Transcript Child Psychiatry

History:
Chief complaint, present illness, developmental
his., psychiatric his., medical his., family social
his. & parents’ marital status, educational his. &
current school functioning, peer relationship ,
current family functioning, family psychiatric &
medical his.
Physical examination
Neuropsychiatric examination
Physical appearance, parent-child
interaction, separation & reunion,
orientation to TPP, speech & language,
mood, affect, thought process & content,
social relatedness, motor behavior,
cognition, memory, judgment & insight.
MR is the result of a pathological process in the
brain characterized by limitations in intellectual
and adaptive function.
According to DSM-4-TR:MR is significantly sub
average general intellectual functioning resulting
in, or associated with, concurrent impairment in
adaptive behavior & manifested during the
developmental period, before the age of 18.
Mild MR (IQ of 55 to 70):
The largest group of people with MR (about 85% of
all persons with retardation).
Appear similar to nonretarded. Many achieve
academic skills at the 6th grade or higher, and
some graduate from high school. Many of them
hold jobs, and marry, but may appear slow or
need extra help for life’s problems & tasks.
Moderate MR ( IQ of 40 to 55):
Approximately 10% of all MR population.
People with more impaired cognitive & adaptive
functioning.
Typically diagnosed in their preschool years.
Require special education services, achieving academic
skills at the second to third grade level.
Need for supportive services throughout life.
Severe MR (IQ of 25 to 40 ):
Occurs in 3% to 4% of MR population.
Often have one or more organic causes for their delay, &
many show concurrent motor, ambulatory, and
neurological problems.
Most of them require close supervision & specialized
care throughout their lives.
Some of them learn to perform simple tasks & facilitate
their self-care.
Profound MR (IQ of 25 and below)
Affects 1% to 2% of MR population.
Pervasive deficits in cognitive, motor, & communicative
functioning. Impairments in sensory-motor functioning are
often seen from early childhood, & most individuals require
extensive training to complete even the most rudimentary
aspects of self-care, such as eating & toileting.
Show organic causes for their delay & need total supervision &
care throughout life.
Parental cause:
Genetic dis. (Down syndrome, phenylketonuria & other
metabolic dis., fragile X syndrome, …)
Congenital malformations (neural tube defects)
Exposure (congenital rubella, fetal alcohol syn.,
radiation, trauma)
Perinatal cause:
infections, delivery problem (asphyxia)
Postnatal causes:
Infections, toxins( Encephalitis, lead poisoning,
traumas, …)
A group of conditions in which there are
delay & deviance in the development of
social skills, language & communication,
and behavioral repertoire.
Unusual intense interest in a narrow range
of activities, resist change, & are not
appropriately responsive to the social
environment.
Affect multiple areas of development, are
manifested early in life, and cause
persistent dysfunction.
Sustained impairment in comprehending & responding to social
cues, aberrant language development & usage, and restricted,
stereotypical behavioral patterns.
Prevalence:0.05%,
4-5 time more frequent in boys.
The onset is before the age of 3, but in some cases, recognized
until a child is much older.
Patient with IQs above 70 and those who use communicative
language by age 5 to 7 tend to have the best prognosis.
About two thirds of autistic adults remain severely
handicapped & are completely dependent or semidependent.
A development of several specific deficits following a period of
normal functioning after birth.
Normal growth & development in first 6 months after birth,
between 6m to 2y of age, develop progressive encephalopathy
with characteristic features (loss of purposeful hand
movements, replaced by stereotypic movements, loss of
previously acquired speech, psychomotor retardation, and
ataxia, decrease head-circumference growth ( cause
microcephaly) .
Prevalence: 6-7 per 100000 girls.
It is progressive and patient who live into adulthood remain at
a cognitive & social level equivalent to that in the first year of
life.
Persistent pattern of inattention &/or hyperactive
and impulsive behavior that is more severe than
expected in children of that age & level of
development.
To meet the diagnostic criteria of ADHD, some
symptoms must be present before the age of 7y,
although many children are not diagnosed until
they are older than 7y ( cause problems in school).
Symptoms must be present in at least 2 settings.
Incidence:2%-20% of school children.
More prevalent in boys.
Symptoms are present by age 3y, but
diagnosis is made later.
Infancy:
Sensitive to stimuli & easily upset by noise, light,
temperature, & other environmental changes. Sleep little
& cry a great deal (some times reverse, sleep much of
the time, and develop slowly).
School age:
Unable to wait, impulsive response & behavior,
explosive or irritable, emotionally labile, inability to
delay gratification, accident-prone, hyperactivity,
attention deficit (distractibility, failure to finish tasks,
poor concentration)
Course is variable. Symptoms may persist into adolescence or
adult life(15%-20%), they may remit at puberty, or hyperactivity
may disappear, but the decrease attention span & impulse
control problems persist.
Over activity is usually the first symptom to remit, &
distractibility is the last.
Children whose symptoms persist into adolescence are at risk
for developing conduct disorder.
Children with both ADHD & conduct dis. Are also at risk for
substance-related dis.
psychosocial intervention
Pharmacotherapy:
Central nervous system stimulants are the first choice of
agents : e.g. Ritalin 0.3-1 mg/kg tid; up to 60mg/d,
Second-line agents with evidence of efficacy for some
children and adolescents : Atomoxetine (a norepinephrine
uptake inhibitor), antidepressants, such as bupropion,
venlafaxine; and the α-adrenergic receptor agonists
clonidine.
FDA approved the use of dextroamphetamine in children 3
years of age and older and methylphenidate in children 6
years of age and older.
.
Enuresis is the repeated voiding of urine into a child's clothes
or bed; the voiding may be involuntary or intentional.
For the diagnosis to be made, a child must exhibit a
developmental or chronological age of at least 5 years.
According to DSM-IV-TR, the behavior must occur twice
weekly for a period of at least 3 months or must cause
distress and impairment in functioning to meet the diagnostic
criteria. Enuresis is diagnosed only if the behavior is not
caused by a medical condition.
-
Genetic factors
-children
with enuresis with a normal anatomic bladder capacity
report urge to void with less urine in the bladder than children
without enuresis.
-nocturnal enuresis occurs when the bladder is full because of lower
than expected levels of nighttime antidiuretic hormone.
-- Psychosocial stressors appear to precipitate enuresis in a
subgroup of children with the disorder. In young children, the
disorder has been particularly associated with the birth of a sibling,
hospitalization between the ages of 2 and 4, the start of school, the
breakup of a family because of divorce or death, and a move to a
new home.
No single laboratory finding is pathognomonic
of enuresis; but clinicians must rule out organic
factors, such as the presence of urinary tract
infections, that may predispose a child to
enuresis.
Structural obstructive abnormalities may be
present in up to 3 percent of children with
apparent enuresis.
A treatment plan for typical enuresis can be
developed after organic causes of urinary
dysfunction have been ruled out. Modalities that
have been used successfully for enuresis include
both behavioral and pharmacological interventions.
The first step in any treatment plan is to review
appropriate toilet training.
Other useful techniques include restricting fluids
before bed
Behavioral Therapy: Classic conditioning with
the bell and pad apparatus is generally the
most effective treatment for enuresis
Pharmacotherapy:Imipramine has been
approved for short-term.
Desmopressin (DDAVP), an antidiuretic
compound . The most serious adverse effect
reported with the use of desmopressin to
treat enuresis was a hyponatremic seizure
experienced by a child.