CHILD AND

ADOLESCENT
PSYCHIATRY
Sajaratul Syifaa Binti
Ibrahim
0313887

Learning Outcomes
Know the various types of common
psychiatric disorders in presenting
in children and adolescents.
Pervasive development disorders
(Autistic spectrum disorders)
ADHD
Depression in children
School refusal and truancy

 Know the epidemiology of these

conditions
Able to discuss the aetiopathogenic factors of each
condition
Able to identify clinical features
of these conditions in the
community

Pervasive
Development Disorder
(Autistic Spectrum
Disorder)

Pervasive Developmental
Disorder
A group of disorders characterized by
defects in understanding and
expressing language and the
production of speech
These disorders affect multiple areas
of development (social skill and etc)
Manifested early in life and cause
persistent dysfunction

In DSM-III-R and DSM-IV Pervasive

developmental Disorder includes 5 disorder
which are :
1. Autistic Disorder
2. Retts Disorder
3. Childhood disintegrative disorder
4. Aspergers disorder
5. Pervasive developmental disorder not
otherwise specified

Autistic Disorder
Autism as a
syndrome of social
communication skill
deficits combined
with repetitive and
stereotyped
behaviors and as
having an onset in
early childhood.

Retts Disorder
Severe developmental
deterioration that shows
characteristic features after a period
of at least 6 months of normal
function and growth
Clinical Features :
microcephaly, lack of purposeful
hand movements, poor receptive and
expressive communication, poor
coordination

Childhood Disintegrative
Disorder
Disintegration of intellectual, social,
language function after at least 2 years
of normal development.
Clinical Features:
1. Impaired ability in language,
2. Impaired in social behavior, adaptive
behavior, bowel or bladder control, play
and motor skills.
3. Onset occurs at age 3 to 4 years

Aspergers Disorder
Patient SHOWS IMPAIRMENT IN SOCIAL INTERACTION and
RESTRICTED REPETITIVE PATTERNS OF BEHAVIOR.
There are no significant delays in language, cognitive
development, or age-appropriate self-help skills.
Clinical Features
1. Markedly abnormal nonverbal communicative gestures, failure
to develop peer relationships,
2. The lack of social or emotional function
3. Impaired ability to express pleasure in other peoples
happiness.
4. Restricted interests and patterns of behavior are always
present

Pervasive Disorder Not Otherwise

Specified
Characterized by severe, pervasive
impairment in social interaction or
communication skills or the presence
of stereotyped behavior, interests, and
activities
However lacks the criteria for :
-specific pervasive developmental
disorder, -schizophrenia
-avoidant personality disorder

DSM-V now replaces all of

these diagnoses with a single
diagnosis, autistic spectrum
disorder.

Diagnostic Criteria for Autistic Spectrum Disorder (DSM-V)

Criterion A
1. Persistent deficits in reciprocal social
communication
2. Deficits in nonverbal communicative
behaviors used for social interaction
3. Lack in developing, managing, and
understanding relationships.

Criterion B
Restricted, repetitive patterns of
behavior, interests, or activities, as
manifested by at least two of the
following :
1. Stereotyped or repetitive motor
movements, use of objects, or speech
2. Insistence on sameness, inflexible
adherence to routines, or ritualized
patterns of verbal or nonverbal behavior

3. Highly restricted, fixated interests

that
are abnormal in intensity or
focus
Criterion C
Symptoms must be present in the early
developmental period
Criterion D
Symptoms cause clinically significant
impairment in social, occupational, or
other important areas of current
functioning.

Criterion E
These disturbances are not better
explained by intellectual disability or
global developmental delay.
Intellectual disability and autism
spectrum disorder frequently cooccur
To make comorbid diagnoses of autism
spectrum disorder and intellectual
disability, social communication
should be below that expected for
general developmental level.

Genetic Factor
Family and twin studies
suggest that autism
spectrum disorder has
significant genetic
contribution

Etiology of
Autistic
Spectrum
Disorder

1 5 percent of cases of
autism spectrum disorder
appear to be associated
multiple genes mutation.

Other Factor
Immunological factors
Perinatal and prenatal
complications
- Comorbid neurological
disorder
- Environmental factor
-

Epidemiology of Autistic Spectrum

Disorder
Worldwide statistics
It is estimated that worldwide 1 in
160 children has an ASD
Four to five times more common in
males compared to female. However
female who are affected will usually
associated with severe mental
retardation.
Onset before age of 3 years old (18
to 36 months old)

Malaysia statistics
There is no local epidemiological
study on ASD prevalence in Malaysia.
However few data collected
concluded that
1. Children of 18 to 36 months are
affected
2. Prevalence of ASD in Malaysia was
approximately 1.6 in 1,000.

Differential Diagnosis for

ASD
Schizophrenia with childhood onset.
- accompanied by delusions and hallucinations
Mental retardation with behavioral symptoms.
Acquired aphasia with convulsion.
- child is normal for several years before
losing both receptive and expressive language
- most of them have seizures

 Congenital deafness or severe

hearing impairment
Psychosocial deprivation
-improve when placed in favorable
environment

Course and Prognosis

Autistic disorder is generally a
lifelong disorder
Two-thirds remain severely
handicapped and dependent.
Improved prognosis if:
1. IQ >70
2. Communication skills are seen by ages
5 to 7
years.

Management for ASD

Remediation
Structured classroom training in
combination with behavioral methods
Language and academic remediation
are often required
Psychotherapy
Parents are often distraught and need
support and counseling.

Pharmacotherapy
The administration of antipsychotic
medication reduces aggressive or
self-injurious behavior.
Serotonindopamine antagonists
(SDAs) such as Risperidone and
olanzapine

ATTENTION DEFICIT
HYPERACTIVITY
DISORDER

What is ADHD
Is a neuropsychiatric condition
Characterized by a pattern of
diminished sustained attention,
and increased impulsivity or
hyperactivity.

What Happen in ADHD

There is problem in multiple regions of the brain
and several neurotransmitter. However
d o p a m i n e is said to be focus of investigation
regarding ADHD symptoms.
The prefrontal cortex of the brain has been
implicated because of its high utilization of
dopamine
This leads to impairment in reciprocal
connections with other brain regions involved in
attention, inhibition, decision-making, response
inhibition, working memory, and vigilance.

Diagnostic Criteria for Attention Deficit Hyperactivity Disorder (DSM-V)

Two broad groups of symptoms:

1) Inattention
2) hyperactivity and impulsivity
) The criteria required that at least 12 of
18 symptoms (6 from the domain of
attention and 6 from the domain of
hyperactivity-impulsivity) be
) Present for at least 6 months

1. Inattention
a. Often fails to give close attention to
details or careless.
b. Often has difficulty sustaining
attention in tasks or play activities.
c. Often does not seem to listen when
spoken to directly.
d. Often does not follow through on
instructions.

e. Often has difficulty organizing tasks and

activities.
f. Often avoids, dislikes, or is reluctant to
engage in tasks that require sustained
mental effort.
g. Often loses things necessary for tasks or
activities.
h. Is often easily distracted by extraneous
stimuli.
i. Is often forgetful in daily activities.

2. Hyperactivity And Impulsivity

a. Often fidgets with or taps hands or
feet or squirms in seat.
b. Often leaves seat in situations when
remaining seated is expected.
c. Often runs about or climbs in
situations where it is inappropriate.
d. Often unable to play or engage in
leisure activities quietly.

e. Is often restless or to
keep up with
f. Often talks excessively.
g. Often blurts out an
answer before a question
has been completed
h. Often has difficulty
waiting his or her turn
i. Often interrupts or
intrudes on others

CRITERION B
Several inattentive or hyperactive-impulsive symptoms were
present prior to age 12 years.
CRITERION C
Several inattentive or hyperactive-impulsive symptoms are
present in two or more settings (classrooms or home)
CRITERION D
There is clear evidence that the symptoms interfere with, or
reduce the quality of social, academic, or occupational
functioning.
CRITERION E.
The symptoms do not occur exclusively during the
course of schizophrenia or another psychotic disorder
and are not better explained by another mental disorder
(e.g., mood disorder, anxiety disorder, dissociative disorder,
personality disorder, substance intoxication or withdrawal).

Epidemiology of ADHD
ADHD affects up to 5 to 8 percent of
school-aged children
-60 to 85 percent continuing to meet criteria in
adolescence

-60 percent continuing to be symptomatic into

adulthood.

Male to female ratio is 3:1 to 5:1

Etiology of ADHD

Perinatal trauma
Genetic factor
Psychosocial factors.
Evidence of noradrenergic and
dopaminergic dysfunction in
neurotransmitter systems.
Frontal lobe hypoperfusion and lower
frontal lobe metabolic rates have
also been noted.

Course and Prognosis of

ADHD
Course is variable and most patients undergo
partial remission.
In some cases, the hyperactivity may
disappear, but the decreased attention span
and impulse-control problems persist.
Patients are vulnerable to antisocial behavior,
substance use disorders and mood disorders.
Learning problems often continue throughout
life.

Treatment for ADHD

Psychotherapy
Multimodality treatment is often
necessary for child and family such as :
1. Social Skills Groups
2. Behavioral Intervention,
3. Individual Psychotherapy
4. Family Therapy
5. Special Education

Pharmacotherapy
Stands alone as the single most
efficacious
treatment for ADHD for individual of
all ages.
First Line Agent
1. CNS stimulants
( Methylphenidate,
Dextroamphetamine)
- Act by enhancing neurotransmission of
mostly dopamine and to the lesser extent
is norepinephrine

Second Line Agent

1. Antidepressant (Bupropion)
2. Alpha-adrenergic receptor agonist
(Clonidine)
3. Norepinephrine reuptake inhibitor
(Atomoxetine)

DEPRESSION IN
CHILDREN

Major Depressive Disorder

Insidious onset
Occurs in child who has had several years of difficulties
with
hyperactivity, separation anxiety disorder or
intermittent depressive symptoms.
Symptoms: Depressed or irritable mood
Loss of interest or pleasure
Failure to gain weight
Insomnia or hypersomnia
Psychomotor retardation or agitation
Diminished ability to think or concentrate
Reccurent thoughts of death

Diagnostic Criteria According to

DSM-V

Dysthymic disorder

- Consist of depressed or irritable

mood for most of the day
- Over a period of at least 1 year.
- Patients may have previous MDD
episodes.

Epidemiology of Depression in
Children
Extremely rare in preschool children
Prevalence increases with age.

Etiology of Depression in Children

1. Increased incidence among children of parents with
mood disorders and relatives of children with mood
disorders.
2. Increased secretion of growth hormones during sleep in
children with depressive disorder.
3. Possible link of hypothyroidism and depression.

Course and Prognosis

Young age of onset and multiple disorders predict poorer
prognosis.
Reoccurrence of a major depressive episode is :
40% by 2 years
70% by 5 years
Dysthymic episodes last on average 4 years and are
associated with :
MDD (70%)
Bipolar disorder (13%)
Substance abuse (15%)
Suicide (12%)

Treatment
1)Hospitalization
-) Indicated when patient is suicidal or has
coexisting substance abuse or dependence.
2) Psychotherapy
-) Aim to challenge maladaptive beliefs and
enhance problem-solving abilities and social
competence.
-) Active treatment such as relaxation
techniques Helpful in mild or moderate
depression.
-) Family education and participation are necessary.

 3) Pharmacotherapy
- Anti-depressants (SSRIs)
Drug of choice in depressive disorders in
children and adolescents.
SSRIs used in caution in children due to
increase risk of suicidal acts
Close monitoring of suicidal ideation and
behaviour
- Bupropion (Wellbutrin)
Depression as well as ADHD
-Velafaxine (Effexor)
Adolescent depression

School Refusal and

Truancy

School Refusal and Truancy

School refusal
When a child refuses to go to school with
good reason
Generally associated with separation
anxiety, school phobia

Truancy
The action of staying away from school
without good reason; absenteeism

Epidemiology of School Refusal

Approximately 1 to 5 percent of all school-aged
children have school

Clinical Features of School Refusal

Fearfulness
Panic symptoms
Crying episodes
Temper tantrums
Threats of self-harm
Somatic symptoms that present in the morning
and improve if the child is allowed to stay home

 Considered an urgent non-life threatening

situation
May occur in:
Young child first entering school
Older child or adolescent transitioning into a
new grade or school

Requires immediate intervention the

longer it continues, the more difficult to
interrupt
In adolescent severe psychopathology
(anxiety, depressive disorder) is present

Differences Between Refusal And

Truancy

Management
Family-oriented treatment plan is necessary
Whenever possible, a separation-anxious child should be brought
back to school the next school day, despite the distress
A contact person within the school (counsellor, teacher)
should be involved; praise the child for tolerating the school
situation
If school refusal occurs for months or years or when the family
members are unable to cooperate treatment program from
the hospital
Medication is prescribed after behavioural intervention has been
tried tricyclic antidepressants (imipramine)

References
Sadock B, Sadock V, Ruiz P. Kaplan &
Sadock's Synopsis of Psychiatry. 11th
ed. Wolters Kluwer; 2015
Sadock B, Sadock V, Ruiz P. Kaplan &
Sadock's Pocket Handbook of Clinical
Psychiatry. 5th ed. Wolters Kluwer;
2010