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					 Child &
adolescent
Good review of CAMH treatments in
  Dec 2003 issue of Journal of the
  American Academy of Child &
      Adolescent Psychiatry
Child & adolescent

General notes on
  aetiology &
  assessment
      Causes of disorders in kids

• Child
   – Congenital: chromosomal/intrauterine
   – Acquired: CNS injury, chronic disease
   – Temperament
• Parents
   – Psychopathology
   – Parenting skills
   – Relationship between parents
• Relationship with parents
   – Attachment
   – Neglect and abuse
• Environment
   – Living conditions, number of siblings, peer group
                       MSE in kids
Appearance & behaviour (social and motor)
Speech
Thought content
Intellectual functioning
Emotional state
Attitudes towards family
Attitudes towards school
Sleep
Behaviour problems
Fantasy life & play (draw a good & a bad dream, Three wishes, Desert
island, Family drawing, Bird in nest, Best things and worst things that
could happen to the child: ToDD FiBBs)
Social adjustment
Self-image
Attitude to referral
          Assessment of kids
• Note symptoms as multi-determined rather than
  due to one diagnosis
• Drawing: include self, family, house*
• Assess with family
• More emphasis on social/psychological treatment
• Differences in medication use
• Much less admission
• Role of school
• Child protection issues
               Development
• Growth: incremental increase of a characteristic
• Maturation: phases of development that are
  mainly due to innate or endogenous factors
• Development: changes in behaviour and structure
  that can be systematically related to age
• Freud: emotional
• Piaget: cognitive
• Erikson: social
Gist                  Cognitive & development
                      Piaget development is the result of the
                 interaction between the individual and the
                 environment
               Neurological maturation
               Exposure to experience, applying more
FACTORS THAT




               complex reasoning, practising new skills
 INFLUENCE




               learnt
               Social interaction and schooling
               Structures*




                    Schemas      Internal representations of
                                 an action eg. grasping
                    Operations Higher order internal rules
                                 that are reversible
Sensori-         Piaget‟s stages
              Reflexes e.g. feeding dominate
              Self & non-self recognitions
motor
              Object permanence
0-2
Pre-          Egocentric thinking: can‟t imagine others have a point of view
operational   Animistic thinking*
              Problems with conservation: vol, no., mass, time
2-7           Rejects chance
              Rigid morality: adult‟s illness seen as own fault
Concrete      Logical
operational   Conservation
              Can imagine there is another‟s point of view
7-12          Reversibility: 2+2=4 therefore 4=2+2

Formal        Abstract/hypotheticodeductive reasoning
operational   Content changes: future, ideological issues
12+
     Normal infant development
m Social                               Cognitive Language
    Prefers faces 6 W
2   Direct eye contact 8 W
    Actively seeks stimulation by gazing
    Recognises carer‟s face                     Babbles
3
    Laughter
4
5
    Selective carer/stranger anxiety            Will stop babbling
6                                               if deaf
   Developmental: Adolescence


• Kenniston: Refusal of socialization
• Levinson: Novice phase (sorting through
  possibilities in love and work)
• Erikson: psychosocial moratorium (free role
  experimentation) Identity vs. Role confusion
• Parsons: “the roleless role”
• Piaget: growth in hypothetico-deductive reasoning
                  Gender issues
Gender         2-4 kids realize
identity       Influenced by physical factors
                  Adrenal hypoplasia: masculinization of
                  female fetuses
                 Absent father & over-involved mother:
                 gender confusion
 Gender role             Influenced by later social factors
 Sexual          Developed in adolescence
 identity        More likely Only comorbidities should if
Ethical: is treatment justified?to chose homosexuality be
treated?         gender confused as a child
                                Play
            Drive satisfaction         Theorists
Functions
            Ego defence                Sigmund & Anna Freud
            Individuation              Erikson
            Conflict resolution        Winnicot
            Modelling                  Piaget
            Transitional object        Kohut
            Language development                   In psychiatry
Nurtures
            Motor skill development
                                                   Use in therapy
            Frustration/affective tolerance
                                                   Clue to development
            Discrimination between fantasy
            & reality                              Clue to abuse
            Social skills development              Clue to psychopathology
                 Leadership                        Influence of TV
                 Turn-taking                       Emotional deprivation
                 Tolerance of others
                  Resilience*
The phenomenon of not developing antisocial
behaviour or other serious psychopathology despite
adverse psychosocial experiences
Personal Temperament
            Intelligence
factors
           Self-esteem
           Talent in a particular area
           Success in various contexts
Family /   Positive & high expectations by family
           Opportunities for participation e.g. in peer activities
social
           Connectedness in family
factors    Warm relationship with one parent
ADHD
                       ADHD
Epidemiology      3-7% of school age (UK 1% vs US 3-5%!)
                  in boys 3-5x
      Genetic     60-92% heritability in twin studies
Aet
                  Mono 2x di
                  Temperamental predisposition
      Neurodev    1st trimester insult e.g. virus?
                  Non-specific EEG abn & soft neuro signs
                  PET: lower frontal function
      Neurochem   Locus ceruleus: NA involved in attention
                  DA: because stimulants work
      Psych       in institutions & improves with adoption:
                  Emotional deprivation
                  Family stresses
                  Not associated with socioeconomic class
Associated   Behavioural problems
with
                      ADHD
             Learning problems
             Accidents and injuries
             Drug & alcohol use
             Comorbid ODD, CD in 50%
Course       Improves by adolescence
             Can progress into adult life 10-20% esp. if
                 Family history
                 Negative life events
                 Comorbid CD/dep/anx
             Often manifesting as ASPD/SA with age
             Controversial diagnosis in adults & indistinguishable
             from comorbidities
             No evidence of effectiveness stimulants in adult
             ADHD
             ADHD controversy
• UK, US diagnosis rate difference
• Male, female difference
• Is it just part of normal spectrum of activity
• Comorbidities e.g. conduct & learning disorder: is
  it a separate disorder
• Are the benefits of stimulants long term?
• How long should treatment be continued?
• Side-effects of treatment:
    – Tic disorders (probably an association only)
    – Mood disorders
    – Headache, insomnia etc.
≥6 for more than 6 months of 1 or 2 aide memoir
            DSM-IV on ADHD*
1. Inattention
Careless mistakes, fails to give close att.   Fills name in all fields of paper
Difficulty sustaining att. In tasks or play   Forgets paper, looks out window
Doesn't listen when spoke to                  Ignores teacher
Doesn't follow through on instructions        Keeps writing though told to stop
Difficulty organizing tasks                   Bags paper, brings book
Avoids tasks requiring concentration          Told to write, plays with chalk
Loses things necessary for tasks              Can't find pen in bag
Easily distracted                             Starts running after rat
Forgetful in daily activities                 Forgets bag and leaves with bell

2. Hyperactivity
Fidgets or squirms                            fidgets & squirms at Drs
Leaves seat                                   gets up
Runs about                                    runs about
Can't do things quietly                       told to draw, sings while he does
“on the go”, “driven by a motor”              runs with propeller behind
talks excessively                             held in place by dr, talks at him

Impulsivity
Blurts out answers                            Dr asks, he cuts in
Can't wait turn                               Jumps between other family
Interrupts others                             Cuts in while Dr giving feedback
              ADHD - Diagnosis
• DSM-IV
•   Inattention or hyperactivity/impulsivity
•   Symptoms before 7
•   At least 6 months
•   Impairment in at least 2 settings
• ICD-10 (Hyperkinetic disorder)
• Inattention and hyperactivity
• Symptoms before 6
• Long duration
         ADHD:
Assessment Multimodal     assessment
             Long observation: perseveration, inappropriate affect
             can occur
             Variety of settings
             Family assessment
             Psychometric testing
             Neurological assessment: soft signs e.g.
             incoordination
Ddx to       Temperamental variation
             PDD
assess for
             CD
             Learning/cognitive problems
             Depression/anxiety/mania
             Family dysfunction
             Sequelae of abuse/trauma
             Drugs: BDZ/barbiturates
                         ADHD
Non-pharm:      Family/school support
                Family/school psycho-education
No evidence
                Behavioural management strategies:limit setting
that addition       Direct contingency management
to stim             Clinical behaviour therapy*
improves        Individual tx for comorbidities
outcome         Coordinate services
Pharm           Better for ADH than behavioural problems
                Monitor progress at least every 12 months
                Educate re use/limitations
                Monitor for /anxiety SE
                Do not use if movement disorders:
           Stimulants for ADHD
Methylphenidate          Similar efficacy
vs.                      Dex: longer time course of effect
dexamphetamine
Side effects             Anorexia
                         Insomnia
                         Abdo pain
                         Tearfulness/depression
                         Headache
                         Tics
Toxicity                 Hypertension/tachycardia
                         Thrombocyto/leucopaenia
Efficacy   80% respond
             ADHD - Treatment

• Behavioural
   – Home and school
• Medication
• 1st line
   – Stimulants
      • methylphenidate (Concerta), dexamphetamine
• 2nd line
   – TCAs
   – α2-noradrenergic agonists
      • guanfacine, clonidine
Important Side-Effects of Stimulants


• Low appetite/weight loss
    – So measure and weigh
    – May need to refer to dietitian
• Insomnia
    – So don‟t give late
•   Depression/dysphoria
•   Worsening of tics
•   Tachycardia, hypertension
•   Thrombocytopaenia, leucopaenia
    – Warn family of signs
Diet
• Some families find certain foods make it
  worse
• So avoid those foods, if no nutritional
  compromise
• Blood and skin tests won‟t predict which
  children will respond to dietary exclusion
Key RCT - MTA

• MTA Cooperative Group, 1999
• 576 school-aged children with ADHD
• Randomised to one of four treatments:
   – Intensive medication management
   – Intensive psychosocial intervention
      • family therapy, social skills, intensive summer camp,
        classroom management
   – Combined medication + psychosocial
   – Typical community-based intervention
      • Many had medication
Results

• Medication/combined better than other two
• Psychosocial intervention (no medication) similar
  outcome to community-based
• Little difference between medication alone and
  combined
   – Lower doses of medication if combined
   – On some secondary measures, combined but not
     medication alone superior to other two treatments
      • oppositional/aggressive symptoms, internalizing symptoms,
        teacher-rated social skills, parent-child relations, reading
        achievement
        Atomoxetine (Strattera)
Pharm   NA reuptake inhibition via effect on pre-
        synaptic NA transporter
        ADHD mechanism of action is unknown
Use     ? Intolerable SE of stimulants
        SE: abdo pain & vomiting
        May affect growth
        CYP2D6 metabolised
        1.2mg/kg ≈ methylphenidate in open label
        Can be given once (or twice) daily
  Child & adolescent

    Disruptive
Behaviour disorders
     Disruptive behaviour disorders
Classification*
        DSM: > or < 10
        Mild. Moderate or severe

Prevalence

5-10% Of 8 to 16yr olds
Boys > girls 3:1
Towards adolescence gender difference lessens ++ esp. for ODD
          Aetiology of DBD
1. Family environment and rearing:

• lack of clear rules
• poor supervision,
• harsh and esp. inconsistent discipline
• violence towards or in front of the child
• Marital disharmony
• Large family size
NB Parental mental illness or D&A abuse
             Aetiology of DBD
2. Biopsychological factors

•   high impulsivity,
•   active/difficult temp. & bad fit with parenting style
•   CNS 5-HT
•   cognitive difficulties e.g. low IQ leading to impaired
    school performance
•   genetic inheritance
•   autonomic hypoarousal/arousability
           Aetiology of DBD
3. Social factors

 peer delinquency
 gang membership
 urban residence, esp. in high crime
  neighbourhood
 large family size
 poverty
 Disruptive Behaviour Disorders
• Conduct disorder is persistent violation of
  socially-defined rules
• Oppositional defiant disorder is milder
  disobedience/arguing/anger
• Delinquency refers to law breaking
  – may be part of peer activity
Associations
• Hyperactivity
• Depression
   – In minority (Qu 45)
• Psychiatric disorders more likely in girls than boys
• Educational failure
• Poor interpersonal relations
   – ICD-10 has socialised and non-socialised CD,
     depending on presence of normal peer relations
Biology
• Environmental factors more important
  – high concordance in MZ and DZ twins
• Associated with maternal smoking in
  pregnancy
  – stronger for males, persistent CD, violent CD
• Monoamine abnormalities
• Heritability of 0.4 for CD
Heritability of Behaviour Disorders
• Heritability: the contribution of genetic differences to
  observed differences among individuals for a particular
  trait in a particular population at a particular time
• About 0.4 for conduct disorder (0.7 for ADHD)
• Greater heritability for early onset and persistent behaviour
  disorder
• Latent class analysis suggests strong genetic influence for
  ADHD/conduct disorder symptoms but almost no genetic
  influence for „pure‟ CD Sx
Juvenile Delinquency
•   90% against property
•   Peak in law-breaking in late teens
•   Peak in violence in early 20s
•   ½ to ¾ of convicted don‟t repeat
                            DBD
Assoicated   Learning disorders
             ADHD
with
             Mood/anxiety disorders
             SA
             Low self-esteem
Course &     •Direct: 20-30% CD  ASPD
             •Common cause: biological predisposition or
links with   environmental deprivation leading to later adult
adult        personality disorder
ASPD         Co-morbidities:
                 >50% have some problems as adults
                      SA
                      Forensic
                      Mood
                 DSM-IV: or more
Negativistic, hostile, defiant & 4ODD for 6 months
1. loses temper                       screaming at adult
2. argues with adults                 animated argument
3. defies rules                       crosses arms and says no
4. deliberately annoys people         topples coffee cup
5. blames others for mistakes         blames sister for it
6. touchy                             dad tries to hold, he jumps
7. angry and resentful                throws a tantrum
8. spiteful and vindictive            accuses dad of sexual ab!

B: Clinically significant impairment in either of 3 areas
C: Exclude other psych disorders
D: No meet criteria for CD or (if > 18) ASPD
3 or more for 6 months, 1 for at least 12, child hood onset if <10

Aggression:                           DSM-IV: CD
              1. bullies, threatens, intimidates               standing over kid at school
              2. initiates fights                              starts hitting him
              3. uses weapons                                  kid runs, he throws brick
              4. cruel to people                               hits him, he starts kicking him
              5. cruel to animals                              dog starts barking, throws brick
              6. mugging                                       threatens groundskeeper for keys
              7. forced sex                                    goes to park, rapes girl

Property destruction:

              8. fire setting                                  starts fire at classroom wall
              9. other damage                                  throws brick in window

Deceit and theft:

              10. break and enter                              hops in through window
              11. lies to get way                              cops come, says heard screams
              12. theft                                        grabs other's bag on his way out

Rules violation
            13. stays out at night before 13                   goes to older druggie's till 5
            14. runs away twice or once for ages               gets shit in am, runs away
            15. truant from school before 13                   not at school next day
         Treatment of DBD
• Education and liaison with referring school:
  teacher training, school-based intervention
• Individual therapy

  - Can be taught how to initiate conversations, respond to
  others, refuse requests, and make requests of others
  - “Wilderness School” programs
  - Treatment Foster Care

BUT NONE OF THESE WILL WORK WITHOUT…
    Parent management training
• Behaviour diary: ABC (Antecedents, Behaviour,
  Consequences)
• Positive reinforcement training. Taught to reward
  prosocial behaviour with praise, star charts, treats
  etc.
• Moderated negative consequences. Restriction of
  privileges or time-out
• Monitoring & supervision.
• Problem-solving/negotiation strategies.
 Other parent training programs
• Parent Child Interaction Training PCIT
• Training parents to give appropriate
  commands
• Group discussion videotape modelling
  (GDVM)
• ADVANCE

• Family therapy
         Techniques taught in PT*
•   Overcorrection
•   Time out
•   Extinction
•   Differential reinforcement
•   Punishment
     • follow the child‟s behaviour,
     • be delivered immediately after the child‟s behavior,
     • hurt enough to be significant to the child,
     • be consistently applied, and
     • have verbal clarification
     Techniques taught in PT

Reinforcing positive behaviour:

Vigilance for prosocial behaviour, flexibility and
doing the right thing so that…

Verbal recognition
Reward such as treats
Privileges
Reward systems such as star charts
Child & Adolescent

  Persistent
developmental
   disorder
                      PDD DDx
• Other PDD:
   –   Autism
   –   Asperger‟s
   –   Rett‟s
   –   Childhood disintegrative disorder
   –   PDD NOS
• Schizophrenia
• OCD
• Schizoid personality disorder
                  Autistic disorder
Epid       0.2%                       First described in 1935: Leo Kanner
           Boys > girls 3x
Aet: Bio   Genetic: 50xrisk in siblings, mono 40-90%, ? neuroligin gene on X
evid.      30% have epilepsy (5% if normal IQ)
           Enlarged ventricles, change finger prints
           PET & EEG abnormalities
           Autopsy & imaging evidence for Cb & frontotemporal abn
           Sx of other neuro (10%):
                CMV/rubella,
                tuberous sclerosis,
                PKU
                Down‟s
           Herpes encephalitis can lead to similar sx in previously well
 No
Also evidence for psychosocial aet. No relationship with SCZ.
         ID: 70% < 70, 40% < 50
         Autism: neurobiology
Just et al. fMRI
Brain 2004 17 Normal IQ autism vs 17 normals
            Differential Broca‟s, Wernicke‟s
            activation
            Under-connectivity theory: above
            results combined with previous findings
            abn of white matter =>?problem is in
            level of connection between brain areas
                  DSM-IV on Autism
≥6 of before age 3:
1.Social
                             aide memoir


non verbal                                       mask face
Less friends than peers                           the exodus
No seeking of friends                             the sit down
No social or emotional reciprocity                the broken arrow

2. Communication (50% never acquire useful language)
 or non-verbal                                   blond and gaffa tape
if verbal  initiation                            slow lips
inappropriate verbal/stereotypies                 swears
 fantasy play                                    thought bubble's the same

3. Restricted Interests, obsessional/compulsive/ritualistic/repetitive beh
Restricted interests                              the remote control car
Needs routine/ritual                              hears the call to prayer
Physical sterotypies                              waves hand in front of eyes
Fascination with parts of objects                 comments on the knees!
          Treatment of autism
Goals     pro-social behaviour
          Communication: verbal & non-verbal
          Develop self-care skills
          Allieviate family stress
Methods   Social Family & schools support
                   Special schooling
                   Self-help/Carer groups
          Psych Behaviour therapy
          Pharm Behaviour: risperidone, HPL, Li
                Asperger‟s
DSM           = Autism -
                 communication criteria
                 & no ID
Schizoid       Aloof, distant, lacking in empathy
personality of Obstinate
childhood (≈ Aggressive outbursts if needs not met
Asperger‟s)
               As adults become schizotypal PD
Asperger‟s Syndrome
• Language (vocab and grammar) not delayed
   – but still abnormal
• Less aloof
   – often interested in other people
   – impaired empathy and social responsiveness
• Restricted/repetitive behaviours
   – Preoccupations/interests rather than motor stereotypies
• Marked clumsiness more than autism
•
     Pharmacological tx in PDD
    Antipsychotics
    – Haloperidol
       • Improved stereotypies, withdrawal, irritability, hyperactivity,
         temper outbursts
    – Risperidone
       • Improved tantrums, aggression, self-injury
    – Significant side-effects
• Stimulants
    – Improve hyperactivity
    – Increase repetitive behaviours
                    Other PDD
Rett‟s*          1) Normal pre and perinatal development
                 2) Normal psychomotor development up to age 5/12
0.007% of        3) Normal head circumference at birth
                 Then
girls            1) Deceleration of head growth from 5-48 months
                 2) Loss of developed hand skills
                 3) Loss of social engagement
                 4) Onset of poor gait or trunk mvts
                 5) Severe expressive and receptive language development, and
                 severe psychomotor retardation
                 1) Apparently normal development for at least 2 yrs (social interaction,
Childhood        communication, adaptive behaviours)
                 2) Loss of previously obtained skills before age 10
disintegrative         a. Social interaction

disorder               b. Communication
                       c. Play

(0.005%                d. Bowel and bladder control
                       e. Motor skills
Child & adolescent

Mood &
 anxiety
disorders
                  Depression

• Most depressed adolescents have co-morbid
  disorder
   – 40% CD
   – 34% anxiety disorders
• Which came first?
• Roughly true to say cortisol:DHEA increases in
  depression
• Complicated changes in cortisol and DHEA
  (dehydroepiandrosterone), possibly varying with
  chronicity, severity, gender
Treatment of Adolescent Depression
• Good evidence (3RCTs) for fluoxetine
  (Emslie, TADS)
• Minimal/non-significant/inconsistent
  efficacy for paroxetine, venlafaxine,
  citalopram, sertraline
• Significant S/Es of SSRIs
• Possible increase in suicidality (very small
  numbers)
• MHRA guidance December 2003 on U18
  – Unfavourable benefit:risk ratio for all except
    fluoxetine
  – All SSRIs to be given only „with specialist
    advice‟
  – Consider continuing SSRI if still on it
  – www.mhra.gov.uk
• BUT, many studies excluded severer
  depression/suicidality/co-morbidity
• We can prescribe anything if we can justify
  it
• Cochrane review of TCAs
• No effect on remission rates
• Minimally significant improvement in
  symptoms in adolescents
• No significant improvement in symptoms in
  children
• Significant side-effects
• Methodological problems in primary studies
• Variable evidence for CBT (meta-analysis,
  BMJ)
• Evidence for IPT (Mufson et al * 2)
• No evidence for family therapy

• Draft NICE guidelines recommend IPT or
  CBT first; medication should be alongside
  psychological treatment
                              SSRIs in Kids
              Anxiety            OCD
              Best evidence
                                 GAD
Indications

                                 SAD
              Depression         Use fluoxetine
              Poor evidence
                                 Avoid paroxetine
              Pervasive          Social adjustment
              Developmental
              Disorder           Behavioural sx
                                 Obsessitionality
                          SSRIs in Kids
          Risk                     4% SSRI
          Of ideation
                                   2% placebo
          No completed suicides
          in controlled trials     Age (I.e. adolescents)
                                   Depression vs Anxiety disorders
Suicide



          Usage protocol           Treat comprehensively e.g. CBT/IPT
          Per College practice
          guidelines (joint with
                                   Discuss risks & benefits
          RACP & RACGP)            Warn re risk of suicidal ideation
                                   Start low go slow
                                   Monitor ++ in first weeks
                                   Use C&A psychiatrist if possible
                                   Continue 6-12 months post remission
                                   Don‟t cease abruptly
                Self-harm in adolescents
Associated Diagnoses:
•   A. Depression
•   B. Personality disorder or traits
•   C. Schizophrenia
•   G. Bulimia
•   D. Substance abuse
•   E. PTSD
•   F. Dissociative disorder

Associated social circumstances:
1.  Family disharmony
2.  Homelessness
3.  Sexual abuse
4.  Poor school performance
5.  Poor peer relationships
6.  Peers self-harming
Epid Separation
      4%
                               anxiety disorder
         Female > male
         Peaks age 7-8
         Most common comorbidity: specific phobia
Theorists:     Bowlby, Freud, Winnicot, Kohut, Barlow, Lorenz
Aet      Child     Shy temperament
                   Developmentally immature
                   Dependent on mother
                   Hx traumatic separations e.g. hospitalisation
         Fam       Close-knit & over-protective
                   Anxious mother: isecure attachment
                   Panic/ag mother: higher SAD
                   Anxiety disorder: modelling
         Bio       Shy: HR & cortisol in social situations
                   Family hx anxiety disorder:  risk
        Separation anxiety disorder*
A. Developmentally inappropriate and excessive anxiety concerning
separation from home or from those to whom the individual is attached, as
evidenced by three (or more) of the following:
(1) recurrent excessive distress when separation from home or major
attachment figures occurs or is anticipated
(2) persistent and excessive worry about losing, or about possible harm
befalling, major attachment figures
(3) persistent and excessive worry that an untoward event will lead to
separation from a major attachment figure (e.g., getting lost or being
kidnapped)
(4) persistent reluctance or refusal to go to school or elsewhere because of
fear of separation
(5) persistently and excessively fearful or reluctant to be alone or without
major attachment figures at home or without significant adults in other
settings
(6) persistent reluctance or refusal to go to sleep without being near a
major attachment figure or to sleep away from home
(7) repeated nightmares involving the theme of separation
(8) repeated complaints of physical symptoms (such as headaches,
stomachaches, nausea, or vomiting) when separation from major
attachment figures occurs or is anticipated
   Separation Anxiety Disorder


• Anxiety about separation from major attachment
  figures
• Normal in early life
• Commonest anxiety disorder in pre-pubertal
  children
• Most cases get better
• No evidence for heritability
• Inhibited temperament associated with generalised
  social anxiety at adolescence, but not separation
  anxiety
Treatment
• Behavioural treatment
  – Graded exposure
  – Alter reward/disincentive balance
• Cognitive treatment: positive self-
  statements
• Parental reassurance/explanation to child
       General Anxiety Disorder
•   Evidence of effectiveness for:
–   fluoxetine
–   fluvoxamine
–   CBT
              Family Anxiety
• Cobham et al, 1998
• All children received individual CBT for anxiety
  disorders
• Parents randomised to parental anxiety
  management or not
• If high parental anxiety, big difference in response
  rate of children
   – 77% vs 39%
• (No difference if low parental anxiety)
Intellectual
 disability
    Mental retardation: DSM-IV-TR
A. Significantly subaverage intellectual functioning: an IQ
of approximately 70 or below on an individually
administered IQ test (for infants, a clinical judgment of
significantly subaverage intellectual functioning).
B. Concurrent deficits or impairments in present adaptive
functioning (i.e., the person's effectiveness in meeting the
standards expected for his or her age by his or her cultural
group) in at least two of the following areas:
communication, self-care, home living, social/interpersonal
skills, use of community resources, self-direction,
functional academic skills, work, leisure, health, and safety.
C. The onset is before age 18 years.
 Mild > 50-55 moderate > 35-40 severe >20-25 profound < 20
Epid   1%Intellectual disability
       Boys>girls
       Highest incidence 10-14
       2/3 have identifiable cause
Clin   The more profound the earlier detected &
       lower language & social skills are
       Cog/          Hyperactivity
                     Inattention
       emotional
                    Affective instability
                    Low frustration tolerance
       Behaviour    Aggression
                    Self-injury
                    Stereotypies
            Down’s                                   Trisomy type
Chrom.      Fragile X
            Prader-Willi
            Cri-du-chat
                          Causes of ID
            Rett’s                                   R, L & A are X-linked
Inherited   Lesch-Nyhan syndrome                     PKU is recessive
            Adrenoleukodystrophy
            PKU
                                             PDD     N & T are dominant
                                                     L: compulsive self-mutilation, purine
            Neurofibromatosis                        metabolism problem
            Tuberous sclerosis                       NB Translocation Down‟s is inherited

            Prematurity                              Prematurity & very low birth
Perinatal   vLBW                                     weight associated with ID
            Infections:            Most common:
                  –Rubella
                  –CMV             Down‟s,
                  –Toxo
                  –AIDS            Fragile X
                  –Herpes
                  –Syphillis       PKU
            FAS
            Maternal malnutrition/drug use
            Uncontrolled diabetes
            Encephalitis                             More common in low socioeco
Acquired    Meningitis
            Prolonged seizures      Socioemotional
            Head trauma             deprevation
            Drowning hypoxia
          Down‟s syndrome
Epid     1 in 700, 1 in 100 > 32, 1 in 3 with trans.
Aet      Trisomy (non-disjunction at meiosis)
         Mosaicism (normal & trisomy cells in tissue)
         Translocation (heritable)
Clin     Absent Moro, hypotonia
         Single palmar crease
         Oblique palpebral fissures, small flattened skull
         Abundant neck skin
Course   OK til 1 year then ID with IQ ≈ 30
         Placid til teenage then behavioural/emtional
         >30 dementia* (plaques & tangles)
Epid     Fragile X syndrome
        1 in 1000 males
        1 in 2000 females
        2nd most common cause of ID after Down‟s
        IQ declines in adolescence
Aet     Mutation at Xq27.3 expressed in some cells
        Asymptomatic carriers
Clin    Long head & ears
        Hyperextensible joints
        Short stature
        Post-pubertal macro-orchidism
Psych   ID, ADHD, LD, PDD
        Language problems:
            perseveration,
            sentence construction difficulty
        Socially adaptable
           Prader-Willi Syndrome


           1 in 10,000
Epid
           Chromosome 15
Aet
           Hypothalamus is involved
           Short
Clinical
           Obese
           Small hands and feet
           Hypogonadal
           Ataxic
           Food: Overeating, food stealing
Psych
           Axis II: developmental (esp. language & motor), mental retardation
           Axis I: psychosis, affective (esp. with psychosis), OCD
           Behavioural: aggression, skin-picking, hoarding, tantrums
       Cri-du-chat syndrome
Aet    Chromosome 5
Clin   Cat‟s cry: laryngeal abn, changes with age
       Microcephaly
       Micrognathia
       Low-set ears
       Oblique palpepbral fissures
       Hypertelorism
                      PKU
Epid   1 in 10,000, 1 in 5 in siblings
Aet    Heritable
       Absent phenylalanine hydroxylase
Clin   ID
       30%: eczema, vomiting, seizures
       Communication (non&verbal) poor: autism
       Behaviour problems: tantrums, hyperactivity
       Bizarre upper body movements
Tx     Heel prick at birth & dietary restriction leads
          ID: treatment strategies
Biological Intervene early e.g. PKU
prevention Genetic screening
Family/     Educate
socio       Advocate
            Reduce social isolation
Non-        Behaviour therapy works
pharm       Cognitive therapy with relaxation

Pharm       Aggression: mood stabilisers & risperidone
            Obsessions/compulsions: SSRIs
            ADHD: stimulants only of short term benefit
ID & comorbid psychopathology
Epid 30% have comorbid MI MI
       2-5% schizophrenia
       10-50% mood disorder
Risk Increases with
          severity of ID
          Epilepsy
Clin Atypical presentation e.g ill-informed delusions
       Look for behaviour change
       Get collateral
Spec Down‟s & Fragile X associated with Autism
       Fragile X associated with ADHD
 Child & adolescent


Communication
  disorders
      Expressive language disorder
A. The scores obtained from standardized individually administered
measures of expressive language development are substantially
below those obtained from standardized measures of both nonverbal
intellectual capacity and receptive language development. The
disturbance may be manifest clinically by symptoms that include
having a markedly limited vocabulary, making errors in tense, or
having difficulty recalling words or producing sentences with
developmentally appropriate length or complexity.
B. The difficulties with expressive language interfere with academic or
occupational achievement or with social communication.
C. Criteria are not met for Mixed Receptive-Expressive Language
Disorder or a Pervasive Developmental Disorder.
D. If Mental Retardation, a speech-motor or sensory deficit, or
environmental deprivation is present, the language difficulties are in
excess of those usually associated with these problems.
 Child & adolescent

Learning disorders:
formerly academic
  skills disorders
                    Reading disorder*
A. Reading achievement, as measured by individually
administered standardized tests of reading accuracy or
comprehension, is substantially below† that expected
given the person's chronological age, measured
intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes
with academic achievement or activities of daily living that
require reading skills.
C. If a sensory deficit is present, the reading difficulties are
in excess of those usually associated with it.

     Developmental reading disorder or Dyslexia: “'a marked impairment
     in the development of word recognition skills and reading
     comprehension that is not explained by mental retardation or
     inadequate schooling and that is not due to a visual or hearing
     defect or a neurological disorder’”
            Reading disorder
Epid 5%        tempero-parietal, tempero-
     M > F 3:1 occipital, cerebellar on f.Imaging
Comorbidity   ADHD: ?risk factor for RD & CD
              CD:
                   ? Frustration
                   worsens prognosis
Leads to Self-esteem problems
         School underachievement
         Social phobia/refusal
         Early school leaving
Reading disorder: some details

• Reading is recognition of words (top down) plus decoding letter
  sequences (bottom up)
• Majority SRD phonological dyslexia
    – difficulty decoding words via letters
    – can read words they recognise (automatic lexical rexognition)
• So less of a problem in more phonetic languages (Italian, German)
• No English/Japanese/Chinese difference
• Surface dyslexia
    – specific difficulty in word recognition
• Hyperlexia
    – Precocious ability to decode
    – Specific difficulty in word recognition
     Disorder of written expression
A. Writing skills, as measured by individually administered
standardized tests (or functional assessments of writing
skills), are substantially below those expected given the
person's chronological age, measured intelligence, and
age-appropriate education.
B. The disturbance in Criterion A significantly interferes
with academic achievement or activities of daily living that
require the composition of written texts (e.g., writing
grammatically correct sentences and organized
paragraphs).
C. If a sensory deficit is present, the difficulties in writing
skills are in excess of those usually associated with it.
             Mathematics disorder
A. Mathematical ability, as measured by individually
administered standardized tests, is substantially below
that expected given the person's chronological age,
measured intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes
with academic achievement or activities of daily living that
require mathematical ability.
C. If a sensory deficit is present, the difficulties in
mathematical ability are in excess of those usually
associated with it.
  Child & adolescent


   Feeding &
eating disorders
                Feeding disorder
A. Feeding disturbance as manifested by persistent failure
to eat adequately with significant failure to gain weight or
significant loss of weight over at least 1 month.
B. The disturbance is not due to an associated
gastrointestinal or other general medical condition (e.g.,
esophageal reflux).
C. The disturbance is not better accounted for by another
mental disorder (e.g., Rumination Disorder) or by lack of
available food.
D. The onset is before age 6 years.
                          Pica
A. Persistent eating of nonnutritive substances for a
period of at least 1 month.
B. The eating of nonnutritive substances is inappropriate
to the developmental level.
C. The eating behavior is not part of a culturally
sanctioned practice.
D. If the eating behavior occurs exclusively during the
course of another mental disorder (e.g., Mental
Retardation, Pervasive Developmental Disorder,
Schizophrenia), it is sufficiently severe to warrant
independent clinical attention.
             Rumination disorder
A. Repeated regurgitation and rechewing of food for a
period of at least 1 month following a period of normal
functioning.
B. The behavior is not due to an associated
gastrointestinal or other general medical condition (e.g.,
esophageal reflux).
C. The behavior does not occur exclusively during the
course of Anorexia Nervosa or Bulimia Nervosa. If the
symptoms occur exclusively during the course of Mental
Retardation or a Pervasive Developmental Disorder,
they are sufficiently severe to warrant independent
clinical attention.
Child & adolescent disorders


   Elimination
    disorders
                      Enuresis
A. Repeated voiding of urine into bed or clothes (whether
involuntary or intentional).
B. The behavior is clinically significant as manifested by
either a frequency of twice a week for at least 3
consecutive months or the presence of clinically significant
distress or impairment in social, academic (occupational),
or other important areas of functioning.
C. Chronological age is at least 5 years (or equivalent
developmental level).
D. The behavior is not due exclusively to the direct
physiological effect of a substance (e.g., a diuretic) or a
general medical condition (e.g., diabetes, spina bifida, a
seizure disorder).
                 Enuresis
• Nocturnal or diurnal wetting
• Primary enuresis often a specific
  developmental disorder
• Males slower to achieve dryness
• From 7, more likely to be secondary
• 7 often threshold for active treatment
• Nocturnal enuresis present in 1% of 14 yo,
  5% of 7yo
Aetiology

• 70% have family history in first degree relative
• UTI, particularly girls
• Stressful events at 3/4 associated with twice risk
  of enuresis
   – also associated with nightmares (Q 40)
   – Sexual/physical abuse
• Other developmental problems
• Social disadvantage
• Encopresis associated
Unlikely/Non Causes

• Structural UT abnormality
   – So don‟t do scan
   – Functional rather than structural bladder capacity lower
• Deep sleep
   – Enuresis random at any sleep stage
   – No evidence sleep is deeper
• Epilepsy
   – No difference in EEGs
• „Anal personality‟
Treatment

• Behavioural
  – Star charts
  – Remove rewards for wetting
  – Normalize behaviour: don‟t punish
• Alarms
• Medication
  – Desmopressin (vasopression (=ADH) analogue)
  – TCA
     • Side-effects
  – Short-term efficacy during use of medication only
                   Encopresis
A. Repeated passage of feces into inappropriate
places (e.g., clothing or floor) whether involuntary or
intentional.
B. At least one such event a month for at least 3
months.
C. Chronological age is at least 4 years (or equivalent
developmental level).
D. The behavior is not due exclusively to the direct
physiological effects of a substance (e.g., laxatives)
or a general medical condition except through a
mechanism involving constipation.
 Child & adolescent


Other disorders
 & miscellany
A. Performance in daily activities that require motor
       Developmental coordination disorder
coordination is substantially below that expected given the
person's chronological age and measured intelligence. This
may be manifested by marked delays in achieving motor
milestones (e.g., walking, crawling, sitting), dropping
things, "clumsiness," poor performance in sports, or poor
handwriting.
B. The disturbance in Criterion A significantly interferes with
academic achievement or activities of daily living.
C. The disturbance is not due to a general medical
condition (e.g., cerebral palsy, hemiplegia, or muscular
dystrophy) and does not meet criteria for a Pervasive
Developmental Disorder.
D. If Mental Retardation is present, the motor difficulties are
in excess of those usually associated with it.
                  Selective mutism
A. Consistent failure to speak in specific social situations (in
which there is an expectation for speaking, e.g., at school)
despite speaking in other situations.
B. The disturbance interferes with educational or occupational
achievement or with social communication.
C. The duration of the disturbance is at least 1 month (not limited
to the first month of school).
D. The failure to speak is not due to a lack of knowledge of, or
comfort with, the spoken language required in the social
situation.
E. The disturbance is not better accounted for by a
Communication Disorder (e.g., Stuttering) and does not occur
exclusively during the course of a Pervasive Developmental
Disorder, Schizophrenia, or other Psychotic Disorder.
         (S)Elective Mutism
• Only speak to close people and in certain
  circumstances
• Eg won‟t speak at school, but
  comprehension normal
• Usually starts 3-5 yo
• No association with SES, family size
                 Associations
• Psychiatric disorders
    – Particularly social phobia
•   Shy personality
•   Language problems
•   IQ average around 85
•   Family history of mutism, social anxiety
•   Traumatic experiences
                Treatment
• Behavioural
  – Change balance of rewards/disincentives to
    speak
  – Gradual desensitisation
• Medication
  – Small study showed efficacy of fluoxetine
      Reactive attachment disorder
A. Markedly disturbed and developmentally inappropriate
social relatedness in most contexts, beginning before age 5
years, as evidenced by either (1) or (2):
   (1) persistent failure to initiate or respond in a
   developmentally appropriate fashion to most social
   interactions, as manifest by excessively inhibited,
   hypervigilant, or highly ambivalent and contradictory
   responses (e.g., the child may respond to caregivers with
   a mixture of approach, avoidance, and resistance to
   comforting, or may exhibit frozen watchfulness)
   (2) diffuse attachments as manifest by indiscriminate
   sociability with marked inability to exhibit appropriate
   selective attachments (e.g., excessive familiarity with
   relative strangers or lack of selectivity in choice of
   attachment figures)
       Reactive attachment disorder
B. The disturbance in Criterion A is not accounted for solely
by developmental delay (as in Mental Retardation) and does
not meet criteria for a Pervasive Developmental Disorder.
C. Pathogenic care as evidenced by at least one of the
following:
    (1) persistent disregard of the child's basic emotional
    needs for comfort, stimulation, and affection
    (2) persistent disregard of the child's basic physical
    needs
    (3) repeated changes of primary caregiver that prevent
    formation of stable attachments (e.g., frequent changes
    in foster care)
D. There is a presumption that the care in Criterion C is
responsible for the disturbed behavior in Criterion A (e.g.,
the disturbances in Criterion A began following the
pathogenic care in Criterion C).*
A. Repetitive, seemingly driven, and nonfunctional motor behavior (e.g.,
     Disorder of stereotyped movement*
hand shaking or waving, body rocking, head banging, mouthing of
objects, self-biting, picking at skin or bodily orifices, hitting own body).
B. The behavior markedly interferes with normal activities or results in
self-inflicted bodily injury that requires medical treatment (or would
result in an injury if preventive measures were not used).
C. If Mental Retardation is present, the stereotypic or self-injurious
behavior is of sufficient severity to become a focus of treatment.
D. The behavior is not better accounted for by a compulsion (as in
Obsessive-Compulsive Disorder), a tic (as in Tic Disorder), a stereotypy
that is part of a Pervasive Developmental Disorder, or hair pulling (as in
Trichotillomania).
E. The behavior is not due to the direct physiological effects of a
substance or a general medical condition.
F. The behavior persists for 4 weeks or longer.
                       School refusal
      Vs truancy (leaves home but doesn‟t get to school)
Def
      Masquerade sdm: abdo pain, viral infection
      Usually at start of school, change of school or change to secondary school
      No sex diff., No socio eco. Diff., No academic ability diff.
      ?Youngest child at greatest risk
      2/3 return to school rest become neurotic & socially impaired adults
      Separation anxiety
Aet
      Specific problem at school
           e.g. bullying or specific phobia of an aspect e.g. gym
      General psych: e.g. depression
      AIM: Early return to school
Tx
      Behaviour therapy: Graded return
      Treat psychiatric comorbidities
      ?Imipramine (Bernstein et al 2000)
           School refusal with MDD and anxiety
               Parasomnias
• Sleep is REM or non-REM
• REM
  – Nightmares
  – Narcolepsy
• Non-REM
  – Night terrors (Stage 4: deep sleep)
  – Somnambulism
Night Terrors
Epid
• 2-7 year olds (1-3% continue into older age)
• Commonest in youngest group i.e. 2-3 year olds
Clin
• Child screams, appears terrified with autonomic arousal,
   hard to comfort, appears dazed/responding to internal
   stimuli
• Goes back to sleep & wakes with no memory of event in
   am
• No clear relationship to psychological problems
Tx
• Reassure parents: kid won‟t remember it
 Child & Adolescent


Tic disorders
                                  Tic disorders
               Sudden, rapid, repetitive,         Simple
 Definitions




               stereotyped, non-rhythmic, which         Motor: eye blinking, abnormal tensing
               arise often with a premonitory           Vocal: throat clearing, grunting, snorting, chirping
               urge and relieve a sense of        Complex
               tension.                                 Motor: jumping, squatting, echopraxia
                                                        Vocal: words and phrases (palilalia, echolalia)
               Tourette's disorder
Types




               Chronic motor or vocal tic disorder: Tourette‟s but MOTOR OR VOCAL not both
               Transient tic disorder: <   12 months but > 4 weeks
               Tic disorder NOS

               • Worsened by stress. Somewhere between voluntary and involuntary like a sneeze.
               • Usually not present during sleep or goal-directed activity but some people wake up with
                 them.
Comments




               • OCD & ADHD often co-morbid (in 40% & 50% of Tourette‟s respectively)
               • Ddx: neurological, habit, PD disorders
               • Social anxiety & socio-occupational impairment may result because of fear of
                 shame/stigmatisation
               • Male > female 5:1
             Multiple motor and one or more vocal tics
DSM
            Tourette‟s syndrome
             > 1 year, never > 3months tic free
             Several times a day
             < 18 start
             Not due to substance or Gen Med
             Coprolalia in 10% NOT REQUIRED for diagnosis
             Genetic: mono > di
Aetiology
             Soft neurological signs & EEG abnormalities
             Neural circuits: BG-T-Cx circuit implicated
             Neurochemical:
                  DA: D2 blockers help, amphetamines worsen
                  NA: clonidine helps
                  Opioids: naltrexone helps
             Assess & treat effects of disorder on child & family
Tx                Explanation: child has minimal control on symptoms
                  Family function, self-esteem building, etc.
                  help with consequences but don‟t affect disorder much
             Non-pharm: behaviour therapy better for CMTV than Tourette‟s
             Pharm: sulpride*, haloperidol, SSRIs, clonidine†
 College on Child Sexual Abuse
• All adult-child sex is exploitative & harmful
  because of unequal power
• Address protective/safety issues before treatment
  of resulting MI
• MHP assessment required for all victims/offenders
• Assess cultural, social, family context
• Coordinate services: legal, protective, therapeutic
  (for victim & offender)
• Community awareness aids detection
• Research required
• Sexualization of C&A in advertising is bad
(a) evaluating and validating the claim of of CSA
Role of psychiatrist in assessment abuse;
(b) defining the nature of abuse;
(c) evaluating the impact (emotional/physical)
upon the child of abuse;
(d) recognition of the physical consequences of
abuse and appropriate referral;
(e) evaluation of the continuing risk to child and
others in the family;
(f) evaluation with a view to notifying authority or
for medico-legal purposes;
(g) evaluation of the therapeutic needs of child,
family, abuser.
        CSA assessment
Assessment Rapport & trust
           Age appropriate language
                                             issues
process
               Dolls/drawings
               Avoid leading questions
               Allay fears of consequences of disclosure
Legal          Whose agent? Court or patient‟s?
               Consent re information disclosure
               Confidentiality
               Mandatory reporting
               Custody issues/secondary gain from claims
Family         Effect of disclosure on family
               Family attempting to protect perpetrator
               Using disclosure as tool in relationship e.g. to punish
Counter-       Non-judgementality
transference   Not showing vicarious interest!
         Issues in child custody
•   Preferences of child/parents
•   Child‟s developmental stage
•   Child‟s adjustment at school/home/social
•   GMC, MI & SA in child/parents
•   Family conflicts & effects on child
        <16 from both parents & in C&A
ConsentForensic issues family
Reports Note they may be used in court
          Note difference between legal & clinical report
          Note lower confidentiality if writing for court
Police    Note developmental implications
involve
ment
Misc      Get corroborative info: police, welfare, parents
    College on kids with MI parents
•   Assess MI
•   Assess safety, living circumstances
•   Assess direct effects of MI on child
•   Assess supports
•   Assess parenting ability
•   Assess parent‟s own concerns
•   Consider child protection issues
•   Consider CAMHS involvement
•   CAMHS to liaise with adult services
          Physical illness & C&A
      2x increase in MI, but 70% of families cope well
Bio            Treatments e.g. steriod or ß-agonists
               Direct neurological e.g. hypoxia
Psych          Internalising disorders e.g. SAD, somatoform
               Language/academic delay
Social         Peers:
                   Ostracized, teased, bullied at school
               Family:
                   Over/under-protection
                   Relationships placed under stress

Modulated      Severity
by             Handicap: how much school do they miss
               Age of onset
               Invasive procedures
               Family hx (modulates family response)

				
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