child and adolescent psychiatry Flashcards
of children will experience a psychiatric disturbance that is sufficiently severe to require treatment or to impair their functioning during the course of a year
5% - 15%
Significantly sub-average intellectual functioning (IQ)
Significant limitations in adaptive functioning
Communication
Self-care
Life skills
Health and safety skills
Mental Retardation (DSM-IV)/Intellectual Disability (DSM-V)
range of mild ID
moderate?
severe?
profound?
Mild ID 55 - 70
Moderate ID 40 - 55
Severe ID 25 - 40
Profound ID under 25
85% of individuals with Intellectual Disability
Educable with special education assistance
Read, write, simple math
Concrete thinker
Expect to be able to hold a job, live independently
Mild Intellectual Disability
10% of individuals with Intellectual Disability
Talk, recognize name, basic hygiene, do laundry, handle small change
Minimal academic progress
Live with family or in supervised group home
Work in sheltered workshop or supervised activities
Moderate Intellectual Disability
Unable to complete self help
Likely to require care in an institutionalized setting
Profound and SevereIntellectual Disability
Affects 1%-2% of the population
Mild: .37% to .5% of population
Moderate/Severe/Profound: .3%-.4%
Mild more common in lower SES, Moderate/Severe/Profound are equally common across SES
Male to female ration 2:1
Intellectual Disability Epidemiology
what are the MC cause of mental retardation?
most common chromosomal cause?
most common heritable cause?
Fetal Alcohol Syndrome most common cause
Down Syndrome most common chromosomal cause
Fragile X Syndrome most common heritable form of mental retardation
Inborn errors of metabolism (e.g., Tay-Sachs) account for a small percentage of cases
t/f. Moderate/Profound/Severe often have identifiable cause
true
what causes mild MR?
Mild often does not have an identifiable cause and is likely developed through a combination of genetic and other factors
name 3 prenatal factors that may cause intellectual disability?
Prenatal factors
Substance use/abuse
Maternal malnutrition and illnesses
Exposure to mutagens
name 5 perinatal factors and early postnatal factors
IT HEM
Perinatal and Early Postnatal factors
Traumatic delivery/brain injury
Infections
Head injury
Exposure to toxins
Malnutrition
Attention Deficit/ Hyperactivity Disorder
Disruptive Behavior Disorders
Mood Disorders
Anxiety Disorders
Habit disorders and stereotypies
Seizure Disorder
all the above disorders are _______
Intellectual Disability Comorbidity
what are three factors that can impact a child’s level of functioning?
Child’s level of functioning can be impacted by:
Environmental stimulation
Poverty in environment
Cultural factors
can intellectual disability be cured?
intellectual disability tx?
Intellectual Disability itself is not treated or cured
Treat problematic behaviors
Treat comorbid conditions
Teach independent living skills
Provide special education assistance
Inability to achieve in a particular academic area at the level predicted by an individual’s cognitive abilities
Generally Borderline IQ or above
Diagnosis requires standardized IQ and achievement testing
Disorder is “treated” through special education services
Learning Disorders
Reading Disorder
Mathematics Disorder
Disorder of Written Expression
Disability can be in one or more areas
In DSM-V, child is diagnosed with Specific Learning Disorder, with impairment in reading, written expression, or mathematics
2-8% of children
Male to female ratio 2-4:1
what are learning disorders
what are three learning disorder comoribidities?
ADHD
Mood Disorder
Truancy, School Refusal, Substance Abuse
These may be associated with frustration due to school difficulty and failure
Expressive Language Disorder
Mixed Receptive-Expressive Language Disorder
- Combined into Language Disorder in DSM-V
Phonological Disorder
Speech Sound Disorder in DSM-V
Stuttering
Childhood Onset Fluency Disorder in DSM-V
Communication Disorder NOS
what are communication disorders
An impairment in the comprehension and/or use of a spoken, written or other verbal symbol system
Receptive-taking information in
Expressive- getting information out
Language Disorders
Poor articulation or pronunciation
Substitution- wight for right, toat for coat aminal or animal
Distortions-brlu for blue, crat for cat
Omissions- oke for joke, ining for signing
Additions- aluminininum for aluminum
Phonological Disorder
Repetitions & prolongation of sound, syllables or words, that interrupt the flow of speech
Occasional secondary characteristics or tics such as stamping the foot or throwing the head out to get the sound out.
Stuttering
what are 4 assessment issues in speech?
Concomitant retardation or learning disability
Dialect
Regionalism
Facial structure (cleft palate etc.)
what are the 5 pervasive developmental disorders that are
In DSM-V, these are subsumed under Autism Spectrum Disorder
Autistic Disorder
**Rett’s Disorder- **only in females;6 months of normal development, followed by regression
Childhood Disintegrative Disorder
At least 2 years of normal development, followed by regression
Asperger’s Disorder
PDD NOS (pervasive developmental disorder not otherwise specified)
Qualitative impairment in social interaction and social communication
Restricted repetitive and stereotyped patterns of behavior, interests, and activities
Symptoms are present in the early developmental period
Autism Spectrum Disorder
Parents may notice problems with social interaction in first few months of life
May not develop normal pattern of smiling or responding to cuddling
Failure to develop spoken language often leads parents to seek medical attention
Range from complete lack of speech to mildly deviant speech and language patterns
Intense and rigid commitment to maintaining specific routines
Autism Spectrum Disorder
70% show some evidence of mental retardation
25% have comorbid seizure disorder
Prevalence: 10-15 per 10,000 individuals
More common in males, 3:1 or 4:1
Only 2-3% are able to progress normally through school or live independently
Etiology unknown
No link to childhood immunizations has been proven
Early diagnosis and early intervention leads to best outcome
Universal screening at 18 months is recommended
Autism Spectrum Disorder (con’t)
how to do you tx autisim spectrum disorder?
Special education intervention
Speech and Language Therapies
Usually done by speech therapists
Social Skills Training
Sensorimotor Therapies
Usually done by occupational therapists
Intensive Behavior therapy
Start as early as possible
Home-based approach seems best
Pharmacotherapy
Does not alter the natural history and course of autistic disorder, but can be helpful in controlling specific symptoms (aggression, sleep problems, etc.)
Many categories of medications are used, including antipsychotics, SSRIS, stimulants, anticonvulsants, and alpha-adrenergic agonists
Often referred to as “mild,” “high-functioning” autistic disorder
Impairment in social interaction
Restricted, repetitive and stereotyped patterns of behavior, interests and activities
No clinically significant delay in language development
No clinically significant delay in cognitive development
Asperger’s Disorder
If an individual has marked deficits in social communication with no additional criteria of Autism Spectrum Disorder, consider evaluation for ________, a new disorder in DSM-
Social (Pragmatic) Communication Disorde
how is asperger’s diagnosed?
Asperger’s Disorder is no longer in DSM-V, but subsumed under Autism Spectrum Disorder. Autism Spectrum Disorder is diagnosed with specifiers:
Level of Severity
With or Without Intellectual Impairment
With or Without Language Impairment
all subtypes of:
Combined Type
Predominately Inattentive Type
Predominately Hyperactive-Impulsive Type
ADHD NOS
Attention-Deficit/Hyperactivity Disorder
Significant difficulty focusing and maintaining attention
Significant hyperactivity and impulsivity
Symptoms present for at least 6 months
Onset before age 7 (age 12 in DSM-V)
Impairment occurs in at least two settings
Attention-Deficit/Hyperactivity Disorder
-Frequent mistakes/Failure to pay close attention -Difficulty sustaining attention -Does not listen when spoken to directly -Fails to finish work/Does not follow instructions -Lacks organizational skills -Avoids sustained mental effort -Misplaces items -Easily distracted -Forgetful
ADHD- Primarily Inattentive
Often fidgets or squirms
Leaves seat
Difficulty being quiet in leisure activities
On the go, as if driven by a motor
Talks excessively
Shouts answers out of turn
Runs instead of walks
Difficulty waiting for turn
Interrupts or intrudes
ADHD – Primarily Hyperactive/Impulsive
Planning
Organizing
Starting and stopping activity
Managing behavior
Persisting on tasks
Problem solving
Working memory
Executive Functioning Deficits in ADHD
Lack of will power
Inadequate parenting
Lack of motivation
Lack of intelligence
Laziness
things that do not cause ADHD
3% – 10% of children
Male to Female ratio 3:1
Occurs in all cultures
ADHDEpidemiology
**ADHD prognsois **
At least half of all children with ADHD have a good outcome, completing school
Persistence into adolescence and adulthood
1/3 continue to meet full criteria
1/3 have some symptoms
1/3 full remission
Academic failure
Relationship problems
Legal difficulties
Smoking and Substance Abuse
Injuries
Motor vehicle accidents
Occupational/vocational problems
ADHD is associated with increased incidence of:
Girls have a stronger family history than boys
Associated with familial mood disorders, learning disorders, substance abuse, and antisocial personality disorder
Genes related to dopamine have been implicated
ADHD genetics
Maternal smoking, alcohol and drug abuse, complications during delivery, exposure to toxins, viral infections, maternal malnutrition
nongenetic factors relating to ADHD
neuroimaing in ADHD?
Not currently being used to diagnose ADHD or to guide treatment selection
this disorders are all examples of:
Oppositional Defiant Disorder (60%)
Anxiety Disorder
Depressive Disorder
Learning Disability
Conduct Disorder
Substance Use Disorder
ADHD Comorbidity
3 tx of ADHD?
Behavior Modification with child and parent(s)
Classroom/Workplace
Accommodations Medications
Preferential seating
Shorter assignments
Closer supervision
Clearer instructions
Help in getting started on assignments
Daily report card program
Allow time for movement
Extra set of books
Environment with fewer distractions during tests
Classroom Accommodationsfor ADHD
2 stimulants used for ADHD tx?
methylphenidate
amphetamine/dextroamphetamine
Atomoxetine (Strattera)
used in what?
ADHD
which two alpha adrenergic agonists used to tx ADHD?
clonidine (brand name: Catapres)
guanfacine (brand name:Tenex)
which two anti-depressants used for tx of ADHD?
bupropion (brand name: Wellbutrin)
tricyclic antidepressants
imipramine (brand name: Tofranil)
t/f. Treatment with stimulant medications has been associated with a decreased risk for substance abuse
true
4 ADEs for ADHD meds?
Decreased appetite (anorexia)- Most common side effect
Growth retardation
Tics
Black box warnings for high abuse potential and serious cardiovascular adverse events and sudden death
A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
often loses temper
often argues with adults
often actively defies or refuses to comply with adults’ requests or rules
often deliberately annoys people
often blames others for his or her mistakes or misbehavior
is often touchy or easily annoyed by others
is often angry and resentful
is often spiteful or vindictive
Oppositional Defiant Disorder
3%-15% of children
Male to Female ratio 3:1
Commonly comorbid with ADHD
Usually diagnosed before age 8, almost always before adolescence
Oppositional Defiant Disorder Epidemiology
A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated
Three (or more) criteria in the past 12 months; with at least one criterion present in the past 6 months
Childhood-onset type begins prior to age 10
Conduct Disorder
Often bullies, threatens, or intimidates others
Often initiates physical fights
Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
Has been physically cruel to people
Has been physically cruel to animals
Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
Has forced someone into sexual activity
Conduct Disorder Aggression to People & Animals
Destruction of Property, Deceitfulness or Theft, Serious Violation of Rules
Deliberate fire setting
Deliberately destroyed others’ property
Broken into someone else’s house, building, or car
Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
Has stolen without confronting a victim
Often stays out at night, beginning before age 13 years
Run away from home overnight at least twice
Is often truant from school, beginning before age 13 years
Conduct Disorder
6-16% in boys, 2-9% in girls
Ratio of males to females with conduct disorder: 3:1 - 12:1
- 2:1 status offenses
- 5:1 minor theft
- 5:1 robbery
Conduct Disorder Epidemiology
Conduct disorder can be a precursor to Antisocial Personality Disorder in adulthood
almost half of kids with CD develop significant APD symptoms
number of CD symptoms and early age of onset predict the development of APD
Conduct disorder may be associated with early death, unemployment, marital conflict, financial instability, and poor interpersonal relationships in adulthood
Conduct DisorderPrognosis
Conduct DisorderComorbidity
Learning Disorders
ADHD
Mood Disorder
Substance Abuse
Inconsistent discipline
Poor supervision
Low IQ
High family conflict
Low family warmth and supportiveness
Low parental acceptance and affection
Parental criminality, alcoholism, and drug abuse
Parental psychopathology
Risk factors for the Disruptive Behavioral Disorders
Behavior management training for parents and child
Social skills training
Problem solving skills
Conflict management
Multisystemic Therapy (MST)
Treatment for the Disruptive Behavior Disorders
three feeding and eating disorders
Pica
Persistent eating of nonnutritive substances for a period of at least 1 month
Rumination Disorder
Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning
Feeding Disorder of Infancy or Early Childhood
what are three tic disorders?
**Tourette’s disorder- **Both motor and vocal tic
Chronic Motor or Vocal Tic Disorder-Doesn’t meet criteria for Tourette’s because either motor or vocal tics are present, but not both
Transient Tic Disorder
Doesn’t meet criteria for Tourette’s because it hasn’t lasted long enough
Both multiple motor and one or more vocal tics occur during the illness, but not necessarily concurrently.
A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization
Tics occur many times a day 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
The onset is before 18 years
Not due to the direct physiological effects of a substance (e.g., stimulants), or a general medical conditions (e.g., Huntington’s disease or postviral encephalitis)
Tourette’s Disorder
Affects from 1 to 10 school children per 10,000 between the ages of 6 and 17
Up to 20% of children experience transient simple tics
Male-to-female ratio of 3:1
Motor tics typically begin between the ages of 3 and 8, several years before the appearance of vocal tics
Symptoms peak in adolescence
20% of people have a remission of symptoms in their 20’s
Tourette’s Disorder (con’t)
how do you tx tourette’s?
two alpha-adrenergic and two neuroleptics
a-adrenergic agents
clonidine
guanfacine
Neuroleptics
Haloperidol (brand name: Haldol)
Pimozide (brand name: Orap)
what are the two elimination disorders?
Enuresis
Chronological age of at least 5 years
Behavioral treatments
Enuresis alarms – THE MOST EFFECTIVE TREATMENT
Medications
Deamino-8-D-arginine vasopressin (DDAVP) or desmopressin
imipramine
Encopresis
Chronological age of at least 4 years
Treatment is more complex
what is the behavioral and medication tx for enuresis?
Behavioral treatments
Enuresis alarms – THE MOST EFFECTIVE TREATMENT
Medications
Deamino-8-D-arginine vasopressin (DDAVP) or desmopressin
imipramine
Separation Anxiety Disorder
Selective Mutism
Reactive Attachment Disorder
Stereotypic Movement Disorder
Disorder of Infancy, Childhood or Adolescence NOS
Other Disorders of Infancy, Childhood, or Adolescence
_______anxiety is a normal maturational experience – develops at 9 months
Separation
** is a level of anxiety beyond that expected for child’s developmental level**
Causes impairment
Lasts at least 4 weeks
Separation Anxiety Disorder
Three or more of the following:
Excessive distress when separation from home or major attachment figures occurs or is anticipated
Worry about losing, or about possible harm befalling, major attachment figures
Worry that an untoward event will lead to separation from a major attachment figure (such as kidnapping)
Reluctance or refusal to go to school or elsewhere because of fear of separation
Fearful of being alone or without major attachment figures
Reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
Repeated nightmares involving the theme of separation
Physical symptoms when separation is anticipated or occurs
Separation Anxiety DisorderCriteria
Consistent failure to speak in specific social situations, where there is an expectation for speaking, despite speaking in other situations
Children with __________often will speak at home but nowhere else
Prevalence: <1%
Selective Mutism
Disturbed and developmentally inappropriate social relatedness that begins before age 5
Associated with grossly pathological care
Inhibited: child fails to initiate and respond to social interactions in a developmentally appropriate way
Disinhibited: child exhibits indiscriminate sociability or a lack of selectivity in the choice of attachment figures
Reactive Attachment Disorder of Infancy or Early Childhood
Motor behavior that is repetitive, seemingly driven, and nonfunctional
Interferes with normal activities or results in self-inflicted bodily injury that requires medical treatment
Most commonly associated with Intellectual Disability
Stereotypic Movement Disorder
1- only in females;6 months of normal development, followed by regression
2.At least 2 years of normal development, followed by regression
1. Rett’s Disorder- only in females;6 months of normal development, followed by regression
2. Childhood Disintegrative Disorder
At least 2 years of normal development, followed by regression
- Persistent eating of nonnutritive substances for a period of at least 1 month
- Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning
Pica
Persistent eating of nonnutritive substances for a period of at least 1 month
Rumination Disorder
Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning
