Child and Adolescent Psychiatry

DR NORHAYATI NORDIN
MD, MMed(Psych) UKM Cert in Child & Adolescent Psychiatry (Aust)

Psychiatrist Hospital Mesra Bukit Padang

Child and Adolescent Disorders

Learning, Motor Skills & Communication Disorders
Reading, Math, & Written Expression Disorders Developmental Coordination Disorder
Expressive Language Disorder Mixed Receptive Expressive Language Disorder

Phonological Disoder Stuttering

Child and Adolescent Disorders

Pervasive Developmental Disorders
(PDDs)
Autistic Disorder Asperger's Disorder Rett's Disorder Heller's Syndrome

Child and Adolescent Disorders

Attention-deficit & Disruptive Behavior Disorders
Attention-deficit and Hypersensitivity Disorder (ADHD)

Conduct Disorder

Oppositional Defiant Disorder

Child and Adolescent Disorders

Feeding & Eating Disorders

Pica Rumination Feeding & Eating Disorder

Child and Adolescent Disorders

Tic Disorders
Tourette's Disorder Chronic Motor or Vocal Tic Transient Tic Disorder

Child and Adolescent Disorders

Elimination Disorders
Encorpresis Enuresis

Child and Adolescent Disorders

Others
Anxiety Disorders Separation Anxiety Disorder Selective Mutism Reactive Attachment Disorder Sterotypic Movement Disorder Schizophrenia w/ Childhood Onset Mood Disorders

Child and Adolescent Disorders

mental retardation

mild

moderate

severe

profound

Mental Retardation
Subaverage general intellectual functioning

(IQ) Significant limitations in adaptive functioning

Communication Self care Home living Social/interpersonal skills Use of community resources, self direction Functional academic skills Work, leisure,health and safety

Mental Retardation
Subaverage general intellectual

functioning (IQ) Mild 50-55 to 70 Moderate 35-40 to 50-55 Severe 20-25 to 35-40 Profound below 20-25

Child and Adolescent Disorders

Pervasive Developmental Disorders
(PDDs)
Autistic Disorder Asperger's Disorder Rett's Disorder Heller's Syndrome

Autistic Disorders
Sustained impairments in reciprocal

social interactions
No

social smile,facial expressions or eye to eye gaze No nonverbal forms of communication. Ie body postures or gestures No desire to form friendships Dont share, show or point out objects they find interesting

Autistic Disorders
Marked impairment in communication
Delay

or total lack of language development Impaired ability to initiate or sustain conversation Abnormal pitch, intonation,rate rhythm or stress

Autistic Disorders
Restrictive, repetitive or stereotyped patterns

of behaviour,interests or activities:

Encompassing preoccupation with 1 or more pattern of interest Eating the same meal in the same place at the same time each day Whole body rocking Presistent preoccupation with parts of objects eg buttons
Comorbid seizure rate of 25% Mental retardation rate of 75%

AUTISTIC DISORDEREpidemiology
Rare
Prevalence is 2-5 cases per 10,000 children

under age 12 3-5 times more common in boys than girls Autistic girls more seriously affected and tend to have family history of cognitive impairment Earlier thought to be more common among families of higher socioeconomic status, but over the past 25 years more cases have been found in lower socioeconomic groups

AUTISTIC DISORDER Etiology

- congenital rubella, phenylketonuria, tuberous sclerosis, & Retts disorder Perinatal complications, especially in 1st trimester maternal bleeding, meconium in amniotic fluid, high incidence of medication usage during pregnancy Genetics - 36% concordance in monozygotic twins, however no specific genetic defect has been found. * there is an association w/ Fragile X Syndrome Immunological incompatibility between mother and child resulting in neural or extraembryonic tissue damage during gestation

Associated with conditions that have neurological lesions

AUTISTIC DISORDER Differential Diagnosis

Mental retardation w/ behavioral symptoms Mixed receptive-expressive language

disorder Congenital deafness or severe hearing disorder Schizophrenia w/ childhood onset Pyschosocial deprivation Disintegrative (regressive) psychoses

AUTISTIC DISORDER
Course & Prognosis
Long course
Those IQ above 70 and those who use

communicative language by ages 5-7 have the best prognoses 2/3 of autistic adults remain severely handicapped and dependent or semidependent 1-2% acquire normal and independent status 5-20% achieve borderline normal status Prognosis is improved if environment or home is supportive and can meet the needs of the child

AUTISTIC DISORDER Treatment Educational and behavioral methods

* specialized day programs * behavioral management techniques to reduce rigid & stereotyped behaviors * training and counselling parents as well. Haloperidol - reduces behavioral symptoms & accelerates learning Fenfluramine (reduces blood serotonin) - effective in some Lithium for aggressive or self-injurious Behaviors Anticonvulsants in those w/ comorbid seizure disorder Risperidone & Naltrexone being explored

Child and Adolescent Disorders

Attention-deficit & Disruptive Behavior Disorders
Attention-deficit and Hypersensitivity Disorder (ADHD)

Conduct Disorder

Oppositional Defiant Disorder

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Persistent & dysfunctional pattern of over-

activity, impulsiveness, inattention and distractibility Epidemiology

* 3-5% of prepubertal elementary school children * male:female ratio is 3-5:1 * most common in first-born boys * parents show increased incidence of hyperkinesis, sociopathy, alcohol use and conversion disorder

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Aetiology Unknown Contributing factors include perinatal injury, malnutrition, & substance exposure some genetic basis since greater concordance in monozygotic twins & 2x greater risk of ADHD in siblings of child with ADHD than general population Differential Diagnosis * Age-appropriate behaviour * Oppositional Defiant Disorder * Mood Disorder

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Course & Prognosis Highly variable - symptoms may persist into adolescence/adulthood or remit at puberty Over-activity is usually the 1st to remit and distractibility the last If symptoms persist into adolescence, there is a high risk of developing Conduct Disorder, Personality Disorders, Mood Disorders, or Substance-related Disorder Optimal outcome is promoted by ameliorating the childs aggression & improving the family functions early

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Treatment

* CNS stimulants - dextroamphetamine (3 yrs old), methylphenidate (> 6 yrs old), pemoline * Antidepressants - SSRI,imipramine, desipramine, nortriptyline (for children w/ comorbid anxiety or depressive disorders) * Clonidine * Individual pyschotherapy,behavior modification, parent counselling & treatment of co-existing learning disorder

Child and Adolescent Disorders

Attention-deficit & Disruptive Behavior Disorders
Attention-deficit and Hypersensitivity Disorder (ADHD)

Conduct Disorder

Oppositional Defiant Disorder

CONDUCT DISORDER
Repetitive & persist pattern of behaviour in

which the the basic rights or others or other major age-appropriate societal norms are violated
Epidemiology

* 6-16% of boys & 2-9% of girls under age 18 * male:female ratio is 4-12:1 * more common in children of parents with antisocial personality disorder or alcohol dependence

CONDUCT DISORDER Aetiology

Parental factors - chaotic home life, alcoholic or

substance abusing parents, child abuse, neligence, etc. Socio economically deprived children Neurobiological factors

* low plasma dopamine B- hydroxylase (converts dopamine to nor epinephrine) * increased plasma 5-HT & decreased CSF 5-HIAA (correlates w/ aggression & violence)

CONDUCT DISORDER
Differential Diagnosis * Mood Disorders * Psychotic Disorders * Learning Disorders * Attention-deficit Hypersensitivity Disorder Course & Prognosis Poorest prognosis in those w/ symptoms at young age, exhibit greatest number of symptoms or express them more frequently Good prognosis in those w/ mild conduct disorder, absence of coexisting psychopathology & normal intellectual functioning

CONDUCT DISORDER Treatment

Environmental structure w/ consistent rules

and expected consequences at home and school Individual psychotherapy to help improve problem solving skills Treatment of aggression - Haloperidol, Lithium, Carbamazepine, Clonidine Treatment of concurrent disorders (ADHD, learning disorders, mood disorders & substance-related disorders)