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Child Psychiatry - Part 1
1. Child Psychiatry – Part 1
Dr Bhakti Murkey
Assistant Professor, Department of Psychiatry (PMCH Udaipur)
2. Outline
Classification (ICD-10)
History taking in Child Psychiatry
ADHD
Autism
Asperger’s Syndrome
Intellectual Disability Disorder
Specific Learning Disorders
Tic Disorder
Disruptive Behavior Disorders
Oppositional Defiant Disorder
Conduct Disorder
Anxiety Disorders in children
Childhood Depression
Childhood Mania
Childhood onset Schizophrenia
Elimination Disorders
Rating Scales in children
References
3. Classification of Childhood Psychiatric Disorders
(ICD-10)
F 70-73: Mental Retardation
F 80-83: Specific Developmental Disorders
F 84: Pervasive Developmental Disorder
F 90: Hyperkinetic Disorder
F 91: Conduct Disorder
F 93: Emotional Disorders with childhood onset
F 94: Disorders of social functioning
F 95:Tic Disorder
4. History Taking in Child Psychiatry
Chief complaints
History of Present Illness
Past History
Personal History
Medication History
Family History
Social History
Childhood History
5. Childhood History
Pregnancy
Perinatal history: birth asphyxia? LBW? NICU stay? Major medical/ surgical illness?
Developmental milestones: gross and fine motor, social and language
Behavioral symptoms: temper tantrums, head-banging, thumb-sucking, regressive
behavior, stereotypy?
Schooling history: behavior, performance at school, any complaints? Relationship
with peers?
Assessment of Temperament
8. Childhood History contd…
Family environment
Parenting styles
Relationship with sibling/s
Any major life events or recent stressor (for example, death of pet or
change in school, etc)
Feeding and sleep patterns
Indulgence in substance use
11. Attention Deficit Hyperactivity Disorder
Impairment in attention and/or hyperactivity-impulsivity
In at least 2 settings
Interfering with developmentally appropriate functioning (social, academic or
extracurricular)
For at least 6 months
1-2% prevalence
3 times more common in boys
Genetic vulnerability
DA and NA dysfunction in prefrontal cortex
Up to 50% children will have other co-morbid psychiatric illnesses
12. Attention Deficit Hyperactivity Disorder
Up to15% of cases continue to meet diagnostic criteria for ADHD at the age of
25 years
50% of individuals will suffer some impairment from residual symptoms
5 times greater risk for antisocial behavior, substance abuse and other
psychiatric disorders
15-20% develop substance misuse problems
Poor prognosis if early stressful life experiences (poverty, overcrowding,
expressed emotions and parental psychopathology) or severe symptoms,
predominantly hyperactive - impulsive and associated with conduct, language
or learning disorder
17. Autism Spectrum Disorder
(Pervasive Developmental Disorders)
PDD is an umbrella term, which includes Autism, Asperger’s syndrome,
Rett’s syndrome and Childhood Disintegrative Disorder
Characterized by: impaired reciprocal social interactions, communication
difficulties, aberrant language development, and restricted behavioral
repertoire
Typically emerge before the age of 3 years
Four times more frequent in boys
There is no cure or treatment for autism
Early and effective management is desirable for a better outcome, and
involves a comprehensive assessment of the child and family’s needs
18. Autism Spectrum Disorder
(Pervasive Developmental Disorders)
Management aimed at helping the family, providing vocational training and
support to the person
Psychotherapy may be helpful for verbal skills
Specific intervention programmes:
Applied Behavior Analysis program: based on operant conditioning, imitation
and reinforcement
TEACCH – Treatment and Education for Autistic and related Communication
Handicapped Children program: based on the belief that children are
motivated to learn language, successful in reducing self injurious behaviors
and enhancing life skills
19. Autism Spectrum Disorder
(Pervasive Developmental Disorders)
Pharmacotherapy commonly used as adjunct
SSRIs - most widely used for restricted repetitive behaviors
Second generation antipsychotics are the first line treatment for associated
irritability and aggression
The only licensed medication is Risperidone (0.5 – 2 mg/day)
20. Asperger’s Syndrome
Same type of qualitative abnormalities in reciprocal social interaction that
typify autism with a restricted, stereotyped and repetitive, repertoire of
behavior/interests
IQ and language are usually within normal limits
No significant delays occur in relation to language development., cognitive
development, and/or age appropriate self help skills
One third as common as autism with a prevalence of about 6 in 10,000
Normal IQ and high level social skills have good prognosis
21. Rett’s Syndrome
Rare X linked dominant disorder
Almost exclusively affects females
Head circumference normal at birth
and developmental milestones
unremarkable in early life
Between 6-18 months, head
growth begins to decelerate and
produces microcephaly
Loss of purposeful hand
movements
Stereotypic hand wringing
Loss of previously acquired speech
Psychomotor retardation and
ataxia
Both receptive and expressive
communicative and social skills
plateau
Poor muscle coordination
Unsteady gait
Associated seizures in up to 75%
cases
Irregular respiration, with episodes
of hyperventilation, apnoea and
breath holding
22. Childhood Disintegrative Disorder
Heller’s disease
Marked regression in several areas of functioning after at least 2 years of
apparently normal development
Loss of acquired motor, language, and social skills between ages 3 and 4 years
Loss of skills in two of the following areas: language, social or adaptive behavior;
bowel or bladder control, play and motor skills
Abnormality in at least two of the following categories: reciprocal social interaction,
communication skills, and stereotyped or restricted behavior
Associated seizure disorder
Male predominance
Poor prognosis
24. Mental Retardation
(Intellectual Disability Disorder)
Developmental disability marked by lower-than-normal intelligence and
limited daily living skills
Either normally present at birth or develops early in life
Types:
Borderline intelligence IQ < 80
Mild (IQ = 50-70)
Moderate (IQ = 35-50)
Severe (IQ = 20-35)
Profound (IQ < 20)
25. Mental Retardation
(Intellectual Disability Disorder)
Mild MR:
Individuals can often live on their own with community support
They have minimum retardation in sensory-motor areas
Moderate MR:
They are challenged academically and often are not able to achieve
academically above a second to third grade level
As adults, they may be able to perform semiskilled work under appropriate
supervision
26. Mental Retardation
(Intellectual Disability Disorder)
Severe MR:
Individuals can often master the most basic skills of living, such as
cleaning and dressing themselves
Is often recognized early in life with poor motor development & absent or
markedly delayed speech & communication skills
Profound MR:
Individuals can often develop basic communication and self-care skills
Most individuals have identifiable causes for their condition
27. Mental Retardation
(Intellectual Disability Disorder)
Causes:
Infections (present at birth or occurring after birth)
Chromosomal abnormalities:
Chromosome deletions
Defects in chromosomal inheritance
Errors of chromosome numbers
Problems at birth:
Difficult labor or perinatal hypoxia
Problems during pregnancy (TORCH infection)
Exposure to certain toxins/ teratogenic medication
28. SpLD
(Specific Learning Disability)
Problems with educational achievements
Performance significantly below that expected for IQ or age
Under-achievement in reading, written expression, or mathematics
Genetic predisposition, peri-natal injury and neurological and other medical
conditions can contribute
Affect at least 5% of school age children
Associated with up to 50% risk of co-morbid disorders, including ADHD,
communication disorders, conduct disorders and depression
Commonly present as emotional or behavioral problems
Strong evidence of heritability
30. Tic Disorder (Tourette Syndrome)
Multiple motor and/ or vocal tics
Present for at least a year
Significant distress and impaired function
Facial tics: eye blinks or head jerks are often the initial symptoms, but tics
involving the neck, shoulders, and upper extremities are also common
Vocal tics begin 1- 2 yrs after the onset of motor symptoms and range from
meaningless sounds to clear words
Vocal tics are crucial for diagnosis and may be barks, hisses, hoots and not
necessarily obscene blasphemous utterances (coprolalia), echolalia, or
palilalia(repeating ones own speech)
Treatment: low dose Anti-psychotics (Haloperidol/ Risperidone)
32. Oppositional Defiant Disorder
Enduring pattern of negative, hostile, disobedient and defiant behavior, without
serious violations of societal norms or the rights of others
For at least 6 months
Temper outbursts, active refusal to comply with rules, tendency to blame
others, spiteful and annoying behaviors
Can begin as early as 3 years of age, typically noted by 8 years
Prevalence 2-5%
More prevalent in boys than in girls
25% cases show no symptoms in later life but many progress to conduct
disorder
33. Oppositional Defiant Disorder
Aetiology: temperamental factors like sick or traumatized child and power
struggle between parents & child
ADHD in early life is a predictor of oppositional defiant disorder and conduct
disorder later in life
Almost always interferes with interpersonal relationships and school
performance
Can cause low self-esteem, poor frustration tolerance, depressed mood, and
temper outbursts
Adolescents may abuse alcohol and illegal substances
May evolve into a conduct disorder or a mood disorder
34. Oppositional Defiant Disorder
Poor prognosis: early onset, longer duration of symptoms, co-morbid
anxiety, impulse control & substance misuse
Management:
Family intervention using both direct training of the parents in child
management skills and careful assessment of family interactions
With the child, use collaborative problem solving skills
Teach parents how to alter their behavior to discourage the child's
oppositional behavior and encourage appropriate behavior
Selective reinforcement and praising of appropriate behaviors
Ignoring or not reinforcing undesired behavior
36. Conduct Disorder
Severe and persistent pattern of antisocial, aggressive or defiant behaviors
that defy age appropriate societal norms
Four categories:
Physical aggression or threats of harm to people, cruelty to people and
animals
Destruction of their own property or that of others
Theft or acts of deceit
Frequent and serious violation of age appropriate rules (truancy/running
away)
At least one behavior for at least six months
Begins usually before the age of 13
Prevalence of 5-7%
More common among boys than girls (4:1)
37. Conduct Disorder
Three most significant risk
factors (Ontario Child Health
Survey,1987):
Family dysfunction
Parental mental illness
Low income
Other risk factors (Rutter,1978):
Criminality of father
Overcrowding
Maternal neurosis
Institutional care
Chronic marital discord
Biological risk factors
Temperament:
‘callous-unemotional’
Brain injury
Neuro-chemical: Low CSF
serotonin seen in more
aggressive behavior
Low IQ
38. Conduct Disorder
Psychosocial risk factors:
Maternal smoking during pregnancy
Parental criminality and substance abuse
Harsh and inconsistent parenting
Lack of a warm parental relationship and cold/rejecting family relationships
Domestic violence in the family and child abuse
Large family size
School failure and poor school achievement
Social isolation
39. Conduct Disorder
Conduct disorders further predict risk for numerous problems in adulthood
that includes (Moffitt, 2002)
Criminality and ASPD (antisocial personality disorder)
Serious difficulties in education, work and finances
Homelessness and abuse
Drug and alcohol dependence
Poor physical health including injuries, sexually transmitted infections,
compromised immune function
Variety of mental disorders and suicidal behavior
41. Conduct Disorder
Treatment is multimodal
Psychological therapies form the mainstay of treatment
Parent Management Training based on the principles of social learning
theory has been very successful
NICE recommends group based parent training/education programmes as
mainstay of treatment
Cognitive behavioral therapy:
Social skills training
Anger management
Common targets – aggression, social interaction, self evaluation and
emotional dysregulation
42. Conduct Disorder
Functional family therapy: practicable and relatively inexpensive. There
are four phases of treatment which includes Engagement, Motivation,
Behavioral Change and Generalization (reduce reoffending rates by 50%)
Multi-systemic therapy: Address specific individual difficulties and promote
strengths
Other treatment options:
Treat any co-morbidity
Address any child protection concerns
Anger Management Programme
