Medical student lecture: introduction to child psychiatry

1. Medical student lecture:introduction to child psychiatry Regina Bussing, MD, MSHS Associate Professor and Chief Division of Child and Adolescent Psychiatry

2. LECTURE FOCUS • Child Development • Evaluation Strategies • Treatment Modalities • Childhood Disorders

3. MAJOR DEVELOPMENTAL STAGES • Prenatal/Birth • Infancy (Birth –18 months) Trust - form attachment/bond • Toddler (1.5 - 3 years) Autonomy - walk/talk/tolerate separation • Early childhood (3-5 years) Initiative - build vocabulary, build superego • Middle childhood (6-12 years) Industry - build peer-relations and competencies • Adolescence (12-adult) Identity

4. MILESTONES: Developmental Markers* • Sitting 6 months • Walking 1 year • Talking 1 year • Toilet Training 2 years + • Rides Tricycle 3 years • Dresses Self 5 years • Draws a person (main parts) 5 years • Rides Bicycle 6 years * Normal variation is present; Denver II-R

5. REASONS TO LEARN ABOUT NORMAL DEVELOPMENT • To identify and be supportive of age-appropriate emotional expressions (e.g. expressions of autonomy; stranger anxiety) - these are healthy. • To better identify what is really abnormal so treatment is focused on psychopathology - e.g., adolescent suicide attempts, drug use. • To better understand adult psychopathology. • To better understand common patterns of regression (a return to earlier developmental behaviors) that may occur with illness or stress.

6. CONCEPT OF REGRESSION STRESS ----> Return to earlier developmental stage EXAMPLES: • A 7yr old child with previous normal development now hospitalized with leukemia begins bedwetting, thumb sucking, and using “baby talk”. • A 42 year old previously healthy male becomes totally dependent on his wife for ADLs following a mild heart attack.

7. EVALUATION STRATEGIES Patient Interview Testing (IQ, Education, Projective, Personality, Neuropsych, labs, EEG, MRI) Collateral Information (Parents, School) Observation

9. SHIFTING FOCUS OF ASSESSMENT • Infants and toddlers: History; observation • gross and fine motor functions • language and communication • social behavior • bonding • Usual Concerns: • delayed development (e.g., MR), • abnormal development (e.g., PDD) • poor bonding (e.g., neglect, abuse)

11. Shifting Focus of Assessment SHIFTING FOCUS OF ASSESSMENT • Preschoolers: Observation, personal interview, parent interview • observe milestones • assess what child talks and thinks about (e.g. through play) • Parent-child relation • Possible concerns: as before, plus • speech-language delays, • hyperactivity, • aggressive/defiant behaviors, • excessive anxiety, • toilet training

14. Shifting Focus of Assessment SHIFTING FOCUS OF ASSESSMENT • School-age child: Observation, interviews, reports from school • how does child function in family? • how does child function in school? (behavior and academics) • what kind of peer relations? • formal psychological and academic testing • Common concerns: • learning problems • externalizing conditions • separation anxiety

15. IMPROVING THE ODDS FOR SUCCESSFUL DEVELOPMENTAL OUTCOMES • PROTECTIVE FACTORS • Good parent-child relationship • Easy, outgoing temperament • Positive peer influence • Successful school experiences • Caring adult role models • Participation in pro-social groups • Access to needed services, e.g. healthcare, mental health, crisis intervention

16. TREATMENT MODALITIES**(Usually 2 or more modalities are used simultaneously) • Individual Therapies (play, behavioral, cognitive, supportive, dynamic) • Family Therapy & Parent Training • Group Therapy - especially important for adolescents • Examples of Pharmacotherapy: ADHD Stimulants (e.g., Ritalin) MDD & Anxiety SSRIs (e.g., Prozac, Zoloft) Bipolar Disorders Valproate, Lithium Enuresis DDAVP, TCAs (IMI) Psychosis Antipsychotics

17. CHILD ABUSE1-800-96ABUSE "Abuse" means any willful act or threatened act that results in any physical, mental, or sexual injury or harm that causes or is likely to cause the child's physical, mental, or emotional health to be significantly impaired. Abuse of a child includes acts or omissions. Corporal discipline of a child by a parent or legal custodian for disciplinary purposes does not in itself constitute abuse when it does not result in harm to the child. [Subsection 39.01 (2), F.S.] The Florida Abuse Hotline will accept a report when: • There is reasonable cause to suspect that a child (less than 18 years old) • who can be located in Florida, or is temporarily out of the state but expected to return in the immediate future, • has been harmed or is believed to be threatened with harm • from a person responsible for the care of the child. Know state reporting laws and procedures (http://www5.myflorida.com/cf_web/myflorida2/healthhuman/childabuse/)

18. DISORDERS OF CHILDHOOD AND ADOLESCENCE • Basically all adult Axis I disorders can occur in children and adolescents (Depression, Bipolar, Schizophrenia, Anxiety, etc.). • Personality Disorders (Axis II) are usually not diagnosed (and ASPD can’t be), although personality traits are often identified. • Specific disorders with childhood onset are listed separately in DSM-IV (ADHD, Conduct Disorder, Learning Disorders, MR, etc). These may persist into adulthood. • Comorbidity is common. • Epidemiology: 1 in 5 children involved

19. MENTAL RETARDATION Diagnostic Criteria • IQ 70 or less on an individually administered IQ test • Onset before age 18 years • Concurrent deficits or impairments in adaptive functioning in at least two of these areas: communication, self care, home living, social and interpersonal skills, use of community resources, self direction, functional academic skills, work, leisure, health, or safety. • Epidemiology: 1-3% in US • Causes: • Unknown (50% of mild MR) • Known (75% of severe MR) – Hereditary (Down’s, fragile X; PKU);Toxins; Birth Trauma; Infection.

20. MILD MR: IQ 50/55 to 70 (~ 85%) • School: may acquire skills up to 6th grade level. • Social and Communication Skills: develop spontaneously. • May first be detected in school. • May acquire vocational skills and be self-supportive. MODERATE MR: IQ 35/40 to 50/55 (~ 10%) • Social and Communication Skills: develop, but impaired. • Early detection (i.e., before entering school). • School: unlikely to progress past 2nd grade level. • May work under close supervision (sheltered workshop).

21. SEVERE MR: IQ 20/25 to 35/40 (~ 3%) • School: May learn to sight-read (survival words) • Social/Communication Skills: little or no communicative speech. Often display poor motor development. • May acquire elementary hygiene skills and perform simple tasks; unable to benefit from vocational training PROFOUND MR: IQ Below 20/25 (~ 1-2%) • Social and Communication Skills: rarely have communicative speech efforts; minimal sensorimotor abilities. • Require constant aid and supervision; nursing care.

22. TREATMENT CONSIDERATIONS Family is coping with loss of “ideal” child - Grief and loss issues. Appropriate placement essential: - School setting, day care, group homes, sheltered workshop and respite care. Specific problems may be responsive to medications - Seizures; depression; hyperactivity; aggression. May experience “independent” psychiatric disorders, including schizophrenia, bipolar disorder, etc.

23. Pervasive Developmental Disorder Developmental disorders with severe and pervasive impairment in essential developmental areas • Reciprocal social skills • Language development • Range of behavioral repertoire DSM-IV includes the following under PDD: • Autism • Rett’s Disorder • Childhood Integrative Disorder • Asperger’s Disorder • PDD, not otherwise specified

24. Autism

25. Autism • Prevalence estimates: variable and increasing • Boys are effected 3 to 5 times more than girls • 50 to 70% have some degree of MR • Associated with Congenital Rubella, PKU, Tuberous Sclerosis and Fragile X Syndrome • 20 to 25% have grand-mal seizures and about 50% have non-specific EEG abnormalities • MRI, EEG, Karyotyping indicated in almost all cases

26. INTERVENTIONS IN AUTISM: Presently no curative treatment available; symptomatic interventions focus. Mainstay: Early intervention; speech and language services; structured behavioral and educational programs; OT, PT. Medications: To control seizures, hyperactivity, severe aggression, SIB, repetitive behaviors or mood disorders. CARD PROGRAM: http://card.ufl.edu

27. Retts Disorder • Normal growth for the first few months of life • Deceleration of head growth between 5-48 months • Truncal incoordination • Lack of purposeful hand movements; flapping • Disorder of females • Similar criteria as PDD • Over 80 percent of patients diagnosed with Rett's have a specific mutation in the MeCP2 gene on the X chromosome. This mutation is not inherited, but occurs after conception. http://dukemednews.duke.edu/news/article.php?id=5085

28. I cannot speak, but you understand me.I cannot walk, so you push me.I cannot sing, but I love music.I cannot crawl, so you carry me.I cannot tell jokes, but I love to laugh.I cannot wash myself, so you bathe me.I cannot play with Barbies,but I can push a switch.I cannot wave bye-bye,so you do that for me.I cannot dress myself, so you make me pretty.I cannot read, so you tell me stories.I cannot touch, but I can feel.I cannot go up the stairs, so you put me on the lift.I cannot tell you how much I love you, so look into my eyes and you will see.I cannot tell what the future will hold, but I have the courage to go on “I Have the Courage“

29. Childhood Disintegrative Disorder • Normal Development for at least two years of life. • Clinically significant loss of previously acquired skills prior to age 10 years in two or more of the following areas: • Language • Social Skills Or adoptive behavior • Bowel or bladder control • Play • Motor skills • Abnormal functioning in at least two areas: • Social interaction; communication; patterns of behaviors/interests

30. Asperger’s Disorder • “High functioning autism” • Impaired use of non-verbal communication (gaze, posture, gestures regulating social interaction) • Lack of interactive play, impaired peer relations • Stereotypic, repetitive mannerisms • No delays in language and cognitive development PDD NOS Diagnosis assigned when there is a severe and pervasive impairment in the development of reciprocal social interaction, or communication skills, or when stereotyped behaviors and activities are present but the criteria are not met for a specific pervasive developmental disorder.

31. LEARNING, MOTOR SKILLS, & COMMUNICATION DISORDERS • Measured achievement in a specific (academic, motor, speech) area is substantially below that expected based on the age/IQ of the individual. This differs from MR where the deficits are global in nature. • Types: • Reading Disorder • Mathematics Disorder • Disorder of Written Expression • Developmental Coordination Disorder • Expressive Language Disorder • Mixed Receptive-Expressive Language Disorder • Phonological Disorder • Stuttering

32. ELIMINATION DISORDERS • Encopresis (incontinence of feces) • Repeated passage of feces into inappropriate places • Age at least 4 years • Frequency at least 1x per month x 3 months • Not due to laxatives or medical problem • Specify: with or without overflow incontinence and constipation • Enuresis (incontinence of urine) • Repeated voiding into bed or clothes • Age at least 5 years • Frequency 2x per week x 3 months • Not due to medical problem • Specify: nocturnal, diurnal, or both • More common in males

33. ADHD • Persistent pattern of inattention and/or hyperactivity more frequent and severe than is typical of children at a similar level of development. • Onset before age 7 • Impairment in at least two settings: social, academic, or work • Duration at least six months • Inattention, Hyperactivity, Impulsivity

34. ADHD Continued Epidemiology Incidence: 2 to 20% of grade-school children Boys > Girls; Ratio 3-5:1 Family members (siblings and parents) of affected children are at higher risk Etiology • Specific etiology unknown; contributory factors • Genetics • Pre and perinatal complications • Neurological • Environmental toxins

35. ADHD Continued Treatment Types • Predominantly Inattentive type • Predominantly Hyperactive type • Combined type Pharmacotherapy Stimulants: Methylphenidate, Dextroamphetamine, (Pemoline) Non-Stimulants: Atomoxetine (Strattera); Clonidine and Guanfacine; Bupropion; TCAs; (atypical antipsychotics for treatment unresponsive cases) Psychotherapy Behavioral modifications; environmental structuring; parental Education and training; social skills training

36. Tic Disorders Tics are sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations DSM-IV Diagnoses: • Tourette’s Syndrome • Chronic Motor Tic Disorder • Chronic Vocal Tic Disorder • Transient Tic Disorder • Tic Disorder NOS

37. Oppositional Defiant Disorder • Recurrent pattern of negativistic, defiant, disobedient & hostile behavior towards authority figures • Duration > 6 Months • Impairment in social, academic and work settings • Symptoms not part of the mood or thought disorder • Treatment: Parent training (PCIT) Individual psychotherapy Family Therapy

38. Conduct Disorder • Aggression to people and animals • Destruction of property • Deceitfulness or theft • Serious violation of rules • Treatment: Multimodality treatment programs Environmental structuring Family Therapy Group Therapy Ind. Therapy – problem solving skills Medications as adjuncts

39. ANXIETY DISORDERS • Common in childhood: 15% • Comorbidity is common • All adult anxiety disorders may be seen in children. • PTSD - may be a result of abuse • Separation Anxiety Disorder • Developmentally inappropriate and excessive anxiety about separation from caretakers or home, of at least 4 weeks duration with onset before 18 years • Can lead to school refusal (school phobia) • Associated with physical complaints, fear of sleeping alone, worries about parent’s safety

40. Mood Disorders • Childhood Depression • irritability • sleep cycle disturbance • oppositional behavior • social isolation • crying spells • Dysthymia • symptoms at least 1 year

41. Adolescents and Suicide • In 1998, 4,153 young people, ages 15-24, committed suicide in the United States an average of 11.3 per day.1 • Suicide is the third leading cause of death in this age group following unintentional injury and homicide2 • Suicide accounts for 13.5% of all deaths in this age-group1 1 Murphy, SL, 1998 2 The Surgeon General’s Call to Action to Prevent Suicide, 1999

42. Suicide-Related Fatalitiesby Cause

43. Suicide Prevention • Don’t dismiss suicidal ideation, severe depression, runaway, significant substance abuse, etc. as just “normal” for age. • Educate families to control access to potentially lethal methods of self-harm (Guns; OTC). • Provide crisis hotline information. GAINESVILLE 24 hours / 7 days (352) 264-6789