Child Psychiatry Niloufar Mahdavi Shaheed Beheshti university of Medical sciences

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Child PsychiatryNiloufar MahdaviShaheed
Beheshti university of Medical sciences
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Child psychiatric evaluation

• History
• Chief complaint, present illness, developmental
  his., psychiatric his., medical his., family
  social his. parents marital status,
  educational his. current school functioning,
  peer relationship , current family functioning,
  family psychiatric medical his.
• Physical examination
• Neuropsychiatric examination

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Mental status examination

• Physical appearance, parent-child interaction,
  separation reunion, orientation to TPP, speech
  language, mood, affect, thought process
  content, social relatedness, motor behavior,
  cognition, memory, judgment insight.

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Mental retardation

• MR is the result of a pathological process in the
  brain characterized by limitations in
  intellectual and adaptive function.
• According to DSM-4-TRMR is significantly sub
  average general intellectual functioning
  resulting in, or associated with, concurrent
  impairment in adaptive behavior manifested
  during the developmental period, before the age
  of 18.

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Levels of mental retardation

• Mild MR (IQ of 55 to 70)
• The largest group of people with MR (about 85 of
  all persons with retardation).
• Appear similar to nonretarded. Many achieve
  academic skills at the 6th grade or higher, and
  some graduate from high school. Many of them hold
  jobs, and marry, but may appear slow or need
  extra help for lifes problems tasks.

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Levels of mental retardation

• Moderate MR ( IQ of 40 to 55)
• Approximately 10 of all MR population.
• People with more impaired cognitive adaptive
  functioning.
• Typically diagnosed in their preschool years.
• Require special education services, achieving
  academic skills at the second to third grade
  level.
• Need for supportive services throughout life.

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Levels of mental retardation

• Severe MR (IQ of 25 to 40 )
• Occurs in 3 to 4 of MR population.
• Often have one or more organic causes for their
  delay, many show concurrent motor, ambulatory,
  and neurological problems.
• Most of them require close supervision
  specialized care throughout their lives.
• Some of them learn to perform simple tasks
  facilitate their self-care.

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Levels of mental retardation

• Profound MR (IQ of 25 and below)
• Affects 1 to 2 of MR population.
• Pervasive deficits in cognitive, motor,
  communicative functioning. Impairments in
  sensory-motor functioning are often seen from
  early childhood, most individuals require
  extensive training to complete even the most
  rudimentary aspects of self-care, such as eating
  toileting.
• Show organic causes for their delay need total
  supervision care throughout life.

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Etiology

• Parental cause
• Genetic dis. (Down syndrome, phenylketonuria
  other metabolic dis., fragile X syndrome, )
• Congenital malformations (neural tube defects)
• Exposure (congenital rubella, fetal alcohol syn.,
  radiation, trauma)
• Perinatal cause
• infections, delivery problem (asphyxia)
• Postnatal causes
• Infections, toxins( Encephalitis, lead poisoning,
• traumas, )

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Pervasive Developmental Disorder

• A group of conditions in which there are delay
  deviance in the development of social skills,
  language communication, and behavioral
  repertoire.
• Unusual intense interest in a narrow range of
  activities, resist change, are not
  appropriately responsive to the social
  environment.
• Affect multiple areas of development, are
  manifested early in life, and cause persistent
  dysfunction.

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Autistic disorder

• Sustained impairment in comprehending
  responding to social cues, aberrant language
  development usage, and restricted,
  stereotypical behavioral patterns.
• Prevalence0.05,
• 4-5 time more frequent in boys.
• The onset is before the age of 3, but in some
  cases, recognized until a child is much older.
• Patient with IQs above 70 and those who use
  communicative language by age 5 to 7 tend to have
  the best prognosis.
• About two thirds of autistic adults remain
  severely handicapped are completely dependent
  or semidependent.

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Retts disorder

• A development of several specific deficits
  following a period of normal functioning after
  birth.
• Normal growth development in first 6 months
  after birth, between 6m to 2y of age, develop
  progressive encephalopathy with characteristic
  features (loss of purposeful hand movements,
  replaced by stereotypic movements, loss of
  previously acquired speech, psychomotor
  retardation, and ataxia, decrease
  head-circumference growth ( cause microcephaly) .
  
• Prevalence 6-7 per 100000 girls.
• It is progressive and patient who live into
  adulthood remain at a cognitive social level
  equivalent to that in the first year of life.

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ATTENTION DEFICIT/HYPER ACTIVITY DISORDERS

• Persistent pattern of inattention /or
  hyperactive and impulsive behavior that is more
  severe than expected in children of that age
  level of development.
• To meet the diagnostic criteria of ADHD, some
  symptoms must be present before the age of 7y,
  although many children are not diagnosed until
  they are older than 7y ( cause problems in
  school).
• Symptoms must be present in at least 2 settings.

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ADHD

• Incidence2-20 of school children.
• More prevalent in boys.
• Symptoms are present by age 3y, but diagnosis is
  made later.

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Clinical feature

• Infancy
• Sensitive to stimuli easily upset by noise,
  light, temperature, other environmental
  changes. Sleep little cry a great deal (some
  times reverse, sleep much of the time, and
  develop slowly).
• School age
• Unable to wait, impulsive response behavior,
  explosive or irritable, emotionally labile,
  inability to delay gratification, accident-prone,
  hyperactivity, attention deficit
  (distractibility, failure to finish tasks, poor
  concentration)

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Course prognosis

• Course is variable. Symptoms may persist into
  adolescence or adult life(15-20), they may
  remit at puberty, or hyperactivity may disappear,
  but the decrease attention span impulse control
  problems persist.
• Over activity is usually the first symptom to
  remit, distractibility is the last.
• Children whose symptoms persist into adolescence
  are at risk for developing conduct disorder.
• Children with both ADHD conduct dis. Are also
  at risk for substance-related dis.

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Treatment

• psychosocial intervention
• Pharmacotherapy
• Central nervous system stimulants are the first
  choice of agents e.g. Ritalin 0.3-1 mg/kg tid
  up to 60mg/d,
• Second-line agents with evidence of efficacy for
  some children and adolescents Atomoxetine (a
  norepinephrine uptake inhibitor),
  antidepressants, such as bupropion, venlafaxine
  and the a-adrenergic receptor agonists clonidine.
  
• FDA approved the use of dextroamphetamine in
  children 3 years of age and older and
  methylphenidate in children 6 years of age and
  older.
• .

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Enuresis

• Enuresis is the repeated voiding of urine into a
  child's clothes or bed the voiding may be
  involuntary or intentional.
• For the diagnosis to be made, a child must
  exhibit a developmental or chronological age of
  at least 5 years.
• According to DSM-IV-TR, the behavior must occur
  twice weekly for a period of at least 3 months or
  must cause distress and impairment in functioning
  to meet the diagnostic criteria. Enuresis is
  diagnosed only if the behavior is not caused by a
  medical condition.

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Enuresis

• - Genetic factors
• children with enuresis with a normal anatomic
  bladder capacity report urge to void with less
  urine in the bladder than children without
  enuresis.
• nocturnal enuresis occurs when the bladder is
  full because of lower than expected levels of
  nighttime antidiuretic hormone.
• - Psychosocial stressors appear to precipitate
  enuresis in a subgroup of children with the
  disorder. In young children, the disorder has
  been particularly associated with the birth of a
  sibling, hospitalization between the ages of 2
  and 4, the start of school, the breakup of a
  family because of divorce or death, and a move to
  a new home.

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• No single laboratory finding is pathognomonic of
  enuresis but clinicians must rule out organic
  factors, such as the presence of urinary tract
  infections, that may predispose a child to
  enuresis.
• Structural obstructive abnormalities may be
  present in up to 3 percent of children with
  apparent enuresis.

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Treatment

• A treatment plan for typical enuresis can be
  developed after organic causes of urinary
  dysfunction have been ruled out. Modalities that
  have been used successfully for enuresis include
  both behavioral and pharmacological
  interventions.
• The first step in any treatment plan is to review
  appropriate toilet training.
• Other useful techniques include restricting
  fluids before bed

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• Behavioral Therapy Classic conditioning with the
  bell and pad apparatus is generally the most
  effective treatment for enuresis
• PharmacotherapyImipramine has been approved for
  short-term.
• Desmopressin (DDAVP), an antidiuretic compound .
  The most serious adverse effect reported with the
  use of desmopressin to treat enuresis was a
  hyponatremic seizure experienced by a child.

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The end