Child

psychiatry

Done by : Rina Karborani

Neurodevelopmental disorders

are classified into:

– Autism spectrum disorder

– Attention deficit/hyperactivity disorder

– Specific learning disabilities (writing/reading)

– Communication disorders(language/speech-sound/childhood onset fluency disorders)

– Tic (motor,vocal) /Tourette’s disorder

– Intellectual disability

– Motor disorders (developmental coordination disorder & stereotyping motor movement)

Autism spectrum disorder

– is a neurological and developmental disorder that begins early in childhood and

lasts throughout a person's life. It affects how a person acts and interacts with

others, communicates, and learns.

– Although autism can be diagnosed at any age, it is said to be a “developmental

disorder” because symptoms generally appear in the first two years of life and

in severe cases, a lack of developmentally appropriate interest in social

interactions may be noted even in the first year.

Delay of spoken language, inability to

start conversation,loss of motor skills,loss of

bowel control

Language delay, repetitive movements

DSM5 DIAGNOSTIC CRITERIA :

Criteria A : persistent deficit in social communication and social interaction across multiple contexts as manifested by :

1. Deficits in social-emotional reciprocity .

For example: abnormal social approach and failure of normal

back and forth conversation , reduced sharing of interests

,emotions or affect , and failure to initiate or respond to social

interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction. For example: poorly integrated verbal and nonverbal communication such as ; abnormalities in eye contact and body language or deficits in understanding and use of gestures to a total lack of facial expressions.

3. Deficits in developing, maintaining and understanding relationships. For example : difficulties adjusting behavior to suit various social contexts, difficulties in sharing imaginative play or in making friends , and absence of interest in peers .

•Criteria B: restricted, repetitive patterns of behavior, interests or activities, as manifested by at least 2 of the following: 1) Stereotyped or repetitive motor movements ,use of objects ,or speech . -Simple motor stereotypes -Lining up toys or flipping objects 2) Insistence on sameness , inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior. -extreme distress at small changes. -difficulties with transitions . -rigid thinking patterns -same food every day . 3)Highly restricted fixated intersts that are abnormal in intensity of focus . -strong attachement with unusual objects -excessively circumscribed or perseverative interests. 4) Hyper or hypoactivity to sensory input or unusual interest in sensory aspects of the environment -apparent indifference to pain/temperature -adverse response to specific sounds or textures

Criteria C : Symptoms must be present in the early developmental period ( but may not become fully manifested until social demands exceed limited capacities ) Criteria D : Symptoms cause impairments in social life. Criteria E : Theses disturbances are not better explained by intellectual disability , global developmental delay or intellectual disability.

Epidemiology

Prevalence :

– about 8 cases per 10,000 children (0.08 percent).

– Boys : girls = 4:1

–has not months 18 to 12 by clinicians and parents share concerns about a child who developed any language,or delayed language accompanied by diminished social behavior are frequently the heralding symptoms in autism spectrum disorder

Etiology & pathogenesis

– 1) Genetic factors

– up to 15% of cases appear to be associated with a known genetic mutation

– Researchers who screened the DNA of more than 150 pairs of siblings with

autism spectrum disorder found evidence of two regions on chromosomes 2

and 7 containing genes that may contribute to autism spectrum disorder.

Additional genes hypothesized to be involved in autism spectrum disorder were

found on chromosomes 16 and 17.

Autism may occurs with other conditions . The most common of these inherited disorders is :

– 1.Fragile X syndrome, In 2 to 3 % of individuals with autism spectrum disorder repeat in the 5’ untranslated region of the FMNR1 gene,. Children with fragile X syndrome characteristically exhibit 1.intellectual disability, 2.gross and fine motor impairments, 3.an unusual facies, 4.macroorchidism, 5. significantly diminished expressive language ability.

– 2.Tuberous sclerosis, characterized by multiple benign tumors. Up to 2 % of children with autism spectrum disorder also have tuberous sclerosis.

2)Biomarkers

– The first biomarker identified in autism spectrum disorder was elevated

serotonin in whole blood, almost exclusively in the platelets.

– Several biomarkers of abnormal signaling in the 5-HT system , Because 5-HT is

known to be involved in brain development, it is possible that the changes in 5-

HT regulation may lead to alterations in neuronal migration and growth in the

brain

– There are also changes witnessed in the GABA inhibitory system

– 3)Immunological Factors

– Several reports have suggested that immunological incompatibility (i.e.,

maternal antibodies directed at the fetus) may contribute to autistic disorder.

The lymphocytes of some autistic children react with maternal antibodies,

which raises the possibility that embryonic neural tissues may be damaged

during gestation.

– 4)Prenatal and Perinatal Factors

– •prenatal factors:

– 1. advanced maternal and

paternal age at birth.

– 2. maternal gestational bleeding.

– 3. gestational diabetes

– 4. first-born baby.

–

•Perinatal risk factors : 1. Umbilical cord complications 2. birth trauma 3. fetal distress 4. small for gestational age 5. low birth weight 6. low Apgar score 7. congenital malformation 8.ABO blood group system or Rh factor incompatibility 9. hyperbilirubinemia

ASSOCIATED SYMPTOMS

• physical anomalies:

– 1. ear malformations, and others that may reflect abnormalities in fetal

development of those organs along with parts of the brain.

– 2.A greater than expected number of children remain ambidextrous at an age

when cerebral dominance is established.

- Disturbances in Language Development and Usage ; difficulty putting

meaningful sentences together, even when they have large vocabularies

- pronoun reversals: A child might say, “You want the toy” when she means that

she wants it. Difficulties in articulation are also common.

– As well as:

– self-injurious behaviors

– Insomnia

DIFFERENTIAL DIAGNOSIS

– 1. social communication disorder. (lack of conventional greeting others, taking turns in a conversation, and responding to verbal and nonverbal cues)

– 2. schizophrenia with childhood onset

– 3. congenital deafness or severe hearing disorder or language disorder (Because children with autism spectrum disorder may appear mute or lack language development)

– 4. intellectual disability and psychosocial deprivation. (The main differentiating features between autism spectrum disorder and intellectual disability are that children with intellectual disability syndromes generally display impairments in both verbal and nonverbal areas, whereas children with autism spectrum disorder are relatively weak in social interactions compared to other areas of performance.)

Comorbid Neurological

Disorders

Electroencephalography (EEG) abnormalities and seizure disorders occur with

greater than expected frequency in individuals with autism spectrum disorder. Four

percent to 32 percent of individuals with autism spectrum disorder have grand mal

seizures at some time, and about 20 to 25 percent show ventricular enlargement

on computed tomography (CT) scans.

Course and prognosis

– is typically a lifelong

– best prognosis:

1. IQ>70 and develop communicative language by ages 5-7.

2. improved if the home environment is supportive

Treatment

Psychosocial interventions:

1. intensive behavioral programs ( Cognitive behavioral therapy)

2. parent training

3. academic/educational interventions

– Components of these comprehensive treatments include expanding social skills,

communication, and language.

Psychopharmacological Interventions

Psychopharmacological interventions in autism spectrum disorder are mainly directed at ameliorating behavioral symptoms rather than core features of

autism spectrum disorder. Target symptoms include irritability,

aggression, temper tantrums , self-injurious behaviors, hyperactivity, and impulsivity

– Two second-generation antipsychotics, risperidone and aripiprazole have been approved by the (FDA) for treatment of irritability in individuals with autism spectrum disorder.

* Several randomized placebo controlled trials of methylphenidate(stimulant medication) have been conducted for the treatment of hyperactivity, impulsivity, and inattention in children and adolescents with autism spectrum disorder.

Attention Deficit/Hyperactivity

Disorder

– is a neuropsychiatric condition, characterized by a pattern of diminished sustained attention, and increased impulsivity or hyperactivity.

– Epidemiologic studies suggest that ADHD occurs in about 5 %of youth including children and adolescents, and about 2.5 % of adults.

-The rate of ADHD in parents and siblings of children with ADHD is 2 to 8 times greater than in the general population.

– ADHD is more prevalent in boys than in girls, with the ratio ranging from 2:1 to as high as 9:1.

AGE: Symptoms of ADHD are often present by age 3 years, but unless they are very

severe, the diagnosis is frequently not made until the child is in kindergarten, or

elementary school.

Up to 70 percent of children with ADHD meet criteria for a comorbid psychiatric

disorder, including learning disorders, anxiety disorders, mood disorder conduct

disorders, and substance use.

disorders.

Etiology

– 1)Genetic factors :

the etiology of ADHD is largely genetic(multiple genes) , with a heritability of approximately 75 % that influence the production of neurotransmitters.

-2) neurochemical factors:

– dopamine is a major focus of clinical investigation. (low dopamine level)

– Animal studies have shown that other brain regions such as locus ceruleus, which consists predominantly of noradrenergic neurons (norepinephrine) , also play a major role in attention.

– 3) Neurophysiological Factors EEG studies: increased theta activity, especially in the frontal region.

– 4) Developmental Factors Premature birth and mothers who had maternal infection during pregnancy. Reports indicated that September is a peak month for births of children with ADHD with and without comorbid learning disorders.

– 5) Neuroanatomical correlations with ADHD:

the brainstem, which contains the reticular thalamic nuclei function, is

involved in sustained attention. A review of (MRI), (PET), and single photon emission computerized

tomography (SPECT) suggests that populations of children with ADHD show evidence of

both decreased volume and decreased activity in prefrontal regions, anterior cingulated,

globus pallidus, caudate, thalamus, and cerebellum. PET scans have also shown that

female adolescents with ADHD have globally lower glucose metabolism than both

control female and male adolescents without ADHD.

DSM-5 criteria the DSM-5 diagnosis of ADHD requires ≥6 symptoms of hyperactivity and impulsivity or ≥6 symptoms

of inattention

Differential diagnosis

•Anxiety.

•Mania.

•conduct disorder.

•Specific learning disorders of various kinds must also be distinguished from

ADHD; a child may be unable to read or do mathematics because of a learning

disorder, rather than because of inattention.

Course and Prognosis

– Symptoms persist into adolescence in 60 -85% of cases, and into adult life in approximately 60 % of cases. Persistence is predicted by a family history of the disorder, negative life events, and comorbidity with conduct symptoms, depression, and anxiety disorders.

– •Most patients with the disorder, however, undergo partial remission and are vulnerable to substance use disorders, conduct disorder and mood disorders.

– •Learning problems often continue throughout life.

– •When remission occurs, it is usually between the ages of 12-20.

– •Overactivity is usually the first symptom to remit, and distractibility is the last.

Treatment

Pharmacologic treatment is considered the first line of treatment for ADHD. Central nervous system stimulants are the first choice of agents in that they have been shown to have the greatest efficacy.

Drugs are divided into stimulant and non-stimulant drugs.

- Stimulants are the better choice and used most commonly , they work by increasing dopamine levels, they consist of 3 groups:

1) Ritalin group ( methylphenidate)

2) Adderall group ( mixed amphetamine salts)

3) Dexedrine group ( dextroamphetamine )

– Vyvanse (lisdexamfetamine dimesylate) is a pro-drug of dextroamphetamine and is FDA approved for children above 6 years old.

Methylphenidate

• dopamine agonists

– •FDA approved for children 6 years and older

– •Methylphenidate preparations are highly effective in up to three fourths of children, with relatively few adverse effects.

– •the 10- to 12-hour extended-release form of methylphenidate, is administered once daily in the morning.

– Side effects: headaches, abdominal pain, nausea, and insomnia. Some children experience a rebound effect, in which they become mildly irritable and appear to be slightly hyperactive for a brief period when the medication wears off.

– -risk of addiction

– In children with a history of motor tics, methylphenidate should be used in caution.

– Stimulant drugs are contraindicated In children with cardiac abnormalities.

Non-stimulant medications ( like atomoxetine) :

– Less effective than stimulants

– Nonstimulants don’t tend to cause agitation, or insomnia. They also don’t pose

the same risk of abuse or addiction like stimulants do.

– they have a longer-lasting and smoother effect than many stimulants, which can

take effect and wear off abruptly.

Atomoxetine

– is a norepinephrine uptake inhibitor approved by the FDA for the treatment of

ADHD in children age 6 years and older.

– Its half-life is approximately 5 hours and it is usually administered twice daily

– *Most common side effects include, abdominal discomfort, dizziness, and

irritability. In some cases, increases in blood pressure and heart rate have been

reported

– black box warning for potential increases in suicidal thoughts and

hepatotoxicity

Thank you