Child and adolescent psychiatry Pavel Theiner, MD, PhD Department of Psychiatry Masaryk University Child and adolescent psychiatry •An independent speciality in medicine, only partially overlapping with the psychiatry of adults • •Deals with mental and behavioral disorders of the youth, usually 2-18 years old Child and adolescent psychiatry basic theses •Paediatric medicine = developmetal medicine •Mental development is striking in childhood •There are many pathways to healthy mind of the adult •There are also developmental milestones that must be achieved •Considering pathology = mastering healthy development Paediatric medicine = developmetal medicine •From a newborn baby to an 18 yo adolescent •Several important phases –Newborn –Infant –Toddler –Pre-school –Schoolar –Puberty –Adolescence Mental development is striking in childhood •Brain development is exraordinary in childhood •Motoric development •Speech development •Emotional development •Development of thinking There are many pathways to healthy mind of the adult •Not sure, what is fundamental for healthy mind development •Many pathogenic factors are however known •The concept of vulnerability and resilience There are also developmental milestones that must be achieved •In all kinds of development there are milestones and deadlines to help differ, what is physiological (albeit delayed) and what is pathological • •https://www.cdc.gov/ncbddd/actearly/milestones/index.html Considering pathology = mastering healthy development •To consider if a behavioral, emotional or thoughts-content symptom is pathological, one must master the healthy development. • •Ex.: –Physiological periods of anger, anxiety, perfectionism –No developmental period of depression Assessment of a child •History taken from adults, ideally parents •History must include thorough information about mental and somatic development • •Interview with a child (at least a part of it without a parent) –playing, using toys, drawing… • The comprehensive evaluation of a child • •Description of present problems and symptoms •Information about health, illness and treatment (both physical and psychiatric), including current medications •Parent and family health and psychiatric histories •Information about the child's development •Information about school and friends •Information about family relationships •If needed, laboratory studies such as blood tests, x-rays, or special assessments (for example, psychological, educational, speech and language evaluation) Mental problems in children Schizophrenia, depression, anxiety disorders, bipolar disorder, obsessive-compulsive disorder, eating disorders, suicidal behaviour, adjustment disorders Same disorders as in adults, with lower incidence in children and often with atypical signs and symptoms Hyperkinetic disorders/ADHD, child autism, tics, Tourette sy, conduct disorders, emotional disorders in childhood, specific developmental disorders of speech, learning disorders and mental retardations Disorders with onset in childhood, variable course and sometimes persistence into adulthood Mental problems in children 1.Developmental problems (disorders) –specific (one domaine of development affected) –pervasive (complete development affected) – 2.Emotional and behavioral problems 3. 3.Disorders typical in adulthood with childhood onset Neurodevelopmental disorders in DSM-5 MILD (IQ 50-69) MODERATE ( IQ35-49) SEVERE (IQ 21-34) PROFOUND (IQ less than 20) Intellectual disability (mental retardation) IQ in population IQ calculation mental age calendar age 100 = average IQ. Below 69 = ment. retardation – 5 % 70–89 = under average – 20 % 90–109 = average – 50 % 110–129 = above average – 20 % 130–139 = signif above av - 3 % Above 140 = genius × 100 = ? http://www.inteligence.cz/_data/img/zastoupeniiq.png Gaussian distribution CHILD AUTISM (Kanner, 1943) SOCIAL A EMOTIONAL WITHDRAWAL „Extreme loneliness“ Symptoms present before 36th month of age. Impairment : • social interaction • • communication and playing • • limited, stereotyped habits, aversion to change http://smartpei.typepad.com/.a/6a00d83451db7969e201539286dbdb970b-pi 1975 1985 1995 2001 2904 2007 2009 „Softer“ diagnostic criteria? Increased father age? Better diagnostics and knowledge? Other factors? Symptoms in early childhood • lack of interest for contact with others · decreased face fixation · lack of interest in communication (monologues) · often strange intonation, echolalias, grammatical mistakes · emotional distance or inappropriate emotions · stereotypes adherence (wishing the things to be always same) · anxiety and panic reactions in new situations · stereotyped, non-constructive playing · interest in non-living (non soft) objects · inappropriate exploration and manipulation (sniffing, licking) · bizarr stereotyped movements (arm shaking, wrist twisting…) Autistic regress visible in 30-39% patients around 2. year of age (loss of speech and regresive changes in behaviour) Child autism fingers Lack of empathy and spontaneity, behaviour „mechanic“, indifferent to feelings of other people, peple less attractive than objects. • Eye contact limited, no interest in communication • Speech stereotyped, pedantic, without intonation and emotion, echolalias, answers irrespective to context. • Lack of fantasy and imagination – stereotyped behaviour and restricted interests (fanatical preoccupation with traffic signs, numbers, timetables, birthdates, dinosauruses…) Intelligence : normal (but hardly useful), mental retardation (commonly), sometimes isolated, accented skills (mathematics, music, painting…) kid Autism in older children and adolescents Videos •https://www.youtube.com/watch?v=3w1c4sF4ZTg • •https://www.youtube.com/watch?v=YtvP5A5OHpU • • ASPERGER SYNDROM (1944 - Hans Asperger, Austrian psychiatrist) Social abnormities less pronounced that in autism. Strogn ego-centrism, introversion, normal IQ and speech skills (sometimes even hypertrophic speech), often clumsiness. • lack of empathy, poor recpect to social conventions • emotional withdrawal • problems in social contact • strange intonation and expression (detailed, „small adult“) • poor social skills, pedantic truthfulness, inapproproate, shocking remarks, poor understanding of jokes and hyporboles • samotimes special talents and almost obsessive interests (computers, encyclopedias, collections, chess...) PREVALENCE: boys prevail ( 8 : 1 ) Video •https://www.youtube.com/watch?v=Wi1MW6CTJbc • Attention Deficit Hyperactivity Disorder - ADHD Hyperkinetic disorder Attention deficit Hyperactivity Impulsivity • Attention deficit with hyperactivity • Hyperkinetic conduct disorder • Inattentive • Hyperactive/impulsive • Combined Hyperkinetic disorder/ ADHD SUBTYPES SUBTYPES Prevalence : 3 - 7 % Prevails in boys DSM 5 ICD 10 OCD 0,7 2,9 mil Eating disorder 0,9 1,5 mil Cannabis dependence 1,0 1,4 mil Psychotic disorder 1,2 5,0 mil Personality disorder 1,3 4,3 mil PTSD 2,0 7,7 mil Conduct disorder 3,0 2,1 mil Alcohol dependence 3,4 14,6 mil Somatoform dis. 4,9 20,4 mil ADHD/hyperkin. dis. 5,0 3,3 mil Dementia 5,4 6,3 m il Unipolar depression 6,9 6,3 mil Insomnia 7,0 29,1 mil Anxiety disorders 14,0 61,5 mil Mental Disorders by prevalence (2011) (and estimated number of persons affected in millions) H.U. Wittchen et al. European Neuropsychopharmacology (2011) 21, 655–679 Výskyt ve státech Evropské Unie (EU-27) plus Švýcarsko, Island a Norsko Core ADHD symptoms Attention deficit 1.inattentive during tasks or games 2. skips details, makes mistakes 3. doesn´t follow instructions 4. disorganized 5.absent-minded 6. fails in making plans 7.inpatient, hates effortful tasks 8. loses things 9. forgets tasks, needs prompts Hyperactivity 1. Can´t stay calm 2. Makes useless moves 3. Stands up and runs in classroom 4. Noisy all the time 5. Always on-the-go 6. talkative Impulsivity 7. Answers before a question is finished 8. Can´t stay in queues 9. Interrupts others kluk adhd Etiopathogenesis of ADHD Significantly genetic disorder with variant genes for: -Neurotransmitters -Neurodevelopmental factors - Dysfunction of neurotransmitters important for cognitive functions – dopamine, norepinephrine. Impairments in inhibition of activity, time planning, sequencing Most research evidence suggests deficiencies in the availability of dopamine and norepinephrine among children with ADHD relative to comparison children, although epinephrine and serotonin have also been implicated. Stimulants : Methylphenidate reuptake DA, NE re-uptake inhibitor, also increases release from presynaptic neuron in PFC –improves cogn. deficits Pharmacotherapy in ADHD : Nonstimulating treatment: Atomoxetine Selective NE re-uptake inhibitor - increases NE levels in PFC. Also increases DA levels in PFC but not in BG nor ncl. accumbens Increase in catecholamine levels The efficacy of drug treatment for ADHD is high, probably the best in all psychiatric disorders. TIC DISORDERS Tics : Sudden, irregularly repeated moves/jerks or sounds, stereotyped and purposeless Types : motor, vocal (sounds, words, utterances) Frequent location: mimic muscles (eyelids, nose, mouth, neck) Tics are anticipated by urge Partially voluntarily controlled which is an important sign to consider in differential diagnosis against extrapyramidal disorders If they are suppressed for longer time, the inner tension increases and then tics reappear usually in higher frequency and intensity for a short period of time („rebound” phenomenon). TOURETTE SYDROME ( Gilles de la Tourette, 1885) The most serious tic disorder Onset between age 7-11, improves in early adulthood. Complex motor tics in combination with vocal tics (simultaneously) - motor tics: complex, similar to rituals - vocal ticsy : sounds, words, echolalias, koprolalia TS often comorbid with OCD and ADHD https://www.youtube.com/watch?v=7_dBRDvkbTU Therapy of tics Mild forms: Psychotherapy the first choice Medication if PT fails or tics are persistent and disruptive Tourette: Antipsychotics (antidopaminergic effect) atypical AP (tiaprid, risperidon, aripiprazol), sometimes haloperidol (typical AP, very potent but lot of AE) Conduct disorders •a repetitive and persistent pattern of behavior by a child or teenager in which the basic rights of others or major age-appropriate societal norms or rules are violated. • •Agression towards humans and/or animals (bullying, fights, threats, sexual offence) • Property loss or damage (setting fires, voluntary property destruction) • Deceitfulness or theft (lying, burglary) • serious violations of rules time and time again (escapes, truancy before age 13.) Conduct disorders •SOCIALIZED - the child/teenager is able to socialize, has friends and friendly relationships. The delicts are commited either alone or in a gang •NON-SOCIALIZED – decreased ability for socializing, few friends, ususally alone (poorer prognosis) Oppositional defiant disorder (ODD) Younger children up to 10, age-inappropriate oppositional behaviour, angry/irritable mood, poor respect towards authorities. Aggresive or antisocial behaviour not present! Conduct disorders Conduct disorders •If CD comorbid with ADHD the prognosis is poorer • •If symptoms of CD persist into adulthood, then personality disorder is classified, often antisocial PD Emotional disorders •Separation anxiety disorder •Elective mutism •Phobias •Mixed conduct and emotional disorders •Stress reactions •Post-traumatic stress disorder (PTSD) •Adjustment disorders Separation anxiety disorder Strong and age-inappropriate anxiety if separated from parent(s)/home or even imagining such a situation Irrational concerns (kidnap, losing, beeing killed...) Fear of: leaving home staying home alone sleeping alone going to preschool/school Frequent and significant somatic symptoms (headeaches, abdominal pains, nausea and vomiting) Typically worsens on Sunday evening or Monday morning Pronounced affects during separation Emotional disorders with childhood onset Fobic anxiety disorders in childhood - - abnormal and specific fears of specific objects and situations more pronounced than appropriate in a particular age (e.g. Zoophobia is frequent in preschoolers) h h Animals general zoophobia h Insects entomophobia h Cats ailurophobia h Dogs cynophobia h Snakes ophidophobia h Spiders arachnophobia h Dark nyktophobia h Blood hematophobia h Dirt mysophobia h Heights acrophobia h Closed places claustrophobia h Strangers xenophobia h Fire pyrophobia h Thunder brontophobia Elective mutism •A period of mutism (not speaking) in specific social situations despite the normal development of speech and lack of problems when speaking with family members • •Prevalence 0,3-0,8/1000 children, more girls •Psychological traits like shyness •Good prognosis with therapy, although social phobia as a possible outcome • •https://www.youtube.com/watch?v=WXcgNPpFjBM • Early-onset schizophrenia Symptoms in children: Impairment of interpersonal relations, emotional changes, social withdrawal, bizarr, anxious behaviour, rituals, unjustified fears or flattened emotivity, delusional fantasies, abnormal speech, abnormal motor symptoms Older children: verbal and sometimes visual hallucinations (animals, monsters…) Symptoms are influenced by cognitive development and only after 11 years of age are similar to those in adults Age of onset before 10 – 1% before 15 5% before 17 20% before 25 50% before 30 80% http://schizophrenia.com/photos/szage.onset.gif Prognosis of COS and therapy •Early childhood: •Poor progosis •Mental development is impaired •Chronical course •Often pharmacoresistant • •Later childhood •Insure prognosis • •Adolescence: •Better prognosis • • • • Risperidon Paliperidone Aripiprazol Olanzapin Quetiapin Clozapin Ziprasidon Atypical antipsychotics https://www.youtube.com/watch?v=BIligWBtJus DEPRESSION in children In early childhood the diagnosis is difficult. CHILDREN: depressive mood not necessarily predominates, more anxiety symptoms, anhedonia, unexplicable somatic symptoms, irritability, changes in behaviour and conduct, impaired school performance, reduction of interests and social contacts ADOLESCENTS: more sleep disorders, changes in appetite, suicidal thoughts and attempts, impaired performance, inattention, tiredness, reduction of interests and social contacts, being bored, irritated Quite often delusions and hallucinations. Depression - treatment • •Milder depression- psychotherapy •Severe depression – SSRI antidepressants + psychotherapy • •Antidepressants are less effective than in adults Deliberate, often repeated self-injury – no wish of dying. Superficial cutting, burning with cigarettes – used to diminish inner tension, mental suffering during strong emotions or feelings of inner emptiness. Physical pain reduces the mental one. Often habitual coping strategy (maladaptive) in youth with non-harmonic personality development, eating disorders, anxiety disorders and many other The treatment is focused on primary cause, relationships, better coping strategies Self-harm automutilace Suicidal attepmts Infrequent until 10 years, increase in adolescence and adulthood. In CZ approx. 40 completed suicides in adolescents per year Boys – less attempts but more often completed (use of more dangerous and letal means) Girls - more attempts, more often incompleted (intoxications) Parasuicides (demonstrative s.)- in children are considered serious. Children understand the definitiveness of death by 9 years In adolescence a suicidal attempt is the most common reason for acute psychiatric help and suicide is the second most frequent reason of death. Family and school problems - Family discomfort - Abuse and neglect - death of a parent or divorce - homesickness (college) - school results, failures Suicidal behaviour - causes Personal and relational: - poor acceptance from others - romantic failures - low self-esteem - self-accusation - increased impulsivity http://img.ct24.cz/multimedia/videos/image/1011/medium/303053.jpg Year up to 15 15-19 1996 9 71 1997 6 66 1998 8 52 1999 3 58 2000 12 42 2001 6 39 2002 6 44 2003 9 43 2004 8 43 2005 6 37 2006 3 55 Data from Institute of Health Information and Statistics of the Czech Republic. Child and adolescent suicidality in CZ Eurostat, 2014, suicidal rates 15-19yo Other common disorders •Eating disorders! • •Enuresis (bed-wetting) •Encopresis •Child abuse and neglect (sydrome) CAN • Thanks for your attention If you cannot pay attention due to ADHD, thanks anyway