CHILDHOOD DISORDERS Dr. Rebwar Ghareeb Hama Psychiatrist University of Sulaimani School of Medicine

Classification Learning Disorders Motor Skills Disorders Communication Disorders Pervasive Developmental Disorders Attention –Deficit Disorders Disruptive Behavior Disorders Feeding & Eating Disorders Tic Disorders Elimination Disorders Other Disorders: like separation anxiety disorder, elective mutism ,etc… Mood Disorders Substance Abuse

Confidentiality directly related to age of child/adolescent Must be familiar with normal development and remember what is normal for one age may be a problem for another Example: Tantrum Behavior 2 year old ~ normal and expected behavior 12 year old ~ not expected within normal development Confidentiality directly related to age of child/adolescent Young child ~ all information shared with caretaker Adolescent ~ try to establish privacy agreement between caretaker and adolescent with understanding of what must be shared (significant danger to self and/or others, abuse)

Motor Skills Disorders This is also called developmental coordination disorders Its essential characteristic is a marked impairment in the development of motor coordination It is characterized by imprecise or clumsy gross motor skill

Communication Disorders This category includes disorders of speech & language They include: 1. Expressive language disorder: the child skills in vocabulary ,the use of correct tenses ,the production of complex sentences & the recall of words are below the expected level for his or her age & intelligence 2 . Mixed receptive –expressive language disorder: child is impaired in both understanding and expressing language 3 . Phonological disorder: it is manifested by inappropriate or poor sound production 4 . Stuttering or Stammering: disturbance in the fluency and time patterning of speech that is inappropriate for the patient’s age

Pervasive developmental disorders These disorders are severe ,pervasive impairment in developmental areas ,such as social interaction & communication ,or stereotyped behavior ,interests and activities The impairments are deviant in comparison to a person’s mental or developmental level These disorders include: Autistic disorder Rett’s disorder Childhood disintegrative disorder Asperger’s disorder

Autistic disorder Sometimes called “childhood autism, early infantile autism, Kanner’s autism” Prevalence is 0.02-0.05 % In most cases it starts before the age of 36 months( 3 years) It is more frequent in boys The etiology of autistic disorder is not clear but there is more reliance on biological causes

Clinical features Impairment in social interaction: lacking social smile, fail to show the usual relatedness to their parents and other people, abnormal eye contact, … Disturbance of communication &language Stereotyped behavior :the activities &play are rigid ,repetitive & monotonous. Ritualistic and compulsive phenomena are common Unstability of mood Abnormal response to sensory stimuli( either exaggerated or decreased) Other behavioral symptoms hyperkinesis or hypokinesis ,aggressive behavior ,temper tantrums, self injurious behavior

Prognosis is generally unfavorable The patient needs a complicated care which include: Educational therapy Behavioral therapy Pharmacotherapy: no specific therapy is available. It can be only symptomatic like anti-obsessive, antipsychotic and antiepileptic

In the absence of specific treatment, management has 6 main aspects: Management of abnormal behavior Education and social services Speech and language therapy ,occupational therapy, dietary advice… Treat medical conditions (e.g. epilepsy ,GIT problems) Help for families Pharmacotherapy :symptom management (e.g. antipsychotic for stereotypes ),SSRI for compulsive and self harming behaviors and depression, and anxiety

Aspergers Syndrome( AS) A syndrome first described by Hans Asperger’s in 1944 ,and sometimes called autistic psychopath ,is characterized by:- The child develops normally until about the third year when they begin to lack warmth in relationships, and speak in monotonous stilted ways Severe persistent impairment in social interactions ,repetitive behavior patterns, and restricted interests IQ and language are normal or in some cases, superior Motor mannerisms such as hand and finger twisting, or whole body movements

They are often clumsy and eccentric They are more interested in others than autistic children The disorder is more common in boys than girls A family history of autism may be present The cause of AS is unknown It differ from autism in that there is no general delay or retardation of cognitive development or language They are solitary, and embark on and spend much time in narrow interests

Attention Deficit / Hyperactivity Disorder (ADHD) This disorder is common ,appears more often in boys than in girls and causes disruption in school and at home It is characterized by: Features of hyperactivity: age-inappropriate hyperactivity which is mostly purposeless & intolerable causing a lot of disturbance Poor attention span Impulsivity These symptoms should be present for at least 6 months before the diagnosis is made The symptoms should be present in more than one setting ( home, school, work) And should be severe enough to cause significant impairment

3%-7% of children suffer from ADHD ADHD is diagnosed approximately three times more often in boys than in girls As many as half of those with ADHD also have other mental disorders Over half of the children diagnosed with ADHD carry the disorder into adulthood A large number of adults who were never diagnosed as a child show clear symptoms of ADHD

The symptoms of ADHD are present since the early childhood (before the age of 7 years) The causes of ADHD are unknown ,but the disorder is predictably associated with a variety of other disorders that affect the brain function ,such as learning disorders The suggested contributory factors to ADHD include prenatal toxic exposure, prematurity, and prenatal mechanical insult to the fetal nervous system Food additives ,colorings, preservatives, and sugar have been suggested as possible causes There is evidence for a genetic cause

Symptoms of Inattention must have 6 or more Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities Often has difficulty sustaining attention in tasks or play activities Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish school-work, chores, or duties in the workplace (not oppositional)

5. Often has difficulty organizing tasks and activities 6 5. Often has difficulty organizing tasks and activities 6. Often avoids, dislikes, or is reluctant to engage in tasks that require a sustained mental effort 7. Often loses things necessary for tasks or activities 8. Often easily distracted by extraneous stimuli 9.Often forgetful in daily activities

Symptoms of Hyperactivity-Impulsivity Must have 6 or more Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate (adolescents ~ may be subjective feelings of restlessness) Often has difficulty playing or engaging in leisure activities quietly Often “on the go” or often acts as if “driven by a motor” Often talks excessively

Impulsivity Often blurts out answers before questions have been completed Often has difficulty awaiting turn Often interrupts or intrudes on others

Treatment of ADHD Pharmacotherapy: a. CNS stimulants: dextroamphetamine, methylphenidate, and pemoline b. Antidepressants Psychotherapy : which include behavioral therapy , education of parents and teachers

Disruptive behavior disorders There are two types: Oppositional defiant disorder: described as a recurrent pattern of negativistic, defiant, disobedient, and hostile behaviors toward authority figures Conduct disorder: A repetitive & persistent pattern of behavior in which the basic rights of others or major age- appropriate societal norms or rules are violated

Elimination Disorders Enuresis : The repeated voiding of urine into clothes or bed ,whether, the voiding is involuntary or intentional .The behavior must occur twice weekly for at least 3 months or must cause clinically significant distress or impairment socially or academically. The child’s age must be at least 5 years Encopresis: Passing feces into inappropriate places whether the passage is involuntary or intentional. The pattern must be present for at least 3 months ; the child’s age must be at least 4 years

Separation Anxiety Disorder Defined as an excessive anxiety about separation from home or from those to whom the child is attached This disorder must last for at least 4 weeks Must begin before age of 18 years Must cause significant distress or impairment Separation anxiety requires the presence of at least three symptoms related to excessive worry about separation from the major attachment figures

The worries may take the form of refusal to go to school( school phobia, school refusal), fears & distress upon separation ,repeated complaints of such physical symptoms like headaches & stomach aches when separation is anticipated and night mares related to separation issues The disorder is common and onset may occur during preschool years but is most common in 7-8 years old Prevalence is 3-4% of all school children It occurs equally in males and females Treatment : behavioral therapy

Pediatric Psychopharmacology Summary: Substantial Empirical Evidence Currently Supports Stimulants for ADHD SSRI’s for OCD Well Designed Trials support Risperidone for aggression and self-injurious behaviors in autism Fluvoxamine for Childhood Anxiety Disorders Fluoxetine for Moderate – Severe Major Depression

Pediatric Psychotherapy Summary: Best Evidence for; CBT (cognitive behavioral therapy) for Depression, Anxiety CBT/Behavioral Strategies for Conduct Problems Parent Training for Conduct Problems MST (multi systemic treatment) for Conduct Problems