CHILDHOOD PSYCHIATRIC DISORDERS
Dr. Shewikar El BakryAss. Prof. of Psychiatry
Objectives
Why childhood mental disorders What is mental disorder and warning
signs Why early intervention DSM V classification ADHD
Let us consider…….
Why is it important for parents, caregivers & professionals to know about children’s mental health?
One in five (21%) of children have a diagnosable mental, emotional, or behavioral disorder.
One in 10 suffer from a serious emotional disturbance.
70% of children, however, do not receive mental health services
Why?? “The prevalence of mental disorders
among children is predicted to rise in the next 15 years by 50%, becoming a major cause of morbidity, mortality and disability.”
Suicide is already:
4th leading cause of death between ages 10-14 years
3rd leading cause of death between ages 15-24 years
Why??
All children pass through a rough time at school, with friends or with their families.
Children can be stressed too. Development and life incidents
Brain development
Brain development depends on interaction between the brain cells and their immediate environment.
Both biological and psychosocial factors influence the development of the brain and brain disorders.
Stressful life events, injury, infection, malnutrition, exposure to toxins. childhood maltreatment may lead to mental health disorders.
Stigma Barrier
Negative attitudes and beliefs Fear, rejection, avoidance Disrespect and discrimination Discourages individuals and families from
getting the help they need
Definition of a Mental Disorder
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
There is usually significant distress or disability in social or occupational activities.
Recognize Warning signs
Consider three things if you suspect a child may be experiencing an emotional problem:Frequency: How often does the
child exhibit the symptoms?Duration: How long do they last?Intensity: How severe are the
symptoms?
Early intervention
Can reduce the effects an emotional or mental health disorder may have on children and their families.
Can lessen the duration and severity of the disorder.
Can help children learn positive coping strategies and prevent academic and social failure.
DSM V Neurodevelopmental Disorders Bipolar Disorders Anxiety Disorders Obsessive compulsive related disorders Trauma and stress related disorders Feeding and eating disorders Elimination disorders Sleep disorders Disruptive, Impulse control and conduct
disorders Others
Most common pediatric mental health disorders include: Anxiety disorders (most common) Mood disorders Attention Deficit Hyperactivity Disorders Autism Spectrum Disorders Conduct Disorders Eating Disorders Substance abuse
DSM-IV-TRThe five axes of the DSM-IV-TR.
Axis I Clinical syndromes. (All mental disorders & criteria for rating them except personality disorders/mental retardation, also abuse/neglect)
Axis II Personality disorders, Mental retardation. (Life long deeply ingrained, inflexible & maladaptive)
Axis III General medical condition. (Any medical condition that could effect the patients mental state.)
Axis IV Psychosocial & environmental problems. (Stressful events that have occurred within the previous year)
Axis V global assessment functioning. (How well the patient performed during the previous year)
WHY study ADHD
Symptoms affect all areas of life – academic, social, cognitive and behavioral performance.
Symptoms persist to adulthood in 60-70% Children, adolescents, and adults with ADHD are
at greater risk for experimentation with and abuse of alcohol and drugs, school and job failure, and accidental injuries.
Effective treatment is indirect & adult dependent
Attention-Deficit/HyperactivityDisorder:A Chronic Disorder
♦ADHD is a common neurobehavioral disorder of childhood.
♦Symptoms persist into adolescence andadulthood for majority of patients. ♦Hyperactivity and impulsivity may
diminish at a higher rate than inattention.
ADHD KEY SYMPTOMS
•Must have symptoms for at least 6-Months
•Symptoms must be present prior to age 7
•Impairment Across Settings (2 or more) •Evidence of significant functional
impairment •Symptoms are extremes of normal
behavior
ADHD: Hyperactive/Impulsive
fidgets or squirms can’t stay seated restless loud, noisy always “on the go” talks excessively blurts out impatient intrusive
Often…
ADHD: Inattentive
Appears to not be listening Follows through poorly on
obligations Disorganized Dislikes sustained mental effort Loses needed objects Easily distracted Forgetful Careless errors, inattentive to
detail Sustains attention poorly
Often…
Typical Vulnerabilities
Low self esteem Humiliation Feeling “dumb” Always “in trouble” Quick to lie about behavior Become defensive Feel defeated
Other ADHD qualities
Sometimes work harder at avoiding work than actually doing it
Academic progress is often a roller coaster – up and down all year
Moody Really do want to do well Frustration
Strengths and “Gifts”
Creative Charming Funny Social Sensitive and caring Hyperfocus Enthusiasm
What's it like to have ADHD_.mp4
How to Recognize ADHD Symptoms in Children.mp4
Incidence 5% (one out of twenty) children. 30% to 70% of these cases persist
into adulthood. Often have ADHD children.
Most common psychiatric disorder of childhood.
Often misdiagnosed as an anxiety disorder, manic state, or personality disorder.
ADHDEtiology
ADHD is a heterogeneous behavioral disorder with multiple possible etiologies
CNS = Central Nervous System
Neuroanatomic Neurochemical
Genetic Origins
Environmental Factors
CNS Insults
ADHD
What Causes AD/HD?(we’re not really sure)What we do know It is a “brain-based” disorder the basis of which is
largely genetic – likely due to multiple interacting genes
Some cases may be caused by external factors such as prenatal or perinatal complications or exposures
Dietary factors – continuing area of research Several differences in structure and function ofprefrontal and frontal cortices and basal ganglia have
been shown. Possible increase of norepinephrine with
decrease of inhibition by dopamine
ADHD: Current Working Theory
Symptoms of ADHD are caused by
abnormality in the Executive Function of the brain.
Brain Regions Implicated in ADHD
Prefrontal CortexFrontal LobesLimbic SystemBasal Ganglia
Caudate nucleusCerebellum
AnxietyAnxietyDisorderDisorder
(35%)(35%)
ADHDADHD
CONDUCT (10%) CONDUCT (10%) OppositionalOppositional
Disorder (40-50%)Disorder (40-50%)
MoodMoodDisorderDisorder(5-25%)(5-25%)
Comorbidity Comorbidity Is Common With ADHDIs Common With ADHD
ADHD Only (50%)ADHD Only (50%)
Tools
1. Compliant: onset course duration 2. History : Developmental Medical Family Social 3. Rating scales: Conner’s BASC CBC Vanderbilt SNAP Re evaluate with no improvement or
worsening
ADHDRating Scales
Preschool The Early Childhood Attention Deficit Disorder Evaluation
Scale (ECADDES) Elementary School
Child Behavioral Checklist (CBCL) - Parent, Teacher, or Youth forms
Conners Parent and Teacher Rating Scales (CPRS and CTRS)
Adolescent Conners/Wells Adolescent Self Report of Symptoms
(CAAS) Adolescent Symptom Inventory-4 (ASI-4)
Adults Conners Adult Attention-Deficit Rating Scale (CAARS)
ADHDComponents of Treatment
Education
Medical Interventions
Psychosocial Interventions
Treatments
Behavioral Management: helps patients change or control their ADHD behaviors. Identifies unwanted behaviors and helps to replace them.
Counseling: Helps patients and families identify unwanted behaviors and teaches how to cope with and change them. Can also help with low-self esteem, depression and stubborn behaviors.
Medication: different medications help to improve symptoms so your child can manage better at home, at school, and with friends. Is most helpful when combined with behavioral management and counseling.
Medication Classes
Stimulants Stimulants are the best studied medications in
child & adolescent psychiatry
Antidepressants Antihypertensives Wake-promoting agent used in
narcolepsy
Stimulants First line medication treatment of ADHD
Approximately 70% of children will respond to the first stimulant prescribed
Up to 90% respond to the first or second stimulant attempted
Do NOT “make” children perform better – he/she has to do the work themselves Helps improve executive functioning so they
can successfully complete work
Why give a stimulant to a hyperactive child?
Work by “stimulating” the brain to make more of the neurotransmitters (brain chemical) that help focus attention, control impulses, organize and plan, keep with routines
Increase dopaminergic and noradrenergic activity in frontal cortex (responsible for executive functioning)
Research shows other treatments are more likely to work if the child is taking a stimulant
Medications
Ritalin: (Methylphenidate): helps increase attention span during the day, helps with staying on task, and helps with rapid ADHD morning symptom control so it is
easier to start the day
Dexedrine (Dextroamphetamine): Stimulant Also helps with attention, disruptive behavior and
relationship problems*other medications include Adderall, Straterra, Concerta and
Wellbutrin
Atomoxitine (Strattera)
A noradrenergic reuptake inhibiter that appears to have relatively good effectiveness in decreasing levels of hyperactivity and in helping with increasing attention, concentration, and organization. It has been approved for use in children as young as 6 years old weighing above forty pounds. It generally has lasting effects throughout the day and into the evening. Problems have included changes in appetite and also nausea along with some sleep problems
Atomoxetine (Strattera)
Good points 24 hour coverage, once a day Not abusable
May help co morbid anxiety
Maintains a blood level and dosing can be adjusted
Side effects limited with slower titration
ADHDBupropion (Wellbutrin®)
Advantages may decrease
hyperactivity and aggression
may improve cognitive performance
Double-blind, placebo- controlled studies demonstrate effectiveness
Disadvantages Not as effective as
stimulants for cognitive symptoms
Available dosage forms inappropriate for younger children
may decrease seizure threshold
may exacerbate tics
4.
ADHDClonidine (Catapres®)
Advantages may be useful to
treat very hyperactive or aggressive patient
improves ability to fall asleep
Disadvantages clinical effects may take
several weeks does not affect inattention
symptoms sedation risk of adverse CV effects,
depression, and decreased glucose tolerance
Guanfacine (Tenex®) has a more favorable side-effect profile than clonidine but has only been studied in open trials.
.
Texas Medication Algorithm Project: ADHD Without Comorbidity
Stage 0: Assessment, discussion of treatment alternatives
Stage 1: Monotherapy: Amphetamine vs. Methylphenidate
Stage 2: Monotherapy: Stimulant not used in Stage 1
Stage 3: Monotherapy: Alternate class (Cylert®)-q 2 week LFT’s
Stage 4: Buproprion, Nortryptyline, Imipramine
Stage 5: Antidepressant not used in Stage 4
Stage 6: Alpha-agonists, monitoring cardiovascular status
ADHDPsychosocial Interventions
House rules Appropriate commands (specific, clear, positive) Ignore mild inappropriate behaviors and praise
positive behavior Contingency management with positive
reinforcement (eg, a point chart) and prudent negative consequences (eg, privilege loss)
Behavioral “contracting” in adolescent children
.
Parent TrainingParent Training
ADHDPsychosocial Interventions
Largely employ techniques taught in parent training Daily behavioral report cards
serve to define target behaviors facilitate school-home communication and allow parents to
provide rewards for good school behavior and performance Special classroom accommodations
clearly and consistently posting daily schedules breaking assignments into smaller chunks providing rewards for task completion and consequences
for rule violations
School Interventions
School Interventions
.
ADHDPsychosocial Interventions
Sometimes used to teach the child skills needed in peer relationships and other settings
Interaction skills Conflict resolution Problem-solving skills Anger management
Results of studies of this strategy are inconsistent More effective when taught in group settings such
as summer camps, school-based, and after-school settings
.
Social Skills Training
Behavioral Management
Basic Principles: – The “ABC’s” – Antecedent, Behavior,Consequences – Parents and teachers can intervene in
the antecedent event and set consequences to change behavior.
– Baby steps: Pick one behavior or habit at a time to work on and build up
Behavioral Modification
Topics addressed in Parent Training “Establishing house rules and structure Learning to praise appropriate
behaviors…and ignoring mild inappropriate behaviors (choosing your battles)
Using appropriate commands Using “when…then” contingencies(withdrawing rewards or privileges inresponse to inappropriate behavior)
Planning ahead and working with children in public places
Time out from positive reinforcement (using time outs as a consequence for inappropriate behavior)
Daily charts and point/token systems with rewards and consequences
School-home note system for rewarding behavior at school and tracking homework”
Family Coping with ADD/ADHD
Create a routine Help your adolescent organize Avoid distractions Limit choices Change your interactions Use goals and rewards Help your teen discover a talent
DAILY GOAL
MY GOAL FOR TODAY IS:
Effective Participation in Classroom InstructionDIRECTIONS FOR MY GOAL…. I WILL:
•Raise my hand before answering questions•Look at my teacher when she is talking to the class
•Stay at my desk until given permission to move•Listen without talking to others
DAILY CHECK-IN TO DESCRIBE HOW I DID…….I think that my performance today:
NEEDS IMPROVEMENT 1 2 3 WAS THE BEST My Teacher thinks that my performance today:NEEDS IMPROVEMENT 1 2 3 WAS THE BEST
Tomorrow I will____________________________ :Teacher’s Signature & Comments ___________:
__________________________________
Conclusions ADHD is a valid disorder ADHD is universally found ADHD largely results from biological factors
Genetics, neurology, acquired injuries and interactions ADHD is a disorder of inhibition and executive
functioning (self-regulation), not merely attention Social environment important for its impact on
creating prosthetic environments, reducing impairment, affecting comorbidity and resource availability
ADHD can be successfully managed as a disorder of EF leading to improved life course and outcomes
THANK YOU
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