1. Child and Adolescent Psychiatry Overview Dr. Mahmoud Bashtawi, M.D. Child & Adolescent Psychiatrist Division of Psychiatry -JUST

2. Introduction Child psychiatric assessment requires attention to details of a child's development stages, family structure and dynamics, as well as normative age-appropriate behavior. Consulting with parents and obtaining reports from schools, teachers, and other involved parties are essential for proper assessment. Psychiatric assessment is not easily in children as they are in adults because children, especially, young express emotion in a less abstract way than adults. So interviews require more concrete queries. Children have more comorbid psychiatric disorders than adults, making diagnosis and treatment more complicated.

3. Common Child and Adolescent Psychiatric Disorders Mental Retardation (Intellectual disability) Learning Disorders Autism Spectrum Disorder(ASD) once called Pervasive Developmental Disorders(PVD) Attention-Deficit and Disruptive Behavior Disorders Other Child and Adolescent Psychiatric Disorders

4. Intellectual disability(ID) (ID), once called mental retardation, is characterized by below average intelligence or mental ability and a lack of skills necessary for day to day living.. People with intellectual disabilities can and do learn new skills, but they learn them more slowly. There are varying degrees of intellectual disability, from mild to profound. Someone with intellectual disability has limitations in two areas. These areas are: Intellectual functioning. Also known as IQ, this refers to a person’s ability to learn, reason, make decisions, and solve problems. Adaptive behaviors. These are skills necessary for day-to- day life, such as being able to communicate effectively, interact with others, and take care of oneself.

5. Mental Retardation(Intellectual disability) Characterized by subaverage (IQ below 70) intellectual functioning (IQ below 70) and concurrent deficits or impairments in adaptive functioning. low IQ is not sufficient evidence of mental retardation. Necessary, but not sufficient. Onset before age 18.

6. Mental Retardation(MR) Degrees of Retardation Mild (IQ 50-55 to 70): By family support and special education the children can usually learn to read, write and to hold some type of job in the community. Moderate (IQ 35 to 50): With training, the children can learn to talk, to recognize their name and a few simple words, and to perform activities of daily living without assistance. Severe (IQ 20 to 35) Profound (IQ below 20-25) Children with severe or profound mental retardation typically require care in institutional settings.

7. Mental Retardation Etiology Mental retardation can be thought as a final common pathway of a number of childhood or perinatal disorders. The most common cause of mental retardation is Down's syndrome (trisomy 21). Fragile X syndrome is the most common cause of heritable mental retardation. Pregnancy or perinatal problems(fetal malnutrition, hypoxia, infections, and trauma) Medical conditions of infancy (infection or lead poisoning) Early alterations of embryonic development maternal alcohol consumption can all cause mental retardation

8. Learning Disorders Learning disorders(LD) are characterized by performance in a specific area of learning (e.g., reading, writing, arithmetic) below the expectation of a child's chronologic age, formal education, and level of intelligence. LD diagnosis is confirmed through specific intelligence and achievement testing. Physical factors like hearing or vision impairment must be ruled out. The diagnosis of learning disorder is confirmed through specific intelligence and achievement testing. LD diagnosis is made when the full clinical picture is not explained by other comorbid conditions such as pervasive developmental disorder, MR, and communication disorders.

9. PERVASIVE DEVELOPMENTAL DISORDERS Overview 1. Pervasive developmental disorders (Autistic disorder, Asperger disorder, Rett disorder, Childhood disintegrative disorder)are characterized by the failure to acquire or the early loss of social skills and difficulties with language, resulting in long term problems in social and occupational functioning. 2. Treatment involves behavioral therapy to increase social and communicative skills, decrease behavior problems (e.g., self-injury, aggressiveness ), and improve self-care skills, as well as supportive therapy and counseling to parents.

10. PERVASIVE DEVELOPMENTAL DISORDERS (PVD) Types: Autistic disorder Asperger's disorder Rett's disorder Childhood disintegrative disorder Those types are also called autism spectrum disorders (ASD)because of overlapping aspects of their clinical manifestations.

11. ASD -Autistic Disorder (a severe form of ASD), includes: 1. Significant problems with communication (despite normal hearing) 2. Significant problems forming social relationships 3. Repetitive, purposeless behavior 4. Low IQ about 75% of autistic children 5. Unusual abilities in some children as exceptional memory or calculation skills. - Asperger's disorder (a mild form of ASD). In contrast to autistic disorder, there is normal cognitive development and little or no developmental language delay. However, conversational language skills are impaired.

12. ASD - Rett's syndrome 1. Children with Rett's syndrome appear normal for several months after birth and then develop specific problems ; (decrease in the rate of head growth between months 5 and 48,diminished social, verbal, and cognitive of normal functioning, motor problems later in the illness) 2. Occurrence only in girls (Rett disorder is X-linked and affected males die before birth) 3. Stereotyped, hand-wringing movements 4. Breathing problems 5. Mental retardation -Childhood disintegrative disorder (diminished social, verbal, cognitive, and motor development after at least 2 years of normal functioning.

13. Attention Deficit Hyperactivity Disorder (ADHD) and Disruptive Behavior Disorders of Childhood Overview ADHD and the disruptive behavior disorders ( conduct disorder and oppositional defiant disorder) are characterized by disruptive behavior that causes problems in social relationships and school performance. These disorders are not uncommon and are higher in boy than girls. The differential diagnosis are mood disorders and anxiety disorders. There is no obvious mental retardation (MR).

14. ADHD Characteristics: Persistent and dysfunctional pattern of hyperactivity, impulsiveness, inattention, and distractibility. A child must evidence the onset of inattentive or hyperactive symptoms before age 7. In DSM 5 before age 12. Features must be present in two or more settings (e.g., school, home). Symptoms in only one setting suggest an environmental or psychodynamic cause, and it is important to distinguish ADHD from normal, active behavior, or other psychiatric disorders such as bipolar disorder.

15. ADHD Typically, children stay up late, wake up early, and spend most of their times in various hyperactive and impulsive activities. They may run about the house and cause damage They have tendency for accidents. When they enter school, their difficulties with attention become more obvious. They appear not to follow directions, forget important school supplies, fail to complete homework or tasks and attempt to blurt out answers to teachers before their questions are completed. They fall behind their peers academically and socially.

16. ADHD Etiology The etiology of the disorder is unknown, but perinatal injury, malnutrition, substance exposure, environmental toxins, heredity and damage to brain structure and functions have all been implicated. Management : combination of pharmacotherapy and behavioral treatments. Prognosis: Hyperactivity is the first symptom to disappear as the child reaches adolescence and the most show remission by adulthood.

17. Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD) Conduct disorder (CD) Persistent pattern of behavior in which the basic rights of others,norms or rules are violated. Behaviors include aggression toward people or animals, destruction of property, deceitfulness, theft, or serious violations of rules (e.g., torturing animals, stealing, truancy, fire setting). Studies show a genetic predisposition and psychosocial factors play a major role. Parental separation or divorce, parental substance abuse, severely poor or inconsistent parenting, and association with a delinquent peer group have been shown to have some relationship to the development of conduct disorder.

18. Conduct disorder (CD) CD can begin in childhood or adolescence. CD,ODD as well as ADHD are more likely to be abused by caretakers. Risk for substance abuse, mood disorders and criminal behavior; 40% go on to have adult antisocial personality disorder. Treatment involves individual and family therapy. Medications are used to treat behavioral problems and comorbid ADHD or mood disorder. The long-term outcome depends on the severity of the disorder and the degree and type of comorbidity.

19. Oppositional Defiant Disorder(ODD) ODD is diagnosed in a child with annoying, difficult, or disruptive behavior when the frequency of the behavior significantly exceeds that of other child`s particular culture. Behavior such as anger, argumentativeness, resentment and history of excessive crying and resentment toward authority figures. Behavior does not grossly violate social norms Gradual onset, usually before age 8. A significant number of cases progress to conduct disorder Most children show remission by adulthood Management emphasizes individual and family counseling.

20. Other disorders of childhood Tourette's Disorder TD Child demonstrates multiple involuntary motor and vocal tics. These behaviors can be controlled briefly. A tic is a sudden, rapid, recurrent and nonrhythmic motor movement or vocalization. The disorder is lifelong, chronic, and begins before age 18. It usually starts with a motor tic (e.g., facial grimacing) that appears between ages 7 and 8. While the manifestations are behavioral, the etiology of TD is neurologic. It is believed to involve dysfunctional regulation of dopamine in the caudate nucleus.

21. TD The disorder is a 3:1 male: female ratio and has a strong genetic component. There is a genetic relationship between Tourette disorder and both ADHD and Obsessive Compulsive Disorder. Atypical antipsychotic agents and typical agents are the most effective treatments for Tourette disorder. In milder cases, medication such as clonidine also are helpful. The children and their family should receive education and supportive psychotherapy aimed at minimizing the negative social consequences (e.g., embarrassment, shame, isolation) that occur with this disorder.

22. Separation anxiety disorder The child refuses to go to school. Characterized by an overwhelming fear of loss of a major attachment figure, particularly the mother. The child often complains of physical symptoms such as stomach pain, vomiting or headache to avoid going to school and leaving the mother. The most effective management of a child with this disorder is to have the mother accompany the child to school and when the child is more comfortable, gradually decrease her time spent at school. They are at greater risk for anxiety disorders in adulthood.

23. Selective mutism Children with this disorder speak in some social situations but not in others. The children may whisper or communicate with hand gestures. Children with this disorder more commonly girls. Children usually have social anxiety disorder. Selective mutism must be distinguished from normal shyness. Management by pharmacotherapy and psychotherapy.

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