Overview of child and adolescent

psychiatric disorders
Fikirte Girma (MD, Psychiatrist)
Department of psychiatry
Addis Ababa University
November 2014
 Outline
• Differences between adult and child/adolescent
clinical interview
• Developmental problems
• Behavioral problems
• Psychotic, mood and anxiety disorders
• Disorders affecting somatic functions
 Differences in the Adult vs.
Child/Adolescent Clinical Interview

history
from the
patient

observation collateral history

 Intellectual Disability (ID)
• Intellectual developmental disorder
• A disorder with onset during the developmental
period
• Includes both intellectual and adaptive functioning
deficits in comparison to an individual's age,
gender, and socio-culturally matched peers
• Mild
• Moderate
• Severe
• Profound
 Intellectual functioning
• Reasoning, problem solving, planning, abstract
thinking, judgment, learning from instruction and
experience, and practical understanding
• Verbal comprehension, working memory,
perceptual reasoning, quantitative reasoning,
abstract thought, and cognitive efficacy
• Measured by tests of intelligence
 Adaptive functioning
• How well a person meets community standards of
personal independence and social responsibility, in
comparison to others of similar age and
sociocultural background
 Epidemiology
• Point prevalence
• 1 -3 %
• Incidence is difficult to calculate
• 1.5 times more common among men than women
• In older persons, prevalence is lower
 Etiology
• Prenatal
• exposure to toxins or infectious agents, genetic and
chromosomal abnormalities, maternal malnutrition
• Perinatal
• infections, delivery complication, complications of
prematurity
• Postnatal
• environmental/social, toxins, trauma, malnutrition
 Diagnostic evaluation
• History
• Physical examination
• Laboratory evaluation
• chromosomal analysis
• urine and blood testing for metabolic disorders and
infections
• neuroimaging
• Hearing and speech evaluations
• Psychological Assessment
 Associated features of ID
• Other developmental problems
• Behavioral problems
• Emotional problems
• Abuse
• Suicide
• Accidental injury
• Neurological problems
 Treatment
• Based on an assessment of social, educational,
psychiatric, and environmental need
• Treatment of comorbid conditions
• Preventative measures (primary, secondary, tertiary)
• Comprehensive educational program
• Behavioral and Cognitive therapies
• Family education
• Social Intervention
• Pharmacology
 Prognosis
• The underlying intellectual impairment does not
improve
• Adaptation can be influenced positively by an
enriched and supportive environment
• Mild and moderate mental retardation have the
most flexibility in adapting to various
environmental conditions
• The more comorbid mental disorders there are, the
more guarded is the overall prognosis
 Autism Spectrum Disorders
(ASDs)
• Pervasive developmental disorders (PDDs)-DSM IV
• Autism
• Epidemiology
• prevalence has increased
• rate of around 1%
• ‘Classical’ autism accounts for between 25-60%
• M:F ~4:1
• no clear relation to socio-economic status
 Characteristic features
• Early onset of symptoms in three domains
• Social impairment
• Communication impairment
• Restricted and repetitive activities and interests
 Social impairment
• Quality of reciprocal interactions with others
• Aloof, poor eye contact, a lack of interest in people
as people, fails to seek comfort when hurt
• Poor capacity for empathy
• Limited ability to form close friendships
 Communication impairment
• Comprehension as well as expression
• Gesture as well as spoken language
• Babble may be reduced
• 30% of individuals with classical autism never
acquired useful speech
• Milestones are typically markedly delayed
• Loss of acquired skills
• Deviant speech
Communication impairment cont’
• Echolalia, pronominal reversal, neologisms
• Primarily talks at other people
• use speech mainly for demanding things
• talk at length about one of their current preoccupations
• Speech
• abnormal in intonation or pitch
• Gestures
• reduced and poorly integrated
Restricted and repetitive activities
and interests
• Resistance to change
• Insistence on routines and rituals
• Stereotypies
• Ordering play
• Attachment to unusual objects
• Fascination with unusual aspects of the world
• Intense preoccupations with restricted subjects
• Pretend play is typically lacking
 Early onset
• Rarely recognized in the first year of life
• At least some symptoms must have been present
by 36 months (DSM IV Autism)
 Associated features of ASDs
• Intellectual disability
• in about 40% -severe, and in 30% -mild; the remaining
30% have an IQ in the normal range
• Seizures
• 25% - autism + ID, and 5% - autism + normal IQ
• Seizures often begin in adolescence
• Other psychiatric problems
• problems with ADHD, behavior(self-injurious behaviors,
food faddism), emotions (social anxiety disorder, temper
tantrums, phobia), sleep
 Treatment
• Appropriate educational placement
• Provision of adequate support for parents
• Treatment of comorbidities
• Seizure
• Emotional problems
• Behavioral problems
 Prognosis
• ~ 10% of individuals who initially had the full
autistic syndrome are working and able to look
after themselves
• Fewer have good friends, marry, or become parents
• The best predictors of long-term social
independence
• IQ
• whether speech was present by 5 years of age
• milder variants of ASD
 Communication disorders
• Language disorder
• Speech sound disorder
• Childhood onset fluency disorder (stuttering)
• Social (pragmatic) communication disorder
• Unspecified communication disorder
 Specific learning disorder
• With impairment in reading
• With impairment in written expression
• With impairment in mathematics
 Attention-deficit/hyperactivity
disorder (ADHD)
• Hyperkinesis (ICD 10)
• is a severe subtype of ADHD
• Epidemiology
• Prevalence ~ 2–5%
• M:F = 3:1
• Commoner in younger children
• linked with various markers of deprivation
• commoner in inner cities, very poor rural areas, in families of
low socio-economic status and among children reared in
institutions
 Defining characteristics
• Marked hyperactivity, inattentiveness and
impulsiveness
• Pervasiveness
• In multiple settings
• Chronicity and early onset
• at least six months of symptoms
• by or before 7 years of age (12 years-DSM 5)
• Hyperactivity
• wriggle and squirm in their seats, fiddle with objects or
clothing, repeatedly get up and wander about when
they should be seated, change activity frequently

• Inattention
• easily distracted, have difficulty persisting with any one
task, does not listen, loses items, forgetful

• Impulsivity
• acting without due reflection, engaging in rash and
sometimes dangerous behaviors, blurting out answers in
class, interrupting others, and not waiting their turn in
games
 Associated features of ADHD
• Disruptive behavioral disorder
• Problems with social relationships
• Disinhibited
• Lower IQ
• Learning problems
• Coordination problems and neurodevelopmental
immaturities
• A history of specific developmental delay
 Treatment
• Education
• Parents and teachers
• Reduce the chances of the child acquiring an additional
behavioral disorder
• Psychological treatments
• Behavioral management
• Parent training
• Medication
• Stimulants
• Atomoxetine
• clonidine, bupropion and tricyclics
 Prognosis
• Symptoms persist into adolescence or adult life in
approximately 50 %
• Over-activity typically wanes in adolescence
• Many have continuing problems with inattentiveness,
impulsiveness and an inner sense of restlessness
even in adult life
• Educational attainments are often poor
• Lower occupational status in adult
• ADHD + behavioral disorder
• High risk of antisocial personality disorder and substance
abuse in adult life
 Summary
• Treatment - multidisciplinary
• Individual psychotherapy
• Play therapy
• Behavioral therapy
• Pharmacotherapy
• Residential treatment
• Day treatment
• Hospital treatment
 Summary cont’
• Impact & consequences
• Developing profound mental illness
• Poor academic achievement
• Burden on the society
• Antisocial activities
• Legal problems
• Substance abuse
• Unemployment