Transcript psychiatric problems

PSYCHIATRIC DISORDERS
IN
CHILDREN
ATTENTION-DEFICIT /
HYPERACTIVITY DISORDER
• Most common mental disorder in children
• Estimates of 3-5% of preschool and school-age
children have ADHD (2 mil. in USA)(NIMH)
• 1 in a class of 25-30
• Begins in preschool and elementary school
• Often lasts into adulthood: 30-70% of children
with ADHD will continue to have symptoms as
adults
• Boys diagnosed 3x girls--probably because boys
more hyperactive and disruptive
AACAP, 2009
NORMAL BEHAVIOR Vs. ADHD
• Lasts more than six months
• Occurs in more than just one setting
(typically at home and at school)
• Regularly disrupts school, play, and other
daily activities
• Causes problems in relationships with
adults and other children
• Consider age and cognitive development
ADHD: INATTENTION SYMPTOMS
 Fails to pay close attention to details or makes
careless mistakes in schoolwork or other activities
 Trouble sustaining attention during tasks or play
 Seems not to listen even when spoken to directly
 Difficulty following through on instructions and often
fails to finish schoolwork, chores or other tasks
 Has problems organizing tasks or activities
 Avoids or dislikes tasks that require sustained mental
effort, such as schoolwork or homework
 Frequently loses needed items, such as books,
pencils, toys or tools
 Easily distracted
 Often forgetful
ADHD: Hyperactivity symptoms
 Fidgets or squirms frequently
 Often leaves his or her seat in the classroom or in
other situations when remaining seated is
expected
 Often runs or climbs excessively when it's not
appropriate or, if an adolescent, might constantly
feel restless
 Frequently has difficulty playing quietly
 Always seems on the go
 Talks excessively
 Blurts out the answers before questions have
been completely asked
 Frequently has difficulty waiting for his or her turn
 Often interrupts or intrudes on others'
conversations or games
ADHD: Girls vs. boys
• Boys are more likely to be hyperactive, whereas
girls tend to be inattentive.
• Girls who have trouble paying attention often
daydream, but inattentive boys are more likely to
play or fiddle aimlessly.
• Boys tend to be less compliant with teachers and
other adults, so their behavior is often more
conspicuous.
ADHD: treatment
 Without treatment children fall behind in school, have
social problems, higher rates of: substance abuse,
conduct disorder, accidents, divorce, job loss.
 Combination of behavioral and medication therapy.
 Behavior therapy: point systems or charts to reward
good behavior, “time out,” family time and positive
attention.
 Individual therapy: examine upsetting thoughts or
feelings, learn alternative ways of handling emotions,
change or better cope with ADHD symptoms-- organizing
schoolwork or dealing with emotional experiences.
 Social skills training: model social skills--waiting for a
turn, sharing toys, or asking for help, reading others’
facial expression or tone; Structured play dates.
 Medications: Stimulant and non-stimulant meds.
Oppositional Defiant Disorder
• Occasional oppositionality
is
common
especially
when hungry, tired, or
stressed—especially age
2-3 and early adolescence.
• ODD is an ongoing pattern
of uncooperative, defiant,
and
hostile
behavior
toward authority figures
that seriously interferes
with a child’s day to day
functioning.
ODD: symptoms
Frequent temper tantrums
Excessive arguing with adults
Often questioning rules
Active defiance and refusal to comply with
adult requests and rules
Deliberate attempts to annoy or upset people
Blaming others for his or her mistakes or
misbehavior
Often being touchy or easily annoyed by others
Frequent anger and resentment
Mean and hateful talk when upset
Spiteful attitude and revenge seeking
ODD: frequency & causes
 Multiple settings—home, school, after-school
activities
 1-16 % of all school-age children and adolescents
have ODD
 No clear causes, but some factors are:
 The child's inherent temperament
 The family's response to the child's temperament
 A genetic component that when coupled with
certain environmental conditions — such as lack of
supervision, poor quality child care or family
instability — increases the risk of ODD
 A biochemical or neurological factor
 The child's perception that he or she isn't getting
enough of the parent's time and attention
Mayo Clinic, 2007
ODD: risk factors
A parent with a mood or substance abuse
disorder
Being abused or neglected
Harsh or inconsistent discipline
Lack of supervision
Poor relationship with one or both parents
Family instability such as occurs with divorce,
multiple moves, or changing schools or child
care providers frequently
Financial problems in the family
Exposure to violence
Substance abuse in the child or adolescent
Parents with a history of ADHD, oppositional
defiant disorder or conduct problems
Mayo Clinic, 2007
ODD: treatment
Parent Management Training Programs to help
parents and others manage the child’s behavior.
Individual Psychotherapy to develop more
effective anger management.
Family Psychotherapy to improve communication
and mutual understanding.
Cognitive Problem-Solving Skills Training
Therapies to assist with problem solving and
decrease negativity.
Social Skills Training to increase flexibility and
improve social skills and frustration tolerance
with peers.
Medication for ADHD, anxiety, mood disorders
AACAP
Depression
Sadness over loss, disappointments, or stress is
normal
Depression is an illness when the feelings of
depression persist and interfere with a child or
adolescent’s ability to function.
About 5 percent of children and adolescents in
the general population suffer from depression at
any given point in time.
Children under stress, who experience loss, or
who have attentional, learning, conduct or
anxiety disorders are at a higher risk for
depression.
Depression also tends to run in families.
Depression: symptoms
 Frequent sadness, tearfulness, crying
 Decreased interest in activities; or inability to
enjoy previously favorite activities
 Hopelessness
 Persistent boredom; low energy
 Social isolation, poor communication
 Low self esteem and guilt
 Extreme sensitivity to rejection or failure
 Increased irritability, anger, or hostility
 Difficulty with relationships
 Frequent complaints of physical illnesses such as
headaches and stomachaches
 Frequent absences from school or poor performance
in school
 Poor concentration
 A major change in eating and/or sleeping patterns
 Talk of or efforts to run away from home
 Thoughts
or
expressions
destructive behavior
of
suicide
or
self
Depression: treatment
Individual Therapy
• Cognitive Behavior Therapy (CBT): changing unhealthy
patterns of thinking. The therapist then helps the child
replace this thinking with thoughts that result in better
feelings and behaviors.
• Interpersonal Therapy (IPT) helps improve mood by
improving interpersonal relationships.
Family Therapy
focuses on helping the family function in more
positive and constructive ways by looking at patterns of
communication and providing support and education.
Group Therapy
Medications
Antidepressants, mood stabilizers
Bipolar Disorder
 Manic +/- depressive symptoms.
 Some may have mostly depression and others a
combination of manic and depressive symptoms.
Highs may alternate with lows.
 Bipolar disorder can begin in childhood and during
the teenage years, although it is usually diagnosed
in adult life.
 The illness can affect anyone. However, if one or
both parents have Bipolar Disorder, the chances
are greater that their children may develop the
disorder. Family history of drug or alcohol abuse
also may be associated with greater risk for
Bipolar Disorder.
Bipolar disorder: symptoms
• Severe changes in mood-either unusually happy
or silly, or very irritable, angry, agitated, or
aggressive
• Unrealistic highs in self-esteem – e.g., a
teenager who feels all powerful or like a
superhero with special powers
• Great increase in energy and the ability to go
with little or no sleep for days without feeling
tired
• Increase in talking - the adolescent talks too
much, too fast, changes topics too quickly, and
cannot be interrupted
• Distractibility - the teen's attention
moves constantly from one thing to the
next
• Repeated high risk-taking behavior;
such as, abusing alcohol and drugs,
reckless driving, or sexual promiscuity
• Overlaps with symptoms of: drug
abuse, delinquency, ADHD, or even
schizophrenia.
Bipolar Disorder: treatment
• Education of the patient and the family about
the illness
• Psychotherapy helps the child understand
himself or herself, adapt to stresses, rebuild
self-esteem and improve relationships.
• Medications: Mood stabilizing medications
such as lithium, valproic acid, or “atypical
antipsychotic”, and psychotherapy.
Mood stabilizing medications
often reduce the number and severity of
manic episodes, and also help to prevent
depression.
ANXIETY DISORDERS
Separation anxiety
• Constant thoughts and intense fears about the
safety of parents and caretakers
• Refusing to go to school
• Frequent stomachaches and other physical
complaints
• Extreme worries about sleeping away from home
• Being overly clingy
• Panic or tantrums at times of separation from
parents
• Trouble sleeping or nightmares
Phobias
• Extreme fear about a specific thing or situation (ex.
dogs, insects, or needles)
• Fears cause significant distress and interfere with
usual activities
Social anxiety
• Fears of meeting
or talking to
people
• Avoidance of
social situations
• Few friends
outside the
family
Obsessive-compulsive disorder
• Obsessions:
undesirable,
unpleasant, intrusive thoughts,
images, or impulses that
reoccur uncontrollably; over
and over again and feel out of
your control. Contamination,
illness, harm, sexual ideas,
order.
• Compulsions:
acts performed
repeatedly (often according to
"rules”) to reduce anxiety of
obsessions; not pleasurable.
Hand washing, checking locks,
excessive & useless orderlines.
PTSD
• Children usually quite resilient and recover from
stressful events
• Catastrophic, life-threatening, or repeated trauma may
lead to PTSD in vulnerable individuals
• Initially show agitated or confused behavior; intense
fear, helplessness, anger, sadness, horror or denial.
• Repeated trauma may produce emotional numbing that
deaden or block the pain and trauma: dissociation.
• May become less responsive emotionally, depressed,
withdrawn, and more detached from their feelings
• Avoid situations or places that remind them of the
trauma.
• Symptoms last months to years
AACAP, 1999
PTSD: symptoms
• Frequent memories of the event, or in young
children, play in which some or all of the trauma
is repeated
• Upsetting and frightening dreams
• Acting or feeling like the experience is happening
again
• Repeated physical or emotional symptoms when
the child is reminded of the event
Other symptoms of anxious children
• Many worries about things before they happen
• Constant worries or concerns about family,
school, friends, or activities
• Repetitive, unwanted thoughts (obsessions) or
actions (compulsions)
• Fears of embarrassment or making mistakes
• Low self esteem and lack of self-confidence
Anxiety disorders: treatment
• Cognitive Behavioral Therapy (CBT)
• Exposure and response prevention (ERP)
• Medications:
antidepressants (SSRIs), antianxiety meds
Schizophrenia
• A serious psychiatric illness that causes strange
thinking, strange feelings, and unusual behavior.
• Uncommon in children and is hard to recognize in
its early phases.
• Cause of schizophrenia is not known. Current
research suggests a combination of brain
changes, bio-chemical, genetic and environmental
factors may be involved.
• Early diagnosis and medical treatment are
important.
• Schizophrenia is a life-long disease that can be
controlled but not cured.
Schizophrenia: symptoms
• Seeing things and hearing voices which are not
real (hallucinations)
• Odd and eccentric behavior, and/or speech
• Unusual or bizarre thoughts and
ideas
• Confusing television and dreams from reality
• Confused thinking
• Extreme moodiness
• Ideas that people are out to get them or talking
about them (paranoia)
• Severe anxiety and fearfulness
• Difficulty relating to peers, and keeping
friends
• Withdrawn and increased isolation
• Decline in personal hygiene
Schizophrenia
• The behavior of children with schizophrenia
may change slowly over time.
• Children who used to enjoy relationships with
others may start to become more shy or
withdrawn and seem to be in their own world.
• Talking about strange fears and ideas.
• Cling to parents or say things which do not
make sense.
• May first be noticed by the child's school
teachers.
Schizophrenia: treatment
• Need a comprehensive treatment plan.
• Combination of medication, individual
therapy, family therapy, and specialized
programs (school, activities, etc.) is often
necessary.
• Anti-psychotic medication can be helpful
for many of the symptoms and problems
identified.
Alcohol and substance abuse
• Use is common in teens: 50-80% have used some
drug recreationally
• For many this is short lived
• For some leads it to abuse (maladaptive pattern of
use) or dependence (physiological tolerance and
withdrawal)
• Average age of first marijuana use is 14 (26% HS
seniors have used)
• Alcohol use can start before age 12 (88% seniors
have used)
• Annually, 10,000 young people in the United States
are killed and 40,000 injured in alcohol-related
automobile accidents.
AACAP 2009
Substance abuse: risk factors
•
•
•
•
•
Family history of substance abuse
Depression
Low self-esteem
More anxious, less assertive, more impulsive
Feel like they don't fit in or are out of the
mainstream
• Vulnerable to peer pressure
• Associated with ADHD and conduct disorder
• Stimulant treatment for ADHD not associated
with adult drug use
Substance abuse: consequences
• Increased risk of serious drug use later in
life
• Truancy, school failure
• Antisocial behavior, conduct disorder
• Poor judgment which may put teens at
risk for accidents, violence, unplanned
and unsafe sex, and suicide.
• Sexual violence and victimization
Substance abuse: warning signs
• Physical:
Fatigue, repeated health complaints, red and
glazed eyes, and a lasting cough.
• Emotional:
Personality change, sudden mood
changes, irritability, irresponsible behavior, low
self-esteem, poor judgment, depression, and a
general lack of interest.
• Family:
Starting arguments, breaking rules,
or withdrawing from the family.
• School:
Decreased interest, negative attitude,
drop in grades, many absences, truancy, and
discipline problems.
• Social problems:
New friends who are less
interested in standard home and school
activities, problems with the law, and
changes to less conventional styles in dress
and music.
Autism & PDD
• A neurodevelopmental condition usually diagnosed
in the first 3 years of life.
• Delays in speech development, limited social
relatedness, and restricted interests and activities.
• Child may avoid direct eye contact and exhibit odd
behaviors such as focusing on parts of objects (e.g.
the spinning wheel of a toy car).
• Unusual motor movements such as hand flapping,
self stimulation, or walking on toes.
• Cause is unknown, but believed due to genetic,
environmental, metabolic and neurological
conditions
AACAP 2009
Autism & PDD: diagnosis
3 domains
1. Social relatedness includes marked impairment in
non-verbal communication, peer relationships and
social-emotional reciprocity.
2. Communication/play includes either a delay or
total lack of spoken language and lack of
developmentally-appropriate make-believe or
social play.
3. Restricted/stereotyped interests and activities
includes encompassing preoccupations,
adherence to non-functional routines or rituals,
stereotypies and motor mannerisms.
AACAP 2009
Autism & PDD: social
communication deficits
• Laughing (and/or crying) for no apparent reason;
showing distress for reasons not apparent to
others
• Prefers to be alone; aloof manner evident to
strangers and family members
• Tantrums and low frustration tolerance
• Difficulty in initiating social contact with others
• Uncomfortable with physical contact even when
given with affection such as a hug
AACAP 2009
• Little or no eye contact even when spoken to
directly
• Unresponsive to normal teaching methods (S)
• Apparent over-sensitivity or under-sensitivity
to pain
• No real fears of danger despite obvious risks
of harm.
• Noticeable physical over-activity or extreme
under-activity
• Impaired fine motor and gross motor skills
Autism & PDD: communication
deficits
• Difficulty in expressing needs verbally, using
gestures or pointing instead of words
• Repeating words or phrases in place of normal,
responsive language
• Non-responsive to verbal instructions; often
appears as if child is deaf although hearing tests
in normal range (C)
• May not have mental retardation
AACAP 2009
Autism & PDD: Stereotypies
• Insistence on sameness in routines
• Focus on spinning objects such as a fan or
the propeller of a toy helicopter
• Obsessive attachment to particular objects
• Rocking, flapping hands
• Repetitive use of language
AACAP 2009
Autism vs. Asperger Syndrome
• Children with Asperger disorder do not present
with delays in language acquisition or with marked
unusual behaviors and environmental
responsiveness during the first years of life.
• May achieve developmental milestones in first 3
years
• Speech patterns may be unusual and lack
inflection or may be formal, but excessively loud or
high pitched
• Conversation is one way, self-centered,
unresponsive to others
• Restricted and obsessive interests
AACAP 2009
Autism & PDD: treatment
• No cure
• Behavioral & educational interventions to
address specific cognitive, linguistic, &
social deficits
• Medication to treat symptoms
• Aggression, self-injurious behavior -Risperidone
• ADHD
• Anxiety, OCD
• Mood disorder and mood lability
AACAP 2009
Cutting & self-injurious behavior
• Self-injury is the act of deliberately destroying body
tissue, at times to change a way of feeling or relieve
painful feelings.
• Carving, scratching, branding, marking, picking and
pulling skin and hair, burning/abrasions, cutting,
biting, head banging, bruising, hitting
• To take risks, rebel, reject their parents' values, state
their individuality or merely be accepted.
• Desperation or anger to seek attention, to show their
hopelessness and worthlessness, or because they
have suicidal thoughts.
• Associated with: depression, psychosis, PTSD and
bipolar disorder.
• Some may develop Borderline Personality Disorder
as adults.
AACAP, 1999