PEDIATRIC MENTAL HEALTHAges 4-12

BRAIN AND BEHAVIOR

ADHDSubtypesPredominantly Inattentive TypePredominantly Hyperactive-Impulsive TypeCombined TypeNot Otherwise Specified

ADHD INATTENTIVE6 or more symptoms for at least 6 monthsFails to give close attention to details/makes careless mistakesDifficulty sustaining attention tasks/playDoes not listen when spoken to directlyPoor follow through on chores, duties, etc.Has difficulty organizingAvoids tasks that require mental effortFrequently loses itemsEasily distractedForgetful of daily activities

ADHD HYPERATIVE/IMPULSIVE6 or more for at least 6 monthsFidgets with hands or squirms in seatLeaves activities when expected to stay excessively motor active when inappropriateHas difficulty with leisure activities/being quietdriven by motor or often on the goTalks excessivelyBlurts out answersTrouble waiting for turnOften interrupts or intrudes on others

ADHDAt least some of the symptoms were obvious before the age of 7Impairment is seeing in two or more settingsImpairment must be clinically significant in social, occupational or academic setting

ADHD HISTORICAL TIMELINE

Minimal Brain Damage

1920s

Minimal Brain Dysfunction

1930s

Efficacy of Amphetamine

1937

Hyperactive Child Syndrome

1950

Hyperkinetic Reaction of Childhood (DSM-II)

1968

ADD or Hyperactivity (DSM-III)

1980

ADHD (DSM-III)

1987

ADHD (DSM-IV)

1994

ADHD FACTSPrevalence 10 % of school children(2% female 8% male)Most commonly diagnosed behavior disorder of children ages 6 - 12 years old in North America

ADHD RATING SCALESElementary SchoolChild Behavioral Checklist (CBCL)- Parent, Teacher, or Youth FormsConners Parent and Child Rating scales (CPRS and CTRS)SNAP (Swanson, 1988)Vanderbilt AD/HD Diagnostic Rating Scales

VIDEO CLIPhttp://www.pbs.org/wgbh/pages/frontline/shows/medicating/watch/

Robins Story

DISRUPTIVE BEHAVIOR DISORDERS

Conduct DisorderOppositional Defiant DisorderDisruptive Behavior D/O NOS

CONDUCT DISORDER(1)Aggression to People/AnimalsBullies, threatens or intimidatesInitiates physical fightsUsed weapon that can cause harmPhysically cruel to people/animalsHas stolen w/o confronting victimForced sexual activity

CONDUCT DISORDER(2)Destruction to PropertyDeliberate fire setting behaviorDeliberate destruction of property

CONDUCT DISORDER(3)Deceitfulness or theftBreaking into homes/carsLies to obtain goods or favors or to avoid obligationsStolen items of nontrivial nature w/o confronting a victim

CONDUCT DISORDER(4)Serious violations of rulesStays out later than approved by parentsHas run away from home two timesTruant from school, beginning before age 13

CONDUCT DISORDER(5)Behavior causes clinically significant impairment in functioningIf > age 18 criteria not met for Antisocial personality disorder

CONDUCT DISORDER(6)Childhood onset (sxs present prior to age 10)Adolescent onset (sxs absent prior to age 10)

OPPOSITIONAL DEFIANT D/OPattern of negative and hostile bxs for atleast 6 months (4+)Loses temperArgumentative with adultsDefies rulesDeliberately annoys peopleBlames others for his/her mistakesTouchy or easily annoyedAngry and resentfulSpiteful and vindictive

DISRUPTIVE BX D/OClinically significant impairment that does not meet criteria for ODD or CD.

TIC DISORDERSTourrettes DisorderChronic Motor of vocal Tic DisorderTransient Tic DisorderTic Disorder, NOS

TOURETTES DISORDERMultiple motor and 1 + vocal ticsTics occur throughout day, nearly every day for 1 yearTic causes marked distress/impairmentOnset before age 18

OTHER TIC DISORDERSChronic motor tic disorder: one or more motor tics for greater than one yearChronic vocal tic disorder: one or more vocal tics for greater than one yearTransient tic disorder: one or more tics for greater than 4 weeks but less than 12 monthsTic disorder NOS (not other wise specified)

MOOD DISORDERSBipolar DisorderMajor Depressive DisorderDysthymic Disorder

BIPOLAR DISORDER4 of 7Inflated self-esteem or grandiosityDecreased need for sleepIncreased talkativeness or pressureRacing thoughts or flight of ideasDistractibilityIncreased activity or psychomotor agitationExcessive involvement in consequential bxs.

Symptoms must last for one week

BP VS ADHD

Mania ItemBipolarADHDIrritable Mood97%72%Grandiosity85%7%Elevated Mood87%55%Daredevil Acts70%13%Uninhibited People Seeking68%21%Silliness/Laughing65%21%Flight of Ideas6%10%Accelerated Speech97%78%Hypersexuality45%8%

VIDEO CLIPhttp://www.pbs.org/wgbh/pages/frontline/parents/

The Medicated ChildDebate over BipolarJessicas Story

MAJOR DEPRESSIONDepressed or irritable moodAnhedoniaSleep difficultiesWeight or appetite changeDecreased concentrationThoughts of suicide or deathPsychomotor agitation or retardationFatigue or loss of energyFeelings of worthlessness/guilt

DYSTHYMIC DISORDERAppetite changeSleep changeDecreased energyLow self esteemDifficulty making decisionsFeelings of hopelessness

ANXIETY DISORDERSSeparation Anxiety DisorderGeneralized Anxiety Disorder (overanxious d/o)Reactive Attachment DisorderSpecific PhobiaSocial PhobiaPost Traumatic Stress Disorder

PREVALENCE OF PEDIATRIC ANXIETY DISORDERS

Anxiety Disorder

Children

Adolescents

Separation Anxiety Disorder

3.5 4.7%

0.7 2.0%

Generalized Anxiety Disorder

2.9 4.6%

5.9 7.3%

Social Phobia/Avoidant

0.9 1.6%

1.1%

Specific Phobia

2.4 9.2%

3.6 4.6%

Panic Disorder

SYMPTOMS OF ANXIETYCardiovascular RespiratorySkinMusculoskeletalGastrointestinalOther physicalPsychologicalSocial/Behavioral

Palpitation, ^bpSOB, ^ respirationFlushing, sweatyTemors, crampsDiarrhea, nauseaHA, chest painFears, stressClingy,

SEPARATION ANXIETY DISORDERExcessive distress during separationPersistent worry about harm, lossForecasting of harmful eventsReluctance to go places w/o parent/otherFear of being alone w/o parent/otherReluctance to go to sleep w/o parent/otherNightmare of separation themesSomatic complaints

GENERALIZED ANXIETY DISORDER

Excessive anxiety (X 6 months)Restlessness or feeling keyed upEasily fatiguedTrouble concentratingIrritabilityMuscle tensionSleep disturbance

REACTIVE ATTACHMENT DISORDERDevelopmentally inappropriate relatedness prior to age 5 AEBFailure to initiate or respond appropriately to social interactions/relationships (inhibited subtype)Indiscriminate sociability with attachment figures/strangers (disinhibited subtype)

SPECIFIC PHOBIAPersistent fear that is excessive or unreasonable Cued by specific object or situationResults in anxiety responseAvoidance leads to impairment of routine> than 6 months in duration for minors

COMMON PHOBIAS IN CHILDRENAnimalsBloodThunderDark StrangersFireGerms/dirtHeightsSpidersZoophobiaHematophobiaBrontophobiaNyctophobiaXenophobiaPyrophobiaMysophobiaAcrophobiaArachnophobia

SOCIAL PHOBIA/ANXIETYFear of performanceFear of unfamiliar people/situationsAfraid of scrutinyForecasts embarrassmentSituations are avoidedChildren will express with tantrums/tearfulness, freezing or shrinking

PTSD IN VERY YOUNG CHILDRENVery young children may present with few PTSD symptoms. This may be because eight of the PTSD symptoms require a verbal description of one's feelings and experiences. Instead, young children may report more generalized fears such as stranger or separation anxiety, avoidance of situations that may or may not be related to the trauma, sleep disturbances, and a preoccupation with words or symbols that may or may not be related to the trauma. These children may also display posttraumatic play in which they repeat themes of the trauma. In addition, children may lose an acquired developmental skill (such as toilet training) as a result of experiencing a traumatic event. Journal AACAP October 1998

Journal AACAP October 1998

POST TRAUMATIC STRESS DISORDER (1)Re-experiencing the traumatic eventNightmares/flashbacks/distressing memoriesRepetitive play with event related themesSudden catastrophic anxiety with cuesSense of reliving event (trauma re-enactement)Intense physiological/psychological distress with similar events

POST TRAUMATIC STRESS DISORDER (2)Avoidance or emotional numbnessEfforts to avoid thoughts/feelingsEfforts to avoid activities/placesLimited recall of aspects of traumaDiminished interest in activitiesFeelings of estrangement/detachmentRestricted affectSense of foreshortened future

POST TRAUMATIC STRESS DISORDER (3)Increased symptoms of arousalDifficulty with sleepIrritability/anger outburstPoor concentrationHypervigilanceExaggerated startle response

POST TRAUMATIC STRESS DISORDER (4)Symptoms present for more than one monthSymptoms cause impairment of functioning

PTSD IN MINORS14-43% of boys/girls have experienced at least one traumatic event in their life3 to 15% of girls and 1 to 6% of boys could be diagnosed with PTSD.

ADJUSTMENT DISORDERS(1)Onset of sxs related to stressorEither Marked distress (more than typical)Significant impairment in identified domain.

ADJUSTMENT DISORDER(2)Cannot be related to bereavementAcute-less than 6 months in durationChronic-more than 6 months in duration

ADJUSTMENT DISORDER(3)Subtypesw/ depressed moodw/ anxietyw/ anxiety and depressionw/ disturbance of conductw/ mixed emotions and conductunspecified

*Sxs must be maladaptive and cause functional difficulty*Sxs must be maladaptive and cause significant difficulty*Requires 3 items x12 months and one item x6 months*There are no published epidemiological studies of mania in prepubescent children*5/9 for 2 wks*Mood issues last for 1 yr w/o 2 months sx free--- must have sadness and 2 criteria*Three or more of the following/ early onset before age 6/ sxs must occur X4 wks prior to age 18/ functional disturbance*Also known as overanxious d/o of childhood, 3 or more of sxs, clinically significant distress*1 or more*3 or more*2 or more