Presentation on theme: "Medical student lecture: introduction to child psychiatry"— Presentation transcript:
1 Medical student lecture: introduction to child psychiatry Regina Bussing, MD, MSHSAssociate Professor and ChiefDivision of Child and Adolescent Psychiatry
2 LECTURE FOCUS Child Development Evaluation Strategies Treatment ModalitiesChildhood Disorders
3 MAJOR DEVELOPMENTAL STAGES Prenatal/BirthInfancy (Birth –18 months) Trust - form attachment/bondToddler ( years) Autonomy - walk/talk/tolerate separationEarly childhood (3-5 years) Initiative - build vocabulary, build superegoMiddle childhood (6-12 years) Industry - build peer-relations and competenciesAdolescence (12-adult) Identity
4 MILESTONES: Developmental Markers* Sitting 6 monthsWalking 1 yearTalking 1 yearToilet Training 2 years +Rides Tricycle 3 yearsDresses Self 5 yearsDraws a person (main parts) 5 yearsRides Bicycle 6 years* Normal variation is present; Denver II-R
5 REASONS TO LEARN ABOUT NORMAL DEVELOPMENT To identify and be supportive of age-appropriate emotional expressions (e.g. expressions of autonomy; stranger anxiety) - these are healthy.To better identify what is really abnormal so treatment is focused on psychopathology - e.g., adolescent suicide attempts, drug use.To better understand adult psychopathology.To better understand common patterns of regression (a return to earlier developmental behaviors) that may occur with illness or stress.
6 CONCEPT OF REGRESSIONSTRESS ----> Return to earlier developmental stageEXAMPLES:A 7yr old child with previous normal development now hospitalized with leukemia begins bedwetting, thumb sucking, and using “baby talk”.A 42 year old previously healthy male becomes totally dependent on his wife for ADLs following a mild heart attack.
9 SHIFTING FOCUS OF ASSESSMENT Infants and toddlers: History; observationgross and fine motor functionslanguage and communicationsocial behaviorbondingUsual Concerns:delayed development (e.g., MR),abnormal development (e.g., PDD)poor bonding (e.g., neglect, abuse)
11 Shifting Focus of Assessment Preschoolers: Observation, personal interview, parent interviewobserve milestonesassess what child talks and thinks about (e.g. through play)Parent-child relationPossible concerns: as before, plusspeech-language delays,hyperactivity,aggressive/defiant behaviors,excessive anxiety,toilet training
14 Shifting Focus of Assessment School-age child: Observation, interviews, reports from schoolhow does child function in family?how does child function in school? (behavior and academics)what kind of peer relations?formal psychological and academic testingCommon concerns:learning problemsexternalizing conditionsseparation anxiety
15 IMPROVING THE ODDS FOR SUCCESSFUL DEVELOPMENTAL OUTCOMES PROTECTIVE FACTORSGood parent-child relationshipEasy, outgoing temperamentPositive peer influenceSuccessful school experiencesCaring adult role modelsParticipation in pro-social groupsAccess to needed services, e.g. healthcare, mental health, crisis intervention
16 TREATMENT MODALITIES* *(Usually 2 or more modalities are used simultaneously) Individual Therapies (play, behavioral, cognitive, supportive, dynamic)Family Therapy & Parent TrainingGroup Therapy - especially important for adolescentsExamples of Pharmacotherapy:ADHD Stimulants (e.g., Ritalin)MDD & Anxiety SSRIs (e.g., Prozac, Zoloft)Bipolar Disorders Valproate, LithiumEnuresis DDAVP, TCAs (IMI)Psychosis Antipsychotics
17 CHILD ABUSE ABUSE"Abuse" means any willful act or threatened act that results in any physical, mental, or sexual injury or harm that causes or is likely to cause the child's physical, mental, or emotional health to be significantly impaired. Abuse of a child includes acts or omissions. Corporal discipline of a child by a parent or legal custodian for disciplinary purposes does not in itself constitute abuse when it does not result in harm to the child. [Subsection (2), F.S.]The Florida Abuse Hotline will accept a report when:There is reasonable cause to suspect that a child (less than 18 years old)who can be located in Florida, or is temporarily out of the state but expected to return in the immediate future,has been harmed or is believed to be threatened with harmfrom a person responsible for the care of the child.Know state reporting laws and procedures(http://www5.myflorida.com/cf_web/myflorida2/healthhuman/childabuse/)
18 DISORDERS OF CHILDHOOD AND ADOLESCENCE Basically all adult Axis I disorders can occur in children and adolescents (Depression, Bipolar, Schizophrenia, Anxiety, etc.).Personality Disorders (Axis II) are usually not diagnosed (and ASPD can’t be), although personality traits are often identified.Specific disorders with childhood onset are listed separately in DSM-IV (ADHD, Conduct Disorder, Learning Disorders, MR, etc). These may persist into adulthood.Comorbidity is common.Epidemiology: 1 in 5 children involved
19 MENTAL RETARDATION Diagnostic Criteria IQ 70 or less on an individually administered IQ testOnset before age 18 yearsConcurrent deficits or impairments in adaptive functioning in at least two of these areas:communication, self care, home living, social and interpersonal skills, use of community resources, self direction, functional academic skills, work, leisure, health, or safety.Epidemiology: 1-3% in USCauses:Unknown (50% of mild MR)Known (75% of severe MR) – Hereditary (Down’s, fragile X; PKU);Toxins; Birth Trauma; Infection.
20 MODERATE MR: IQ 35/40 to 50/55 (~ 10%) MILD MR: IQ 50/55 to 70 (~ 85%)School: may acquire skills up to 6th grade level.Social and Communication Skills: develop spontaneously.May first be detected in school.May acquire vocational skills and be self-supportive.MODERATE MR: IQ 35/40 to 50/55 (~ 10%)Social and Communication Skills: develop, but impaired.Early detection (i.e., before entering school).School: unlikely to progress past 2nd grade level.May work under close supervision (sheltered workshop).
21 PROFOUND MR: IQ Below 20/25 (~ 1-2%) SEVERE MR: IQ 20/25 to 35/40 (~ 3%)School: May learn to sight-read (survival words)Social/Communication Skills: little or no communicative speech. Often display poor motor development.May acquire elementary hygiene skills and perform simple tasks; unable to benefit from vocational trainingPROFOUND MR: IQ Below 20/25 (~ 1-2%)Social and Communication Skills: rarely have communicative speech efforts; minimal sensorimotor abilities.Require constant aid and supervision; nursing care.
22 TREATMENT CONSIDERATIONS Family is coping with loss of “ideal” child - Grief and loss issues.Appropriate placement essential: School setting, day care, group homes, sheltered workshop and respite care.Specific problems may be responsive to medications - Seizures; depression; hyperactivity; aggression.May experience “independent” psychiatric disorders, including schizophrenia, bipolar disorder, etc.
23 Pervasive Developmental Disorder Developmental disorders with severe and pervasive impairment in essential developmental areasReciprocal social skillsLanguage developmentRange of behavioral repertoireDSM-IV includes the following under PDD:AutismRett’s DisorderChildhood Integrative DisorderAsperger’s DisorderPDD, not otherwise specified
25 Autism Prevalence estimates: variable and increasing Boys are effected 3 to 5 times more than girls50 to 70% have some degree of MRAssociated with Congenital Rubella, PKU, Tuberous Sclerosis and Fragile X Syndrome20 to 25% have grand-mal seizures and about 50% have non-specific EEG abnormalitiesMRI, EEG, Karyotyping indicated in almost all cases
26 INTERVENTIONS IN AUTISM: Presently no curative treatment available; symptomatic interventions focus.Mainstay: Early intervention; speech and language services; structured behavioral and educational programs; OT, PT.Medications: To control seizures, hyperactivity, severe aggression, SIB, repetitive behaviors or mood disorders.CARD PROGRAM:
27 Retts Disorder Normal growth for the first few months of life Deceleration of head growth between 5-48 monthsTruncal incoordinationLack of purposeful hand movements; flappingDisorder of femalesSimilar criteria as PDDOver 80 percent of patients diagnosed with Rett's have a specific mutation in the MeCP2 gene on the X chromosome. This mutation is not inherited, but occurs after conception.
28 “I Have the Courage “I cannot speak, but you understand me. I cannot walk, so you push me. I cannot sing, but I love music. I cannot crawl, so you carry me. I cannot tell jokes, but I love to laugh. I cannot wash myself, so you bathe me. I cannot play with Barbies, but I can push a switch. I cannot wave bye-bye, so you do that for me. I cannot dress myself, so you make me pretty. I cannot read, so you tell me stories. I cannot touch, but I can feel. I cannot go up the stairs, so you put me on the lift. I cannot tell you how much I love you, so look into my eyes and you will see. I cannot tell what the future will hold, but I have the courage to go on
29 Childhood Disintegrative Disorder Normal Development for at least two years of life.Clinically significant loss of previously acquired skills prior to age 10 years in two or more of the following areas:LanguageSocial Skills Or adoptive behaviorBowel or bladder controlPlayMotor skillsAbnormal functioning in at least two areas:Social interaction; communication; patterns of behaviors/interests
30 Asperger’s Disorder PDD NOS “High functioning autism”Impaired use of non-verbal communication (gaze, posture, gestures regulating social interaction)Lack of interactive play, impaired peer relationsStereotypic, repetitive mannerismsNo delays in language and cognitive developmentPDD NOSDiagnosis assigned when there is a severe and pervasive impairment in the development of reciprocal social interaction, or communication skills, or when stereotyped behaviors and activities are present but the criteria are not met for a specific pervasive developmental disorder.
31 LEARNING, MOTOR SKILLS, & COMMUNICATION DISORDERS Measured achievement in a specific (academic, motor, speech) area is substantially below that expected based on the age/IQ of the individual. This differs from MR where the deficits are global in nature.Types:Reading DisorderMathematics DisorderDisorder of Written ExpressionDevelopmental Coordination DisorderExpressive Language DisorderMixed Receptive-Expressive Language DisorderPhonological DisorderStuttering
32 ELIMINATION DISORDERS Encopresis (incontinence of feces)Repeated passage of feces into inappropriate placesAge at least 4 yearsFrequency at least 1x per month x 3 monthsNot due to laxatives or medical problemSpecify: with or without overflow incontinence and constipationEnuresis (incontinence of urine)Repeated voiding into bed or clothesAge at least 5 yearsFrequency 2x per week x 3 monthsNot due to medical problemSpecify: nocturnal, diurnal, or bothMore common in males
33 ADHDPersistent pattern of inattention and/or hyperactivity more frequent and severe than is typical of children at a similar level of development.Onset before age 7Impairment in at least two settings: social, academic, or workDuration at least six monthsInattention, Hyperactivity, Impulsivity
34 Epidemiology Etiology ADHD ContinuedEpidemiologyIncidence: 2 to 20% of grade-school childrenBoys > Girls; Ratio 3-5:1Family members (siblings and parents) of affected children are at higher riskEtiologySpecific etiology unknown; contributory factorsGeneticsPre and perinatal complicationsNeurologicalEnvironmental toxins
35 Types Treatment ADHD Continued Predominantly Inattentive type Predominantly Hyperactive typeCombined typeTreatmentPharmacotherapyStimulants: Methylphenidate, Dextroamphetamine, (Pemoline)Non-Stimulants: Atomoxetine (Strattera); Clonidine and Guanfacine; Bupropion; TCAs; (atypical antipsychotics for treatment unresponsive cases)PsychotherapyBehavioral modifications; environmental structuring; parental Education and training; social skills training
36 Tic Disorders DSM-IV Diagnoses: Tics are sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizationsDSM-IV Diagnoses:Tourette’s SyndromeChronic Motor Tic DisorderChronic Vocal Tic DisorderTransient Tic DisorderTic Disorder NOS
37 Oppositional Defiant Disorder Recurrent pattern of negativistic, defiant, disobedient & hostile behavior towards authority figuresDuration > 6 MonthsImpairment in social, academic and work settingsSymptoms not part of the mood or thought disorderTreatment: Parent training (PCIT)Individual psychotherapyFamily Therapy
38 Conduct Disorder Aggression to people and animals Destruction of propertyDeceitfulness or theftSerious violation of rulesTreatment: Multimodality treatment programs Environmental structuring Family Therapy Group Therapy Ind. Therapy – problem solving skills Medications as adjuncts
39 ANXIETY DISORDERS Common in childhood: 15% Comorbidity is common All adult anxiety disorders may be seen in children.PTSD - may be a result of abuseSeparation Anxiety DisorderDevelopmentally inappropriate and excessive anxiety about separation from caretakers or home, of at least 4 weeks duration with onset before 18 yearsCan lead to school refusal (school phobia)Associated with physical complaints, fear of sleeping alone, worries about parent’s safety
40 Mood Disorders Childhood Depression Dysthymia irritability sleep cycle disturbanceoppositional behaviorsocial isolationcrying spellsDysthymiasymptoms at least 1 year
41 Adolescents and Suicide In 1998, 4,153 young people, ages15-24, committed suicide in the United States an average of 11.3 per day.1Suicide is the third leading cause of death in this age group following unintentional injury and homicide2Suicide accounts for 13.5% of all deaths in this age-group1In 1998, 4,153 young people, ages 15-24, committed suicide in the United States an average of 11.3 per day.Suicide is the third leading cause of death in this age group following unintentional injury and homicideSuicide accounts for 13.5% of all deaths1 Murphy, SL, The Surgeon General’s Call to Action to Prevent Suicide, 1999
43 Suicide Prevention GAINESVILLE (352) 264-6789 Don’t dismiss suicidal ideation, severe depression, runaway, significant substance abuse, etc. as just “normal” for age.Educate families to control access to potentially lethal methods of self-harm (Guns; OTC).Provide crisis hotline information.GAINESVILLE24 hours / 7 days(352)