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Child Psychiatry for Child Psychiatry for Medical Students Part IMedical Students Part I

Khalid Bazaid, MB BS, FRCPCKhalid Bazaid, MB BS, FRCPCAssistant ProfessorAssistant Professor

Child & Adolescent PsychiatristChild & Adolescent PsychiatristDepartment of PsychiatryDepartment of Psychiatry

College of MedicineCollege of MedicineKing Saud UniversityKing Saud University

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OutlinesOutlines Introduction to Child & Adolescent psychiatryIntroduction to Child & Adolescent psychiatry

Review disorders first usually diagnosed in Infancy, Childhood and Review disorders first usually diagnosed in Infancy, Childhood and AdolescenceAdolescence– MR; PDDMR; PDD– LD; Motor Skills; S/L; TSLD; Motor Skills; S/L; TS– ADHD; Disruptive DisordersADHD; Disruptive Disorders

Review childhood presentation of general psychiatric disordersReview childhood presentation of general psychiatric disorders– Elimination disordersElimination disorders– MoodMood– AnxietyAnxiety– PsychosisPsychosis

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Remember: Children are not miniature adultsRemember: Children are not miniature adults

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5 Days5 Days 2 Months2 Months

1 Year1 Year 28 Years28 Years

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IMPROVING THE ODDS FOR IMPROVING THE ODDS FOR SUCCESSFUL DEVELOPMENTAL SUCCESSFUL DEVELOPMENTAL

OUTCOMESOUTCOMES

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

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DISORDERS OF CHILDHOOD DISORDERS OF CHILDHOOD AND ADOLESCENCE - 1AND ADOLESCENCE - 1

DISORDERS OF CHILDHOOD DISORDERS OF CHILDHOOD AND ADOLESCENCE - 1AND ADOLESCENCE - 1

• MD of the conceptualization of the transitionsMD of the conceptualization of the transitions

• Unique clinical and academic skills that differentiate a child from Unique clinical and academic skills that differentiate a child from adultadult

• Specialty rather than subspecialtySpecialty rather than subspecialty

• Pediatric medicine 20Pediatric medicine 20thth century century

• Number of Child/Adolescent Psychiatrist per capita/populationNumber of Child/Adolescent Psychiatrist per capita/population

• It is fundamentally a team service rather than individualized It is fundamentally a team service rather than individualized

• Biopsychosocail modelBiopsychosocail model

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DISORDERS OF CHILDHOOD DISORDERS OF CHILDHOOD AND ADOLESCENCE - 2AND ADOLESCENCE - 2

DISORDERS OF CHILDHOOD DISORDERS OF CHILDHOOD AND ADOLESCENCE - 2AND ADOLESCENCE - 2

• Basically all adult Axis I disorders can occur in children and Basically all adult Axis I disorders can occur in children and adolescents (Depression, Bipolar, Schizophrenia, Anxiety, etc.)adolescents (Depression, Bipolar, Schizophrenia, Anxiety, etc.)

• Personality Disorders (Axis II) are usually not diagnosed (and Personality Disorders (Axis II) are usually not diagnosed (and ASPD can’t be), although personality ASPD can’t be), although personality traitstraits are often identified are often identified

• Specific disorders with childhood onset are listed separately in Specific disorders with childhood onset are listed separately in DSM-IV-TR (ADHD, Conduct Disorder, Learning Disorders, MR, etc). DSM-IV-TR (ADHD, Conduct Disorder, Learning Disorders, MR, etc). These may persist into adulthood.These may persist into adulthood.

• Comorbidity is commonComorbidity is common

• Epidemiology: 1 in 5 children involvedEpidemiology: 1 in 5 children involved

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EVALUATION STRATEGIESEVALUATION STRATEGIESEVALUATION STRATEGIESEVALUATION STRATEGIES

Patient InterviewPatient Interview

Testing Testing (IQ, Education, Projective,(IQ, Education, Projective, Personality, Neuropsychiatry,Personality, Neuropsychiatry, labs, EEG, MRI)labs, EEG, MRI)

ObservationObservation

Collateral InformationCollateral Information (Parents, School)(Parents, School)

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TREATMENT MODALITIES*TREATMENT MODALITIES**(Usually 2 or more modalities are used *(Usually 2 or more modalities are used

simultaneously)simultaneously)

TREATMENT MODALITIES*TREATMENT MODALITIES**(Usually 2 or more modalities are used *(Usually 2 or more modalities are used

simultaneously)simultaneously)

• Individual Therapies (play, behavioral, cognitive, Individual Therapies (play, behavioral, cognitive, supportive, dynamic)supportive, dynamic)

• Family Therapy & Parent TrainingFamily Therapy & Parent Training

• Group Therapy - especially important for adolescentsGroup Therapy - especially important for adolescents

• Examples of Pharmacotherapy: Examples of Pharmacotherapy: ADHD: Stimulants (e.g., Ritalin, Concerta) andADHD: Stimulants (e.g., Ritalin, Concerta) and

Atomoxetine (Strattera)Atomoxetine (Strattera) MDD & Anxiety: SSRI's (recent Black Box warnings)MDD & Anxiety: SSRI's (recent Black Box warnings) Bipolar Disorders: Valproate, LithiumBipolar Disorders: Valproate, Lithium Psychosis: AntipsychoticsPsychosis: Antipsychotics

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Mental RetardationMental Retardation• Epidemiology: 1-3% in USEpidemiology: 1-3% in US• IQ 70 or less on an individually IQ 70 or less on an individually

administered IQ testadministered IQ test• Onset before age 18Onset before age 18• Delays in two or more adaptive areas, Delays in two or more adaptive areas,

e.g., self care; communication; work; e.g., self care; communication; work; leisure; health; or safetyleisure; health; or safety

• Testing:Testing:• Intelligence testing - compares Intelligence testing - compares

individual test performance to individual test performance to normative of age group normative of age group • E.g., WISC-IV (6 to17y) or E.g., WISC-IV (6 to17y) or

Stanford-Binet V5 (2 to 85+y)Stanford-Binet V5 (2 to 85+y)• Vineland Adaptive Behavior Vineland Adaptive Behavior

Scales -measure of personal and Scales -measure of personal and social skillssocial skills

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Mental RetardationMental Retardation

(~ 85%)(~ 85%)

(~ 10%)(~ 10%)

(~ 3%)(~ 3%)

(~ 1-2%)(~ 1-2%)

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MILD MR: MILD MR: IQ 50/55 to 70 (~ 85%)IQ 50/55 to 70 (~ 85%)

• School: may acquire skills up to 6th grade level.School: may acquire skills up to 6th grade level.

• Social and Communication Skills: develop spontaneously.Social and Communication Skills: develop spontaneously.

• May first be detected in school.May first be detected in school.

• May acquire vocational skills and be self-supportive.May acquire vocational skills and be self-supportive.

• Social and Communication Skills: develop, but impaired.Social and Communication Skills: develop, but impaired.

• Early detection (i.e., before entering school).Early detection (i.e., before entering school).

• School: unlikely to progress past 2nd grade level.School: unlikely to progress past 2nd grade level.

• May work under close supervision (sheltered workshop).May work under close supervision (sheltered workshop).

• Social and Communication Skills: develop, but impaired.Social and Communication Skills: develop, but impaired.

• Early detection (i.e., before entering school).Early detection (i.e., before entering school).

• School: unlikely to progress past 2nd grade level.School: unlikely to progress past 2nd grade level.

• May work under close supervision (sheltered workshop).May work under close supervision (sheltered workshop).

MODERATE MR: MODERATE MR: IQ 35/40 to 50/55 (~ 10%)IQ 35/40 to 50/55 (~ 10%)

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SEVERE MR:SEVERE MR: IQ 20/25 to 35/40 (~ 3%) IQ 20/25 to 35/40 (~ 3%)

• School: May learn to sight-read (survival School: May learn to sight-read (survival words)words)

• Social/Communication Skills: little or no Social/Communication Skills: little or no communicative speech. Often display poor communicative speech. Often display poor motor development.motor development.

• May acquire elementary hygiene skills and May acquire elementary hygiene skills and perform simple tasks; unable to benefit perform simple tasks; unable to benefit from vocational trainingfrom vocational training

• Social and Communication Skills: rarely have Social and Communication Skills: rarely have communicative speech efforts; minimal sensorimotor communicative speech efforts; minimal sensorimotor abilities.abilities.

• Require constant aid and supervision; nursing care.Require constant aid and supervision; nursing care.

• Social and Communication Skills: rarely have Social and Communication Skills: rarely have communicative speech efforts; minimal sensorimotor communicative speech efforts; minimal sensorimotor abilities.abilities.

• Require constant aid and supervision; nursing care.Require constant aid and supervision; nursing care.

PROFOUND MR:PROFOUND MR: IQ Below IQ Below 20/25 (~ 1-2%)20/25 (~ 1-2%)

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Treatment ConsiderationsTreatment Considerations

• Family is coping with loss of “ideal” child:Family is coping with loss of “ideal” child: Grief and loss issuesGrief and loss issues

• Appropriate placement and support:Appropriate placement and support: School School setting, day care, group homes, sheltered workshop and relief setting, day care, group homes, sheltered workshop and relief carecare

• Specific problems responsive to medications:Specific problems responsive to medications:e.g. seizures; depression; hyperactivity ; aggressione.g. seizures; depression; hyperactivity ; aggression

• May experience “independent” psychiatric disorders: May experience “independent” psychiatric disorders:

e.g. schizophrenia, bipolar disorder, etc.e.g. schizophrenia, bipolar disorder, etc.

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Pervasive Developmental DisordersPervasive Developmental Disorders

Disorders with severe and pervasive impairment in essential Disorders with severe and pervasive impairment in essential developmental areas:developmental areas:

Reciprocal social skillsReciprocal social skills Language developmentLanguage development Range of behavioral repertoire Range of behavioral repertoire

DSM-IV includes the following under PDD:DSM-IV includes the following under PDD:1.1. AutismAutism2.2. Rett’s DisorderRett’s Disorder3.3. Childhood Disintegrative DisorderChildhood Disintegrative Disorder4.4. Asperger’s DisorderAsperger’s Disorder5.5. PDD, not otherwise specifiedPDD, not otherwise specified

Language Disorders: Autism and Other Pervasive Developmental Disorders, Pediatr Clin N Am 54 (2007) 469–481

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Autism Spectrum Disorders (ASD)Autism Spectrum Disorders (ASD)

ASD are increasingly common neurodevelopment disorderASD are increasingly common neurodevelopment disorder

Characterized by functional impairments in a triad of symptoms:Characterized by functional impairments in a triad of symptoms: (1)(1) limited reciprocal social interactionslimited reciprocal social interactions (2) disordered verbal and nonverbal communication(2) disordered verbal and nonverbal communication (3) restricted, repetitive behaviors or circumscribed interests(3) restricted, repetitive behaviors or circumscribed interests

These behaviors can vary in severity from mild to disablingThese behaviors can vary in severity from mild to disabling IQ:IQ: At least half of all children who have autism haveAt least half of all children who have autism have mentalmental retardation retardation Autism appears in early childhood, often as young as age 2 or 3Autism appears in early childhood, often as young as age 2 or 3 Prevalence rate for all ASDPrevalence rate for all ASD 0.6%0.6% (Am J Psychiatry 2005; 162(6): 1133-41)(Am J Psychiatry 2005; 162(6): 1133-41)

Up to 25% have grand-mal seizures and about 50% non-specific EEG Up to 25% have grand-mal seizures and about 50% non-specific EEG abnormalitiesabnormalities

boys to girls 4:1boys to girls 4:1 Asperger’s disorder 10:1 as many boys to girls Asperger’s disorder 10:1 as many boys to girls Genetic / environment Genetic / environment

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Epidemiology of AutismEpidemiology of Autism

• Prevalence rate of Autism Spectrum Disorders is Prevalence rate of Autism Spectrum Disorders is about 1%about 1%

• Up to 25% have grand-mal seizures and about 50% Up to 25% have grand-mal seizures and about 50% non-specific EEG abnormalitiesnon-specific EEG abnormalities

• 50 to 70% have some degree of MR50 to 70% have some degree of MR

• Boys are effected 3 to 5 times more often than girlsBoys are effected 3 to 5 times more often than girls

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Etiology of AutismEtiology of Autism

• Psychological theories have not been confirmed:Psychological theories have not been confirmed: Not caused by “refrigerator mother” or bad parentingNot caused by “refrigerator mother” or bad parenting

• Heritability over 90%Heritability over 90%

• Association with a variety of disorders: Association with a variety of disorders: Congenital rubella & Postnatal infectionCongenital rubella & Postnatal infection Genetic disorders, including Fragile XGenetic disorders, including Fragile X Metabolic disordersMetabolic disorders Tic disordersTic disorders OCDOCD

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Asperger’s DisorderAsperger’s Disorder

• ““High functioning autism”High functioning autism”

• No delays in language and cognitive developmentNo delays in language and cognitive development

• Stereotypic, repetitive mannerismsStereotypic, repetitive mannerisms

• Lack of interactive play/communicationLack of interactive play/communication

• Impaired communication skillsImpaired communication skills                                                                            

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PDD NOSPDD NOS

When there is no severe and pervasive When there is no severe and pervasive impairment in the development of reciprocal impairment in the development of reciprocal

social interaction, or communication skills, or social interaction, or communication skills, or when stereotyped behaviors and activities are when stereotyped behaviors and activities are

present, but the criteria are not met for a present, but the criteria are not met for a specific pervasive developmental disorder.specific pervasive developmental disorder.

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Interventions in PDD/AutismInterventions in PDD/Autism

Presently:Presently:

No curative treatmentNo curative treatment; early detection and symptomatic ; early detection and symptomatic approachesapproaches

Mainstay:Mainstay:

Structured behavioral and educational programs; speech and Structured behavioral and educational programs; speech and language serviceslanguage services

Medication:Medication:

To control seizures, hyperactivity, SIB, severe aggression, or To control seizures, hyperactivity, SIB, severe aggression, or mood disordersmood disorders

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Rett’s DisorderRett’s Disorder

• One in every 10,000 to 15,000 live One in every 10,000 to 15,000 live female birthsfemale births• Normal growth for the first few months of lifeNormal growth for the first few months of life• Deceleration of head growth between 4-8 monthsDeceleration of head growth between 4-8 months• ““Hand washing” stereotypies, Loss of purposeful hand Hand washing” stereotypies, Loss of purposeful hand

movementsmovements• Truncal incoordination; gait problems; SeizuresTruncal incoordination; gait problems; Seizures• Most are in wheelchair by their late teens and die Most are in wheelchair by their late teens and die

before 30.before 30.• Disorder of femalesDisorder of females; in up to 80% due to mutation of ; in up to 80% due to mutation of

MECP2 gene on X chromosomeMECP2 gene on X chromosome

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Childhood Disintegrative DisorderChildhood Disintegrative Disorder

• Normal development for at least the first two years of Normal development for at least the first two years of lifelife

• Clinically significant loss of previously acquired skills Clinically significant loss of previously acquired skills (before age 10 years) in 2 or more of the following (before age 10 years) in 2 or more of the following areasareas:: LanguageLanguage Social skills or adoptive behaviorSocial skills or adoptive behavior Motor skillsMotor skills Play Play Bowel or bladder controlBowel or bladder control

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Questions after lecture?Questions after lecture?

Please e-mail (kbazaid@ksu.edu.sa) or call Please e-mail (kbazaid@ksu.edu.sa) or call (01 467 1717)(01 467 1717)

Interested in learning more about child and Interested in learning more about child and adolescent psychiatry?adolescent psychiatry?– Arrange to attend OPD Arrange to attend OPD – Consider an elective rotation during internship Consider an elective rotation during internship

or otherwiseor otherwise

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Externalizing Disorders in Children Externalizing Disorders in Children (ADHD, CD, ODD)(ADHD, CD, ODD)

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Attention Deficit/Hyperactivity Disorder Attention Deficit/Hyperactivity Disorder (ADHD)(ADHD)

• Present before age 7Present before age 7• Persist for at least 6 months and be more frequent and severe Persist for at least 6 months and be more frequent and severe than is typical for children at comparable developmental stagesthan is typical for children at comparable developmental stages• Symptoms in two or more settings• Boys to girls 3 : 1Boys to girls 3 : 1 • DSM-IV-TR distinguishes ADD WITH & WITHOUT hyperactivity, and recognizes a predominantly hyperactive subtype • Persists in some patients into adolescence and AdulthoodPersists in some patients into adolescence and Adulthood

• Normal IQNormal IQ

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INATTENTIONINATTENTION

no attention to detailsno attention to details difficulty focusingdifficulty focusing not listeningnot listening easily distractedeasily distracted forgetful not forgetful not

following throughfollowing through difficulty organizingdifficulty organizing avoids effortful tasksavoids effortful tasks loses thingsloses things

HYPERACTIVITYHYPERACTIVITY

IMPULSIVITYIMPULSIVITY fidgetsfidgets leaves seatleaves seat runs/climbsruns/climbs loudloud on the goon the go excessive talkexcessive talk blurtsblurts can't wait turncan't wait turn interrupts/butts ininterrupts/butts in

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ADHD Low selfesteem

Academiclimitations

Relationships

Smoking andsubstance abuse

InjuriesMotor vehicle

accidents

Legaldifficulties

Occupational/vocational

ChildrenA

du

lts

Adolescents

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ADHD DiagnosisADHD Diagnosis

• ADHD is more difficult to reliably diagnose in early childhood ADHD is more difficult to reliably diagnose in early childhood (age 4-6)(age 4-6)

• Obtain developmental and medical historyObtain developmental and medical history

• Get standardized questionnaires from parents and teachersGet standardized questionnaires from parents and teachers

• Observation in clinic setting may or may not show symptoms Observation in clinic setting may or may not show symptoms described by parentsdescribed by parents

• Psycho-educational testing useful if LD suspectedPsycho-educational testing useful if LD suspected

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الطفل : المستشفى : ........................................ اسم ................العمر : ............................. رقم

:التعليماتالعبارات من واحده كل أمام الطفل وصف يناسب الذي الرقم حول دائرة وضع الرجاء

:التالية  0 كثيرا

جدا0كثير

ا0قليًال0

أبدا0

الطفل وصف تسلسل

3 2 1 0 مقعده . في يتحرك أو يتململ ما غالبا0 )1(

3 2 1 0 . 0 جالسا البقاء في صعوبة يجد )2(

3 2 1 0 انتباهه . تشتيت السهل من )3(

3 2 1 0وسط دوره انتظار في صعوبة يجد

أقرانه . )4(

3 2 1 0على االجابة في يندفع ما غالبا0

تفكير . دون األسئلة )5(

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3 2 1 0 التعليمات . اتباع في صعوبة يجد )6(

3 2 1 0يطلب فيما انتباهه حصر في صعوبة يجد

عمله . منه )7(

3 2 1 0 ، إكماله قبل نشاط من ينتقل ما غالبا0

آخر . نشاط إلى )8(

3 2 1 0 بهدوء . اللعب في صعوبة يجد )9(

3 2 1 0 بافراط . يتكلم ما P0 غالبا )10(

3 2 1 0نفسه يقحم اآلخرين يقاطع ما غالبا0

عليهم .)11(

3 2 1 0 اإلنصات . عدم عليه يبدو ما غالبا0 )12(

3 2 1 0 ) األدوات الخاصة أشياءه يضيع ما غالبا0

( 0 مثًال المدرسية)13(

3 2 1 0دون بدنيا0 خطرة بأعمال يقوم ما غالبا0

ذلك . عن ينتج لما اكتراث)14(

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ADHDADHD

EtiologyEtiology

NeuroanatomicalNeurochemical

Genetic

CNS insult

Environmental

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NIMH Press Release November 12, 2007 NIMH Press Release November 12, 2007 Brain Matures a Few Years Late in ADHD, Brain Matures a Few Years Late in ADHD,

But Follows Normal PatternBut Follows Normal Pattern

http://www.nimh.nih.gov/science-news/2007/brain-matures-a-few-years-late-in-adhd-but-follows-normal-pattern.shtml

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ADHD Child Home

Behavioural Therapy

MedicationSchool

Treatment

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ADHD TreatmentADHD Treatment

• Psychoeducation essential; medication alone is usually not Psychoeducation essential; medication alone is usually not sufficient for the treatment of ADHDsufficient for the treatment of ADHD

• Parent training in behavioral management and school-Parent training in behavioral management and school-based behavioral interventionsbased behavioral interventions

• FDA approved medications include FDA approved medications include stimulantsstimulants and and AtomoxetineAtomoxetine Note: Stimulant medications improve attention in Note: Stimulant medications improve attention in

normal individuals as well as children with ADHDnormal individuals as well as children with ADHD• Establish communication with teachers/school; potentially Establish communication with teachers/school; potentially

includes accommodations and IEPincludes accommodations and IEP

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The CONCERTAThe CONCERTA®® Formulation Formulation

MPH Overcoat

Tablet Shell

Push Compartment

MPH Compartment

#2

Laser-Drilled Hole

MPH Compartment

#1

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ADHD OutcomesADHD Outcomes

ADHD can be a lifetime disorder, with nearly 2/3 of children ADHD can be a lifetime disorder, with nearly 2/3 of children continuing with symptoms as adultscontinuing with symptoms as adults

Learning disabilities frequently comorbid in children with Learning disabilities frequently comorbid in children with ADHD and not responsive to medicationsADHD and not responsive to medications

Adult outcome studies show more relationship problems, Adult outcome studies show more relationship problems, lower educational and professional achievement, more traffic lower educational and professional achievement, more traffic violations and higher health care costs for cohort members violations and higher health care costs for cohort members with ADHD compared to unaffected controlswith ADHD compared to unaffected controls

Long term outcome strongly influenced by comorbid ODD, Long term outcome strongly influenced by comorbid ODD, CD, and substance abuseCD, and substance abuse

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DepressionDepression

EpidemiologyEpidemiology

• 2.5% of children, up to 5% of adolescents

• Prepubertal-1:1/M:F; adolescence - 4:1/F:M

• Average length of untreated MDD - 7.2 months

• Recurrence rates - 40% within 2 years

• Most important risk factor for the development of depressive illness is having at least one parent with depression

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DepressionDepressionDSM- IV-TR Modifications DSM- IV-TR Modifications

for children:for children: irritable mood (vs. irritable mood (vs.

depressive mood)depressive mood) observed apathy and observed apathy and

pervasive boredom (vs. pervasive boredom (vs. Anhedonia)Anhedonia)

failure to make expected failure to make expected weight gains (rather than weight gains (rather than significant weight loss)significant weight loss)

somatic complaintssomatic complaints social withdrawalsocial withdrawal declining school declining school

performanceperformance

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Treatment of Depression

P sycho ed uca tio na l T he ra py

In te rpe rson a l C og n it ive / B eh av io ra l P lay

P sycho the ra py A n tid ep ressan ts

D e pressed Ch i ld

Treatment for Adolescents with Depression Study (TADS):Treatment for Adolescents with Depression Study (TADS):

• Multi-site (13 sites) clinical research study Multi-site (13 sites) clinical research study

• For adolescents aged 12 to 17For adolescents aged 12 to 17

• Compared short- and longer-term effectiveness of medication and Compared short- and longer-term effectiveness of medication and psychotherapy for depression psychotherapy for depression

• Flouxetine and cognitive-behavioral therapy combined produced the best success Flouxetine and cognitive-behavioral therapy combined produced the best success rate in treating depression in adolescents (71% responded)rate in treating depression in adolescents (71% responded)

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SuicideSuicide Publicity regarding suicide may prompt other adolescents to Publicity regarding suicide may prompt other adolescents to

attempt suicideattempt suicide

Attempts- 3:1/F:M, Completions- 4:1/M:FAttempts- 3:1/F:M, Completions- 4:1/M:F

Most common means of completed suicide: FIREARMSMost common means of completed suicide: FIREARMS

Most often associated with depressive disorder. Also Most often associated with depressive disorder. Also consider schizophrenia and substance abuse.consider schizophrenia and substance abuse.

Risk factors: Age, sex, presence of psychiatric illness, family Risk factors: Age, sex, presence of psychiatric illness, family history, isolation from friends, substance abusehistory, isolation from friends, substance abuse

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Adolescents and SuicideAdolescents and Suicide

In 1998, In 1998, 4,153 young people4,153 young people, ages 15-24, committed , ages 15-24, committed suicide in the United States, an average of 11.3 per day.suicide in the United States, an average of 11.3 per day.11

Suicide accounts for Suicide accounts for 13.5%13.5% of all deaths in this age- of all deaths in this age-groupgroup11

Suicide is the Suicide is the third leading causethird leading cause of death in this age of death in this age group following unintentional injury and homicidegroup following unintentional injury and homicide22

1 Murphy, SL, 1998

2 The Surgeon General’s Call to Action to Prevent Suicide, 1999

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Suicide-Related Fatalities by Suicide-Related Fatalities by CauseCause

393 320

34

1211

41 47 490

200400600800

100012001400

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Suicide PreventionSuicide Prevention

Don’t dismiss suicidal ideation, depression, runaway, Don’t dismiss suicidal ideation, depression, runaway, substance abuse as just “normal” for age.substance abuse as just “normal” for age.

Educate families to control access to potentially lethal Educate families to control access to potentially lethal methods of self-harm.methods of self-harm.

Provide crisis hotline information.Provide crisis hotline information.

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Bipolar DisorderBipolar DisorderADULTSADULTS

At least one At least one manic/mixed episode manic/mixed episode

MANIA includes MANIA includes expansive, irritable or expansive, irritable or euphoric mood plus euphoric mood plus (3/7) grandiosity, (3/7) grandiosity, decreased need for decreased need for sleep, pressured speech, sleep, pressured speech, racing thoughts, racing thoughts, distractibility, distractibility, psychomotor agitation, psychomotor agitation, increase in high risk increase in high risk activitiesactivities

CHILDREN & ADOLESCENTSCHILDREN & ADOLESCENTS

More likely to present with More likely to present with aggressiveness, irritability, aggressiveness, irritability, and emotional labilityand emotional lability

Harder to delineate specific Harder to delineate specific episodesepisodes

Prone to chronic mixed or Prone to chronic mixed or rapid cycling with agitated rapid cycling with agitated affect and explosive angeraffect and explosive anger

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Diagnosing Diagnosing Bipolar DisorderBipolar Disorder

Not to be confused with normal development coupled with Not to be confused with normal development coupled with parenting issuesparenting issues

Symptoms may include the full range of child psychiatric Symptoms may include the full range of child psychiatric symptoms of childhoodsymptoms of childhood

Expansive or irritable moodExpansive or irritable mood Rapid cycling of mood for little or no reasonRapid cycling of mood for little or no reason Explosive ragesExplosive rages Non specific aggressionNon specific aggression Defiance of authorityDefiance of authority Inappropriate sexual behaviorInappropriate sexual behavior Impaired judgment, impulsivity, dare devil behaviorImpaired judgment, impulsivity, dare devil behavior GrandiosityGrandiosity

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Treatment of Bipolar DisorderTreatment of Bipolar Disorder

Limited data is available on the efficacy and safety of mood Limited data is available on the efficacy and safety of mood stabilizing medications in youth.stabilizing medications in youth.

The essential treatment for this disorder in adults involves The essential treatment for this disorder in adults involves the use of appropriate doses of mood stabilizers, most the use of appropriate doses of mood stabilizers, most typically lithium and/or valproate, often combined with typically lithium and/or valproate, often combined with atypical antipsychotic medications.atypical antipsychotic medications.

Research on the effectiveness of these and other medications Research on the effectiveness of these and other medications in children and adolescents with bipolar disorder is ongoing. in children and adolescents with bipolar disorder is ongoing.

In addition, studies are investigating various forms of In addition, studies are investigating various forms of psychotherapy, including cognitive-behavioral therapy and psychotherapy, including cognitive-behavioral therapy and well-being therapy, to complement medication treatment for well-being therapy, to complement medication treatment for this illness in young people. this illness in young people.

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School Refusal: Symptom, not disorder – may School Refusal: Symptom, not disorder – may accompany different anxiety disordersaccompany different anxiety disorders

esp. separation anxiety disorderesp. separation anxiety disorder

Recurrent vague, Recurrent vague, mysterious physical mysterious physical complaintscomplaints

No physical cause found on No physical cause found on initial and F/U exams. initial and F/U exams. Labs when necessary.Labs when necessary.

Symptoms predominate in Symptoms predominate in the AM then disappear. the AM then disappear.

Child has missed five or Child has missed five or more days of school for more days of school for same symptom(s).same symptom(s).

Average pediatrician Average pediatrician should diagnose 2 cases should diagnose 2 cases a montha month

5% of elementary 5% of elementary school students, 2% of school students, 2% of middle school studentsmiddle school students

Most common somatic Most common somatic symptom linked to symptom linked to school refusal / anxiety - school refusal / anxiety - ABDOMINAL PAINABDOMINAL PAIN

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Specific PhobiasSpecific Phobias Marked and persistent fear of Marked and persistent fear of

a specific object or situation a specific object or situation with exposure causing an with exposure causing an immediate anxiety responseimmediate anxiety response

Must interfere with normal Must interfere with normal activities or relationshipsactivities or relationships

0ne-year community 0ne-year community prevalence estimated at 11%prevalence estimated at 11% In general, decreases with In general, decreases with

ageage About 2 - 3% of About 2 - 3% of

adolescents have adolescents have significant fearssignificant fears

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Specific PhobiasSpecific Phobias

Animal phobias most Animal phobias most common childhood phobiacommon childhood phobia

Also frequently afraid of Also frequently afraid of the dark and imaginary the dark and imaginary creaturescreatures

In older children, fears are In older children, fears are more focused on health, more focused on health, social and school problemssocial and school problems

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Selective MutismSelective Mutism Failure to speak in specific Failure to speak in specific

social situations despite social situations despite speaking in other speaking in other situationssituations

Classified as an anxiety Classified as an anxiety disorderdisorder

High association with High association with depressiondepression

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Generalized Anxiety DisorderGeneralized Anxiety Disorder

Excessive anxiety and worry for Excessive anxiety and worry for at least 6 monthsat least 6 months

Worry about performance at Worry about performance at school and sportsschool and sports

DSM IV-TR criteria less DSM IV-TR criteria less stringent for childrenstringent for children Need only one criteria Need only one criteria

instead of three of sixinstead of three of six

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Obsessive Compulsive DisorderObsessive Compulsive Disorder Presence of obsessions (thoughts) Presence of obsessions (thoughts)

and/or compulsions (behaviors)and/or compulsions (behaviors)

Although adults with OCD Although adults with OCD should have insight, kids may notshould have insight, kids may not

Interferes with life or causes Interferes with life or causes distressdistress

0.3-1.0% of pediatric population0.3-1.0% of pediatric population

One-third to one-half of all adult One-third to one-half of all adult patients report onset in childhood patients report onset in childhood or adolescenceor adolescence

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SchizophreniaSchizophrenia• Need two of the following five symptoms over six months:Need two of the following five symptoms over six months:

DelusionsDelusions HallucinationsHallucinations Disorganized speechDisorganized speech Disorganized behaviorDisorganized behavior Negative symptomsNegative symptoms

• Onset in childhood is rare (1 in 10,000 children)Onset in childhood is rare (1 in 10,000 children)

• Genetic, organic, and environmental risk factorsGenetic, organic, and environmental risk factors

• Prodromal symptoms may include attention deficits and Prodromal symptoms may include attention deficits and poor executive functioning – may look like ADHDpoor executive functioning – may look like ADHD

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Questions after lecture?Questions after lecture?

Please e-mail (kbazaid@ksu.edu.sa) or call Please e-mail (kbazaid@ksu.edu.sa) or call (01 467 1717)(01 467 1717)

Interested in learning more about child and Interested in learning more about child and adolescent psychiatry?adolescent psychiatry?– Arrange to attend OPD Arrange to attend OPD – Consider an elective rotation during internship Consider an elective rotation during internship

or otherwiseor otherwise