diminished
sustained attention and higher levels of
impulsivity than expected to the child’s
age level

It is generally categorized as
Inattentive type,
Hyperactive type, and
Combined type
The symptoms should start before
the age of 12 years
125
ADHD…
Not diagnosed before the age of 12 years
until their behaviors cause problems in
school and other places
Impairment must be observable in at least
two settings and interfere with appropriate
functioning socially, academically, or in other
areas
ADHD is not diagnosed when symptoms
occur in autistic spectrem disorder,
schizophrenia, or other psychotic disorder
126
 ADHD Epidemiology
 Prevalence:Varied figure (1% - 20%) in
school children [western countries]
 Male to female ratio= 2 – 9: 1
 Girls are often inattentive/ boys are
hyperactive
 1st degree biological relatives are at higher
risk
 Symptoms start at the age of 3 years

127
Etiology of ADHD
Genetics
High risk among monozygotic twins if one
develops the disorder
Biological parents have higher risk than
adoption parents
Children with ADHD are at risk of developing
conduct disorder, alcohol use disorder and
antisocial personality disorder
Developmental factors
prenatal infection during 1st trimester
pregnancy 128
Etiology of ADHD…
Brain damage
Physical damage to the brain during early
infancy by infection, inflammation and trauma
Neuro chemical factors
Possible dysfunction in both adrenergic and
dopaminergic systems
Not accounted to a single neuro transmitter

129
 Diagnosis of ADHD
 Detailed history of child development is
crucial
 Direct observation of the child in situations
that require attention
 Hyperactivity may be severe at school; less
in sports and games
 Persistent, impairing symptoms of either
hyperactivity/impulsivity or inattention that
cause impairment in at least two different
settings

130
Dx of ADHD…
 Inattentiveness
 At school, a child cannot follow instructions and
often demand extra attention from their
teachers.
 At home, they often do not comply with their
parents' requests; act impulsively; show
emotional lability, and are explosive and irritable
 Hyperactive children are referred more
frequently than inattentive children

131
Dx of ADHD…
 Hyperactive children are more exposed to
conduct disorder than inattentive
 School history and teachers' reports in
evaluating a child's difficulties in learning and
school behavior
 are primarily caused by the child's inability to
sustain attention or compromised understanding
of the academic material
 Additional school difficulties can result from
attitudinal or maturational problems, social
rejection, and poor self-image because of felt
inadequacies
132
Dx of ADHD…
 How the child has related to siblings, to peers,
to adults, and to free and structured activities
 It also helps to identify the complications of the
disorder
 MSE
 Secondarily depressed mood, but no thought
disturbance, impaired reality testing, or inappropriate
affect
 A child may show great distractibility, perseveration,
and a concrete and literal mode of thinking

133
Dx of ADHD…

 Children may have problems with motor

coordination and difficulty copying age
appropriate figures, rapid alternating
movements, right-left discrimination

134
Clinical features
 Infants with the disorder are overly
sensitive to stimuli and are easily upset by
noise, light, temperature, and
environmental changes

 In school, children with ADHD may act

rapidly, but answer only the first two
questions. They may be unable to wait and
may respond before everyone else
135
Clinical features …
 At home, they cannot be put off for even a
minute
 Children with ADHD are often explosive or
irritable
 The irritability may be set off by relatively
minor stimuli
 They are frequently emotionally labile and
easily set off to laughter or to tears;
 their mood and performance are to be
variable and unpredictable 136
Clinical features…
 Impulsiveness and an inability to delay
gratification are characteristic
 The most cited characteristics of children
with ADHD, in order of frequency, are
◦ hyperactivity,
◦ perceptual - motor impairment,
◦ emotional lability,
◦ general coordination deficit,
◦ attention deficit (short attention span,
distractibility, perseveration, failure to finish tasks,
inattention, poor concentration),
137
Clinical features…
◦ impulsivity (action before thought, abrupt
shifts in activity, lack of organization,
jumping up in class),
◦ memory and thinking deficits,
◦ specific learning disabilities,
◦ speech and hearing deficits, and
◦ equivocal neurological signs and EEG
irregularities

138
 ADHD

HYPERACTIVITY
DSM 5 Diagnostic criteria for ADHD

A. A persistent pattern of
1. Inattention and/or
2. Hyperactivity-- Impulsivity that interferes
with functioning or development.

B. Several inattentive or hyperactive-impulsive

symptoms were present prior to age 12 years.

C. Several inattentive or hyperactive-impulsive

symptoms are present in two or more settings
(e.g., at home, school, or work; with friends
or relatives; in other activities).
DSM-V Criteria cont. . .
D. There is clear evidence that the symptoms interfere
with, or reduce the quality of, social, academic, or
occupational functioning.

E. The symptoms do not occur exclusively during the

course of schizophrenia or another psychotic disorder
and are not better explained by another mental
disorder (e.g., mood disorder, anxiety disorder,
dissociative disorder, personality disorder, substance
intoxication or withdrawal).
A-1 Inattention

 At least 6 symptoms For at least 6 months

duration,
(5 Sx for 17 yrs and older):
1. Often fails to give close attention to details or makes
careless mistakes in school work, at work, or during
other activities
2. Often has difficulty sustaining attention in tasks or
play activities
3. Often does not seem to listen when spoken to
directly
4. Often does not follow through on instructions and
fails to finish schoolwork, chores, or duties in the
workplace
 A-1 Inattention cont. . .

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or is reluctant to engage in tasks

that require sustained mental effort

7. Often loses things necessary for tasks or activities

8. Is often easily distracted by extraneous stimuli

9. Is often forgetful in daily activities

A-2 Hyperactivity & Impulsivity
At least 6 symptoms For at least 6 months
duration, (5 Sx for 17 yrs and older):
1. Often fidgets with or taps hands or feet or squirms
in seat.
2. Often leaves seat in situations when remaining
seated is expected
3. Often runs about or climbs in situations where it is
inappropriate.
4. Often unable to play or engage in leisure activities
quietly.
5. Is often “on the go,” acting as if “driven by a motor”
 A-2 Hyperactivity & Impulsivity cont . . .

6. Often talks excessively.

7. Often blurts out an answer before a question has

been completed (e.g., completes people’s sentences;
cannot wait for turn in conversation).

8. Often has difficulty waiting his or her turn (e.g.,

while waiting in line).

9. Often interrupts or intrudes on others (e.g., butts

into conversations, games, or activities; may start using
other people’s things without asking or receiving
permission)
Sub types
1. ADHD; Combined type
- If both criteria A1 and A2 are met for > 6 months
2. ADHD; Inattentive type
- If A1 is met for > 6 months
- A2 is not met
3. ADHD; Hyperactive type
- If A2 is met for > 6 months
- A1 is not met

 Partial remission: When full criteria were previously met,

fewer than the full criteria have been met for the past 6 months, and the
symptoms still result in impairment in social, academic, or occupational
functioning.
Differential Diagnosis
 Anxiety disorders
 Childhood depression
 Bipolar I D/o: Manic episode
 Conduct disorder

147
AUTISM ADHD
Both exhibit social dysfunction and difficult to manage behavior.

Has no great desire to be Wants to be social. Feel sad,

social confused on isolation.

Repetitive patterns of behavior Absent

are present.

Difficulty in communication is There is no difficulty in

present. communication.
Course & Prognosis
 50% progress to adolescence and adulthood
 50% got remission at puberty or early
adulthood
 Remission occurs from 12 – 20 years
◦ Remission before the age 12 years is unlikely
 Hyperactivity is the first symptom to remit
 Distractibility is the last symptom to remit
Factors that make ADHD persistent
- Family history,
- Negative life events
- Co morbid problems

149
 ADHD is a deficit in self-control-in what
some professionals call the executive functions
critical to planning, organization, and carrying
out complex human behavior over long
periods of time.
 That is, in a child with ADHD, the
“executive” in the brain that is supposed to
be organizing and controlling behavior,
helping the child plan for the future and
follow through on those plans, is doing a
very poor job.
 ADHD drugs primarily target the prefrontal
cortex (PFC), a region of the brain that is
associated with attention, decision-making
and an individual's expression of personality.
 ADHD drugs fall into a class of medications
known as stimulants. ADHD stimulants
boost levels of two neurotransmitters, or
chemical messengers in the brain, known as
dopamine and norepinephrine.
A Possible Developmental Pathway for ADHD
PATHOGENESIS
Lower activity in brain regions associated with
executive function (particularly abnormalities in
Frontostriatal circuit):
Prefrontal cortex
Basal ganglia
Cerebellum(vermis)
These areas of the brain are associated with
executive function abilities:
Attention, spatial working memory, and
short-term memory.
Management of ADHD
Pharmacotherapy
- Is first line management of ADHD
- CNS stimulants are first choices
- Methylphenidate (Ritalin)
- Dextroamphetamine (Dexedrine)
- Dextroamphetamine and amphetamine salt
combinations
- 2nd line choices include anti depressants like
Imipramine, Bupropion,Venlafaxine
- Should be used cautiously because of their effect of
impairing liver activity

154
STIMULANTS:
1. Methylphenidate:
• Available in immediate and sustained release.
• Absorption: From the GI tract, slow and
incomplete
• Dose(Ritalin): 5mg (0.3mg/kg/dose) PO BID
before breakfast and lunch.
– Increase by 5-10mg/day (0.2mg/kg/day) at
weekly intervals.
– Max = 60mg/day (2mg/kg/day).
2. Dexmethylphenidate
• Better absorbed.
• Initial Dose: 2.5mg PO BID OR 10mg PO
(XR).
Side effect of stimulant
• Common: Anorexia, Sleep disturbance,
Weight loss, Nervousness/ Restlessness,
Growth retardation Increased blood
pressure.
• Severe: Tics, Arrhythmia, Psychosis, Sudden
cardiac death, drug abuse potential.
3. Amphetamines:
Dextroamphetamine
- 5mg PO once or twice daily
- MAX: 40mg/day.
NON-STIMULANTS
• Usually second-line treatments
– If stimulants are poorly tolerated or ineffective
– As mono therapy or adjunct to stimulants
Atomoxetine:-
-- selective nor epinephrine reuptake inhibitor.
• Second-line treatment or alternative for patients with
history of drug abuse.
• Dose: 0.5mg/kg,
• Max = 1.4mg/kg

Side Effects: -
– Common: weight loss, abdominal pain, appetite
suppression, sleep disturbance
Alpha-2 adrenergic agonist:-
-Clonidine and Guanfacine
Clonidine at 3-10 mg/kg/day used as alternative
or adjunctive to Methylphenidate.

Tri cyclic anti depressant:-

Imipramin, Nor imipramin, Nor tryptline
-inhibit NE and serotonin.
Non Tri cyclic anti depressant:-
• Bupropion:-
– inhibits NE and DA.
- 3-6 mg/Kg/day
Stopping Therapy
• Consider stopping if patient is stable and
doing well.
 Stop for 1-4 weeks then reevaluate.
Mgt…
Psychosocial intervention
- Social skills groups,
- Training for parents of children with ADHD,
- Helping parents develop usable behavioral
interventions with positive reinforcement at both
social and academic areas
- Behavioral interventions at school and at home
- Evaluation and treatment of coexisting
disorders
- Children with medications should be taught
the purpose of the medication so as to reduce
their anxiety and misconceptions
161
Mgt…
- Group therapy aimed at both refining social
skills and increasing self-esteem
- Resource room,
- tutor for homework,
- classroom intervention,
- exercise routines,
- extracurricular activities

162
Guiding Principles for Raising a Child with
ADHD (Barkley, 1995)
1. Give your child more immediate
feedback and consequences
2. Give more frequent feedback
3. Use incentives before punishment
4. Strive for consistency

163
Guiding Principles for Raising a Child with
ADHD (cont’d)
6. Act, don’t yak (talk)!
7. Plan ahead for problem situations
8. Don’t personalize your child’s problems
or the disorder
9. Practice forgiveness

164
Additional Tips for Managing ADHD Behaviors

 Pay positive attention to your

child…catch them being good
 Give effective commands
◦ Short, sweet, and straightforward
◦ Limit the number of tasks to 1-2 per
command
 Maintain clear and consistent
expectations
 Communicate realistic consequences for
inability to meet expectations
165
Tips for Managing ADHD (Cont’d)
 Manage the child’s environment
◦ Limit distracting influences during times when
child is asked to be on task (i.e. homework)
 Maintain a regular and predictable daily
schedule
 When eliciting child’s input, limit (but don’t
eliminate) the number of choices available
to him/her to 2-3 options

166
Tips for Managing ADHD (Cont’d)

 Be patient
 Be persistent
 Be understanding
 *Most importantly, remember to
differentiate the behaviors from the child
◦ Bad behaviors are not synonymous with a
bad child

167
CONDUCT DISORDER

By:- Tesfalem A. (BSc.PH, MSc Psychiatry)

March, 2018,
Mekelle, Ethiopia
Learning Objectives
After finishing this topic, you are expected:
- To discuss what conduct disorder is,

- To describe common clinical features of CD,

- To explain DSM diagnositic criteria for CD

- To deal with management of CD

Introduction
 Disruptive behavior disorders can be divided into
two different group of symptoms categorized as
 Oppositional defiant disorder

 Conduct disorder,

◦ both of them result in impaired social or

academic functioning
Introduction

 Oppositional and aggressive behaviors

during childhood are among the most
frequent reasons that a given youth is
referred for mental health evaluation.
Intro…

 Repeatedly violating important societal rules

or the personal rights of others as
manifested by:
◦ Aggression to people and animals
◦ Destruction of property
◦ Deceitfulness or theft
◦ Serious violation of rules
 DSM-5 specifies two types of CD: childhood
onset (<10 yrs) and adolescent onset.
Intro…
 Conduct disorder is more common among
boys than girls
◦ (with a boys to girls ratio of 4:1 to 12:1 )
 Conduct disorder occurs with greater
frequency in the children of parents with
antisocial personality disorder and alcohol
dependence than
 It is related to socioeconomic factors
Intro…

 Childhood onset is associated with

◦ male predominance
◦ more physical aggression
◦ impaired peer-relationships
◦ co morbid ADHD
Intro…
 Adolescent-onset have
◦ few symptoms before puberty
◦ less likely to be aggressive
◦ more likely to be females.
◦ Most adolescents with this sub-type have friends but with
the context of gang or other delinquent group.
 The prognosis for adolescent onset is better than the
childhood onset
 Prevalence approximately 5 %
Intro…
 The average age of onset of conduct
disorder is younger in boys than in girls.
 Boys most commonly meet the diagnostic
criteria by 10 to 12 years of age,
 whereas girls often reach 14 to 16 years of
age before the criteria are met.
DSM-5 Diagnostic Criteria for CD

A. A repetitive and persistent pattern of behavior 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
DSM 5 …

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
DSM 5 …
 Destruction of property
8.has deliberately engaged in fire setting with the
intention of causing serious damage
9.has deliberately destroyed others' property
(other than by fire setting)
DSM 5 …
 Deceitfulness or theft
10. has broken into someone else's house, building,
or car
11.often lies to obtain goods or favors or to avoid
obligations
12.has stolen items of nontrivial value without
confronting a victim (e.g., shoplifting, but without
breaking and entering; forgery)
DSM 5 …

 Serious violations of rules

13. often stays out at night despite parental
prohibitions, beginning before age 13 years
14. 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)
15. is often absentee from school, beginning
before age 13 years
DSM 5 …
B. Impairment in academic or social life

C. Occur before age 18 yrs

Clinical presentation

 School-age children can become :-

◦ bullies

◦ Initiate physical fights

◦ Destroy property

◦ Set fires.
Etiology…

 Conduct disorder is associated with many

other psychiatric disorders including
◦ ADHD
◦ Depression
◦ Learning disorders
◦ Psychosocial factors
Etiology…

Psychosocial factors such as

◦ Harsh
◦ Punitive parenting
◦ Family discord
◦ Lack of appropriate parental supervision
◦ Lack of social competence
◦ Low socioeconomic level.
◦ Abuse
Etiology…
Psychological factors
 Children brought up in chaotic
(disorganized), negligent conditions
◦ often express poor modulation of emotions,
including anger, frustration, and sadness.
 Poor modeling of impulse control
 and the chronic lack of having their own
needs met leads to a less well-developed
sense of empathy.
Etiology…

Abuses
 Child abuse and maltreatment
 Maternal abuse
 Caregiver’s physical / or sexual abuse
Differential Diagnosis
 Mood disorder
◦ Bipolar Disorder
 Psychotic Disorder
 ADHD
Course and prognosis
 CD remits in many youths, but some lead
lives of delinquency or develop antisocial
personality disorder.
 Low IQ, parental antisocial personality,
early age of onset, greater number of
symptoms exhibited predict persistence
of CD.
 Successful interventions of the pre morbid
conditions also predict the outcome of CD
 Course and prognosis

 ODD 30% CD40%ASPD( Anti _

social personality d/o)
 ODD 10%ASPD

191
Treatment
 Psychotherapy mostly cognitive-Behavioral
 Parent management training
 Group therapy
 Pharmacotherapy
OPPOSITIONAL
DEFIANT
DISORDER (ODD)

By:- Tesfalem A. (BSc.PH, MSc Psychiatry)

March, 2018,
Mekelle, Ethiopia
OPPOSITIONAL DEFIANT DISORDER

Learning Objectives:
After finishing this chapter, you should be
able:
- To discuss what ODD is,
- To describe common features of ODD,
- To explain etiology and epidemiology of
ODD,
- To clarify DSM diagnostic criteria for
ODD,
- To deal with management of ODD
 ODD…
 It is Characterized by enduring patterns of
negativistic, disobedient, and hostile
behavior toward authority figures,
 Inability to take responsibility for mistakes,
leading to placing blame on others
 Children with ODD frequently argue with
adults and become easily annoyed by
others, leading to a state of anger and
anger
 ODD…
 may have difficulty in the classroom and with
peer relationships,
 but generally do not choose to physical
aggression or significantly destructive behavior
 a child's temper outbursts, active refusal to
comply with rules, and annoying behaviors
exceed
 The disorder is an enduring pattern of
negativistic, hostile, and defiant behaviors in the
absence of serious violations of social norms or
of the rights of others.
 Epidemiology of ODD
 Prevalence rates for this disorder range from
2 to 16%
 Although it can begin as early as 3 years of
age, it typically is noted by 8 years of age and
usually not later than adolescence
 16 to 22% of school-age children
 Common in boys than girls (3:1)
 Etiology of ODD
 Several psychosocial mechanisms have been
hypothesized:
 Parents use inconsistent methods of
disciplining, structuring and limit-setting

◦ Children identify with an impulsive parent

◦ Parents have insufficient time and emotional

energy for the child

 Untreated other childhood psychiatric

disorders
 Clinical presentations
 Children with oppositional defiant disorder
often
◦ Argue with adults
◦ Lose their temper
◦ Angry
◦ Resentful
◦ Easily annoyed by others
 Clinical presentations
 Frequently
◦ They actively defy(refuse to obey)adults' requests
or rules
◦ Deliberately annoy other person
◦ They tend to blame others for their own mistakes
and misbehavior
 Manifestations of the disorder are almost
invariably present in the home,
 But they may not be present at school or
with other adults or peers
 Clinical presentation…
DSM-5 has divided ODD into 3 types
◦ Angry/irritable
◦ Argumentative/defiant
◦ Vindictive

1. Angry/Irritable
◦ children often lose their tempers, are easily
annoyed, and feel irritable much of the time
 Clinical presentation…
2. Argumentative/Defiant
- a pattern of arguing with authority figures, and
adults such as parents, teachers, and relatives
- actively refuse to comply with requests,
deliberately break rules, and purposely annoy
others
- often do not take responsibility for their actions,
and often blame others for their misbehavior
3. Vindictive type
- children are spiteful, and have shown vindictive
or spiteful actions at least twice in 6 months
to meet diagnostic criteria
 ODD: DSM-5 Diagnostic criteria
A. A pattern of angry/irritable mood,
argumentative/defiant behavior, or
vindictiveness lasting at least 6 months as
evidenced by at least four symptoms

Angry/Irritable Mood
1. Often loses temper
2. Is often touchy or easily annoyed
3. Is often angry and resentful
 DSM-5 criteria…
Argumentative/Defiant Behavior
4. Often argues with authority figures or, for
children and adolescents, with adults.
5. Often actively defies or refuses to comply with
requests from authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or
misbehavior.
Vindictiveness
8. Has been spiteful or vindictive at least twice
within the past 6 months
DSM criteria…
B. The disturbance in behavior causes
clinically significant impairment in social,
academic, or occupational functioning

C. The behaviors do not occur exclusively

during the course of a psychotic or mood
disorder
 ODD: Specifiers
 Mild: symptoms and disturbances are
confined to one setting
 Moderate: symptoms are present in
at least 2 different settings
 Severe: some symptoms are present
in 3 or more settings
Differential Diagnosis
 Intellectual disability
 ADHD
 Schizophrenia
 Course and prognosis
 Good prognosis is related to having intact families
who can modify their own expression of demands
and give less attention to the child's argumentative
behaviors
 Risk factors for progression of ODD to CD
include
◦ parental characteristics (parents who abuse
substances)
 Risk factors in the child are
◦ low IQ
◦ physical fighting
◦ resistance to parental discipline
 Management of ODD
 family intervention using both direct training of
the parents in child management skills and
careful assessment of family interactions
◦ Behavior therapists emphasize teaching parents how
to alter their behavior to discourage the child's
oppositional behavior and encourage
appropriate behavior
◦ Behavior therapy focuses on selectively reinforcing
and praising appropriate behavior and ignoring
or not reinforcing undesired behavior
 Management…
 Individual therapy to the child
◦ to develop a sense of mastery and success in
social situations with peers and families
◦ eliminating harsh, punitive parenting and
◦ increasing positive parent child interactions
MOOD DISORDERS AND SUICIDE IN
CHILDREN AND ADOLESCENTS
Prepared by : Mr. Tesfalem Araya (Msc. Psychiatry)
LEARNING OBJECTIVES
 At the end of these session you will be
able to:
◦ Define what we mean by mood disorders
◦ Describe types of mood disorder
◦ Describe the prevalence of mood disorders in
children and adolescents
◦ Explain possible cause for mood disorders in children
and adolescents
◦ Identify common differential diagnosis and co
morbidities
◦ Assess and manage mood disorders
Mood Disorder
 Mood is a pervasive and sustained feeling
tone that is experienced internally and that
influences a person’s behavior and
perception of the world.
 Affect is the external expression of mood.
 Mood can be
◦ Normal
◦ Elevated
◦ depressed
Mood Disorder
 Healthy person
◦ Experience a wide range of mood and affect
◦ They feel in control of their moods and affects
 Normal mood - the state of not feeling
particularly euphoric or sad, except under
the right circumstances
 Mood disorder
◦ Loss of sense of control
◦ Subjective experience of great distress
Mood Disorder
 Mood disorders involve a depression or
elevation of mood as the primary disturbance
 Mental health problems ranging from
depression to bipolar disorder are known as
mood disorders, or affective disorders.
 The division is based on whether the person
has ever had a manic or hypomanic episode.
◦ Depressive disorder (UPD)
◦ Bipolar disorder (BPD)
Depressive disorder
 DSM-5 diagnostic category includes
◦ Major depressive disorder
◦ Persistent depressive disorder
◦ Disruptive mood dysregulation disorder
◦ Pre menstrual dysphoric disorder
◦ Substance/medication induced depressive disorder
◦ Depressive disorder due to another medical
condition
◦ Other specified depressive disorder
◦ Unspecified depressive disorder
Types of mood disorders
 Major depression. A period of a depressed or
irritable mood or a noticeable decrease in interest or
pleasure in usual activities, along with other signs,
lasting at least two weeks.
 Persistent depressive disorder (dysthymia). A
chronic, low-grade, depressed or irritable mood for
at least 1 year.
 Bipolar disorder. Manic episodes (period of
persistently elevated mood), interspersed with
depressed periods, or periods of normal emotional
response.
 Disruptive mood dysregulation
disorder. A persistent irritability and
extreme inability to control behavior
exhibited in children under the age of 18.
 Premenstrual dysmorphic disorder.
This includes depressive symptoms,
irritability, and tension before menstruation.
 Mood disorder due to a general medical
condition. Many medical illnesses (including
cancer, injuries, infections, and chronic medical
illnesses) can trigger symptoms of depression.
 Substance-induced mood disorder.
Symptoms of depression that are due to the
effects of medication or other forms of
treatment, drug abuse, or exposure to toxins.
Depressive disorder in children and
adolescents
 Public health concern – high prevalence and
high Impact
◦ Adverse effect on emotional, social and cognitive
development
◦ Early onset depressive disorder
 More lifetime depressive episodes
 More suicide attempts
 Greater psychiatric and medical co-morbidities
 Poor quality of life
 Early identification leads to evidence-based
treatment
 Under diagnosed - Different expression
from adults /difficult to identify
Features of depressive disorder
 Resemblance between child, adolescent and
adult
 Influenced by developmental level
 Similar DSM criteria except the possibility to use
irritable mood instead of depressed mood
 Suicidality is not common but in severely
depressed youth it can be present
Developmental issues and depressive
disorder
 Recurrent suicidal ideation but are unable
to propose a realistic suicide plan or to
carry out their thought
 Vulnerable to influence of severe social
stressors
◦ Chronic family disagreement
◦ Academic failure
◦ History of:- abuse, neglect, family mental illness,
sub abuse, poverty is common
Epidemiology
 Depressive disorders increase with age
 Preschoolers – 0.3 to 0.9%
 School age children – 2 to 3%, G=B
 Adolescents – 4 to 8%, 2 to 3x more in females
 By 18yrs - cumulative incidence is 20%
 Family history 1st degree – 3x
 Double depression --- 9.9%
 Among psychiatrically hospitalized –20% -40%
Etiology
 Genetics
 Prenatal factors
 Family relationships
 Parental depression*
 Stressful life events
 Lack of parental care
 Familiality
◦ Twin studies – 40 to 50% heritability
◦ Highest risk when parent developed the disorder
early
◦ Younger children – environmental influence more
dominant
◦ First episode in adolescence – heritability play
larger role
◦ Before 18yrs – one parent with the disorder risk
of offspring doubles, two parents risk quatriples
Diagnosis and clinical features

 Major depressive disorder

◦ Easy to diagnose when it is acute and when
there is no previous psychiatric symptoms
◦ The fact in early onset depression is
 Insidious onset
 Several years of difficulties with hyperactivity,
separation anxiety disorder, or intermittent
depressive symptom
Major depressive disorder in diagnostic
criteria children and adolescents
 At least one major depressive episode
 At least 2weeks period of
◦ Depressed or irritable mood or loss of interest
or pleasure
◦ At least four of the following symptoms
 Wt loss/gain/failure to make expected weight
gain/increase or decrease in appetite
 Insomnia/hypersomnia,,
 ◦ Psychomotor agitation/retardation,
◦ Fatigue/loss of energy
◦ Feeling of worthlessness/excessive
inappropriate guilt
◦ Decreased ability to think or concentrate or
indecisiveness
◦ Recurrent thoughts of death/suicidal
ideation/attempt/plan
 Cause impairment in functioning or cause
clinically significant distress
Clinical feature
 In pre pubertal child/Very young children
 Sad, listless (ignorant) or apathetic
 Unable to articulate (clear out) their feeling

 Somatic complains

 Psychomotor agitation

 Mood-congruant auditory hallucination

 Adolescents/Late adolescence
◦ More severe
◦ Pervasive(persistent) anhedonia
◦ Severe psychomotor retardation
◦ Delusion
◦ Sense of helplessness
◦ Hopelessness
 More universal ( common) symptoms
◦ Somatic complains:- headache and stomachache
◦ Withdrawn and sad appearance
◦ Poor self-esteem
 Adolescence additional features
◦ Negativistic or frank antisocial behavior
◦ Use of alcohol or other illicit substance –
consider ODD, CD and substance abuse or
dependence
◦ Feeling of restlessness, Irritability, aggression,
reluctance to cooperate, withdrawal from
social activities, isolation from peers, school
difficulties, gives less attention to personal
appearance and shows increased sensitivity
to rejection
 All age group
◦ Suicidal ideation
◦ Depressed or irritable mood
◦ Insomnia
◦ Diminished ability to concentrate
 Adults
◦ Sleep and appetite
Differences According to Age
 School performance is affected by a
combination of
◦ difficulty concentrating
◦ slowed thinking
◦ lack of interest and motivation
◦ Fatigue
◦ Sleepiness
◦ depressive ruminations and preoccupations
 Difficult to differentiate from learning
disorder
 Children and adolescents with severe forms of major
depressive disorder may have hallucinations and/or
delusion
 Depressive hallucinations - a single voice speaking to
the person from outside his or her head, with suicidal
content.
 Depressive delusions - themes of guilt, physical
disease, death, nihilism, deserved punishment,
personal inadequacy
 Adolescent onset of a mood disorder can be
complicated by use of alcohol or drugs
Coo morbidity
 One comorbidity Present in 40%-90% of
youth with MDD; two or more comorbid
disorders present in 20%-50% youth with
MDD
 Comorbidity in youth with MDD: Dysthymia or
anxiety disorders (30%-80%), disruptive
disorders (10-80%), substance abuse
disorders (20%-30%)
 Children manifest separation anxiety;
adolescents manifest social phobia, GAD,
conduct disorder, substance abuse
COURSE AND PROGNOSIS
 Depends on the severity of illness, the
rapidity of interventions, and the degree
of response to the intervention
 90% of youth recover from a first
episode of moderate to severe major
depressive disorder within 1 to 2 years
 The Younger the age of onset, greater
recurrence of multiple episodes, and
presence of co morbid disorders predict
poorer prognosis
Course and progress

 Development of depression under acute

toxic family stressor will improve when
the underlying cause improve
 Insidious onset, Episodic, lasts about a
year
 The mean length of an untreated episode
is 8 to 12 months
COURSE AND PROGNOSIS
 Higher risk for the development of future
bipolar disorder, compared to adults(20
to 40 percent)
 In pre-pubertal children with major
depression
◦ 33 percent developed bipolar I disorder
◦ 48 percent develop bipolar II
Clinical Course: Risk of Bipolar
Disorder
 20%-40% MDD youth develop bipolar
disorder in 5 years of onset of MDD
Predictors of Bipolar I Disorder Onset:
 Early onset MDD
 Psychomotor agitation
 Psychosis
 Family history of psychotic depression
 Heavy familial loading for mood disorders
 Pharmacologically induced hypomania
COURSE AND PROGNOSIS
 Depressive disorders are associated with
◦ short-term and long-term peer relationship
difficulties and complications
◦ compromised academic achievement
◦ persistently low self-esteem.
Clinical Course: MDD Episode
Predictors of longer duration: depression
severity, co-morbidity, negative life events,
parental psychiatric disorders, poor
psychosocial functioning
 6%-10% MDD are protracted ( prolonged)
Clinical Course: Relapse
Predictors of relapse: Lack of compliance,
Negative life events, Rapid decrease or
discontinuation of therapy
 40%-60% youth with MDD have relapse after
successful acute therapy
 Indicates need for continuous treatment
Clinical Course: Recurrence
Recurrence predictors:
 Earlier age at onset
 Increased number of prior episodes
 Severity of initial episode
 Psychosis
 Psychosocial stressors
 Dysthymia & other comorbidity
 Lack of compliance with therapy
Treatment

 Mild depression –Psycho-education and

supportive intervention
 Moderate depression – CBT or IPT
 Moderate to severe depression or
recurrent episodes of major depression
- both psychopharmacological and CBT.
Check need for hospitalization
Psychiatric Hospitalization
 Assess suicidality
 Safety should be assessed
 Depressed children and adolescents
who express suicidal thoughts or
behaviors require some extended
evaluation in the safety of the
psychiatric hospital
Concerns about Treatment of MDD
 Treatment research is relatively sparse for
MDD in children and adolescents
 Varied opinions about whether psychotherapy
or pharmacotherapy, or a combination should
be the first-line treatment
 Initial acute treatment depends on: severity of
MDD symptoms, number of prior episodes,
chronicity, age, contextual issues in family,
school, social, negative life events, compliance,
prior treatment response, motivation for
treatment
Treatment of MDD in Children &
Adolescents
 Antidepressants can be used for: non-rapid
cycling bipolar disorder, psychotic
depression, depression with severe
symptoms that prevents effective
psychotherapy or that fails to respond to
adequate psychotherapy
 Due to psychosocial context,
pharmacotherapy alone may not be
effective
 Evidence-based treatment studies
◦ SSRIs, CBT and combination was assessed and
all were efficient in treatment of depression and
combination was optimal starting from the early
treatment phase and has benefit of decreasing
persistent suicidal ideation and potential
treatment-related emergence of suicidal
ideation
Pharmacotherapy
 Fluoxetine and sertralin approved for the
treatment of major depression in adolescent
 Common side effects observed with fluoxetine
include headache, gastrointestinal symptoms and
insomnia
 Response rate of SSRI is 60% as compared to
49% of placebo
 A potential side effect of selective serotonin
reuptake inhibitors (SSRIs) in depressed
children is
◦ behavioral activation, or induction of hypomanic
symptoms.
◦ all antidepressant medication indicating the
increased risk of suicidal thoughts and behaviors in
children and adolescents being treated with
antidepressant medications, and the need for close
monitoring for these symptom
◦ But no risk of suicide or serious suicide attempt
Duration of Treatment

 Maintaining antidepressant treatment for 1

year in a depressed child who has achieved
a good response
 Discontinue the medication at a time of
relatively low stress for a medication-free
period
 Pharmacologic Treatment Strategies for
Resistant Depression
◦ If failed to respond to the first SSRI
◦ Change to another SSRI
◦ If not responsive to the second SSRI
medication
◦ either a combination of antidepressants or
augmentation strategies may be reasonable
choices as well as an antidepressant from
another class of medications.
 Psychosocial intervention
◦ CBT
◦ IPT
Electroconvulsive Therapy

 Safe and effective for adolescents who have

 With psychotic features
◦ catatonic symptoms
◦ persistent suicidality
SUICIDE

 Third leading cause of death among

adolescents(USA)
 Rare in children who have not reached
puberty
 During the last 15yrs completed suicide
and suicidal ideation rates have decreased
among adolescents.
◦ ?Due to SSRI medication
Suicidal Ideation and Behavior

 Suicidal ideation, gestures, and attempts are

associated with depressive disorders
 Express suicidal intention before 24hrs of
the act to a friend or relative
 Occurs in all age groups
 High rate of admission
 Completed suicide is rare before 12yrs –
cognitive immaturity is a protective factor
 Completed suicide 5x boys> girls
 Suicide attempt 3x girls> boys
 Method of the suicide
 Firearm>hanging(B),ingestion
of toxic
substance(G) >carbon monoxide poisoning
 Risk factors
 Family history of suicidal behavior
 Exposure to family violence
 Impulsivity and aggressive behavior
 Substance abuse
 Availability of lethal methods
 Mood and anxiety disorders
 Disruptive behavior problem
 Hopelessness
 Poor problem-solving skills
Epidemiology

 suicidal thought(1%) > suicidal ideation

with plan(0.3%) > suicide attempt
(0.25%)> completed suicide(1/100,000)
 Completed suicide is less common in
children and younger teens below 10 to
14yrs
 Suicidal behavior is more in girls than
boys
Etiology

 Inability to synthesize viable solutions to

ongoing problems and the lack of coping
strategies to deal with immediate crises.
 Failure to deal with issues like
◦ recurrent family disagreement
◦ rejection or failure
 Psychosocial Factors.
 severe major depressive illness(20% increase in risk)
 A sense of hopelessness, impulsivity, recurrent
substance use, and a history of aggressive behavior
 Maltreatment, including physical and sexual abuse
and neglect, exposure to violent and abusive homes,
endured chronically stressful family lives.
 Being disconnected, isolated, or alienated from peers.

 Protective factors is strong connection to school and

peers even in the face of other risk factors.
Diagnosis and Clinical Features
 40% had previous attempt and 40% previous
psychiatric treatment, Presence of
psychiatric disorder
 In younger adolescent impending
disciplinary actions, impulsive behavioral
histories, and access to loaded guns
 Adolescents without mood disorders with
histories of disruptive and violent,
aggressive, and impulsive behavior may be
susceptible to suicide during family or peer
conflicts
 High achiever and perfectionist adolescent
facing adverse event such an academically
proficient adolescent humiliated by a poor
grade on an exam
 Typical precipitants of suicidal behavior
include conflicts and arguments with family
members and boyfriends or girlfriends
 A child who has lost a parent by any means
before age 13 is at higher risk for mood
disorders and suicide
Precipitating factors
 lossof face with peers
 A broken romance

 School difficulties

 Unemployment

 Bereavement

 Separation, and rejection.

Treatment

 Low lethality to high risk for completion

 Determine need for hospitalization(high
risk/low risk)
 CBT
 SSRI
Next
Early-Onset Schizophrenia
Definition
 Schizophrenia is a pervasive, devastating, severe
neuropsychiatric disorder associated with extreme deficits in
cognition, behavior, and social functioning
 Early-onset schizophrenia -Onset before age 18
Childhood onset -Onset before 13 years
Adolescent onset - Onset before 18 years
Epidemiology
 Childhood onset schizophrenia – 1/40,000
 Adolescents between the ages of 13 and 18 years is 1 to 2
per 1,000, adult prevalence is 1:100
 More severe, chronic, and treatment-refractory
 High rate of co-morbidity
Epidemiology
EOS occurs predominantly in males
Ratio M/F: 2/1
Rare before 5years of age
Diagnosis
 Diagnostic criteria are the same for all ages with minimal
modifications for Early Onset Schizophrenia
 Children should have at least two of the following
characteristic symptoms for at least one month:
delusions, hallucinations, disorganized speech,
disorganized or catatonic behavior, negative symptoms
Diagnosis
 Hallucinations and delusions are less complex than in adults
 Failure to achieve expected levels of interpersonal, academic,
or occupational achievement
 Other psychotic conditions must be ruled out
Clinical Characteristics
 Prodromal period is often prolonged in EOS:
 Insidious onset is more common in children
 Acute onset is more often in adolescents
 Prodromal symptoms often include:
 Deficit in attention
 Poor coordination and gross motor skills
 Impaired academic performance
 Limited Social skills
 Social withdrawal and isolation
 Some degree of functional impairment and aggression
 Dysphoria, anxiety, physical complaints, sleep changes
 Idiosyncratic or bizarre behaviors/preoccupations
Clinical Characteristics
In most series, majority of children have received a
psychiatric diagnosis prior to the onset of psychotic
symptoms
Most common previous diagnoses:
 Autism spectrum disorder
ADHD
Other diagnoses: ODD, CD
Clinical Characteristics
 Once symptoms appear, phenomenology is similar to that
seen in adults
 Most common characteristics:
-- Hallucinations: 80%, AH > VH
--Delusions: 60%
-- Blunting of affect
--Disorganized speech: less common
 Progressive increase in complexity as the child is getting
older
 Illogical thinking and Loosening of Associations can be
reliably diagnosed but not poverty of speech and
incoherence; Catatonia is rare
 Laugh at a sad event
 Make poor eye contact
 Show little body language or facial expression
Differential Diagnosis
 Predictors of Childhood onset schizophrenia – Severe
psychosis – auditory hallucinations, flattened affect,
increased latency of speech
Autism spectrum Disorders
 Absence or transitory nature of psychotic symptoms
 Predominance of the characteristic deviant language
pattern
 Aberrant social relatedness
 Early age of onset < 3 years of age for autism versus > 5
years for VEOS
Other disorders
 OCD: Intrusive thoughts and repetitive ritualistic
behaviors may be difficult to differentiate from psychosis
in children
 Developmental Language Disorders: speech abnormalities
mistakenly diagnosed as being thought disorder
 Schizotypal and schizoid personality disorders
Outcome
 In general, the earlier the onset of (Childhood Onset
Schizophrenia)COS, the poorer the prognosis.
 Predictors of better prognosis include higher premorbid
intelligence, more positive than negative symptoms, and
cooperation of family in treatment (Remschmidt 2002)
 Long-term follow-up over 6-40 years indicates that
significant impairment persists into adulthood; only 7% of
the sample were able to maintain a stable relationship;
59% were unmarried and living alone; 73% had some
form of employment, 27% were unable to work (Eggers,
2002).
Treatment
 Early diagnosis and treatment is important
 Must involve both the child and the family
 Combination of psychosocial and pharmacological
treatment approaches
 psychoeducation for families
 pharmacological interventions,
 psychotherapeutic interventions
Pharmacological Approaches Special
considerations
 Children metabolize medications faster than adults: may
need to consider multiple daily doses; plasma half-life
 Higher density (concentration) of D2 receptors in children
compared to adults
 Likely more sensitive to side effects than adults
Conventional Antipsychotics
Haloperidol is effective for treating children with
schizophrenia
Haloperidol found to be effective in reducing symptoms of
thought disorder, hallucinations and persecutory ideation
 Clozapin is found to be effective for half of the patients
who do not respond to other antipsychotics
 Use of Clozapin is limited due to its toxic effect and
about 1/3rd has to stop the medication
Risperidone
 Treated patients had significantly greater reduction
decrease in PANSS scores

 Treated patients had significant decrease in hallucinations,

delusional thinking, and other symptoms of their illness.
Psychosocial Therapies
Individualized educational program
Psycho educational programs
Inpatient treatment for stabilization
Thank You
Elimination disorders
By:- Tesfalem A. (BSc.PH, MSc Psychiatry)
March, 2018,
Mekelle, Ethiopia

293
 Learning Objectives
After completion of this course; the students should
be able to:
 Describe what enuresis and encopresis are
 Identify common diagnostic criteria (DSM-5)
 Discuss management principles for children with
elimination problems

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 Normal Development

 Bowel Continence

 Bladder Continence

295
 Introduction
 All involve the inappropriate elimination of
urine or feces and are usually first diagnosed
in childhood or adolescence
 This group of disorders includes
◦ enuresis, the repeated voiding of urine into
inappropriate places, and
◦ encopresis, the repeated passage of feces into
inappropriate places

296
 Introduction
 The normal sequence of developing control over
bowel and bladder functions is the development of:
◦ nocturnal fecal continence,
◦ diurnal fecal continence,
◦ diurnal bladder control, and
◦ nocturnal bladder control.

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 Introduction…
 Bowel and bladder control develops gradually
over time
 Toilet training is affected by many factors,
◦ such as a child’s intellectual capacity and social
maturity,
◦ Cultural determinants, and
◦ the psychological interactions between child and
parents

298
 Introduction…
 It also depends on the maturation of
neurobiological systems, so that children with
developmental delays may also display delayed
continence of bowel and bladder.
 When children exhibit incontinence of urine or
feces on a regular basis, it is troubling to the child
and families, and often misunderstood as voluntary
misbehavior.

299
 Introduction…
 Diagnosis is not made for

◦ age 4 years, for encopresis, and

◦ age 5 years for enuresis

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encopresis

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 Encopresis
 Encopresis is characterized by a pattern of
passing feces in inappropriate places, such as
in clothing or other places,
 At least once per month for 3 consecutive
months,
 whether the passage is involuntary or
intentional

302
 Encopresis…
 Up to about 80% of children with fecal
incontinence have associated constipation
 A child with encopresis typically exhibits
dys regulated bowel function;
◦ for example, with infrequent bowel movements,
◦ constipation, or
◦ recurrent abdominal pain and
◦ sometimes pain on defecations

303
Encopresis…
 Affects
◦ 3% of 4-year-olds and
◦ 1.6% of 10-year-old children
◦ 0.75% of 10-12 year old children
◦ virtually absent in youth with normal
intellectual function by the age of 16 years
◦ Male: Female = (3 - 6): 1

304
 Encopresis…
 It is considered interplay between
physiological and psychological factors
leading to an avoidance of defecation
 Can be due to medical conditions
 Parents insisting that their children attempt
to defecate before they are adequately
treated

305
Encopresis…
 an expression of anger or rage in a child whose
parents have been punitive or of hostility at a
parent
 can also be present on an involuntary basis in
the absence of physiological abnormalities
 The feces may be of normal, near-normal, or
liquid consistency
 In rare cases, the involuntary overflow of stool
results from psychological causes of diarrhea

306
Encopresis…
 To receive a diagnosis of encopresis, a
child must have a developmental or
chronological level of at least 4 years

 If the fecal incontinence is directly related

to a medical condition, encopresis is not
diagnosed

307
Encopresis: DSM-5 Diagnostic Criteria
A. Repeated passage of feces into inappropriate
places (e.g., clothing, floor), whether involuntary
or intentional
B. At least once per month for at least 3 months
C. Chronological age is at least 4 years (or
equivalent developmental level)
D. The behavior is not attributable to the
physiological effects of a substance or medical
condition except constipation

308
 Encopresis: Course & Prognosis
 In some cases, encopresis is self-limiting
 It rarely continues beyond middle
adolescence
 To family members, who may assume that the
behavior is due to “laziness,” and family
tensions are often high, the outcome is
guarded

309
Encopresis: Course & Prognosis…
 It is affected by
◦ family’s willingness and ability to participate in
treatment without being overly punitive and
◦ the child’s ability and motivation to engage in
treatment

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 Encopresis: Treatment
Combination of medical and behavioral
treatment the most effective approach
 Medical Treatment
◦ Clean out the bowel
◦ Enemas
◦ Laxatives
◦ Increase fiber and exercise
◦ Ensure regular bowel movements

311
Encopresis: Treatment
 CBT
◦ Regular attempts to have bowel movements in the
toilet, and to diminish anxiety related to bowel
movement
Regular, timed intervals on the toilet
 Family tensions about the symptom must be
reduced, and
 a non punitive atmosphere should be
established
 Similar efforts should be made to reduce the
child’s embarrassment at school
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 Encopresis: Treatment…
 Interactive parent–child family guidance
intervention
 Supportive psychotherapy and relaxation
techniques
 Laxatives for those with constipation

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enuresis

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 Enuresis

 It is repeated voiding of urine into bed or

clothes, whether involuntary or intentional

 Prevalence
◦ 5 to 10 % in 5-year-olds,
◦ 1.5 to 5 % in 9- to 10-year-olds, and
◦ 1% in adolescents 15 years and older

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Enuresis…
 Among boys
 Nocturnal enuresis is about 50%more
common and
 Accounts for about 80%of children with
enuresis

316
Enuresis: Diagnostic Criteria
 Enuresis
◦ Repeated voiding of urine into bed or clothes
◦ Clinically significant
 Twice per week for at least 3 consecutive months
 Impairment in daily functioning (e.g., social academic)
◦ Chronological Age: 5 years (or developmental
equivalent)
◦ Behavior is not due exclusively to the direct
physiological effect of the following:
 Substance (e.g., diuretic)
 General Medical Condition (e.g., diabetes. Seizure disorder)

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Enuresis: Definition
 Enuresis Types:
◦ Diurnal
 Voids occurring during the daytime
◦ Nocturnal
 Voids occurring during the nighttime

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 Enuresis: Etiology
 Enuresis involves complex neurobiological
systems
 Excessive volumes of urine produced at night
may lead to enuresis at night in children
without any physiologic abnormalities
 Nighttime enuresis often occurs in the
absence of a specific neurogenic cause
 Daytime enuresis may develop based on
behavioral habits developed over time

319
 Enuresis: Etiology
 Daytime enuresis may occur in the absence
of neurological abnormalities
◦ resulting from habitual, voluntary tightening of
the external sphincter during urges to urinate
 Genetic/familial factors
 Psychosocial stressors appear to precipitate
enuresis

320
 Enuresis: DSM – 5 Diagnostic
criteria
A. Repeated voiding of urine into bed or clothes,
whether involuntary or intentional
B. Either a frequency of at least twice a week for at
least 3 consecutive months or
the presence of significant distress or impairment in social,
academic or other important areas of functioning
C. Chronological age is at least 5 years (or equivalent
developmental level)
D. The behavior is not attributable to the
physiological effects of a substance or another
medical condition 321
Enuresis: Assessment
 Medical Assessment
◦ Rule out significant medical condition
◦ Most often already ruled out by the time you
see the kid
 Behavioral Assessment
◦ Assess general behavior using a broad-band
rating scale

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Enuresis: Assessment
 Behavioral Assessment: Interview
◦ Behavioral or developmental problems
◦ Medical conditions
◦ History and current status of problem
◦ Family history
◦ Potty training history

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Enuresis: Assessment
 Behavioral Assessment: Interview
◦ Environmental contributors (e.g., when, how
much fluid intake, proximity to b-room, sleep
routine and arrangements)
◦ Consequences (e.g., how do parents handle it,
how does the child react)
◦ Child’s feelings and motivation to treatment

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Enuresis: Assessment
 Behavioral Assessment: Recording Data
◦ Provide Chart for recording voids
◦ Assess time of night, number of voids, size of
void, reaction

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 Physical Exam
 Abdominal pain/distention
 Height/Weight
 Neurological Exam
 Skin Exam
 Rectal Exam
 Abdominal XRAY
 Stool Collection
 Blood Testing
 Rectal Biopsy/Barium Enema

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Enuresis: Treatment
 Behavioral
◦ Moisture Alarm (Bell and Pad)
 Classical Conditioning
 Full bladder
 Voids
 Alarm sounds
 Awakenings
 Operant Conditioning
 Avoid aversive conditions during night (e.g., waking up to
a wet bed, cleaning up procedures, changing bed linens)

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Enuresis: Treatment
 Moisture Alarm
◦ Generally achieve dry nights within 2- 4
months
◦ Research suggests up to 70% successful
outcomes
◦ High Response Effort

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Enuresis: Treatment
 Arousal Training –Focus on R+ getting up
◦ Awakens
◦ Turns off alarm
◦ Attends the restroom for toilet sit
◦ Reattach enuresis alarm

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Enuresis: Treatment
 Pharmacological
◦ Imipramine (Trofanil)
 Tricyclic antidepressant
 Once medication discontinued, bedwetting resumes
 Relapse rate varies from 60% to 90%
 Duration of treatment varies without consensus

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Enuresis: Treatment
 Pharmacological
◦ Desmopressin Acetate (DDAVP)
 Analogue of Vasopressin (ADH)
 Supports urine concentration
 Decreases urine volume during nighttime
◦ Research findings yield mixed outcomes
 Increased number of dry nights
 Dryness may not maintain once terminate DDAVP
 Relapse rate varies from 50% to 95%

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