Psychiatric Disorders in Children Flashcards
What are the 4 sources to consult in child psychiatry?
What kind of information do they report?
-
The child
- Report info in concrete terms
- Give accurate details about emotional states
-
Parents
- More reliable for info about conduct, school performance, problems w/ law
- Child’s developmental hx & issues w/ other family members (medical/psychiatric conditions, problems in family function, etc)
-
Teachers
- Child’s conduct, academic performance, peer relationships
-
Child welfare/juvenile justice
- If applicable
What are 4 other methods of gathering information?
-
Play, stories, drawing
- Help to assess conceptualization, internal states, experiences, etc.
-
Kaufman Assessment Battery for Children (K-ABC)
- Intelligence for ages 2.5 to 12
-
Weschler Intelligence Scale for Children-Revised (WISC-R)
- Determines intelligence quotient (IQ) for ages 6 to 16
-
Peabody Individual Achievement Test (PIAT)
- Tests academic achievement
What is the DSM-IV criteria for mental retardation?
- Significantly subaverage intellectual functioning w/ an IQ of 70 or below
- Deficits in adaptive skills appropriate for the age group
- Onset must be before the age of 18
Mental Retardation
- Prevalence: ___%
- Mild vs. Severe
- Men vs. Women
- Prevalence: 2.5%
- 85% mild cases
- Males 2x affected as females
What are the 4 subclassifications of mental retardation?
-
Profound
- IQ <25
- 1-2% of MR
-
Severe
- IQ 25-40
- 3-4% of MR
-
Moderate
- IQ 40-50
- 10% of MR
-
Mild
- IQ 50-70
- 80% of MR
What are 4 causes of mental retardation?
- Genetic
- Prenatal: infection & toxins (TORCH)
- Perinatal
- Postnatal
What are genetic causes of mental retardation?
-
Down’s syndrome
- Trisomy 21 (1/700 live births)
-
Fragile X syndrome
- 2nd most common cause of retardation
- Involves mutation of X chromosome
- Males >> females
- Many others
What are prenatal causes of mental retardation?
TORCH
- Toxoplasmosis
- Other (syphilis, AIDS, alcohol/illicit drugs)
- Rubella (German measles)
- Cytomegalovirus (CMV)
- Herpes simplex
What are perinatal causes of mental retardation?
- Anoxia
- Prematurity
- Birth trauma
What are postnatal causes of mental retardation?
- Hypothyroidism
- Malnutrition
- Toxin exposure
- Trauma
Always rule out __________ in the workup before diagnosing learning disorders.
hearing or visual deficit
What is the DSM-IV criteria for a learning disorder?
- Achievement in reading, mathematics, or written expression that is significantly lower than expected for chronological age, level of education & level of intelligence
- Affect academic achievement or daily activities
- Cannot be explained by sensory deficits, poor teaching, or cultural factors
- Often due to deficits in cognitive processing (abnormal attention, memory, visual perception, etc.)
What are the 4 types of learning disorders?
- Reading disorder
- Mathematics disorder
- Disorder of written expression
- Learning disorder not otherwise specified (NOS)
Reading Disorder
- ___% of school-age children
- Boys vs. girls
- 4% of school age children
- Boys 3-4x as often as girls
Mathematics Disorder
- ___% of school-age children
- Boys vs. girls
- 5% of school-age children
- May be more common in girls
Disorder of Written Expression
- ___% of school-age children
- Boys vs. girls
- 3-10% of school-age children
- Male to female ratio unknown
What is the etiology and treatment of learning disorders?
- Etiology
- Genetic factors, abnormal development, perinatal injury, neurological or medical conditions
- Treatment
- Remedial education tailored to child’s specific needs
What are the disruptive behavioral disorders?
- Conduct disorder
- Oppositional defiant disorder
What is the DSM-IV criteria for conduct disorder?
- Pattern of behavior that involves violation of the basic rights of others or of social norms & rules, with at least 3 acts w/i the following categories during the past year:
- Aggression toward people & animals
- Destruction of property
- Deceitfulness
- Serious violations of rules
_______ is the most common diagnosis in outpatient child psychiatry clinics.
Conduct disorder
Conduct Disorder
- Prevalence: ___%
- Etiology involves…?
- ___% risk of developing antisocial personality disorder in adulthood
- Prevalence
- 6-16% boys
- 2-9% girls
- Etiology involves genetic & psychosocial factors
- Up to 40% risk of developing antisocial personality disorder in adulthood
If a child has conduct disorder, they have increased incidence of what disorders/behavior?
- Comorbid ADHD & learning disorders
- Comorbid mood disorders, substance abuse, criminal behavior in adulthood
How is conduct disorder treated?
- Multimodal treatment approach most effective
- Structure child’s environment w/ firm rules that are consistently enforced
- Individual psychotherapy that focuses on behavior modification & problem-solving skills
-
Adjunctive pharmacotherapy
- Antipsychotics or lithium for aggression
- SSRIs for impulsivity, irritability, mood lability
What is the DSM-IV criteria for Oppositional Defiant Disorder (ODD)?
At least 6 mo of negativistic, hostile & defiant behavior during which at least 4 of the following have been present:
- Frequent loss of temper
- Arguments w/ adults
- Defying adults’ rules
- Deliberately annoying people
- Easily annoyed
- Anger & resentment
- Spiteful
- Blaming others for mistakes or misbehaviors
Oppositional Defiant Disorder
- Prevalence: ___%
- Age of onset
- Boys vs. girls
- Prevalence: 16-22% in children >6 yo
- Begins by age 8
- Onset before puberty: boys >> girls
- Onset after puberty: boys = girls
If a child has oppositional defiant disorder, they have increased incidence of what disorders/behavior?
How many children have remissions?
- Increased incidence of comorbid substance abuse, mood disorders, ADHD
- Remits in 25% of children
- May progress to conduct disorder
How is ODD treated?
- Individual psychotherapy that focuses on:
- Behavior modification
- Problem-solving skills
- Parental skills training
2/3 of children with _____ also have conduct disorder or oppositional defiant disorder.
ADHD
What are the 3 subcategories of ADHD?
- Predominantly inattentive type
- Predominantly hyperactive-impulsive type
- Combined type
What is the DSM-IV criteria for ADHD?
- At least 6 symptoms involving inattentiveness, hyperactivity or both that have persisted for at least 6 months
- Inattention - problems listening, concentrating, paying attention to details or organizing tasks; easily distracted, often forgetful
- Hyperactivity-impulsivity - blurting out, interrupting, fidgeting, leaving seat, talking excessively, etc.
- Onset before age 7
- Behavior inconsistent w/ age & development
The etiology of ADHD is multifactorial, including….
-
Genetic factors
- Monozygotic twins > dizygotic twins
-
Prenatal trauma/toxin exposure
- Fetal alcohol syndrome
- Lead poisoning
-
Neurochemical factors
- Dysregulation of peripheral & central noradrenergic systems
-
Neurophysiological factors
- Abnormal EEG patterns
- Positron-emission tomography scans
-
Psychosocial factors
- Emotional deprivation
How is ADHD treated?
- Pharmacotherapy
- Individual psychotherapy
- Behavior modification techniques
- Parental counseling
- Education & parental skills training
- Group therapy
- Help pt improve social skills, self-esteem
What specific pharmacotherapy is used to treat ADHD?
-
CNS stimulants
- First line: Methylphenidate (Ritalin)
- Dextroamphetamine (Dexedrine)
- Pemoline (Cylert)
-
SSRIs/TCAs
- Adjunctive therapy
What are pervasive developmental disorders (PDD)?
- Group of conditions that involve problems with social skills, language & behaviors
- Impairement noticeable at early age of life
- Involves multiple areas of development
What are examples of pervasive developmental disorders (PDD)?
- Autistic disorder
- Asperger’s disorder
- Rett’s disorder
- Childhood distintegrative disorder
What is the DSM-IV criteria for Autistic Disorder?
-
Problems with social interaction (at least 2)
- Impairement in nonverbal behaviors (facial expression, gestures, etc)
- Failure to develop peer relationships
- Failure to seek sharing of interests or enjoyment with others
- Lack of social/emotional reciprocity
-
Impairments in communication (at least 1)
- Lack of or delayed speech
- Repetitive use of language
- Lack of varied, spontaneous play, and so on
-
Repetitive & stereotyped patterns of behavior & activites (at least one)
- Inflexible rituals
- Preoccupation w/ parts of objects, and so on
Autistic Disorder
- Prevalence: ___%
- Boys vs. Girls
- Inheritence?
- 0.02-0.05% in children under age 12
- Boys 3-5x higher incidence than girls
- Some familial inheritance
What conditions are autistic disorder association with?
- Fragile X syndrome
- Tuberous sclerosis
- Mental retardation
- Seizures
What is the age of onset for autism?
What percent of autistic pts have mental retardation?
- May be apparent at an early age due to delayed developmental milestones (social smile, facial expression)
- Almost always begins before age 3
- 70% of pts are mentally retarded (IQ <70)
- 1-2% can function completely independently as adults
What is the etiology of autism?
- Prenatal neurological insults (infections, drugs)
-
Genetic factors
- 36% concordance rate in monozygotic twins
- Immunological & biochemical factors
How is autistic disorder treated?
- Remedial education
- Behavioral therapy
- Neuroleptics
- Help control aggression, hyperactivity, mood lability
- SSRIs
- Adjunctive therapy to help control stereotyped & repetitive behaviors
- Some children benefit from stimulants
What is the DSM-IV criteria for Asperger’s Disorder?
-
Impaired social interaction (at least 2)
- Failure to develop peer relationships
- Impaired use of nonverbal behaviors (facial expression, gestures, etc.)
- Lack of seeking to share enjoyment or interests w/ others
- Lack of social/emotional reciprocity
- Restricted or stereotyped behaviors, interests or activities (inflexible routines, repetitive movements, preoccupations, etc.)
Unlike autistic disorder, children with Asperger’s disorder have normal ________ & ________.
language
cognitive development
Asperger’s disorder
- What is the incidence?
- Boys vs. Girls
- Incidence unknown
- Boys > girls
What is the etiology of Asperger’s disorder?
- Unknown etiology
- May involve genetic, infectious or perinatal factors
How is Asperger’s disorder treated?
- Supportive treatment
- Similar to autistic disorder
- Social skills training & behavior modification techniques may be useful
What is the typical patient population of Rett’s disorder?
What is the time course for cognitive development?
- Seen only in girls
- Early development appears normal
- Diminished head circumference & stereotyped hand movements eventually ensue
- Cognitive development never progresses beyond that of the first year of life
What are the 9 things Rett’s disorder is characterized by?
- Normal prenatal & perinatal development
- Normal psychomotor development during the first 5 mo after birth
- Normal head circumference at birth, but decreasing rate of head growth btwn ages of 5 & 48 months
- Loss of previously learned purposeful hand skills btwn ages 5 & 30 months, followed by development of stereotyped hand movements (hand wringing, hand washing, etc.)
- Early loss of social interaction, usually followed by subsequent improvement
- Problems w/ gait or trunk movements
- Severely impaired language & psychomotor development
- Seizures
- Cyanotic spells
Rett’s disorder
- Age of onset
- Boys vs. Girls
- Prevalence
- Genetic testing?
- Onset btwn age 5-48 months
- Girls predominantly
- Boys have variable phenotype
- Developmental delay
- Many die in utero
- Rare
- Genetic testing available
What is the etiology & treatment of Rett’s Disorder?
- MECP2 gene mutation on X chromosome
- Supportive treatment
What is the DSM-IV criteria for Childhood Disintegrative Disorder?
- Normal development in the first 2 yrs of life
-
Loss of previously acquired skills in at least 2 of the following areas:
- Language
- Social skills
- Bowel or bladder control
- Play
- Motor skills
-
At least 2 of the following
- Impaired social interaction
- Impaired use of language
- Restricted, repetitive & stereotyped behaviors & interests
Childhood Disintegrative Disorder
- Age of onset
- Boys vs. Girls
- Incidence
- Onset age 2-10
- Boys 4-8x higher than girls
- Rare
What is the etiology & treatment of Childhood Disintegrative Disorder?
- Etiology unknown
- Treatment supportive (similar to autistic disorder)
What are tics?
What tics are Tourette’s disorder characterized by?
- Tics: involuntary movements or vocalizations
- Tourette’s disorder
- Most severe tic disorder
- Multiple daily motor/vocal tics w/ onset before age 18
- Vocal tics may appear yrs after motor tics
What are some examples of motor tics & vocal tics?
- Motor tics
- Involved the face & head
- Example: blinking of the eyes
- Vocal tics
- Copralalia: repetitive speaking of obscene words (uncommon in children)
- Echolalia: exact repetition of words
True or False
Both motor & vocal tics must be present to diagnose Tourette’s disorder
True
The presence of exclusive motor or vocal tics suggests a diagnosis of motor tic disorder or vocal tic disorder
What is the DSM-IV criteria for Tourette’s Disorder?
- Multiple motor & vocal tics (both must be present)
- Tics occur many times a day, almost every day for >1 year (no tic-free period >3 mo)
- Onset prior to age 18
- Distress or impairment in social/occupational functioning
Tourette’s Disorder
- Prevalence: ___%
- Boys vs. Girls
- Age of onset
- High co-morbidity with what conditions?
- 0.05% of children
- Boys 3x more than girls
- Onset btwn ages 7-8
- High co-morbidity w/ OCD & ADHD
What is the etiology of Tourette’s Disorder?
-
Genetic factors
- 50% concordance rate in monozygotic vs. 8% in dizygotic twins
-
Neurochemical factors
- Impaired regulation of dopamine in the caudate nucleus (possibly impaired recognition of endogenous opiates & the noradrenergic system)
How is Tourette’s Disorder treated?
- Pharmacotherapy
- Dopamine receptor antagonists
- Haloperidol
- Pimozide
- Dopamine receptor antagonists
- Supportive psychotherapy
The great majority of cases of enuresis spontaneously remit by age ___.
7
What is enuresis?
What should be ruled out before diagnosis?
- Urinary continence established before age 4
- Enuresis: involuntary voiding of urine
- Rule out medical conditions
- Urethritis
- Diabetes
- Seizures
What are the 4 types of enuresis?
-
Primary
- Child never established urinary continence
-
Secondary
- Manifestation occurs after a period of urinary continence, most commonly btwn ages 5-8
-
Diurnal
- Includes daytime episodes
-
Nocturnal
- Includes nighttime episodes
What is the DSM-IV criteria for Enuresis?
- Involuntary voiding after age 5
- Occurs at least 2x/wk for 3 mo or with marked impairment
What is the prevalence of Enuresis?
7% of 5-year-olds
prevalence decreases w/ age
What is the etiology of enuresis?
- Genetic predisposition
- Small bladder or low nocturnal levels of antidiuretic hormone
- Psychological stress
How is Enuresis treated?
- Behavior modification
- Example: buzzer that wakes child up when sensor detects wetness
- Pharmacotherapy
- Antidiuretics (DDAVP)
- TCAs (imipramine)
What is Encopresis?
What should be ruled out before diagnosis?
- Bowel control normally achieved by age 4
- Bowel incontinence can result in rejection by peers & impairement of social development
- Rule out
- Metabolic abnormalities (hypothyroid)
- Lower GI problems (anal fissure, IBD)
- Dietary factors
What is the DSM-IV criteria for Encopresis?
- Involuntary or intentional passage of feces in inappropriate palces
- Must be at least 4 yo
- Has occured at least 1x/mo for 3 mo
Encopresis
- Prevalence: ___%
- (increases/decreases) w/ age
- Associated w/ what psychiatric conditions
- 1% of 5-year-old children
- Incidence decreases w/ age
- Associated w/ conduct disorder & ADHD
What is the etiology of encopresis?
- Psychosocial stressors
- Lack of sphincter control
- Constipation w/ overflow incontinence
How is encopresis treated?
- Psychotherapy, family therapy, behavioral therapy
- Stool softeners (if etiology is constipation)
What is selective mutism?
What is the epidemiology? How is it treated?
- Rare condition, girls >> boys
- Not speaking in certain situations (like school)
- Onset age 5-6
- May be preceded by a stressful life event
- Treatment
- Supportive psychotherapy
- Behavior therapy
- Family therapy
What is the clinical presentation of separation anxiety disorder?
- Excessive fear of leaving one’s parents or other major attachment figures
- Children may…
- Refuse to go to school or sleep alone
- Complain of physical symptoms
- When forced to separate, they become extremely distressed & may worry excessively about losing their parents forever
Separation Anxiety Disorder
- Prevalence: ___%
- Age of onset
- How do parents react?
- Treatment
- Up to 4% of school-age children
- Boys = girls
- Onset around age 7, may be preceded by stressful life event
- Parents often afflicted w/ anxiety disorders & may ex
What does child abuse include?
What should doctors do when they know abuse is occuring?
- Physical abuse, emotional abuse, sexual abuse, neglect
- Doctors are legally required to report all cases of suspected child abuse to appropriate social service agencies
- Children may be admitted to the hospital w/o parental consent in order to protect them
Adults who were abused as children have an increased risk of developing…..
- Anxiety disorders
- Depressive disorders
- Dissociative disorders
- Substance abuse disorders
- Posttraumatic stress disorder
- Increased risk of abusing their own children
Who does child sexual abuse most commonly involve?
What is the most common age?
What is the prevalence?
- Male who knows the child
- Existence of true pedophilia in abuser rare
- Most common btwn ages 9-12
- Report being sexually abused as children
- Women 25%
- Men 12%
What is evidence of sexual abuse in a child?
- Sexually transmitted diseases
- Anal or genital trauma
- Knowledge about specific sexual acts (inappropriate for age)
- Initiation of sexual activity w/ others
- Sexualy play with dolls (inappropriate for age)
