Medical student lecture: introduction to child psychiatry

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Medical student lectureintroduction to child
psychiatry

• Regina Bussing, MD, MSHS
• Associate Professor and Chief
• Division of Child and Adolescent Psychiatry

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LECTURE FOCUS

1. Child Development
2. Evaluation Strategies
3. Treatment Modalities
4. Childhood Disorders

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MAJOR DEVELOPMENTAL STAGES

• Prenatal/Birth
• Infancy (Birth 18 months) Trust - form
  attachment/bond
• Toddler (1.5 - 3 years) Autonomy -
  walk/talk/tolerate separation
• Early childhood (3-5 years) Initiative - build
  vocabulary, build superego
• Middle childhood (6-12 years) Industry - build
  peer-relations and competencies
• Adolescence (12-adult) Identity

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MILESTONES Developmental Markers

• Sitting 6 months
• Walking 1 year
• Talking 1 year
• Toilet Training 2 years
• Rides Tricycle 3 years
• Dresses Self 5 years
• Draws a person (main parts) 5 years
• Rides Bicycle 6 years
• Normal variation is present Denver II-R

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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.

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CONCEPT OF REGRESSION

• STRESS ----gt Return to earlier developmental
  stage
• EXAMPLES
• 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.

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EVALUATION STRATEGIES
Patient Interview
Testing (IQ, Education, Projective,
Personality, Neuropsych, labs, EEG, MRI)
Collateral Information (Parents, School)
Observation
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SHIFTING FOCUS OF ASSESSMENT

• Infants and toddlers History observation
• gross and fine motor functions
• language and communication
• social behavior
• bonding
• Usual Concerns
• delayed development (e.g., MR),
• abnormal development (e.g., PDD)
• poor bonding (e.g., neglect, abuse)

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Shifting Focus of Assessment
SHIFTING FOCUS OF ASSESSMENT

• Preschoolers Observation, personal interview,
  parent interview
• observe milestones
• assess what child talks and thinks about (e.g.
  through play)
• Parent-child relation
• Possible concerns as before, plus
• speech-language delays,
• hyperactivity,
• aggressive/defiant behaviors,
• excessive anxiety,
• toilet training

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Shifting Focus of Assessment
SHIFTING FOCUS OF ASSESSMENT

• School-age child Observation, interviews,
  reports from school
• how does child function in family?
• how does child function in school? (behavior
  and academics)
• what kind of peer relations?
• formal psychological and academic testing
• Common concerns
• learning problems
• externalizing conditions
• separation anxiety

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IMPROVING THE ODDS FOR SUCCESSFUL DEVELOPMENTAL
OUTCOMES

• PROTECTIVE FACTORS
• Good parent-child relationship
• Easy, outgoing temperament
• Positive peer influence
• Successful school experiences
• Caring adult role models
• Participation in pro-social groups
• Access to needed services, e.g. healthcare,
  mental health, crisis intervention

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TREATMENT MODALITIES(Usually 2 or more
modalities are used simultaneously)

• Individual Therapies (play, behavioral,
  cognitive, supportive, dynamic)
• Family Therapy Parent Training
• Group Therapy - especially important for
  adolescents
• Examples of Pharmacotherapy
• ADHD Stimulants (e.g., Ritalin)
• MDD Anxiety SSRIs (e.g., Prozac, Zoloft)
• Bipolar Disorders Valproate, Lithium
• Enuresis DDAVP, TCAs (IMI)
• Psychosis Antipsychotics

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CHILD ABUSE1-800-96ABUSE

• "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 39.01 (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 harm
• from a person responsible for the care of the
  child.
• Know state reporting laws and procedures
• (http//www5.myflorida.com/cf_web/myflorida2/healt
  hhuman/childabuse/)

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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 cant 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

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MENTAL RETARDATION Diagnostic Criteria

• IQ 70 or less on an individually administered IQ
  test
• Onset before age 18 years
• Concurrent 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 US
• Causes
• Unknown (50 of mild MR)
• Known (75 of severe MR) Hereditary (Downs,
  fragile X PKU)Toxins Birth Trauma Infection.

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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).

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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
  training

PROFOUND 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.

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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.

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Pervasive Developmental Disorder

• Developmental disorders with severe and pervasive
  impairment in essential developmental areas
• Reciprocal social skills
• Language development
• Range of behavioral repertoire
• DSM-IV includes the following under PDD
• Autism
• Retts Disorder
• Childhood Integrative Disorder
• Aspergers Disorder
• PDD, not otherwise specified

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Autism
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Autism

• Prevalence estimates variable and increasing
• Boys are effected 3 to 5 times more than girls
• 50 to 70 have some degree of MR
• Associated with Congenital Rubella, PKU, Tuberous
  Sclerosis and Fragile X Syndrome
• 20 to 25 have grand-mal seizures and about 50
  have non-specific EEG abnormalities
• MRI, EEG, Karyotyping indicated in almost all
  cases

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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
http//card.ufl.edu
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Retts Disorder

• Normal growth for the first few months of life
• Deceleration of head growth between 5-48 months
• Truncal incoordination
• Lack of purposeful hand movements flapping
• Disorder of females
• Similar criteria as PDD
• Over 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.
• http//dukemednews.duke.edu/news/article.php?id50
  85

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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

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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
• Language
• Social Skills Or adoptive behavior
• Bowel or bladder control
• Play
• Motor skills
• Abnormal functioning in at least two areas
• Social interaction communication patterns of
  behaviors/interests

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Aspergers Disorder

• High functioning autism
• Impaired use of non-verbal communication (gaze,
  posture, gestures regulating social interaction)
• Lack of interactive play, impaired peer relations
• Stereotypic, repetitive mannerisms
• No delays in language and cognitive development

PDD NOS
Diagnosis 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.
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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 Disorder
• Mathematics Disorder
• Disorder of Written Expression
• Developmental Coordination Disorder
• Expressive Language Disorder
• Mixed Receptive-Expressive Language Disorder
• Phonological Disorder
• Stuttering

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ELIMINATION DISORDERS

• Encopresis (incontinence of feces)
• Repeated passage of feces into inappropriate
  places
• Age at least 4 years
• Frequency at least 1x per month x 3 months
• Not due to laxatives or medical problem
• Specify with or without overflow incontinence
  and constipation
• Enuresis (incontinence of urine)
• Repeated voiding into bed or clothes
• Age at least 5 years
• Frequency 2x per week x 3 months
• Not due to medical problem
• Specify nocturnal, diurnal, or both
• More common in males

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ADHD

• Persistent pattern of inattention and/or
  hyperactivity more frequent and severe than is
  typical of children at a similar level of
  development.
• Onset before age 7
• Impairment in at least two settings social,
  academic, or work
• Duration at least six months
• Inattention, Hyperactivity, Impulsivity

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ADHD Continued
Epidemiology
Incidence 2 to 20 of grade-school children Boys
gt Girls Ratio 3-51 Family members (siblings and
parents) of affected children are at higher risk
Etiology

• Specific etiology unknown contributory factors
• Genetics
• Pre and perinatal complications
• Neurological
• Environmental toxins

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Treatment
ADHD Continued
Types

1. Predominantly Inattentive type
2. Predominantly Hyperactive type
3. Combined type

Pharmacotherapy Stimulants Methylphenidate,
Dextroamphetamine, (Pemoline) Non-Stimulants
Atomoxetine (Strattera) Clonidine and
Guanfacine Bupropion TCAs (atypical
antipsychotics for treatment unresponsive
cases) Psychotherapy Behavioral modifications
environmental structuring parental Education and
training social skills training
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Tic Disorders
Tics are sudden, rapid, recurrent, nonrhythmic,
stereotyped motor movements or vocalizations
DSM-IV Diagnoses

• Tourettes Syndrome
• Chronic Motor Tic Disorder
• Chronic Vocal Tic Disorder
• Transient Tic Disorder
• Tic Disorder NOS

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Oppositional Defiant Disorder

• Recurrent pattern of negativistic, defiant,
  disobedient hostile behavior towards authority
  figures
• Duration gt 6 Months
• Impairment in social, academic and work settings
• Symptoms not part of the mood or thought disorder
• Treatment Parent training (PCIT)
• Individual psychotherapy
• Family Therapy

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Conduct Disorder

• Aggression to people and animals
• Destruction of property
• Deceitfulness or theft
• Serious violation of rules
• Treatment Multimodality treatment
  programs Environmental structuring Family
  Therapy Group Therapy Ind. Therapy
  problem solving skills Medications as adjuncts

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ANXIETY DISORDERS

• Common in childhood 15
• Comorbidity is common
• All adult anxiety disorders may be seen in
  children.
• PTSD - may be a result of abuse
• Separation Anxiety Disorder
• Developmentally inappropriate and excessive
  anxiety about separation from caretakers or home,
  of at least 4 weeks duration with onset before 18
  years
• Can lead to school refusal (school phobia)
• Associated with physical complaints, fear of
  sleeping alone, worries about parents safety

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Mood Disorders

• Childhood Depression
• irritability
• sleep cycle disturbance
• oppositional behavior
• social isolation
• crying spells
• Dysthymia
• symptoms at least 1 year

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Adolescents and Suicide

• In 1998, 4,153 young people, ages
• 15-24, committed suicide in the United States an
  average of 11.3 per day.1
• Suicide is the third leading cause of death in
  this age group following unintentional injury and
  homicide2
• Suicide accounts for 13.5 of all deaths in this
  age-group1

1 Murphy, SL, 1998 2 The Surgeon Generals Call
to Action to Prevent Suicide, 1999
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Suicide-Related Fatalitiesby Cause
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Suicide Prevention

• Dont 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.

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