Child psychiatry
Introduction:
Child psychiatry is the branch of psychiatry concerned with the assessment and treatment of children’s emotional behavioural and relationship problems.
Children are immature individual passing through stages of growth and development till they reach adulthood.
The development is the product of the continuous interaction heredity and the maturation of different systems and the environmental influences.
The childhood period start from birth till eighteen years old (0-18) passing from infancy(0-2), childhood from three years till puberty(3-13) and adolescence from(14-18)
The abnormality in child psychiatry is elicited by comparing the child behaviour to the corresponding normal range of the age group.
It is truly that we obtain the majority of our information from the observation made by the parents, caregivers, and teachers, but also we have to observe the child.
We always should take in consideration the developmental stage of the child, for example temper tantrums in a two years old child is not considered pathological, however, in a nine years old it isconsidered pathological.
The children are developing physically, emotionally, intellectually, and socially.
The assessment of the child follows the usual steps of the adult assessment, taking in consideration the following steps:
-Flexibility
-Preferably the two parents should attend the assessment interview.
- Ideally the child is left with his parents in the room which should be large, with different set of toys put in each corner of the room, or put it separately on a table, the room should be safe and secure and the child is watched by the therapist through a camera,given enough time for play. The therapist should observe the choice of toys, the degree of attachment to parents, any abnormal movements, the nutritional status, evidence of neglect or abuse.The therapist introduce himself to the patient, and the history and assessment are done as usual. To observe the ease of separation the therapist could ask the parents to go away after explaining to the child that they will be outside.
A detailed personal history should be obtained, the family history should be taken with special emphasis on the following points:
-Quality of parenting
-Parent –child relationship.
-Pattern of family relationship
-Separation from the care giver for more than a week
-General health (eating, elimination, sleeping, and physical complaints.
-School (achievement, sociability with schoolmates, relationship with teacher, andif he likes or dislikes the school .
-Attention span, concentration, and activity.
The treatment of children depends mainly on non pharmacological treatment mainly play therapy ,behaviour therapy and training, changing the attitude of the parents towards their children, working with the family and teachers and coordinating the efforts to help him.
The ICD-10 or the DSM IV is nearly describing the same disorders with different names. All categories used in DSM-IV are found in ICD-10, but not all ICD-10 categories are in DSM-IV.
-Mental Retardationis the same on both classification
-Learning disorders(DSMIV)is Specific developmental disorders of scholastic skills(iICD-10)
-Motor Skills Disorder (DSMIV) is Specific developmental disorder of motor
Function(ICD-10)
-Communication Disorders(DSMIV) is Specific development disorders of speech and language(ICD-10)
-Pervasive Developmental Disorders is the same in both classifications.
-Attention deficitand disruptive behaviour (DSMIV) is the Behavioural and emotional disorders with onsetUsuallyoccurring in childhood and adolescence(ICD-10) including conduct and hyperkinetic disorder
Feeding and Eating Disorders of Infancy or Early Childhood in(DSMIV)is Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence (ICD-10)
TIC Disorders is the same in both classifications.
Elimination Disorders(DSMIV) is included inOther behavioral and emotional disorders with onset usually occurring in childhood and adolescence (ICD-10)
The DSM-IV contains 5 axis
Axis I consists of mental disorders .
Axis II consists of mental retardation and personality disorders.
Axis III lists any physical disorder or general medical condition that is present in addition to the mental disorder.
Axis IV is used to code psychosocial and environmental problems
Axis V Global Assessment of Functioning (GAF)
ICD-10 is composed of three axes:
- Clinical Diagnoses
- Disablement
- Contextual Factors.
We will discuss the most important diagnostic entities which are (autism,attention deficit hyperactivity disorder,mental retardation, tic disorders, separation anxiety disorder,childhood phobias , elimination disorders)
AUTISM
This is a condition in which there is delay or deviance in the development of social skills, language and communication and behavioural repertoire. It affect s multiple areas of development, manifested early in life and causes persistent dysfunction
Epidemiology:
Life time prevalence is 5/10.000 children (0.05%)
The onset is before three years.
Sex Distribution :male to female ratio is 4-5 :1 .
socio- economic status : No association between autistic disorder and any socioeconomic status
Etiology and pathogenesis.
Autistic disorder is a developmental behavioural disorder biological in origin and the emotionally unresponsive refrigerator mother of Kanner is obsolete.
Psychosocial and Family factors:
All recent studies show no significant changes in rearing practice of autistic parents.
However autistic children are responding with exacerbated symptoms to psychosocial stressors including family discord, the birth of a new sibling or a family move, and they are extremely sensitive to even small changes in their families and immediate environment.
Biological factors:
The high rate of mental retardation and seizure disorders suggest a biological basis for autistic disorder. 75% of autistic are mentally retarded, one third are mild to moderate and close to half are severely mentally retarded they show marked deficits in abstract reasoning social understanding and verbal tasks than in performance tasks such as block design and digit recall in which details can be remembered without reference to the "Gestalt " meaning.
1-32% have grand mal epilepsy.
20-25% ventricular enlargement.
- E.E.G abnormalities from 10-83%, there is some indication of failed cerebral lateralization.
- Hypoplasia of cerebellar vermal lobules VI& VII.
- Cortical abnormalities (polymicrogyria) these abnormalities reflect abnormal cell migration in the first six months of gestation.
- Fewer Purkinje's cells.
- Increase diffuse cortical metabolism by P.E.T.
- It is associated with neurological conditions, congenital rubella phenyl ketonuria, tuberous sclerosis.
- More perinatal complications.
- More minor congenital physical anomalies suggests abnormal development within the first trimester of pregnancy.
Genetic factors:
2-4% of siblings of autistic children are autistic, 50 times more than in general population.
Concordance rate in two studies 36in monozygotic to zero in dizygotic, 96in monozygotic to 27 in dizygotic.
- Fragile x syndrome 1% have fragile X
- Tuberous sclerosis 2% have this disorder
- Chromosomes 2&7 there is two region
16,17 have autism related genes.
Immunological factors:
Maternal antibodies directed to fetus (lymphocytes of fetus react with maternal antibodies raising the possibility that embryonic neural or extraembryonic tissues may be damaged during gestation.
Perinatal factors: Maternal bleeding, meconium in the amniotic fluid, respiratory distress syndrome and neonatal anaemia.
Neuroanatomical factors: total brain volume is larger than normal but mentally retarded autistic have smaller brain.
Increase insize in the occipital lobe, parietal and temporal lobe, no differences were found in the frontal lobes. Specific origins of these enlargement are unknown. It could be explained by increase neurogenesis, decreased neuronal death and increased production of nonneuronal brain tissue, such as glial cells or blood vessels. Brain enlargement has been suggested as a possible biological marker for autistic disorder.
The temporal lobe is believed to be a critical area of brain abnormality in autistic disorder.
Biochemical factors:
Increase serotonin in autism and in mental retardation , increase in HVA in C.S.F with increase withdrawal and stereotypes
Physical characteristics:
Attractive look, minor physical anomalies such ear malformations indicating the particular fetal developmental period in which the abnormality arises, ambidexterity, abnormal dermatoglyphics suggesting a disturbance in neuroectodermal development.
DSM-IV - TR Diagnostic Criteria for Autistic Disorder
A-A total of Six (or more) items from (1), (2) and (3), with at least two from (1), and one each from (2) and (3(.
(1)Qualitative impairment in social interaction, as manifested by at least two of the following:
a) Marked impairment in the use of multiple nonverbal behaviours such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction.
b) Failure to develop peer relationships appropriate tothe developmental level.
c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest(.
d) lack of social or emotional reciprocity.
(2)Qualitative impairments in communication as manifested by at least
one of the following:
a) delay in, or total lack of , the development of spoken languagenot accompanied by an attempt to compensate throughalternative modes of communication such as gesture or mime.
b) in individuals with adequate speech, marked impairment in theability to initiate or sustain a conversation with others.
c) Stereotyped and repetitive use of language or idiosyncraticlanguage.
d) lack of varied, spontaneous make-believe play or social imitativeplay appropriate
to developmental level.
(3) Restricted repetitive and stereotyped patterns of behaviour, interests,
and activities, as manifested by at least one of the following:
a) encompassing preoccupation with one or more stereotyped andrestricted patterns of interest that is abnormal either in intensityor focus.
b) Apparently inflexible adherence to specific, non-functional rational routines or rituals.
c) Stereotyped and repetitive motor mannerisms (e.g., hand orfinger flapping or twisting, or complex whole-body movements).
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
C. The disturbance is not better accounted for by Rett's disorder orchildhood disintegrative disorder
.Differential Diagnosis:
The major differential diagnosis are
1- Schizophrenia with childhood onset.
2- Mental retardation with behavioural symptoms.
3- Mixed receptive – expressive language disorder.
4- Congenital deafness or severe hearing disorder.
5- Psychosocial deprivation.
6- Disintegrative psychoses.
Children with pervasive developmental disorder usually have many concurrent problems, therefore a step –wise approach to the differential diagnosis is suggested.
1-Determine I.Q.
2- Determine level of Language development.
3-Child's behaviour is appropriate for
a)chronological age.
b)Mental age.
c)Language age.
4-if not appropriate consider differential diagnosis of psychiatric disorder according to.
i- Pattern of social interaction.
ii- Pattern of Language.
iii- Pattern of play.
iv- Other behaviour.
5-Identify any relevant condition.
6-Consider whether there are any relevant psychosocial factors.
Course and prognosis:
1-Life long disorder with guarded prognosis, those who have I.Q > 70 and use communicative language by age 5-7 tend to have the best prognosis . High I.Q. autistic at age of 13 no longer met criteria for autism but have some features. They show positive changes in communication and social domains overtime. The symptoms that did not improve overtime those related to ritualistic and repetitive behaviours. 2/3 of autistic live in complete or semi dependence either with relative or institutions. Only 1- 2% acquire abnormal independent status with gainful employment and 5-20% achieve a borderline line normal status the prognosis improve if the environment is supportive and capable of meeting their needs. In some cases self mutilation or aggressiveness and regression. 4-32% have G.M.E in late childhood and adolescence it affects the prognosis.
Treatment: the goals of treatment are to increase socially acceptable and prosocial behaviour to decrease odd behavioural symptoms and to improve verbal and non verbal communication.
- Language remediation – Academic remediation.
- Appropriate behavioural interventions to reinforce socially acceptable behaviours and encourage self – care skills for M.R. autistic.
- Insight – oriented individual psychotherapy proved ineffective.
- Educational and behavioural interventions are considered the treatment of choice.
- Structured classroom training in combination with behavioural method, is the most effective treatment.
- Parental support and counselling and training of parents in the concepts and skills of behaviour modification.
- Resolution of the parent's concern lead to considerable gain in children, language cognitive and social areas of behaviour.
- "Facilitated communication" is a technique by which autistic with some language is aided in communication by a teacher who helps the child pick out letters on a computer or letter board.
- There are no specific medications to treat the core symptoms of autistic disorder.
- Pyschopharmacotherapy is a valuable adjunctive treatment to ameliorate associated behavioural symptoms.
Mental retardation
Definition:
Intellectual impairment starting early in life associated with educational and social disabilities
Level of mental retardation:
Classified according to the I.Q determined by standard psychometric tests
Mild mental retardation: IQ level 50–55 to approximately 70 about 75%
Moderate retardation: IQ level 35–40 to 50–55 about 15%
Severe mental retardation: IQ level 20–25 to 35–40 about 8%
Profound mental retardation: IQ level below 20 or 25 about 2%
N.B -Borderline mental retardation <90
Co- morbidity with other psychiatric disorders is high because of the possible genetic etiology, presence of organic brain disease, reaction to the stigma of subnormality, parental attitude either rejection or overprotection, as a consequences of the abnormality e.g. deficient social skills
N.B making the diagnosis of the co- morbid disorder is sometimes difficult due to the low level of intelligence and the poor verbal fluency.
1-Depression is common but not expressed verbally
2-adjustment disorders prominent in the mild mental retardation
3-personality disorder may lead to problem specially legal
4-75% of autistic are mentally retarded
5-Schizophrenia (gifted schizophrenia)more deterioration of mental functions, delusion and hallucination are less likely to be expressed clearly
Causes:
-congenital,chromosomes or gene defects
Clinical Findings and Laboratory Abnormalities That Increase Suspicion for Underlying Metabolic Disorder
Growth abnormality
Recurrent, unexplained illness
Seizures
Ataxia
Loss of psychomotor skills
Hypotonia
"Coarse" appearance
Eye abnormalities (cataracts, ophthalmoplegia, corneal clouding, retinal abnormality)
Recurrent somnolence/coma
Abnormal sexual differentiation
Arachnodactyly
Hepatosplenomegaly
Metabolic/lactic acidosis
Hyperuricemia
Hyperammonemia
Low cholesterol
Structural hair abnormalities
Unexplained deafness
Bone abnormalities (dysostosis, occipital horns, punctate calcifications)
Skin abnormalities (angiokeratoma, "orange-peel" skin, icthyosis)
-intrauterine infections
-perinatal complication: anoxia, intraventricular hemorrhage, kernicterus ,etc..
-postnatal complication: encephalitis meningitis,trauma , etc...
-Psychosocial factors : sensory deprivation or poor stimulating environment.
Assessment
-detailed history including:family history of inherited diseases, prenatal perinatal and neonatal history,milestones.
-physical examination
-behavioural assessment
-psychometric assessment of I.Q
N.B clinically we can have a rough idea about the intelligence of a child
One to two year old can imitate drawing a line
Three year old can imitate drawing a circle
four year old can imitate drawing a square
five year old can imitate drawing a triangle
seven year old can imitate drawing a lozenge.
Management:
-Special education and training
-Family support and education
-Regular reassessment and follow up
Physical and psychological treatment .
Tic disorders
Definition: A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.
There is three types of tics :
-chronic motor or vocal tics
-transient tic disorder
-Tourette’s disorder
Tourette’s disorder (Gilles de la Tourette’s syndrome)
Tourette's disorder is a neuropsychiatric disorder with onset in childhood that is characterized by chronic intermittent motor and vocal tics.
Epidemiology:
-Prevalence is about 4-5 /10.000
-Mean age of onset seven years of age
-Boys to girls ratio is 3:1
DSM-IV Diagnostic Criteria for Tourette's Disorder
A.Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently.
B.The tics occur many times a day (usually in bouts), nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
C.The onset is before age 18 years.
D.The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).
Motor and vocal tics can be simple or complex. Simple tics are the first to appear.
Examples:
Simple motor tics: eye blinking, head jerking, facial grimacing.
Simple vocal tics: coughing , grunting , sniffing.
Complex motor tics: hitting self, jumping.
Complex vocal tics: coprolalia (use of vulgar words ),Palilalia(repetition of own words, echolalia (repeating other’s word).
Aetiology:
-Definite aetiology is unknown.
-Evidence of genetic transmission:
i- it runs in families
ii- higher incidence in monozygotic twins than dizygotic
-Evidence of neurobiologic causes : E.E.G abnormalities in about 50% of patients.
-Dopamine abnormality:
i- abnormal levels of homovanilic acid in CSF
ii-Stimulants (methyl phenidate) which are dopamine agonists worsen tics or precipitate their occurrence.
iii-Dopamine antagonists(haloperidol) improve tics
Differential diagnosis:
-Dyskinesia
-Syndenham’s chorea
-Huntington’s disease
Prognosis:
-Social ostracism is frequent
If the condition is untreated, the course is usually chronic with periods of lessening alternating with period of exacerbation of tics.
Treatment:
-Psychopharmacological:
a-Dopaminergic antagonist: carries the risk od inducind tardive dyskinesia.
i-Haloperidol gives good results in 85 % of cases
ii-Pimozide
b-Alpha-2 adrenergic agonist:
Clonidine gives fair results in treating tics but it has the benefit of not producing tardive dyskinesia.
-Psychological counselling is necessary to the family and the child
-Psycho education to the family and child(nature of the disorder, how to cope with it)
-Group psychotherapy to deal with the social ostracism and reduce the social isolation.
Chronic motor or vocal tic disorder
Similar to tourette’s, but it comes either with vocal tics or motor tics whether single or multiple.